Offline: Gender and global health—an inexcusable global failure

Abstract

WHO has identified “Ten threats to global health in 2019”. Surprisingly—one should say shockingly—gender inequity is not one of them. It is not only WHO that is failing by excluding women and girls from its priority list of dangers. The entire global health community has abdicated its responsibility for achieving gender justice in health. This situation is strange because a vast quantity of evidence linking gender inequity to poor health exists and the mandate is clear, as set out in Sustainable Development Goal 5. The global health community has not, but must, make SDG 5 an indispensable part of its work to achieve healthy lives for all. Ending all forms of discrimination against women and girls. Eliminating all forms of violence against women and girls. Eliminating all harmful practices against women and girls (eg, forced marriage). Recognising and valuing unpaid care and domestic work. Ensuring women's full participation and equal opportunities for leadership in all parts of public life. Ensuring universal access to sexual and reproductive health and rights. Implementing reforms to give women equal rights to economic resources. Enhancing the use of technologies to promote women's empowerment. Finally, adopting policies and laws to promote gender equality. Rarely, if ever, do we hear global health leaders promoting such far-reaching reforms as essential prerequisites for health. We must ask: why not? In May, 2018, The Lancet launched its Commission on Sexual and Reproductive Health and Rights for All, led by Ann Starrs and Alex Ezeh. The health landscape for women is simply appalling. 200 million women who want to avoid pregnancy have no access to modern contraception. 30 million women do not give birth in a health facility. 45 million women have inadequate or no antenatal care. 25 million women have unsafe abortions each year. One in three women experience sexual violence. Over 1 million women die from cancer of the breast, cervix, ovary, and uterus annually. These predicaments exist (and are failing to be resolved anywhere near fast enough) because of gender inequity. Our Commission set out the evidence in support of an essential package of sexual and reproductive rights and health services that should be universally available. I wish I could report otherwise, but this evidence has been comprehensively ignored by global health leaders. But we also need to go beyond SRHR. Ana Langer led a Lancet Commission on Women and Health, published in 2015. She drew attention to the economic, environmental, social, political, and demographic determinants of women's health. The locus for action to advance women's health and rights lay not only with the health system, but also with society. The response to multiple global health threats facing women has largely omitted gender-specific analyses and actions. Women's contributions to health as caregivers are still grossly under-appreciated. Gender-sensitive policies to address deep-rooted inequities are mostly missing. As that Commission concluded, “Sustainable development needs women's social, economic, and environmental contributions, which will increase when women are healthy, valued, enabled, and empowered to reach their potential in all aspects of their lives.” Again, this call to action has been insufficiently heeded. Something has gone wrong in global health. Gender was a more prominent issue during the era of the MDGs, if too narrowly defined through the lens of women's, children's, and adolescent health. It's time to hold men especially accountable for this regression. Given their political prominence and power, they (we) have a special responsibility to speak out for gender equity. Too often we do not. Air pollution and climate change, non-communicable diseases, the risk of a global influenza pandemic, fragile and vulnerable settings, antimicrobial resistance, Ebola and other high-threat pathogens, weak primary health care, vaccine hesitancy, dengue, and HIV. These issues are important, and one can understand why WHO has identified them as particular threats in 2019. But, as Gro Harlem Brundtland (a former Director-General of WHO) once observed, poverty has a woman's face. The whole of health is shaped by our approaches to gender. Men must do more to amplify the importance of gender in global health, to listen, to engage, to advocate, and to create the conditions for women to flourish. The fact that, collectively, we are not doing so is a particularly ugly disfigurement of our community.