A Milestone Moment: Well-Behaved Women Seldom Make History (And Disruptive Women Seldom Make it into

Key reflections from The Lancet Women Theme Issue Launch in London and New York

A powerful feeling was palpable throughout the launch of the Lancet Women Theme Issue, as scholars, experts, and advocates in science, medicine and global health gathered for the milestone moment in gender equality. Starting off the first launch event in London was Richard Horton, Editor-in-chief of the Lancet, who spoke about the Hallam Centre - the host venue for the launch. For a long time, the centre was the embodiment of western patriarchy in medicine, as it had once housed the General Medical Council, dominated by white men in the West dictating healthcare for the masses around the world. Witnessing the juxtaposition between the centre’s historical significance and the Launch’s predominantly female, diverse audience of accomplished feminist researchers, physicians, journalists, policymakers, and advocates from all levels in healthcare was a profoundly humbling and important realization for all in the room.

The sessions continued with dynamism, a healthy dose of ferocity and speakers who were refreshingly candid in calling out policy, social structures, and systemic failures that continue to affect women.

Background

Feminism is for everyone. The voice of bell hooks continues to echo in the opening of the special Lancet Issue on Advancing women in science, medicine and global health [1]:

“To be ‘feminist’ in any authentic sense of the term is to want for all people, female and male, liberation from sexist role patterns, domination, and oppression.”

The much-awaited issue has catalyzed the research and policy community to think harder about gender and broader diversity-- all important determinants of health and development. In December 2017 [2], editors Jocalyn Clark, Elizabeth Zuccala and Richard Horton opened a call for papers, as a response to global calls to action by many individuals and groups - including Women in Global Health [3] - to highlight the gender determinants in global health, medicine, and science. After a year of submissions ranging in the hundreds, a rigorous peer-review process, and critical thought analysis by the esteemed Lancet Women International Advisory Group, the issue’s launch in London and New York is a momentous occasion. This issue explores international evidence on gender bias, explores topics of diversity, intersectionality, harassment, and masculinity; and delivers a call for different approaches to research, institutional change, funding, recognition, and global health.

“This collection highlights that gender equity in science is not only a matter of justice and of rights but is absolutely crucial to producing the best evidence and the best patient-care.”

- Dr. Jocalyn Clark, Executive Editor the Lancet, UK

Women in Global Heath’s Takeaways from the Lancet Women Launch

1. Barriers exist at all levels, but we must address systemic, structural barriers.

Global health leadership continues to be gender imbalanced. Although women’s representation has slowly increased over the past decades, women still encounter discrimination and bias in comparison with men in these fields [4]. With only 20% gender parity at governing bodies of global health organisations, the absence of gender parity in top leadership reveals these systemic gender biases (a figure even more striking considering that women comprise 70% of health workers) [5]. Gender transformative leadership is needed to create an enabling environment for all genders, especially women. Science, medicine and global health are fields guided by evidence, and must continue to support the advancement of women in these fields and the health sector to close the gender data gap, especially from global south perspectives. The story that is written is not the only story, and we must challenge that to capture what is being missed in science and put forward smarter global health.

"The fight for gender equity is everyone's responsibility, and this means that feminism, too, is for everybody—for men and women, researchers, clinicians, funders, institutional leaders, and, yes, even for medical journals [6]."

- Professor Sonia Bhalotra, University of Essex, United Kingdom

2. The roles of men and masculinity in gender-transformative leadership in global health

“Today is the start of a new narrative. Advancing women in science, medicine and global health is an issue for women and men, and it is time for men to upgrade their idea of masculinity... time to listen and adapt.”

- Dr. Richard Horton, Editor-in-Chief of The Lancet, United Kingdom

The Lancet Women theme issue has highlighted the role of men, hegemonic masculinity and the crucial importance of men as allies, mentors and sponsors. Those that traditionally hold the power must step out of their comfort zones to accelerate inclusivity and diversity in global health, medicine and science. Traditional masculinity has shaped health and the medical sciences for thousands of years, and its influence is so pervasive that systemic efforts must be employed to truly level the playing field. This includes actively dismantling existing biases, rectifying structural disadvantages and elevating inclusive and equitable leaders.

