By Jamie Hansen, Communications Manager

(Cover Image: Gender impacts the health and wellbeing of all people. The Imbuto Foundation is a Rwandan organization dedicated to advancing health, education, and youth empowerment. Here they hold a men’s focus group to openly discuss family matters, including sexual and reproductive health questions.)

Pediatrician Gary Darmstadt, MD, MS has long been driven by a desire to reduce disparities and improve health outcomes for mothers and children around the world.

While working on these challenges at the Bill & Melinda Gates Foundation during 2008-2014, he noticed that issues related to gender were consistently holding back efforts to improve maternal and child health. For instance, cultural norms around women’s roles in society, including limitations in their mobility and decision-making power, often prevented them from accessing prenatal or postpartum care. Yet, gender norms weren’t just impacting women. In his own life, as a new father, Darmstadt realized his institution offered no paternity leave to trainees. He had to advocate for taking two weeks off to spend critical bonding time with his new child and supporting his spouse.

“Issues of gender inequality affect everyone,” he said. “They impact women and girls because of the power dynamics at play, but they also impact men and gender-diverse individuals, who can be restricted in some of their opportunities to achieve their full human potential.”

He recalls that when he started to talk with colleagues about these issues, “basically the sentiment that came out is that we understand that gender is important, and we’d like to be able to help, but we don’t know what to do.” 

So Darmstadt decided to focus on understanding gender’s role and impact in health and possible solutions to the disparities it created — work he has continued at Stanford as Associate Dean for Maternal and Child Health, and Professor of Neonatal and Developmental Medicine in the Department of Pediatrics.

Over the years, he and global colleagues set out to research the relationship between gender and health outcomes — and develop a framework for addressing the root causes of these disparities.

A new report by the Lancet Commission on Gender and Global Health, published this spring, does just that. It builds on an earlier Lancet series on gender equality, norms, and health and seeks to raise awareness of how gender inequality impacts health outcomes. It also provides clear, actionable recommendations that policymakers, donors, healthcare practitioners, researchers, and educators can use to incorporate gender considerations into health systems, policies, programs, and research.

The report results from nearly five years of work, begun in 2020, by an international commission that included wide-ranging experts in political science, sociology, humanities, gender, and public policy and public health.

The commissioners hope their findings and recommendations will help cultivate societies and healthcare systems where a person’s gender does not dictate their health outcomes or access to universal human rights — a concept they call gender justice.

“It’s the idea of health and equality going hand in hand while also addressing the drivers of gender-based discrimination and inclusion,” Darmstadt said. “It’s focusing on rights, it’s focusing on health, and it’s trying to get at the roots of why those disparities exist.”

The commission conducted a historical and political analysis to understand the forces that shaped current gender inequalities. “Our work showed that current attitudes and practices around gender are deeply ingrained in essentially all of our systems,” Darmstadt said. “Power dynamics are embedded into those systems in ways that we may not even notice unless we step back and analyze them.”

Commissioners had a real-time example of gender’s role in political, economic, and health systems as they witnessed and analyzed the response to the COVID-19 pandemic.

“When we came to analyze COVID-19 policy framings and plans, it was shocking how missing gender was,” Darmstadt said. “Gender was absent on a global front in terms of understanding the conditions under which people contract COVID-19, how lockdown policies differentially impact men, women, and gender-diverse individuals, and how gender impacts their access to care.” 

For instance, when the pandemic began, more women found themselves in caregiving roles and were therefore more likely to be exposed to COVID-19. Yet only nine percent of national COVID-19 policies addressed or even acknowledged the role of gender concerning the acquisition of the disease. 

The COVID pandemic also underscored another key finding of the commission: that gender equality matters for the health of everyone, not just women and girls. 

For instance, men, women, and gender-diverse individuals tended to experience COVID-19 lockdowns differently, based on the jobs and societal roles they were most likely to have. 

Another example from the commission’s report underscores how ignoring gender in health research can lead to critical oversights — this time, for men in particular.  The commission analyzed data from the 2019 Global Burden of Disease study related to hypertension globally. They found that in both high-income and low-income countries, males with hypertension were generally less likely to be diagnosed and to enter treatment than were females with hypertension. 

“I wouldn’t have thought that was true. I would’ve thought the opposite,” Darmstadt said. When health data are not disaggregated by sex or gender identity, he added, health professionals can miss out on critical information. This information can help identify who is most at risk, and illuminate targeted preventive efforts and strategies to address disparities in health outcomes.

“What we’re trying to say is that gender affects everything, and you need to think about it in a broad, analytic, and systematic sense to pull out those dimensions where gender is playing a role in the health outcome of interest,” he said.

Ultimately, the report recommends steps toward a world where people can thrive regardless of gender, with full inclusion, non-discrimination, and the realization of human rights. 

The report’s five key recommendations include: 

Other recommendations include incorporating training about gender and health into healthcare education, leveraging new data sources and qualitative research to understand gender dynamics, and recognizing that health systems reflect the gender inequalities present in broader society. 

Darmstadt highlighted the need to fund more qualitative research to better understand the root causes of some gender-based differences in health outcomes. While randomized controlled trials are seen as the gold standard in research, they can miss the “rich contextualization required to implement a health intervention effectively,” Darmstadt said, adding that he’s seen the benefits of qualitative research in his work. 

When working to address high rates of HIV among adolescent girls in Zambia, he and his colleagues analyzed existing data and literature. They found that when young women had attitudes about sex outside marriage that were discordant with their sexual experiences, sex prior to marriage became a forbidden topic. These women were less likely to take preventive measures and therefore at higher risk for HIV  — a phenomenon researchers labeled “the taboo gap.”

“Until then, we’d had this global statistic about the risk of HIV among adolescent girls in Africa being two times higher than for boys, but we’d never sat back and analyzed the wealth of information at a cultural level that sets the stage for that disparity,” Darmstadt said. “By finally understanding the cause of the disparity, we could begin to do something about it, for example by introducing multifaceted, gender transformative programs which engage peers and stakeholders in schools, churches, clinics, and families, particularly parents.”

“Despite the challenging (political) circumstances that we’re in now, we believe that many of the recommendations of the Lancet Commission can still be taken forward,” Darmstadt said. “A lot of them have to do with developing an awareness and incorporating into our daily activities principles that would lead us to consider gender and to be able to act upon the inequalities across gender to improve human rights and health.”

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