For the present system to work, poor people must be excluded from the innovation, because if they could get access at an affordable price, then affluent people would find ways to buy it cheaply as well - and then the innovator would be poorly rewarded and introductions of new medicines would decline.

Dictatorial regimes often manage to keep themselves in power because they are recognized by foreigners as representing the state and its people, and therefore as entitled to sell the country's natural resources and to borrow money in its people's name. These privileges conferred by foreigners keep autocrats in power despite the fact that they were not elected and do not rule in the interest of the population.

Income inequality matters more on a day-to-day basis. Wealth matters more for political influence.

You may know that in India now the Tata car is becoming all the rage; you can buy it for one lakh - $2000 dollars - it's very, very cheap. So India seems to be going the route that China went a few years ago and that developing countries all over the world seem to want to follow, namely, to rely on these personal vehicles, which is just an irrational way of organizing transport.

In the domain of pharmaceuticals, we need a metric for health impact, and with this metric we can then assess the value of the introduction of a new product and pay its innovator accordingly, say on the basis of the product's measured health impact during its first ten years on the market. In exchange, innovators must of course renounce the usual rewards they are otherwise entitled to, namely the patent-protected markup on the price of their product.

If you ask yourself who is paying for pharmaceutical innovation today, the answer is that it's the more affluent populations paying for still-patented advanced medicines at the pharmacy, for comprehensive insurance coverage or for a national health system.

Each powerful player, or coalition of players, will make concessions in areas where it has relatively less at stake in exchange for other such players making reciprocal concessions in other areas where it has relatively more at stake. Such trades are collectively rational insofar as they get each of the powerful players more of what it wants. But such trades are also dangerous because the whole international rule-system will become incoherent and therefore vulnerable to crises that will continue to become increasingly severe.