Gender Equity And Public Health in Europe - A Discussion Document
1. Introduction: gender equity and health in a global context

The last decade has seen a growing debate about the links between gender and health. On the one hand, women have been campaigning under a human rights banner for their needs to be taken more seriously in health planning. These arguments were reinforced in the Platforms for Action developed at the UN conferences in Cairo (1994) and Beijing (1995). On the other hand, there has been a growing consensus on the broader economic and social gains to be made from promoting the health of women. The World Bank in particular has argued for investment in women’s health as a rational use of resources especially in the poorest communities (World Bank 1993 and 1995).

In response to these pressures, international organisations and national governments have prepared gender action plans which include health -related objectives. These have focussed mainly on reproductive issues but there is a growing acceptance of the need to integrate gender concerns into all aspects of health care. This is in line with the Beijing Platform which recommended ‘an active and visible policy of mainstreaming a gender perspective in all policies and programmes.’

The EU delegation to Beijing played a major role in support of the strategy of gender mainstreaming. Member countries have responded individually to the two Platforms for Action while the Commission itself has been involved in regional follow-up and review meetings (Commission 2000a). These activities have measured progress in the EU on a number of fronts but little attention has been paid to developments in the health sector.

This paper will explore the reasons for this relative neglect and identify the ways in which gender equity could be more effectively promoted within the context of public health policies in the EU.

The first section will give a brief account of existing gender equity and public health policies in Europe, highlighting the potential for greater integration between the two. The next section will provide a conceptual framework for the development of gender equity policies and will identify some of the major challenges they pose in a public health context. This is followed by a brief account of current patterns of gender and health across the member states. This will set the scene for the remaining sections of the paper which will identify the strategies to be adopted if gender is to be mainstreamed into EU public health policy in the manner recommended at Cairo and Beijing and required by the Treaty of Amsterdam.

2. Gender mainstreaming and public health in the EU: the current picture

The current situation in the EU is one where gender equality strategies and public health policies exist in very separate domains. Gender concerns are now highlighted in the overall mission of the EU but are differentially addressed in the various policy arenas. Public health policies have not been central to the work of the Commission and have received little or no attention from those concerned with mainstreaming gender. As the public health agenda gains momentum it is essential that the needs of women and men receive equal attention in this sphere as in others.

Gender mainstreaming in the European Union: progress on some fronts

The promotion of gender equity has been a longstanding theme in the philosophy and operations of the EU. As the scope of activities has broadened, equal opportunities issues have received increasing attention, especially in the context of the labour market. The mainstreaming of gender was formalised in the Treaty of Amsterdam with the pursuit of equality between women and men incorporated into Articles 2 and 3. This brought equality into the general competencies of the Community making it a fully-fledged part of the mission, alongside economic development and cohesion (Geyer 2000; Rees 1998).

In 1998 the Commission reviewed progress to date on equal opportunities and considerable achievements were noted in the fields of development cooperation, employment policy, education and training and youth policies, and in the staffing policies of the Commission itself (Commission, 1998). However progress in other areas was patchy. As the Commission’s own report observes, the majority of these achievements were ‘isolated measures’ which do not ‘seriously influence the orientation of mainstream Community policies’ (Commission 1998 p.5). This is certainly true in the arena of public health policy where gender has received very little attention indeed.

Health policies in the EU: the poor relation ?

The origins of the EU lie in the economic realm. Though gradual changes have been introduced over the years, this bias has continued to be evident in most of its activities (Geyer 2000; Mossialos & Permanand 2000). The Treaty of Rome did contain a commitment to the improvement of social conditions but only as part of the process required for the creation of an effective economic unit. Public Health did not appear as a separate item within this agenda but was incorporated in the more general field of health and safety at work.

The Treaty of European Union (or the Maastricht Treaty) of 1992 embodied the first legal competencies for the Community in relation to public health. Article 3(0) empowered the Community to ‘contribute to the attainment of a high level of health protection for its citizens’ while Article 129 stated that this should be achieved by ‘encouraging co-operation between the member states and, if necessary, lending support to their action’. The Treaty also contained the statement that ‘health protection requirements shall form a constituent part of the Community’s other policies’.

These were important beginnings, which reflect the trend towards a wider social protection agenda in the EU as a whole (Geyer 2000). However community activities in the field of health have continued to be limited by two important factors. First, the principle of subsidiarity has placed major constraints on any intervention in matters relating to health services delivery. This responsibility remains firmly with the individual member states who have guarded it jealously. Second, the 1992 public health competencies themselves were limited in their conceptualisation and offered few opportunities for effective policy making (Mossialos & Permanand 2000).

