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Access to healthand financial burdens to individuals, families andcommunities, and in some cases they accentuatemarginalization because the diseases and their consequencesare highly stigmatized.Leprosy and tuberculosis are among the most stigmatized,and individuals known to be infected are often excluded fromparticipating in social, economic and family life. Butdermatitis and blindness from onchocerciasis andlymphoedema from filariasis both also result inmarginalization, particularly for women with obvious diseasewho may lose family support and be subject to personalviolence. The psychosocial impact of such conditions maylead to reluctance to present for care, although in addition,affected individuals often lack the financial and otherresources to seek treatment.While there has been extensive research on HIV, includingin low- and middle-income countries, limited attention hasbeen paid to marginalization and discrimination againstpeople known to be infected, and the health implications ofthis. While in many countries legislation provides formalprotection of their rights, People Living With HIV/AIDS(PLWHA) often face direct and structural discrimination intheir daily lives and are severely socioeconomicallydisadvantaged. This in part is because HIV is typicallyassociated with high-risk, marginalized activities – illicit druguse and sex work. Often people in these categories arediscriminated against for other reasons associated withgender, class, caste, poverty and ethnicity. Differentialtreatment by health staff exacerbates marginality and resultsin poorer overall health for PLWHA. For example, women whoconceive often receive inadequate or no prenatal care and donot disclose their HIV status at delivery; disrespectful anddiscriminatory treatment at health care facilities is a primarybarrier to disclosure and care.Individuals with physical and intellectual impairments areeverywhere poorer, marginalized and disabled by theircommunities. Social attitudes shape access to care, quality ofcare, risk factors of complications and co-morbidity. Access tocare is often inhibited because of inappropriatecommunication and discriminatory attitudes, systems andenvironments. Although disabled people have receivedrelatively little attention by public health services or themedical and health research community, there is growingevidence of their increased vulnerability, including to HIVinfection and targeted physical, psychological and sexualviolence and exploitation. Disabled people are less likely thanable-bodied peers to be included in health educationprogrammes, and information may be inaccessible dependingon the nature and severity of their impairments. Moregenerally, there is a lack of information about health andhealth services in accessible forms for disabled people, thereis little accessible information about rights, and poor physicalaccess to services, buildings and transport.Health status, life chances and life outcomes of individualsare all influenced by such social inequalities andmarginalization. Other people from marginalized groups –people who are homeless, misuse alcohol and illicit drugs, orare sex workers, for example – routinely experienceOther people from marginalized groups – people whoare homeless, misuse alcohol and illicit drugs, or aresex workers, for example – routinely experiencediscrimination, and again have poor access to healthservices, receive poorer quality care when they dopresent, and are at higher risk of infectious diseasediscrimination, and again have poor access to healthservices, receive poorer quality care when they do present,and are at higher risk of infectious disease. Increasingly too,structural violence is punctuated with direct violence – sexualviolence, civil war, terror, and the long-term effects of war.This produces further violence and other adverse healthoutcomes, including increased gender-based violence as aresult of war, permanent injuries from bombs and landmines,and the sustained psychological and emotional toll of violentdisruption to civil society. In addition, damage toinfrastructure and the breakdown of basic services results inan increase in communicable disease, leading to furtherpoverty and inequality.One area addressed by the Global Forum for HealthResearch, where social marginalization has affected health, isin relation to sexual violence. Gender-based violence,including sexual violence, is pervasive, with short- and longtermnegative effects on women’s physical and mental health.Such effects include reproductive health problems, chronicillness, post-traumatic stress disorder, anxiety anddepression. Women subject to domestic violence and sexualviolence within and beyond the home are marginalizedbecause of assumptions about their role in provoking theabuse. They often lack access to counselling centres andshelters that could provide short-term protection and ongoingsupport. Little has been done to address the perpetration ofviolence and the deeply entrenched and systemic genderbiases that excuse – and even legitimize – men’s violent andabusive behaviour. Sexual violence in particular had receivedinsufficient attention from researchers, clinical practitionersand policy-makers, and for a long time was ignored as ahuman rights and health issue. The Sexual Violence ResearchInitiative (SVRI) of the Forum was launched to supportresearch and advocacy in this area in a variety of settings.The concept of the “10/90 gap” acknowledgesthe inequalities in scientific research that exist betweencountries and the health conditions that affect differentpopulations. But in addition, far less research is conductedabout people who are socially marginalized than about thosewith higher social status: people with physical impairmentsattract less research attention than those without impairmentsbut with curable conditions; people labelled as havingintellectual impairments receive less attention than thosewith common physical impairments; the elderly less thanyoung adults, and so on. Even less research is done withpeople who are socially marginalized. Rarely are theirperspectives, insights and knowledge, and activeparticipation considered when defining the research060 ✜ Global Forum Update on Research for Health Volume 4