Women in Global Health advocates for Gender-Transformative Leadership, a leadership style grounded in a vision of gender equality, that goes beyond parity, by challenging privilege and imbalances in systems to ensure no-one is left behind. Kopano Ratele and co-authors write that “whereas gender transformative work with men has been done in many countries and on a range of topics, little is done to specifically engage men in STEMM and global health”(7). The collective privilege and power of men over women in broader society means that men who are committed to the principles of gender equality must critically reflect and mobilise, as groups or individuals, and transform masculinity to allow for more inclusive spaces in STEMM and global health. Men should be engaged to support women in challenging gender discrimination within institutions dedicated to STEMM and global health and beyond, transforming economic, political and cultural structures. Yet, the engagement of men cannot be done in an ad-hoc manner or be left to individuals. Systematic programmes towards gender equality and the transformation of masculinity are required at an institutional level including the board, committees, policies and executives(7).

3. Redefining excellence and intersectionality, and improving diversity in global health

The danger of a “single story” that Chimamanda Adichie presciently warns us about is particularly relevant, as we reflect on multifaceted power structures that sustain unequal health outcomes. Global health is shaped by relationships across multiple levels of power and identities - the question of “Who has the opportunity to tell their stories?” arises repeatedly. Applying an intersectional lens in order to contextualise academic research within these social, cultural, and political identities is essential to understanding these power dynamics [8].

“Intersectionality is about how power is distributed in our lives.”

-Dr. Anuj Kapilashrami, University of Edinburgh, United Kingdom

Diversity itself is not monolithic and we must acknowledge the different realities that any one person is living. Groups that are often portrayed as relatively homogenous, including women, men, migrants, and indigenous people, display important differences. Inequities are shaped by interactions between multiple levels of power and factors both within groups and between individuals [8]. Using an intersectionality lens allows us to unpack diversity, power, privilege, positionality -- the haves and the have nots in a multi-faceted manner, more akin to reality. These identities and realities impact career and health--and in science, we must factor that into our understanding-- whether it is race, socioeconomic, immigration (first vs second generation), caste, education, gender and geography. This includes being critically engaged and positioning research in the context of all cultural, political, and ideological structures that drive science.

"Recognizing in global health there are different backgrounds, different realities, the reality is we need to recognize diversity and acknowledge that even if people look similar, they may not be similar"

- Dr. Ruth Ndjaboue, Laval University, Canada

In the panel on “Better diversity for better science” Gemma Tracey raises the question about the role of excellence in diversity and inclusion;

"Removing bias in our decision making processes" "How do we define excellence? How do you break that down? We need to open up what we define as excellence" "How do we include being a supportive leader, being a supportive member of the research community, as part of this definition of excellence?"

- Gemma Tracey, Wellcome Trust, United Kingdom

Excellence is a concept that perpetuates norms of power and privilege, skewed against marginalized groups. If aim for great diversity and inclusion, we must also challenge what we consider excellence - degrees, publications, and institutions should not be the basis for an esteemed career. We must change our thinking because women and minorities in science, medicine and global health engender better research and health equity [9]. Diverse teams lead to better science and better solutions.

Leaving no one behind - however it is important to keep in mind that being inclusive means having deliberate programs and policies that include all people. Parental leave policies that sideline women also sideline same-sex male parents who want to take parental leave. As expressed by Imogen Coe, “Similarly, we often exclude transgender populations, as patients, providers, and leaders from the topic of gender equality in health, leading to poorer health outcomes in these communities”. We need intersectional, equitable efforts to embrace all, including trans individuals, in inclusive gender-equality movements.

