Many women's health issues are now seen as major areas for research. While we still have much to learn, the future looks bright.
Written By Wanda K. Jones, DrPH and Barbara B. Disckind
During the last 10 years, women's health has become a well-established aspect of U.S. health care and health policy. Consequently, we in the U.S. government are in a unique position to advance women's health research, education, and services. To better understand the progress the United States has made in women's health over the centuries, let's look to the past.
In the late 19th and early 20th centuries, women's health was seen primarily in terms of reproductive organs, maternal health, and the role of women as mothers. One hundred years ago, most people in this country did not live beyond their 48th birthday. For a woman, tuberculosis, infectious diseases, and childbirth were the greatest threats to her life. Heart disease was the number one killer of men and women, but infectious diseases comprised most of the other top 10 causes of death.
Since the 1900s, a woman's life expectancy has increased by 30 years. Several factors have contributed:
- Advances in medicine, such as the introduction of antibiotics
- Achievements in public health, such as improved sanitation and better nutrition
- The development of a public health infrastructure, which increased women's access to health services, including prenatal care and immunizations.1
One more factor must be recognized — the role that women have played in improving their own lives. Furthermore, women have often been in the forefront of changing the health-care system to safeguard the well-being of their families. More recently, health advocates and professional women (including health professionals) worked together to form a legislative agenda on women's health research.
A Congressional investigation in 1990 showed that women were not being studied adequately and led to the first Women's Health Equity Act. The law now requires that women and minorities be included in clinical research studies. In the fall of 1990, the Office of Research on Women's Health (ORWH) was created at the National Institutes of Health (NIH). [NIH is one of the agencies of the U.S. Public Health Service, which, in turn, is part of the U.S. Department of Health and Human Services (DHHS).] ORWH was tasked with monitoring the inclusion of women and minorities as subjects in NIH's clinical research trials.
DHHS' Office on Women's Health, which I now lead, was established in 1991 to improve women's health by coordinating federal women's health programs, promoting health education and disease prevention, and leading efforts to eliminate health disparities for women. By the mid-1990s, the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and other agencies in the U.S. Department of Health and Human Services had established offices of women's health. The remaining agencies — including the Administration on Aging and the Administration for Children and Families, as well as the Centers for Medicaid & Medicare Services — designated a liaison on women's health issues.
Although this may be progress, it is only in the context of two profound trends that we can take the next steps to promote the health of American women. The first trend is the aging of the U.S. population, particularly those born from 1946 to 1964. Because women tend to outlive men by roughly five to six years, America is becoming a nation of more older women than older men. In 2000, the average life expectancy at birth for women in the United States was 79.5 years, while men's was 74.1, a difference of five years. Just 20 years ago, the difference was seven years.
Here's a secret to the narrowing gap in the United States: Men have gotten smart; their smoking rates have dropped precipitously over the past 30 years. Women's smoking rates peaked in the 1960s, but even now they remain higher than they were earlier in the last century. As a result, men's death rates from heart disease and lung cancer have declined. While women's death rates from heart disease have also declined, the pace has been slower than for men. Diseases of the heart remain the number one killer of all American women. And, since 1987, lung cancer has killed more U.S. women than breast cancer.
According to the most recent data from the 2000 census, approximately 20.7 million women now living in the United States are over age 65. By 2030, that number is projected to reach more than 39 million, when almost 22 percent of American women will be over age 65. This year, 3.1 million U.S. women are over age 85. By 2030, that number is expected to almost double to 5.7 million. Almost 12 million American women will be 85 years of age and older in 2050, compared to 7.4 million men.
The second trend we are addressing is the growing diversity of the U.S. population. The proportion of racial and ethnic minorities will continue to rise through the 21st century. As of the summer of 2001, white, non-Hispanic women comprised 69 percent of the female population, compared to 13.1 percent for African American women, 12.4 percent for Hispanic women, 4.1 percent for Asian/Pacific Islander women, and less than 1 percent for American Indian/Alaska Native women.
