Women's health is more than reproductive health. Why does this phrase still need to be repeated? This commentary highlights the urgent need to encourage more women to lead, research, and educate to move beyond stereotypes and to ensure we push forward in improving the lives of women everywhere.
Now, more than ever, it is critical that priorities in global women's health advance beyond reproductive and maternal health. Indeed, a few high-profile calls to action have drawn attention to other major threats to the health of girls and women. For instance in 2016, on World Cancer Day, the former United Nations (UN) Secretary General Ban Ki Moon called for “the elimination of cervical cancer” (Ref. 1) as a public health priority, and a feminist commentary by Michelle Bachelet, the Honourable President of Chile, entitled 'Women, power, and the cancer divide' (Ref. 2) accompanied a three-part series in The Lancet, 'Health, equity, and women's cancers'. In 2017, leaders from the WHO, The Global Fund, the World Bank, the US National Cancer Institute (NCI), and other organizations urged priority actions to address the unmet challenges of cervical cancer3.
Almost as many women die each year from cervical cancer as from complications from pregnancy and childbirth, and despite having the evidence and available preventive treatments, cervical cancer remains virtually without international funding4. Moreover, the new Resolution on Cancer Prevention and Control adopted at the 2017 World Health Assembly urges member states to “integrate and scale up national cancer prevention and control as part of national responses to noncommunicable diseases, in line with the 2030 Agenda for Sustainable Development” (Ref. 5). Yet, we have made little progress, beyond words. By 2016, 10 years after the introduction of human papillomavirus (HPV) vaccines, 47 million girls and women had been immunized, but only 1% were from a low or lower-middle income country6; in general, these countries have not implemented population-based cervical screening and treatment programmes. Without screening and treatment of precancerous lesions, an estimated 19 million women worldwide will die from cervical cancer over the next 40 years7.
“...we might wonder if a hidden reason explains the policies and funding gaps that are restricting progress in improving women's health”
The current emphasis on “women's health along the life course” (Ref. 8) from birth to death hasn't amounted to much in terms of actual policy change, nor has this paradigm generated any real action. Some experts argue that this inertia is due entirely to the limited fiscal resources that all countries are facing, particularly those struggling to address the so-called 'double burden' of communicable and noncommunicable diseases. Some truth accompanies this claim; however, when we dissect the nature of funding for global health, and reflect on who the decision-makers and thought-leaders are, we might wonder if a hidden reason explains the policies and funding gaps that are restricting progress in improving women's health.
Historically, the leading voices from what is now considered the 'global health arena' have mostly come from men. This disparity should not come as a surprise, reflecting as it does the gender divide in every domain of academia, drug development, health policy, research, and politics. Men are responsible for some of the tremendous advances in global women's health, playing a pivotal part in the progress made in some countries towards achieving the Millennium Development Goal 5 (to improve maternal health), and Goal 3 (to promote gender equity and to empower women)9. Nevertheless, women's health coverage in the lay press and in policy papers is often framed as something separate, fragile, and uniquely vulnerable, in ways that male health issues are never perceived. In the current global political climate, in which even basic reproductive health and rights are at risk, why should we even try to assert our concerns about leadership in global health? On the contrary, such threats are precisely why the time is ripe for more women to be engaged, and to take leadership roles in every domain, especially in global health.
Call to action
A recent commentary by Roger Glass10, Director of the US NIH Fogarty International Center for global health research, raises a key question: how can we encourage female leaders in global health? In the current model for progress, the metrics by which success is measured, as well as the mechanics and the infrastructure upon which academic careers are made, are inherently competitive and possibly even adversarial. Is the system itself patriarchal? Perhaps, but women can be complicit, and not all men are comfortable with the status quo. How can this style of leadership ever be expected to lead to gender-neutral, let alone feminist health policy?
I suggest that in no other field of health research is this issue more important than in global women's health, and no domain has more at stake. For example, when we consider women's cancers in low-income and middle-income countries, we should acknowledge that, in addition to the general access and affordability barriers that many men, women, and children face globally, women with breast or gynaecological cancers in many countries also experience a dimension of shame and self-blame, accompanied by a fear of being ostracized by their husbands and families. Women in this situation report feeling challenged by their illness on 'what it means to be a woman', in their relationships, and in society. Thus, gender inequality further contributes to the limitations of 'agency' — a person's capacity for self-determination2.
