Women in global health

Anita Zaidi, President of The Gender Equality Division at the Gates Foundation, joins Gavin to discuss women in global health from visibility in data all the way through to women in leadership positions in global health. Also on the agenda is the impact of vaccines, innovations in gender equity, and challenges and successes in addressing maternal mortality.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello and welcome to The Lancet Voice. It's June 2024 and I'm Gavin Cleaver. I'm joined today by Anita Zaidi, President of Gender Equality at the Gates Foundation, to explore her journey from being a paediatrician in Pakistan to a leader in global health. In this episode, we talk about the vital role of women in research, the impact of vaccines, innovations that have improved gender equity recently, and the importance of women in leadership roles.

Anita's got some insights on the challenges and successes in addressing maternal mortality. We talk about access to family planning, and we discuss the importance of policy action and advancing gender equity. I hope you enjoy listening to me talking with Anita Zaidi.

Anita, welcome to the podcast. Thanks so much for joining us. We're really excited to have you here. You're the president of the Gender Equality Division at the Gates Foundation, and you're originally from Pakistan. So why don't you tell us a little bit about your journey to this point? 

Anita: I'm a pediatrician.

I love children, and it's a really important part of my identity. I practiced for many years in Pakistan, and one of the things, the sort of big lessons for me was how. The way that the health system is organized, how that does not take care of the needs for, of women and children, and how much gender is a part of the access to care or lack of access to care.

How much we depend on moms for care for children. And then the other thing in my career in Pakistan was really understanding and marveling at the impact, the huge magic bullet impact of vaccines on children's lives. And I carried those two teams with me. And in 2014 I had the opportunity to join the Gates Foundation to work on rotavirus vaccines, which are, rotavirus is the biggest killer of children from diarrhea and on typhoid vaccines.

And so in 2014, I joined the Gates Foundation to work on those things. But in 2020, I had the amazing opportunity to become the founding president of the gender Equality Division. And that was then an opportunity to have back at a much wider scale in the world, continuing the work on children, but also now expanding the impact potential to also work for women and girls.

Gavin: It sounds like an amazing role. What's your day to day like at the Gender Equality Division? 

Anita: Yes. So it's of course a lot of meetings as all of us, as all of us have, but it's a lot of it is also like thinking through and finding the partners and amazing people around the world who can in their daily lives, in their work, advance lives and livelihoods for women and girls.

So it's a lot of meeting partners. That's why I'm here in London right now and spending a lot of time in Europe as well. Meeting people who are doing amazing work and how to help them do even more amazing work. 

Gavin: So before this role, you worked in vaccines and vaccination. I think you mentioned it a little bit there in the first answer, but how has vaccination changed the field of global health over the last few decades?

And what does the future sort of hold for vaccination programs? Obviously, there's been a lot of vaccine talk in the news over the last four years. 

Anita: So vaccines are one of the most impactful, perhaps the most impactful tools that we have in the public health arena to really save lives. And through this amazing organization called GAVI, the Vaccine Alliance, we have been able to, we, it includes many of us working on this, have been able to immunize more than a billion children around the world.

And we've made incredible progress in child mortality and child deaths. So if we look at the year 2000, when GAVI was formed, 10 million children were dying every year. And now it's almost down to four, four and a half million. That's still a lot of children dying, but it's half child mortality, number of deaths has been reduced by half.

And that's a genuine progress. It's a genuine progress that people actually don't realize how much progress we've made in preventing child deaths. And GAVI and ability to get vaccines against diarrheal diseases, like rotavirus, against pneumonia, against measles, is what's the big reason behind these reduction in deaths.

Thanks. So it's been an amazing program and from the foundation, from the Gates Foundation, we are one of the proud supporters of Gavi. But it's also the government of UK and government of many European countries. 

Gavin: It's it feels like Gabby's been around forever by this point, but like you say, it's only 2000.

It's only a relatively recent in there. 

Anita: It's yes, it's coming up to its 25th anniversary. 

Gavin: Yeah. So you took over the gender equality division in 2020. In fact, you were saying you were, you found this gender equality division. What changes in gender equity have you seen since then? Especially thinking about what a post COVID landscape looks like.

Anita: So some things are going really well, and I would say that they are tailwinds. So for example, HPV vaccine, and I talk about that also because it relates to what Gavi is trying to do now. HPV vaccine is 100 percent protective against HPV related cancers. Cervical cancer is all HPV. It's a virus that causes cervical cancer.

