Women’s Health — Holistic Approach to Address Persisting Gaps
(Women’s Health is such a huge topic and this is one of many in this series. Every time I dive into the topic of Women’s Health, I get to share and learn.)
“I’m interested in women’s health because I’m a woman. I’d be a darn fool not to be on my own side.” — Maya Angelou
As a woman physician, from a family with a strong matriarch (my close to 90-year old grandmother), daughter of a beloved mother, a mother of 2 beautiful girls, sibling of 2 amazing women, and someone who enjoys multiple supportive sisters circles and friendships, it is no surprise that Women’s Health is not only of deep professional interest or an academic exercise but also a very personal topic to me. Personal experiences, observations from family, friends and communities globally, medical practice and a recent online crowdsourcing, continue to inspire my commitment to not be a by-stander to numerous persisting gaps in women’s health.
💡Did you know — The female clitoris is not a nub and 90 percent of its bulk lies beneath the surface like an iceberg, aptly described by Australian urologist Helen O’Connell in 2005. Imagine how much more we still don’t know about women bodies.
Medical school exposed me to knowledge beyond common public information, since I left General Medical Practice, I expanded that knowledge about the origins, gaps and progress in the areas of women’s health through continuous interest and learning. You have the right and power to be informed about your health, health of your daughters (Shoutout to Girl Dads and Moms!) and of other women in your life. By being a vocal advocate, you can play a crucial role in improving women’s health as there is a significant opportunity on the other side of these gaps to bring about positive changes.
Definitions
Women: Women in this article is used to describe individuals that identify as women or will grow into women. individuals such as transgender and gender-fluid may have other health needs not covered by the general views shared.
Health: In the WHO Constitution (1948), health is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.
Women’s Health: With the above understanding, Women’s health is not just the absence of diseases in women but include physical, mental, social, and spiritual wellness. Like the definition of health in the Ottawa Charter of 1968, women’s health is also created in the context of everyday life and environment, where they live, love, work, and play.
Women account for about half the population of the world and in some societies like the United States, outnumber men slightly. So, it is unacceptable that we continue to be minoritized and underserved. While women live longer on average than men, they face a lower quality of life (less health-span) for a larger proportion of their lifespan. For a gender that utilizes the health system more for self and family, it is a perplexing paradox that our healthcare is largely modeled after research conducted mostly in men and the treatment we receive subpar.
“An ER doc said to us, “Women’s heart attack symptoms are atypical.” Atypical? Does that mean only men are typical?” Ingrid Embree, Managing Director at GlobalGiving
Going beyond the human and moral case for closing health gaps for women, in a recent report titled “Closing the Women’s Health Gap: A $1 Trillion Opportunity to Improve Lives and Economies” by McKinsey and WEF in January 2024, an economic case was also made. The report describes the benefits of narrowing the gap would include allowing 3.9 billion women to live healthier, higher-quality lives, extending economic productivity by at least $1 trillion per year.
A Brief Historical Context
The gaps in medical knowledge in women’s health, women’s experience in healthcare, quality of life, investment in women’s health research and technologies have deep roots in history and culture.
In the man-made world, women’s bodies and minds have been the primary battleground of gender oppression. To dismantle this painful legacy in medical knowledge and practice, we must first understand where we are and how we got here. — Elinor Cleghorn, author of Unwell Women
In the 3rd century BCE, Aristotle described the female body as the inverse of the male body, with its genitalia “turned outside in.” The primary function of a woman was tied to her capability and duty in reproduction. In the US (as in many other countries), the biased concept of male dominance and societal perception of women not only affects education, work, property ownership, vote etc., it also affects medical education and healthcare. This is why the Women’s Right Movement is connected with the Women’s Health Movement. It wasn’t until 1989 and 1993 that participation of women in clinical research was made an NIH policy and US federal law respectively.
Historically many men, and frankly some women, have acted as gatekeepers of women’s health and restrained women from being active participants in their health decisions. A speculative dystopian view of this is portrayed in the movie Handmaid’s Tale. It is encouraging to observe recently that some of the greatest researchers and advocates for women’s health actively working to close these gaps, are men.
Persisting Gaps in Women’s Health and Opportunities
Women’s health covers conditions that are sex-specific and conditions that affect women differently or disproportionately. It is inclusive of sexual and reproductive health (sometimes termed ‘bikini health’). Despite progress, there are several gaps in women’s health that can be framed in multiple ways. Good news is that these gaps present opportunities to do better, and the best time to address them is now.
