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Relationship Gender and Health Care by Fay Hakemulder, PhD

1. Introduction

In the context of Human Rights, we see all over the world that women do not have the same rights as men. I am certainly not a so called feminist, but I have observed suppression of women in so many places on earth that I think that a university such as the Intercultural Open University Foundation has a task.

The objectives of this paper are:

  1. To raise awareness and understanding of the crucial importance of gender analysis to public health programmes;
  2. To contribute to promotion, expanding and guiding the integration and application in the work of IOUF and in health research, prevention of illnesses and treatment of diseases.


2. The Influence of Gender Roles on Women's Lives

Comparing the situation in various countries and cultures, we observe that every society describes special gender roles. These direct the activities of people men and women, boys and girls. These rules and regulations are strictly described or belong to a so called unwritten way of behaviour. Gender roles are influenced by socio-economic factors and also by status differences between women and men. These differences show various degrees of limitations. In general I have the impression that once the role of gender is emphasized as a subject of limitation in a particular society, the lower is the status of women. This can also be observed in the division of labour between men and women. All over the world we witness a dramatic social change, and the suppression of women in one way or the other way does not belong to a future world society of peace and justice.

The world wide sweeping social change, labelled as globalization and urbanization, is changing the life style in the most remote areas of the world. In the beginning of the eighties, with the cooperation of Madras University I conducted an educational project in the remote areas of Tamil Nadu, Southern India. Visiting the area last year, I was more than surprised about the complete change in life style of the villagers. Only one exception: the role of women!

Social changes demand role changes. That includes adaptations in life at home and in work. That means that these are related to differences in the place of gender. Significant changes are necessary, but research shows that the role changes of women most of the times are slow. There develops a new world, but for women the old one still exists. The problem for women is that they are caught between the two worlds. They have responsibilities in both and have to cope with them. This also is a fact in the place of women in dimensions of health and illness. Because of the relation of this dimension with women's roles in daily life, we need to include this in a systematic analysis.

In comparison with men, many more women die from illnesses as osteoporosis, diabetes, hypertension, arthritis and most immune disorders. But the remarkable thing is that the innate constitution of women give women an advantage over men. This certainly is true for the life expectancy. We can conclude that when this greater potential for longevity is not realised, then there are serious health hazards in their environment. On the other hand, for men changes in gender division of labour resulted in new risks. Industrial economies required men to accept life threatening jobs. This has been reason that male deaths from occupational causes have been higher than for females. On top of that, smoking and greater exposure to carcinogens on the job is also responsible for much higher death rates amongst men. Next to this, in many parts of the world young men have a greater risk than young women of dying from accidents and violence. But in general, we are world wide confronted with unequal attention for women's health.

Women in the industrialized world are confronted with this double role. Modern social reformers stress the point that women need to work outside their homes in order to be independent, be part of society and have to work on their career. But we also have to keep in mind that the economy and the market need it. Women are working in a job, they have to care for children, and men still are not fully aware of the fact that in those cases they have to assist in the house hold work. The result is women suffering from the burn-out syndrome, and children showing bad behaviour because too early they were left at the care of nurseries. But these characteristics are luxury problems of the rich world.

When we look at the gender roles inside homes, I think that we do not know enough of the physical health consequences because of the heavy work load. This is certainly relevant in remote agricultural areas where the physical input is the greatest. Travelling along the roads in Africa South of Sahara, one can see women carrying loads of wood, water cans, etc. They need to carry loads that would be not permitted by women and men in countries with official health regulations. Lack of information or illiteracy is the cause that there is a dangerous exposure to chemicals or dirt. Women mainly are responsible for the kitchen in most parts of the world, but particular in rural areas. However, this also is true in the poverty areas of big cities. Women not only are working in the kitchen to prepare food for the family, many times they also are involved in some income generating activities. We are not sufficiently aware of the ecological and personal dangers. To name a few, we see dirty water, poor sanitation, dangerous energy supply, primitive handling of food and storage, bad equipment. The total designs have large effects on women. That means that women not only have a heavy work load, but also are confronted with burns, cuts, falls, air pollution in the kitchen.

