While more than 50 percent of the U.S. population is female, as recently as three decades ago, women's health was neglected in the halls of public policy, at the research bench, and in clinical settings. Women were largely excluded as subjects in medical research studies and data was not analyzed for sex and gender differences. In the past, national education campaigns to prevent tobacco use, to encourage healthy diets or to reduce cholesterol did not target women. Additionally, women often paid more for the same insurance plans than did men and medical education did not include a focus on sex differences. There were no offices of women's health, conferences, fellowships or reports. Additionally, there was a dearth of senior women scientists and health leaders in our nation's medical institutions. These public health oversights had put women's health at risk -- with rising rates of undetected heart disease, lung cancer, autoimmune illnesses, mental and addictive disorders, and the epidemic of HIV/AIDS.
The convergence of Women's History Month with the commemoration of the 25 anniversary of the establishment of the Office of Women's Health within the U.S. Department of Health and Human Services (OWH HHS) provides a timely opportunity to reflect on the progress that has been made as well as what more needs to be done to advance women's health in the 21 century. I am proud to have played a leadership role in exposing major disparities in women's health in the 1980's and then to serve as the country's first ever Deputy Assistant Secretary for Women's Health and the Director of the Office of Women's Health in HHS, working to move women's health issues and the career development of women in science and medicine to the forefront of our nation's health care agenda where they belonged. Yet, despite the major advances made during this period to advance women's health, the focus has shifted to other issues in recent years. Additionally, lifestyle and environmental factors have changed dramatically over the past 25 years for women with rising obesity and smoking rates, lack of physical activity, problems accessing health care, and increased stress in women's lives. Maternal mortality rates have increased with America experiencing the highest maternal mortality rate of all high income countries. In terms of life expectancy, 25 years ago, American women were in the middle as compared to other peer countries, but now it has fallen to the bottom. When analyzed in more detail, there is a geographic component with 42 percent of U.S. counties having higher mortality rates since the 1980's. White women with lower education experience significantly lower life expectancy than better educated white women. Women from some minority groups have higher death rates from some diseases like cardiovascular illness, diabetes, AIDS, and stroke. The bottom line: today, the health of women in the United States is significantly worse than the health of females in many other high income countries so there is still much more work to do.
Since childhood, women's health mattered to me. When I was 10 years old, my mother developed thyroid cancer. I will never forget visiting her at the hospital and feeling helpless against this disease. It was then that I decided to become a doctor. I spent summers working in research laboratories during my high school and college years acquiring knowledge and skills about how to conduct research. I also served in the Medical News Bureau at the Stanford Medical Center learning about the importance of communicating scientific advances to the public. I chose my college curriculum with medicine in mind. In my first year of college, my mother developed breast cancer. In my last year of medical school, the disease metastasized to her spine so that she could no longer walk. She fought the disease with great courage and dignity and lived long enough to see her daughter become a doctor. Thirty five years ago, when my mother died of metastatic breast cancer, I vowed that no other woman should have to suffer the way she did. So it's hasn't been just a job, but rather a calling and an honor to dedicate my career to improving women's health.
I did this first as a research scientist and branch chief in the 1980s at the National Institutes of Health, where I worked with other advocates and researchers to expose the inequities in women's health. Just as women have battled for equality in educational and occupational opportunities, those working in the women's health field had to shatter a myriad of barriers and prejudices in health care practice and research to bring women's health to the forefront. Then in 1993, I was honored to be appointed as the country's first Deputy Assistant Secretary for Women's Health in HHS. This new senior level position was created to rectify past health disparities and to write a new national prescription to improve women's health in our country. As Director of the HHS Office on Women's Health (HHS OWH), my goal was to weave a women's health focus into the fabric of all of the Department's agencies, offices and regions as well as to collaborate with other public and private sector organizations to improve girls and women's health across the lifespan and eliminate health disparities. We also worked with health officials globally to address these issues worldwide.
