1. Global Health and Gender Michele Barry, M.D., FACP Professor of Medicine and Global Health Yale University School of Medicine Director of Office of International Health AYA April 30, 2004 Michele Barry, M.D., FACP Professor of Medicine and Global Health Yale University School of Medicine Director of Office of International Health AYA April 30, 2004

2. Gender and Global Health Women Gender and 10/90 GapWomen Gender and 10/90 Gap HIV/AIDS and WomenHIV/AIDS and Women Maternal and Reproductive HealthMaternal and Reproductive Health Missing WomenMissing Women Gender Based ViolenceGender Based Violence Research on Gender and Global HealthResearch on Gender and Global Health Women Gender and 10/90 Gap HIV/AIDS and Women Maternal and Reproductive Health Missing Women Gender Based Violence Research on Gender and Global Health

3. Gender and 10/90 GAP 10/90 GAP = only 10% current global funding for research is spent on diseases that afflict 90% of the world ’ s population In developing countries- Women have less access to health care and Women have less access to health care and gender analysis to health research is lacking. gender analysis to health research is lacking. There are distinct differences in patterns of There are distinct differences in patterns of health and health outcomes when gender analysis is applied health and health outcomes when gender analysis is applied 10/90 GAP = only 10% current global funding for research is spent on diseases that afflict 90% of the world ’ s population In developing countries- Women have less access to health care and Women have less access to health care and gender analysis to health research is lacking. gender analysis to health research is lacking. There are distinct differences in patterns of There are distinct differences in patterns of health and health outcomes when gender analysis is applied health and health outcomes when gender analysis is applied

4. Leading Causes of Death in Women Worldwide - 2001 HIV/AIDS1.3 million Malaria 592,000 Maternal Conditions 509,000 Tuberculosis 500,000 Source: World Health Report 2002, World Health Organization HIV/AIDS1.3 million Malaria 592,000 Maternal Conditions 509,000 Tuberculosis 500,000 Source: World Health Report 2002, World Health Organization

5. Gender and Global Health Women Gender and 10/90 GapWomen Gender and 10/90 Gap HIV/AIDS and WomenHIV/AIDS and Women Maternal and Reproductive HealthMaternal and Reproductive Health Missing WomenMissing Women Gender Based ViolenceGender Based Violence Research on Gender and Global HealthResearch on Gender and Global Health Women Gender and 10/90 Gap HIV/AIDS and Women Maternal and Reproductive Health Missing Women Gender Based Violence Research on Gender and Global Health

6. HIV/AIDS and Women More than 50% of those living with HIV are women < 1% globally have access to anti-retrovirals < 1% globally have access to anti-retrovirals In sub-Saharan Africa nearly twice as many women as men are infected More than 50% of those living with HIV are women < 1% globally have access to anti-retrovirals < 1% globally have access to anti-retrovirals In sub-Saharan Africa nearly twice as many women as men are infected

7. HIV/AIDS and Women Potential reasons Biological differences of risk of acquisition Biological differences of risk of acquisition Economic vulnerability leading to transactional sex Economic vulnerability leading to transactional sex Coerced sex/rape/marriage Coerced sex/rape/marriage Inability to negotiate condom use Inability to negotiate condom use Potential reasons Biological differences of risk of acquisition Biological differences of risk of acquisition Economic vulnerability leading to transactional sex Economic vulnerability leading to transactional sex Coerced sex/rape/marriage Coerced sex/rape/marriage Inability to negotiate condom use Inability to negotiate condom use

8. HIV/AIDS and Women Biological differences of risk of acquisition Several studies have shown that it is easier for a woman to contract HIV/AIDS from a sexual contact with an infected man than it is for a man with an infected woman The presence of an untreated STI increases the risk to contract 10X. STIs often do not give rise to any symptoms in women so they remain untreated or unrecognised Coerced sex increases risk of micro-lesions; more frequent for women, although also important in young boys Several studies have shown that it is easier for a woman to contract HIV/AIDS from a sexual contact with an infected man than it is for a man with an infected woman The presence of an untreated STI increases the risk to contract 10X. STIs often do not give rise to any symptoms in women so they remain untreated or unrecognised Coerced sex increases risk of micro-lesions; more frequent for women, although also important in young boys

