About time: gender equity in global health starts in the C-suite

Steve Davis
Mar 7, 2018 · 10 min read
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Dr. Nanthalile Mugala (center, with PATH colleagues) leads our work in Zambia. Photo: PATH/Christopher Nelson Photography

As we celebrate International Women’s Day today, the global health and international development community swells with inspiring messages of women’s empowerment, leadership, and equity. But today is also a day for acknowledging not just how far we’ve come but how far we have yet to go.

Last fall, I spoke on a panel at the inaugural Women Leaders in Global Health conference. Held at Stanford University, this conference convened to address an uncomfortable contradiction. On one hand, women’s health is the center of much of the work of global health, and women make up the majority of the global health workforce. On the other hand, leadership positions at global health organizations are overwhelmingly filled by men; and too often, the work we do fails to take the impact of gender inequality into account.

My panel, called Engaging Men to Advance Change, was the only one that included men. As the head of a large global health organization with a decent track record of promoting women to leadership positions, my role was to offer a perspective from someone who more or less “gets it.” But like every man on the planet who is honest with himself and the women he knows, I know I have a long way to go before I get to the bottom of my gender-related assumptions and biases — conscious and unconscious — and understand how they influence my actions, decisions, and even my career trajectory.

So, as far as being a man who gets it, I didn’t have all that much advice to give. Still, what I said seemed to have resonated. Afterward, a number of women encouraged me to share what I talked about at the panel more broadly. I’m also spurred by recent headlines that remind us yet again that no sector is free from gross imbalances of power drawn along gender lines.

How deeply entrenched is the gender imbalance in global health? In many countries, women account for three-quarters or more of those working in health. But 70 percent of the world’s ministers of health, 26 of the 34 members of the World Health Organization’s executive board, and 26 of the 27 health care companies included in the Fortune Global 500 are led by men. At the World Economic Forum in Davos in late January, every senior-level discussion about health care that I attended was dominated by men.

At PATH, we are striving to recognize the challenges of balancing work and family and we are piloting innovative approaches to flexible work schedules. We are also encouraging women to take on leadership roles, adopting better models for supporting women in recruiting and hiring practices, and creating more space for discussions about bias and assumptions. And while we are doing better as a result, I’ll be the first to admit that PATH still has much work to do.

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Jo Addy, a veteran corporate strategist and international economist, is a member of PATH’s board of directors. Photo: PATH/Stefan Bosch

One thing I did say was that I am fully committed to achieving gender equity— in pay, in leadership, and in power. As a longtime activist in the gay rights movement, and as someone who has spent a significant part of my career using my law degree to work to advance human and civil rights, I believe that the gender imbalance in global health is an injustice that we have a fundamental responsibility to correct.

But, I believe that as important as it is to achieve gender parity when it comes to pay and access to opportunity, something much bigger is at stake.

It’s matter of life and death

In global health, gender equity is quite literally a matter of life and death. Deep discrimination is an inherent part of everyday life for most vulnerable and poor women around the globe, and gender-based violence is common. Gender-based harassment and intimidation are routine in health systems that are run by men where the majority of patients and workers are female — the norm in most of the world. Gender-based bias and cultural assumptions about the roles of men and women even affect how research is conducted, how we treat diseases, and who receives medical care. Here in the United States, and in many countries around the world where PATH works, deeply entrenched racial bias compounds the impact of all these issues for women of color. The result is that millions of women and girls suffer and die needlessly every year.

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Coumba Dado Diouf leads a meeting in a neighbor’s home on the proper use of bednets. She is one of PATH’s community champions in the fight to eliminate malaria in Senegal. Photo: PATH/ Gabe Bienczycki

Our ultimate goal must be to look at how gender affects the entire global health agenda — how assumptions, biases, and cultural norms influence the decisions we make about what research to fund, what diseases we focus on, and how we provide health care.

Cervical cancer is an example of how the gender imbalance at the top almost certainly skews global health priorities. This is a cancer that is highly treatable if detected early enough through regular screening, and one that can be prevented with a vaccine for the human papillomavirus. But every year, half a million women die from this disease. Most of these deaths occur in low- and middle-income nations, where vaccines are lacking and screening and treatment programs are rare — rare because the people who decide where to focus global health efforts haven’t chosen to prioritize research, prevention, or treatment of cervical cancer. And rare because in many communities, one of the most common effects of systemic gender inequality is that women are relegated to the back of the line when it comes to receiving medical services.

It’s certainly reasonable to wonder if the situation would be different if more women and people of color where among the leaders at the table when decisions are made about what diseases to tackle and which to ignore. And it’s probably safe to assume that if there were more equitable representation by gender and race, we would have a global commitment to achieve a significant reduction in the incidence of cervical cancer in the world, and black women in the United States wouldn’t be more than twice as likely to die from cervical cancer than white women.

Around the world, women and girls suffer and die disproportionately for a wide range of reasons that are a direct result of gender norms. It’s a list that includes female infanticide, female genital cutting, early and forced marriage, polygamy, sexual assault and rape, HIV (the rate of infection is now higher for women than men), and even things as seemingly straightforward as being young (pregnancy is one of the leading causes of death for adolescent girls) and growing old (older women have less access to retirement benefits, health care, and social services than men).

