Research Inequality in Nanomedicine
The 10-90 gap is an idea in the healthcare literature that less than 10%of all research funding goes to solving health problems that are 90%of the global disease burden. This paper examines whether there is inequality in nanotechnology healthcare research(nanomedicine). Tounderstand the inequality innanomedicine, I conducted a bibliometric review of Web of Science and PubMed databases. Overall there is not large inequality in nanomedicine research. The bibliometric analysis shows that most nanomedicine research is done in high income countries, but their research portfolios extend beyond richworld diseases likeAlzheimer’s disease and diabetes to include research on malaria, tuberculosis and HIV/AIDS. Of the nanomedicine articles that are directed towards specific diseases (about 20% in Web of Science and PubMed), themajority of the research (86%)will help both the rich and the poor, while only 7% of the research focuses solely on richworld diseases and 7% focus solely on diseases of poverty. The most researched nanomedicine
topic is cancer. It accounts for 16% of nanomedicine literature. Overall less than 20% of nanomedicine research goes to solving health problems that are 50% of the global disease burden.Given nanotechnology is so linked to chemistry and the chemicals industry, the inequality within nanomedicine will impact how those industries supplymaterials, supplies and information to the various stakeholders involved in nanotechnology and healthcare.
1 Backround/Literature Review
Access to health care is a basic human right and over the past twenty years healthcare has
become a focus of development and aid organizations. One major initiative to improve
global health is the United Nations’ (UN) Millennium Development Goals (MDGs) that were adopted in 2000. The MDG’s outline eight different poverty arenas that the world community wants to alleviate by 2015 (United Nations, 2010a). Three of the goals, child health, maternal health, and HIV/AID, deal directly with healthcare. With regards to child health, the UN wants to reduce under five-child mortality rate by two-thirds by focusing on decreasing pneumonia, diarrhea and measles. For maternal health, the MDG is to reduce the maternal mortality ratio by three-quarters and ensure that every woman has access to pre-and postnatal care. Finally the world community has committed to halting and reversing the spread of HIV/AIDS. It’s estimated that HIV/AIDS is the 6th most deadly disease and that the disease kills 2 million people each year (World Health Organization, 2008).
Despite efforts to improve the health of the indigent, the poor live a greater proportion of their lives sick compared to the rich and they have significantly lower life expectancy than the rich (World Health Organization, 2008). A potential cause of the health disparity is that there is not much research on diseases that affect the poor. The Global Forum for Health Research came up with the term the 10/90 gap to describe the inequalities in health research funding (Global Forum for Health Research, 2004). The 10/90 gap refers to the phenomenon that less than 10% of research funding goes to studying diseases that are 90% of the disease burden. Since 1990, the Global Forumfor Health Research has brought awareness to the 10/90 gap by producing reports that track research disparity and engaging with the public and media about the problem. A report by the Médecins Sans Frontières found that health research expenditures are still heavily imbalanced. Four major diseases in developing countries tuberculosis, leishmaniasis, malaria, and trypanosomiasis are 5% of the global disease burden, but research expenditures for this disease are 0.1% of global health R&D (Global Forumfor Health Research, 2004;Médecins Sans Frontières, 2001). Other studies have discussed the 10/90 gap in other healthcare arenas like medicines(Reich, 2000), female healthcare research (Doyal, 2004), cardiovascular diseases
research (Martini et al., 2003) and healthcare publications (Mari et al., 2010; Pastrana et al.,
2010). In general these studies reach similar conclusions as the Global Health Forum and Médecins Sans Frontières;medicine and health R&D is unequal and that society needs major reforms to fix the problem.
Compared to income and education inequality, health inequality is particular dangerous because unlike other problem facing society, diseases can easily jump borders and spread around the world. Bacteria and infections are not biased; they can infect the rich and poor, global north and global south. In the past century rich countries undertook vast campaigns to eradicate several diseases like malaria and mumps. However if the diseases are not treated in other parts of the world, they could reemerge in healthier nations. Recently The National Institute of Allergy and Infectious Disease in the USA identified five reemerging diseases including the mumps virus, streptococcus (strep throat), staphylococcus aureus (staph infection) (NIH, 2010).