And now we know through research that's been funded that one dose of HPV vaccine can prevent cervical cancer. And that's 300, 000 deaths a year, 600, 000 cases of cervical cancer a year. It's just incredible. And I'm just now to think about that every girl in the world can be protected by one dose of HPV vaccine and does not need to, does not need to ever worry about getting cervical cancer.

It's, that's a huge advance. Other things, there's just a lot more attention on women's health needs. Why are women still dying in childbirth and trying to do something about that. Many more women are getting access to contraception on the work. So those are the good things. On the headwind side, there is, as I'm sure many of our listeners will know, a huge backlash against progress in gender equality, where people are just pushing back against women's rights, against reproductive rights, and have really weird ideas about women's roles in society.

Gavin: I'd imagine that the progress isn't even, either, across the world. 

Anita: Yes, that's true. Some countries are making much more progress than others are. There are definitely some bright spots and some dark spots, or becoming dark spots. Yes, progress is uneven and some, and there is some regression. There's not even, can't even call it progress, it's like backsliding.

Gavin: I wanted to ask you about some of the recent innovations that have affected gender equity that you've noticed in your role. 

Anita: Yes, we talked about HPV vaccines, which I think are game changers. Another one is the realization that making sure that all women, all pregnant women around the world have access to prenatal vitamins, which is a staple in the rich world.

Every woman who's pregnant in the UK would get prenatal vitamins, but there are only 10 percent of women have access to prenatal vitamins in lower income countries. And we now know that actually the impact of prenatal vitamins in pregnancy, if a population is malnourished, is way more than if you have access to a healthy diet.

We know that if a woman gets prenatal vitamins during her pregnancy and and she's living in a lower income country, the chance that she'll have a stillbirth or that she'll herself suffer from anemia is much, less. Or that her baby will be born premature. Or that her baby will die soon after birth.

is like 10 to 20 percent lower. And so now there's a big push to get prenatal vitamins to all pregnant women around the world. And I think that will be a huge innovation that we can all be proud. 

Gavin: And is that a good example of what is a relatively cheap intervention as well? 

Anita: Costs less than the cost of a coffee.

Yes. It's unbelievably cost effective. Another one so we're still talking about innovations, right? Another one that I think will really make a huge difference is a product, is a medicine product called IV iron. So many women suffer from anemia during pregnancy because your iron requirements go up.

And until very recently, there was a very old form of iron that had to, has to be given in a drip over many hours. And now we have a product that's it's a combination of the iron, the element, and some sugar, which is, it's a tough name, ferric carboxymaltose. So if you can put ferric carboxymaltose in a small injection, it can be given over 15 minutes.

And it's a magic cure for anemia. And anemia in pregnancy is one of the biggest causes of bleeding after childbirth, what we call postpartum hemorrhage. So being able to treat that anemia during pregnancy, especially severe anemia, will prevent many women from leading to death during childbirth or after childbirth.

So I think that's something that's going to be also, we'll see this make a huge difference in the number of women dying in childbirth, which is unfortunately still a very big number around the world. Lots of other innovations are coming down the pike. Another one that we think will change lives a lot, especially early referral, and this is also an issue in the U.

K. and in the U. S. for pregnant women, is being able to get ultrasound and AI enabled or artificial intelligence enabled ultrasound in the hands of frontline health workers. You don't need a very technically skilled person to be able to do an ultrasound and interpret an ultrasound community health worker, a midwife, a school nurse.

could do an ultrasound and see if this woman is going to have, get into trouble during her labor and delivery, and should I refer early. So I can, there's, I have a very nerdy long list of innovations that are like that, but there's a lot of excitement in the field. There's another opportunity to make a difference is what we call the postpartum hemorrhage bundle for treatment, where if you, now we know that if you have a simple plastic drape under a woman when she's given birth and you can tell how much blood she's losing and act on it early with a bundle of interventions instead of doing it step by step that you can actually prevent severe postpartum hemorrhage and death by 50 to 60 percent by acting early and by detecting early and acting early.

And so we think that's also going to be a huge lifesaver for women around the world. There's, 14 of these exciting innovations and I'm happy to come back and talk about the other ones which are going to take a little bit longer to get out there. But there's a lot happening in this space, which is very exciting.

And I think that if I talk to you five years from now, I'll be able to tell you how many lives have been saved by doing all of these things. 

Gavin: That's fantastic. It's great. There's so many things in the pipeline. And I'd imagine they all have a sort of multiplying effect on each other. If they're saving X amount of lives here and Y amount of lives here, then actually combined the effect with all these low cost interventions becomes seismic.