A number of activities were undertaken under the rubric of Article 129 but these consisted largely of vertical, disease oriented programmes with AIDS , cancer and drug abuse receiving particular attention. These were valuable initiatives but had little cumulative impact on the major health problems facing the member states (Mossialos & Permanand 2000). Moreover the limitations of existing powers were highlighted by a number of 'health scares' particularly the crisis over BSE. In an attempt to alleviate these problems the drafting of the Amsterdam Treaty incorporated a strengthening of the EU public health mandate.

The wording of Article 152 of the Treaty represented a shift from a conservative and narrowly preventive approach to a more positive one of ‘improving public health, preventing human illness and obviating sources of danger to human health' . The Treaty also included a statement to the effect that human health should be protected in ‘all Community policies and activities’. However much remains to be done if the EU is to offer appropriate support to present and future member states in dealing with the public health challenges they are now facing.

In June 1999 the incoming Commission President Romano Prodi announced the setting up of a new Directorate General (DG XXIV) combining health and consumer protection. Alongside these organisational changes a new Public Health Programme was unveiled in May 2000 (Commission 2000a). This represents an important step forward and contains much of value. The commitment of new resources and a more integrated approach to the social determinants of health are very welcome but there are also significant gaps. In the light of the wider mission of the EU the failure to mention any aspect of gender is especially surprising.

The potential for synergy

The European Union therefore has two important but unfinished agendas. First, the strategy of gender mainstreaming has been started but remains partial. It has been applied in some parts of the Commission's work but not in others. Second, the public health agenda has been limited and poorly focussed and has not been viewed through a gender lens. The launch of the new Public Heath Programme offers an opportunity to bring these two streams of work together. However this will require both political will and careful planning. The next section of this paper will explore the conceptual underpinnings of gender equity strategies and identify some of the challenges that will have to be faced if they are to be effective.

3. The case for a gender sensitive public health strategy

The first question that needs to be addressed is the meaning of 'gender equity' in a public health context. The most obvious definition would be the achievement of the same life expectancy and health status for women and for men. However this would clearly be unachievable since individuals differ enormously in their genetic inheritance. Moreover we know that women have the biological potential to live longer than men. Hence realistic strategies for gender equity cannot be focussed on equalising longevity or health outcomes. Instead they must ensure that women and men have equal access to the resources they need to realize their potential for health- whatever that potential may be (Doyal 2000).

These resources will include high quality and appropriate medical care. They will also include the range of social, economic and cultural goods that individuals need to promote their own well being. Many of these resources will be common to both women and men. However there are also significant differences between the two groups in their health needs and in their access to the relevant resources. These differences will need to be identified and acted upon if health policies are to be equitable.

Sex differences in health needs: the biological dimension

The most obvious differences in the health needs of women and men are those related to their reproductive characteristics. Women's capacity to conceive and give birth can have major effects on their wellbeing. If they cannot control their own fertility or lack the resources to move safely through pregnancy and childbirth, women will be unable to realise their potential for health. This is why reproductive rights have been so high on the agenda of feminist health advocates around the world (Petchesky & Judd 1998; Sen, Germain & Chen 1994).

Beyond the reproductive arena men and women also have different health care needs as a result of their susceptibility to sex-specific diseases such as cancer of the prostate or cancer of the cervix. They also appear to be at differential risk of developing some diseases that affect both sexes. All things else being equal, men are more likely than women to die prematurely from heart disease for example, while women appear to have a greater susceptibility to a number of diseases including rheumatoid arthritis, systemic lupus and osteoporosis.

Differences in male and female biology must therefore be a central concern in any strategy for promoting more equitable health policies. Most importantly, reproductive health care must be given a high priority.

But the whole range of sex differences in mortality and morbidity need to be taken into account in the planning of both research and service delivery.

Gender inequality and health: the social dimension

Though biological differences between the sexes are clearly important they can tell only part of the story. Socially constructed inequalities or gender differences between males and females also play a central role in determining whether individuals are able to realize their potential for a long and a healthy life. This is because gender divisions have a direct impact on the health needs of women and men as well as affecting their access to care.

All societies are divided in two along a male/female axis. Those who are defined as female are given primary responsibility for household and domestic labour. Conversely males have been more closely identified with the public world, with the arena of waged work and the rights and duties of citizenship. In most societies there are not just differences but inequalities inherent in the social definitions of femaleness and maleness.

Those things defined as male are usually valued more highly than those things defined as female and men and women are rewarded accordingly. These patterns of discrimination are more extreme in some communities than in others. However there are no societies in which women and men are treated equally or where women are treated better than men (UNDP 1995). Not surprisingly these inequalities often prevent women from realising their potential for health (Doyal 1995).

