TEDxCanberra
Thomas Pogge: Medicine for the 99 percent
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Can we incentivize companies to produce much-needed drugs? Thomas Pogge proposes a $6 billion plan to revolutionize the way medications are developed and sold.
(Filmed at TEDxCanberra.)
Thomas Pogge - Philosopher
Philosopher Thomas Pogge wants to ensure medications get to those who need it most. He has published on a wide range of subjects such as global justice and human rights. Full bio
Philosopher Thomas Pogge wants to ensure medications get to those who need it most. He has published on a wide range of subjects such as global justice and human rights. Full bio
Double-click the English transcript below to play the video.
00:09
I hope you're all healthy,
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我希望你們都很健康，
00:11
and I hope we will all remain healthy
for the indefinite future.
for the indefinite future.
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我也希望在無盡的未來
我們都會保持健康。
我們都會保持健康。
00:15
But that hope is a little bit unrealistic,
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但這樣的希望有點不切實際，
00:18
and so I've got a second back-up hope.
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所以我還有備用的第二個希望。
00:20
The second back-up hope is that,
insofar as we have health problems,
insofar as we have health problems,
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備用的第二個希望就是，
在我們的健康出問題的時候，
在我們的健康出問題的時候，
00:24
we will have good medicines
to take care of them.
to take care of them.
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我們會有好的藥物
來處理那些問題。
來處理那些問題。
00:28
Medicines are very cheap to produce
and they're very effective --
and they're very effective --
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藥物的生產很便宜，
且它們非常有效——
且它們非常有效——
00:32
much more pleasant, actually,
than the alternatives:
than the alternatives:
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也比其它替代方案更討喜許多：
00:35
hospitalization, operations,
emergency rooms, the morgue ...
emergency rooms, the morgue ...
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住院、手術、急診室、停屍間……
00:40
None of these are good things.
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這些都不是好事。
00:41
So we should be very grateful
that we have pharmacologists around,
that we have pharmacologists around,
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所以我們應該要很感激
有藥理學家在，
有藥理學家在，
00:45
people who research these things
and develop new medicines.
and develop new medicines.
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他們就是負責研究
這類東西並開發新藥的人。
這類東西並開發新藥的人。
00:49
And we should be grateful
that we have a pharmaceutical industry
that we have a pharmaceutical industry
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我們也該非常感激有製藥業存在，
00:52
that supports their activities.
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製藥業能支持他們的活動。
00:55
But there is a problem,
and you can tell from the fact
and you can tell from the fact
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但有一個問題，你們也看得出來，
00:58
that the pharmaceutical
industry isn't well-loved.
industry isn't well-loved.
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製藥業並不是很受到喜愛。
01:01
In fact, in terms of popularity, they rank
just about with the tobacco companies
just about with the tobacco companies
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事實上，就受歡迎程度來說，
製藥業的排名
製藥業的排名
只好過菸草公司
和軍火製造商而已。
和軍火製造商而已。
01:06
and the arms manufacturers.
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01:08
So that's the problem
I want to talk with you about today.
I want to talk with you about today.
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那就是我今天想要
和大家談的問題。
和大家談的問題。
01:13
How would you organize
the pharmaceutical industry?
the pharmaceutical industry?
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你會如何組織製藥業？
01:16
If we did it all over again,
how would you do it?
how would you do it?
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若我們能重來一次，你會怎麼做？
我想，我們會想出三條主要原則。
01:18
I think we would think
of three main principles.
of three main principles.
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01:22
The first one is:
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第一：
01:23
we want patients to have access
to all the important medicines.
to all the important medicines.
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我們希望病人能取得
所有重要的藥物。
所有重要的藥物。
01:27
Remember, these things
are very cheap to produce.
are very cheap to produce.
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別忘了，藥物的製造是很便宜的。
01:30
So everybody in the world
should have access
should have access
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所以世界上的每個人都應該要能夠
01:33
to all the important medicines.
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取得所有重要的藥物。
01:36
Secondly, we want innovative activities,
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第二：我們希望藥廠所做的活動、
01:39
the research and development
that pharmaceutical companies do,
that pharmaceutical companies do,
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研究，和開發，都能夠有所創新，
01:42
to track the diseases that are
the most important, the most damaging.
the most important, the most damaging.
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以追蹤最重要、傷害最大的疾病。
01:46
We want them to aim
for the greatest health impact.
for the greatest health impact.
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我們希望它們把目標設在
對健康最大的影響上。
對健康最大的影響上。
01:50
And thirdly, we want
the whole system to be efficient.
the whole system to be efficient.
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第三：我們希望
整個體制能夠有效率。
整個體制能夠有效率。
01:53
We want as little of the money
that goes into the system to go to waste,
that goes into the system to go to waste,
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我們希望進入這個體制的金錢
盡可能不要被浪費，
盡可能不要被浪費，
01:58
to go for overhead,
for red tape, and so on and so forth.
for red tape, and so on and so forth.
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不要花在過多的非製造的費用，
以及繁文縟節上。
以及繁文縟節上。
02:02
Very simple three points.
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非常簡單的三點。
02:05
Now what about the existing system?
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那麼，既有體制有什麼問題嗎？
02:07
I think it does poorly
on all these three counts.
on all these three counts.
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我認為在這三點上它都做得很糟。
02:11
First, universal access: forget about it.
