A women and health agenda: It’s time

Spring/Summer 2010 ]

by Julio Frenk, Dean, Harvard School of Public Health

In today’s global health agenda, women’s experiences—from birth to death and in all their diversity—deserve to occupy center stage.

Why? Because at the most basic level, we are talking about sheer survival. Each year, hundreds of thousands of women die in pregnancy and childbirth. The overwhelming majority of these deaths are preventable with cost-effective measures. The fact that 99 percent of maternal deaths take place in poor countries makes this the most inequitably distributed health indicator in the world.

Yet the United Nations’ Millennium Development Goal (MDG) that most directly addresses this tragedy—MDG 5—is the one that most lags in outcomes. Goal 5 calls for reducing by three-quarters from 1990 levels the maternal mortality ratio, and for universal access to reproductive and sexual health services by 2015. The MDG targets—adopted at the U.N. Millennium Summit of 2000—aim at slashing poverty, hunger, disease, maternal and child deaths, and other ills by a 2015 deadline.

In June 2010, I became chair of the Board of the Partnership for Maternal, Newborn and Child Health (PMNCH), a global alliance bringing together more than 300 members from six constituency groups: partner governments, multilateral organizations, donors and foundations, civil society, academics and researchers, and health care professionals. PMNCH is dedicated to advancing progress toward not only Goal 5, but also Goal 4 (reducing by two-thirds from 1990 levels the mortality rate among children under five).

While these U.N. objectives summarize some of the most urgent public health problems today, they are part of a larger picture. When I think about Women and Health (not just “women’s health”), I see a set of issues:

  • Maternal death and disability. Health is a fundamental human right, and in countries where children die early and mothers die in the act of giving life, injustice breeds.
  • The spectrum of sexual and reproductive health issues. These include urgent challenges such as STDs, sexual violence, and access to reproductive health services. [See story about women’s exploitation in India and other South Asian nations.]
  • All forms of disease and disability confronted by females throughout their lives.
  • Women and Health—including the roles of women in the health system, from informal providers of care to primary decision makers about health in their families to their growing ranks as health professionals. [See stories about an HSPH student and an alumna in public health who aim to make a difference.]
  • Differences between women and men in access to, and quality of, health care.

Maternal deaths

Many political leaders wrongly perceive that the problem of mother, infant, and child mortality is too difficult and expensive to solve. Women and children have historically lacked powerful advocates, and when they have voiced their needs and demands on the political stage, they have often been ignored.

When I was Mexico’s Minister of Health from 2000 to 2006, I made this issue a top priority. In the country’s “Fair Start in Life” program, the government boosted funding for health care networks, equipment, drug supplies, and safe blood; expanded the ranks of obstetric nurses and traditional birth attendants; and identified high-risk pregnancies early by covering prenatal care.

The results were compelling. Between 1990 and 1999, Mexico’s maternal mortality dropped an average of 1.8 percent per year. But since 2000, the rate of decline has nearly doubled, to 3.5 percent per year, and maternal mortality dropped from 72 deaths per 100,000 live births to 58. The country still has a long way to go, but it is now on the right track towards universal coverage.

Sexual and reproductive health

By far the most controversial action of my administration was revising Mexico’s family planning policy. The government introduced three new family planning methods in its essential drug list: the subdermal progestin implant, the female condom, and the morning-after pill. When used after unprotected or unplanned sex, or forced sex, such as a rape, the morning-after pill can prevent unwanted pregnancies.

As might be expected, these measures generated intense public debate. But according to opinion surveys, Mexico’s family planning policy was one of the most popular government measures. I draw two lessons from this debate. First, scientific evidence can bolster controversial policy decisions. Second, we should not underestimate people’s aspirations for health policies that will improve their lives.

Disease and disability

In women’s lives, disease and disability have many forms and many sources. That’s why in Mexico our focus on women and health led us to two initial priorities: reducing violence against women, and cancer.

In 2003, the first national survey on violence against women showed that one out of five women had suffered from intimate partner violence in the previous 12 months. Based on this and other studies, the government in 2006 passed a law that punishes psychological and physical violence against women, provides for the immediate arrest of the presumptive aggressor, and offers protection to the victim.

Cancer, meanwhile, increasingly strikes in developing nations. This regional increase now accounts for 46 percent of the one million new cases of breast cancer diagnosed worldwide each year, and for 55 percent of deaths. Similarly, 80 percent of cases of cervical cancer occur in developing countries, where screening is inadequate and the HPV vaccine priced out of reach for poor people. In Mexico, timely detection and treatment have been key, including more resources for early mammography and Pap smears. Also essential is confronting cultural resistance, prejudice, and stigma, especially against breast cancer patients.

