I Bang My Head Less Often Now: Reflections on Integrating Gender in Pharmaceutical Systems Strengthening

By Lynn Lieberman Lawry, Senior Gender Advisor

How do I make gender concepts practical, actionable, and not scary? This is the question that plagued me at the beginning of my tenure as gender advisor for MTaPS. What was the best way to go about making “gender” digestible to professionals committed to strengthening pharmaceutical systems?

Like most global health projects, MTaPS had a list of “must dos” for gender: sex-disaggregated data, gender balance, and gender empowerment, among others.

Gender inequities persist in employment opportunities and financial pay gaps (women earn 77 cents to every dollar a man earns). At the start of the project, it would take 300 years to close the global gender gap, and then the pandemic added another 32 years to the gap.

Building safe pharmaceutical systems globally certainly needed more than gender balance and needed to account for the end user of health services―the moment you prescribe or administer medicine to a patient, you either help them, or doom them to poor outcomes. Understanding how their sex or gender determines the outcome is a priority.

As I searched my mind for practical solutions, there, holding up my broken office chair leg, was my now dusty Pharmacology textbook (sorry to my pharmacology professors). And in section 1 chapter 1, there the explanation was: Medicines are metabolized and act differently on the body based on sex and can cause harm if a one-size-fits-all approach is used.

This was a good start, but first, the team needed to understand the differences between sex (biological) and gender (social) and that both impact how medicines are accessed, absorbed, metabolized, and excreted (pharmacokinetics). These factors can determine the side-effects (pharmacovigilance) or even how medicines act on the body (pharmacodynamics). When I explained this in year 1, I saw the ah-ha moments for some, but others were not convinced.

Then COVID happened . . .

The pandemic showed us vivid examples of why the impact of sex and gender matters. Yet, paying attention to sex and gender concepts would not be a priority when there were personal protective equipment (PPE) stock-outs and contraception, HIV and TB medicines, and vaccine supply chain challenges. Thus, the Gender Gist blogs were born. With their succinct and practical style and eye-catching illustrations, the blogs became the most read pages on the MTaPS website.

I published my first blog in 2021, when COVID-19 vaccines were just being rolled out, on how females mount a much better immune response to the vaccines than males because they are chromosomal Superwomen. But with higher titers of protective antigens, they also suffer 80% of all side-effects. Then I discussed the need for addressing gender social and cultural norms in mass vaccination to ensure that women have equitable access to information and vaccination. The third installment focused on the impact of both sex and gender in supply chain; early in the pandemic, nurses wearing garbage bags for PPE exemplified this best when PPE was not prioritized for them. Even though they represent 70% of front-line health care providers, they wore ill-fitting PPE, sex differences were not considered when supplies were ordered.

We missed the lurking dangers from unchecked antimicrobial resistance (AMR), which increased dramatically during COVID and is impacted by sex and gender. During the pandemic, overburdened health care systems deprioritized antimicrobial stewardship programs by diverting resources, personnel, and attention from the diagnosis and management of antimicrobial resistance to COVID-19 diagnosis and tracing and infection prevention and control (IPC). Antibiotic misuse elevated the risk of AMR. If we ignore sex and gender differences and inequities, we will not succeed in reducing the global threat of AMR.

MTaPS Philippines was the most successful in integrating sex and gender into its activities, the only country to employ a sex and gender analysis, which led to eLearning modules to ensure that all health care providers understand how to address the gaps. Philippines updated their Gender Equality and Women’s Empowerment Plan 2019-2025 to include a more diverse sub-set of genders, including specific mentions of sexual and gender minorities (SGMs)—Philippines is one of very few countries that addresses barriers for SGMs in their pandemic plan. Tanzania also took a significant and commendable step—their updated National Action Plan for AMR is the first to mention sex and gender effects on AMR.

So, what are my hopes and dreams?

Sex and gender disaggregation happens without me having to ask for it.

That we move away from using gender and women synonymously and are inclusive of all genders and think about equity.

All genders, and especially SGMs, are at the table to ensure health is for everyone.

We normalize that all health information systems include sex and gender variables and/or fields that ensure that no one is harmed by taking a medicine.

More than anything, I hope everyone reads my blogs and reflects on how to make medicines safe for all. Within the MTaPS program, the conversation has started. We have started to talk about sex and gender as a cross-cutting issue across all pharmaceutical system strengthening activities. But, we have far to go. We cannot be blind to how sex and/or gender impact patient health outcomes. There is always more to do and there is a need to not think about sex and gender concepts as expendable; they must be prioritized and normalized so that medicines are safe and effective for everyone.