Question: Why is gender specific care important?
Paula Johnson: Gender-specific care is very important because if we reflect on where we are today scientifically—it’s the era of the potential of the genome, it’s the era of “the emergence of personalized medicine”—and if we think about sex-specific or gender-specific care (and I just want to be clear, sex is who we are genetically women have two X chromosomes. Men have an X and a Y. And gender is how we are responded to in society because of our sex). If we think about this era of the potential of science, and we think about the fact that men and women are different biologically—you know every cell has a sex, and that’s the phrase that the institute of medicine coined. The potential for the development of science, as we think about sex differences is just enormous.
What it means when we think about sex differences in health and diseases [is] that men and women differ in every aspect of health and disease. The potential for discovery here is tremendous. Today we only are at the very early stages of understanding what some of differences are, from a clinical standpoint, and we really have a long way to go before we fully understand the scientific basis for some of those differences.
Just to give you an example, if you look at a woman who has heart disease, where there are symptoms that make one think that she might blockages in her arteries, we know that those symptoms differ between men and women. Now that’s a clinical observation, what we don’t know is why we see those differences and symptoms. Then, if you do testing in a man or a woman, the qualities of the test, the sensitivity and the specificity the characteristic of the test differ, between man and women—certain tests are better in women that they are in men. And then, very interestingly when you actually look at the type of disease women have, so their arteries actually look like, the arteries can look different, and what we begin to understand is that some of the standard tests that we’ve been using for many years, that are based on the typical disease that man have, may not function as well in women.
We’ve had many years of women undergoing this test and being told that they are actually fine. So today we are on a different place, we understand that there are some of these differences, some of that knowledge is not as generalized as widely understood as we need it. What we don’t understand is, biologically, why we do we see those differences? So, as you can see, there is this cycle between clinical observation, science getting the word out, translations of that science to clinical care, and observation, once again feeding more science
Question: Are there health issues specific to women?
Paula Johnson: I wouldn’t say that there are specific issues that are unique to women, what I would say that there are issues that are either more prevalent in women: those need to be focused on. And [there are] some risks that impact women differently. So for example, if you look at diabetes—for reasons that we don’t fully understand, the impact of diabetes on women’s heart health seems to be more profound than it is in men. And so diabetes will wipe away some of the early protection woman have against heart disease. But women will be more likely to die of cardiovascular disease. And then, when you layer over that some differences in, for example, cross-racial ethnic groups, you’ll see some very stark differences, for example in African-American women, compared with white women—with African-American women having much higher rates of diabetes, and also having much higher rates at the very early age of cardiovascular disease. Another major health problem is depression: depression is more common in women, and also [it] seems as though depression may be more linked in to development of further events, further coronary events, when women already have heart disease. So once again—differences on the prevalence of disease, and then differences, potentially, in the impact on outcomes in women.
Question: Are there medical technologies being developed specifically for women?
Paula Johnson: There are some newer technologies in the area of cardiology that I think are very exciting for women. So for example if we look at the fact that women are more likely to lay down plaque in their arteries in a way that is diffusely laid down, as opposed to there being a very discreet blockage in the artery that can be opened up, for example, with a stent. If women will have that more diffused disease more frequently, then it’s hard to see with our traditional test which is the cardiac catheterization.
Newer innovations with things like intro-vascular ultrasound, which allow us to put a tiny ultrasound probe into the artery and look at the artery almost from the inside out—that is a very important development for women in particular. Not that every women should have it, but for certain women for example, who might have [a] positive stress test—they get in the catheterization lab, the traditional test is done and there is no answer—this might be the appropriate next step.
Another exciting advancement is the use of small wires that measure flow throughout the artery if women are more likely to have what we call a micro vascular disease, disease in the tiny arteries. The small arteries are coming off the big one, once again that you can’t see with our goal standard tests. Then, once again, for certain women for whom the answer is not totally clear with the traditional test, this [is] maybe an option, and this is very important because it allows us to make a diagnosis in an important subpopulation of women.
By thinking about women in how they differ, it will help us look at all patients differently. And it’s always my belief that by looking at women, I’m looking at science and translating that science into clinical care. We actually improved the health of everybody, because we begin really thinking about what each and every individual needs appropriate to the evidence.
Question: How is access to medical care affected by sex and race?
Paula Johnson: Access to care is complicated: there’s a part of access that has to do with being insured, there’s a part of access that has to do with being able to find the care that you need, and part of access has to do with, when you find the care or when you go to your Physician, or you’re in a emergency room, actually being given the care that is indicated, the most appropriate care. With all three points, we really have to think about the impact of one’s sex and also how that intersects with one’s race.