The HHS OWH convened conferences and consultations, issued reports, developed and supported model programs and innovations in women's health, and worked to educate consumers, researchers and health professionals about a broad spectrum of issues. As a result of this new national focus, women's health is now a top priority, funding has dramatically increased, a broad spectrum of research is underway, and prevention and service delivery programs are targeting women's unique needs. In the State Department, an Ambassador for Women's Issues has been appointed, women and girls are a major focus of development and health programs internationally including PEPFAR, and gender mainstreaming is a priority of U.S. foreign policy.
Writing a New National Prescription to Improve Women's Health
It's been said that, "it is better to light a candle than to curse the darkness." Over the past 25 years, a new national prescription has been written to improve women's health both in the Federal Government and in the private sector that has yielded lifesaving dividends. I am proud to have helped write that prescription, the guiding principle being that our country's research, prevention and service delivery programs must target all of the nation's women, of all races, ages, socioeconomic and ethnic groups, and must address the health needs of the whole woman -- in body and in mind.
At the HHS OWH, we defined women's health as promoting good health over the life cycle as well as addressing conditions that are specific to women; are more common or more serious in women; have distinct causes or manifestations in women; have different outcomes or treatments in women; or have high morbidity or mortality in women. We focused on issues for girls, adolescents, women in mid-life and seniors.
Some of the milestones achieved during my tenure as our country's first Deputy Assistant Secretary of Women's Health include developing a coordinated national approach and building infrastructure in the United States to improve women's health. A women's health focus was woven into the fabric of all HHS agencies including NIH, CDC, FDA, HRSA, and many new initiatives were established on a broad range of health issues. Scientific and public awareness was significantly increased as were collaborations across agencies of the government and the private sector using a health in all policies approach. I appointed regional women's health coordinators to work at the state level and also envisioned and established the National Centers of Excellence in Women's Health. These Centers serve as national models for improving research, services, public and professional education, and community involvement as well as provide a network to share best practices in women's health. They also foster the recruitment, retention, and promotion of women in academic medicine and scientific careers. A women's health curriculum was designed and distributed to health professional schools so that health care providers and researchers will address important sex differences in disease. National Community Centers of Excellence were also formed to strengthen linkages between community based organizations to enhance women's health care.
Because knowledge is power when it comes to health, I believed that women needed a single user-friendly point of access to state-of-the-art, comprehensive information about their health and was among the first in the government to harness the power of the internet for health education by establishing the National Women's Health Information Center (NWHIC). The Center, accessible through a toll free telephone number (800-944-WOMAN) and on the Internet at www.womenshealth.gov, provides consumers, health professionals, and researchers with free, state-of-art information on a broad range of women's health issues linking them to thousands of cutting-edge resources in the Federal government and private sector. The site provides trustworthy, comprehensive information on a broad range of topics and conditions. Since I first envisioned this Center and website in 1994, it's amazing to think how much has changed as a result of the information technology revolution. At that time, the internet was not being widely utilized in many fields. In fact, some representatives from the NIH, CDC and other federal organizations were reluctant to provide their brochures and other materials for inclusion on this new website, worried that their public affairs budgets might be negatively impacted by this new "one stop shopping" portal for women's health information. This led to my working with the U.S. Department of Defense -- the agency where the internet was first established -- to build the portal. Over the next few years, as the web emerged as a powerful communications tool, we moved the website back to the U.S. Department of Health and Human Services for launching.
A critical priority for me as the first Deputy Assistant Secretary for Women's Health was to ensure that our national prevention campaigns, whether to stop smoking, to encourage a healthy diet, to participate in physical activity, and to prevent HIV/AIDS, focused on women's unique needs. That's because today, the major killers of American women are chronic diseases including heart disease, chronic lung disease, cancer, stroke, diabetes, and also injuries -- conditions for which as much as 50 percent of the cause is attributable to behavioral and lifestyle factors such as smoking, obesity, lack of physical activity, alcohol, opioid and other substance abuse, unsafe sexual practices, and injuries. For example, I worked with the Girl Scouts to establish the first partnership between the government and this organization. It was a smoking prevention merit badge initiative that was launched at the White House with First Lady Hillary Rodham Clinton. We also collaborated with Federal and private sector organizations and the media to develop eating disorders and osteoporosis prevention campaigns as well established a Women and AIDS Task Force. We focused on heart disease in women to educate the public and their health care providers that cardiovascular illness, long considered a man's disease, was in fact, the leading killer of American women but symptoms may present very differently.