Gender inequalities are most obvious in the distribution of income and wealth. This reflects women's unequal position in the labour market, their less favourable treatment in most social security systems and their lower status within the household. Discrimination against women is also evident in the political sphere. Their access to power is not commensurate with their numbers, their needs or their contributions as citizens. All these dimensions of gender inequality are very evident in the member countries of the EU just as they are in other parts of the world (Commission 2000c)

In recent years women and their advocates have built up a large body of work demonstrating the intimate interrelationship between these gender inequalities and patterns of health and health care (Doyal, 1995; Kitts & Roberts, 1996; Stein, 1997; Tinker et al., 1994). Studies have looked not just at life expectancy but also at more qualitative dimensions of well being. They have shown that many of the health problems women face are not related in any direct way to their specific biological characteristics. Depression for instance, is more commonly reported by women than by men yet there is no evidence that women are constitutionally more susceptible to these problems (Busfield, 1996).

Within the household women often have little support and the nature of their labours may affect their health. Household work and child care can be debilitating especially for those living in poverty or in unfamiliar surroundings. The time consumed in caring for others can lead some women to neglect their own health. For too many this may be exacerbated by domestic violence. Work outside the home can also be hazardous to both physical and psychological health. While some of these risks are the same as those borne by men, others are very different, reflecting the gendered divisions in the labour force and the workplace.

As well as affecting women's physical and mental health, gender inequalities also affect their use of health care and the quality of the services they receive. In most EU countries women are offered equal access to basic health care. However their use of those services may be hindered by a number of gender related factors which are likely to affect poor women in particular. These include lack of culturally appropriate care, lack of transport and lack of substitute care for dependents (WHO 1998; Gijsbers van Wijk et.al 1996). When they do get access to care there is evidence that women may receive treatment which is technically inferior to that received by men and may also be delivered in less respectful ways (WHO 1998; Petticrew, McKee & Jones 1993).

Though they have a longer average life expectancy than men, most women do not lead healthier lives. Moreover, a considerable amount of the illness they experience can be traced back to the gender discrimination that shapes many aspects of their existence (Annandaleand Hunt 2000). If public health strategies in Europe are to promote gender equity, they will need to reduce the discrimination women face not just in the health sector but also in the wider society. The policy implications of this will be explored in the following sections but before moving on we also need to explore the implications of gender for men.

Is gender a problem for men too?

Little attention has been paid to the impact of gender on the health of men (Cameron & Bernardes 1998). However new research is now emerging about the potential hazards of masculinity for health. In the former socialist societies in particular, the growing gap between male and female life expectancy has attracted a great deal of attention (Boback et al., 1998; Leon et.al., 1997; Watson, 1995 and 1998). If 'gender ' is to be more than just a synonym for 'women', it is important that we examine these concerns in more detail and assess their implications for gender equity in public health.

At first sight it might seem evident that being a man must be health promoting. As we have seen, men have privileged access to a wide variety of resources. In most societies they also have fewer constraints on the choices they can make. The physical, psychological and social barriers that prevent many women from making healthy decisions are much less likely to stand in the way of men.

However it is also apparent that the nature of 'masculinity' itself may be damaging to men's health (Sabo and Gordon 1993). Though there are advantages to living a man's life it can also be risky. The most obvious illustration of this can be found in the workplace where the stereotyped role of 'provider ' often puts men at greater risk than women of dying prematurely from occupational accidents (Waldron, 1995). For many there are few options if they are to carry out the duties socially expected of them.

Similar, but less direct pressures seem to lead men to expose themselves to hazards in other areas of their lives. Many feel compelled to engage in risky behaviour in order to ‘prove’ their masculinity (Connell 1995; Kimmel and Messner, 1993). This means that they are more likely than women to be murdered, to die in a car accident or in dangerous sporting activities. In most societies they are also more likely than women to drink to excess and to smoke, which in turn increases their biological predisposition to early heart disease and other health problems (Waldron, 1995). They also seem to be more likely than women to desire unsafe sex (Zeidenstein and Moore, 1996)

The significance of a male identity in the context of mental health has also received attention. It has been argued that growing up male renders many men unable to realize what might be their emotional potential. The desire to be seen as a ‘hard’ man for instance may prevent them from exploring the ‘caring’ side of their nature while a refusal to admit weakness may prevent them from consulting a doctor when they are ill (Harrison et.al., 1992; Kristiansen, 1989).

These are important issues which need to be taken seriously in the debate about gender equity in health. However their policy implications are complex. Strategies can be devised to help men to free themselves from the unhealthy constraints of rigidly defined gender roles. This could be done through less gendered educational programmes, more flexible employment policies and changes in the structure of state benefits. Such initiatives could help some men to behave in healthier ways. However they will only promote gender equity if they are part of a much wider public health strategy which will also protect women from the hazards that continue to be created by inequality and discrimination.

4. Sex and gender differences in patterns of health and illness in the EU

The development of an equitable strategy will need to be based on a clear understanding of how sex and gender influence patterns of health across the member states. However the lack of standardised systems of data collection and the absence of common indicators makes such comparisons extremely difficult. Though the Commission produces statistical compilations derived from a range of sources very little of the health information is disaggregated by sex (Commission, 1997; Eurostat, 1998 ). This section can therefore provide only a brief introduction to the differences in the health of men and women. Recommendations for improving methods of data collection are made later.