If we were to think about women, many women are at higher risk, for example, of loosing their insurance—especially since more women are dependent, for example, on their spouse’s insurance, so if a job is lost it’s a difficult situation. Many more women are employed on a part-time situation [in] which health insurance is not offered or may not be offered—once again an access issue. But then there are times when we actually are insured that women may not actually be able to find the types of care that they need. For example, we know that there are access issues with regards to primary care that [are] pretty general not only for women but also for men. But we also know that women are more likely to seek medical care, so that lack of access will experienced more acutely.
There are some categories of health issues for which there are relative shortages of healthcare providers; for example, in the mental health area it may be difficult to access the appropriate mental health provider and if we know that, for example, women had higher rate of depression this may impact access more significantly for women. Another area where there is an emerging shortage, for example, is mammographers. We all know that, especially over the age of 40, you need to get your yearly mammogram, and for a set of complex reasons, the number of radiologists going to Mammography is actually decreasing. So I think women’s health can shed a real light unto health areas and providers that can really help up us to think about our system.
There is also very good data that suggests that minority women, especially African-American women, are not offered the same types of advanced care that white males may be offered. And this [has] been shown now in a number of studies and that is something that we do need to take in to account as we work within our health systems, to make sure that care is appropriate but that people who do have significant medical problems are getting the types of care that they need.
Question: What policy changes would you like to see address those issues?
Paula Johnson: So for women’s health in particular, access with regards to insurance coverage is critical as we expand coverage. We’ve done that in the state of Massachusetts. Hopefully we will see that happening throughout the United States, but as we improve coverage for the whole segment of population that is uncovered, [it] will absolutely assist women. We also want to make sure that we don’t pull back on some of the government and state sponsored programs such as Medicaid that are also particularly helpful to women. So I think that it one area that is very important.
The second is this idea and issue of access, and the appropriate number of health care providers, ensuring that we have enough Physicians and other providers in the area of primary care and changing some of the incentives so that we have incentives for our health care providers to pursue careers in primary care. I think, once again, this is very, very important as we think about comprehensive care and everything from prevention to some of the more complicated complex coronary care that is essential in our system.
The third is to think about some of the areas that are more specific to women—and make sure that we don’t leave this off the table. So, for example, in the area of reproductive health, there’s clearly a lot of controversy in those areas, much to my dismay. But there’s pretty good evidence that good family planning services should be really included within a set of preventative services, and to pull those out and make them a political agenda is something that is not in the best interest of women. So I think looking once again at specific areas to women is going to be very important.
Then, if you look across the life span, there other areas that are important to both women and men, but I think women bare some of the greater burdens—so, for example, longer term care: What happens to the elderly? What happens to the caregivers? The majority of people providing care in their homes to either ill parents or ill spouses or children are in fact women. We know that this [has] a tremendous impact on their own health. So how do we begin to think about comprehensive health services that include the care of the caregivers, and then work policies that also help to support caregivers? There are number of issues across the spectrum across the lifespan that are very important.
Lastly, there’s another one that I think is frequently left off at the table, which is the health of young women—we tend to think about women’s health almost beginning at the time of childbirth. So [we need] very good policies to cover women who are pregnant with the next generation—but in fact we do relatively poorly with regard to low birth rate deliveries compared to other countries and for where we are in terms of our level of income, and I think there is emerging data that really suggests, to improve those numbers, we have to improve the health of young women before they’re even thinking about pregnancy. So comprehensive, integrated preventative care for our young female population is critical not only for there health but frankly for the health our next generation.
Question: What is the state of global women’s health issues?
Paula Johnson: Addressing women’s health globally is also something that is critically important, and although it gets addressed in particular ways, really creating a very powerful movement to lift the health of women globally can really transform the health of the world. Margaret Chan, the current head of the World Health Organization, has made such statements, as [with] others such as Hilary Clinton, but women around the world are frequently not only left behind with regard to health—specially in the developing world—but health is a very complex issue. It’s not only about health and wellness but it’s about one’s social status, it’s about one status because she’s a woman in society who wants access to education. But if you begin to truly address the health of women, and use that as a motivating force, and think about how to transform the health of women through the development of health systems, we really can change the health of our world. I would make sure that we include the United States in that thinking.
Question: Are technologies being developed to improve healthcare accessibility?
Paula Johnson: [There is] emerging technology that allows us to access healthcare, to provide information to our healthcare providers, in ways we never had imagined. It will be [a] very powerful tool in the future. And if we think about populations that can’t get up and easily get to the physicians office or nurse practitioners office, these type of technologies that are already out there are rapidly developing will become even more important.
Now with all of that said, it will be very important as these technologies develop for us to remember that there is a very important component of care, that is about care, that is about the human interaction and about the relationship. It’s about trust, so that as we advance technologically—we are advancing—to make sure that we combine that with the human aspects of care and I think then we will truly have the ability to revolutionize the system.
Recorded on: June 6, 2009