As a result of the new national prescription that has been written over the past 25 years, a broad spectrum of research is now being supported on the conditions and diseases that affect women over the lifespan. Several major studies have been established on the seasons of women's lives including studies of child health, adolescent health, the SWAN study of women at mid-life and the NIH's Women's Health Initiative -- the largest clinical research study ever conducted in either men or women focusing on the health of post-menopausal women. Findings from this study have significantly changed recommendations for the treatment and prevention of disease in older women.
There has also been a dramatic change in the way research is conducted in the United States but problems remain. Prompted by women's advocacy and activism, a Congressional Report in 1990 revealed that only 13 percent of the National Institutes of Health budget was spent on women's health research and that data was not being adequately analyzed for sex and gender differences. This led to the passage of legislation in 1993 requiring that women and minorities must be included in clinical trials, where appropriate. As a result, today women constitute 57 percent of all participants in clinical trials supported by the NIH. However, last year the Government Accountability Office (GAO) released a report that evaluated the current status of women's participation in NIH supported clinical trials since the 1993 legislation was enacted. While the GAO report found good news -- the majority of participants in clinical trials are now women -- it also found that some problems remain. The NIH still was not providing data on the percentages of women and men participating in studies of specific diseases (e.g., AIDS, heart disease, cancer, and depression) or by Institutes. Additionally, the agency was not providing public information about whether data from the research it had supported was analyzed for possible sex differences as required by the 1993 law. As a result, according to the GAO report, "NIH is limited in its ability to identify whether women are sufficiently represented in studies in specific areas -- such as cardiovascular disease -- or if the agency-wide data inadvertently mask enrollment challenges. By not examining more detailed data on enrollment below the aggregate level, NIH cannot know whether it is adequately including women in all of the research it supports, in a manner consistent with its Inclusion Policy." Additional actions are now needed to disaggregate the data in these ways. Furthermore, greater attention must be paid to reporting of racial/ethnic differences in women's health.
Additionally, while an Institute of Medicine report underscores that sex matters at the molecular, cellular, and organ system levels, the majority of basic science studies supported by the NIH have included only male animals and cells, potentially obscuring understanding of critical sex influences in health and disease. This was an issue that I worked to address during my tenure as the Deputy Assistant Secretary for Women's Health. However, at that time the NIH believed that ensuring women in clinical trials participation was its first priority and that it would be too complex and costly for basic studies with animals to include both sexes. Twenty years later, the NIH is now taking the steps necessary to rectify this omission in the conduct of research. In January 2016, new NIH guidance was issued requiring that all basic science research studies supported by the agency include both male and female animals and cells, unless there is a compelling reason for using only one sex, such as research on a sex specific disease like ovarian or prostate cancer. This new policy will help to identify sex-specific differences that shape hypotheses before human clinical trials are conducted. Additionally, in August, 2014, the FDA released an Action Plan to improve the collection of demographic subgroup data on how drugs and medical devices affect subpopulations, improve women and minority participation in research trials, and make results available on product labels.
Even as these issues are addressed at the NIH, FDA and other government agencies, it should be remembered that these regulations and recommendations do not necessarily apply to research studies conducted by private industry and other organizations that do not receive federal funds. Pharmaceutical companies, for example, are major supporters of Phase 3 clinical trials. In medical journals, sex differences are rarely reported in publications unless they are the explicit focus of the study. This too must change.
