Gender and NCDs—benign neglect in the face of a gaping window of opportunity

NCDs are finally having their moment. Diabetes is very much in the public eye from Dhaka to Dakar, the global 'epidemic' of obesity is currently the subject of numerous television shows, the row over sugar sweetened beverage taxes and alcohol unit taxes the stuff of parliamentary debates and public information and misinformation battles. Quickly and surprisingly terms such as the commercial determinants of NCDs entered the public health lexicon. And almost overnight public regulatory approaches, for example to marketing junk food to children or reformulating the salt content of unhealthy foods, are being seen as not only policy options but necessary to stem the social, health and economic costs associated with the rise of NCDs. NCDs are finally not only on the agenda, but on the top of many.

This is a good thing; with so much public and political attention on NCDs, 2018 could be a turning point in societal and political approaches to the epidemic. In September the United Nations will host a High-level Meeting on NCDs. Dr. Tedros, the head of WHO, has invested considerable political capital in the event, among other things by launching a high-level independent Commission to make recommendations to inform the negotiations on the meeting's Political Declaration. Expectations are understandably high.

Yet against this backdrop of cautious optimism, one issue must give cause for concern – the deafening silence on the issue of gender in the discussion. Gender, as distinct from biological sex, is an important driver of NCD outcomes and the equitable distribution of those outcomes. Gender, is a social construct, determined by history, laws, policies, community beliefs and family structures. Gender defines the norms of acceptable (and often expected) behaviours and opportunities for everyone in society – from who is "allowed" to smoke or drink alcohol or drive a truck (answer: men in many societies) to who is expected to look after you when you fall sick (answer: that's often a woman's role).

Gender influences NCD rates in three interlinked ways: through interaction with the social, political and economic determinants of disease (poverty, education, occupation, etc); through influences on health behaviours (including the behaviours that put people at NCD risk – smoking tobacco, drinking alcohol, healthy diet and access to exercise – as well as the norms and expectations of care-seeking behaviours); and through gendered pathways of care in health services (the intensity of investigation, effectiveness of treatment and experience of stigma).

The gendered norms of behaviour are particularly pernicious in driving NCD risks – and are frequently capitalised on by commercial companies seeking to associate their products with certain gender norms. Think of tobacco smoking and you might see the obvious connection between Marlboro man and the portrayal of a masculine ideal, but the activities of tobacco companies to link their products with messages of "freedom, emancipation, and empowerment" were highlighted by the US Surgeon General as contributing not only to the rise in women's smoking in the mid-20th Century, but also to the greater reluctance of women to give up smoking even when the harms became more generally known. The concern for many tobacco activists now is that the same companies are using similar tactics to target newly empowered and financially secure women in low- and middle-income countries.

Unfortunately, the global health community seems to be decades behind the tobacco (and alcohol) and advertising industries when it comes to thinking about and acting on gender. A recent report by Global Health 50/50 (GH5050), which reviewed the gender-related policies and practices of 140 global health organizations, found data to back up those concerns. Only one third made a commitment to gender equality for all people. Only 40% had gender-responsive programming. And only a third reported sex-disaggregated data. Equally worryingly, GH5050's review of service delivery organisations found that only a handful were addressing NCDs, with the vast majority focusing on maternal health, child health and infectious diseases.

Despite its importance, gender is absent or treated superficially in the NCDs community. The two previous UN Political Declarations on NCDs (2011 and 2014) fleetingly acknowledge that NCDs can affect women and men differently, and call for gender-based approaches. The draft report of the above-mentioned Commission failed to do either. For the reasons mentioned above, this oversight will have major public health consequences and represent a serious missed window of opportunity.

Let's not miss this opportunity to make gender work to prevent premature mortality from NCDs for all.

This story is republished courtesy of PLOS Blogs: blogs.plos.org.