It is clear that the impact of an inadequate kitchen will be felt by the whole family. It influences food and drinks, the hygiene of the home, and every member of the family is subject of accidents. In house air pollution is also a risk for the family. It can contribute to acute respiratory infection in infants and it also is responsible for chronic respiratory and heart disease. This is shown in women in a number of the world's most poor countries.

It is a mistake made by many so called aid organizations to think that women are ignorant about the problems and the related solutions. As Regional Consultant of the United Nations Economic Commission for Africa (UN/ECA), my husband started to supply video recorders to women in remote villages. They recorded exactly the problems they were facing and solutions they had found to overcome the problems. Via videothekes the recordings were spread to other villages to show the neighbours how problems could be solved. These solutions showed a more intelligent and problem-solving spirit than many well meaning persons of NGO.s could supply. The spread of AIDS, however, has ended many of the projects.

It is clear that the gender roles are different and with that there are different priorities in daily life. This many times is the cause of family conflicts resulting in scolding and beating of women. It is a task of education to change the mind of men. Especially with the spread of television even to remote places it is possible to show a different approach in families. It is a pity that the movie industry too much is based on violence and aggression and, therefore, it is good to approach the Hollywoods and Bollywoods of this world to start with producing films with educating purposes.

Another failure of development policy has been that education and training were directed to men. This resulted in an increase of gender gaps in skills, knowledge and income-generating power. At the level of the household, different priorities and decision-making power need to be introduced. Therefore I was happy to conduct an extensive project for women in Pakistan. With enormous difficulties to overcome the resistance of the husbands, we succeeded to combine primary and secondary educational programmes up till matriculation admission to the university with income generating training. Because women were better educated to give guidance to their sons combined with a higher income it gave them more status. (See: Islam: Women and the Devil, Jaipur 2006, Fay Hakemulder).

Next to the exposure to chemical hazards, the domestic work itself can be damaging to the health of women. The labour can be too hard and too difficult for the women. I observed in rural areas of developing countries that the most lucrative crops were for the domain of the men. Women need to assist their husbands on the land, but they are especially responsible for the less lucrative crops on land of a bad quality. Many times less nutritious foods are grown which have negative influences on health and nutrition of the family. It is important that men and women agree about the pieces of land under cultivation for cash crops or the amount to be sold. Also here some outside guidance is important because men largely control the income. This even is true during the time that women have to work during pregnancy.

As an example, I would like to state that women engaged in substance agriculture have to work very long hours. They do this in severe heat with lack of food or water. Upon return to their homes, the domestic work is waiting for them including sexually satisfying their husband.

The result of domestic life is also influencing the mental health of women. In developed countries, we see a lot of research evidence that women staying at home to look after the children are feeling alone and are subject of depressions. Research regarding the position of full-time 'house-wives' shows feelings of emptiness and worthlessness. This very much is caused by the political and social promotion of women in the labour process. In many various cultures it has become evident that domestic life for women causes anxiety and depression.

Next to the political and social promotion for getting women to work outside the home, I am sure that the low status related to domestic work is reason for this, and also isolation and lack of an independent income.

The different roles and related different valuation are the cause that men and women all over the world do not have equal access to resources which are needed for health. In some parts of the world, food, income and medical care are not distributed accordingly to the needs. In many societies, the cultural rules and regulations promote that men in the household have the main share of income and wealth. They also have a higher status and , therefore, they are the decision-makers. In the house, women have a caring role; and this caring role is extended to the functions outside the house. Therefore, women are employed in caring jobs, such as secretaries, nursing, service industry, teaching in nursery schools, etc. Most of the times, these are the jobs with not too high incomes.

The inequalities in power within the family can certainly affect the reproductive life of the women. Many societies promote a group of moral beliefs about the nature of women and men in the sexual context. Much is related to the purposes of sexual activities and the meaning of being parents and of family life in general. The can result in the fact that many women find themselves restricted between lines of duties and these may drastically limit their ability to make their own decisions.

Many women all over the world are engaged in economic activities. Statistics show that around 40% of women in the world are taking part in the labour force. In my opinion, this is underestimated, because so much of womens work is not recorded. The reason is that work especially in the informal sector, the free lance and volunteer work, is predominantly female. But to be practical, we can attack working circumstances of women, but for those who are living in poverty with few sources of economic and social support, there is no way out except education!