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首先，普羅大眾都可取得：算了吧。
02:14
The vast majority of human beings
do not have access to medicines,
do not have access to medicines,
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大部分的人都無法取得藥物，
02:18
at least while they're still under patent.
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尤其是在藥物還有
專利的時候更是如此。
專利的時候更是如此。
02:22
There are extremely high markups,
and that's the problem.
and that's the problem.
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賣價比成本價高很多，
這就是問題所在。
這就是問題所在。
02:25
The problem is that even though
these medicines are very cheap to produce,
these medicines are very cheap to produce,
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問題就是，即使製造
這些藥物很便宜，
這些藥物很便宜，
02:29
they cost a great amount of money
during the time that they're under patent,
during the time that they're under patent,
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在它們的專利期間，
它們的價格非常高，
它們的價格非常高，
02:34
and the reason for that is
that rich people can pay a lot of money.
that rich people can pay a lot of money.
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而原因是因為
有錢人能付得起很多錢。
02:39
Pharmaceutical companies
have a temporary monopoly;
have a temporary monopoly;
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藥廠有暫時性的獨佔；
02:41
they price for the rich,
they forget about the poor.
they forget about the poor.
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它們會根據有錢人來定價，
根本不理會窮人的需求。
根本不理會窮人的需求。
02:45
The second problem is innovation.
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第二個問題是創新。
02:48
Again, we don't focus on the diseases
that do the most damage,
that do the most damage,
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同樣的，我們不把焦點放在
傷害最大的疾病上，
傷害最大的疾病上，
02:52
and that's often put
into the phrase "the 10/90 gap."
into the phrase "the 10/90 gap."
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通常，就會用「10/90 落差」
這個詞來形容。
這個詞來形容。
02:57
Ten percent of all the money spent
on pharmaceutical research
on pharmaceutical research
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花在藥物研究上
所有的錢，只有 10%
所有的錢，只有 10%
03:01
is focusing on diseases
that account for ninety percent
that account for ninety percent
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被投入在造成 90%
全球疾病負擔的那些疾病上。
全球疾病負擔的那些疾病上。
03:04
of the global burden of disease.
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03:06
And vice versa -- ninety percent
of the money is spent on diseases
of the money is spent on diseases
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反之亦然——花在藥物
研究上的錢，有 90%
研究上的錢，有 90%
投入只在造成 10%
全球疾病負擔的那些疾病上。
全球疾病負擔的那些疾病上。
03:10
that account for only ten percent
of the global burden of disease.
of the global burden of disease.
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03:13
So there's a huge mismatch between
where we spend the research money
where we spend the research money
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所以，我們投入研究經費的地方，
和最大問題所在的地方，
兩者有很大的落差。
兩者有很大的落差。
03:18
and where the greatest problems are.
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03:21
Now, both these problems --
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這兩個問題——
創新問題和可得性問題——
03:23
the problem with innovation
and the problem with access --
and the problem with access --
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和這個議題有關：
03:25
have to do with this:
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03:28
the distribution of money in the world.
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世界上的金錢分佈非常不平均。
03:30
It's extremely unequal.
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03:31
The blue area here is the top quarter
of the human population.
of the human population.
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藍色區域是人類
人口的前四分之一。
人口的前四分之一。
03:36
They have more than ninety percent
of the global household income.
of the global household income.
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90% 以上的全球
家庭收入都屬於這群人。
家庭收入都屬於這群人。
03:40
The bottom half of humanity,
on the other hand,
on the other hand,
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另一方面，屬於後一半的人，
03:42
has not even three percent
of global household income.
of global household income.
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擁有的全球家庭收入
甚至還不到 3%。
甚至還不到 3%。
03:46
So if you're a pharmaceutical company
and you look for profit opportunities,
and you look for profit opportunities,
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如果你是一間藥廠，
你在尋找獲利的機會，
你在尋找獲利的機會，
03:50
you look at this sort of chart and say,
"Where's the money?
"Where's the money?
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你看著這類的圖表，
說：「錢在哪裡？
說：「錢在哪裡？
03:53
What am I going to research?
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我要研究什麼？
03:55
Who am I going to provide with medicines?"
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我要把藥物提供給誰？」
03:58
And again, that is in the context
of there being only one way
of there being only one way
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同樣的，會有那樣的狀況是因為
在當前的體制之下，
藥廠賺錢的唯一途徑，
藥廠賺錢的唯一途徑，
04:02
in which pharmaceutical companies
make money under the present system,
make money under the present system,
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04:06
that is, through patent-protected markups.
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就是利用專利保護來賺取暴利。
04:08
That's how they make their money,
through markups.
through markups.
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藥廠就是這樣賺錢的，靠加價。
04:10
And if you make money through markups,
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如果你靠加價賺錢，
04:12
then obviously, you will go to where
the people have the most income.
the people have the most income.
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那麼，很顯然，你的目標
就會是最有錢的人。
就會是最有錢的人。
04:19
Now in terms of overall efficiency,
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體制在整體效益上的表現
04:20
the system also does very, very poorly.
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也非常非常差。
04:24
A lot of money goes
for lobbying politicians
for lobbying politicians
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許多錢被花在遊說政客，
04:27
in order to extend patent periods --
to "evergreen," as it's called.
to "evergreen," as it's called.
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這樣才能將專利期延長——
到所謂的「長青」。
到所謂的「長青」。
04:30
Data exclusivity and so on.
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資料獨有性等等。
04:32
A lot of money goes for gaming,
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許多的錢被花在操縱上，
04:34
where brand-name companies pay generic
companies to delay entry, for example.
companies to delay entry, for example.