Demographic trends

The overall health of the EU population is among the best in the world. Life expectancy has increased for both women and men over the post war period with the male average now standing at 75 years compared with a female average of 81 years (Eurostat, 1998). Thus women now live an average of 6 years longer than their male compatriots of the same socio-economic status and this gap is continuing to widen in most member states. This raises important questions about the biological and social influences on longevity and about the different policies needed to maximise life expectancy in the two groups.

One consequence of these demographic trends has been an increase in the number of older people in the EU. People over 60 now make up at least 18% of the population in all member states (Eurostat 1998). This increase has led to a ‘feminisation’ of the older age groups. Across the EU, around a quarter of women are now over the age of 60 compared with only about 18% of men and this predominance is especially marked among those in the over 80 group. This greater longevity raises important questions about the quality of life of those who survive. Since many women appear to be especially disadvantaged in old age this will need to be reflected in planning health and social care for the future (Arber& Ginn 1995; Ginn & Arber 1994).

At the same time that the population is aging, there has also been a decline in fertility from around 2.59 children per woman in 1960 to an all time low of 1.45 in 1998 (Eurostat 1998). The infant mortality rate has improved significantly, falling from 23 per 1000 in 1970 to 5 per 1000 in 1998 (Eurostat 1998). Maternal mortality too has dropped from an average of 35 per 100,000 live births in 1970 to just over 7 per 100,000 in 1992 (Eurostat 1998). This makes the EU one of the safest places in the world for mothers and children. However there are significant ethnic and social class differences in both maternal and infant/child mortality rates and the 25% of EU households headed by women are often at greatest risk.

Causes of death

Data on causes of death provide important indicators of sex and gender differences in health. 47% of all deaths in women are the result of cardiovascular diseases and 22% are the result of cancer while the comparable figures for men are 39% and 28%. Thus male and female causes of death are broadly similar. However closer examination reveals significant differences between the sexes and these have important implications for the development of public health strategies.

Diseases of the circulatory system (ischaemic heart disease and cerebrovascular diseases or stroke) are the most common cause of death for citizens of EU member states. Mortality rates from coronary heart disease have decreased in all countries since 1970 but it remains a major cause of death and disability for both males and females. Men are more likely to die prematurely from the disease than women and this reflects in part their greater biological susceptibility. However it is also a result of gender differences in daily life especially smoking patterns. This raises important questions about the different strategies needed to control coronary heart disease in men and in women.

Cancer is also a major cause of death in both men and women but again, there are significant differences in the patterns found in the two groups. Some of these are biological in origin. Breast cancer for instance, is a predominantly female disease. It causes more than 20% of all female (cancer) deaths and a woman living in the EU has a 2-3% chance of developing the disease during her lifetime (Commission 1997). The cervix is the second most common site accounting for 2% of all cancer deaths. Men too are at risk of sex-specific disease with cancers of the prostate and testes causing around 17% of (cancer) deaths per year. The allocation of resources for research and treatment of these different cancers poses considerable challenges but it is important that gender equity is one of the criteria used in making these decisions.

Lung cancer shows a very different pattern since the same disease affects both males and females but not to the same extent. Standardised mortality ratios for cancer of the lung, bronchus and trachea now stand at 73 for men and 15 for women (Eurostat 1998). Hence it is a disease that predominantly affects men. However the rate is currently rising among women. Around 9% of all cancer deaths in women are now attributable to lung cancer and the female mortality rate for the disease has risen by 45% since 1970. This narrowing of the gap between men and women is in large part a reflection of social trends especially changes in the smoking habits of both groups. Hence prevention strategies will also need to be gendered in response.

Patterns of morbidity

While mortality data offer some insights into sex and gender differences in causes of death they are limited in what they can tell us about patterns of sickness and health across the lifecycle. However information on morbidity is sparse at the EU level and the available data are rarely gender-disaggregated. One of the few exceptions is self-reported illness and disability and this does show marked gender differences ( Eurostat 1998) At all ages, women are more likely than men to perceive their health as bad or very bad and this pattern can be observed across almost all the member states. The overall average for women reporting (very) bad health is 25% compared with 20% for men. This confirms the pattern found in many smaller scale studies of women experiencing less good health and raises important questions about how this phenomenon should be addressed ( Macintyre, Hunt and Sweeting 1996)

Despite the limitations of the data, this overview has highlighted the relevance of both sex and gender issues in shaping patterns of health and illness across the EU. However there have been relatively few efforts to incorporate these insights into policy making. The promulgation of the new Public Health Programme offers an important opportunity for achieving this. The remainder of this paper will discuss how this could be done. It will identify policies for mainstreaming gender issues in the collection of official statistics, in health research and in the delivery of services. The final section will highlight the importance of multi-sectoral approaches to the promotion of health for both women and men in all aspects of the Commission's work.