Gender division in the labour market continues, which means that increasing numbers of unskilled women are entering the labour force. The result is that there is a concentration of women in poorly paid jobs. Many of these jobs combine high levels of responsibility with low levels of control. In the informal sector, workers even have no control over working hours and working conditions. Especially domestic workers are often severely under paid, and exploited.

As has been discussed before, women in paid work are most of the times not freed from the responsibility of the domestic labour in their own homes. Many of them also are engaged simultaneously in childbearing, care of dependants and a range of social and economic activities. Their lives in general, also their leisure time, are more fragmented in comparison with men. The pressures of their multiple responsibilities are often causing a drain on their mental and physical health.

Summarising we can conclude that there are different impacts on women and men in a dramatically changing world. There is, of course, a tremendous difference related to cultures and societies. But in general we can conclude that the co-existence and co-responsibility of numerous tasks usually fall on the shoulders of women. The double burden of productive and reproductive activities, most of the times without adequate status, can be damaging for women. .

3. Gender Inequalities in Health Care

In the foregoing part, I have concentrated on gender influences on health itself. We have identified differences in the way men and women are treated in general. It is important that we now look more closely to the inequality between the sexes regarding access to health care.

3.1. Inequalities in medical research

Various organisations, including the World Health Organisation, supply evidence that medical research very much is an activity related to gender. This is related to the methods used, the analysis of the research data, etc. It all reflects to be directed to male problems. It is remarkable that common problems causing health problems for women have received little attention. There is an exception with the problems related to the reproductive role of women. Women health problems such as osteoporosis (brittle bones), dysmenorrhoea (female periods disturbances) and incontinence are frequently reported as examples of neglect.

This neglect is certainly not limited to the developing world. In industrialised countries research shows a failure to reduce the extremely high mortality rate from breast cancer. In a number of countries medical authorities are accused of not giving sufficient funds for research in this disease. The situation, however, is completely different in comparison with the position of women in developing countries. Womens organisations in the so-called rich world have caused a change in this policy so that at the moment more research is being conducted in the typical female health problems.

But world wide, the prevalence for male problems is evident. This is not limited to the choice of research topics, but also to the design of many studies. From scientific and social point of view, it is a failure that disease affecting both men and women has neglected the possible differences between the sexes. This failure includes diagnostic indicators, symptoms, prognosis and the effect of the various treatments.

There also is a difference in medical research and health care between tropical countries and the other parts of the world. We observe a difference in approach concerning tropical diseases in general and HIV/AIDS in particular. Completely strange and wrong that coronary heart disease (CHD) is regarded to be a female disease as has been reflected in many research designs. Major studies on CHD in North America and Western Europe have concentrated on samples that are mainly male. This has been leading to the questionable conclusion that more men than women die from CHD.

More detailed analysis proves that CHD also is the single most important cause of mortality for women in the post-menopause. We can conclude that there are certainly sex differences in diseases related to heart disease. But because of the bias in attention and research design. I am convinced that our knowledge of this field is not sufficient, and this hampers either strategies in clinical treatment and in approaches for prevention.

Scientists have been defending the bias concerning their choices: They argue that the cyclical hormonal changes make research results difficult for interpretation. Furthermore, women may become pregnant during the research period and that not only would influence the outcome of the research but also could bring the foetus at risk. I think that these problems certainly are valid and are posing ethical and methodological difficulties. But I strongly oppose that these are reasons to exclude women from epidemiological studies or clinical experiments. I regard the arguments of the scientists as giving cheap excuses for limiting the medical capacity by ignoring health problems of women. I cannot agree with the scientific strategy to treat men as the norm. What we see now is that results from mainly male subjects are without questioning applied to female patients.

3.2. Inequalities in health care access

There is a growing body of evidence of gender differences in access to health care. I have to add, however, that the situation in various parts of the world is very different. In fact, women in developed countries are more using the services of medical care than men. This has given them very important benefits.

Some feminist organisations have complaints, namely that medical specialists get too much influence on the life of women. They argue that the normal process of pregnancy and childbearing has got too much the idea of a medical event and that much of the control is taken away from women. I think that this is a sort of criticism we can ignore. But another sort of questioning is more righteous: in too many cases depressed women are quickly supplied with pills. In my opinion, for women in psychological difficulties an extensive discussion is needed to investigate the causes. These can be that they are subject of violence at home, or that the reason can be found in living and working conditions.

