Downs, Jennifer A. MD, MSc; Reif, Lindsey K. MPH; Hokororo, Adolfine MD, MMED; Fitzgerald, Daniel W. MD
Worldwide, nearly one million young women die each year because of maternal complications, breast cancer, or cervical cancer—deaths mostly preventable in resource-rich settings.1 Women in Sub-Saharan Africa have a lifetime maternal mortality risk of 1 in 31—100-fold higher than women in wealthier regions.2 Maternal deaths particularly devastate families: children whose mothers die are three times more likely to die than other children.3 Neglect of women’s health is causally related to discrimination in access to education, employment, and economic opportunities.4 Because of high rates of preventable mortality among women in resource-poor countries, women’s health is a central focus of global health. Of the eight Millennium Development Goals established by the United Nations to eradicate extreme poverty by 2015, two specifically target women’s health.5
We define global health as a multi disciplinary field of service, research, and training that seeks to improve the health of both individuals and populations and to achieve health equity for all people worldwide, especially for the resource-poor.6 Given the importance of women’s health to global health, it is surprising that female leadership in the field is sparse. For instance, women constitute only 26% (14/54) of African ministers of health and 24% (12/50) of directors of global health centers at the top 50 U.S. medical schools. We espouse the principle stated recently by Anne-Marie Slaughter in The Atlantic: “Only when women wield power in sufficient numbers will we create a society that genuinely works for all women.”7 Although a gender gap in leadership exists in many fields, including government, business, law, and education, the gap in global health is particularly troubling because women’s health and reducing unjust health inequalities are central to the field. Closing the gender gap in global health leadership will not in itself solve all women’s health problems. But it is an overdue first step.
The potential benefits of female leadership have been cogently demonstrated in development work. A recent study in India examined neonatal mortality by district, comparing only districts in which an elected official of one gender defeated a politician of the opposite gender by a margin of <3.5%, based on the assumption that the gender of the elected official in these very close elections is “quasi-random.” Investigators showed that, for every one-standard-deviation increase in the number of female-held seats in the district council, neonatal mortality dropped by 1.5%.8 Women leaders were also more likely to support health facilities, antenatal care, and immunizations.8 Another study in India exploited the randomization created by a 1993 constitutional amendment that required rural villages, based randomly on a village’s long-standing administrative number, to have or not to have their village councils headed by a female leader. After controlling for multiple confounders, investigators demonstrated that women tended to invest in public works more closely linked to women’s concerns, such as clean drinking water, while men invested in works more aligned with men’s concerns, such as irrigation systems for farming.9 Ten years after the implementation of these random leadership assignments, adolescent girls in the villages with female leaders received significantly more education, had higher job aspirations, and spent less time on domestic chores than girls in the villages without female leaders.10 A similar study in rural Afghanistan showed that women living in villages that had been randomly assigned to a program requiring 50% female council representation, compared with women in villages without the requirement, were significantly more likely to generate their own income and to rate their village leaders as acting in the best interest of the entire village.11 These field analyses and others support the principle that leaders’ genders influence both their decisions and the welfare of women in their jurisdictions.12–14
On the basis of this tenet, we believe that striving for gender parity in global health leadership will affect global health policy and practice. In this article, we investigate reasons for the female leadership shortage in global health and propose solutions. We focus on academic global health as an example, recognizing that global health is a broad field additionally encompassing disciplines such as human rights, development, and politics. We draw on both the literature and our experience in Africa and the United States.
The training pathway for academic global health typically begins with an advanced graduate degree (MD, PhD, MPH, etc.) followed by postdoctoral field work and, ultimately, a career in academia, government, or multilateral or nongovernmental organizations. Global health careers for individuals from resource-rich countries usually require a significant time commitment to international field work. Individuals from resource-poor countries frequently must travel abroad long-term to obtain graduate education and advanced training. Additionally, the field of global health necessitates a broad skill set including scientific capability, facility with foreign language, cultural sensitivity, flexibility, diplomacy, leadership, team building, and physical stamina to work in remote, resource-poor areas.
WOMEN IN GLOBAL HEALTH AT VARIOUS CAREER STAGES
At Cornell University, where we work, 84% of undergraduate and 70% of graduate students interested in global health are women. However, the percentage of women progressively decreases at each step in the global health career ladder, such that fewer than 25% of leadership roles in the field are held by women (Table 1). In many resource-poor countries, women in global health are scarcer at all stages of their careers. At the Tanzanian medical school where we serve as faculty, women constituted only 36% of matriculating medical students and 17 of 58 physicians (29%) pursuing specialization from 2010 through 2012. Only one of Tanzania’s four regional referral hospitals and one of its five major medical schools have female directors. We share this perspective of the women in global health at our two institutions in the United States and Tanzania with the concern that this represents a larger trend and with the hope that this demonstrates that there are many young women committed to filling the gender gap in global health leadership if career obstacles can be overcome.
