Closing the global gender gap

Education is the key to not only better health outcomes but also less global conflict

Today, sex-based inequalities and inequities shape how individuals are disproportionately exposed to adverse determinants of health. Our sex can determine how well or ill we become, and if or how our health care needs are acknowledged and met.1 The underlying reasons for this disparity are complex and diverse, shaped by how sex and sexual customs interact within varying political and social contexts. Discriminatory values, norms and behaviours, different exposures and disease vulnerability, and health system and health research biases all interact to result in sex-based inequities in health outcomes.1 Conversely, ill health, in and of itself, can also negatively influence social and economic outcomes.

The World Economic Forum has developed a framework, the Global Gender Gap Index, to measure sex-based disparities among countries and to track these disparities over time.2 The framework outlines and examines inequities between men and women in four broad categories: economic participation and opportunity; educational attainment; health and survival; and political empowerment. These four “pillars” are considered essential in recognising the importance of the role of women in society and in diminishing the gaps between the sexes. According to this framework, no country has, as yet, achieved sex equity in all of these four categories, although some countries (eg, Scandinavian countries) are getting close to achieving this goal.

The framework also highlights that high-income countries often have fewer sex-based inequities than low-income countries.2 It is well known that, generally speaking, women in low-income countries fare far worse in terms of health outcomes, and are more likely to experience death during youth and adolescence than those in high-income countries. Maternal mortality exemplifies this, with the vast majority of maternal mortality occurring in low-income countries with weak institutional (including health) structures.

Why has no country in the world achieved sex-based equity? Is inequity between the sexes not an abuse of human rights? It is imperative that action be taken, and I would argue that the most fundamental action required is to provide all women with the opportunity of education.

Educating women has been shown not only to improve health, but also to decrease population growth, decrease child mortality, decrease child marriages and increase the participation of women in the labour force — all of which lead to faster economic growth and decreased poverty. Education is the key to building community capacity, as it provides individuals with the knowledge to participate in society.3 Education is also the key to resolving conflict, locally, regionally and globally, as it has also been shown that less conflict occurs in societies where women have higher economic and social status.4

Globally, there have been strong efforts to ensure access to primary education for all children. World Bank Group data show that, in 1999, 105.6 million children were identified as out-of-school children (ie, not enrolled in primary school); 58% of these were girls and 42% were boys. By 2009, the number of out-of-school children had decreased to 67 million; 52% of these were girls.5 Education is lacking in many regions in the world,3 so this global gap is much larger in specific regions of conflict or low-income countries.

For example, in Afghanistan, 2009 data from the World Bank Group show that the expected years of schooling for a child vary greatly by sex. Boys are in school for an average of 11.2 years; girls, 6.8 years.5 From a global perspective, sub-Saharan Africa is home to half of the world’s out-of-school girls, and South Asia to a quarter.6 Nigeria, Pakistan and India, the three countries with the most out-of-school children, are recognised for their poor treatment of women.6

We need to ask why women are treated as second-class citizens in terms of access to health care and education in developing countries. A global effort is needed to change this pattern, to change the societal view of women, with the goal of promoting equal access to education for girls. Our path forward, as men and women, is to complement each other, not to compete; to create a balance and harmony in relations, not to strengthen one over the other; for all to be strong, and to eradicate domination. Collective efforts are needed from us all, because no one person or group can do everything. Men’s participation, awareness and engagement in this goal will be vital. A global society of freedom, justice and peace will not be achieved unless all human needs are met.7

Australia’s dietary guidelines and the environmental impact of food “from paddock to plate”

Incorrect text: In “Australia’s dietary guidelines and the environmental impact of food ‘from paddock to plate’” published in the 21 January 2013 issue of the Journal (Med J Aust 2013; 198: 18-19), there was an error in the third paragraph of the article. The statement “Around half of Australia’s fisheries are overfished” is incorrect. It should read “Forty per cent of Australia’s managed fish stocks have been deemed overfished”, with a reference to: Srinivasan UT, Watson R, Sumaila UR. Global fisheries losses at the exclusive economic zone level, 1950 to present. Marine Policy 2012; 36: 544-549.

Lost and found: improving ascertainment of refugee-background Australians in population datasets

To the Editor: We strongly support Paxton and colleagues in the call for inclusion of year of arrival in routine health datasets to inform improvement in health service provision in Australia.1

We also argue that a consistent and rigorous approach needs to be applied to the use of country of birth (COB) in health research. COB is usually included in routine health data sets and, as an indicator of refugee background, enables research to specifically target populations that for linguistic, cultural or societal reasons may be underrepresented in traditional epidemiological research. How we define source countries of humanitarian entrants, and also group COB by world region, is likely to affect study results.2–4 National immigration data, matched by period to the study dataset, can be used to identify COBs with high proportions of humanitarian entrants.5 The United Nations’ definitions of world regions can be used as a reproducible framework for grouping countries if required.

Using a consistent method to determine probable refugee background, description of which specific countries are represented in a world region and how many participants are from each country allows comparison of results for particular populations with those of other studies. However, it is uncommon for the methods used to determine refugee background to be described in much detail.

An awareness of potential limitations associated with COB is also needed. It is important to note that COB is not sufficient to identify ethnicity. Country borders can change over time, especially with conflict. Matching year of arrival and COB against national immigration profiles could help overcome this problem. Accuracy and consistency in the use of COB, together with year of arrival, and more detailed explanation of population selection methods would improve identification of people with a refugee background who are accessing the health system and also enable comparison of results for resettled refugee populations.

Given that the health care needs of refugees are greater than those of the general population, we also advocate that refugee background be incorporated into health funding models, as occurs with Aboriginal and Torres Strait Islander background. Identification of refugee background, even if by COB and year of arrival, is an essential step in this process.