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Women's Health: Decades Later, What's Still Neglected

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Women's health matters. The recent release of the Institute of Medicine Report, Women's Health Research, Progress, Pitfalls and Promise as well as the publication of findings from the 10 year follow up of the Women's Health Initiative, underscore that focusing on women's health and the study of sex and gender differences in disease has contributed to increased knowledge as well as improvements in the health of women in the United States over the past 20 years.

While more than 51 percent of the U.S. population is female and occupy multiple significant roles in society as well as serve as the primary caregivers making 80 percent of health care decisions in families, as recently as just two decades ago, women's health was neglected in the halls of public policy, at the research bench, and in clinical settings. This International Women's Day provides an opportunity to reflect on the progress that has been made as well as what more needs to be done. I am proud to have played a leadership role in exposing the inequities in women's health in the 1980's and then serving as the country's first Deputy Assistant Secretary for Women's Health in the U.S. Department of Health and Human Services, working to move these issues to the forefront of our nation's health care agenda where they belonged as well as collaborating with other governments' officials to make advancing the health of women and girls a priority worldwide.

Since childhood, women's health mattered to me. When I was 10 years old, my mother developed thyroid cancer. I will never forget visiting her at the hospital and feeling helpless against this disease. It was then that I decided to become a doctor. I spent summers working in laboratories at Stanford University School of Medicine during my high school and college years acquiring knowledge and skills about how to conduct research. I also served in the Medical News Bureau at the Medical Center learning about the importance of communicating scientific advances to the public.

I chose my college curriculum with medicine in mind. In my first year of college, my mother developed breast cancer. In my last year of medical school, the disease metastasized to her spine so that she could no longer walk. She fought the disease with great courage and dignity and lived long enough to see her daughter become a doctor. Thirty years ago, when she died of metastatic breast cancer, I vowed that no other woman should have to suffer the way she did. So it's hasn't been just a job, but rather a calling and an honor to dedicate my career to improving women's health.

I did this first as a research scientist and branch chief in the 1980s at the National Institutes of Health, where I worked with other advocates to expose the inequities in women's health. Then in 1993, I was honored to be appointed as the country's first Deputy Assistant Secretary for Women's Health in the U.S. Department of Health and Human Services (HHS). It was new senior level position created to rectify past inequities and focused around writing a new national prescription to improve women's health in our country.

As Director of the HHS Office on Women's Health, my goal was to weave a women's health focus into the fabric of all of the Department's agencies and offices as well as to collaborate with other public and private sector organizations to improve women's health across the lifespan and eliminate health disparities. I also worked with health officials globally to address these issues worldwide.

The office convened conferences and consultations, issued reports, developed and supported model programs and innovations in women's health, and worked to educate consumers, researchers and health professionals about a broad spectrum of issues. As a result of this new national focus, women's health is now a top priority, funding has dramatically increased, a broad spectrum of research is underway, and prevention and service delivery programs are targeting women's unique needs. In the State Department, an Ambassador for Women's Issues has been recently appointed and women and girls are a major focus of development and health programs internationally.

Women's Health History

Until fairly recently in our nation's history, women were largely excluded from being subjects in medical research and data was not analyzed for sex and gender differences, despite the fact that women are 51 percent of the U.S. population, 61 percent of the population over the age of 65, and comprise 70 percent of the population over age 85. In fact, women's health was a cause that for all too long was neglected in research, services and public policy, despite the fact that women seek more medical care, use more health services, spend more on medications than do men, and suffer greater disability from disease. Many studies on the safety and effectiveness of medications did not include women despite the fact that women use more medications and have higher rates of side effects than do men.

In the past, preventive interventions for tobacco use, to encourage health diets or to reduce cholesterol did not include women. Additionally inequalities in health care limited women's access to certain diagnostic procedures and therapies proven to be effective for specific conditions and women paid more for the same insurance plans than did men because of the possibility of pregnancy and other female conditions!

The bottom line: despite well document differences in the bodies and experiences of men and women, most research studies in the past were conducted in men only, as if they were the "generic" humans. The results were then generalized to guide the diagnosis, treatment, and prevention of disease in women. This omission of women as research subjects and as the focus of prevention campaigns had put women's health at risk -- with rising rates of undetected heart disease, lung cancer, autoimmune illnesses, mental and addictive disorders, and the epidemic of AIDS.