Here we enter into an extremely difficult and touchy process. We have to question the appropriate medical approaches towards the life of women. The decision we have to make here is if the problem is medical. Medical doctors are extremely badly educated in psychological and social problems in general and those of women in particular. The danger is that medical specialist are taking charge of the situation the woman is confronted with without having any training or educational background to solve such problems.

In my opinion, however, these are minor problems in comparison with the situation in developing countries. We can extend our worries to those who are poor in some parts of the industrialised world. In a rich country such as the United States for instance, around 50 million people do not have a medical insurance. From these people women are more victim of having no access to health care than men.

In comparison with the industrialised countries, the situation of health care in general and of that of women in particular is disastrous. In the first place there is in many cases a low level of expenditure on health care in general. In accordance with data of the WHO, the expenditure on health care in England is around $ 1,039.--, in Bangladesh the figure is $ 7.-- only, and for Mozambique this is $ 5.--. It is obvious that from this lack of finance, both sexes are suffering. But in poverty conditions it usually is the group of women which is facing the greatest problems in getting access to health care services.

I know that many households in some regions of the developing world are spending less on health care for women and girls. Women in those countries have a lower social status and, consequently, they do not have any decision-making power. Most of the times, men control the finance. They refuse to pay for womens health care or for transporting them to hospitals. On top of that, women are spending the little money available on their children.

These problems are even more severe in areas where customs and values do not allow women to travel alone. This especially is true in Muslim countries, where women also are not allowed to be in the company of men who do not belong to their immediate family. Sometimes female health workers and nurses are not available. In those cases women have to go without being properly looked after, because treatment by a man may be a shame for the woman and for the entire family.

In agricultural societies it is a disaster if a woman gests health problems during the time of harvest. The question is: who is going to do her work in the field and at home? Consequently, the necessary visit to a health care centre many times imposes heavy burdens on the household. Net result is that the woman continues working up till the time that it is too late.

Another problem we are facing is that in many cultures women are taught to believe that suffering belongs to their life. This means that the emotional and social attitudes of women themselves limit the access for them to health care. For example, problems as backache or dizziness may be accepted as a normal situation and that it has to be accepted as a part of life. Women do not want to complain because of the low status they have in society. A problem will be ignored if it is a disease that is disapproved of by the community.

It is because of the lack of education that women do not have the self esteem to take care for themselves. On top of that, they do not get the opportunity to understand their own bodies. Therefore, they cannot make a proper assessment if they need health care or not.

In traditional communities, the health care of women concentrated on their reproductive needs, such as contraception and childbearing. I think this is to be understood in a more or less logical way: the toll is huge of reproductive ill health that affects the poorest women in the world. But is has had important limitation.

First of all, young women were and are denied access to health care during periods they very much need it.

Secondly, women of the age of childbearing many times do not get any assistance for problems not related to child birth. This is especially in cases of mental illnesses. For these matters, very few services are available in the developing world.

3.3. Differences in quality of health care

The main conclusion from what has been mentioned above is that women have more needs than only those related to reproductive abilities. The question we are facing now is if the quality of the services for men and women is of the same level. But |I would like to state in advance that it is very difficult to make observations in this field. Not only gender but also questions of class and/or race have to be combined. But there are sufficient indications that difference in gender status are a factor of limitation of the quality of health care for women.

Social or sexist approaches by medical doctors, are making difficulties for women. Medical doctors in general present themselves as being superior, and that makes it difficult for women patients to speak freely. This also limits their possibilities in decision-making regarding their own bodies. This is especially true with regards to black and ethnic minority women. They are given insufficient personal respect and therefore they lack opportunity of speaking freely and making correct decisions.

Health care providers in many cases are focused on reproductive health services and, therefore, they are mainly concerned with controlling womens fertility. Women get reluctant to make use of the services available because they feel a lack of cultural understanding and getting a dehumanising treatment.

I think that we can conclude that there are significant gender differences in quality of caring and also in effective clinical care.

4. Some provisional conclusions

In the first place, we can conclude that there is an unequal distribution between men and women in relation with research in health care, and the availability of treatments of illnesses. This is the fact for physical diseases, and even more for mental problems.

