EDITORIALS

Gender and the 10/90 gap in health research

Lesley Doyal

Professor of Health and Social Care, University of Bristol, Bristol, England (email: l.doyal@bristol.ac.uk); and Gender Adviser to the Global Forum for Health Research, Geneva, Switzerland

Currently, less than 10% of current global funding for research is spent on diseases that afflict more than 90% of the population. This is referred to as the 10/90 gap in health research, and efforts to close it are mounting as part of the wider equity agenda in health.^a Increasingly it is being recognized that gender issues must be central to these efforts,^b since women comprise the majority of the world's poor. The health of these women is affected not just by their poverty and by failures to meet many of their sex-related (i.e. biological) and reproductive health needs, but also by the wider gender (i.e. social) inequalities that continue to shape their lives. Men's health can also be negatively affected by their masculinity, with the poorest often at the greatest risk. Health researchers will need to take these factors just as seriously as more widely accepted determinants of health such as race, class, and ethnicity.

There are marked differences in the patterns of health and illness experienced by women and men, the most obvious stemming from their biological differences. Some relate directly to the male or female reproductive systems, with women being at particular risk in this respect. However, there are also broader genetic, hormonal and metabolic differences between the sexes (1), with men being more susceptible to many infectious diseases and women more likely to develop auto-immune problems.

The socially constructed variations in the daily lives of women and men also have a major effect on their health (2). Gender differences in living and working conditions and in the nature of male and female roles mean that men and women exhibit different risks of developing some health problems. Gender inequalities in access to a range of resources also have a major impact on health.

Women are more likely to experience problems resulting from domestic work (3) and are at greater risk of depression (4). Their household duties may also expose them to greater risk of some infectious diseases (5). Gender-based violence is an additional health burden borne by women, especially in situations of political conflict and instability (6). In contrast, men are more likely to die prematurely from work-related injuries, smoking-related diseases, male-on-male violence, and road traffic injuries (2).

Gender also influences the access of individuals to health services. In many parts of the world, women have less entitlement than men to food and medical care and usually have fewer financial resources to pay for treatment — a situation that has been exacerbated by health sector reform (7). Men's access to health care may, however, be compromised by their reluctance to admit weakness (1, 8). Even when barriers to access have been overcome, women and men may receive treatment of different quality, with many women (particularly the poorest) reporting the lack of respect they experience from health workers.

Greater sensitivity needs to be paid to sex and gender issues in all areas of health research (9). Failure to recognize this will lead to bad science and avoidable mortality, morbidity, and disability. Lost opportunities of this kind are clearly unacceptable, especially in the context of the 10/90 gap.

If real gains are to be achieved, policies are needed to build the capacity for sex- and gender-sensitive research, particularly in countries where medical research is still in its early stages. The links between sex and gender need to be identified and their relationship with the wider determinants of health clarified. This will require closer working between biomedical and social scientists, especially in developing countries.

Finally it is important that strategies be devised to ensure that women are able to play a more active role in health research. Policies to build research capacity in countries where it is weakest should include strategies to tackle the obstacles that currently prevent women from entering medical research on equal terms with men. More work is also needed to enable women to become actively involved in determining research priorities, designing and implementing studies, and in wider debates about their implications for gender equity.

1. Wizemann T, Pardue M. Exploring the biological contribution to human health: does sex matter? Washington (DC): National Academy Press; 2001.

2. Doyal L. Sex, gender and health: the need for a new approach BMJ, 2001;323:1060-3.

3. Sims J, Butter M. Health and environment: moving beyond conventional paradigms. In Sen G, George A, stlin P, editors. Engendering international health: the challenge of equity. Cambridge (MA): MIT Press; 2002.

4. Patel V, Abas M, Broadhead J, Todd C, Reeler A. Depression in developing countries: lessons from Zimbabwe BMJ, 2001;32:482-4.

5. Hartigan P, Price J, Tolhurst R. Communicable diseases: outstanding commitments to gender and poverty. In Sen G, George A, stlin P. Engendering international health: the challenge of equity. Cambridge (MA): MIT Press; 2002.

6. Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet, 2002;359:1232-7.

7. Standing H. Frameworks for understanding health sector reform. In: Sen G, George A, stlin P. Engendering international health: the challenge of equity. Cambridge (MA): MIT Press; 2002.

8. Cameron C, Bernardes D. Gender and disadvantage in health: men's health for a change. Sociology of Health and Illness, 1998;18:673-93.

9. Doyal L. Sex and gender: the challenges for epidemiologists. International Journal of Health Services, 2003:33;569-79.

a Work in this field is being done by WHO, Global Forum for Health Research (GFHR) among others.
b The Global Forum for Health Research, for example, has recently embarked on a policy of gender mainstreaming in all its areas of work (see www.globalforumhealth.org), while WHO has developed a number of important resources reviewing the links between gender, health and poverty (see http://www.who.int/gender/en/).