Applying a "Gender Lens" to Women's Health Care and Research

    • August 20, 2014

Overview. How do sex and gender affect health and health outcomes? Why do diseases such as cardiovascular disease and depression manifest differently in women and men?

When Paula A. Johnson, MD, MPH, became a Robert Wood Johnson Foundation Harold Amos Medical Faculty Development fellow in 1993, she continued a life-long professional and personal journey to answer these questions.

Background. Growing up in Brooklyn, N.Y., Paula A. Johnson loved spending time with her grandmother, Mamar. Together they savored pictures of Mamar’s trips to Europe, danced to her favorite music, and drank warm milk with a touch of coffee. But when Johnson was eight years old and her grandmother was 60, “something changed,” Johnson recalled.

“She no longer worked or traveled. She no longer danced. There were no more coffee times,” Johnson said. “Her care became all consuming for our family. And by the time a diagnosis was made, she was in a deep spiral. My grandmother had depression—a deep, life-altering depression from which she never recovered.”

Johnson had known from childhood that she wanted to be a doctor. It was her grandmother’s struggles that led her on a lifelong quest to understand women’s health issues and how gender impacts disease and health care. During her first year at Radcliffe College of Harvard University, Johnson got a glimpse of her future when she took a course on gender and health from Ruth Hubbard, PhD, the first woman at Harvard to hold a tenured professorship position in biology.

“It really focused on how being female—and the sexism that was experienced in science—influenced the way science was carried out and also the way health care was delivered,” Johnson recalled decades later during a seminar at the Harvard School of Public Health. “This was an eye-opener to me. This was a path that I knew I’d follow at some point.”

In 1985, Johnson graduated with both her MD and her Master’s in Public Health degrees from Harvard. She completed her residency in internal medicine in 1988 at Brigham and Women’s Hospital in Boston, where she was drawn to a specialty in cardiology with a concentration in cardiology care for women.

After completing a fellowship in cardiovascular disease in 1991 and serving as chief medical resident at Brigham and Women’s Hospital (the first African-American in the history of the hospital to hold this position), Johnson received an offer for a prestigious two-year career development award from the American Heart Association.

It seemed to be an exceptional fit for this young cardiologist. But Johnson turned down the award in order to pursue another opportunity—one that offered not only research funding but also the mentorship this junior faculty physician knew was important—the Harold Amos Medical Faculty Development Program, a four-year, postresidency fellowship funded by Robert Wood Johnson Foundation (RWJF) that supports the research and career development of physicians and dentists from historically disadvantaged backgrounds.

“There were colleagues of mine and mentors who had been (Harold Amos) fellows, who had described the experience as so critically important to their careers,” Johnson said. “I felt so strongly that it would be an amazing experience.”

Connecting with the Harold Amos program. Johnson was accepted into the program in 1993. She was one of the program’s first clinical research investigators (as distinguished from bench research, which is research done in a controlled laboratory setting using nonhuman subjects, with the focus on understanding cellular and molecular mechanisms that underlie a disease or disease process).

Her research project focused on health outcomes of patients with chest pain, and as predicted, she got outstanding feedback and support from her advisory committee. And the larger network of Amos faculty and Amos fellows past and present “provided a tremendously strong foundation that gave me the ability to develop my career,” she said.

During her four years as a fellow, Johnson continued along a traditional research path—conducting research, developing a research group, seeing patients at Brigham and Women’s Hospital, and teaching in Harvard Medical School. She then switched from doing mostly research and clinical care to doing applied research while focused on quality of care, and was named director of Quality Management Services at Brigham and Women’s.

Applying a gender lens to research and treatment. In 2002, Johnson was able to combine all of her academic pursuits, quality initiatives, cardiovascular research, and interest in gender-specific disease and health care differences when she became founder and executive director of the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital. The mission of the Center is to improve the health of women and transform medicine by applying a gender lens that acknowledges gender-based differences in diseases and treatments. Cardiac disease is one of the prime focuses of the Center.

Now Johnson is using her visibility to insist that the medical research community apply the same gender lens to its work. In her opinion piece, “Every Cell has a Sex,” published in the Jan. 5, 2014, Boston Globe, she makes a strong case for “sex-specific research to better understand how cellular and molecular difference in males and females affect every aspect of health.”

“We are on the verge of being able to dramatically improve the health of women,” Johnson wrote in the article. “We know that when we apply a gender lens to science and practice, lives are saved. We know that when we invest in women’s health research and in understanding how the health of women and men differ, breakthroughs can happen.”

Her December 2013 TED talk, “His and Hers ... Healthcare,” makes the same case and had nearly 900,000 views as of July 2014.

Determined not to leave health to chance. In March 2014, Johnson and the Connors Center hosted a national policy summit in Boston marking the 20th anniversary of the National Institutes of Health (NIH) Revitalization Act of 1993. The landmark law required all NIH-funded biomedical research to include women and minorities, but as reported at the conference, health disparities still exist:

  • Cardiovascular disease is the leading cause of death for women in the United States, but only 34 percent of cardiovascular clinical trial subjects are female.
  • Lung cancer is the leading cause of cancer death among women in the United States, and accounts for more annual deaths than breast, ovarian, and uterine cancers combined. Yet the lack of sex-specific research hinders prevention, diagnosis, and care of this disease.
  • Women are 70 percent more likely than men to suffer from depression, yet little is know about what causes these differences or how to address them.

“Research on sex and gender differences must become the norm, not the exception, for us to achieve health equity and to improve health outcomes for women and men now, and in future generations,” Johnson said. “When we fail to routinely consider the impact of sex and gender in research, we are leaving health to chance.”

Grantee perspective. For Johnson, choosing the Harold Amos fellowship over another opportunity was always simple. “You have to understand: the RWJF fellowship is not just about money,” she said. “That’s the gift in this award. It provides very important funding, but it also provides mentorship and helps to solidify the relationship you have with your mentor and creates a circle of mentorship that is invaluable for a young faculty member.

“This program is one that, in my mind, is a gold standard of what young faculty and particularly young faculty of color, need to grow their careers. It is a model program that has transformed the face of academic medicine for minorities. It’s truly transformative.”

RWJF perspective. The Harold Amos Medical Faculty Development Program is a four-year postdoctoral fellowship launched by RWJF in 1983. Its purpose is to increase the number of faculty from minority and other historically disadvantaged backgrounds who achieve senior rank in academic medicine and dentistry. A commitment to eliminating health disparities is among the selection criteria. Read the Program Results Report for more information.

The program supports one of RWJF’s major objectives: To increase diversification of the medical and dental professions and, as a consequence, improve the health care received by the nation’s underserved populations.

Of Amos program scholars, RWJF senior program officer David M. Krol, MD, MPH, says:

“Ultimately, we would like to see these individuals from disadvantaged backgrounds becoming full professors at prestigious institutions, putting out important, valuable work, looking at a variety of different issues—including how to decrease the disparities between rich and poor, majority and minority—while climbing the academic ladder. The measure of the success of the program is the success of the individuals who participate in it and their contributions to building a culture of health.”

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Heart disease is the leading cause of death for women, but only 34% of clinical trial subjects are female.