Anita: Absolutely. It's compounding. Yes. It's some is going to be bigger than the parts. Another one that we haven't talked about is access to family planning and modern contraception, which half of all pregnancies around the world are unintended. And when a woman has an unintended pregnancy or a girl, it has a profound influence on her life and her ability to take care of herself and if there's going to be a baby and she's not ready.

So having access to contraception so you can plan your family, you can plan when you have a baby, will make, will also make a huge difference to maternal mortality as like a, the ultimate thing. But of course it makes a huge difference to her own life and her ability to take care of kids that she might already have.

Gavin: Of course. I wanted to ask you a little bit more about, the broader thinking topics in your role. How important to you is the inclusion and visibility of women and girls in, in research and especially in data? 

Anita: Yeah. So that's a really key issue that we deal with and have, and it's a centuries old issue where women and vulnerable groups have been excluded from medical research.

And so a lot of the medicines that we have in our arsenal today have never been tested formally in, in women, in pregnant women, especially, and in children. And so we are guessing. We're guessing at what the right dose is. We're guessing at what the effect is. And often from the older trials, we don't even have what we call sex and gender disaggregated data.

So we don't even know what were differences were seen in that trial among women, even if women were included. Okay. But first of all, they're not even included. But even if they were included, let's say 10 percent of the participants in our clinical research trial were women. We don't have their data separately reported out.

So we don't know if any differences were seen. That really needs to change. And now agencies around the world are asking to see sex and gender disaggregated data. But more needs to be done on inclusion and research in the first place so that we should know how many women were included in this trial. We should know how many people of different ethnicities were included in this trial.

Pregnant women is a special category where we think that we are protecting women and their fetus from not including them in research because they're a vulnerable group. But actually we've caused a lot of harm. One example that is dear to my heart from my vaccine's work is Cholera vaccine.

Cholera spreads in unhygienic conditions and sometimes it spreads as explosive outbreaks. And the, if you're pregnant and you get Cholera, the chances that you die are much higher than the general population. Yet, because the vaccine, which is an oral vaccine, is not tested in pregnant women, so when humanitarian agencies are delivering Cholera vaccine, pregnant women are not tested.

would not be given the vaccine, and they are at the highest risk of dying. We had to do the research to show that the vaccine was safe in pregnancy, so that women could be given vaccine if there was a cholera outbreak. Those are the kinds of things that, this is just one example, but there are countless such examples of where women who are at higher risk of a disease are left out of the studies, because people think that they will distort the results of the study.

Gavin: Yeah. No it's super important. Isn't it? Some of the last has been working on recently with helping introduce the SAGER guidelines across Elsevier, ensuring that women are reported in data and just in basic terms in disaggregation like you're talking about, but it's also important as well to have women in research roles too, isn't it?

Conducting these studies. 

Anita: Yes, exactly. So having women in research, having women in global health, senior roles, having women and then big pharma companies in leadership roles. We'll change all of this because they, you, they will bring attention to the neglect that is there in global medicine and the way that women and vulnerable groups have been treated in medical research.

Gavin: It's also important, isn't it, to get more women into leadership roles around in global health roles like yourself? 

Anita: Absolutely. So global health is one area where there, it's 70 percent of the global health workforce is female. And yet, when you look at top leadership positions, seriously under representation of women.

And it's at the bottom of the pipeline, there is a lot of talent. That talent is not, does not rise to the top. And we have to look at why that is. And it's one of the areas that in the Gender Equality Division at the Gates Foundation, we are very carefully looking at and seeing how we address. Now, why this happens, there are several underlined underlying issues, but it's not that women are not in global health.

I just said that 70 percent of the women in global health, 70 percent of the people in global health are women. It's the sort of organizational factors, societal factors, and then individual barriers that women face with child care responsibilities, with not being encouraged, quashing ambition. So all of those are factors that need to be addressed to make sure that we have gender parity in leadership and global health.

Gavin: It's something that's, it feels more difficult to address than medicine in a way. You know what I mean? Because it involves changing these societal attitudes. 

Anita: No, it is not, none of this is easy as this is a long term, keep trying, look at the historical arc of progress. Things can take a hundred years, but you have to start and you have to keep, 

Gavin: yeah, you can nudge them along the way.

We're talking about women's role in, in the world and talking about women's health. I wanted to ask you what some of the most important steps were for empowering women across the world to participate in the economy, which I believe is something you've been doing talking about in your role in the Gates Foundation.