In 2050, white, non-Hispanic women will constitute an estimated 53 percent of the U.S. female population. Two minority female populations are expected to double: the proportion of Hispanic women is estimated to reach 24 percent, and Asian/Pacific Islander women will comprise 9 percent of the total U.S. female population. The proportion of African American women will grow slightly to 13.5 percent, while that of American Indian/Alaska Native women will decline, from 0.9 percent to 0.8 percent. How we think about and what we do to improve the health of women must continue to become more inclusive of all racial/ethnic groups.
In recognition of these trends, we are modifying ongoing health initiatives and developing new women's health programs. We are sharpening our focus in the Bush administration on cardiovascular disease, diabetes, cancer, and HIV/AIDS, while not ignoring mental health and family violence issues and neurological and immunological problems that affect women's lives differently than they do men. President Bush and HHS Secretary Tommy G. Thompson are also bringing prevention efforts to the forefront of the nation's attention. Through programs such as the President's HealthierUS initiative and the Secretary's Steps to a HealthierUS, we can all reduce our risk for a number of health conditions that are largely preventable.
In the last decade, women's health has become an important element of our nation's health agenda. Under the direction of Secretary Thompson and President Bush, DHHS has committed nearly $6.7 billion to women's health this year, an increase of roughly $1 billion since 2000. Large-scale clinical trials that look at the biological journey of women through their lifespan are underway, particularly NIH's Women's Health Initiative. The delivery of health-care services is now reaching more underserved women, and women are the focus of public-education campaigns on important health issues such as osteoporosis and breast cancer.
We have become aware of the importance of behavioral factors to women's health, such as weight management; physical activity; diet; drug, tobacco, and alcohol use; sexual practices; the use of safety devices; preventive health care; and violence. These factors are estimated to be at the root of 50 percent of premature deaths in America.
Today's women are confronted with numerous challenges — from the demands of home and family to the pressures of work. But we must remember this truth as we conduct our day-to-day lives: Nothing influences our health more than the choices we make and the actions we take to ensure our own well-being. In order to take good care of others, we must take personal responsibility for our health: from weight management, to adequate nutrition, to physical activity, to stress release, to spirituality.
And yet despite this modern-day awareness of how we can affect our own health, American women are not necessarily enjoying greater health. In the last 100 years, the causes of death have shifted. Except for pneumonia and influenza, infectious diseases and maternal mortality are no longer leading killers. Now, chronic diseases such as cardiovascular disease, cancer, stroke, diabetes, and obstructive pulmonary diseases are the major killers, and prevention is our only vaccine.
Tobacco use is the single most preventable cause of death and disease in the United States. At present, roughly 22 million adult women smoke cigarettes. The use of tobacco has been shown to increase the risk of cancer, heart and respiratory diseases, oral cancers and other problems in the mouth, and reproductive disorders. In 1999, approximately 165,000 women died from smoking-related diseases.
Diabetes is an example of a health problem that can largely be prevented, particularly type 2 diabetes. About 90 to 95 percent of people with diabetes have type 2 diabetes, which usually develops in adults over the age of 40. Eighty percent of these individuals are overweight. The alarming rate of adults and adolescents who are obese or overweight, coupled with an increasingly sedentary society, could reverse many of the health gains that we have achieved in the United States in recent decades. Overweight and obesity could soon cause as much preventable disease and death in the country as cigarette smoking.
Infectious diseases remain a problem, even though remarkable advances in medicine and public health have been made. Pneumonia and influenza are vaccine-preventable, yet we forget about adult immunization. Among those infected with HIV (human immunodeficiency virus), about one-quarter are women, particularly young minority women living in urban communities.
Because all women are highly vulnerable to HIV infection, prevention is particularly important. Worldwide, women face the greatest risk of acquiring HIV due to sexual contact. Factors include a high prevalence of nonconsensual sex; sex without condom use; and unknown, high-risk behaviors of their partners. Women are roughly eight times more likely to become infected through sexual activity with an infected man than vice versa. More than half of those infected with HIV show no symptoms for more than 10 years, a period during which those with multiple sex partners can transmit the deadly infection. It's critical to remove the stigma of HIV/AIDS. We must find ways to protect women from further infection and address the social ramifications.