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比如，品牌公司付錢給無品牌的公司，
要它們晚點進入。
04:40
A lot of money goes to take our patents
in all the different jurisdictions.
in all the different jurisdictions.
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許多錢都花在將我們的專利
帶到不同的管制範圍。
帶到不同的管制範圍。
04:43
Money goes – even larger
amounts – for litigation.
amounts – for litigation.
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甚至更大的金額被花在訟訴上。
官司沒停過。
04:46
They're litigating endlessly --
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04:48
brand-name company
against brand-name company,
against brand-name company,
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品牌公司對上品牌公司，
04:50
brand-name company
against generic company ...
against generic company ...
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品牌公司對上
製造無品牌藥的公司……
製造無品牌藥的公司……
04:52
Enormous amounts go there.
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很多錢都花在那裡。
04:54
People say pharmaceutical companies
make a lot of profit.
make a lot of profit.
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大家都說藥廠的利潤很高。
04:57
Well, yes and no; they do, but a lot of it
goes to these wasteful activities.
goes to these wasteful activities.
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對，也不對；它們的利潤很高，
但很多利潤都投入浪費的活動中。
但很多利潤都投入浪費的活動中。
05:02
Deadweight losses -- I won't
even tell you what they are,
even tell you what they are,
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無謂的損失——我不會告訴你們
這是什麼，因為太複雜了。
這是什麼，因為太複雜了。
05:04
because it's too complicated.
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但行銷上也有浪費。
05:06
But there's also wasteful marketing.
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05:08
A lot of the money
that pharmaceutical companies make
that pharmaceutical companies make
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藥廠賺的錢當中，
05:12
goes into advertising campaigns,
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有很多花在廣告宣傳上，
05:13
trying to win favor with doctors,
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試圖贏得醫生的偏愛，
05:15
trying to persuade patients
to try this medicine.
to try this medicine.
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試圖說服病人來嘗試這種藥。
05:18
And these marketing battles,
of course, are a pure waste,
of course, are a pure waste,
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當然，這些行銷戰
也都是純粹的浪費，
也都是純粹的浪費，
因為一家藥廠花這麼多錢
來讓病人用它的藥，
來讓病人用它的藥，
05:21
because what one company spends
to get patients over to their drug,
to get patients over to their drug,
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另一家藥廠又花
這麼多錢把病人搶回來。
這麼多錢把病人搶回來。
05:24
another company spends to win them back.
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05:27
And then there is counterfeiting
in the developing countries.
in the developing countries.
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此外，在開發中國家還有仿製品。
在這些國家，很多假藥佔
市場銷售量的一半以上，
市場銷售量的一半以上，
05:30
A lot of the drugs there, often more than
fifty percent of what's sold,
fifty percent of what's sold,
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都是仿製品，當地人會說：
05:33
are counterfeit drugs, where people say,
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「因為藥太貴了，
我能提供給你更便宜的版本。」
我能提供給你更便宜的版本。」
05:35
"Because the drug is so expensive,
I can offer you a cheaper version."
I can offer you a cheaper version."
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但，當然，那不是真貨，
05:39
But of course it's not the real thing,
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若不是稀釋過，就是根本沒有用。
05:40
it's either diluted
or it's completely inert.
or it's completely inert.
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05:43
So on the whole, all the money
that is spent on pharmaceuticals --
that is spent on pharmaceuticals --
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整體來說，所有花費在
藥物上的錢——
藥物上的錢——
05:47
and it's roughly a trillion dollars
now, per annum --
now, per annum --
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每年大約是一兆美金——
05:50
much of that money
is absolutely going to waste,
is absolutely going to waste,
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大部分都完全浪費掉了，
05:53
it's not going to where
it should be going,
it should be going,
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錢沒有花在該花的地方，
05:55
namely, to the development
of new medicines
of new medicines
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該花的地方就是新藥的開發
05:58
and to the manufacturing
of ones that we already have.
of ones that we already have.
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以及舊藥的製造。
06:02
Now, many people think
that the solution to the problem
that the solution to the problem
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許多人認為，這個問題的解決方案
06:04
is moral pressure
on pharmaceutical companies.
on pharmaceutical companies.
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就是對藥廠施加道德壓力。
06:08
And, sure -- pharmaceutical companies
have moral obligations,
have moral obligations,
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當然，藥廠跟我們一樣
有道德上的義務，
有道德上的義務，
06:12
just like we do.
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當我們必須要在花一點額外的錢
和拯救人命之間擇一時，
和拯救人命之間擇一時，
06:13
When we have to make a choice,
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06:14
often between having a little extra money
and saving a human life,
and saving a human life,
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06:19
we often feel that we have a duty
to spend the money
to spend the money
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我們通常會覺得我們有責任要花錢
06:22
and save the life.
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來拯救人命。
藥廠不是也應該這樣嗎？
06:23
And why should pharmaceutical
companies be any different?
companies be any different?
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06:27
But really, it isn't realistic
to expect pharmaceutical companies
to expect pharmaceutical companies
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但，其實，期望藥廠做出
和你我一樣的作為，並不實際。
06:32
to act as well as you
or maybe I might act.
or maybe I might act.
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06:36
And the reason is threefold.
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理由有三個。
06:38
One is that pharmaceutical companies
are bound to their shareholders.
are bound to their shareholders.