However the legitimacy of the 10/90 gap has been challenged (Stevens, 2007). The opponents
of the 10/90 gap argue that the poor’s higher mortality rates have little to do with research
portfolios, but rather other societal conditions that prevent the poor fromgetting the necessary
treatment. The opponents cite that most individuals in developing countries do not die from obscure diseases, but rather from more common illnesses like lower respiratory infections and heart disease. These diseases afflict both the rich and the poor (World Health Organization, 2008) and hence it is an exaggeration to say that 90% of all research funding goes to solving problems of the rich. Moreover critics note that other major killers of the poor, like malaria and diarrheal diseases, have been thoroughly studied and many medicines exist to treat these ailments.Individuals die from these diseases because of other societal factors that prevent treatment, not from a lack of research. Finally the opponents of the 10/90 problemstate that many organizations, like the Infectious Disease Research Institute, study diseases of poverty and hence there is not a dearth of research on neglected diseases (Stevens, 2007).
This paper investigates the 10/90 gap in relation to nanotechnology. Many believe that nanotechnology is the next big research trend. One scholar,Mohamed Hassan (2005), says that
“nanotechnology could prove to be a ‘transformative technology comparable in its impact to the steam engine in the 18th century, electricity in the 20th century, and the Internet in contemporary society” (Hassan, 2005). As a result many countries, especially poorer
countries, are heavily investing in the technology. A study conducted by Salamanca-Buentello et
al. (2005) outlines ten different nanotechnologies that will help the world’s poor. Three of the ten technologies, disease diagnosis, drug delivery, and health monitoring, deal with healthcare issues (Salamanca-Buentello, 2005).
There is often confusion in defining nanotechnology (Balogh, 2010). This paper uses the National Nanotechnology Initiative definition of nanotechnology which “is the understanding and control of matter at dimensions between approximately 1 and 100 nanometers,where unique phenomena enable novel applications. Encompassing nanoscale science, engineering, and technology, nanotechnology involves imaging, measuring, modeling, and manipulating matter at this length scale” (PCAST, 2010). At the nanoscale, matter has different properties, like conductivity and reactivity,whichmake it possible to do novel research and create new products. Central to nanotechnology is chemistry. Chemistry specializes inmanipulating atoms andmolecules to create new substances (Whitesides, 2005). Without chemistry, nanotechnology and hence nanomedicine, could not exist as an emerging technology.
It is estimated that in 2005 there were 38 nano-enabled medical products with sales of about $6.8 billion, over 150 companies working in nanomedicine. This market was expected to double by 2012 (Wagner,Dullaart, Bock,& Zweck, 2006). In addition to these products, the field of nanotechnology will have a variety of economic impacts like increasing the productivity of manufacturing, create a bigger market for scientists familiar with nanotechnology, and increase competition between sectors (Zawislak,Marques, Esteves,& Rublescki, 2010). Chemistry and chemical companies are also expected to benefit from the increased emphasis on nanomedicine. Chemical companies supply many of the materials and equipment to conduct
nanomedicine research.Moreover chemists are often used in nanotechnology labs to do
research. (Zawislak et al., 2010). Hence it is important for chemists and chemical businesses
to understand nanomedicine in order to participate in this new emerging field and market.
2 Research Problem
Though there is some agreement that nanotechnology can help the world’s poor, is there poverty related nanotechnology research being conducted or is all the research geared to
the problems of the rich and luxury goods? Is the 10/90 gap strong in nanomedicine or is the
gap a different ratio? This study is a descriptive investigation of research intensity in nanomedicine and inequality in nanomedicine research.
There are three factors of nanomedicine inequality. First inequality in nanomedicine occurs between the different income levels of countries. Do very high income countries dominate the research or is the research occurring equally across the world? The global distribution of nanomedicine is affected by two competing trends. Scholars have observed that nanotechnology research is taking place in both rich and poor countries. Many poor countries view nanotechnology as the next technology revolution so they are investing in the field early
so they will not be left behind (Hassan, 2005). As a result it is expected that nanomedicine
research will be done in low income countries. However medical research is still dominated by
rich countries (Médecins Sans Frontières, 2001) and therefore it is also likely that nanomedicine
will follow the same trend as general medical research.
Hypothesis 1: Nanomedicine research is predominantly conducted in very high income countries
A second factor of inequality in nanomedicine is whether it focuses on diseases of very high income or low income countries. The currently literature on the 10/90 gap supports the idea that medical research will focus on diseases of the rich. Moreover,much of themedical research
is funded by governments. Since the very high income countries invest more in R&D than mediumand low income countries, it is expected that most of the money will focus on problems
that affect those countries.
