November 9, 2009
Excellencies, colleagues in the UN system, colleagues in public health, representatives of civil society, ladies and gentlemen,
What gets measured gets done.
I commissioned this report on women and health to gather a baseline of data about the health of women and girls throughout the life-course, in different parts of the world, and in different groups within countries.
I did so based on my conviction that the health of women has been neglected, that this neglect is a major impediment to development, and that the situation needs to improve. I did so based on my conviction that women matter in ways far beyond their role as mothers.
My conviction is backed by commitment. When I took office in early 2007, I made the health of women and of the people of Africa my top priorities. Because so many factors shape health outcomes in these two groups, improvements are a good measure of the overall performance of WHO.
From this report, we clearly see that the health status of girls and women in sub-Saharan Africa is, by nearly every measure, the lowest in the world. Let me give just one example. For women aged 20 to 60 years in affluent countries, the risk of premature death is only 6%. In sub-Saharan Africa, the risk is 42%, or seven times higher.
Before taking action on any health problem, we must first take stock. Efficient policies for change must deliberately address areas where progress is inadequate, specific needs are not being met, deaths and illness can be prevented, or trends over time give cause for alarm.
When we compare the health of women and men, what differences do we see, and what does this tell us? When we compare women across geographical regions, cultures, and income groups, where are the gaps in health outcomes and what are the trends? Where gaps exist, can we pinpoint the reasons why?
Through its epidemiological analysis of existing data, this report on women and health deepens my conviction that many health needs of women are not being met. It deepens my commitment to call for action and guide a targeted response.
But let me be very clear at the start. As this report reveals, the obstacles that stand in the way of better health for women are not primarily technical or medical in nature. They are social and political, and the two go together.
We will not see significant progress as long as women are regarded as second-class citizens in so many parts of the world. We will not see significant progress as long as women are excluded from educational and employment opportunities, are paid less or not paid at all, are denied the right to own property, are victims of violence, have no control over household income, and have no freedom to spend money on health care, even if it means saving their own lives.
We will not see significant progress when so many women accept their inferior status, acquiesce, suffer, and endure. In so many societies, men exercise political, social, and economic control. The health sector has to be concerned. These unequal power relations translate into unequal access to health care and unequal control over health resources.
In fact, an assessment of health outcomes in girls and women is a reliable way to quantify what the low social status of women really means. And this must be our starting point.
What gets measured gets done. And what this report has measured is the profound impact that social status has on the health of women and girls.
Now that we know what we are up against, how do we move forward? I can assure you: this is not an easy task. In public health, it is arguably easier to deliver medicines, bednets, and other interventions, even on a massive scale, than it is to change attitudes and behaviours, including sexual behaviours, fight discrimination, and raise the status of women.
But societies create unequal relationships and policies sustain them. These things can change.
Ladies and gentlemen,
Let us look at some of the evidence.
Thanks to this report, we are beginning to see some patterns and beginning to get some answers. But if we want to base action on evidence and answers, we are only at the start. The neglect of women's health extends to the research community and statistical services.
One of the striking findings of the report is the paucity of statistics on key health issues that affect girls and women, especially in developing countries. In some areas, we are still in the dark. In others, the picture is becoming clear.
Girls begin life with a biological advantage. In general, women live six to eight years longer than men. As the report shows, female babies and young girls do not die with greater frequency than boys. Childhood immunization programmes show no gender inequality in coverage. Girls are protected just as well as boys.
But as we look at data along the life-course, this early situation changes and the impact of women's lower social status becomes apparent. Where this situation prevails, females will continue to be taken for granted, and taken advantage of.
From the report, we know that up to 80% of all health care and 90% of care for HIV/AIDS-related illness is provided in the home, almost always by women. Most of this work is unsupported, unrecognized, and unremunerated. Women are less likely than men to be in formal employment. They work most of their waking hours but are not paid. Because they are less likely to be part of the formal work force, women lack access to job security and the benefits of social protection, including access to health care.
Worldwide, more than 580 million women are illiterate, which is more than twice the number of illiterate men. The impact of educational status on the health of women and their families is very well documented. How can we tolerate such a huge difference in such a hugely important opportunity?
A full 38% of girls in developing countries, notably in Asia, marry before the age of 18, and 14% do so before the age of 15. If these young ladies are lucky, health services will be able to manage at least some of the well-know health risks associated with early childbearing. But public health cannot prevent early marriage.
These are social and political problems. They extend beyond the borders of public health and are too big, too tangled up in social and cultural norms to be solved by technical or medical interventions alone, or even by much-needed reforms in health systems.
Societies and the political leaders who govern them must first decide that the health of women matters. Public health can do some things, of course. We can promote better access to sexual and reproductive health services. We can do something about cervical cancer or risks for the many chronic diseases that plague women later in life. We can map out clear technical strategies for reducing deaths associated with pregnancy and childbirth.
