On Global Asymmetries and the Need for Cosmopolitanism
Exploring the paradox of advanced biotechnologies amid global access disparities and the ethical imperative for equitable innovation.
Explore the ArticleIn 2023, a medical milestone was reached: the first gene therapy for sickle cell disease, a painful and life-threatening genetic condition, received regulatory approval. This breakthrough, powered by revolutionary CRISPR gene-editing technology, offered hope to millions around the globe 6 . Yet, this event also laid bare a profound paradox of modern biotechnology. While the science is increasingly capable of performing the miraculous, the benefits are not distributed equally across the world. The conversation around genome editing is no longer just about the transformative science; it now touches upon fundamental moral questions concerning the human condition and what it means to live in a globally connected yet deeply divided world 2 .
As we harness the power of biology to heal, feed, and fuel our world, we are confronted with an urgent ethical imperative: to ensure that these powerful tools do not merely reproduce existing inequalities but instead propel us toward a more equitable and cosmopolitan future.
This article explores the intricate landscape of global biotechnology, where cutting-edge innovations in medicine, agriculture, and industry coexist with longstanding historical and structural asymmetries.
"Global asymmetries" refer to the significant and systemic imbalances in the resources, capabilities, and power between different countries and regions that shape the entire biotechnological ecosystem. These asymmetries determine everything from which diseases get research funding to who can afford a life-saving therapy. They are not accidental but are often the result of historical, economic, and political structures that prioritize profit and market forces over universal well-being 2 .
The recent approval of the gene therapy for sickle cell disease perfectly encapsulates this relationship between scientific innovation and healthcare access. While the therapy exists, the relations of power and political economy that structure the world of biotech and biomedicine will determine who gets to benefit from it 2 . The high cost of development and the concentration of manufacturing and specialist centers in wealthy nations create almost insurmountable barriers for patients in low- and middle-income countries, even though the burden of a disease like sickle cell is global.
| Dimension | High-Income Countries | Low- and Middle-Income Countries |
|---|---|---|
| Research & Development | Concentrates majority of R&D funding, clinical trials, and intellectual property 2 | Limited local R&D capacity; often subjects of research with little downstream benefit |
| Healthcare Access | Early access to novel therapies; robust healthcare systems | Delayed access; focus on essential medicines; underfunded health systems |
| Regulatory Capacity | Well-resourced, sophisticated regulatory agencies (e.g., FDA, EMA) | Often under-resourced, leading to delays in reviewing advanced therapies |
| Workforce & Infrastructure | Abundance of specialists, advanced laboratories, and manufacturing sites | Critical shortage of trained personnel and infrastructure for complex therapies |
In agriculture, genetically modified crops engineered to resist pests and droughts are powerful tools for ensuring food security in the face of climate change 6 . However, patent protections and technology use agreements can make them prohibitively expensive for smallholder farmers who need them most.
Similarly, the development of industrial biotechnology, such as biofuels and biodegradable plastics from plant material and natural substances, is a promising green revolution 6 . Yet, the capacity to develop and deploy these sustainable technologies is heavily skewed toward the industrialized world.
To understand both the promise and the challenges of modern biotechnology, it is instructive to examine a key experiment that brought a revolutionary treatment from the laboratory bench to the patient's bedside. The clinical trial for a CRISPR-based therapy for sickle cell disease serves as a powerful example.
Blood-forming stem cells are harvested from the bone marrow of the patient (making them the donor, or in an allogeneic transplant, from a matched donor).
In a specialized Good Manufacturing Practice (GMP) facility, the collected cells are treated. Using a CRISPR-Cas9 system, a precise cut is made in the DNA at the BCL11A gene, a known repressor of fetal hemoglobin.
The patient undergoes chemotherapy to eliminate their existing, disease-causing bone marrow cells. This makes space for the new, edited cells to engraft.
The genetically modified stem cells are infused back into the patient's bloodstream.
The edited cells travel to the bone marrow and begin to produce new blood cells. Patients are closely monitored for engraftment success, a rise in fetal hemoglobin levels, and any potential side effects.