Hypothesis 2: There is a disproportionate amount of nanotechnology research conducted on diseases of very high income countries as opposed to the diseases of other countries
A third factor of inequality is whether researchers are focusing on themost dangerous diseases or are their attentions drawn to diseases that cause relatively few deaths. The literature suggests that research is focused on diseases that cause relatively few deaths while neglecting
diseases that cause a lot of deaths (Global Forum for Health Research, 2004).
H1.3 The majority of nanomedicine research will only address diseases that kill relatively few people.
This study fills a gap in the literature. Most other studies discuss the societal and ethical
implications (SEI) of nanotechnology and describe potential problems that may arise because of it (ETC Group 2006; Meridian Institute, 2006; Roco & Bainbridge, 2005). But there are few articles that quantitatively analyze inequality in nanotechnology research. This paper, on the other hand, examines the actually trends in nanomedicine research to determine if scientists are studying nanotechnology for the poor. In addition, this study not only explores where the research is being conducted, but it analyzes the content of the publications to determine which diseases are receiving themost attention.
To analyze inequality in nanomedicine research, I conducted a bibliometric examination ofWeb of Science (WoS) and PubMed databases. Web of Science is one of the largest publication databases. It contains over 13,000 journals in 200 disciplines ranging from 1900 until today
(Thomson Reuters, 2012). WoS is a prominent database used by bibliometricians (Leydesdorff, 2008) to study publication and collaboration patterns in diverse topics like including tropical medicine (Falagas, Karavasiou,& Bliziotis, 2006), nano/biosensors (Huang, Peng, Guo, & Porter, 2010) and emerging technologies (S. Cozzens et al., 2010). My analysis is based on a nanotechnology database created by a group of researchers at the Georgia Institute of Technology (Porter, Youtie, Shapira,& Schoeneck, 2007). The database contains a list of all the
nanotechnology articles in WoS. The team created the database by using eight Boolean
logical search phrases to find the nanotechnology articles and then they used a second list of
4.4 Inequality in Disease Burden
The top ten leading causes of death accounted for 30 million deaths or 50% in 2004. The total amount of directed nanomedicine research on these deadly diseases is 10% in WoS and 19% in PubMed. Hence diseases that account for half the world’s death receive between 10% and 19% of research. This suggests that is a 20/50 gap: Less than 20% of nanomedicine research goes to solving problems that account for 50% of the global disease burden. Though this statistic shows that there is inequality in nanomedicine research, it is not as bad as a 10/90 gap.
Some diseases kill relatively few people each year but they receive a lot of attention from researchers; these diseases are over researched. On the other hand some diseases are under researched; these diseases have high mortality rates yet are not heavily researched. Figure 4 shows the disease research to death ratio of several diseases. If the disease to death ratio is less than 1, then scientists are spending less time researching the disease relative to its mortality rate. On the other hand, if the disease to death ratio is greater than 1, then researchers are spending more time studying a disease compared to its mortality rate. Six diseases, diarrhea, COPD, lower respiratory disease, cerebrovascular disease, heart disease, and prematurity/low birth weight in infants receive significantly less research than they deserve2. On the other hand, cancer, hepatitis, Alzheimer’s, Parkinson’s disease and arthritis receive more attention than is warranted. Hepatitis publications are about 3% of all directed nanomedicine research, but it only kills about 0.3% of the world’s population. The disease ratio to research ratio for the three major diseases of poverty, tuberculosis, HIV/AIDS, and malaria are not heavily skewed. The research to death ratio for these diseases range from 0.65% to 0.9%. This shows that scientists are devoting sufficient amount of attention to these diseases and that overall there isn’t research inequality for these diseases.
This paper gives a descriptive analysis of nanomedicine research and classifies whether there is inequality in the research. Overall twenty percent of all nanotechnology articles are related to nanomedicine and in WoS the percent of nanomedicine articles has grown over the past 10 years. Nanomedicine is growing in importance and scientists are developing new medicines to address many of the world’s diseases.
This study has three hypotheses. The first hypothesis is that nanomedicine is predominantly conducted in very high income countries. The data supports this hypothesis. About 77% of nanotechnology research is conducted in very high income countries but these countries only contain 15% of the world’s population. However over the next few decades, it is possible that the trend will change. Medium income countries like China and India are becoming world leaders in nanotechnology and they are rivaling countries with very high incomes in nanomedicine research.