Additionally, understanding only the sex (biological) differences between males and females that affect health and disease is not sufficient. More attention must still be paid to the social and environmental factors that influence women's health -- the gender differences -- as well as quality of life issues. Socioeconomic status is one of the most powerful predictors of health in the United States and worldwide. In America, 56 percent of the 46 million people living in poverty are women and girls. Women still earn 77 cents on the dollar that men earn. Those women with lower income and/or education levels have a higher prevalence and death rates from diseases like AIDS, diabetes and cancer in America and globally. Lifestyle changes including lack of physical activity, obesity, smoking and increased stress faced by women are issues that have negatively impacted women's health over the past 25 years. Therefore, attention to sociocultural, environmental and racial/ethnic factors is critical to advancing women's health.
Another critical challenge for improving women's health is developing innovative strategies to speed the time from scientific discovery to the application of new knowledge in communities. Currently, there is an estimated 15-year science to service gap from the time of a new scientific discovery to its wide application in the community. This must be addressed. The application of mobile technology and social media to help fill this gap, enhance service delivery, and empower women with health information must be made a priority
The war against breast cancer was also a critical concern for my work and that of the HHS Office on Women's Health. The Office directed a Presidential initiative on breast cancer that was a private/public sector partnership. During this time, government and private sector funding increased to find the causes, to enhance early detection, and to improve treatment and prevention strategies. And over the past two decades, there has been some very good news: our national investment is yielding lifesaving dividends. The death rates from breast cancer have decreased from 1990 to 2014.
While the ultimate goal is to prevent breast cancer from ever occurring and to discover a cure, early detection today is critical to finding the disease early when there is the best chance of effective treatment. 20 years ago and again today, there was controversy surrounding the age at which women should obtain their first mammogram. What struck me in this debate is that mammography, the current "gold standard" for detection, is a 60-year-old technology, and that three out of four lesions it finds are benign leading to many unnecessary biopsies. Furthermore, mammograms miss about 15 percent of breast cancers. I thought that if scientists could see the surface of Mars with the Hubble telescope, then perhaps it was possible to more accurately detect small tumors in women's breasts right here on earth. That's why in 1995, I contacted the Director of the CIA, the Administrator of NASA and the General in charge of the Department of Defense's Medical Research Command, to explore whether these agency's imaging technologies used for missile detection, intelligence purposes and space exploration might be applied to improve breast cancer detection.
In 1996, the HHS Office on Women's Health convened a conference that I chaired with scientists from the intelligence, space, and defense communities along with our nation's top radiologists. Recommendations from this meeting resulted in an initiative that I called "From Missiles to Mammograms." This unique program transferred imaging technology from the CIA used by satellites to find tanks camouflaged behind trees to find small tumors camouflaged by dense breast tissue. The initiative fueled developments in computer assisted diagnosis and 3-D imaging. While much progress has been made since my mother suffered from breast cancer, clearly much more needs to be done to eliminate the suffering and death caused by this international enemy of women. The new "precision medicine" initiative will contribute new knowledge, as well as the study of epigenetics and behavioral, lifestyle and environmental risk and protective factors leading to a new generation of therapeutics for breast and other cancers.
Mental health is also of the utmost importance for women. In the United States, 1 out of 5 Americans will experience a mental illness annually. Some of these illnesses disproportionately affect women such as depression and anxiety disorders. Depression is the leading cause of disability for women in America. Women are 70 percent more likely to be diagnosed with depression, yet 30-50 percent of women are not diagnosed. Women with substance abuse disorders have a much younger age of death than women in the general population with five times the risk of death. Yet, 30 years ago, when I began my career at the National Institute of Mental Health, there was a powerful societal stigma surrounding these illnesses. At that time, mental disorders were considered by many people to be character flaws or personal weaknesses, rather than real, disabling illnesses just like heart disease or diabetes, for which there were established causes and effective treatments. Thankfully, over the past 25 years, much has changed in our understanding of mental illness. In 1999, the first ever Surgeon General's Report on Mental Health underscored that mental health is fundamental to overall health and encouraged Americans to get help if they are experiencing emotional problems. Over the course of my career, I have worked to increase scientific and public attention about mental illnesses, particularly sex differences in these disorders and their impact. Challenges ahead include increasing knowledge about prevention of mental illness and targeting interventions to women's unique needs. Additionally, we must address the epidemic of opioid use in America with rising addiction rates and overdoses in females. Women have higher rates of the co-morbidity of mental illness and substance abuse as compared to men making treatment more complex. Passage of the Affordable Care Act now provides parity for coverage of mental illnesses and substance abuse disorders which is a major step forward. Other brain disorders such as Alzheimer's disease are a key priority as women are aging and are also often the caretakers for family members with the disease.