We must also address mental health and violence against women. The World Health Organization tells us that mental disorders, including major depression, are a leading cause of disability and death worldwide. Depression affects twice as many women as men. We need to look to the situations facing women, as well as examine the biological causes and appropriate treatment.
Violence against women is not just a social problem or a criminal justice issue, it's a health issue. It affects women across the lifespan, ranging from their own physical or sexual abuse as children, to assault and violence perpetrated by their partners, to rape, to elder abuse. According to the Centers for Disease Control and Prevention, violence is a leading cause of injury for all American women between the ages of 15 and 54. It is another area where we are increasing our efforts.
Disparities in health status and health care continue to plague racial and ethnic minority women in the United States and around the world. They suffer disproportionately from disease, disabilities, and premature death. Many also face tremendous social, economic, education, and cultural barriers to achieving optimal health. Although many factors influence women's health, poverty remains the single best predictor of poor health status. Since 70 percent of the 1.3 billion people around the world living in absolute poverty are women, achieving good health for all women remains a daunting challenge.
We have made progress on the federal level, but we still have much to do. Researchers must continue to make intensive efforts to address the health of the whole woman — body and mind — and as cause or consequence. We still do not know why heart disease kills more women over 50 than men of the same age. We have huge gaps in our knowledge of cancers and how they affect women. We do not know enough about the menstrual cycle, or the real effect of estrogen on even the most basic cellular processes. We do not understand why eating disorders are so prevalent in young women and nearly impossible to cure in some of them.
Autoimmune diseases such as lupus and multiple sclerosis, which disproportionately affect women, remain largely a mystery. We don't know exactly how poor oral health is connected to other health problems, such as heart and lung diseases, diabetes, stroke, and poor birth outcomes. We don't know much about fundamental physiological differences between men and women. The knowledge we gain can benefit men as much as women.
With all the emphasis on obesity — and its close ally, diabetes — many providers remain ignorant about their contribution to urinary incontinence. We tell women to exercise and drink water to achieve a healthy weight and control diabetes, but have we bothered to inquire whether urine leakage is a barrier to a woman's physical activity? She may be too embarrassed to tell us, and so we categorize her as noncompliant, difficult to reach, or "failing intervention."
As for women living with a disability, we remain oblivious to their risk for some diseases and conditions because of our own biases. They do not get adequate reproductive health care, and they may not get the routine screenings offered to women without disabilities. Like older women, women with disabilities may be at greater risk for violence or abuse from a partner or caregiver, which may include withholding medications, toileting, or other assistance, as well as the physical or emotional abuse we think of as "domestic violence."
We have yet to fully understand and invest in the social, behavioral, and psychological aspects of medicine and health, and to integrate those aspects with our health research. We still don't fully understand the cultural context of our Western concepts of health and disease. We don't fully understand how to eliminate the stigma that keeps people from presenting early for care. And we don't fully understand why some recover despite ineffective or absent treatment. (No, it's not the norm, but we see evidence of it weekly in our journals as the "placebo effect.")
Even now, at the dawn of the 21st century, we have so much to learn. There is hope. Ignorance can be cured! Collaboration among health-care providers and clinicians of all disciplines is a first step. The future looks very bright — if not for ourselves, for our mothers, our best friends, our sisters and aunts, and especially for our daughters. All of us must take an active role in ensuring our own health and the health of our loved ones: through edu-cation, advocacy, and action. What we do, and how we feel about ourselves, matters.
1 Office on Women's Health, U.S. Department of Health and Human Services, A Century of Women's Health: 1900-2000, April 2002, pp. 1-2, and Weisman, Carol S., Women's Health Care: Activist Traditions and Institutional Change, The Johns Hopkins University Press, 1998, p. 51.
Wanda K. Jones, DrPH
Dr. Jones is Deputy Assistant Secretary for Health (Women's Health) in the U.S. Department of Health and Human Services and the director of the Office on Women's Health. Since 1998, her focus has been to eliminate health disparities for women through a variety of programs and initiatives.
Barbara B. Disckind
Ms. Disckind is the senior technical writer for the Office on Women's Health in the U.S. Department of Health and Human Services, Wash., DC. She has long provided communications services, including writing, copyediting, research, marketing, and presentation training, to public- and private-sector clients.