The second hypothesis is that there is a disproportionate amount of nanotechnology research conducted on diseases of very high income countries. There is no evidence to support this hypothesis. Scientists are doing nanomedicine research on a variety of diseases that affect both the rich and the poor. Although diseases of the rich like Alzheimer’s and breast cancer receive the most attention, diseases like tuberculosis, malaria and HIV/AIDS also receive some attention from nanomedicine scientists. The disease with the most nanomedicine publications is cancer. Cancer is a leader killer in high income countries, but currently cancer is not a top disease in middle and poor countries. However as people in poor countries get richer and have longer life expectancies, cancer will become a more serious problem.
The third hypothesis is that the majority of nanomedicine research only addresses diseases that kill relatively few people. This hypothesis is partially confirmed. Several diseases like skin cancer, hepatitis, breast cancer, Parkinson’s and arthritis are over researched. These diseases cause relative few deaths yet they receive a lot of attention from scientists. Nevertheless there are several diseases like diarrhea disease, COPD and infant death due to prematurity and low birth weight do not receive enough attention from scientists. However there are many diseases of poverty, like malaria, HIV/AIDS, and tuberculosis that do receive enough attention in relation to the number of people the diseases kill. Moreover there is a 20/50 gap in nanomedicine: less than 20% of nanomedicine research goes to solving diseases that account for 50% of deaths.
There are several limitations to this study. First the study uses Web of Science and PubMed to quantify inequality in nanomedicine. Though these databases are often used in bibliometric studies they have small biases. These databases tend to have a higher representation of English journals and they tend to have more journals from high income countries (UNESCO, 2005). As a result, research from developing countries may be under represented in the dataset. Also this study cannot determine whether the articles were discussing how nanotechnology can cure diseases, cause more diseases or provide patients with more access to nanomedicine. This is especially significant when analyzing cancer. Scientists study both how nanotechnology can fight cancer (Ferrari, 2005) and how it could potential cause cancer (Stern & McNeil, 2008). As a result some of the nanomedicine papers may focus on toxicology as opposed to fighting cancer. Finally many of the top “diseases” do not have much overlap with nanomedicine. For example, traffic accidents is the ninth leading cause of death, and self-inflicted injuries is the sixteenth leading cause of death. It is doubtful that nanomedicine will impact those areas.
From this study it is hard to conclude why nanomedicine does not have large research inequalities like those reported in other medical fields. One potential cause is that research profile is heavily influenced by funding agencies that sponsor disease specific nanomedicine. 15% of the WoS articles in the nanomedicine dataset attribute a funding sponsor. Most of the sponsored research is attributed to large government research funding organizations like the USA National Institutes of Health (NIH). Since cancer is a major focus area for the NIH, scientists may be drawn to cancer research in order to get research money. Other factors that affect scientist motivations may like organization structure and reward system (Fox, 1983).
This study is a first step in understanding inequality in nanomedicine and adds to the discussion on the 10-90 gap. It shows that scientists are studying how emerging technologies, like nanotechnology, can benefit the poor and that many of the inequality trends that existed in research and technology are changing. In the future scholars can add information about whether nanomedicine effects health inequality based on disability adjusted life years (DALY). DALY’s is an alternative measure of the burden of disease that captures the disease burden based on the years of life lost resulting from premature death and the loss resulting from losing full quality of health (World Health Organization, 2008). By studying inequality with DALY we can understand the effects of nanomedicine on non-fatal diseases. Moreover, scholars need to understand why nanomedicine is not following the pattern of other medical research. Is there a reason that nanomedicine is not following the same 10-90 gap that is apparent in other medical fields?
Moral philosophies and belief systems view inequality as bad for society (S. E. Cozzens, 2007). Science and technology can play a crucial role in diminishing inequality however science and technology does not automatically reduce inequality (Woodhouse & Sarewitz, 2007). If the technology is not introduced correctly it can lead to greater inequalities as seen in other areas of medical technologies. The chemicals industry plays a crucial role in nanomedicine. Although it may not be directly involved in choosing the research portfolio for researchers, the chemical industry plays a big part of providing supplies, equipment and expertise for the technology. The research in nanomedicine will influence where companies should operate and what type of nanotechnology products it should offer to consumers. By understanding the research in nanomedicine, the field will be able better respond to customer demand.
I would like to thank Susan Cozzens, Jan Youtie, Diana Hicks, Alan Porter and the reviewers for their comments on this paper. I would also like to that researchers at the Center for Nanotechnology and Society at the Georgia Institute of Technology for letting me use their nanotechnology database. This study was funded by the National Science Foundation, Graduate Student Fellowship and NSF award #0937591.
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