What were the reasons for these inequities? Some speculate there was bias. Also, it was more costly to include women in research studies because of variables such as hormonal factors that had to be considered. And just as women have battled for equality in educational and occupational opportunities, those working in the women's health field had to shatter a myriad of barriers and prejudices in health care practice and research to bring women's health to the forefront.

When I went to medical school, women's health focused on the reproductive system. We learned about the 180 pound male and his anatomy and physiology. But never once did he go through menopause or have ovarian cancer. So, it's not surprising that generations of health care providers and researchers, trained with a male model of disease, were not sensitive to sex and gender differences in the causes, treatment, and prevention of illness. Health education efforts did not target women so they were not aware of their risk for heart disease, AIDS and lung cancer. Still another piece of the explanation was the dearth of senior women scientists and health professionals in our nation's medical institutions. While today women represent as much as 48 percent of medical students and the majority of residents in several medical specialties including pediatrics, psychiatry, obstetrics and gynecology -- there are still few women in leadership positions in medicine. Women represent only 12 percent of the Deans of U.S. medical schools, fewer than 27 percent of tenured professors and 13 percent of the over 2070 Departmental Chairs in our nation's medical schools.

The good news is that there has been a dramatic change in the way research is conducted in the United States. Prompted by women's advocacy and activism, a Congressional Report in 1990 revealed that only 13 percent of the National Institutes of Health budget was spent on women's health research and that data was not being adequately analyzed for sex and gender differences. This led to the passage of legislation in 1993 requiring that women and minorities must be included in clinical trials, where appropriate.

Additionally, a broad spectrum of research is now being supported on the conditions and diseases affecting women over the lifespan. Several major studies are underway on the seasons of women's lives including a study of child health, adolescent health, the SWAN study of women at mid-life and the NIH's Women's Health Initiative -- the largest clinical research study ever conducted in either men or women focusing on the health of post-menopausal women. Findings from this study are changing recommendations for the treatment and prevention of disease in women. For example, results from this landmark study resulted in a sea of change in the use of hormone replacement therapy (HRT) when it found an increased risk of heart attacks, blood clots and breast cancer in women who took hormone replacement therapy for more than five years.

The results of it were recently confirmed with publication of the 10 year follow-up report from the study. In 2002, more than 110 million prescriptions for hormone therapy were filled. By 2009, that number had dropped to 40 million. Furthermore, an Institute of Medicine report reviewing the science underscored that sex matters at the molecular, cellular, and organ system levels. Yet, basic science studies still use mostly male animals. This must change in order to better elucidate sex differences in animal models for hypothesis generation. However, understanding only the sex (biological) differences between males and females that affect health and disease is not sufficient.

More attention must be paid to the social and environmental factors that influence women's health -- the gender differences -- as well as quality of life issues. Furthermore, despite efforts to ensure analysis and reporting of all of sex and gender differences, there remains inadequate attention to these issues in research -- this must be rectified. More reporting of racial/ethnic differences is also needed. This is important for understanding the natural history of human development as well as disease, for medical product approval, and in comparative effectiveness and policy recommendations. I believe that the study of sex and gender differences in health and disease is one of the most important and interesting research frontiers of the 21st century.

Writing a New National Prescription to Improve Women's Health

It's been said that, "it is better to light a candle than to curse the darkness." Over the past 18 years, a new national prescription has been written to improve women's health both in the Federal Government and in the private sector that has yielded lifesaving dividends. The guiding principle of this prescription is that our country's research, prevention and service delivery programs must target all of the nation's women, of all races, ages, socioeconomic and ethnic groups, and must address the health needs of the whole woman -- in body and in mind.

We defined women's health as promoting good health over the life cycle as well as addressing conditions that are specific to women; are more common or more serious in women; have distinct causes or manifestations in women; have different outcomes or treatments in women; or have high morbidity or mortality in women. Additionally, women's health means addressing unique issues as well as disparities for this population in the health delivery system, in health leadership, and in educational programs.

Some of the milestones achieved during my tenure as our country's first Deputy Assistant Secretary of Women's Health include developing a coordinated national approach and building infrastructure in the United States to improve women's health. A women's health focus was woven into the fabric of all HHS agencies and many new initiatives were established on a broad range of health issues. Scientific and public awareness was significantly increased as were collaborations across agencies of the government and the private sector using a health in all policies approach. In addition to women's health offices created in all HHS agencies, I established and appointed regional women's health coordinators to work at the state level. I also created the National Centers of Excellence in Women's Health program to help change the way research is conducted, physicians are trained, and health care is provided to women.