4. Gender-disaggregated data and the gender data gap

"Women are dying because of the gender data gap"

- Caroline Criado Perez, campaigner and journalist

To achieve gender equality we must have access to the right data. Gender data, often described as data disaggregated by sex, is crucial to understand differential outcomes in health and development. Over the past decades preclinical, clinical and biomedical research have shown differences between the sexes at genetic, cellular, physiological and biochemical levels. Yet, women are represented poorly in medical research, with grave consequences. Sue Rosser and her colleagues lay bare the realities of missing gender data [10];

"Obtaining good-quality gender-disaggregated data is essential for measuring institutional change... these data provide evidence of gender inequalities used to inform and persuade key actors to support and provide budgets for actions”

Gender disaggregated data is the first step towards improving not only the ethical standards of research, but the overall quality of the research. The unconscious or conscious inclusion of biases upstream in research severely hinders the ability to draw valid conclusions from data [11]. It is important to consider the variety of gaps that exist in regard to gender data: 1) the gap in sex-disaggregated data, as much of the research, including epidemiological studies and animal models, continues to use "male" as the standard, 2) the near-total absence of gender as a study measure, sex instead being used as a proxy, and 3) the frequent under-representation or exclusion of women in clinical trials.

Academic funders have an important role to play in ensuring that research studies use gendered data appropriately. At the London launch of the theme issue, the CIHR detailed their requirement for applicants to justify either including or excluding sex and gender from their papers. These requirements are important steps to countering conscious and subconscious bias in research.

5. Zero Tolerance

As Sarah Hawkes put it during the launch:

“We need to start talking much more seriously about systems of accountability around claiming our rights -- our rights to a workplace free of harassment and bullying, our rights to fair pay.”

And she’s right. Everyone has the right to decent work and to be treated with dignity. All employers have a duty of care to provide safe workplaces for everyone. From the #MeToo movement to the scathing Independent Expert Panel report on UNAIDS, it’s clear that we have not yet made the necessary changes to address toxic environments at an institutional level.

The need for organisational leadership that sets zero tolerance cultures for sexual harassment, sexual abuse, exploitation and bullying is especially striking in global health and medicine. Women in health face high levels of violence and abuse from colleagues, patients and the community. Sexual harassment in the workplace not only denigrates the rights of women and holds us all back from achieving gender equity, it also negatively interferes with the honourable objectives of these disciplines. A big part of upholding the right for women to have a safe work environment is to push for accountability. This includes highlighting where institutions aren’t doing enough to protect female employees. In her remarks, Sally Davies the Chief Medical Officer for England noted:

“If the system isn't right or we are treated badly, we need to call it out. We often let

things pass that we shouldn't.”

Two young physicians on the panel continued, discussing gross inadequacies in the way we train health workers. Elizabeth Viglianti of the University of Michigan lamented that “we don’t train young female health workers on dealing with harassment from patients or staff. They’re simply expected to deal with it on their own.” Meanwhile, junior doctor Behrouz Nezafat Maldonando continued that “we must normalize calling out policy failures that neglect training on gender in the workplace.”

The call for bold action, ““#TimesUp in health care”, made in both New York and London, is timely. The goal is to create structurally egalitarian workplaces in health, in which genders share equal authority and power, and all are protected from harassment and discrimination. This is a momentous time in history and we must seize this opportunity to turn this heightened awareness into bold and sustainable action.

6. We can’t be what we can’t see - Role models, mentors and champions

The history of medicine is one of the formal, systematic exclusion of women, and it is therefore no surprise that there is a lack of role models that young women can identify with. The exclusion of women from key leadership positions has an effect on the perceptions and expectations of all genders. One of the Lancet Women theme issue articles studied career progression at the fifteen highest-ranked social sciences and public health universities in the world. It indicated clear gender and ethnic disparities remaining at the most senior academic positions, despite the enactment of several diversity policies and action plans [10]. As mentioned at the New York launch, interventions must be a whole-systems approach, addressing multiple upstream constituent factors rather than narrowly focusing on the ultimate triggers of these disadvantages.

Liza Donnelly cartoon for Forbes Women

One key role model for women in health, however, is Sally Davies, the Chief Medical Officer of England. Dame Sally admitted, “I have a problem. I realise, I like as most people do appointing in my own image. I love appointing sparky women," and elaborated that men must also work on the biases that drive them to mentor and sponsor in their own image.

