Professor Kent Buse, Co-founder and Co-director of Global Health 50/50, discusses the relationship between gender and health inequality. Alongside fellow Co-founder and Co-director, Professor Sarah Hawkes, Buse is leading the independent initiative to actively assess global health organisations on their gender equality credentials to stamp out discriminatory policies and practices. Buse is also the Director of the Global Healthier Societies Program at The George Institute for Global Health. ‘Fixing systems, not people’, the programme aims to go beyond the provision of basic healthcare, advocating research-based interventions to help people enjoy lifelong good health.
How did you become involved in the fight against gender and health inequality?
I interrupted my undergraduate studies to spend four months living with a family in a remote village on the Indonesian island of Flores. There was no running water or electricity. Slash-and-burn agriculture penetrated a short distance into the surrounding rainforest, a place which served as a source of building and other materials and a site of animist rituals. I was hosted by a generous family who insisted I sleep in the only bed in their home. They were loving, mutually supportive, and hard working – busy from before dawn till after dusk. I partook in a clumsy way in various tasks of daily living, including planting and harvesting ground nuts and other communal backbreaking toil.
The experience was challenging, rewarding, and life changing. I returned to a different course of studies in Canada, determined to understand how it was that people could work so hard yet have so little in the way of material goods to show for it. Determined to put that understanding into action, I pursued work with non-governmental organisations in countries such as Nigeria, Thailand, and Vietnam, with UNICEF in the South Pacific, and as Chief of Strategy, Policy and Research for UNAIDS for over a decade. Using different opportunities to contribute as best I can to improve equity and social justice – which of course includes gender – is what gets me out of bed in the morning.
Why do you think gender inequality exists?
Inequality isn’t natural or inevitable. It is the result of the unequal distribution of power within and across societies that serves specific groups and interests. Gender inequality is but one of its manifestations. It is one that is terribly entrenched over time and across geographies. In crude terms, men have claimed power and used it to limit the possibilities, privileges, prosperity, and political participation that women can exercise in society. A range of institutions and ideas have been established to maintain gender inequality. Not all men actively support these ideas and institutions, but too many go along with it as the established order. Many women resist and fight for the realisation of the equal rights that they enjoy on paper (or not in some cases). That battle is ongoing, and there is push-back from some governments and sections of society and hence gender inequality persists.One of the most devastating health inequities concerns the stark differences in life expectancies across countries.
What are the main areas for concern in health inequity currently?
One of the most devastating health inequities concerns the stark differences in life expectancies across countries. Whereas in places like Japan, women can expect to live to the age of 88 years, women in countries such as Chad or the Central African Republic have their lives cut short in their mid-fifties. This represents a repugnant difference in opportunity between haves and have-nots. But a country’s economic wealth doesn’t necessarily equate to long and healthy lives for its citizens. For example, the US barely makes it into the top 50 countries for life expectancy – behind Cuba, Lebanon, and Puerto Rico. While there are many causes, inequality plays a major role. And while race and income inequality are major determinants of the unequal distribution of life expectancy in the US, recent analysis points in particular to ‘deaths of despair’ – ie, hikes in suicides and drug and alcohol deaths – among middle-aged white men, frequently found among men with lower education and aligned with the collapse of local economies. In other words, it’s not one single inequality; it’s the intersection of multiple lifelong inequalities and reduced opportunities that drives health inequities.
COVID-19 revealed a great deal about inequalities. Marginalised communities experienced more cases early in the pandemic – reflecting the embedded inequalities they experience across society. But inequalities, including on the basis of age, sex and so on, could be seen across the entire course of the pandemic – as we found in our world’s largest tracker of data on gender and COVID-19.
The pandemic opened people’s eyes to the impact of inequality on health outcomes, and the momentum of that conversation should not be lost. The prevailing approach to dealing with poor health outcomes is to look to biomedical ‘solutions’. But inequities are social, political, and economic problems and need to be addressed as such. We need to tackle the social and commercial determinants of health which impact disproportionately on the marginalised in every society. We need to open up the space for addressing inequities – even if it seems at times that the space is diminishing. I am thinking about trust in government or the multilateral system or even in the belief in some quarters that equity is a good and just thing.
Please could you tell us more about the founding principles of Global Health 50/50 and what the organisation is doing to fight gender and health inequity?
Over many years, my partner, Professor Sarah Hawkes, and I came to understand that patriarchal norms and structures shape institutions, drive poor health outcomes for all populations, determine career pathways, and narrow workplace norms. Among other things, we had written about the problems of gender blindness in global health but found that these concerns didn’t incite any obvious change or action.It takes a village to raise a child, and the same is true to upend inequality in global health institutions.
We decided to adopt a different strategy. In establishing Global Health 50/50, we initiated a more systematic approach to assessing the gender-related policies and practices of a large cross-section of global organisations active in health (200) and created the first-ever interactive Gender and Global Health Index. We enrolled an A-list of experts to serve on an advisory council who would amplify our findings, people like Helen Clark and Katja Iversen. And we used eye-catching charts and infographics in our annual flagship report to ensure our findings had an audience and, hopefully, impact. And finally, we undertook to engage with the organisations whose policies and practices we wanted to see change. This past year, we named and shamed the organisations that had not made any meaningful progress. In short, we established a transparency and accountability tool to drive system change across the sector.