5. Creating gendered public health information systems in the EU

There are major gaps in the data available on health in the EU and one of the priorities of the new programme is to remedy these deficiencies (Commission 2000). If this new information strategy is to provide an effective basis for policy making it is essential that (biological) sex and (social) gender should be a central part of the conceptual framework used both to collect and to analyse data.

Including sex and gender as key variables in routine data collection

Compilations of EU-wide statistics currently offer little in the way of sex and gender disaggregated information. This is especially problematic in the context of morbidity data. While men are more likely than women to die prematurely it is women who experience more chronic ill health, distress and disability, especially in old age (WHO 1998). If these differences are to be properly understood, systems will need to be developed for monitoring gender differences in patterns of health and illness across the lifecycle.

Lack of disaggregated morbidity data is especially problematic in the context of mental health. We know that in most countries women report depression and anxiety about twice as often as men (Desjarlais et al. 1995). The World Mental Health Report has highlighted the increasing burden of psychological illness and its impact on women in particular (Desjarlais et al. 1995). However there is currently no system for monitoring these problems across the EU.

There is also a marked absence of information on sexual and reproductive health, which again is especially significant for women. We know from maternal mortality data that very few women from member states die from reproductive related causes. However this does not mean that there are no issues of concern. More information is needed on contraceptive use and its associated morbidity as well as the availability and use of abortion services. New indicators are now available for measuring qualitative aspects of sexual and reproductive health and these need to be incorporated into the new EU health information systems (WHO, 1997).

As well as making reproductive health more visible, there is also an urgent need for better monitoring of gender violence in the member states. A recent World Bank estimate suggested that domestic violence, rape and sexual abuse together account for 19% of the disease burden among women aged 15-44 in the developed countries (World Bank 1993). Yet EU-wide data on the scale of the problem are still not available. Individual countries will need to work on the development of ethical and culturally appropriate methods for the collection of data in their own settings. However the Commission has an important role to play in supporting these efforts and in disseminating the good practice already developed by a number of NGO's and by WHO (Heise et.al , 1995; WHO, 1999; Jewkes et. al, 2000).

In developing new health information systems, the Commission is likely to make use of the tools associated with the Global Burden of Disease (GBD) approach (Murray and Lopez, 1996). This initiative is designed to map the extent and distribution of death, disease and disability in different settings using the measure of Disability Adjusted Life Years or DALY's. It has been an important methodological innovation, which has contributed significantly to the tool kit available for health planners. However critics have argued that it underestimates the burden of disease borne by particular groups including women. These gender-based critiques will need to be taken into account in any attempt to use DALY's in an EU context (Hanson 1999; AbouZahr 1999 Nygaard 2000).

Recognising diversity in the measurement of gender and health status

Health information systems in the EU require revision if they are to reflect the differences between women and men. However effective planning also requires recognition of the differences between groups of women and groups of men. The disaggregated data currently available offers little help since it usually presents men and women as homogeneous entities. If policies are to reflect the reality of the lives of individuals and communities across the EU, the new information systems will need to reflect the various dimensions of diversity as well as being gender sensitive.

One important differentiating factor between individuals is age. The health needs of both women and men will vary across the life cycle and these need to be reflected in information systems. However EU data currently gives us very little information about women (or men) at either end of the age range. There is very little information available about the reproductive health of younger women for example, despite the very high rates of teenage pregnancy found across the EU. Older women too are largely invisible, despite the major impact of the biological and social aspects of aging on their health ( Arber& Ginn 1995; Ginn & Arber 1994)

Across Europe, women and men are divided not just by age but also by a range of social and economic characteristics including class, nationality and ethnicity. The explanations for these inequalities and differences are complex and there is a continuing debate about their implications for health (Cavelaan et.al 1997; Kunst 1997 and Kunst et al 1998). If the analysis of these issues is to be complete it is essential that gender is included as a relevant variable. This in turn will require the collection and analysis of data to demonstrate the relationship between gender and other dimensions of social stratification.

There appear to be close links between poverty, gender and health for example but more work is needed to disentangle them. Migrant women are more likely than others to have reproductive and mental health problems and may also be more likely to experience domestic violence (Carballo, Divino and Zeric, 1998). The factors behind this include not only poverty but also geographical and cultural mobility, linguistic and other problems limiting access to services as well as the reality of racism in many host communities. However these problems cannot be fully understood without the regular monitoring of the health of particular groups of disadvantaged women.