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第一，藥廠受制於它們的股東。
06:43
The executive of such a company
wouldn't last very long
wouldn't last very long
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在這類公司裡，如果經理
為了做善事而花上大把鈔票，
為了做善事而花上大把鈔票，
06:46
if he gave a lot of money away,
or she, for good purposes,
or she, for good purposes,
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他或她的位置不可能坐很久，
06:50
and thereby lost money
for the shareholders.
for the shareholders.
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因為這樣等於是丟了股東的錢。
06:54
They would be replaced.
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這種經理會被換掉。
06:56
Also, pharmaceutical companies stand
in fierce competition with one another,
in fierce competition with one another,
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此外，藥廠之間的競爭很劇烈，
07:00
and if you do more, if you are nicer
than the other company,
than the other company,
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如果你多做一點，
如果你比其他藥廠更有良心，
如果你比其他藥廠更有良心，
07:04
sooner or later, you'll be
driven out of the market.
driven out of the market.
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遲早，你會被踢出市場。
你無法生存。
07:06
You will not survive.
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另一間藥廠會佔據市場。
07:07
The other company will gain market share.
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07:11
And finally, remember --
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最後，別忘了整個產業的收入
07:12
the entire industry
is dependent for its income
is dependent for its income
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仰賴一樣東西，
07:15
on one thing and one thing only: markups.
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且只仰賴這一樣東西：加價。
07:18
And ultimately, you have
to be sustainable.
to be sustainable.
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最終，你得要做到永續。
07:22
If you spend a lot of money
on helping poor people
on helping poor people
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如果你花很多錢去幫助窮人，
07:25
and you don't get paid for it,
and you lose this money;
and you lose this money;
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且這樣做是沒收益的，
你就是失去了這筆錢；
你就是失去了這筆錢；
07:27
you cannot continue
with your innovative activities.
with your innovative activities.
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你就無法持續你的創新活動。
07:32
So for these reasons,
it's just unrealistic
it's just unrealistic
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基於這些理由，
期望藥廠會以道德
為出發點來解決問題，
為出發點來解決問題，
07:34
to expect that pharmaceutical companies
will solve the problem
will solve the problem
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是很不切實際的。
07:38
on moral grounds.
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那麼，問題該由誰來解決？
我建議由我們來做。
我建議由我們來做。
07:39
Who, then, should solve the problem?
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07:41
I suggest it has to be us.
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07:43
We, citizens and politicians,
have to do better
have to do better
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我們，公民和政治人物，
在規範製藥業方面
必須要做得更好，
必須要做得更好，
07:47
in terms of regulating
the pharmaceutical industry,
the pharmaceutical industry,
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07:50
focusing them,
giving them the right incentives,
giving them the right incentives,
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讓它們聚焦，給它們對的獎勵，
07:53
focusing them on the problems
that really matter.
that really matter.
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讓它們聚焦在真正重要的問題上。
07:57
The potential gains here are enormous.
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這裡的潛在益處是非常巨大的。
08:00
About one third of all deaths
each day, each year,
each day, each year,
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每年每天，開發中國家死亡的人當中
有三分之一死於窮人的疾病。
08:05
are due to the diseases of poverty
in the developing world.
in the developing world.
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每天有五萬人
08:08
Fifty thousand people every day
die prematurely from these diseases.
die prematurely from these diseases.
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因為這些疾病而早死。
08:15
And that's not even counting
all the diseases
all the diseases
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這數字還沒有把所有在富有國家中
08:17
that we know only too well
in the rich countries:
in the rich countries:
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大家都相當熟悉的疾病給納入計算：
癌症、心臟疾病等等。
08:20
cancer, heart disease and so on.
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08:22
Again, poor people die often much earlier,
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同樣的，窮人很年輕就死亡，
因為他們沒有好的醫療照護，
包括沒有好的藥物。
包括沒有好的藥物。
08:24
because they don't have good medical care,
including good medicines.
including good medicines.
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08:29
And even in rich countries, many patients
are not getting the best medicine.
are not getting the best medicine.
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即使在富有的國家中，
許多病人也沒有得到最好的藥。
08:34
That's sometimes due to the fact
that insurance companies won't cover it,
that insurance companies won't cover it,
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有時背後的原因
是因為保險公司不給付，
是因為保險公司不給付，
因為價格實在太荒謬。
08:37
because the price
is so absolutely ridiculous.
is so absolutely ridiculous.
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08:40
And it's also due, sometimes,
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有時，也有可能是因為
08:41
to the fact that doctors
and patients are falsely influenced
and patients are falsely influenced
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醫生和病人受到藥廠
廣告行銷的不當影響。
08:45
by advertising campaigns
of pharmaceutical companies.
of pharmaceutical companies.
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08:50
So what can we do?
How can we change the system?
How can we change the system?
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所以，我們能怎麼辦？
我們要如何改變體制？
我們要如何改變體制？
08:53
I want to show you a way
in which we can better incentivize
in which we can better incentivize
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我想要告訴各位一種方式，
它可以提供更好的獎勵
它可以提供更好的獎勵
08:56
pharmaceutical innovation and
the provision [of] medicines
the provision [of] medicines
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來鼓勵藥物創新
和平等地供應藥物給窮人和富人。
09:00
to poor people and rich alike.
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09:02
And that is the Health Impact Fund.
