Some 500 million people, including 260 million children under the age of five, have died from hunger and remediable diseases in peacetime in the 30 years since the end of the cold war. This is vastly more than have perished from wars, civil wars, and government repression over the entire twentieth century. And poverty continues unabated, as the official statistics amply confirm: of the 7.6 billion people alive today, 821 million are officially counted as undernourished, 150 million are homeless and about 1.6 billion lack adequate shelter, 2.1 billion have no safe drinking water at home, and 4.5 billion lack safe sanitation, 1.2 billion lack electricity, 2 billion are lacking access to essential medicines, 750 million adults are illiterate, and 152 million children (aged 5–17) are victims of child labor – often under slavery-like and hazardous conditions as soldiers, prostitutes, or domestic servants or in agriculture, construction, or textile or carpet production.

We are living in the shadow of the COVID-19 pandemic – anxious about our families, our friends and ourselves, depressed by worldwide suffering and anxiety, upset by knowing that once more the poor and marginalized are worse affected. Could the rules and practices organizing healthcare around the world have been better suited to this outbreak? Let us consider the Health Impact Fund as a plausible institutional reform of the current regime for developing and marketing new pharmaceuticals.

The pharmaceuticals sector

Medicines are among humanity's greatest achievements. They have helped realize dramatic gains in health and longevity as well as huge cost savings through reduced sick days and hospitalizations. The global market for pharmaceuticals is currently worth US$1,430 billion annually, 1.7 per cent of the gross world product (IFPMA, 2017: 5). Roughly US$800 billion thereof is spent on brand-name products, which are typically under patent (IFPMA, 2017: 51).

Commercial pharmaceutical research and development (R&D) efforts are encouraged and rewarded through the earnings that innovators derive from sales of their branded products. These earnings largely depend on the 20-year product patents they are entitled to obtain in WTO member states. Such patents give them a temporary monopoly, enabling them to sell their new products without competition. Under the protection of their patents, they can raise a product's price far above manufacture and distribution costs while still maintaining a substantial sales volume. Such mark-ups yield large profits for commercial innovators and enable them to invest in new R&D, currently at a rate of US$189 billion a year (Mikulic, 2020).

While we should evidently want pharmaceutical R&D to be sustainable, it is worth asking whether our current way of funding is optimal. There are three main concerns.

Firstly, innovators motivated by the prospect of large markups tend to neglect the – mostly communicable – diseases specific to poor people, who cannot afford expensive medicines. The 20 World Health Organization-listed neglected tropical diseases together afflict over a billion people (WHO, n.d.) but attract only 0.35 per cent of pharmaceutical industry R&D (IFPMA, 2017: 15 and 21). Another 0.12 per cent of this R&D spending goes to tuberculosis and malaria, which kill 1.7 million people each year.

Thomas W. Pogge begins with the need to distinguish between the concept of justice and various conceptions of justice. In this perspective, he distinguishes international justice, which has been around and covers the interactions and the rules states do or should commit themselves to, and global justice, where it is individual human beings who have primary rights and are the subjects of global justice. On this basis, Pogge explores the conditions under which the pursuit of global justice could be better achieved.

Dignity is not an independently existing thing, but an attribute – of human beings, for example. It is essential to our notion of dignity that it has two distinct but related meanings. Using one meaning, we say that each human being has an inherent dignity, which is inalienable and equal for all. Using the other meaning, we say that the dignity of human beings is precarious and stands in need of social protection.

We find both meanings used side by side in the Universal Declaration of Human Rights (UDHR). In the first three occurrences of the word, it is used in its first sense:

In the next occurrence, ‘dignity’ is used in its other sense:

To call these rights indispensable for dignity is to say that any person lacking in these rights also falls short in dignity. Article 22 thus suggests that dignity is both alienable and possibly unequal: those who have dignity can lose its indispensable preconditions and therefore dignity itself – and will then not be ‘equal in dignity’ with those who still have it.