Women and Health

In 2003, Mexico’s Ministry of Health established the National Center for Gender Equity and Reproductive Health to promote a gender perspective on policy, budgets, and health data collection.

We also examined the role of women as informal health providers. As chronic diseases rise, the burden of care for patients at home disproportionately falls on women. The trend has huge implications for women’s participation in the workforce and for the health of female caregivers.

At the same time, we have seen growing numbers of women enter the health workforce—in patterns that reinforce gender inequity in many countries. This plays out not just in the traditional gender divide between doctors and nurses, but in the stratification of the medical profession itself, with women (who now are a majority in most U.S. medical schools) in lower-paying areas of medicine.

Women, men, and health care

Globally, heart attacks and strokes—conventionally considered “male” problems—are the two leading killers of women. Women often show different symptoms from men, and develop heart disease later in life than men do—both of which contribute to underdiagnosis in women. AIDS is the leading cause of death among women ages 15 to 44 worldwide—nearly 60 percent of those living with HIV in sub-Saharan Africa are women.

And while women’s reproductive health is crucial, we must also pay attention to other physical and mental problems, from diabetes to depression.

HSPH’s role in Women and Health

One of my key priorities at HSPH is to fill knowledge gaps and to translate existing science into policy. The School has a distinguished history in research on maternal and child health, one upon which we plan to build.

Before she became chair of child and maternal health at HSPH in 1957, for example, Martha May Eliot was a leading pediatrician and key architect of postwar programs at the National Children’s Bureau. Isabelle Valadian, now professor emerita, helped document disease patterns in career-long research with the Longitudinal Study of Child Health and Development.

Today, Marie McCormick, the Sumner and Esther Feldberg Professor of Maternal and Child Health, investigates health outcomes of infants with neonatal complications and interventions to help them avoid lifelong disability. HSPH Professor Kenneth Hill has improved methods to measure maternal mortality in developing nations. Wafaie Fawzi, HSPH professor of nutrition and epidemiology, has conducted studies in Tanzania that have shown that strengthening health systems and bridging gaps between health facilities and the community can reduce maternal and neonatal deaths. The School also offers an Interdisciplinary Concentration on Women, Gender, and Health, coordinated by Nancy Krieger, professor of society, human development, and health, and Sofia Gruskin, director of the Program on International Health and Human Rights.

HSPH has been a vital player in the Global Task Force for Expanded Access to Cancer Control and Care in the Developing World, an ambitious initiative that includes the Harvard Global Equity Initiative, the Dana-Farber Cancer Institute, and Harvard Medical School. The task force was announced last year at an international conference, co-sponsored by the School, to develop an action and research agenda on breast cancer in developing nations.

Solving the Problem

How do we make a global Women and Health agenda a reality?

Investing in maternal, newborn, and child health strengthens a nation’s health system. If a country can provide high-quality 24-hour emergency care to women experiencing problems during delivery, it’s a sign that the nation’s health system has the right physical and human resources in place.

We have seen many successful examples. Sri Lanka reduced its maternal mortality rates over the last 60 years by offering free and expanded medical services in underserved areas. Thailand has reduced both child and mother mortality rates, in part because 97 percent of births are now attended by skilled professionals.

On the worldwide stage, the International Health Partnership (IHP)—a coalition of health agencies, governments, and donors—announced a $5.3 billion package to give 10 million more women and children free health care access.

In 2009, the Obama Administration launched a $63 billion Global Health Initiative (GHI) with an explicitly “woman- and girl-centered approach.” Melanne Verveer, the new U.S. Ambassador-at-Large for Global Women’s Issues, will mobilize support for women’s and girls’ access to health care and education, and for combating violence against women and girls.

And last November, the WHO report “Women and health: today’s evidence, tomorrow’s agenda” concluded that societies are failing to meet the health care needs of women at key moments in their lives, in areas ranging from reproduction and caregiving to mental health problems and sexual violence.

Health is a window through which to understand the most pressing challenges in today’s world. Healthier women mean stronger societies. Healthier children mean surviving societies. And an investment in women’s and children’s health is an investment in the social and economic development of our societies. A Women and Health agenda will guide us to where we need to put our energy, resources, and commitment.

Photo by Kent Dayton