However, It is often said that women are over-mentored and under-sponsored. And indeed, a critical factor in the systematic exclusion of women in health leadership is that while women get mentors, men get sponsors and champions, given direct access to crucial opportunities that help them to get ahead.

"I think this issue is terribly important and we can look at it from a number of aspects, one is structural. What are we doing structurally to support women coming through and taking their appropriate place? I want all people, whether it's women, whether it's BME, whether it is young white men actually, to be offered a fair opportunity.”

- Professor Sally Davies, Chief Medical Officer for England, UK

7. Gender pay gap and gender gaps in grant funding

“Inequality means public investment is not fully realised.”

- Dr. Holly Witteman, Université Laval, Canada

Global health has a serious money problem: gender pay gaps in health, medicine and science remain pervasive across countries, sectors and disciplines. Not only are women systematically paid less than their male counterparts, much of women’s work in health is underpaid, under-recognised and informal. The average monthly income of male physicians in Peru is five times higher than that of their female counterparts [12]. The global health pyramid rests on the fragile base of women’s unpaid and underpaid work, an injustice that can be traced back to society’s flawed expectation of women taking on the majority of household and care work.

Women are also less likely to get grants, and receive smaller amounts of money. A natural experiment of a national funding agency, published in the theme issue, not only determined that these gender funding gaps existed, but furthermore showed that these were attributable to the assessment of women as principal investigators, rather than the quality of the grant proposal [13]. Holly Witteman, from Universite Laval, also deconstructed several prevailing myths that both men and women perpetuate about the reasons for gender inequality in funding and research. With each myth, she provided clear evidence that this is not the case, forcing many to reconsider their reasoning. For example, she dispelled the myth that men write better grant applications, explaining that “Men self-cite substantially more than women do. Women write equally good grants but are not evaluated as equally good scientists due to underlying bias”. Disproportionate funding is also a much broader issue that goes beyond gender. At the New York launch, Sharmila Mhatre shared that 70% of funding money stays in the Global North to change lives in the Global South. Giving those impacted by the problem access to this funding will rebalance power dynamics in global health.

“Funders have the power to set the agenda — we need to ask whether the money is going to those who are making transformational change. We have the chance to lead differently through who we choose to support.”

- Sharmila Mhatre, Open Society Foundations

8. Courage

Finally, a central theme that is not often recognised in conversations around gender equality is courage; the courage to push against norms and to question prevailing and pervasive attitudes. Imagen Coe, of the Lancet Women Advisory Board, discussed how acts that challenge gender norms, carried out by courageous individuals at every level of power, are often unpopular. For example, it takes “academic courage to address inequities experienced by researchers who take parental leave; it’s a core competency for leaders. It’s a human right.” Richard Horton also spoke of the courage it takes to hold up a mirror and look at one’s own work and organisation, to “be critical, honest and self-reflective, intentionally addressing institutional culture”. Richard Horton was unequivocal that the Lancet Women theme issue has also forced the team to look inwards, leading to a “complete reappraisal of who we are and what we do”. He pledged to correct past failures in gender equality and urged other organisations and individuals to do the same. At the New York launch, Jocalyn Clark, editor at the Lancet, shared how The Lancet has been working on purposeful gender representation. The Lancet committed to a public diversity pledge, achieving gender parity on all editorial advisory boards by the end of 2019, increasing the number of women and LMIC reviewers by 25% by 2020, making local reviewers compulsory for all global health content, as well as ensuring representation of both women and the Global South in authorship.

Importantly, the courage we need must come from those with the power and privilege to change the systems that have elevated them into these positions in the first place. While gender-transformative leadership is needed from all, men especially must have the individual courage and humility to use their power to make space for systematically excluded and underrepresented groups.

In closing, our overarching message is that gender equality means smarter global health. Gender determinants affect everybody’s health, and are therefore everybody’s business. Progress will be more about consistency than epiphany.