Access to healthquestions, developing the research agenda or setting in placeresearch governance structures.Such marginalization in research agendas contributesfurther to the “10/90 gap”. Redressing the “10/90 gap”involves developing partnerships among marginalcommunities and researchers, building the research capacityof these communities, and a commitment to a new researchethic that implicitly demands the full and active engagementof these communities in any and all research that pertains tothem. Ethical and Human rights principles require fairnessand equality not only in access to medical services, but indefining the questions and shaping the information to developmedical and health policy and programmes. Activeinvolvement in research is a critical step to remove inequalityand marginality, and to improve the health of all people. ❏Lenore Manderson is a research professor in the School ofPsychology, Psychiatry and Psychological Medicine at MonashUniversity, Melbourne, Australia and is renowned for her work as amedical anthropologist and social historian, and in sociology andpublic health. Doctor Manderson was awarded an inauguralAustralia Research Council Federation Fellowship, and inassociation with this has been conducting research in Australia andSouth-East Asia on chronic illness, disability, social relationshipsand well-being. She has worked extensively to strengtheninstitution capability and develop research capacity in the socialsciences and health, including with the Special Programme forResearch and Training in Tropical Diseases (TDR). She is a Fellowof the Academy of Social Sciences in Australia and the WorldAcademy of Art and Science.Global Forum Update on Research for Health Volume 4 ✜ 061
Page 3 and 4: Editorial Advisory Board:Luis Gabri
Page 5 and 6: Contents096 Child immunization: acc
Page 7 and 8: IntroductionResearch contributions
Page 9 and 10: IntroductionType IType IIType IIIPr
Page 11 and 12: Introductionmaking), takes account
Page 13: Access to healthStrengthening healt
Page 16 and 17: Access to healthTraining more healt
Page 18 and 19: Access to healthimperative for acti
Page 20 and 21: Access to healthReferences1.Further
Page 22 and 23: Access to healthDeterminantsAvailab
Page 24 and 25: Access to healthThe authors are inv
Page 26 and 27: Access to healthCombining health an
Page 28 and 29: Access to health100%Availability of
Page 30 and 31: Access to healthhypothesis that an
Page 32 and 33: Access to healthMandatory clinical
Page 34 and 35: Access to healthWhile there are som
Page 36 and 37: Access to healthItemDefinition/Expl
Page 38 and 39: Access to healthReferences continue
Page 40 and 41: Access to healthintegrating individ
Page 42 and 43: Access to healthA social determinan
Page 44 and 45: Access to healthemployment conditio
Page 46 and 47: Access to healthMaking human rights
Page 48 and 49: Access to healthResources outsideth
Page 50 and 51: Access to healthReferences1.McCoy D
Page 54 and 55: Access to healthDiscrimination as a
Page 56 and 57: Access to health“Two months ago I
Page 60 and 61: Access to healthsocio-cultural and
Page 62 and 63: Access to healthIntergovernmental P
Page 64 and 65: Access to healthand conference stat
Page 68 and 69: InnovationTowards the development o
Page 70 and 71: InnovationMajor classificationMajor
Page 72 and 73: Innovation60% of enterprises5040302
Page 74 and 75: InnovationUsing the power ofintelle
Page 76 and 77: Innovationbe adapted - and harnesse
Page 78 and 79: InnovationFinancing of vaccine R&D-
Page 80 and 81: InnovationFinancing Ultimate Interm
Page 82 and 83: Innovationsome of this risk might b
Page 84 and 85: InnovationChild immunization:accele
Page 86 and 87: Innovationare revealing previously
Page 88 and 89: InnovationDeveloping countries % De
Page 90 and 91: Innovationcapacities. It is indeed
Page 92 and 93: InnovationSome plausible causes of
Page 94 and 95: Innovationwhere he was a programme
Page 96 and 97: Research resourcesResearch impact o
Page 98 and 99: Research resourcesBiotechnologists6
Page 100 and 101: Research resources1,61001,41,219080
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Research resourcesReferences1.The R
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Research resources✜ A group of nu
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Research resourcesReferences1.Inter
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Research resourcesThe threat of pan
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Research resourcesChanging environm
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Research resourcesPartnerships offe
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Research resourcesWe encourage othe
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Research resources181614No. of PPPs
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Research resources12010080604020Pro
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Research resourcesCapacity strength
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Research resourcestreatment is prov
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Research resourcesSmall scale busin
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Research resourcesthis process in a
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Research resourcesways. For instanc
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Decision-making148 Delivering evide
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Decision-makingChallenges in employ
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Decision-makingUsing evidence forpo
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Decision-makingdesire to publish. T
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Decision-makingsystems development.
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Decision-makingTowards evidence-inf
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Decision-making✜ develop a critic
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Decision-makingwas prior to 2001, a
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Decision-makingGlobal and regional
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Decision-makingHigh-incomeChildrenE
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Decision-makingLow- and middle-inco
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Decision-makingLow- and middle-inco
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Decision-makingthan a quarter of th
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Decision-makingThe potentials of in
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Decision-makingGenerally, any resea
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Decision-makingReferences1.Hawes H.
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