Reprinted with permission from Knowable Magazine

OPINION: Systemic inequity means women in the US die younger and suffer more than they should. It’s time for health for all.

One of the big news stories of 2022 was the overturn of Roe v. Wade, which threw America’s appalling treatment of women’s reproductive health into the international spotlight. But the problem of how the US is failing women’s health goes far beyond abortion rights. This wider issue deserves more attention.

The state of women’s health in the US is shocking — even to us, medical sociologists and demographers with a history of studying gender and health. Population health statistics paint a sobering portrait. Women in the US fare poorly in one way or another compared with women in other high-income countries, compared with US men, and even compared with previous generations of American women. And there’s no sign that these patterns are improving.

Mortality statistics show that US women live substantially shorter lives than women in other high-income countries. While US women’s life expectancy at birth was similar to the average across 23 comparison nations in the Organization for Economic Cooperation and Development in 1980, by 2019 the US had fallen to the bottom of the pack. That year, US women’s life expectancy was 81.4 years — 3.2 years lower than the average across those comparison nations and more than four years lower than in Italy, Switzerland, France, Spain and Japan.

US rates of maternal mortality and severe maternal morbidity — “near-miss” events that could have resulted in death — are inexcusable. They have been rising for decades, with troubling increases in recent years. Between 2018 and 2020, the US maternal mortality rate increased from 17.4 deaths per 100,000 live births to 23.8. For comparison, in 2020, the US maternal mortality rate was more than three times higher than that of 10 other high-income countries, including Canada, the UK and Germany. A 2022 CDC report suggests most pregnancy-related deaths in the US are preventable.

Delivery isn’t the only risk to pregnant people in the US: They die even more often from homicide than they do from pregnancy-related causes. Homicide also ranks among the top five causes of death for girls and women up to age 44 in the US overall.

Women’s health in the US and elsewhere also suffers needlessly from the silence and stigma about female bodies that persist in science, medicine and society. The lack of science on the clitoris, even its basic anatomy, is a notable example. Experts agree, too, that our understanding of basic uterine and menstrual physiology is lacking. Endometriosis, a painful and poorly understood condition that involves endometrial tissue growing outside the uterus, affects over 11 percent of women aged 15 to 44 in the US, many of whom wait years for a diagnosis. Millions more suffer during menopause from night sweats, memory lapses and sleep difficulties. Too many dismiss all this pain and suffering as natural — something to be endured.

The leading cause of death among US women is heart disease. A 2022 study of emergency room visits by adults 55 and under revealed that women who came in with chest pain waited longer to see a doctor or nurse and were less likely to be admitted for observation than men. A 2009 experimental study found that when women and men reported exactly the same cardiovascular symptoms, doctors were less certain of how to diagnose women than men, and were twice as likely to misdiagnose middle-aged women with a mental health condition compared with men.

Similar things happen with other health conditions. For example, women who came to an emergency room with abdominal pain in the US waited longer for pain medication, and were less likely to be given opioid analgesics, than men.

These statistics all point in the same direction. The United States is failing women’s health. But why?

People often assume that the main reason for women’s poor health is underlying sex-based biology. But biology is unlikely to explain why women in the US die younger than women in other high-income countries. Neither is health care spending. The US spends more per capita on health care than any other country in the world.

The root cause of US women’s poor health is non-medical. It is systemic inequity: everything from unfair structures and practices that benefit the advantaged, to gender bias in science, to cultural expectations about what can and should be. Scientists have shown how sexism — together with racism, nativism, ablism, and other systems of privilege and oppression — shape the scientific questions we ask, as well as our everyday experiences, with profound implications for health.

It’s powerfully telling that Indigenous women and Black women in the US are two to three times more likely to die from pregnancy-related complications than white women. That less educated women die years earlier than more educated women, and that women in Mississippi die younger than women in Massachusetts. Some suggest that the source of these inequalities lies in preexisting chronic conditions and things like obesity, smoking and individual actions labeled “health behaviors” that are assumed to be a matter of personal choice. But this misses the point. These differences, too, reflect systemic inequity. Our bodies — indeed, our biology — do not exist apart from our social surroundings.

To make change, a shift towards equity — in and out of science — is needed.

Inclusive science means, among other things, equitable funding. Despite progress, a 2021 study reported that the National Institutes of Health (NIH) — the largest public funder of health research in the US — tends to overfund research on diseases that disproportionately affect men, while underfunding those primarily affecting women. Funding for research on the health of transgender and gender non-binary people also lags. On the hopeful side, the NIH’s Office of Research on Women’s Health, the National Institute on Minority Health and Health Disparities, and the Office of Behavioral and Social Science Research, among others, are working to advance research on the social foundations of health. That should be applauded.

The overturn of Roe v. Wade, and recent moves to legislate abortion bans, undermine everyone’s health. Laws matter, and changing laws in the direction of equity (instead of away from it), would be an important step. But laws alone can’t create the shift we need. Systemic injustice courses through all sectors, and will give rise to unjust legislation or practices again and again. We need a wholescale social movement that is broader.

We need to think things can and should be different, and make them so. Systems and structures rely on people to create and maintain them. The progress of the MeToo and Black Lives Matter movements are signs of hope. We can get there: It’s time to double down and advocate for health for all.

Susan E. Short and Meghan Zacher are sociologists at the Population Studies and Training Center at Brown University. They research the social foundations of health.