Global Health 50/50 aims for ‘better health and equal opportunities for all people of all genders, everywhere’. What progress have you made to date?
They say it takes a village to raise a child, and the same is true to upend inequality in global health institutions. We provide robust data in our Gender and Global Health Index and engage with organisations directly to shift the status quo. We have seen change over five years, particularly around commitments to gender equality (25% increase), workplace gender equality policies (27% increase), and a 15% reduction in leadership bodies with less than a third of women represented. In addition, 55 organisations have improved by at least three points in the Gender and Health Index since 2020. We have a great many testimonials that our data have led to discussions within organisations and decisions to develop new policies and to do things differently. But we have made an indirect impact, too. For example, in 2022, the Swedish International Development Agency (Sida) used our findings to urge and support the organisations it works with to improve their performance on gender equality. One of the great things is to see the mentality of gender equality embedded in institutional processes, for example, seeing job ads in organisations (eg, PSI, PATH) referring to Global Health 50/50. Having said all that, there is still so much to be done.
What is a typical day in the office like for you as Co-director?
Ha, good question. What does a typical day in the office look like for anyone working in global health after the pandemic? When Sarah and I established Global Health 50/50 we did so along with a collective scattered all over the globe, working largely remotely on this passion project. But we finally did set up an office, and our employers both allow us the flexibility to devote time each week to the initiative. When I go in, I rarely take a laptop, opting instead to use the time to meet and speak with colleagues, go for lunch with them and, if possible, have dinner or a drink thereafter. It’s all about connectedness.
What are your goals for the future at Global Health 50/50?
One of our immediate priorities is to increase the engagement that we have with global health organisations moving from a ‘calling out’ approach to one of ‘calling in’ – working with those who want support to improve their gender-related practices. We have also just partnered with CREHPA to apply our methodology at country level in Nepal. We’ve learned a lot of lessons from this partnership, and there is a great interest in other countries. We have also been collaborating with IFPRI and UN Women on Global Food 50/50, and there’s interest in Global Planetary Health 50/50 (Climate 50/50).
You are also the Director of the Global Healthier Societies Program at The George Institute for Global Health. Could you tell us more about this and what you are currently working on there?
I was thrilled when The George Institute approached me to serve as the inaugural Director of their Healthier Societies Program. Most research to improve health focuses on better diagnostics and treatment, stronger healthcare systems, and access to medicine. With Healthier Societies, we are researching, and advocating for, interventions that keep people healthy by creating conditions that promote and protect health and wellbeing across the life course in harmony with a healthy planet. This programme is about realising the rights to the determinants of health and wellbeing beyond the universal right to health care – fixing systems, not people.Gender inequality has a negative impact on everyone’s health and wellbeing. It is not a zero-sum game.
What policies or interventions are you most proud of being involved with for Healthier Societies?
Colleagues at The George Institute are researching a huge range of opportunities offered by a Healthier Societies approach. For example, in health promotion, a groundbreaking study in China demonstrated that replacing salt with a reduced-sodium, added-potassium ‘salt substitute’ significantly lowers the risk of stroke, heart disease, and death. This very low-cost intervention could prevent millions of premature deaths. We are now working with governments and industry to scale up the intervention more widely. In public health and human rights law, we developed a unique tool that measures and holds countries to account for implementing the United Nations Convention on the Elimination of All Forms of Discrimination against Women. We have worked to inform the global drowning prevention agenda based on research in those countries which bear the largest burden – like Bangladesh. I am excited about the research on the commercial determinants of health – which ranges from our FoodSwitch App allowing consumers to make better food choices to new work on the health impacts of autonomous vehicles.
What can companies, governments, and individuals do to stamp out gender and health inequality?
On the question of gender inequality, I would like to see a shift in mindsets to the recognition that gender inequality has a negative impact on everyone’s health and wellbeing. It is not a zero-sum game. Gender equality is not about taking something away from half the population but about ensuring fairness and promoting opportunity for everyone. This requires a whole-of-society approach, ranging from addressing the unequal norms within families, relationships and communities to tackling the laws, policies, and structures where inequality is reinforced.
On the question of health inequality, I want to return to the fact that good health is created by the environments we live in. Biology plays a part, but our social world seems to play an even bigger role. Health systems are generally designed to treat us when we’re sick. Recently, the Director General of the World Health Organization called on governments for a paradigm shift to focus on these environments. I have offered a five-point agenda to help make that happen.
Let me close by emphasising that inequalities in health and gender reflect wider inequalities in societies. I think that beyond looking for companies and governments to take action, we as individuals need to join forces with others to question, mobilise and demand more equal societies from the so-called 1% who are said to own as much of the world’s wealth as the rest of us combined.