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Welcome to the the Office of the President

Women's Health Issues: You've Come a Long Way

February 15, 2000

Thank you for that kind introduction. I am delighted to be here this evening and appreciate the opportunity to share a few thoughts with you. When the invitation was extended for me to come and talk with you, I was asked to speak on the topic of women's health. This seems more than a little ironic to me, as I suspect that each of you is more of an expert in this topic than am I. Despite my best efforts to prepare for this talk, I fear that my own lack of expertise will become readily apparent to you. For that, please accept my apologies in advance.

While in the spirit of open disclosure, let me also indicate my intent to avoid talking about specific medical conditions or their treatment. Although some of you may have come here expecting to hear the latest recommendations on screening for breast cancer or whether it is advisable to take hormone replacement therapy, alas I will not be dispensing such advice. Nor am I here to solicit business for the very capable clinicians at the Medical University. As much as I might sometimes feel like a walking advertisement for the Medical University, I am not here as a marketer.

My purpose tonight is to talk in a much more general way about women's health care. The perspective of this talk is not that of health care from an individual's point of view, but rather from the point of view of society. That is to say, we will be looking at the health of women in the aggregate. As social norms and expectations have changed dramatically over time, this topic is best viewed within an historical context. This talk is not entirely a lesson in history, however. My hope is to leave you with suggestions for developments that are on the horizon.

Before we proceed further, it is important for me to define what I mean by women's health. For the purposes of this discussion, I will adopt the definition that is used by the National Institutes of Health. The NIH has identified a series of criteria that can be used to determine whether a particular health matter is an issue for women. The most obvious criterion is whether or not the condition is unique to women or some subgroup of women. For example, pregnancy-related conditions would fall into this category.

A second criterion is whether the condition is more prevalent among women than among men. An example of this category would be depression, which is about twice as common among women as among men. A third criterion is whether the condition tends to be more serious among affected women than among affected men. For example, women are more likely than men to develop complications of sexually transmitted diseases.

A fourth criterion is whether the condition has risk factors among women that are different from those among men. For example, at every level of cigarette smoking, women are more likely than are men to develop lung cancer. This suggests that women have some underlying greater susceptibility to the harmful effects of cigarette smoke. A final category includes conditions for which the treatment patterns differ for men and women. There are data to suggest, for instance, that women with heart disease are less aggressively evaluated and treated than are men.

Let me recap; the definition of women's health that we will be using tonight is broad. It encompasses not only the conditions that occur exclusively or disproportionately among women, but also those for which women differ from men with respect to risk factors, treatment patterns, or clinical outcomes. When you think about it, this definition implies that what is considered a women's health issue will depend to some extent on the current state of knowledge about patterns of risk factors, disease occurrence, treatment, and clinical results. As these patterns tend to change over time, so must our definition of women's health issues.

Let's begin then with a look backward in time. I thought that it would be particularly poignant to use a local historical reference for this purpose. I recently came across a fascinating paper written by Peter McCandless, an historian on the faculty of the College of Charleston. Last October, in the Journal of the History of Medicine, Dr. McCandless published a paper entitled: "A Female Malady? Women at the South Carolina Lunatic Asylum, 1828-1915." In this article, my attention was drawn to a couple of quotations, both because of their content and because of the persons to whom they were attributed.

The first quote was by Samuel Henry Dickson. Dr. Dickson was one of the founding faculty members of the Medical College of South Carolina — the forerunner of the Medical University. He was a graduate of Yale and the University of Pennsylvania School of Medicine. He was twice the dean of the Medical College of South Carolina and was recognized nationally for his scholarly works on medical and other subjects. In his textbook, Essays on Pathology and Therapeutics published in 1845, Dickson suggested that "sexual irregularities" might give rise to more insanity in women than men because females seemed "to be more under the dominion of the genital system than males."

