The Commission on Health Research for Development based at Harvard University demonstrated in a landmark 1990 study that less than 10 percent of the world’s resources for health research were being devoted to 90 percent of the world’s health problems. This disparity has since become known as the “10/90 Gap.” The 1990s saw considerable efforts to address this significant mismatch between funds for research and the significant burden of disease in developing countries. Some of the advances included a threefold increase in global resources for health research put forward by institutions in both the private sector and the public sector, such as the National Institutes of Health (NIH), and from large philanthropic foundations like the Bill and Melinda Gates Foundation, the Wellcome Trust, and the Rockefeller Foundation. Equally important was the establishment of networks to lobby for increased support, such as the Global Forum for Health Research, as well as the establishment of more public-private partnerships to implement programs and develop new drugs, vaccines, and diagnostics for diseases of importance in developing countries.

To further address the research disparity, the Global Forum for Health Research recently brought together international researchers, donors, ministers of health, nongovernmental organizations (NGOs), and many others to update efforts in health research. The parties were especially concerned with meeting three of the eight UN Millennium Development Goals that address major health issues: child mortality, maternal health, and infectious diseases such as HIV/AIDS and malaria. Though there has been much progress in health research in developing countries since the initial report, the 10/90 Gap still exists. In fact, research on many of the conditions noted above remains significantly under-funded.

The Imperative of Research

Why should the world be concerned with this disparity in health research funding? What is wrong with counting on researchers from the West to do appropriate research, some of which can be carried out in the developing country, but some also from the safety of a laboratory in Cambridge, Massachusetts? After all, research institutions in developing countries are often poorly staffed and equipment is usually outdated and/or poorly maintained. In fact, why are developing countries unable to simply utilize the information generated in the developed world? In the end, information will gradually be disseminated. All people will eventually have the same problems, so is it not just a matter of time?

There are many responses to these questions. The days when a country could erect a cordon sanitairé around itself are long over. We are part of a global ecosystem in which human disease is but one factor. Every country has been affected by the global AIDS pandemic. The avian flu epidemic has the potential to threaten us all. The millions of deaths that might occur from this or any other global flu epidemic—well over 25 million died in the 1918 global epidemic—will be rapidly distributed throughout the world. Poor health and disease clearly contribute to instability within societies. The degree and speed of development is directly related to the health of society. In East Asia, good health preceded development. Societies burdened by HIV/AIDS, malaria, or similar conditions have a difficult time escaping the cycle of poverty. If global markets are to be opened, societies must develop economically, and that must begin with issues of health.

Then there are the lessons that we can learn from each other. Information not only flows from North to South, but from South to North. Examples include the development of Oral Rehydration Therapy (ORT), new anti-malarials, and new and improved strategies for delivering treatments for tuberculosis and AIDS. We have also learned that use of paraprofessionals may lead to better health care and is more efficient. Few, if any, of these innovations would likely have come from research institutions based in the North. It has thus become clear that science should be taken to where the problem lies. And this science must be adapted to the realities of work in resource-poor environments.

Because of severe resource constraints, developing countries should, wherever possible, use “evidence-based” rather than “faith-based” decision making. The term “faith-based” means we simply need to believe in an idea to make it correct. Because of economic dependency, many developing countries are often pressured to carry out public health programs that may be guided more by political ideology or religious beliefs than by evidence and science. They should instead be able to gather their own evidence on what works and what does not. This is all the more critical for a developing world that has only three scientists per 10,000 people, compared to the developed world’s three per 1,000 ratio.

In addition to the disparity in resource allocation, research capacity in developing countries, where well-trained and competent scientists are few, must be improved. Without the development of research capacity, the quality of equipment will marginally improve, proper facilities will not be built, and local governments will not give adequate support to their own scientists, who will continue to have difficulties accessing local and global research funds. Research is not an option; it is a necessity.

Developing the South

What, then, should be the strategic approaches to promoting health research capacity in developing countries? There are many strategies and goals to be pursued, none of which are sufficient alone.

The global health research agenda must be developed by scientists from both the North and the South. Too often, the research agenda of developing countries is set by others outside the country. The golden rule of development—“He who has the gold makes the rules”—usually applies. This is particularly true of health services research wherein local scientists may wish to address questions that seem unimportant to outside donors. These scientists may want to conduct a study similar to one already done elsewhere, a study that is nonetheless essential because it will convince their own medical establishment of the importance of the work. Many countries carried out studies on ORT that added little to the international literature but helped to convince their own pediatricians of the importance of this intervention to treat diarrhea.

Developed countries should commit themselves to training scientists in research methodology appropriate to the countries in which they are working. Learning techniques that cannot be applied in one’s country of origin simply frustrates local scientists and hastens their departure to the country in which they were trained.