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那就是「健康影響基金」。
09:04
The Health Impact Fund is basically
opening up the second track
opening up the second track
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基本上，健康影響基金
是開拓了第二條路，
是開拓了第二條路，
09:08
with which pharmaceutical innovators
can be rewarded for their activities.
can be rewarded for their activities.
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來獎勵藥物創新者的活動。
09:13
They have a choice.
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他們有選擇。
09:14
They can either go with the old system,
with patent-protected markups,
with patent-protected markups,
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他們可以選擇舊體制，
即專利保護的加價，
09:18
or they can go with the new system,
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也可以選擇新體制，
09:21
being rewarded on the basis
of the health impact
of the health impact
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根據他們所開發出來的藥物
有多大的健康影響，
有多大的健康影響，
09:24
of the medicines that they develop.
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來取得對應的獎勵。
09:26
And with each particular medicine,
they have their choice.
they have their choice.
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他們可以針對每一項藥物做選擇。
09:29
So they can be partly on one track,
partly on the other,
partly on the other,
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所以他們可以
針對某些產品選擇舊體制，
針對某些產品選擇舊體制，
某些產品選擇新體制。
09:32
with different products.
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09:34
Now, how would
the Health Impact Fund work?
the Health Impact Fund work?
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健康影響基金如何運作？
09:38
There would be a fixed
reward pool every year.
reward pool every year.
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每年都會有固定的
共同資金作為獎賞。
共同資金作為獎賞。
09:40
We start with maybe six billion dollars,
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2000
我們可能會從六十億美金開始，
09:42
but that can eventually be revved up.
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1795
但最終還可以加到更高。
09:44
Remember that the total money
that the world spends on pharmaceuticals
that the world spends on pharmaceuticals
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別忘了，全世界花在藥物上的總金額
是一兆美金。
09:47
is a trillion.
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1158
09:48
So it's a thousand billion;
six billion is a drop in the bucket.
six billion is a drop in the bucket.
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580989
3050
那就是一千個十億美金；
六十億美金只是鳳毛麟角。
六十億美金只是鳳毛麟角。
09:52
It's relatively small,
but it would work with six billion,
but it would work with six billion,
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六十億美金相對是小金額，
但它能讓基金運作，
但它能讓基金運作，
09:54
and we'd get a lot of bang for the buck
if we introduced the Health Impact Fund
if we introduced the Health Impact Fund
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如果我們開始就有六十億美金
來推出健康影響基金，
來推出健康影響基金，
我們能得到很大的迴響。
09:58
with just six billion dollars.
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10:00
If you have a product
and you want to register it
and you want to register it
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如果你有一項產品，
你想要向健康影響基金登記，
10:04
with the Health Impact Fund,
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1712
10:06
you will be rewarded
for a period of 10 years.
for a period of 10 years.
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3391
你就能得到為期十年的獎賞。
10:09
During these 10 years, you get a share
of these annual reward pools.
of these annual reward pools.
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在這十年間，你能分到
這些年度獎賞共同資金。
10:15
That share would be proportional to
your share of the health impact achieved
your share of the health impact achieved
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分到的比例就看你所達成的健康影響
在所有登記產品所達成的
影響中佔多少百分比。
影響中佔多少百分比。
10:20
by all these registered products.
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1869
10:23
So if your product accounts
for eight percent of the health impact
for eight percent of the health impact
196
615162
4645
所以，如果所有登記產品
產生的總健康影響中
產生的總健康影響中
有 8% 是由你的產品所貢獻，
10:27
of all the registered products,
197
619831
2095
10:29
you get eight percent
of the reward money that year.
of the reward money that year.
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3684
在那年，你就能得到 8% 的獎金。
10:33
That repeats for 10 years,
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這個流程會重覆十年，
10:35
and at the end of the 10 years,
your product goes generic,
your product goes generic,
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十年結束時，你的產品
就成為非專利藥，
就成為非專利藥，
10:38
so you basically lose
any further income from it.
any further income from it.
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630911
3314
基本上，你就會失去
所有它後續帶來的收入。
所有它後續帶來的收入。
10:44
Each year, the health impact
from your product would be evaluated,
from your product would be evaluated,
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4069
每年都會評估你的產品
所產生的健康影響，
所產生的健康影響，
10:48
and you would be paid on that basis.
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2599
並以它為基礎，付款給你。
10:51
Now, if you take that reward
from the Health Impact Fund,
from the Health Impact Fund,
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3453
如果你從健康影響基金得到獎賞，
10:54
you can't claim the other reward,
you can't mark up the price.
you can't mark up the price.
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2954
你就不能申請其他獎賞，
你就不能加價。
你就不能加價。
你必須要以成本價售出。
10:57
You have to sell at cost.
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1486
10:59
What does that mean?
207
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1591
那是什麼意思？
11:01
Well, it doesn't mean
that the pharmaceutical company tells us
that the pharmaceutical company tells us
208
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2910
意思並不是藥廠告訴我們
它們的成本是多少；
它們的成本是多少；
11:04
what their cost is;
209
656637
1164
11:05
but rather, our preferred way
of determining what the real cost is
of determining what the real cost is
210
657825
4197
若要判斷製造、
生產一種藥物的真實成本，
生產一種藥物的真實成本，
11:10
of making a medicine, of manufacturing it,
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2757
我們偏好用的方式
11:12
is to ask the registrant to put
the production of the medicine
the production of the medicine
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3633
是請登記者把該藥物的生產
11:16
out for tender, let generic companies
compete for the production,
compete for the production,
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5194
開放競標，
讓無品牌藥廠來競爭成為生產藥廠，
11:21
and then the innovator would buy
the product from the cheapest supplier
the product from the cheapest supplier
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3944
接著，創新者就可以
向最便宜的供應商購買產品，
向最便宜的供應商購買產品，
11:25
and would sell it at that same
lowest possible price to patients.
lowest possible price to patients.