These Centers serve as national models for improving research, services, public and professional education, and community involvement as well as serve as a network to share best practices in women's health. They also foster the recruitment, retention, and promotion of women in academic medicine and scientific careers. A women's health curriculum was designed and distributed to health professional schools so that tomorrow's health care providers and researchers will address important sex differences in disease and health. National Community Centers of Excellence have also been established to strengthen linkages between community based organizations to enhance women's health care.

Because knowledge is power when it comes to health, I believed that women needed a single user-friendly point of access to state-of-the-art, comprehensive information about their health and was among the first in the government to harness the power of the internet for health education by establishing the National Women's Health Information Center (NWHIC). The Center, accessible through a toll free telephone number (800-944-WOMAN) and on the Internet at www.womenshealth.gov, provides consumers, health professionals, and researchers with free, state-of-art information on a broad range of women's health issues linking them to thousands of cutting-edge resources in the Federal government and private sector. This kind of resource center is critical because the public can be confused by conflicting findings and opposing recommendations from health research that is publicized in the news. This site provides trustworthy, comprehensive information on a broad range of topics and conditions. Furthermore, there is currently a 15 year science to service gap between the time of a new discovery in a research lab and its wide dissemination into clinical practice. In the Information Age, why shouldn't it be reduced to a nanosecond?

Since I first envisioned this Center and website in 1994, it's amazing to think how much has changed as a result of the information technology revolution. At that time, the internet was not being widely utilized for health. In fact, some representatives from the NIH, CDC and other federal organizations were unwilling to provide their brochures and other materials for inclusion on this new website because they were worried that their public affairs budgets might be affected by a new "one stop shopping" portal for women's health information. This led to my working with the U.S. Department of Defense -- the agency where the internet was first established -- to build the portal.

Over the next few years, as the web emerged as a powerful communication tool, we moved the site back to the U.S. Department of Health and Human Services for launching. I also directed the design and implementation of a website for college women's health, 4collegewomen.org, built by Brandeis University students for college women everywhere and three other federal government websites including nutrition.gov, safeyouth.org, and globalhealth.gov.

Another focus of my work and that of the HHS Office on Women's Health was to establish public-private sector partnerships in osteoporosis, AIDS, girl's health, senior women's health, eating disorders, mental illness, autoimmune disorders, and heart disease. For example, we established a focus on heart disease in women to educate the public and their health care providers that cardiovascular illness, long considered a disease of men only, is in fact, the leading killer of American women.

The war against breast cancer was also a top priority for my work and that of the HHS Office on Women's Health. We directed a Presidential initiative on breast cancer that was a private/public sector partnership. During this time, government and private sector funding increased to find the causes, to enhance early detection, and to improve treatment and prevention strategies. And over the past two decades, there has been some very good news: our national investment is yielding lifesaving dividends. The death rates from breast cancer have decreased from 1990 to 2008.

While the ultimate goal is to prevent breast cancer from ever occurring and to discover a cure, early detection today is critical to finding the disease early when there is the best chance of effective treatment. 15 years ago and again today, there was controversy surrounding the age at which women should obtain their first mammogram. What struck me in this debate is that mammography, the current "gold standard" for detection, is a 50-year-old technology, and that three out of four lesions it finds are benign leading to many unnecessary biopsies. Furthermore, mammograms miss about 15 percent of breast cancers. I thought that if scientists could see the surface of Mars with the Hubble telescope, then perhaps it was possible to more accurately detect small tumors in women's breasts right here on earth. That's why in 1995, I contacted the Director of the CIA, the Administrator of NASA and the General in charge of the Department of Defense's Medical Research Command, to explore whether these agency's imaging technologies used for missile detection, intelligence purposes and space exploration might be applied to improve breast cancer detection.

In 1996, the HHS Office on Women's Health, under my direction, convened a conference with scientists from the intelligence, space, and defense communities along with our nation's top radiologists. Recommendations from this meeting resulted in an initiative that I called "From Missiles to Mammograms." This unique program transferred imaging technology used by spy satellites to find tanks camouflaged behind trees to find small tumors camouflaged by dense breast tissue yielding a peace dividend from our national investment in defense.