9. Gender and Global Health Women Gender and 10/90 GapWomen Gender and 10/90 Gap HIV/AIDS and WomenHIV/AIDS and Women Maternal and Reproductive HealthMaternal and Reproductive Health Missing WomenMissing Women Gender Based ViolenceGender Based Violence Research on Gender and Global HealthResearch on Gender and Global Health Women Gender and 10/90 Gap HIV/AIDS and Women Maternal and Reproductive Health Missing Women Gender Based Violence Research on Gender and Global Health

10. Maternal Deaths

11. Reasons for Maternal Deaths in Low Income Countries Low income countries - 53% attended during delivery 30% receive postnatal care

13. Safe Motherhood Projects NGOs White Ribbon Alliance – www.whiteribbonalliance.org Family Care International – www.familycareintl.org Save the Children – www.savethechildren.org Technology in Health (PATH) (technical assistance to discourage FGM) – Technology in Health (PATH) (technical assistance to discourage FGM) – www.path.org Gates Institute for Population and Reproductive Health www.jhsph.edu/GatesInstituteNGOs White Ribbon Alliance – www.whiteribbonalliance.org Family Care International – www.familycareintl.org Save the Children – www.savethechildren.org Technology in Health (PATH) (technical assistance to discourage FGM) – Technology in Health (PATH) (technical assistance to discourage FGM) – www.path.org Gates Institute for Population and Reproductive Health www.jhsph.edu/GatesInstitute

14. Gender and Global Health Women Gender and 10/90 GapWomen Gender and 10/90 Gap HIV/AIDS and WomenHIV/AIDS and Women Maternal and Reproductive HealthMaternal and Reproductive Health Missing WomenMissing Women Gender Based ViolenceGender Based Violence Research on Gender and Global HealthResearch on Gender and Global Health Women Gender and 10/90 Gap HIV/AIDS and Women Maternal and Reproductive Health Missing Women Gender Based Violence Research on Gender and Global Health

15. Missing Women Number of Women per 1000 Men, India

16. Missing Women 60 million “ missing girls ” mostly in Asia Reasons: Neglect of female children in health care, admissions to hospitals and feedingsNeglect of female children in health care, admissions to hospitals and feedings Female infanticide/abortions/dowry deathsFemale infanticide/abortions/dowry deaths Maternal mortalityMaternal mortality 60 million “ missing girls ” mostly in Asia Reasons: Neglect of female children in health care, admissions to hospitals and feedingsNeglect of female children in health care, admissions to hospitals and feedings Female infanticide/abortions/dowry deathsFemale infanticide/abortions/dowry deaths Maternal mortalityMaternal mortality

17. Missing Women – Young Adults DOWRY DEATHS:DOWRY DEATHS: –Bride burning - Dowry Deaths India –1987 - 1,786 dowry deaths in India (frequently kerosene burning) –Maharashtra state 19% deaths women 15-44 “ accidental burns ” –< 1% in Guatemala, Ecuador HONOR KILLINGS: (1000 Pakistan – 1999)HONOR KILLINGS: (1000 Pakistan – 1999) DOWRY DEATHS:DOWRY DEATHS: –Bride burning - Dowry Deaths India –1987 - 1,786 dowry deaths in India (frequently kerosene burning) –Maharashtra state 19% deaths women 15-44 “ accidental burns ” –< 1% in Guatemala, Ecuador HONOR KILLINGS: (1000 Pakistan – 1999)HONOR KILLINGS: (1000 Pakistan – 1999)