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5377
同時在賣給病人時
把價格壓到最低。
11:31
So the innovator would make no money
at all on selling the product,
at all on selling the product,
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4988
所以，創新者在銷售這項產品時
不會賺到任何錢，
11:36
but would make all its money
from the health impact rewards.
from the health impact rewards.
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4341
所有賺到的錢
都來自健康影響獎賞。
都來自健康影響獎賞。
11:42
Now, how do we assess the impact
of the introduction of a medicine?
of the introduction of a medicine?
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4418
那麼，我們要如何評估
一項藥物推出之後的影響？
一項藥物推出之後的影響？
11:47
Well, we assess it relative
to the preceding state of the art.
to the preceding state of the art.
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3759
我們評估的方式是
和推出前的狀態做相對的比較。
和推出前的狀態做相對的比較。
11:51
So some people,
before the medicine came along,
before the medicine came along,
220
703072
2668
所以，在推出這種藥物前，
有些人完全沒有被治療。
有些人完全沒有被治療。
11:53
had no treatment at all.
221
705764
1338
11:55
Now for the first time, they have
treatment, because it's cheap;
treatment, because it's cheap;
222
707126
3029
這是他們首次得到治療，
因為它很便宜的；大家負擔得起。
11:58
people can afford it.
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1220
所以，在這裡，影響就是
11:59
So here, the impact is the difference
between being treated
between being treated
224
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3397
被治療和沒被治療之間的差距。
12:02
and not being treated.
225
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1327
12:04
In other cases, the new product
is better than the old products,
is better than the old products,
226
716766
3670
在其他情況中，新產品比舊產品好，
12:08
and so a person gets switched over
to a better product,
to a better product,
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720460
3128
所以病人能換用較好的產品，
12:11
and we pay for the impact,
for the difference the new product makes.
for the difference the new product makes.
228
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4327
而我們支付時考量的影響，
就是新產品造成的不同。
就是新產品造成的不同。
12:16
If you have a product
on the Health Impact Fund
on the Health Impact Fund
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728748
2288
若你向健康影響基金
登記了一項產品，
登記了一項產品，
12:19
and you simply switch somebody
from an existing product
from an existing product
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2690
且你把某位病人原本使用的產品
12:21
to another product, to your product,
and it's no better,
and it's no better,
231
733774
2846
轉換為你的產品，
卻沒有比較好，那你就得不到錢。
12:24
you get no money.
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736644
1156
這種方式和既有的體制完全相反，
12:25
That's in stark contrast
to the existing system,
to the existing system,
233
737824
2932
12:28
where you get a lot of money
for switching somebody from one product
for switching somebody from one product
234
740780
3361
在既有體制下，當你讓某位病人
把原本使用的產品
把原本使用的產品
轉換為你的同性質產品時，
你會賺很多錢。
你會賺很多錢。
12:32
to an equal product that is your product.
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2762
12:35
The Health Impact Fund
does not pay for that.
does not pay for that.
236
747400
2686
健康影響基金不會付這種錢。
12:39
We quantify health impact in terms
of quality-adjusted life years.
of quality-adjusted life years.
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3636
我們把健康影響給量化成
生活品質調整生命年數。
生活品質調整生命年數。
12:43
That method has been around
for about 20 years,
for about 20 years,
238
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2459
這種方法早在二十年前就有了，
12:45
and it's very easy to explain.
239
757578
1528
要解釋它非常容易。
12:47
Just think of a human life
as a kind of plank.
as a kind of plank.
240
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2621
只要把人的壽命想成是一塊木板。
12:49
It's eighty inches long, one inch high.
241
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2731
木板大小是八十英吋長，一英吋高。
12:52
And when you die prematurely
before you reach 80,
before you reach 80,
242
764530
2472
當你在八十歲之前就早死，
12:55
well, the plank is a little shorter.
243
767026
1936
木板就比較短一點。
12:56
And if you're sick during
the time that you live,
the time that you live,
244
768986
3102
如果你在活著的時候有生病，
13:00
the plank is a little bit thinner.
245
772112
1810
木板就會薄一點。
13:02
And what diseases can nibble away,
medicines can restore,
medicines can restore,
246
774688
3700
因為疾病而一點一點被蠶食的部分，
能夠用藥物來恢復，
13:06
or medicines can avert
the taking away of these parts.
the taking away of these parts.
247
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4251
或用藥物來避免這種狀況。
13:11
And they get paid for that.
248
783203
2314
基本上，這個方法就是這樣，
針對這種情況來付錢。
13:13
That's the method, basically.
249
785541
1672
13:16
Now, we look – of course,
each year, we have to assess.
each year, we have to assess.
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當然，每年我們得要做評估檢查，
13:20
We have to spend
a considerable amount of money
a considerable amount of money
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我們得要花很大量的金錢，
檢查向健康影響基金
登記的各種藥物
登記的各種藥物
13:22
looking at how these various medicines
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13:24
that are registered
with the Health Impact Fund
with the Health Impact Fund
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在各國的狀況如何。
13:26
are doing in various countries.
