Women as second-class (health) citizens

June 13, 2011 — As Remapping Debate recently reported, new findings show that life expectancy for women has declined significantly in hundreds of U.S. counties over the course of the last generation. That trend is leading many to ask why so many states fail to put basic public health measures in place, especially since the absence of those measures — often thought of as “gender neutral” — exerts a profoundly negative and disproportionate effect on women.

“The lack of a range of programs, from smoking cessation programs to food access to insurance eligibility, falls harder on women,” said Judy Waxman, vice president of health and reproductive rights at the National Women’s Law Center (NWLC), a women’s advocacy group. “So do cuts in those programs where they do exist. These are public health issues, and they are also very much women’s issues.”

While the Patient Protection and Affordable Care Act (ACA) includes several provisions aimed at improving public health in general and women’s health in particular, most states have also cut their public health budgets since the recession began, including some — like Oklahoma, Tennessee, Missouri, and Louisiana — which consistently report poor health outcomes for women. And in many places around the country, efforts to increase funding for public health programs have come to naught. Even proposals that would cost the government nothing but would have a proven public health benefit— such as tobacco bans — have stagnated. In the face of these developments, many public health experts are worrying that things may get still worse for women.

A disproportionate effect

A new study from the Institute of Health Metrics and Evaluation (IHME) at the University of Washington shows that the life expectancy of women actually declined between 1987 and 2007 in over 300 U.S. counties. That compares to only six counties where life expectancy decreased for men in the same time period (though men in these same areas tended to have worse outcomes than men elsewhere).

The authors of the IHME study believe that certain behavioral risk factors — especially smoking, eating habits, and exercise habits — do account for much (but not all) of the decline. A variety of proven policy options for countering those factors exist, public health experts say, though many are not in place in the states that saw declines.

According to Georges Benjamin, the executive director of the American Public Health Association, rising tobacco use deserves much of the blame for poor outcomes in women. “When women entered the workplace in the mid-’40s and early ’50s, they began to smoke more and more, and tobacco companies began to see them as customers,” he said. “So even now, while we’re seeing smoking rates in men decline, we see women catching up.

Benjamin added that the obesity epidemic has also hit women especially hard. According to data from the Centers for Disease Control, despite the fact that a greater percentage of American men are overweight than women, obesity rates are higher in women in every age group and racial and ethnic category except for white adults 60 or older.

Socioeconomic factors

Though there is some debate over what portion of these gender disparities can properly be attributed to biological and cultural factors, Susan Wood, director of the Jacobs Institute of Women’s Health at George Washington University’s public health school, said that the evidence does undoubtedly show that public health outcomes are closely correlated with socioeconomic factors.

“We know that the poor are made up disproportionately by women,” she said. “Women are more likely to be single parents, and they are more dependent on publicly-funded programs like Medicaid. Cross that with issues of having access to healthy foods, [and of] living in safe places where they can get outside and exercise, and you see that there are reasons why you find these health disparities around the country.”

The importance of socioeconomic factors has led some women’s advocates, like Waxman, to turn their attention to programs such as Medicaid, the Supplemental Nutrition Assistance Program — commonly known as the food stamp program — and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The Affordable Care Act does set some “floors” for program eligibility below which states cannot fall, but there is great variation between states that provide only the minimum and those that are in the forefront of protecting the health of their residents. Waxman said that those states that provide less access deserve greater scrutiny.

Erica Lubetkin, a professor of community health and social medicine at the City University of New York, agreed that increasing access to care and healthy food was important, and added that numerous states have failed to adopt a variety of “basic” programs that have been shown to improve health outcomes. Those include smoking bans in workplaces, bars, restaurants, and other public places; taxes on tobacco; required physical education and health education in schools; restrictions on unhealthy food being served in schools; and incentivizing physicians and nurses to practice in rural and underserved areas to increase access to care.

“I think the weirdest thing about this is that we know a lot about how to improve outcomes,” Lubetkin said.