In the second place, we see a large gap in provision of health care between people in developing countries and the industrialised world. This gap is that large, that we need to think about training middle level health care workers and psychotherapists in stead of wasting time of high level medical and psychological specialists for many times easy problems.

5. Recommendations

I realise that at the level of the possibilities of a foundation, the contributions of the Intercultural Open University (IOUF) are small in comparison with the problems of a magnitude such as has been described above. But I think that there are some suggestions which may be carried out by IOUF and if successful these suggestions may also have influence on the strategies of other foundations.

I will bring my recommendations in five parts:

  1. Integrated Medicine
  2. Training of middle level Health Care Staff
  3. Making use of available alternative health care workers, such as shamans and witch doctors in developing countries, and personnel trained outside the regular medical schools
  4. Mental Problem approaches: Psychological Interventions
  5. Management of Health care centres: Hospitals, doctors offices, etc.
  6. Research Techniques in Health Care


5.1. Integrated Medicine

It is a well known fact that methods used by integrated medicine e.g. based on Chinese Traditional Medicine, Ayurveda, Homeopathy etc. are very much opposed by the so called academically technological based western medicine. This attitude is supported by the pharmaceutical industry, the old fashioned medical schools, and medical doctors who are afraid for loss in status and income. Even organisations such as the World Health Organisation are not really interested in Integrated Medicine. All kind of research and promotion in this direction is hampered by the pharmaceutical industry, because organisations depend on funds for research and promotion.

Although Western Medicine has made great advances in surgery and therapy in emergency cases, in nearly all other illnesses and diseases Integrated Medical approaches are superior. In general, the last approaches do not need the very costly equipment and therefore they are a more cost-effective way in health care.

Task for IOUF:
Continue with promotion of Integrated Medicine and expanding training of medical personnel, and research in all faculties and departments.

5.2. Training of middle level Health Care Staff

It is clear that health care in many countries is not used properly. Personnel available is for a larger percentage used for diagnosis and treatment of men. There is need to train more middle level personnel so that the not justified division of attention between women and men can be made more equal.

Task for IOUF: In the training of health care personnel, it is necessary that more attention is given to specific problems women are facing, such as social circumstances, work pressure combined with domestic work, results of violence, etc.

5.3. Use of available traditional health care workers

In many developing countries all kind of traditional medical and psychological people are available. We call them shamans, witch doctors, sorcerers, traditional doctors, etc. Of course, the academic trained doctors in most cases look down on these traditional health workers. In my opinion, however, there is need for a complete change in attitude concerning the many medical therapists who did not get the training in school medicine. These traditional healers are trusted by the local population, and research has shown that they have sometimes successful methods and herbs for treatments unknown to school medicine.

An example of cooperation between various groups with regards to health care I have observed during the 4 years I was working for the UN/ECA in Ethiopia. During services of the Ethiopian Church it happens many times that priests are confronted with people who are suffering from 'spirits'. I do not give an opinion about these kind of illnesses, but for the patients involved it is a reality. Priest of the Ethiopian Church are trained in exorcism, and they are able to give patients a cure for their suffering. If the priest is not able to help the patient, he will send them to the hospital. The hospital at its turn is sending patients for treatment to priests.

Next, I would like to underline the case of many doctors working in China and Tibet. Here we are witnesses of medical approach which certainly do not belong to primal medicine. In fact, these forms of medical care belong to the very sophisticated ones. Most of the time they have a longer training and experience in comparison with the academic trained doctors. The workers in the field of traditional Chinese medicine can make use of the orally or written information assembled for centuries. In comparison, Western medicine is only a very young approach. Many treatments and prescriptions used by these alternative doctors are unknown in western medicine and in many cases have remarkable results. It is a point of progress that Chinese universities are conducting research on the traditional methods. The proven successful approaches are even included in the Chinese hospitals and medical centres. It is an example for the world that patients entering a Chinese hospital have the choice between Western and Eastern medicine. Doctors in the hospitals are trained in both Eastern and Western approaches. It has been my experience that in China there is no difference in status between Eastern and Western medical practitioners. In Tibet, the traditional doctors even have a higher status in comparison with the practitioners of Western medicine.

Also in India is developing the same collaboration between ayurveda/yoga specialists and western trained medical doctors.