Today, technologies including ultrasound, MRI, PET scanning, and molecular imaging are improving the diagnosis of breast and other cancers. Knowledge about the genetics and biology of cancer is leading to the development of a whole new generation of therapies with fewer side effects based on an understanding of how cancer arises and is leading to the customization of therapies -- "personalized medicine" -- for individual patients. The ultimate goal in the war against breast cancer is to prevent the disease from occurring in the first place. Studies have found that lifestyle changes (e.g., diet, physical activity, maintaining a healthy weight, limited alcohol intake) as well as certain medications (e.g., tamoxifen and aromatase inhibitors) and prophylactic mastectomies in some high risk women can help reduce the risk of breast cancer.

Clearly, much progress has been made since my mother developed the disease. Then, we could not say the word "cancer" out loud nor share her struggle with others. Today, knowledge has been expanded, the stigma has been shattered, and there is now an entire generation of women who call themselves, "cancer survivors." However, much more needs to be done to eliminate the suffering and death caused by this international enemy of women.

Mental health is also of the utmost importance for women. According to a World Health Organization report, 5 out of the 10 leading causes of disability globally are mental illnesses and one out of five people in the United States will experience a mental disorder during any year period. Yet, 25 years ago, when I began my career at the National Institute of Mental Health, there was a powerful societal stigma surrounding mental illness. At that time, these disorders were considered by many as character flaws or personal weaknesses, rather than as real, disabling illnesses just like heart disease or diabetes, for which there were established causes and effective treatments.

Thankfully, over the past two decades, much has changed in our understanding of mental illness. In 1999, the first ever Surgeon General's Report on Mental Health was released that encouraged Americans to get help if they are experiencing emotional problems. The report also underscored that mental health is fundamental to overall health. The report reviewed the scientific advances that have occurred in our understanding of the brain and behavior as well as in the causes and treatment of mental disorders over the life cycle. This new knowledge provides hope for shattering the stigma that has surrounded mental illness in the past.

Over the course of my career, I have worked to increase scientific and public attention about mental illnesses, particularly sex differences in these illnesses. For example, why do women experience eating disorders nine times more often as do men? Why do women suffer from depression twice as often as men? Why are men's suicide rates four times higher than women, but women attempt suicide four times as often as men? Why do boys have higher rates of learning disabilities and attention deficit hyperactivity disorder (ADHD)? Why do some diseases have their onset in childhood and adolescence and others later in life? What are the biological, psychosocial and environmental factors and their interactions that contribute to these differences?

Today, a broad spectrum of research is being conducted that is increasing knowledge about sex and gender differences in the causes and treatment of mental and addictive disorders. National education campaigns and service delivery programs are being supported that target the unique needs of women. Challenges ahead include increasing knowledge about prevention of mental disorders as well as achieving parity in health insurance coverage for these illnesses.

Violence against women was also made a critical priority. It is estimated that 30 percent of women are victims of physical or sexual abuse. Our nation had more animal shelters than battered women's shelters. That's why a multifaceted initiative was implemented including the establishment of a National Advisory Council, a Federal Coordinating Committee that I co-chaired, a domestic violence hotline (800-799-SAFE), increased funding for intervention and prevention programs as well as implementing training initiatives for health care providers and law enforcement officials.

Additionally, employing a health in all policies approach where all agencies of government were mobilized to address critical health issues, I established several Federal Coordinating Committees on Breast Cancer, New Imaging Technologies, and on Women's Health and the Environment to identify and eliminate environmental factors that might be contributing to increased rates of certain diseases affecting women over the past several decades.

Prevention is Preferable to Cure

Over 2000 years ago, Hippocrates wrote, "Prevention is preferable to cure." Yet, the United States is a treatment-oriented society rather than a prevention-oriented society. Our nation spends only 3-5 percent of an over 2.6 trillion dollar health care budget on population-based prevention, yet 75 percent of deaths in the United States are linked to preventable lifestyle and environmental factors.

Why is prevention so important? One hundred years ago, women and men, on average, did not live beyond their 48th birthday. Then, women died primarily from infectious diseases and also from complications of childbirth. But thanks to the triumph of government sponsored public health interventions including improved sanitation, immunization programs, safer food and water, environmental and safety regulations, advances from medical research and improved access to health care services, women in the U.S. have gained almost 30 additional years of life expectancy over the course of the past century.