Violence against women was also made a critical priority during my tenure as the first Deputy Assistant Secretary for Women's Health. It is estimated that as many as 30 percent of women in America are victims of physical or sexual abuse. The experience of violence is the highest correlate of chronic disease in women. Violence is linked to higher rates of heart disease, obesity, depression, substance abuse and pain. A multifaceted initiative was implemented during my tenure including the establishment of a National Advisory Council, a Federal Coordinating Committee that I co-chaired, a domestic violence hotline (800-799-SAFE), increased funding for intervention and prevention programs as well as implementing training initiatives for health care providers and law enforcement officials.
Additionally, employing a health in all policies approach where all agencies of government were mobilized to address critical health issues, I established several other Federal Coordinating Committees on Breast Cancer, New Imaging Technologies, and on Women's Health and the Environment to identify and eliminate environmental hazards that might be contributing to increased rates of certain diseases affecting women over the past several decades.
Health Care Reform
Just as women had been excluded from research and preventive interventions, they had been discriminated against in the health care system. Women were more likely than men not to have health insurance because they were unemployed or part-time workers or lost insurance as a result of divorce or a spouse's death. Additionally, women were often charged more than men for health insurance premiums. As a result of the passage of the Affordable Care Act of 2010, this missing piece of the national prescription to improve women's health was finally addressed. The ACA redesigns and modernizes the health care system for the 21st century by increasing efficiency, effectiveness, and equity. The legislation eliminates discriminatory insurance practices. Women can no longer be charged more for insurance than men. It provides parity in health coverage for mental illness and also covers preventive services with no deductible or cost sharing. As a result of the ACA, today, 90 percent of Americans are insured. The rate of uninsured women in America has dropped from 19 percent before the law was enacted to 11 percent in 2014. The legislation also accelerates a prevention revolution with incentives for individuals, businesses, schools and communities to enact prevention programs. Preventive services, including routine check-ups, certain disease screenings, vaccinations, HIV testing, prenatal care and counseling regarding smoking, alcohol use, nutrition and obesity, are now covered by participating insurance plans with no deductible or cost sharing. The legislation also established a Prevention Fund to support innovative community based programs. However, despite these advances, there are still many women who do not have access to health care because of cost which must be addressed.
When comparing the health status of women in the US with other industrialized nations, it should be noted that America spends more on health care but less on social services including child care and family leave. Public policies in the United States that support women with services, alleviate the stress in their lives, and advance their socioeconomic status will contribute to improving their health in the years ahead.
Improving Women's Health: A Global Issue
There are over 3.52 billion women worldwide and in most regions of the world, women outnumber men. In an interconnected, interdependent world, women's health is a global health issue. The spread of infectious diseases which account for 17 percent of deaths worldwide including AIDS, TB, Malaria, Zika and Ebola, epidemics like tobacco use and obesity, the safety of the food and water supply, violence against women, human trafficking, and the threat of bioterrorism do not recognize national borders. A woman dies in childbirth every minute in the world. A number of factors including poverty, discrimination, and violence undermine women's health worldwide. The health status of women is critically linked to their empowerment and fundamental freedoms. Women's rights are essential to national development, economic growth and global progress and for the stability of families and communities, and prosperity and opportunity for all. That is why worldwide education, occupational opportunities, and access to health care are critical components for a healthier future for women.