18. Gender and Global Health Women Gender and 10/90 GapWomen Gender and 10/90 Gap HIV/AIDS and WomenHIV/AIDS and Women Maternal and Reproductive HealthMaternal and Reproductive Health Missing WomenMissing Women Gender Based ViolenceGender Based Violence Research on Gender and Global HealthResearch on Gender and Global Health Women Gender and 10/90 Gap HIV/AIDS and Women Maternal and Reproductive Health Missing Women Gender Based Violence Research on Gender and Global Health

19. Violence Against Women - Internationally Female Circumcision and Mutilation >80 million women in 39 countries worldwide have undergone female mutilation of the external sex organs. 2 million annually undergo circumcision Female Circumcision and Mutilation >80 million women in 39 countries worldwide have undergone female mutilation of the external sex organs. 2 million annually undergo circumcision

20. Violence Against Women - Internationally Definitions: 3 types of “ female mutilation ” 1.Circumcision (type I - sunna) cutting of the hood of the clitoris (least severe) - least practiced 2.Excision (type II - reduction) removal of clitoris and labia minora 3. Infibulation (Type III - “ pharaonic circumcision ” ) cutting of clitoris, labia minora and medial part of labia. Two sides of the vulva are sewn with catgut and a small opening is left for menses Age: few days old (Ethiopia), 7 years (Egypt, Central Africa), Adolescence (Nigeria, Tanzania) Age: few days old (Ethiopia), 7 years (Egypt, Central Africa), Adolescence (Nigeria, Tanzania) Definitions: 3 types of “ female mutilation ” 1.Circumcision (type I - sunna) cutting of the hood of the clitoris (least severe) - least practiced 2.Excision (type II - reduction) removal of clitoris and labia minora 3. Infibulation (Type III - “ pharaonic circumcision ” ) cutting of clitoris, labia minora and medial part of labia. Two sides of the vulva are sewn with catgut and a small opening is left for menses Age: few days old (Ethiopia), 7 years (Egypt, Central Africa), Adolescence (Nigeria, Tanzania) Age: few days old (Ethiopia), 7 years (Egypt, Central Africa), Adolescence (Nigeria, Tanzania)

21. Documented Female Circumcision

22. Violence Against Women-Internationally Health Sequelae of Female Circumcision 83% women will have a medical complication Immediate: hemorrhage (within 10 days) urethral damage or other adjacent organs, tetanus, infection, urinary retention from pain Long term: chronic infections, scarring, pelvic infections, dysmenorrhea, dyspareunia (painful intercourse), difficulty with urination Effects on Childbirth: need for de-infibulation delayed labor-increased mortality fistulas Unknown Effects: ?HIV transmission, sexuality, psychological trauma ?HIV transmission, sexuality, psychological trauma 83% women will have a medical complication Immediate: hemorrhage (within 10 days) urethral damage or other adjacent organs, tetanus, infection, urinary retention from pain Long term: chronic infections, scarring, pelvic infections, dysmenorrhea, dyspareunia (painful intercourse), difficulty with urination Effects on Childbirth: need for de-infibulation delayed labor-increased mortality fistulas Unknown Effects: ?HIV transmission, sexuality, psychological trauma ?HIV transmission, sexuality, psychological trauma

23. Violence Against Women - Internationally Potential Solutions Cultural consciousness (WHO position papers on female mutilation)Cultural consciousness (WHO position papers on female mutilation) Education (street theater-India describing dowry deaths)Education (street theater-India describing dowry deaths) Grassroot activism (e.g. Brazil ’ s all female police station)Grassroot activism (e.g. Brazil ’ s all female police station) Legal reform (female mutilation)Legal reform (female mutilation) SheltersShelters International cooperation/fundingInternational cooperation/funding Potential Solutions Cultural consciousness (WHO position papers on female mutilation)Cultural consciousness (WHO position papers on female mutilation) Education (street theater-India describing dowry deaths)Education (street theater-India describing dowry deaths) Grassroot activism (e.g. Brazil ’ s all female police station)Grassroot activism (e.g. Brazil ’ s all female police station) Legal reform (female mutilation)Legal reform (female mutilation) SheltersShelters International cooperation/fundingInternational cooperation/funding

