Equity, Almost: Justice, Gender and the Health of Populations

As we contemplate a potential Hillary Clinton presidency, it would be easy to think that we live in a new era of equality between the sexes. How, after all, could one woman be on the verge of cracking what she once called the "highest and hardest glass ceiling" if things were otherwise? How could we see women operating at the top levels of the corporate and political world if real progress had not been made? Here in in the U.S., after all, we've seen women serving as frontline soldiers, running Harvard University, and sitting on the Supreme Court.

But this rosy picture is, in many ways, a mirage, and it is particularly so when it comes to gender equity and the health of populations.

Let us start with the obvious. If your daughter is coming of age in 2016, the situation facing her is this: If she lives in a poorer country, her chances of having appropriate access to reproductive care will be around 50-50. If she lives in Texas, her odds of obtaining such care may soon be about as slim. The outcome of a current case in front of the Supreme Court will test the constitutionality of a law requiring clinics that provide abortions to meet the same standards as ambulatory surgery centers, effectively making it impossible for many of these clinics to operate. Despite the Court's encouraging decision last week to block a similar Louisiana law, the rights of women to receive basic reproductive care remain hotly contested throughout the country.

But the challenges to gender equity and health extend much deeper than reproductive health. At heart, challenges to the health of women rest on the inequities that shape many of the foundational causes of health worldwide. Equity, in the context of health, refers to health outcomes that are determined by social, economic, cultural, and political factors that are unfairly distributed across and among populations. It is the difference, for example, between a mental health problem arising from a genetic mutation and depression arising from the combined stressors of gender segregation, a wage gap, and, all too often, the specter of domestic violence. In order to make things better, we must identify and attack these fundamental drivers of inequity, these social causes of disease.

A forward-looking approach to this issue should aspire to tackle the root causes of gender inequities in health, in accordance with the aspirations of public health. This is not just a matter of a matter of doctors treating patients. We must address the fact that when a woman enters the workforce, she will likely be paid less than her male peers. Sadly, the probability of her participating in the global labor force at all currently stands at about 16 percent less than that of men.

In an age when our daughters are obliged to hear politicians debate whether the right of women to make their own reproductive choices is actually a right at all, policymakers continue to drag their feet on issues of equity. When they are not dithering, they are often actively impeding the process, as in Texas. The consequences of this can be seen in the poor health outcomes in states where such counterproductive behavior is particularly widespread.

This represents a tremendous missed opportunity. An abundance of evidence shows that legislation designed to level the gender playing field, such as policies that provide support for working mothers, are associated with better health. Social, structural, and economic policies shape both workplace conditions and the possibility for social and economic mobility. It is, unfortunately, the case that such policies are sorely lacking in many countries worldwide--particularly, and glaringly, in the United States.

It is important to note that when the gender playing field is not level, it hurts men, too. This issue affects not just the health of women, but also that of their families, social networks, and children, resulting in intergenerational effects that have health consequences that far outlast the present circumstances that shape gender equity today.

Should Hillary Clinton win the nomination, and then the presidency, it will be a landmark achievement in the struggle for a more equal society. But it will not be a game-changer. The Supreme Court's decision to reopen the question of abortion rights for the first time in almost a decade--together with International Women's Day today, March 8--remind us that indeed we have a long way to go.