The complaint of Western universities and medical practitioners about not available research in Chinese and Indian medicine is only showing a resistance against Eastern medicine. There is a large body of research, showing that these practitioners are more successful than allopathic doctors with most of the illnesses.

Task for IOUF: There is need for more research in and attention for primal traditional medicine. Furthermore, these research results have to be compared with Western, Chinese and Indian medical approaches. It is not realistic to think that soon the developing world will have sufficient doctors and therapists. Consequently, there is need to make use of what is already available.

5.4. Mental problems

Also in this case we have to be realistic. We cannot expect that in the next decennia there are sufficient therapists to assist patients suffering from psychological problems. Therefore, we will need short-term training programmes for workers with patients and clients with mental difficulties.

In general, all over the world there is need for recognition of Mental Health Problems. There is still a strong stigma attached to mental problems, with its association with madness and loss of control, risk of harm to themselves or others, and the added implications of weakness and lack of personal strength. Psychological and psychopharmacological interventions can be extremely effective and, contrary to popular but misguided opinion, can contribute to the empowerment and increase in quality of life.

There are obstacles to the recognition of mental health problems. Symptoms such as tiredness, loss of interest in things, headaches or chest pain, could be due both to physical and psychological disorders. It is crucial to exclude a primarily physical cause to such symptoms. But doctors may become so focused in their need to find a physical explanation, that endless and unnecessary tests are performed. The result is that they fail to consider the possibility of psychological factors.

All workers in the field of medical science need more training and understanding about mental difficulties. They agree that there is need for a better assessment of mental health problems.

In general, I would like to refer to a special approach in particular cases of mental problems. This way of treatment is known under the name of ˜Cultural and Spiritual Interaction'', developed by J.R. Hakemulder, Intercultural Open University Foundation. (IOUF Press)

Furthermore, there is need for introduction of psychological interventions, such as:

  1. Psycho-educational interventions
  2. Problem solving
  3. Interpersonal psychotherapy
  4. Cognitive-behavioural therapy
  5. Counselling and supportive therapy
  6. Psychodynamic therapies
  7. Breaking bad news
  8. Bereavement and grief
  9. Palliative care (pain killing)

Task for IOUF: Need for research and training of health care workers in the psychological field.

5.5. Management of Hospitals, doctors offices and health care organizations

There is an enormous waste of finance and manpower in centres all over the world. But the most important waste of time and money is in the industrialised world. Many times, too expensive medicines and equipment are unnecessarily used for the status of the practitioners.

It also becomes more and clearer that in coffee shops, cafeteria is too much time is wasted. Together with endless discussions and meeting about the own position and salaries, the costs - effectiveness of many centres is extremely low.

More effective use of the available recourses will benefit the care for patients in general and for women in particular.

Task for IOUF:
Training of managers specialised in health care institutions, such as hospitals, doctors offices, etc. In the training programmes, special attention needs to be given to the needs of women.

5.6. Research techniques in health care

It is essential that the situation of women will be more accurately reflected in health care statistics. It is particularly important to have data which are disaggregated by sex and age as well as social class. A clearer focus on the health and status of young girls could highlight the problems they face in nutrition or in health care. At the other end of the life cycle the changing circumstances of older women also need to be accurately monitored.

The problem in developing countries is a lack of complete and accurate vital registration system. On top of that there is a general attitude to ignore the special women problems. Maternal mortality for instance is often not accurately reported due to a variety of social, religious, and practical factors. Under the last ones, we have to consider the stigma of abortion, in a number of countries regarded as a criminal act.

Domestic violence represents a huge public health problem that has not yet been accurately documented.

Securing the appropriate number of female research subjects is important and a continuing dialogue between researchers, women's health advocates, and users of medical technology are essential.

There is a need for quantitative methods in documenting some of the more structural aspects of gender inequalities in health and well being. Qualitative methods are also needed so that the full range of influences on human health is properly understood.

To summarise gender-sensitive research, I would like to mention the following points:

  1. women and men's roles and responsibilities
  2. women and men's positions in society
  3. women and men's access to and use of resources
  4. social codes governing female and male behaviour that affect health

Task for IOUF:


To broaden understanding, IOUF has to promote collaborative studies between epidemiologists and clinical scientists with cultural anthropologists using a range of methods to illuminate broader dimensions of women's and men's lives.