24. A Life Cycle Approach

25. Female literacy and health: 1 additional year schooling = 3.4% reduction in mortality

26. A Life Cycle Approach

28. Gender and Global Health Women Gender and 10/90 GapWomen Gender and 10/90 Gap HIV/AIDS and WomenHIV/AIDS and Women Maternal and Reproductive HealthMaternal and Reproductive Health Missing WomenMissing Women Gender Based ViolenceGender Based Violence Research on Gender and Global HealthResearch on Gender and Global Health Women Gender and 10/90 Gap HIV/AIDS and Women Maternal and Reproductive Health Missing Women Gender Based Violence Research on Gender and Global Health

29. Gender “ Mainstreaming ” Mainstream gender issues and awareness into programs at WHO, UN, World Bank, public health initiatives Mainstream gender issues into research www.who.int/gender/enwww.globalforumhealth.org Mainstream gender issues and awareness into programs at WHO, UN, World Bank, public health initiatives Mainstream gender issues into research www.who.int/gender/enwww.globalforumhealth.org

30. Source: Abou-Gareeb, Lewallen, Bassett and Coutright. Gender and blindness: a meta-analysis of population based prevalence surveys. Opthalmic Epidemiology 2001; 8:39-56 Source: Abou-Gareeb, Lewallen, Bassett and Coutright. Gender and blindness: a meta-analysis of population based prevalence surveys. Opthalmic Epidemiology 2001;8:39-56 BURDEN OF BLINDNESS IN MEN AND WOMEN

31. Higher prevalence of blindness among women:Why? Do the greater life spans of women account for the greater burden of degenerative blindness? - But more women are blind at all older ages. Must be another explanation. Is there differential mortality among blind men/women? - - Available evidence does not seem to suggest this. Do the greater life spans of women account for the greater burden of degenerative blindness? - But more women are blind at all older ages. Must be another explanation. Is there differential mortality among blind men/women? - - Available evidence does not seem to suggest this.

32. Higher prevalence of blindness among women: Why? Studies show that women have a higher biological predisposition Studies show that women have a higher biological predisposition to cataract than men, and a socio-cultural predisposition to to cataract than men, and a socio-cultural predisposition to trachoma (i.e. through child care activities, household trachoma (i.e. through child care activities, household environment etc). environment etc). Differential use of eye-care services due to differences Differential use of eye-care services due to differences in gender roles and behaviors. in gender roles and behaviors. Studies have found distinct differences between men and women Studies have found distinct differences between men and women in surgical coverage across age groups – access to cataract in surgical coverage across age groups – access to cataract surgery/trachoma surgery/trachoma Studies show that women have a higher biological predisposition Studies show that women have a higher biological predisposition to cataract than men, and a socio-cultural predisposition to to cataract than men, and a socio-cultural predisposition to trachoma (i.e. through child care activities, household trachoma (i.e. through child care activities, household environment etc). environment etc). Differential use of eye-care services due to differences Differential use of eye-care services due to differences in gender roles and behaviors. in gender roles and behaviors. Studies have found distinct differences between men and women Studies have found distinct differences between men and women in surgical coverage across age groups – access to cataract in surgical coverage across age groups – access to cataract surgery/trachoma surgery/trachoma

33. Gender Mainstreaming at World Health Organization Gender and Women ’ s Health Department at WHO Gender and Women ’ s Health Department at WHO Gender Team at WHO - Gender Team at WHO - promote awareness into programs at WHO and public health work public health work Gender Task Force – Gender Task Force – senior level managers report gender mainstreaming to Director General Gender and Women ’ s Health Department at WHO Gender and Women ’ s Health Department at WHO Gender Team at WHO - Gender Team at WHO - promote awareness into programs at WHO and public health work public health work Gender Task Force – Gender Task Force – senior level managers report gender mainstreaming to Director General