Today, the major killers of American women are chronic diseases including heart disease, chronic lung disease, cancer, stroke, diabetes, and also injuries -- conditions for which as much as 50 percent of the cause is attributable to behavioral and lifestyle factors such as smoking, obesity, lack of physical activity, alcohol and substance abuse, unsafe sexual practices, and failure to use seat belts. While public health interventions have resulted in a dramatic decline in tobacco use over the past 40 years, smoking continues to be the #1 preventable cause of death in the United States with 18 percent of women smoking in our country today. Additionally, studies on sex differences have found that nicotine is more addictive and tobacco is more carcinogenic in women as compared to men. In fact, in 1987, lung cancer surpassed breast cancer as the leading cancer killer of women in the United States. Smoking also interferes with a woman's ability to become pregnant, have a healthy pregnancy and a healthy child.

Another enemy to women's health in the 21st century is the growing epidemic of obesity and sedentary behavior, the second leading preventable cause of death in the United States. Every year, 113,000 deaths a year in the U.S. are linked to obesity. 61.2 percent of women are overweight and 35.5 percent are obese. 55 percent of Americans do not get the recommended amount of physical activity by the Federal Government. In the United States, 15 percent to 18 percent of children and teenagers are overweight representing a tripling in rates since 1960. Worldwide, 400 million people are obese, and 1.6 billion are overweight. The dramatic rise in obesity has led to an epidemic of type II diabetes, the sixth leading cause of death in the United States. A recent report predicts that if these trends continue, by 2050, one in three people in America will develop type II diabetes. As a result, this may be the first generation of children that is not as healthy or live as long as their parents.

These statistics underscore why developing and implementing strategies to reduce health-damaging behaviors are so important and could decrease premature death in America by as much as 50 percent, reduce chronic disability, as well as dramatically cut health care costs. That's why a critical priority for me as Deputy Assistant Secretary for Women's Health, was to ensure that our national prevention campaigns, whether to stop smoking, to encourage a healthy diet and physical activity, and to prevent AIDS, focused on women's unique needs.

For example, I worked with the Girl Scouts to establish the first partnership between the government and this organization. It was a smoking prevention merit badge program that was launched at the White House with First Lady Hillary Rodham Clinton. We also collaborated with Federal and private sector organizations and the media to develop eating disorders and osteoporosis prevention campaigns as well as to establish a Women and AIDS Task Force.

In 2002, I served as an architect for a new HHS initiative, the Healthier U.S. campaign, to encourage Americans to engage in physical activity, eat right, obtain life-saving screening exams, and avoid other risky behaviors. In 2004, a blueprint for action was released with recommendations for various sectors of society, challenging individuals and families, schools, communities, the media, healthcare providers, researchers and businesses to put prevention first. Many new activities are underway in the public and private sectors to help women make smart and informed health decisions for themselves and their families and to ensure that the prevention of disease and the promotion of good health is a top priority.

The recent health care reform legislation, the Patient Protection and Affordable Care Act, helps to accelerate a prevention revolution by mobilizing all sectors of society to promote health. Preventive services, including routine check-ups, certain disease screenings, vaccinations, prenatal care and counseling regarding smoking, alcohol use, nutrition and obesity, will be covered by many private plans, by Medicare and by Medicaid on a state-by-state basis as the law is implemented over the next several years. The legislation also established a National Prevention Council with representation from all agencies of government as well as the creation of a National Prevention Strategy.

Prevention begins with ensuring that every girl in America has a healthy start in life. The U.S. Department of Health and Human Services (HHS) developed the Girl Power campaign and invested in risk avoidance programs as well as strategies to boost girls' self-esteem to promote a healthier future. First Lady Michelle Obama has established the Let's Move Campaign to eradicate obesity within a generation. After all, young people are our national treasures and represent 100 percent of our nation's future.