While problems cross borders -- so do solutions. We are the first generation that has the science, technology, and now let's stir in the commitment and political will -- to eradicate preventable disease and to promote a culture of health in communities in our country and around the world.
It's why the U.S. Department of Health and Human Services, the U.S. Department of State, the United Nations and many private sector organizations support a broad spectrum of international health programs and initiatives to prevent and treat a range of global health threats to women and to empower them with education and occupational opportunities.
Over the past 15 years, 189 member countries of the United Nations worked together to achieve the Millennium Development Goals (MDGs). The progress during this period has had lifesaving ramifications for women and girls including reductions in extreme poverty by more than 50 percent; the number of undernourished people has decreased by almost 50 percent; child mortality was cut by more than half and new HIV infections fell by 40 percent between 2000 and 2013. Now developed and developing nations will work together over the next fifteen years to meet the Sustainable Development Goals (SDGs) to eliminate extreme poverty, reduce the impact of infectious and non-communicable diseases and address climate change as well.
After all, the quest for better health crosses cultures, languages, politics, and governments. And if we can improve women's health, then we will improve the health of families, communities and countries.
Summary
Madame Curie once remarked, "I never see what has been done, I only see what remains to be done." Yes, much progress has been made in women's health over the past 25 years, but much work remains to be done. Increased research is needed on sex and gender differences in health and on the conditions that affect women across the lifespan, data must be disaggregated with any sex differences reported. We must also work together to make the shift from a treatment-oriented society to an emphasis on prevention; to increase the level of preparedness to meet and beat new threats to women's health and safety like the Zika epidemic; to close the gap when it comes to health care disparities for women; and to more effectively translate what we know from science and public health to improve the delivery of services to women that address their unique needs. We must also strengthen investments in global health and development. The complex healthcare challenges ahead and the opportunities to address them require a multi-sectorial strategy -- a health in all policies approach. Multiple domains must be addressed to improve women's health including health systems, health behaviors, socio-economic conditions, the physical and social environment and public policies and social values.
The good news is that over the past 25 years, the government and private sectors have been mobilized and are working together in partnerships today, leveraging skills and resources, to improve prevention, research, and service delivery programs for women in our country and around the world. If we remain vigilant, the results of these efforts should brighten the health futures for women -- and men -- in the 21st century.
Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Public Health Editor of the Huffington Post. She served as the country's first Deputy Assistant Secretary for Women's Health and Director of the Office on Women's Health in the U.S. Department of Health and Human Services (HHS). For more than two decades, she held senior health leadership positions in the federal government in the Administrations of four U.S. Presidents including as Assistant Surgeon General of the United States and as Senior Global Health Advisor in HHS. She also served as a White House health advisor. Dr. Blumenthal provided pioneering leadership in applying information technology to health, establishing some of the first health websites in the government (womenshealth.gov) and the "Missiles to Mammogram" Initiative that transferred CIA, DOD and NASA imaging technology to improve the early detection of breast and other cancers. Prior to these positions, Dr. Blumenthal was Chief of the Behavioral Medicine and Basic Prevention Research Branch, Head of the Suicide Research Unit, and Chair of the Health and Behavior Coordinating Committee at the National Institutes of Health. She has chaired many national and global commissions and conferences and is the author of many scientific publications. Currently, Rear Admiral Blumenthal is the Public Health Editor of The Huffington Post, a Senior Fellow in Health Policy at New America and a Clinical Professor at Tufts and Georgetown University Schools of Medicine. She is also the Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the U.S. Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. Named by the New York Times, the National Library of Medicine and the Medical Herald as one of the most influential women in medicine, Dr. Blumenthal was named the Health Leader of the Year by the Commissioned Officers Association and as a Rock Star of Science by the Geoffrey Beene Foundation. She is the recipient of the Dr. Rosalind Franklin Centennial Life in Discovery Award.
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