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PATH staff and youth advocates from around the world at the 2016 Women Deliver conference. Photo: PATH

Another one is menstruation. In Nepal in early January, a 22-year-old woman named Guari Kumari Bayak died while observing a traditional practice that requires women who are menstruating to sequester themselves because they are considered impure. She died of asphyxiation caused by the small fire she lit to stay warm in the tiny hut meant for goats where she went to sleep. Dozens of women and girls have died in Nepal in recent years because of this custom, even though the Nepalese government recently outlawed the practice.

Gender bias in research hurts women in the world

The impact of our assumptions and attitudes about gender affect even the most fact-based and supposedly unbiased of human endeavors — scientific research. There’s a growing body of evidence that suggests that research led by men is assumed to be more credible than research led by women, and that men have a higher chance of being hired by universities than women. According to a study published in Nature in 2013, in most scientific fields, men earn more than women in comparable jobs and receive larger research grants. And research by two Montana State University social psychologists even found that men are biased against studies that suggest they have bias.

Not only does gender bias affect who does research and how much credit and compensation they receive, it has a significant impact on the quality of the research itself. According to a study of gender bias in medical research published in the Journal of the Royal Society of Medicine, women’s diseases tend to receive less research funding, fewer women are included in research studies, and gender-based data are often not reported, which means doctors make treatment decisions for women based on data that are only scientifically valid for men. As that study concluded, “the evidence basis of medicine may be fundamentally flawed because there is an ongoing failure of research tools to include sex difference in study design and analysis.”

How to address all this? By continually challenging our assumptions about every aspect of global health work. This means asking ourselves and each other a lot of questions. Questions such as how a given treatment, technology, or disease might affect women differently than men, or girls differently than boys. Or if culture constrains women’s choices or their ability to access and use health solutions. When it comes to research, we need to look at the role gender plays in decisions about what we choose to study, how women and girls respond to being research subjects, and who is included, who is excluded, and why.

The truth is that these questions are more likely to be asked and answered in ways that will lead to better health for everyone if there are more women serving in leadership roles and making decisions about which initiatives to fund, what research is conducted, what health care is provided, and how health care is delivered. We already know that when we focus the right amount of attention on women’s health issues, it can have a remarkable impact. Because maternal health has been at the center of the global health agenda for many years, the number of women who die in childbirth around the world has been cut in half within the past quarter century.

We won’t solve this until more women are at the table

One of the important conclusions of the Women Leaders in Global Health conference was that the quest to achieve gender parity isn’t just a matter of fairness for women who work in the industry. A commentary written by a group of conference participants that was published in The Lancet noted that “the need to diversify leadership is not only an aspiration for inclusivity but is also supported by evidence for better outcomes.”

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The Hon. Sarah Opendi, State Minister of Health for General Duties, Republic of Uganda, speaks at the Innovation Effect Africa conference last May. Photo: PATH/Stefan Bosch

We have made so much progress in the last 25 years in advancing health equity around the world through global efforts to fight infectious diseases like malaria, HIV, and tuberculosis; by improving how we care for new mothers and their babies; through new vaccines; and by improving health care delivery systems.

It is clear now that one of the most important things we can do to make even greater progress in the future is to focus on gender equity at the organizations that have helped make this progress possible. Before we can truly hope to achieve parity between women and men in health outcomes around the world, we need to achieve parity around the tables where decisions about global health priorities are made.

Even for someone who supposedly gets it, I know it’s a lot easier to talk about parity than it will be to achieve it. As a man in a system where my gender has the unfair advantages of disproportionate power, built-in networks that exclude women, and generations of implicit and explicit bias that perpetuate the habits and practices that systematically exclude women from top leadership roles, I have to start by recognizing that I am both a symptom and a cause of the gender imbalance in global health.

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Women make up the majority of the global health workforce, but a tiny minority of global health leaders. Photo: PATH

From there, I know I will have to be willing to do many things differently, including promoting more women to senior management roles. I’ll need to consider different criteria for who we hire and how we decide which health issues to prioritize. And I’ll need to devote more of my time to mentoring women and more of my organization’s resources to finding ways to help women balance work and family. Every one of my male colleagues in positions of leadership in global health must be willing to do the same.

Taking a stronger gender-oriented approach to how we prioritize research, development, and implementation of health care around the world is the single most powerful thing we can do today to improve health and well-being on a global scale. That will only happen if many more women serve in leadership positions at every kind of organization that plays a role in global health — nongovernmental organizations like PATH, ministries of health, foundations, health care delivery systems, multilateral organizations, pharmaceutical companies, and more. And that will only happen if there are fair and equal opportunities for women at every level across the global health industry.

As my brilliant colleague Katja Iversen, who is the CEO of Women Deliver, often says, “Women deliver far more than babies.” Let’s place gender equity at the center of the global health agenda and commit to real, measurable, and long overdue progress in increasing the number of women in leadership roles in our labs, clinics, executive suites, and board rooms.

Learn more about PATH and our work at www.path.org.

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