Voice of Women: Women know their bodies and experiences in ways medical professionals and researchers don’t. Many discussions about women’s health tend to be in the form of academic, policy and technology roundtables and symposia of experts, leaving out people living with the unmet needs. Including the voices of diverse women ensures that research is planned and technology is developed holistically in the field, avoiding blindspots, especially those magnified by other determinants of health. Patient or community-led research in women’s health could also be explored.
Research, Scientific and Medical Knowledge: Women are frustrated by many symptoms and conditions that clinicians say do not have clear causes, correlations, clinical guidelines or interventions. The basic science research to understand the underlying biology for many physiology and pathology in women bodies continues to be a gap in addition to conducting multidisciplinary research and disaggregation of clinical conditions by sex. These results in missed diagnosis, delayed diagnosis, misdiagnosis, under-treatment, ineffective and harmful treatment.
“… I’m still flabbergasted (as a survivor of preeclampsia) that the medical community does not understand the cause and uses such manual and “watch and wait” approaches to such a prevalent and dangerous medical condition in pregnancy. I suspect this gap is due to limited research opportunities …” — Bethany Hills Grois JD/MPH, Life Sciences, Health Tech Innovation Strategist
Spontaneous abortions (miscarriages) that occur in 10–20% of confirmed pregnancies, sexual health, menopause, hormonal interventions, preterm labor and many more will benefit from closing this gap.
Medical Education and Training: Despite recent progress, many medical school curricula have limited content on women’s health and do not include sex and gender training. These contribute to the delay in knowledge translation from bench to bedside. Postgraduate medical training for Obstetricians and Gynecologists also have gaps in standards which can be remedied by further research and attention to conditions with severe impact on women and families beyond physical health.
Ashley Leiser, Strategic Growth and Innovation Leader in Women’s Health, wrote: “There is no medical standard of care for pregnancy loss. Something that happens 2x as frequently as heart attacks in the US”.
Pregnancy loss takes both physical and mental toll on women who experience it. Practice bulletins and clinical guidelines must include holistic management. Multidisciplinary management is another aspect of training where there is a gap. In conditions coexisting with pregnancy, for example, patients can be better served by collaboration between the Obstetrician and Primary Care Provider (PCP).
Funding and Investment: Women’s Health Research and Innovation are still grossly underfunded but in the public and private sectors. For example, in 2020, only an estimated 11% of NIH funding was allocated to Women’s Health research. Some companies have allegedly shut down their Women’s Health focus or prioritized other areas. FemTech like many other women founder dominated areas also face underfunding.
Data Generation, Collection and Analysis: Gathering the right insights and reaching trustworthy conclusions in women’s health research requires expanded datasets. Depending on the research questions and analytical needs, this could include disaggregated data, Patient Generated Health Data (PGHD), hormonal data, Social Media data, lifestyle, data on women perception and experience etc. Patient-centered outcomes research also requires data aggregated across multiple systems, which reveals limitations of data collection and standards. Leveraging AI/ML in the field also requires similar robust datasets with caution for the entrenched bias and changes to medical knowledge. Discussions with founders indicate that start-ups and new organizations exploring newer models of women’s health research and management have the added burden of gathering data from scratch while ensuring privacy.
Public-facing and Personalized Women’s Health Libraries: The gaps in knowledge and research around women’s health makes it a target of misinformation for mostly or purely commercial gains. Many women have already fallen victim of dubious misinformation further worsening trust in genuine offerings and the health system. Trustworthy resources for up to date women’s health information in common terms continue to have gaps.
Health Technology and Innovation: Relative to other industries, health and healthcare tends to lag in the adoption of technology, this is even truer for women’s health. The desired characteristics of technology include speed, ease, and quality, yet very little has changed in technology powering efficient products (including medical instruments and devices), interventions, and services. The comment below highlights the consequence of a medical instrument gap:
“…let’s modernize gynecology and replace century-old traumatic instrument, such as the tenaculum causing most of the pain in transcervical procedure. Who would like to get pinched by a sharp instrument developed to extract bullets from soldiers a century ago? …Think about the consequences of women not choosing to get an IUD because of fear of pain. It’s time to take women’s pain seriously and to support women with better and gentle care!” — Ikram Guerd, an Award-wining International Healthcare Marketer
Ongoing efforts to replace 19th century medical instruments, like the tenaculum and speculum and others, with those better suited for the 21st century should be funded and supported. Affordability and accessibility should be included in these goals too. Digital health gap also has the potential of dissuading girls and younger women from seeking health.