We believe that women leave the global health career pipeline partly because they encounter gender-based obstacles as their careers advance. We recognize that some generational differences may exist. More young women in 2013 are interested in global health than in 1973,15,16 and percentages of female leaders may increase as this generation ages. But clearly we have not reached parity in leadership despite the overwhelming interest of young women and the centrality of women’s health to the field. We postulate that, despite increased numbers of interested young women, we will not reach parity without proactive efforts to remove obstacles that uniquely hinder the ability of women to pursue careers in global health.
Strategies have been successfully implemented to expand female leadership in business and politics. One company, named by McKinsey and Company as one of the top 12 gender-diverse companies of 2012, offers intense training to promising midlevel career women, giving them protected time away from work for executive leadership conferences; most of these women are ultimately promoted to senior management positions.17 After the 1994 Fourth World Conference on Women in Beijing, 189 governments signed the Beijing Platform for Action, agreeing to a target that at least 30% of their national decision-making positions should be held by women.18 The worldwide percentage of females in national assemblies has nearly doubled since then, with highest female leadership rates in countries that have added a female quota requirement to their constitutions.19,20 These examples demonstrate that the enactment of programs and policies designed to increase female leadership does, in fact, achieve this goal.
Below, we describe gender-based obstacles and suggest possible solutions, applicable both in resource-wealthy and resource-poor settings, to overcome these impediments. We group issues into three categories: (1) challenges climbing institutional career ladders, (2) tensions between career and family responsibilities, and (3) health and safety issues. Some of these issues affect women in other disciplines of academic medicine and also affect men, but these issues are more acute for women in global health because of international travel, prolonged periods overseas, health and safety concerns in developing countries, and the lack of payment for providing service to poor patients who cannot pay for clinical care.
Obstacle 1: Challenges Climbing Institutional Career Ladders
Professional women in global health commonly confront gender bias and discrimination at work.21,22 In resource-poor settings, discrimination is frequently overt. Female colleagues in Africa report enduring sexual harassment, being discouraged from becoming pregnant during training, and encountering difficulty being promoted if they are perceived as outspoken.23,24 In resource-rich countries, bias is often covert. A recent randomized, double-blind study demonstrated that science faculty members at American universities viewed men as more competent and deserving of a higher starting salary than equivalently qualified women.25 American female physicians are promoted less often than men, even after adjusting for number of hours worked, productivity, and specialty choice.26
Financial constraints can further impair the ability of both men and women to pursue careers in global health. Funding for global health work is relatively scarce, and competition for financial support can be fierce even at the medical student level.27 After achieving faculty appointments, those working internationally cannot easily make up a portion of their salary through clinical work because they are working with poor populations who cannot pay clinical fees. Therefore, these individuals may require more departmental financial support. Those who attempt to balance clinical or teaching work in their home country with time overseas may face the complication of repeatedly asking colleagues to cover for them. In our experience, this issue is exacerbated for women in their childbearing years, whose colleagues may also be required to provide coverage during their maternity leaves.
Leadership grants for women from resource-poor countries.
We urge donors to fund career development grants or scholarships to cultivate female leadership in health care institutions within resource-poor countries. These grants should provide time for women to focus on training, including (1) didactic courses to acquire technical skills; (2) mentored service, research, or training projects; and (3) leadership and management training. Grants should ensure sufficient protected time from clinical/teaching responsibilities, with flexible schedules to accommodate maternity leave. Grants should be contingent on institutional commitment to promote dedicated and productive women to positions of leadership.
Mentors and role models strongly influence career advancement. We suggest that global health organizations and centers create mentorship and career guidance teams specifically for women. Because female mentors in global health are limited, we recommend involving female mentors from other global or international professions. Mentors can suggest strategies for balancing career and family, advise on prioritizing work that will enhance mentees’ leadership and career, and help mentees discern when and how to say “no” when supervisors ask them to assume responsibilities that are not in their career interest.28 Global health organizations in both resource-wealthy and resource-poor countries should formalize and financially support mentorship for female trainees and young professionals.
International conferences should organize small sessions at which women can discuss career development. Opportunities for women to share their experiences and challenges may enable the formation of relationships and bolster women’s resolve to remain committed to global health. In addition, academic institutions should ensure that women in global health have funding to attend international meetings. This may facilitate their ability to meet other women in the field and permit networking with women leaders who can serve as role models, provide informal mentoring, and share strategies they have used to negotiate obstacles as they have risen to leadership in the field.