Barriers to Progress

While there have been significant advances in recent years, barriers exist that have slowed down progress in improving women's health. Socioeconomic status is the most powerful predictor of health globally. Yet, worldwide, 70 percent of the 1.4 billion people living in poverty are women. In the United States, women still earn 80 cents for every dollar earned by men. Additionally, in America today, 47 million people -- a large proportion of them women -- lack health insurance; and the number is growing. Therefore, ensuring educational and economic opportunities for women and improving access to quality health care across the life cycle are critical to achieving a healthier future for women. The recent health care legislation, The Patient Protection and Affordable Care Act should help to achieve a healthier future for women in the United States.

Another obstacle is low health literacy. Nearly one half of American adults face higher risks of health problems because they have trouble understanding medical terms and instructions. Women -- and men -- require education when it comes to their health including the medications they use and the tests and procedures that they should receive. It's our job to make that kind of health information meaningful, helpful, and easy to read and use. Several initiatives are underway to improve health literacy in the U.S. Department of Health and Human Services and in the private sector. An HHS Task Force has been established to develop strategies to effectively communicate research based health messages to women.

There's another challenge for women's health summed up by the author, Goethe, who once wrote, "Knowing is not enough; we must apply; willing is not enough; we must do." An estimated 17-year science to service gap exists from the time of a new scientific discovery to its wide application in the community. In the Information Age, why shouldn't this be a nanosecond? A great deal of important information about preventing and treating disease --the best practices of public health and evidenced based medicine -- are currently available and could be used today to improve women's health in our country and globally. Furthermore, to avoid the confusion that can occur with the release of new scientific findings on women's health (such as what occurred with the publication of the results from the Women's Health Initiative about the use of HRT), research studies should include plans for disseminating findings to the public, providers and policymakers. Intensified efforts are also needed to work with the media to communicate findings accurately to the public.

Several years ago, HHS released a report, The Decade of Health Information Technology (HIT), with recommendations about how to create a seamless information infrastructure to increase the efficiency of the health care system, to decrease medical errors, and to disseminate life saving information quickly and effectively in the United States and worldwide. Today, the Office of the National Health Information Technology Coordinator in HHS is working to integrate HIT into health care practices. The recent Economic Stimulus package as well as health care reform legislation provides funding and incentives to accomplish this goal. Developing innovative strategies to speed the time from scientific discovery to the application of new knowledge in communities is a critical priority for women's health in the 21st century in the U.S. and internationally.

Improving Women's Health: A Global Issue

Today, women's health is very much a global issue. There are over 3.4 billion women worldwide and in most regions of the world, women outnumber men. Yet, a number of factors including poverty, discrimination, and violence undermine women's health. The health status of women is critically linked to their empowerment and fundamental freedoms. Women's rights -- human rights -- are essential to national development, economic growth and global progress. However, for women in many countries, discrimination and denial of basic rights, beginning in infancy, negatively impacts their health and the trajectory of their lives. That is why worldwide education, occupational opportunities, and access to health care are critical components for a healthier future.

In many developing nations, women are experiencing the double jeopardy of both chronic and infectious diseases. While life expectancy has increased for females in most developed and developing countries, it has decreased dramatically in sub-Saharan Africa as a result of AIDS. In the early 1980's, AIDS was a disease thought to affect men only so that research and prevention efforts targeted just males leaving women unaware that they were at risk. Today, women account for 50 percent of those who have died from the disease since the beginning of the epidemic. Initiatives are underway to prevent and treat AIDS in women as well as to prevent maternal/child transmission.

Furthermore, the spread of infectious diseases including AIDS and TB (which account for 25 percent of deaths worldwide), epidemics like tobacco use and obesity, the safety of the food and water supply, violence against women, human trafficking, and the threat of bioterrorism do not recognize national borders. A woman dies in childbirth every minute in the world. In 2008, an estimated 358,000 women died due to complications during pregnancy and childbirth. These health threats are preventable.

The world's population is aging and the incidence and deaths from chronic diseases including heart disease, cancer, diabetes and Alzheimer's disease is increasing dramatically. The number of people over age 60 is expected to rise from 770 million to 1.4 billion in the next two decades -- the majority will be older women. In the United States, women represent 12 percent or the population over the age of 65. By 2050, this will rise to one in five women. Women are also the majority of caretakers for aging family members. It's why promoting healthy aging must be a top priority in America and worldwide.