Anita: Yes. So in the, in our gender equality division we have a big focus on health as we just talked about, but we also have a big focus on women's economic opportunity and empowerment. And that's because half of the world is women and women are held back from participating in the economy. And we know that this is not a side issue.

This is, it's the sort of fundamental underlying. determinant of progress in societies and countries. If women are participating in the labor force, if women are working, if women have the ability to reach their full potential and are not being held back. We look at how, what works. And one of the things that I think our listeners will be surprised by, for example, in Africa, one in four African women is an entrepreneur.

And when you talk to what's holding them back from expanding their business, increasing their income and revenue. It's lack of access to credit, lack of access to capital, because women the regulations the interest of the banking industry in giving women loans that work for them, it's not there, or it's very low.

And so women have, they really struggle with access to capital to expand their businesses. And so these are, so we are looking at ways at how you change that. What are the regulations? What are the rules? What are the laws? Does she need her husband or father to sign for a loan? And what's the cost of capital to her?

Is she being charged like astronomical rates that are unaffordable? What are the terms of the loan? Can you make loans that are more suitable for her business, customizable products that work for her? How do you When you don't have collateral, which many women don't, how do you Use data trails in previous history of returning credit on time to make her credit more credit worthy.

Those are all things that we are investing in with many partners in Africa and South Asia to understand better how to help women access to credit. 

Gavin: That's really fascinating 'cause that's changing The economy could cause such changes on a societal level. And I wanted to talk to you as well about maternal mortality, which obviously is a major focus of your work at the Gates Foundation.

Some of the rates remain quite high and we've touched on this in our conversation so far even in developed countries and family planning methods You talked about the innovations of family planning methods being available to people but Sometimes they are quite difficult to access for women around the world.

What are you doing to address these challenges and what more can be done? 

Anita: Yes, so maternal mortality of women dying during or after, during pregnancy, during childbirth or after childbirth, it's one of the, I would say, the saddest statistics for me right now because we have made no progress in the last 15 years.

The number of women that were dying 15 years ago and the number of women dying today is still the same. For And even more shocking is that there's actually increasing maternal mortality in some countries including countries like the United States and in the UK, for example, we now know that maternal mortality for if you're a woman of color, your risk of dying during childbirth during pregnancy and after childbirth.

And this is really most maternal deaths are preventable, 90 percent are preventable, and it's really a failure of all of society that this is still happening, and it's an addressable issue with it, we don't need to be, I'm very pessimistic about not being able to address that because we know what works.

We know having access to skilled birthing facilities, having access to good antenatal care, having access to the innovations that we, we talked about can really prevent a lot of these deaths. In terms of innovations, I think the biggest one that we talked about is postpartum hemorrhage and being able to detect it early and act early.

I think. We need more research on many of the issues. For example, there is one pregnancy disorder called preeclampsia, which, like hypertension during pregnancy, which does not have any treatment. And it's a very underfunded area of research. And we need to put much more effort in it as a global R& D community to understand what causes preeclampsia, how to prevent it, and how to treat it.

And then, yes, family planning, putting family planning tools in the hands of women, I think will make a big difference. And there is one contraceptive that can be right now given by self injection, and it can last for three, three to four months, which is a very popular family planning method around the world that women are taking up.

And I think having more of that available around the world can also make a big difference. 

Gavin: Yeah, so it's a relatively easy win there, but It's shocking, like you say, that almost no progress has been made in 15 years. 

Anita: Correct. Yes. It's a sort of neglect of women and pregnant women by the health system.

Gavin: I wanted to finish up by asking you in broader terms, because obviously the Gates Foundation operates as well on quite a political or policy level, talking with governments at quite a high level. What sort of political or policy action is the most important thing for advancing gender equity, do you think?

Anita: Yes, I'll answer that question at the individual level. So all of us who are listening have it within their power to do something. And whether it's raising children who are, who believe in fairness and equity, boys and girls, or at your local community level, or if you have the power to be active on social media in your workplace.

in your community to be able to do what will make the world a better place. And that includes being, living in a gender equitable world. I think we should do. So it's a call to action for everyone. 

Gavin: That's great. And a good note to end on. Anita, Zaidi, thank you so much for joining us on The Lancet Voice. We really appreciate you coming in.

Anita: Thank you. It's such a pleasure being here and being able to talk to you. Thank you.

Gavin: Thanks so much for listening to The Lancet Voice. Remember, you can subscribe to The Lancet Voice wherever you usually get your podcasts, and we'll see you next time.