Obstacle 2: Tensions Between Career and Family Responsibilities
The critical career-building years between receiving a graduate degree and obtaining a leadership role are also women’s reproductive years, “when the fast track and the reproductive track are on a collision course.”29 This can be challenging for both male and female young faculty members, but the “baby penalty” is higher for women, many of whom leave behind their careers at this time.30,31 Female scientists at top U.S. universities have fewer children than their male counterparts and admit to having fewer children than they desire.32 For women interested in global health, whether from resource-poor or resource-rich settings, tensions between career building and family are further exacerbated by the need to spend considerable time abroad. Women from dual-career households need partners who also work internationally, partners with flexible careers who can continue their own work while abroad, or willingness as a couple to spend significant time apart while child rearing. Similarly, single women who desire children frequently have difficulty meeting partners abroad and, worried about fleeting childbearing years, seek appointments in their home countries. Although some of these issues can also be problematic for men, they are often more acute for women whose fertility declines earlier33,34 and who, even when their academic degrees are comparable to their partners, typically bear the larger burden of household work.35,36
Strengthen health education in resource-poor countries.
If educational opportunities exist in-country, women from resource-poor countries will not have to travel to obtain advanced training. Donors should invest in health education capacity building in resource-poor countries, making support contingent on respect for gender equity. Online education is revolutionizing international education by providing world-class course work and training to anyone who can access the Internet. For women from resource-poor countries, distance learning permits access to advanced instruction and mentoring without prolonged travel. Such human capacity building in resource-poor countries is widely recognized as an effective and sustainable investment and is a major strategy of international organizations including the United Nations Development Program; the Fogarty International Center; the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and the President’s Emergency Plan for AIDS Relief.37–43
Global health research-enabling grants.
Glimcher pioneered small “research-enabling grants” that provide women researchers with funding during “perhaps the most vulnerable time in a young female scientist’s career.”44 Global health-enabling grants could support expenses including bringing dependents along for periods of extended field work or graduate study, employing an assistant to continue research during maternity leave, providing child care or children’s educational expenses that would not be incurred in the home country, or covering travel for family events or emergencies that would otherwise not be possible. Global health professionals working in resource-poor countries cannot supplement their income through clinical work and typically earn less than their peers working in wealthy countries. Small grants may make the difference between women remaining in or abandoning global health.
Time extensions to accommodate maternity leave and child rearing.
Training periods, career clocks, and grant periods need to be more flexible for women in global health. Many academic institutions now routinely offer one-year tenure extensions to faculty with new children, as well as either shared tenure-track positions for two part-time faculty members or a part-time tenure track that allows women to segue back to full-time work after their children are older.45 Women working internationally may need longer extensions, permitting them to return home in late pregnancy, when risks of complications and preterm delivery are highest, and to remain home during the early neonatal period. Tenure-clock extensions need to be funded, and time and no-cost extensions to grants should be easily obtainable.
Obstacle 3: Health and Safety Issues
Gender-related health problems make work in resource-poor countries a health risk for women. Sexual violence against women working internationally is an all-too-common reality. Between 2000 and 2009, female Peace Corps volunteers reported more than 1,000 sexual assaults, of which 221 were rape, for a rape rate of 5.3 per 1,000 female volunteer-years.46 This rate is higher than in any single nation reporting to the United Nations.47
Pregnant women working in resource-poor settings are also at increased risk of maternal and fetal complications from tropical infections and poor prenatal and obstetrical care. For example, the United States Centers for Disease Control and Prevention recommends that pregnant women avoid travel to areas with malaria transmission, if possible.48 This is not possible for health care workers living and working in resource-poor settings. Female health care workers in these settings suffer from many of the same health problems as the populations they serve.
Women working in most resource-poor settings will be more vulnerable to health and safety risks than women working in wealthier settings. Although many of these risks cannot be controlled, they can be strategically managed and mitigated. We suggest that institutions provide women in global health with supplemental health insurance that includes coverage for emergency evacuation in the event of a health or civic emergency and preventive travel medications and vaccinations. Global health research-enabling grants for women should be flexible enough to support expenses such as travel vaccinations and prophylactic medications for their family members, timely procurement and administration of age-appropriate vaccinations for their children, or traveling to obtain obstetrical care not available in resource-poor settings.
We recognize that women committed to global health and service in resource-poor countries may assume some personal risk and sacrifice, earn less than their peers, and face an arduous training and career pathway. This is all the more reason to support women making this commitment. Randomized trials demonstrate that women in leadership positions in governmental organizations implement different policies than men and that these policies are more supportive of women and children. Other studies show that proactive interventions to increase the proportion of women in leadership positions within businesses or government can be successful. Therefore, increasing female leadership in global health is feasible and a critical step towards addressing the problem of women’s health globally. The advancement of women in global health careers will be bolstered by strategic investments to provide leadership training grants, mentorship from female leaders in global professions, strengthening for health education in resource-poor countries, and research-enabling grants. Further institutional changes in academic promotion, maternity leave, and provision of mentorship can also have meaningful impact. We believe that making a small investment to retain talented, highly motivated women in global health will prove to be a low-cost intervention that will yield a new generation of female leaders who will change global health practice and improve the health of women worldwide.
Acknowledgments: The authors wish to thank Dr. Rebecca Stoltzfus and Jeanne Moseley for providing information regarding Cornell University undergraduates obtaining a global health minor. We also thank Dr. Warren Johnson and Dr. Mary Charlson for their helpful comments and edits.
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