For technology solutions it is also important to avoid point solutions as best possible and cater to majority or entire journey as possible. Similar thoughts is highlighted below:
“…Each solution seems to address one dimension of women’s health but the goal would be to have a continuum of care from adolescence to menopause in a cohesive offering so that as consumers, women don’t have to chase after each different solution in secret or confusion.” — Ann Joo Kim, a Chief Operating Officer and Payor Executive,
Workforce Diversity and Cultural Competence: This is crucial for delivery of culturally sensitive health services and creativity that fuels equitable innovation. Headlines and qualitative research highlighting the gender bias in the delivery of healthcare are common - women not being believed by doctors, women being under-treated, misdiagnosed, and dismissed by doctors, women overdiagnosed with mental health conditions in the face of genuine pain, etc, moreso for minorites. While most clinicians I know really strive to do their best for patients, lack of diversity, cultural competence and knowledge gaps, contribute to the volume of these incidents and perceptions.
Laws and Policies: This is a very crucial existing and unfolding gap. National, local and work policies plays a great role in women’s health. With the inextricable link between work, health insurance, time flexibility (RTO, WFH), and benefits (like childcare) etc. gaps here have dire consequences for women. Progress in women’s health gets stalled and reversed when laws and policies contradict adoption. Speaking on national/local policies:
“How about access to a Gynecology care at all… Personally, I feel strongly that restricting women’s control of their bodies regarding reproductive care is not only inherently damaging, but the consequence of these policies are also resulting in further creation of care deserts, as physicians flee. This is further harming women and their health.” — Jennifer Hone MD, a seasoned physician executive highlighted.
Culture, Norms and Stigma: Given the history described above, the connection here is very apparent. When restrictive cultures, beliefs and norms are prevalent, it exacerbates the adverse effects of other gaps discussed earlier. It also has ramifications for the transformation needed in shaping the perspectives of girls and young women about their health.
“…De-stigmatize / normalize women’s health, starting with the basics: menstruation, menopause etc. …Typical approaches are educational campaigns, which tackles the rational part of the brain. However, there also needs to be emotional oriented campaigns that appeals to the heart. When both (rational + emotional) are well integrated, that’s when hearts and minds change.” — Yogesh Chavda, a Strategic Marketing and Brand Building Expert recommended the following leaning on his expertise.
Progress So Far
“Communities and countries and ultimately the world are only as strong as the health of their women.” — Michelle Obama
· The ‘silence culture’ among women around women’s health and subjects previously considered ‘taboo’ has been overturned. More personal stories are shared on various platforms.
· Creation of the Office of Research on Women’s Health in the NIH
· The 1975 reference man, a ‘model’ that had been used as a basis for the calculation of radiation doses, metabolism, pharmacokinetics, sizes for organ transplantation etc. has been replaced with reference bodies — one male, one female
· Some institutions and academic medical center now have centers or departments that study differences between both genders and incorporating them in medical curricula. Examples include at brown University and Mass General Hospital.
Some more recent encouraging news in 2024 include:
✅Hint at additional billions in funding for Women’s Health during the State of the Union Address
✅ The White House Initiative on Women’s Health Research and recent $100M announcement of investment towards the ARPA-H Sprint for Women’s Health
✅ The amazing work by Liz Powell et al to organize founder/CEO, innovators, researchers, interest groups, individuals etc. to provide valuable insights to guide the former
✅ Availability of new over-the-counter contraceptive pills, growing FemTech industry and expansion of conditions covered
Conclusion
Women’s health has come a long way from being mischaracterized and hijacked by centuries of ignorance and unjustifiable paternalism to the progress made today. The most important lesson from history may be the honest appreciation of the present and taking actions against regression that puts women’s health progress in jeopardy. Bridging persisting gaps require a ‘woman-centered approach’, understanding the various determinants of health — a long list of social, technological, commercial, information and political — contributing to unmet health needs, humility in accepting different perspectives and potential solutions directed by affected women, rapid translation of scientific research, and aggregation of solutions/offerings. Gaps should be addressed fast yet thoughtfully, keeping the entire health journey of women in mind. Point solutions should be highly scrutinized for appropriateness, to avoid fragmentation that negates holistic outcomes.
We all have roles to play as participants in research/ideation, researchers, innovators, founders, advocates, users, and funders for better women’s health. Our nation (and the world), including men, women and children benefit from enabling women achieve their highest possible health potential.
Additional Reading
a) Sex and Gender Department and Innovation Centers at Universities and Academic Medical Centers like Innovation Center on Sex Differences in Medicine (ICON-X)
b) The WHAM Report: The Case to Fund Women’s Health Research
c) https://time.com/6074224/gender-medicine-history/
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