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在這裡，統計就非常有用。
13:28
And here, statistics is extremely helpful.
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你們都知道「出口民調」怎麼做。
這種方法很類似。
這種方法很類似。
13:30
You all know how exit polling works.
This is a similar method.
This is a similar method.
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13:33
You look for a statistically
significant sample,
significant sample,
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先找一個在統計上顯著的樣本，
13:37
and then try to figure out
what the health impact of the medicine is
what the health impact of the medicine is
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接著試圖找出在不同的地點，
在不同特性的族群身上，
在不同特性的族群身上，
13:41
in different locations,
in different demographic groups ...
in different demographic groups ...
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這種藥物的健康影響是什麼……
13:44
And, of course, you look very carefully
at the actual world --
at the actual world --
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當然，在看真實世界時
要非常小心——
要非常小心——
13:47
this is in contrast to how medicines
are today rewarded.
are today rewarded.
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這和現今藥物
被獎賞的方式是相反的。
被獎賞的方式是相反的。
13:52
Sometimes, there is a reward
based on performance,
based on performance,
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有時，獎賞的依據是藥物的表現，
13:54
but it's the performance in clinical
trials, in the laboratory, if you like,
trials, in the laboratory, if you like,
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但卻只是在臨床試驗，
在實驗室中的表現，
在實驗室中的表現，
13:59
and not the performance in the real world.
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而不是在真實世界中的表現。
14:02
The Health Impact Fund
would look at real-world impact.
would look at real-world impact.
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健康影響基金要看的
是在真實世界中的影響。
是在真實世界中的影響。
14:06
It would look not just
at the quality of a drug,
at the quality of a drug,
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它看的不只是藥物的品質，
14:09
but also at how widely it is distributed,
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還有它被銷售到多廣的範圍，
14:13
whether the innovator manages
to target those patients
to target those patients
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創新者是否能有把能因這種藥物
受益最大的族群設為目標族群，
14:16
who can benefit the most,
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14:18
and also, how well the drug
is used in the field.
is used in the field.
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以及在實際應用中，
這種藥物被用得多好。
這種藥物被用得多好。
14:22
So innovators would have much
stronger incentives than they do now
stronger incentives than they do now
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這麼一來，創新者的動機
就會比現在更強，
就會比現在更強，
14:26
to make sure that every patient
who takes the drug
who takes the drug
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會更想確保每一位用這種藥物的病人
14:29
knows exactly how to take it
to optimal effect.
to optimal effect.
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都知道如何使用才能得到最佳效果。
14:32
Today, most packaged inserts are not even
translated into local languages,
translated into local languages,
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現今，大部分包裝上的說明
甚至未被翻譯為當地的語言，
甚至未被翻譯為當地的語言，
14:37
and so it's not surprising that patients
don't make the best use of the product.
don't make the best use of the product.
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病人沒有把產品發揮到最好，
並不讓人意外。
並不讓人意外。
14:43
Now, how would the financing work?
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那麼，融資如何運作？
14:46
Basically, the Health Impact Fund,
as I said, could start
as I said, could start
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基本上，如我先前說的，
健康影響基金可以從
比如六十億美金開始。
比如六十億美金開始。
14:49
with something like six billion dollars.
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這個數目並不小，但相對於
14:51
It's not nothing, but it's also
not a lot of money,
not a lot of money,
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已花費在藥物上的錢，
也不是太大的金額。
也不是太大的金額。
14:53
compared to what the world is already
spending on pharmaceuticals.
spending on pharmaceuticals.
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最好可以把它想像成
一種新的支付方式，
一種新的支付方式，
14:56
So the best way to think of it
is as a new way of paying
is as a new way of paying
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14:59
for what we are already paying for,
namely, new medicines.
namely, new medicines.
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針對我們已經在付錢的新藥來支付。
15:02
You pay with one hand
through the tax system,
through the tax system,
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你一手透過稅務體制來支付，
15:05
but you get something back
with the other hand,
with the other hand,
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另一手卻能拿回好處，
15:08
because you also get
these medicines for cheap.
these medicines for cheap.
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因為你也能用低價買到這些藥物。
15:10
This is not just for poor people --
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這不只是為了窮人——
人人都可以用成本價買到
15:12
everybody will have these Health Impact
Fund registered medicines at cost,
Fund registered medicines at cost,
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這些向健康影響基金登記的藥物，
15:17
at a very low price.
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價格非常低。
15:20
One very important hurdle here,
politically, is that we have to make sure
politically, is that we have to make sure
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在政治上有個非常重要的障礙，
我們得要確保能保持
對創新者的長期透明度，
對創新者的長期透明度，
15:25
that we have long-term
visibility for innovators,
visibility for innovators,
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15:29
that innovators know
that the money is actually there,
that the money is actually there,
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讓創新者知道那裡真的有錢，
15:31
and so we need governments
to fund the Health Impact Fund,
to fund the Health Impact Fund,
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所以我們需要政府
來資助健康影響基金，
來資助健康影響基金，
15:35
because only governments can make
predictable commitments
predictable commitments
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因為只有政府能做出
可預料的長期承諾。
15:38
for a long period of time.
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15:41
Because the Health Impact Fund
registration is voluntary,
registration is voluntary,
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因為健康影響基金的
登記是自願性的，
登記是自願性的，
15:46
you basically have
a self-adjusting reward rate.
a self-adjusting reward rate.