While problems cross borders -- so do solutions. We are the first generation that has the science, technology, and now let's stir in the commitment and political will -- to eradicate preventable disease. That means our work cannot stop at the United States' borders for humanitarian, economic, and national security reasons. SARS crippled China and Toronto's economies because people were afraid to travel there. Millions of orphans overseas whose mothers have died of AIDS, malaria or tuberculosis are an invitation to political instability. Caring for millions of women with HIV/AIDS, tobacco and obesity related diseases, and Alzheimer's bankrupts nations of the human resources and the funds needed to build healthy communities, economies, and countries.

It's why the U.S. Department of Health and Human Services, the U.S. Department of State and many private sector organizations including the Gates Foundation and the Global Fund to Fight AIDS, TB and Malaria, support a broad spectrum of international health programs and initiatives to prevent and treat a range of global health threats to women and to empower them with education and occupational opportunities. Enhancing surveillance of disease, supporting scientific research, health systems strengthening, including health professional training, cultural sensitivity and emphasizing disease prevention are all critical components.

That's what President Obama's Global Health Initiative is all about and why empowering women is a critical component of Secretary Hillary Clinton's development and diplomacy initiatives including the newly released QQDR. But the focus on health issues in the developing world must address the double jeopardy these nations are facing due to both infectious and chronic diseases. 70 percent of the chronic disease burden is now in the developing world. There is a glaring omission of chronic disease objectives from the Millennium Development Goals (MDGs).

An upcoming United Nations Conference this Fall with address non-communicable diseases but will not focus on neurodegenerative ones like Alzheimer's. These illnesses must become priorities for attention with science and service delivery in the developing world as well. Chronic diseases also disproportionately affect women who will suffer more from these illnesses as they live longer as well as in their roles as the caretakers of family members who are affected by chronic disease and disability. The bottom line: if we can improve women's health, then we will improve the health of families, communities and countries. After all, the quest for better health crosses cultures, languages, politics, and governments.

Summary

Over the past century, advances in women's health in the United States has succeeded in almost doubling the lifespan of the average woman in America and provided a level of care previous generations could not have foreseen. In 1900, even the most prescient of people could not have imagined the dazzling scientific and technological advances such as mapping the human genome and the impact of technology on revolutionizing health care nor could they have anticipated the toll that tobacco, obesity, motor vehicle accidents, and an aging population would take on the health of women in the 21st century.

Madame Curie once remarked, "I never see what has been done, I only see what remains to be done." Yes, much progress has been made in women's health over the past two decades, but much work remains to be done. Increased research is needed on sex and gender differences in health and disease and on the conditions that affect women across the lifespan. The result will be increased knowledge that benefits women as well as men. We must also work together to make the shift from a treatment-oriented society to one of prevention; to increase the level of preparedness to meet and beat new threats to women's health and safety; to close the gap when it comes to health care disparities for women of color; and to more effectively translate what we know from science and public health to improve the delivery of services to women. We must also strengthen investments in global health and development.

The complex healthcare challenges ahead like the epidemics of tobacco use, obesity, AIDS, violence against women, and the need to increase access to quality health care require a multidisciplinary strategy -- a health in all policies approach. We can't solve public health problems alone. That's why the perspectives of public health, medicine, science, and technology must be integrated into a new paradigm to address the opportunities and challenges ahead. The good news is that the government and private sector have been mobilized and are working together in partnerships, leveraging skills and resources, to improve prevention, research, and service delivery programs for women in our country and globally. If we remain vigilant, the results of these efforts should brighten the health futures for women --and men-- in the 21st century.

* Rear Admiral Susan Blumenthal, M.D. (ret.) is the Public Health Editor of the Huffingon Post. She serves as Director of the Health and Medicine Program at the Center for the Study of the Presidency and Congress in Washington, D.C., a Clinical Professor at Georgetown and Tufts University Schools of Medicine, and Chair of the Global Health Program at the Meridian International Center. She served for more than 20 years in health leadership positions in the Federal government in the Administrations of four U.S. Presidents, including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, as a White House Advisor on Health, and as Chief of the Behavioral Medicine and Basic Prevention Research Branch at the National Institutes of Health. Dr. Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the U.S. Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide and was the recipient of the 2009 Health Leader of the Year Award from the Commissioned Officers Association. Admiral Blumenthal has been named by the National Library of Medicine, The New York Times and the Medical Herald as one of the most influential women in medicine and by GQ magazine and the Geoffrey Beene Foundation as a 2010 Rock Star of Science.

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