The other quote is from Dr. Thomas Y. Simons, a contemporary of Dickson's. Simons, a leader of the Medical Society of South Carolina, tried to exert control over the Medical College soon after its creation. All of the original founding faculty members resigned their positions in protest and formed a competing second Medical College in 1832. Dr. Simons became the dean of the original Medical College, but without the distinguished founding faculty, this effort failed and the two Colleges were merged in 1839.

At any rate, four years before his ill fated term as dean, Dr. Simons wrote a text entitled: Observations on Mental Alienation. In that work, he wrote that nymphomania was thought by some "to be an affection of the clitoris, which has been cut off; and in some, in the uterus."

I cite these two quotes, not to ridicule either Drs. Dickson or Simons. Both were expressing views that were prevalent at their time, and it is more than a little unfair to judge them out of their nineteenth century context. They do, however, make an excellent point for us to consider. For most of its existence, medicine has been a male dominated profession, with a rather paternalistic view towards women. Gender bias can be found in beliefs about the causes for disease development, the approach to diagnosing illness, the choice of therapy, and the expectations of clinical outcome. Without doubt, we have made progress since the days of Dickson and Simons. At the same time, we should recognize that the issue of gender bias in medicine is still with us today. Where do we still see gender bias in medicine?

One place to start is to ask the question: Do men and women have equal access to health care? From the following statistics, one might draw the conclusion that women are not disadvantaged in their access to health care. First, women account for more than 60 percent of all visits to physicians. Second, women account for almost 60 percent of the purchases of prescription drugs. These aggregate statistics are misleading, however. I am sure that everyone in this room is well aware of the fact that women tend to live longer than men. The life expectancy at birth for females in the United States is 79.4 years, almost six years longer than that for males. Since older persons tend to have more conditions requiring medical attention, this helps explain the apparent female predominance of physician visits and prescribed medications.

In recent years, there has been increasing attention to whether men and women with similar presenting symptoms of illness are treated similarly. As noted earlier, it has been shown that women presenting with atypical chest pain are less likely to receive as comprehensive a cardiac evaluation as are men with these symptoms. There are also data to suggest that the treatment of women with heart disease may be less aggressive than that of men. Studies of this type, examining gender differentials in treatment patterns, are still relatively infrequent. This raises the question: why is the focus on women's health issues such a relatively recent phenomenon?

Without question, one of the rate-limiting factors was the historical under-representation of women in medicine. In 1970, for instance, only 13 percent of medical students were female. Today, almost half of all medical students are women. It would be nice to think that the progress in the intervening years was purely a product of the recognition of the value that women bring to the healing professions. My hunch, however, is that the Equal Opportunity Act of 1971 probably had as much, or more, influence on the decisions of admissions committees.

This is not to say that gender bias has been legislated away from medical schools. Even today, women are greatly under-represented in research and leadership positions. At our medical school, for example, the first female department chair in the College of Medicine was appointed in 1998. That year was a banner year for us in another respect, because a woman was appointed to an endowed chair for the first time. Today, we have three female chairs of medical school departments and two female occupants of endowed chairs — signs of progress, albeit somewhat delayed.

It would be wrong, however, to think that the women's health movement was fostered primarily by the greater representation and advancement of women within the medical profession. Although this undoubtedly was a factor, much more powerful influences were happening outside of the profession. The decades of the 1960s and 1970s were witness to profound social and cultural transformations that touched many aspects of our lives — including our views about gender and health.

The widespread introduction of the oral contraceptive pill in the 1960s gave women unprecedented control over their reproductive behavior. It was not absolute control, however, as abortion was illegal in all states except for the purpose of saving the life of the mother. In 1973, that was changed with the Supreme Court's landmark ruling in Rowe v Wade. Although still controversial, this ruling undeniably has had a profound impact on the reproductive rights of women.