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基本上，獎賞金額比率
是會自己不斷調整的。
是會自己不斷調整的。
15:50
As the rate rises too high,
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當比率太高時，
15:54
innovators will come in
and drive the rate down.
and drive the rate down.
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會有創新者加入，造成比率下降。
15:56
Conversely, if the rate falls too low,
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相反的，如果比率太低，
15:59
innovators would be reluctant
to register, and the rate will recover.
to register, and the rate will recover.
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3740
創新者不願意登記，
比率就會再回復。
比率就會再回復。
16:03
So the rate will always be
at a reasonable level.
at a reasonable level.
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所以，比率會一直
維持在合理的水平上。
維持在合理的水平上。
16:07
The Health Impact Fund
is beneficial for all parties.
is beneficial for all parties.
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健康影響基金能讓各方都受惠。
16:11
It benefits innovators
by giving them a new market,
by giving them a new market,
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創新者能受惠，因為基金
能給他們一個新的市場，
能給他們一個新的市場，
16:15
and most importantly, by overcoming
their public relations problems
their public relations problems
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最重要的是，
一開始的公關問題也能夠被解決。
16:19
that we started with.
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16:21
It benefits patients,
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病人能受惠，
16:22
because patients are much more likely
to get the right medicine,
to get the right medicine,
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因為病人較有可能取得對的藥物，
16:26
and also for these
medicines to be developed,
medicines to be developed,
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而我們最需要的這些藥物
也會被開發出來。
16:29
the medicines that we most need.
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1799
16:31
And it also benefits governments
or taxpayers, if you like,
or taxpayers, if you like,
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3409
政府，或說納稅人，也能受惠，
16:35
because it creates a permanent source
of pharmaceutical innovation
of pharmaceutical innovation
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因為這基金能創造出
藥物創新的永久來源，
藥物創新的永久來源，
16:38
that will be here for all future times.
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將來也一直都會存在。
16:40
It's a kind of machine that always
directs pharmaceutical innovation
directs pharmaceutical innovation
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它是一種機制，
會一直將藥物創新導向
會一直將藥物創新導向
16:44
to where we have the greatest problems,
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我們最大的問題所在，
16:46
maybe for diseases
that don't even exist yet.
that don't even exist yet.
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也許是目前還不存在的疾病。
16:49
The Health Impact Fund
will always channel innovation
will always channel innovation
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健康影響基金將會一直把創新
16:52
in the direction where it's most needed.
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帶到最需要創新的地方。
16:55
Now, we have a little bit of help already.
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我們已經有了一些協助。
16:57
You can see here the number of people
who have agreed to help us,
who have agreed to help us,
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3784
在這裡列出的是已經
同意要協助我們的人，
同意要協助我們的人，
17:01
but we want your help as well.
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但我們也需要你們的協助。
17:03
We want you to join us,
maybe to talk with your government
maybe to talk with your government
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希望你們能加入我們，
也許和你們的政府談談，
也許和你們的政府談談，
17:08
to help us with publicity,
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在宣傳上協助我們，
17:09
to help us with your ideas in perfecting
the Health Impact Fund scheme.
the Health Impact Fund scheme.
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或是提供你們的點子，
讓健康影響基金的做法能更完美。
讓健康影響基金的做法能更完美。
17:14
And what we most urgently need
for the moment
for the moment
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此時我們最迫切需要的，
17:17
is to start a pilot.
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是開始一項測試計畫。
17:20
The pilot would introduce one medicine
into one jurisdiction
into one jurisdiction
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這項測試會針對一個轄區
推出一種藥物
推出一種藥物
17:24
on the Health Impact Fund model.
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2547
來試驗健康影響基金模型。
17:26
The innovator would get paid according
to the cost of the medicine for the sales,
to the cost of the medicine for the sales,
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我們會針對藥物銷售的成本
來付錢給創新者，
來付錢給創新者，
17:32
and would then get additional money
on the basis of the health impact.
on the basis of the health impact.
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此外，根據健康影響，
創新者還可以得到額外的錢。
創新者還可以得到額外的錢。
17:37
Here, we need funding for the rewards,
funding for the assessment,
funding for the assessment,
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我們需要資金來做獎賞及評估，
17:42
and in particular, we need
political support
political support
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我們還特別需要政治支持，
17:45
to get politicians to support
a pilot of that sort.
a pilot of that sort.
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讓政治人物能支持那類的測試計畫。
17:51
If you have any further questions,
don't hesitate to write us
don't hesitate to write us
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如果你們有任何進一步的問題，
請隨時寫信到這個地址跟我們聯絡。
（www.healthimpactfund.org）
（www.healthimpactfund.org）
17:56
and contact us at this address.
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17:57
Thank you very much.
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非常謝謝。
17:59
(Applause)
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（掌聲）
ABOUT THE SPEAKER
Thomas Pogge - PhilosopherPhilosopher Thomas Pogge wants to ensure medications get to those who need it most. He has published on a wide range of subjects such as global justice and human rights.
Why you should listen
Originally from Germany, Thomas Pogge received a PhD in philosophy from Harvard in 1983. Since then, he has taught philosophy, political science, and ethics at universities around the world. His 2002 book, World Poverty and Human Rights, offers proposals on how to achieve global economic equality. In 2008, he co-authored The Health Impact Fund, which lays out the plan to make life-saving medicines accessible for everyone. He is currently Leitner Professor of Philosophy and International Affairs at Yale.
Thomas Pogge | Speaker | TED.com