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The 10/90 Gap, Global Health Inequities, and Social Justice

Keywords: 10/90 gap, disease burden, global justice

The expression “10/90 gap” (or 90/10) was coined by the Commission on Health Research for Development in a landmark report published in 1990.  The Commission, as most readers of The First probably know, was an international private initiative aimed at the improvement of health in the then called “developing countries”.  Its work was funded by important international institutions, both public and private, such as the United Nations Development Program, the Word Bank, the Nobel Assembly, and the Rockefeller and Ford foundations, among many others for a total of 16 sponsors.  The expression “10/90 gap” refers to the mismatch between disease burden and the financial resources devoted to health research.  In other words, only 10% of health research funding is devoted to the study and relief of the disease burden of 90% of the world population.  Unfortunately, but not surprisingly, the undeserved populations, most of them living in low- and middle-income countries, are the ones neglected by such unequal distribution of research dollars.

Of course, many things have changed since 1990.  More resources are devoted to research today, and more research (particularly clinical trials) is being carried out in low-and-middle- income nations.  It must be added, however, that an increase in the number of clinical trials taking place in a region does not necessarily translate into a greater focus on its health needs.   As a matter of fact, the growth of clinical research in impoverished regions has raised concerns about the danger of exploitation of vulnerable persons and communities.  This topic has received much attention in journal articles and books in the bioethical literature.  We cannot dwell on this important debate in this brief essay, but its relevance must be acknowledged. 

As D. P. O’Mathúna (2008) points out, it is possible that the proportion 10/90 is, at the present time, an overstatement.  Other authors think that the problem is not one of lack of research.  They argue that there are enough drugs to treat most of the diseases affecting the poor: “The issue… is not the unavailability of medicines in the world market.  The problem… is that the poor are unable to access the medicines largely because of poverty, inadequate health infrastructure, and overbearing governments” (Vidyasagar, 2006).

Let us suppose, at least for the sake of argument, that both caveats are well taken.  Does that mean that the fundamental ethical problem of global health inequities goes away?  I do not think so.  In my view, there are several issues that need to be considered for a proper understanding of the problem that lies behind the idea of the 10/90 gap in health research.  Each one of the considerations that follows would need, of course, further elaboration.  In this context, a succinct enumeration of the issues must suffice.

First, I think that it must be admitted that the selection of research topics is largely determined by the availability of funding.  We cannot forget that, for the most part, clinical research is funded by the pharmaceutical industry: “The current global health R&D system relies strongly on market incentives.  About 60% of all health R&D funding comes from the for-profit private sector… When market incentives drive innovation, R&D that is profitable will be preferred… (Viergever, 2013).”  The profit motive works very well in certain areas.  It is, however, inadequate to respond to basic human needs, particularly in the case of impoverished individuals and populations.  In the area of health, it might even stifle innovations as the increased production of me-too drugs would seem to suggest.

Second, let us suppose that the problem is neither the lack of research nor the dearth of therapeutic interventions to serve the needs of underserved populations.  Therefore, it would be a problem of access and distribution.  If such were the case, the ethical problem does not go away.  On the contrary, it can be argued that the ethical problem is magnified.  Vulnerable persons and communities, including children, are suffering and dying of preventable and treatable diseases.  The populations in need do not have access to existing and frequently inexpensive therapeutic interventions, which are readily available to the citizens of more affluent societies and to the well off in developing countries.  If this were the case, the ethical challenge presented by the idea of the 10/90 gap has not gone away.  It has been shifted from the field of basic and clinical research to the area of public health. 

Third, it must be added that health research and issues of justice in health are not limited to basic and clinical research.  Human health is not determined only, not even mainly, by access to physicians, medications, and health-care facilities.  There are social determinants of health.  Access to education, adequate nutrition, clean water, and clean air are just as significant, if not more so. 

Fourth, there is a need to develop research capacity in impoverished regions, including the training of competent scientists, access to updated scientific literature, and the development of research ethics capacity.  Ethical reflection is highly contextual (without denying some universal values).  We cannot take for granted that an ethical reflection produced in the context of affluent societies and first world universities adequately responds to the needs of developing nations. 

Finally, it is possible that the 10/90 gap does not have to be taken literally in a strictly statistical sense.  But there is no doubt that, whether the problem is one of insufficient research or one of distribution and access, it expresses in very dramatic terms the very real problem of world health disparities. From an ethical viewpoint, we are dealing, in my view, with an extremely serious issue of global justice.  The idea of global justice faces serious theoretical challenges from the perspective of traditional western political philosophy.  Traditionally, theories of justice, from Plato to Rawls, have been political theories, linked to a theory of the State.  However, in a globalized world, we need to accept that strict duties of justice exist beyond the structure of the national State.  The growing recognition of human rights, as well as the increased development of international law and courts seem to point in that direction. 

Claims of global fairness and justice find an even stronger foundation for those of us who think and try to live within the context of the Christian tradition.  Universal brotherhood and sisterhood, based on both creation and redemption, require, at the very least, a commitment to global justice in the field of human health and health related research.  I hope that Catholic theological ethicists can engage in this debate enriching it with the insights proper to our tradition.  In his message to the participants in the 32nd International Conference on Addressing Global Health Inequities, on November 2017, Pope Francis quoted number 92 of the New Charter for Healthcare Workers.  The protection of intellectual property and a fair profit to support innovation are legitimate interests that cannot be denied.  However, “ways must be found to combine these adequately with the right to access to basic or necessary treatments, or both, especially in underdeveloped countries, and especially in the cases of so-called rare and neglected diseases, which are accompanied by the notion of orphan drugs.”


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Id., Research as a Restorative Practice: Catholic Social Teaching and the Ethics of Biomedical Research, in Lysaught M. T. & McCarthy M. (Eds.), Catholic Bioethics and Social Justice, Collegeville, Liturgical Press Academic, 2018, 363-375.

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Mandle J., Global Justice, Malden MA, Polity Press, 2006.

O’ Mathúna D. P., On Global Health Research Inequalities, paper presented at the Global Justice & Human Rights PSA Specialist Group, April 1-3, 2008:, retrieved: January 18, 2019.

Petryna A., When experiments travel. Clinical Trials and the Global Search for Human Subjects, Princeton, Princeton University Press, 2011.

Pope Francis, Message to the Participants on the 32nd International Conference on the Theme: “Addressing Global Health Inequalities (16-18 November, 2017):, retrieved: January 21, 2019

Vidyasagar D., Global Notes: The 10/90 Gap Disparities in Global Health Research: Journal of Perinatology 26 (2006) 55-56.

Viergever R. F., The mismatch between the health research and development (R&D) that is needed and the R&D that is undertaken: an overview of the problem, the causes, and solutions: Global Health Action 6 (2013):, retrieved from, retrieved: January 18, 2019.