Measuring health in a broader social context

As well as recognising the diversity of women (and men) it is also essential that the new EU database makes clear links between gendered patterns of individual behaviour and the social and economic variables that shape them. The impact of 'lifestyle' receives some attention in current statistical compilations. Poor nutrition, smoking and lack of exercise have all been identified as causes of disease as has excessive alcohol consumption (Eurostat 1998). However there is very little gender-disaggregated data available at EU level. This gap will need to be filled if the different pressures on women and men to make unhealthy choices are to be properly understood.

Moving beyond individual behaviour there is also a lack of routine data on some of the more structural links between heath and daily life. We know for example, that work can have an impact on health and that these effects are influenced by both sex and gender. However there is little information on this in routine statistics. Occupational health and safety have been central concerns for the EC/EU from its inception. However they have not been integrated into the mainstream of public health activities and gender disaggregated data on injuries, disease or disability are difficult to obtain. Even less information is available on the hazards associated with informal, unwaged and domestic labour, despite their obvious impact on the health of women across all the member states (Doyal 1999)

6. Tackling Gender Bias in Medical Research in the EU

Alongside the development of gender sensitive methods of routine data collection, gender bias in health research will also need to be addressed. Most biomedical research continues to be based on the unstated assumption that women and men are physiologically similar in all respects apart from their reproductive systems. Other biological differences are ignored, as are the social/gender differences that have such a major impact on health. The implications of this bias for prevention and treatment strategies are just beginning to emerge and particular concern has been expressed in relation to heart disease and also to HIV/AIDS (Narrigan et al 1997; WHO 1998).

In the context of coronary heart disease for example, there is a growing volume of evidence to indicate that researchers often behave as though CHD were just a male disease (Freedman and Maine 1995; Sharp 1998).As we have seen, it is also the most important cause of death among women. However too many epidemiological studies and clinical trials continue to be done on all-male samples. As a result, there are still major gaps in our knowledge about the differences between disease processes in males and females and both preventive and curative strategies are too often applied on women when they have only been tested on men (DeBruin 1994; Hamilton 1996; Rosser 1994).

Bringing women into biomedical research

Few women are currently involved in the male-dominated arena of medical research, either as investigators or as subjects. In the US this issue has been widely debated and a number of strategies have been developed to promote gender equity (Auerbach & Figert 1995; LaRosa 1994). This included the passing of legislation to ensure that all federally funded projects have appropriate numbers of men and women in the sample (National Institutes of Health 1997). The law has not been easy to implement and has posed both practical and ethical dilemmas for many researchers (Mastroianni et al 1994). However it has been extremely important in highlighting what had previously been unacknowledged bias in the production of medical knowledge.

The Commission could play an important role in developing similar initiatives in Europe. Criteria for EU funding should include the requirement that all applicants take sex/gender concerns seriously in their research design. This would be one of the conditions for the awarding of grants. Such changes could be accompanied by an educational initiative with guidelines available for those whose expertise was not sufficient to enable them to adhere to such requirements.

The expanded role of the EU in the regulation of pharmaceutical products through the Medicines Evaluation Agency offers an additional opportunity for removing sex/gender bias in medical research. One of the aims of the new Public Health Programme is 'the evaluation of the therapeutic value of pharmaceutical products' (Commission 2000). If this is to be done effectively, it will need to include an assessment of the sex/gender sensitivity of the safety and efficacy data for each product and an analysis of the differential implications of this information for male and female users.

The EU also has an important role to play in ensuring that women have greater role as active participants in the research process itself. Again, the Commission has extremely valuable experience which can be mainstreamed into the health sector. A conference on women and science organised by the Commission in April 1998 concluded that women were seriously under-represented in scientific work in general (Osborn et al 2000). Following this, an expert group of women scientists (ETAN) was set up to work on mainstreaming women in research in Europe (Osborn et al 2000).

Among the key recommendations of the ETAN report was that gender should be mainstreamed into the Sixth Framework Programme for Research and Development and into the programmes by which member states fund science and technology. Strategies were suggested for monitoring women’s position in scientific posts as well as their receipt of research funding and for achieving 40% of women on all advisory committees, evaluation boards and other relevant decision making bodies in research and technology by 2005. The Committee also recommended that ‘one sex only’ reaserch should not be funded unless it was justified. Those developing the Public Health Programme could learn a great deal from these deliberations to aid in the promotion of sex/gender sensitivity in medical knowledge.

Broadening the scope of health research

However the reform of biomedical research can only be a partial strategy for developing the knowledge base of a gendered public health policy. It is also important that new methodologies are developed to broaden the scope of health related research. If both sex and gender influences on health are to be properly understood, a new framework will be needed that can transcend traditional boundaries ( Orosz 1994). The tools of the social sciences will need to be further developed and used either alone or in combination with biomedical approaches.