But such efforts will ultimately have a patchy and limited impact because they do not address the root causes of unmet health needs in girls and women. The root causes reside in social attitudes, norms, and behaviours and the policies that perpetuate them.
When the health status of women in high- and low-income countries is compared, the results are predictable and telling. In all regions and age groups, girls and women in higher income countries have lower levels of mortality and burden of disease than those who live in low-income countries.
It is tempting to conclude that poverty is the single most important determinant of health problems in females, and that, as economies grow, countries modernize, and incomes rise, the problems will gradually, automatically go away all by themselves. Poverty is important, but the evidence points to many other factors.
Women have some biological vulnerabilities, related to their reproductive functions, that make them susceptible to certain special health risks. We have known this for ages. But is biology destiny throughout the life course, before and after the reproductive years? Better health outcomes in high income groups tell us that the answer is no.
Biology certainly cannot explain why 99% of maternal mortality is concentrated in the developing world. Biology cannot explain why the health problems and the leading causes of mortality and disability differ so dramatically between women in high- and low-income groups.
In high-income countries, chronic diseases such as heart disease, stroke, dementias and cancers predominate in the 10 leading causes of death, accounting for more than 4 in every 10 female deaths.
In low-income countries, maternal and perinatal conditions, lower respiratory tract infections, diarrhoeal diseases, and HIV/AIDS account for nearly four in every 10 female deaths. On the positive side, tools are available to prevent or readily treat all of these conditions.
This points to another problem: the failure of health services to meet women's needs. Cervical cancer provides a vivid example of what lack of equitable access to health services means. Globally, cervical cancer is the second most common type of cancer among women. Around 80% of cervical cancers and an even higher proportion of deaths occur in low-income countries. This is a cancer that can be prevented by a vaccine, detected early by screening, and treated early with good results. These deaths should not be happening.
In developing countries, complications of pregnancy and childbirth are the leading cause of death and disability among 15-19 year old women. Unsafe abortion contributes substantially to these deaths. This points to an urgent need to improve access to sexual and reproductive health services.
As noted, women generally live longer than men, but their lives are not necessarily healthy or happy. As the report shows, women are more susceptible to depression and anxiety than men. An estimated 73 million adult women worldwide suffer a major episode of depression each year. While the causes of mental ill health vary from one individual to another, women's low status in society, their burden of work, and the violence they experience are contributing factors.
Trends are ominous and strongly influenced by the globalization of unhealthy lifestyles. The female advantage in life expectancy is being lost in some parts of the world. Malnutrition as a risk factor for poor pregnancy outcome is now joined by high blood pressure, high cholesterol levels, tobacco use, obesity and violence.
Cardiovascular disease, long considered a male disease in rich societies, is now the main killer of older women nearly everywhere.
Ladies and gentlemen,
We have known for ages that, as standards of living improve, health gets better. But this is usually a gradual process stretched out over a considerable time.
Recent decades have seen some striking progress for women. Life expectancy for women has increased from just 51 years in the early 1950s to 70 years in 2007, compared with 65 years for men. The use of contraception in developing countries has risen from 8% in the 1960s to 62% in 2007. Women are generally marrying later, having their first babies later, and living longer.
This is striking progress, but it has taken place over a strikingly long time. This is my big question to you. Do we want to wait for the health of women to gradually improve, or are we compelled to take deliberate action now? What is at stake?
Around 85% of the world's population of 3.3 billion females live in low- and middle-income countries. Poverty is important, but the report also found a direct link between discrimination against women and lower health status.
If women are denied a chance to develop their full human potential, including their potential to lead healthy and at least somewhat happier lives, is society as a whole really healthy? What does this say about the state of social progress in the 21st century?
A call for action must reach beyond the health sector into areas such as education, transport, employment, and legal and judicial frameworks. Essentially, this is a call for women-centred policy-making and programming in all sectors, in a whole-of-government approach.
Above all, primary health care, with its focus on equity, social justice, and giving people a voice, offers an opportunity to make a difference through policy change. And we need the voice and clout of civil society to bring political leaders to account.
With the launch of this report, WHO intends to start a broad policy dialogue to work out an agenda for change both within and well beyond the health sector.
Finally, there is no global prescription for change. Agendas for action must be context-specific. As the report reveals, health problems in women vary considerably across countries and regions. For example, adolescent pregnancy is a major concern in many countries. In others, suicides in women who ingest pesticides need to be addressed. This is a horrific way to die and a clear signal of utter, unbearable misery.
We must be alert to these signals and respond with the compassion and care that are hallmark traits of what it means to be a women, anywhere, everywhere.