This Lancet theme issue is a milestone moment, but consistent action must be taken that reflects what has been said and written. Women led movements like Women in Global Health play a critical role in making space for the most excluded voices in global health, women from the Global South. As a next step, we invite the Lancet to work with WGH and our network of national chapters, as well as extend Lancet Women to showcase the knowledge and perspectives of women from the Global South, with the greatest needs in global health but the least data and research. It is imperative and urgent that there is greater accountability of individuals and institutions in global health to advance gender equality and diversity-- hold a mirror up to oneself, be self-reflective and take the necessary steps to address long-standing gaps in gender inequity.

References:

[1] Editorial. (2019). Feminism is for everybody. The Lancet, Volume 393 (Issue 10171), p493. DOI:https://doi.org/10.1016/S0140-6736(19)30239-9. Full text

[2] Comment. Jocalyn Clark et al. (2017). Women in science, medicine and global health: call for papers. The Lancet, Volume 390 (Issue 10111), p423-2424. DOI:https://doi.org/10.1016/S0140-6736(17)32903-3. Full text

[3] Correspondence. Roopa Dhatt et al. (2017). Act now: a call to action for gender equality in global health. The Lancet, Volume 389 (Issue 10069), p602.

DOI:https://doi.org/10.1016/S0140-6736(17)30143-5 Full text.

[4] Review. Sonia Khang, Sarah Kaplan (2019). Working towards gender diversity and inclusion in medicine: myths and solutions. The Lancet, Volume 393 (Issue 10171), p579-586

DOI:https://doi.org/10.1016/S0140-6736(18)33138-6 Full text.

[5] Correspondence. Myra Betron et al (2019). Time for gender-transformative change in the health workforce. The Lancet, Volume 393 (Issue 10171), PE24-26.

DOI:https://doi.org/10.1016/S0140-6736(19)30208-9 Full text

[6] Online. Sonia Bhalotra (2019). Professor Sonia Bhalotra discusses gender issues at launch of The Lancet Women’s theme issue "Advancing women in science, medicine, and global health". Online: https://www.iser.essex.ac.uk/2019/02/08/lancet-womens-theme

[7] Viewpoint. Kopano Ratele et al (2019). Engaging men to support women in science, medicine, and global health. The Lancet, Volume 393 (Issue 10171), p609-610. DOI:https://doi.org/10.1016/S0140-6736(19)30031-5. Full text

[8] Comment. Anuj Kapilashrami, Olena Hankivaky (2019). Intersectionality and why it matters to global health. The Lancet, Volume 393 (Issue 10171), p2589-2591 DOI:https://doi.org/10.1016/S0140-6736(18)31431-4 Full text

[9] Opinion: Mathias Nielsen et al. (2017). Opinion: Gender diversity leads to better science., Proceedings of the National Academy of Sciences of the United States of America. National Academy of Sciences, Volume 114 (Issue 8), pp. 1740–1742. DOI: 10.1073/pnas.1700616114. Full text

[10] Health Policy. Sameer Khan et al. (2019). More talk than action: gender and ethnic diversity in leading public health universities. The Lancet, Volume 393 (Issue 10171), p594-600. DOI:https://doi.org/10.1016/S0140-6736(18)32609-6. Full text.

[11] Article. Cassidy Sugimoto et al. (2019). Factors affecting sex-related reporting in medical research: a cross-disciplinary bibliometric analysis. The Lancet, Volume 393 (Issue 10171), p550-559

DOI:https://doi.org/10.1016/S0140-6736(18)32995-7 Full text

[12] Correspondence. Victor Sal y Rosas et al. (2019). Gender income gap among physicians and nurses in Peru: a nationwide assessment. The Lancet, Volume 393 (Issue 10171), p. DOI:https://doi.org/10.1016/S2214-109X(19)30034-8. Full text

[13] Article. Holly Witteman et al. (2019). Are gender gaps due to evaluations of the applicant or the science? A natural experiment at a national funding agency. The Lancet, Volume 393 (Issue 10171), p531-540

DOI: https://doi.org/10.1016/S0140-6736(18)32611-4 Full text

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