"Gender inequality is man-made, which means it can be changed"

Dr. Asha George has spent her career researching health systems to ensure health and social justice in low- and middleincome countries, with a special focus on gender and rights. She believes that gender equality is a critical way of ensuring a sustainable future.

As part of our International Women's Day series, we spoke with Dr. George, the South African Research Chair (SARChI) in Health Systems, Complexity and Social Change at the University of the Western Cape’s School of Public Health and a Senior Women’s Health Advisor for Exemplars in Global Health about how gender equality could contribute to this future.

What does International Women's Day mean to you?

Dr. George: International Women's Day has held great meaning for me given its remembrance of the struggle for rights by working-class women. More recently, as I delve deeper into the health world, I realize that these signature days that celebrate women's rights and political struggles are getting lost in the myriad of days we commemorate to different causes. So, it’s important to take time to honor the achievements of women and be reminded of how much work is still ahead. Working to advance gender equality is a continuous revolution and though we have made substantial progress across generations – the possibilities for my grandmother were different for my mother and were subsequently different for me, as they will be for my son’s generation – not enough progress has been made. This is particularly true if we look at women’s representation in political leadership, being paid equally for their work, or being safe from sexual harassment or genderbased violence.

This year’s theme for International Women's Day is 'gender equality today for a sustainable tomorrow.' What does that theme mean to you?

Dr. George: Climate change is an overarching crisis demanding our attention. Climate change particularly impacts marginalized women because of their differential access to water, food, shelter, or the ability to recover from disaster. Take a flood, as an example. In low income settings, women and girls are more vulnerable to drowning than men or boys. In the longer term, they’re also more vulnerable to things like child marriage and sex work due to lack of shelter and loss of livelihoods. But climate change, just like gender inequality, is man-made, which means it can be changed. Revisiting our economic models and addressing gender equality are key aspects of building societies more resilient against shocks in the short term, but also more sustainable in the long term, pre-empting such crisis altogether.

Almost 50 years ago, the world’s first female prime minister said at the UN’s first World Conference on Women: 'We are not here only to demolish discrimination but to envision the benefits to the human race of integrating this forgotten half of humanity in development.' Do those words resonate with you?

Dr. George: Women have always been integrated into development, but they’ve been integrated in ways that are extremely discriminatory. In ways in which their labor was not costed or compensated in equal measure, where they don’t have equal rights to inheritance, or representation before the law. While the focus is often on women, gender equality also profoundly affects and benefits men as well. Look at, for instance, why some men did so badly with COVID-19. They had chronic conditions, smoked more, didn’t want to wear masks, etc. If we lived in a more gender equal world, the negative aspects of how we shape masculinity wouldn't be there. So, men also stand to gain if we achieve gender equality.

Women’s health touches so many health areas. Why is this differentiation important?

Dr. George: Because we haven't achieved gender equality. If we had equality, we wouldn't have the rates of maternal mortality that we have today. We wouldn't have issues like child marriage and female genital mutilation, gender-based violence and the consequences of that. We wouldn’t see adolescent girls becoming infected with HIV at three times the rate of boys in South Africa, and widowhood would not equal impoverishment. So, there’s a need to focus on women’s health, because gender power relations as a driver of health inequality is not adequately addressed.

Even within health, [there's a difference in] the kind of information and services women are and are not getting. Women may get services, for example, but that doesn't mean they're getting quality services that affirm their rights and make them want to come back. So many women don't want to return after going through antenatal care and delivering children, they don't want to come back for post-natal care because they've been treated terribly. So, we need a more holistic perspective, one that focuses on women and addresses gender inequality.

What is the importance of studying voluntary modern contraception and the demand for contraception? What can data on this tell us about a health system?

Dr. George: Voluntary modern contraception is a basic human right that enables women to enjoy their sexuality and plan their reproduction to ensure that they and their families are in the best position to protect their health and support the next generation. While women's right to contraception is not typically one of the metrics of a strong health system, it could be used as a litmus test. In addition to financial protection and supply chain efficiency, these fundamental rights should also be part of how we assess health systems performance.

What have been the trends in the past 50 years in the prevention and management of unintended pregnancies—including for adolescents?

Dr. George: There’s been a lot of change at the aggregate level. And some of that change has been about more than access to a service, it’s been about women's rights to practice their sexuality safely, and determine when they want to have a family, as well as the implications of that decision. It's been about the livelihoods and well-being of their children. The prevention and management of unintended pregnancies is a health care service with huge social implications for the women involved, and that's why it's a strategic concern. We have seen linkages between family planning and maternal mortality, as well as a number of other health outcomes. But this is also an issue of women's rights and empowerment. In many places, women and adolescent girls still face multiple social and legal barriers to being able to access contraception. A lot of adolescent girls in LMICs may be married, but they can't access contraception without permission from their spouses. So, we have a long way to go to really make sure that adolescent girls have the ability to access contraception and exercise their right to self-determination.

Women’s health is not just caring for disease – it’s also about women’s well-being. Can you speak about the importance of thinking more holistically about well-being over a woman’s life course?

Dr. George: In the health field, it is increasingly acknowledged that how a woman experiences health at all stages of her life has implications for the next generation. It is astounding how many different social changes happen over a girl’s and woman’s life course. We need more investment in sociology, oral history, and visual arts to explore the many nuances of those changes across social contexts.

Why has gender equality been so difficult to achieve – and what will it take for us to achieve it?

Dr. George: The nature of power and privilege is that it is never a one-way street. While advancing gender equality is good for men, it does mean that some men and also women will lose privileges in the transitions. Upper- and middle-class families can’t rely on poor women from marginalized backgrounds to care for their children, homes, and hospitals. Factories can’t have cheap labor overseas. Men have to listen and respect women’s autonomy about their bodies, rather than assuming they know best or that it is their prerogative to decide. Change is not easy to accept, and the pace of change has out stripped our ability to make sense of it at times. Globalization has created both opportunity and uncertainty. In the face of change, women’s rights become an arena where families, communities, and politicians can exert control and guard against change.

What have been some of the more challenging aspects of your work in women’s health?

Dr. George: We need to get to an agenda that does not pit women's reproductive health against other health challenges. I would really like to move to a world where those are not at odds with each other, because women have children and they also have mental health issues and when they get older, they have osteoporosis. So, how do we create a common platform where we look over the life course? It’s one of the reasons I’m excited to be doing this work with Exemplars, because this group is going to be thinking about building a common frame for women’s health in ways to make sure that women are able to look after their health, their well-being and, importantly, are supported to do so.

What does success in women’s health and well-being look like to you?

Dr. George: It’s a simple answer to a complex challenge: when girls and women have the political and economic rights that ensure their autonomy over their bodies, and enable them to safeguard their health, livelihood, and well-being, whether related to issues such as female genital mutilation, child marriage, to maternal mortality, to diabetes, obesity, mental health to postmenopausal health conditions. It’s what International Women's Day is all about this year – when we have gender equality we will not only be able to make more sustained advances in women’s health, but also build societies that are stronger and more resilient in facing and resolving the multiple crises facing our planet today.