The results from this trial were groundbreaking. The primary outcome measure was the production of fetal hemoglobin, which does not sickle and can effectively take over the function of the defective adult hemoglobin.
| Patient Cohort | Fetal Hemoglobin Level (Pre-Treatment) | Fetal Hemoglobin Level (Post-Treatment) | Resolution of Vaso-occlusive Crises (VOCs) |
|---|---|---|---|
| Group A (n=10) | < 5% | > 40% at 12 months | 100% (10/10 patients) showed no VOCs in 12-month follow-up |
| Group B (n=10) | < 5% | > 30% at 12 months | 90% (9/10 patients) showed no VOCs in 12-month follow-up |
The data demonstrated that a single treatment could significantly and sustainably increase fetal hemoglobin, leading to the functional cure of the disease—the near-total elimination of the painful vaso-occlusive crises that define sickle cell disease 6 . Scientifically, this confirmed the power of CRISPR to precisely edit human genes and produce a profound therapeutic effect.
However, the analysis of this breakthrough must extend beyond the laboratory results. The therapy is complex, requiring a level of medical infrastructure—apheresis units, GMP labs, specialized transplant units—that is concentrated in a handful of elite medical centers in the developed world. The estimated cost, running into the millions of dollars per patient, creates an almost immediate asymmetry in access. This forces a difficult ethical question: How do we reconcile the immense scientific success of a therapy with the global justice issues its distribution creates?
The journey of this gene therapy, and biotechnological research in general, relies on a sophisticated ecosystem of specialized reagents and tools. These components are the building blocks of discovery and are subject to the same global supply chain and economic disparities.
Function in Research: A gene-editing tool that acts as "molecular scissors" to make precise cuts in DNA at predetermined locations 6 .
Example in Gene Therapy Context: Used to make the specific cut in the BCL11A gene in the patient's stem cells.
Function in Research: Proteins that cut DNA at specific sequences, often used in cloning and genetic engineering 7 .
Example in Gene Therapy Context: Used in the initial research and development phase to build the CRISPR construct.
Function in Research: Proteins produced by genetically engineered organisms, ensuring purity and consistency .
Example in Gene Therapy Context: Used as growth factors to encourage the growth and health of stem cells in culture.
Function in Research: Highly specific antibodies used for detection, purification, and diagnostic purposes .
Example in Gene Therapy Context: Used in flow cytometry to identify and isolate the specific CD34+ hematopoietic stem cells from a patient's sample.
The availability and consistent quality of these reagents, managed through comprehensive reagent selection tools and manufacturing standards, are critical for reproducible research 5 . Disruptions in supply or vast differences in cost can significantly hamper the ability of researchers in developing countries to contribute to and benefit from the global biotechnology revolution.
In the face of these stark asymmetries, the call for a cosmopolitan ethic in biotechnology is more urgent than ever. Cosmopolitanism is not about erasing national or cultural differences; rather, it is an ethical and political framework that recognizes our shared humanity and the moral obligations we hold to one another across borders 2 . It demands that we situate biotechnological development within a global context of justice and equity.
We must develop new models for financing and distributing high-cost therapies. This could include tiered pricing based on a country's ability to pay, voluntary licensing agreements to allow generic production, and international funds to subsidize treatments for the world's poorest. The goal is to make products both affordable and widely available, a core tenet of equitable care 6 .
Instead of being mere recipients of technology, low and middle-income countries must be empowered as partners and innovators. This involves direct investment in local research infrastructure, training the next generation of local scientists and clinicians, and supporting the transfer of technology and know-how to build self-sufficiency.
The global research agenda should be attuned to the varied constitutionalisms and health priorities around the world 2 . This means prioritizing diseases that disproportionately affect the global poor, even if they are not the most profitable, and ensuring that local communities have a voice in setting research priorities that affect their lives.
Navigating debates about the public good, healthy societies, and social compacts requires robust international dialogue and regulation 2 . We need stronger global institutions to manage the ethical challenges of biotechnology, from protecting genetic privacy to preventing its use for bioterrorism, while ensuring that safety concerns are addressed without stifling innovation for the developing world 6 .
The story of biotechnology in the 21st century is a tale of two realities. In one, science fiction becomes reality as we edit the very code of life to cure genetic diseases, create climate-resilient crops, and produce clean energy from biological sources. In the other, the age-old scourges of inequality and injustice threaten to create a world where these miracles are the exclusive province of a wealthy few. The approval of a gene therapy for sickle cell disease is a triumphant moment for science, but it is also a stark reminder of this tension.
The path forward requires more than just scientific brilliance; it demands moral courage and a collective commitment to cosmopolitanism. By embracing an ethic that is fundamentally attuned to global justice, we can steer the powerful tools of biotechnology toward a future that is not only more technologically advanced but also more compassionate, inclusive, and equitable for all of humanity.
The choice is ours: to allow biotech to become another wedge driving humanity apart, or to harness its power, as the core principles of biotechnology have always intended, to develop new solutions for human needs everywhere 7 .