Around the world, studies in the area of sexual and reproductive health in particular but also in mental health are already showing the value of interdisciplinary approaches. Research that brings together quantitative and qualitative methods is proving especially valuable as the basis for policy development. Work of this kind often poses considerable challenges to those trained in more traditional methods. However the Commission is well placed to encourage and support those who try to cross the biological/social science boundaries through both training and funding initiatives.

The example of occupational health illustrates the importance of developing new methodological approaches for exploring new hazards (Daykin & Doyal 1999; European Foundation for the Improvement of Living and Working Conditions 1998). Studies of work hazards have traditionally focussed on men doing 'male' jobs. However there is growing evidence of the disease and disability suffered by women as a result of paid work. This is true of women in what have been seen as 'male' jobs but also of those in jobs traditionally done by women (Doyal 1995 ch 5). If these health hazards are to be properly understood and their risks reduced, occupational health researchers will need to develop greater sex and gender sensitivity in their methods.

Their findings will need to reflect both the biological and the social differences between men and women that mediate the impact of waged work on health. Good practice in these areas is already evident in the Scandinavian countries and in Canada in particular (Messing 1998; Kilbom, Messing & Thorbjornsson 1998). Again, the Commission is well placed to disseminate these ideas through its own commissioning process and through its work with the European Foundation for Living and Working Conditions and the European Health and Safety Commission.

We have seen that much work is needed to create a gender sensitive information base for the new Public Health Programme. This will involve experts from a range of different disciplines and will need to focus on routine data collection as well as individual studies. The Commission can use its existing skills as well as its wider links with partner organisations to make sure that this outcome is achieved. However gender sensitivity in research and data collection is not enough. The information generated will then need to be translated into practical policies for promoting the health of both women and men.

7. Mainstreaming gender in policy and programmes

The mandate of the EU Commission explicitly excludes the delivery of individual health care. However the member states are now facing very similar challenges and this has led increasingly to a search for common solutions (Saltman, Figueras &Sakellarides 1998). Under these circumstances the Commission has an important role to play in disseminating good practice on gender, health and health services. As a prequisite the Community's own health related policies and programmes will need to be gender sensitive in their design, delivery and evaluation.

Putting gender into the planning process

If public health policies are to meet the needs of both women and men, the planning process needs to begin with an appropriately gendered analysis of the setting in which the initiative will take place. This will include an assessment of any differences in male and female access to and control of existing resources and services and an estimation of how any proposed changes will affect each group (WHO 1998). Expertise on gendered needs assessment of this kind already exists within the Commission but needs to be more effectively deployed within the public health setting.

Most of this expertise is currently located in employment and education but other areas of the Commission's work can also offer important resources. The adoption in 1998 of a Council Regulation on integrating gender in development cooperation laid the foundation for gender mainstreaming in projects in a variety of settings. As part of this process, instruments have been developed for gender analysis and impact assessment throughout the planning cycle and these could be of considerable value in developing the new Public Health Programme (Commission 1998).

The importance of incorporating gender analysis in the design and implementation of policy changes is especially evident in the context of health sector reform. Examples from around the world have demonstrated the damaging impact of such changes on women and these need to be carefully assessed in the European context (Standing 1999) It is especially important that reforms in financing and changes in the labour force are analysed from a gender perspective. Again, this offers an opportunity for the Commission to influence the debate among member states about how to face the growing challenges of health service delivery.

One of the most important principles of gender sensitive planning is that women as well as men should be actively involved in the design, implementation and evaluation of all programmes. It is clear that women have traditionally had much less impact than men on all stages of the policy process in the EU as elsewhere in the world. If their needs are to receive as much priority as those of men, more appropriate forms of consultation will have to be developed. This may involve representative organisations, community groups or individuals directly involved in specific projects.

There are now many examples of good practice in consultation in a range of different settings and some of these come from within the Commission itself. A recent conference funded by DGV made a number of recommendations relating to older women and social exclusion (Older Women's Network 1999). Important work has also been done in the context of smoking prevention. Since 1997 the Europe Against Cancer Programme has co-funded the European Branch of the International Network of Women Against Tobacco (INWAT). This organisation has played an important part in raising awareness of gender issues in smoking and their implications for EU policies (Joossens 1999).

These examples illustrate the potential for involving more women in the development of policy. However it is also important that this involvement is carried through to the evaluation stage. Health-related programmes and projects need to be conducted in such a way that the results can be assessed from the perspective of both women and men. Hence the EU funding process should also take account of the need for gender sensitivity in outcome measures. The lessons learned can then be disseminated more widely by the Commission to help those working on similar issues across the member states.

Capacity building for gender sensitivity

If policies and programmes are to be gender sensitive, the importance of educating health workers and policy makers in relevant areas cannot be overstated. Indeed the Commission itself has already identified the lack of appropriate expertise (and attitudes) as a key problem both in gender work more generally and in the arena of public health in particular (Commission 1998). Capacity building programmes will need to focus not just on 'women's issues' but on the wider question of gender itself and its implications for health. They may include broadly based 'gender awareness' courses which have already been offered in other parts of the Commission. At the same time more detailed briefings are needed on topics such as domestic violence, which have too often been excluded from professional training programmes in public health and related areas.

