A colleague of mine at Harvard Medical School, a physician and Bioethics Fellow, asked a visiting president of a global pharmaceutical company: “What are the ethics of global pharmaceutical companies? They’re focused on profits, not people, especially in low-income nations.” The executive, also a physician who travels the world speaking about his firm, began to answer then stopped himself. “Frankly,” he said, “I think a lot of people who ask those questions are arrogant.” The answer was designed to stop the inquiry. The question remains crucial: What makes a good company in a low-income nation?” A good company is ethical, moral, and transparent. To be ethical is to be deliberative; to be moral is to be guided by the outcomes of that deliberation. Nobel laureate Amartya Sen says, “When we try to see how justice can be advanced, there is a basic need for public reasoning, coming from different quarters, and divergent perspectives.” The quest is not to ask, what do we feel like doing, or what can we get away with or justify; but what is the right thing to do? And we need to ask and answer that question in public. Global Pharma Pharmaceutical companies have helped extend and improve millions of lives through insulin, antibiotics, HIV treatment, cancer therapies, and vaccines. Yet this does not erase the pattern of behavior that has too often put shareholders before patients, especially poor patients. For years, major firms have used patents and trade rules to keep prices for lifesaving medicines high in low- and middle-income countries (LMICs), even when governments tried to use legal flexibilities to expand access. Behind that technical language are very concrete consequences: drugs that exist but are out of reach of the poor, government ministers threatened with trade retaliation for seeking generics, and a clear message that the poor must wait for the rich to be served first. Rich nations, even the Canadians and Danes kept their gigantic surpluses of Covid vaccines until almost expiring before providing them to Africans. At the same time, many companies route profits through tax havens, and deprive developing countries of hundreds of millions of dollars in tax revenue that could fund nurses, clinics, clean water, and medicines. NGOs Many international NGOs enjoy a reputation for selfless virtue. A few do extraordinary work, and rigorous evaluations show that well-designed programmes, such as targeted cash transfers, deworming, or education intervention can have measurable impact. But the overall aid and philanthropy system is riddled with inefficiencies. Studies of global health financing describe a landscape of overlapping projects, parallel coordination structures, and fragmented funding streams that multiply reporting burdens for fragile health ministries and make it hard to track what money is doing. In some fragile states, research finds that as the number of donors and projects proliferate, corruption risks and administrative overload grow, while the actual impact on health outcomes can stagnate or worsen. A crowded field of NGOs in Haiti knowingly drains talent from the government, takes the best housing, duplicates services in bigger cities, and leaves rural areas underserved, all the while claiming successes in glossy reports and conferences. Business solutions to poverty hide in plain sight. The problem is not that businesses are bad and NGOs are good, or vice versa. The problem is that we too often judge organizations by their eloquence and branding rather than by alignment, incentives, and outcomes. Nelson Mandela warned, “Overcoming poverty is not a task of charity; it is an act of justice. Like slavery and apartheid, poverty is not natural. It is man-made and it can be overcome and eradicated by the actions of human beings.” If poverty and institutions are both man-made, What do examples of business solutions to poverty look like? And why don’t we notice them more? The ability to keep food cold and safe with refrigeration has prevented untold deaths from food-borne illness and child malnutrition; modern vaccine programs rely on continuous cold chains from factory to remote clinic, without which doses would lose potency and campaigns would fail. Ambulances and organised emergency transport systems dramatically improve survival from trauma, obstetric emergencies, and heart attacks, often saving more life-years in a city than the most advanced specialist hospital. A newer example comes from Rwanda and other countries using fixed-wing drones to deliver blood, vaccines, and essential medicines to remote clinics. These drones can reach facilities within 30 minutes, fly up to roughly 75 miles per hour and serve hundreds of sites from a few distribution hubs. Evaluations and operational data show steep reductions in delivery times, less wastage of rare blood products, and improvements in the availability of emergency supplies at rural health centers. These are not gadgets in search of problems. They are private-sector logistics and storage solutions that turn bad roads and long distances from life-threatening barriers into healthcare solutions, convenience for patients, jobs, and tax revenue for future generations. Such innovations are especially powerful in the Global South, where the basic determinants of health: safe water, stable electricity, decent roads, and functioning supply chains are weakest. So how do we tell the difference between a good company that achieves things for society and a bad company that is rule breaking, rent seeking, and greedy? Profit is not disqualifying. Sustainable solutions usually require it. The question is: profit on whose terms and with what oversight? A good company” is more likely in Rwanda when: Ownership and power 1. A meaningful/majority share of equity is owned by people in the country: workers, local investors, pension funds, cooperatives; and when citizens or trusted local institutions hold real seats and votes on the board of directors. My friend Magatte Wade, the indefatigable Senegalese entrepreneur and author, says, “Africa is not poor because of colonialism, Africa is poor because we have made it impossible for men and women to create wealth.” 2. The firm respects workers’ rights, especially where enforcement is weak. Accountability and justice 3. The firm submits not only to international audits, but also to robust local oversight: domestic regulators, auditors, parliamentary committees, and independent media able to examine its books, safety practices, labor standards, and environmental impact. Good companies support independent oversight even when it constrains them, and they don’t seek special exemptions or monopoly protections. 4. It meets a basic test of justice by paying its taxes where value is created, instead of routing profits through offshore havens while demanding world-class infrastructure and talent from underfunded states. 5. Essential products are priced so that low-income people and public systems can use them. Inclusion and sharing 6. The firm is embedded in local clusters of related and supporting industries: developing local suppliers, training technicians, contracting local transporters so that skills, technology, and bargaining power spread through the ecosystem. 7. It shares technology, data, or intellectual property in ways that expand access and build local capacity. Rwanda’s experience demonstrates this philosophy. In speech after speech, President Paul Kagame has argued that the private sector must drive Africa’s growth, but he is clear about the terms: governments must create a fair and predictable framework in which entrepreneurs flourish commensurate with their advances and the risks they assume, and competition pushes everyone to innovate. He insists that Africa’s goal is not to remain a supplier of cheap commodities but to build productive, competitive firms that create value at home and abroad, and then get paid for that value. The thread that runs from Sen’s public reasoning to Mandela’s insistence that poverty is “an act of injustice” to Kagame’s call for accountable businesses are the decisions we make in boardrooms, ministries, and multilateral banks to treat poor people’s lives as equally worthy of medicine, shelter, nutrition, security, and shareholder value. Rwanda is achieving many of these standards with its ease of doing business reforms, anti-corruption measures, industrial parks, and performance-based contracts. The measure of a company’s greatness in Africa, the Global South, and across the Majority World should not be just the size of its market capitalisation, or the radiance of its philanthropic brand, but the number of people who travel on a paved road to a stocked clinic under a medical drone lifting off into the evening sky, and then home to a humming refrigerator. The author is a member of the President’s Advisory Council, a bioethics Fellow at Harvard Medical School, and a founder of Rwandan-owned Akagera Medicines.