About the same time as the Supreme Court was deciding Rowe v Wade, women's self-help health groups were springing up across the United States. Most of these groups were born from dissatisfaction with health care in general, and in particular, with the frequently condescending treatment of female patients by the male-dominated medical profession. As the name would suggest, these self-help groups sought to empower women to take greater responsibility for their own health and well being.

The next phase of the women's health movement occurred in the 1980s. Largely because of political pressure from grass roots organizations and the Congressional Caucus on Women's Issues, the U. S. Public Health Service created the Task Force on Women's Health Issues in 1983. The Task Force quickly determined that there was a paucity of data on women's health issues. Its first report, published in 1985, recommended that more research should be performed on this topic.

The following year, the National Institutes of Health adopted a policy requiring the inclusion of women as subjects in clinical research. Even with this policy in place, however, there was a continuing under-representation of women's health issues in funded research. In 1989, for example, an audit of NIH research indicated that less than one in seven dollars was spent on women's health research. Moreover, the report also concluded that women were still inadequately represented as study subjects and as investigators.

A direct consequence of this report was the creation in 1990 of the Office of Research on Women's Health. This Office was responsible for assuring that NIH gave sufficient focus to women's health research and adequate representation of females in clinical studies. One of the outgrowths of this effort was the launching in 1982 of a massive study known as the Women's Health Initiative. Since this is such a groundbreaking study, I am going to describe it in a bit of detail.

First of all, the Women's Health Initiative actually is a series of studies. The first of these studies is referred to as a clinical trial. This means that women who are eligible for inclusion and who agree to participate are assigned randomly either to receive or not receive certain treatments. A total of 64,500 women between the ages of 50 and 79 years were enrolled in this experimental study. The treatments under evaluation are:

(1) a low fat diet;
(2) hormone replacement therapy, and
(3) calcium/vitamin D supplementation

These women will be followed for up to 15 years to determine their subsequent health outcomes. Of special focus will be the occurrence of breast and colon cancers, heart disease, and fractures of weakened bones. Other outcomes that the investigators will attempt to assess include the quality of the women's lives and their functional abilities.

Questions that will be posed from this study include:

(1) Does a low-fat diet decrease the risk of breast or colon cancer?
(2) Does hormone replacement therapy decrease the risk of heart disease?
(3) Does hormone replacement therapy increase the risk of breast cancer?

A clinical trial should provide much stronger evidence than presently exists to answer these questions. On the other hand, the environment of a clinical trial can be somewhat artificial. Also, it may be difficult to get the subjects to comply with some of the interventions, such as substantial reductions in dietary fat intake. The simple fact that subjects know that their habits are being monitored can affect their behavior in ways that might affect the results of the study. For these reasons, the investigators are undertaking a second major component within the Women's Health Initiative.

This second effort is referred to as an observational study. That is to say that the investigators observe the study subjects and their health, but do not intervene to alter their exposures. A total of 100,000 women between the ages of 50 and 79 will be enrolled in this national sample. The subjects will be evaluated at the time of enrollment and every 9 to 12 months thereafter. Each evaluation will include detailed medical and health behavior histories, body measurements, blood pressure, and blood chemistries. Over a 15-year period of time, the investigators will attempt to address questions similar to those posed in the clinical trial. For instance, do women who choose to eat a low fat diet have a reduced risk of breast or colon cancer?

While we await the results of the Women's Health Initiative, what can we anticipate about the health issues that will confront women in the years ahead? First, as already pointed out, women account for a disproportionately large percentage of the elderly. As the population ages, attending to chronic conditions, which predominate at older ages, will be increasingly important. Moreover, strategies to prevent the occurrence of these conditions will receive greater attention. At the other end of the age spectrum, it will be a priority to assure that all children have a healthy start in life, free from violence, tobacco, and drugs. Ultimately, assuring economic and educational equity for women may be the single most important measure, since socioeconomic disadvantage is one of the strongest predictors of ill health.

In sum, we have come a long way, but there is so much more to do. Thank you very much.