Across the EU, medical and nursing curricula also need to be reshaped to ensure that gender issues will be properly integrated into the planning and delivery of services in the future. Though the Commission is not directly involved in such training it can help to ensure that these concerns are taken seriously. As the free movement of professionals becomes a greater reality and national regulatory processes are brought into closer alignment, the Commission can highlight gender issues in education and practice. EU Directives on Medical Education are designed primarily to ensure basic standards. However the mandates concerning the definition of competence and the 'promotion of quality care' can also be used to emphasise the importance of gender issues in public health (Garcia-Barber 1995).

Finally there is an important role for the EU in promoting equal opportunities among those working on health issues both inside the Commission and outside it. Internally, it is important that gender-related issues are taken seriously as the EU's work on public health expands. Gender sensitive programmes will need to be accompanied by gender sensitive employment policies and this will necessitate closer cooperation between the new public health programme and the wider employment agenda promoted by the Commission across the EU..

A report funded by the Commission and published in 1997 identified major gender inequalities in access to positions of influence and power in public health and health care institutions across the EU (Vinay 1997). Women make up a large majority of both consumers and workers in health care but still hold a disproportionately small number of senior positions as clinicians, managers and policy makers and are under-represented on the various committees that run health services.

Member states will need to develop their own strategies for enhancing women's opportunities within the health sector. These may include the promotion of an equal opportunities culture, setting of targets and monitoring progress, providing more childcare, and creating mentoring networks. Lessons learned from work carried out by the Commission on equality in local government may be of value here. It will also be important for the Commission to promote more flexible career patterns for doctors through the use of the Directives on Medical Education and Working Hours (Maingay & Goldberg 1998).

There is considerable potential for developing gender sensitivity in the new Public Health Programme. As we have seen this will require the use of a gender lens in all aspects of the work as well as the greater involvement of women themselves. However this will take us only part of the way towards gender equity in health. Much wider social change will be required to promote fairness in the allocation of the resources necessary for health.

8. Intersectoral collaboration for gender equity in health

Most areas of the Commission's work have some relevance to health and all need to be gender sensitive. Sectors as diverse as education, agriculture, consumer affairs, industry, transport and social protection all need to be monitored to assess their implications for the health of both women and men. In many cases policies will need to be developed across what have traditionally been seen as separate areas. Strategies for the prevention of gender violence for example, will require integrated action in criminal justice, law enforcement, health, housing and employment sectors.

Policy in many of these areas remains largely within the control of individual member states. But again the Commission can offer added value through the dissemination of good practice, funding of demonstration projects and facilitating networks for the promotion of change. The Parliament's Committee on Women's Rights and Equal Opportunity also has an important part to play in supporting legislative changes to promote gender equity in the economic and political spheres.

Within the economic sphere, attention needs to be paid not just to the 'official' economy but also to the informal sector and to patterns of unpaid labour. The running down of social services in some countries, alongside the increase in the numbers of women in the labour force, has had significant effects on the well being of those required to carry a double burden of work. Similarly, industrial strategies in some countries have led to very high rates of unemployment among men in heavy industry with consequent damage to both mental and physical health. These hazards can only be effectively tackled when they are understood as a consequence of economic and social choices made in both the public and the private sectors.

The importance of monitoring decision-making from a gender perspective has been highlighted by the Women’s Rights Committee of the European Parliament . In 1998 they undertook a detailed screening of the EU budget to establish how the allocations benefited women and men respectively. A number of countries are now beginning to use similar mechanisms to audit aspects of policymaking. The incorporation of methods of this kind into the EU political process would facilitate the monitoring of both health and gender implications of budgetary decisions.

Gender bias in the allocation of health-related resources can also be controlled through anti- discrimination legislation and the use of a human rights framework. Again, the work of the Commission provides a number of examples of how this can be done. EU directives in the 1980s played an important part in promoting equal pay across the member states, thus enhancing women's access to a range of basic necessities. The EU follow-up activities after Cairo have been framed by reproductive rights and it is important that future development work operates with the same philosophy (Keysers 1999).

In all these areas the Commission will need to work with a variety of partners in developing a gender perspective on public health. This will include not only member governments but also NGO’s representing a wide range of interests and concerns. It will also be important to collaborate with the European Region of WHO whose Strategic Action Plan for the Health of Women is a valuable resource in the development of gender sensitive public health policies. As Agenda 2000 is implemented and new countries join the EU, many of these issues will move higher up the agenda. It is essential that the new Public Health Programme provide a solid foundation for both women and men to develop their full potential for health in the challenging times that lie ahead.

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