Given the calls to action and abundant evidence for controlling (at least) cervical cancer in the immediate term, with elimination of the disease as a long-term goal, what can the community of global health researchers and policy-makers do to set in motion concrete actions to achieve this vision? Women in global oncology can and should take on more active leadership roles. What does it take to be a good mentor for women in global oncology? Encouraging, identifying, and generating opportunities for women trainees at early stages of their careers, in order to develop their creative ideas and leadership potential, would be excellent steps forward for any mentor. Notably, how many women are first authors on research papers, co-principal investigators on grants? When we convene a meeting, do we have something close to gender equality on high-level panels? If women in their early career paths do attend, are their ideas given adequate consideration in Q&A sessions?
On the one hand, some progress has been made, with prominent oncology societies naming and addressing the oncology leadership gap. Notably, ESMO and ASCO have been establishing regular blogs and networking events at conferences, with the aim of increasing the engagement of women in oncology. Over the past 15 years, the number of women entering the field has almost doubled, not only in medical oncology, but also in radiation oncology and surgical oncology. Since 2000, ESMO membership has increased from 20% women to approximately 40%, and half of all ESMO members under the age of 40 years are women11. Similarly, a 2013 ASCO Workforce Survey revealed that the proportion of women involved in all subspecialties is growing, with nearly 45% representation in oncology fellowship programmes in the USA12.
Path to progress
It is important to note, the mere presence of more women in oncology, even in global oncology, will not necessarily translate into more women leaders, or into more-effective leadership to solve inequities in women's health. What can we learn from other movements, and how can we ensure that women in global oncology who reach the top encourage other women to climb the ladder? On the global stage, this empowerment is perhaps of greatest importance for women oncologists and scientists from low-income and middle-income countries, who are, arguably, the least advantaged in our profession.
Perhaps we can learn from the burgeoning Women in Global Health (WGH) movement. As WGH Director Roopa Dhat would suggest, we can educate global (oncology) leaders to be gender-responsive, we can take practical steps to increase the 'talent pool' by creating leadership development programmes, and by providing avenues and pragmatic guidance for mentorship that fosters women leaders through the 'life-course approach', using peer-to-peer strategies that do not necessarily rely on the traditional seniority gap. I would encourage women in oncology whose work includes global health to read and engage more widely about the topic, attend the annual Women Leaders in Global Health (WLGH) conferences, and share what we learn with others.
Does the historical patriarchy continue to influence our priorities in global health? Seemingly yes, at least in part. Might the values of collectivism, community, and collaboration present a more effective paradigm? Perhaps. President Bachelet notes: “To move forward and realize these ideas, particularly around efforts directed to control women's cancer effectively and equitably, we should start by empowering women in societies” (Ref. 2). So, let us conceive of a way forward, together using inspiration from the African proverb: if you want to go fast, go alone... if you want to go far, go together.
- United Nations. Secretary-General's message on World Cancer Day. UN http://www.un.org/sg/statements/index.asp?nid=9437 (2016).
- Women, power, and the cancer divide. Lancet 389, 773–774 (2017).
- Ending cervical cancer: a call to action. Int. J. Gynaecol. Obstet. 138 (Suppl. 1), 4–6 (2017). et al.
- The investment case for cervical cancer elimination. Int. J. Gynaecol. Obstet. 138 (Suppl. 1), 69–73 (2017). &
- World Health Assembly. Cancer prevention and control in the context of an integrated approach. Union for International Cancer Control http://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_R12-en.pdf (2017).
- Global estimates of human papillomavirus vaccination coverage by region and income level: a pooled analysis. Lancet Glob. Health 4, e453–e463 (2016). et al.
- Saving the world's women from cervical cancer. N. Engl. J. Med. 374, 2509–2511 (2016). &
- World Health Organization. Global strategy for women's, children's, and adolescent's health, 2016–2030. WHO http://www.uicc.org/2017-wha-cancer-resolution-global-commitment-national-action (2017).
- United Nations. United Nations millennium development goals. United Nation http://www.un.org/millenniumgoals/ (2015).
- How can we encourage female leaders in global health? Fogarty International Center — NIH https://www.fic.nih.gov/News/GlobalHealthMatters/july-august-2017/Pages/encourage-female-leaders-global-health.aspx (2017).
- European Society for Medical Oncology. ESMO member information. Statistics on ESMO members by gender. ESMO http://esmo.org/content/download/20624/342542/file/W4O_Stats_questionnaire_report.pdf (2013).
- Tracking the workforce: the American Society of Clinical Oncology workforce information system. J. Oncol. Pract. 9, 3–8 (2013). , , , &