April 2008: Medicare and Gender

Let’s tackle health care reform as if women mattered
April 1, 2008

In looking forward, we need to make health care the objective rather than the problem. And instead of seeing expenditures on health care as the primary issue, we should look at the contributions health care makes, not only to the overall economy and corporations, but also to employment and communities. To do so in ways that are equitable and effective, and thus efficient, we need to recognize that gender matters and understand the ways gender matters in health and care.

Women account for 80% of the health care labour force and provide the overwhelming majority of the unpaid personal care. They also comprise the majority of those who use the health care system, in part because they have the babies and because they live longer than men, and in part because of the ways they are treated as workers and patients in health care. Women are also the majority of those who take others for care, although they are a minority of those making the major decisions about health services and about the other factors that shape our health.

Integrating gender into our care strategies thus means beginning with a focus on women and ensuring that they are not missing from the plans for care. It means recognizing differences among women as well. This understanding must be fundamental to research, policy, and practices.

Attending to women’s health goes far beyond boobs and babies to understanding that the lives of women and men, boys and girls are shaped and experienced in different and usually unequal ways. In planning for timely access to care for hips and knees, for example, we need more research into why women are twice as likely as men to need new hips and into how we can ensure that they get access to care in proportion to their need, taking their responsibilities for unpaid care into account. Only then can we work to reduce the need for new hips and organize services in ways that allocate care where it is needed most and that are appropriate to these needs.

We must start by asking what services are required and where, for which women and men, and why. For example, we know from research by the Aboriginal Women’s Health and Healing Research Group that AIDS cases are almost three times higher among Aboriginal women than among non-Aboriginal women. First Nations and Inuit women have a diabetes rate nearly five times that of other women, with higher relative rates than men. We need to investigate the factors contributing to these differences and inequities, examining the daily conditions of their lives, as well as ideas about these women and their bodies, and the ways they are treated in care.

This means establishing not only what services have to be provided to them but also what kinds of services are available and where they are located--all critical to understanding questions of timely access, efficiency, and equity. Without culturally appropriate services near where they live and without services provided in ways that address causes, relationships and confidentiality, women cannot receive timely, effective access and they, along with the entire health care system, will pay more in the long run. In short, we should begin long before these women reach the health service and evaluate the services with different criteria in mind.

Attending to women’s health care work means re-examining the structures and relations in health care work and integrating a gender analysis into our plans for care services. Let me give you some examples.

First, consider the concern over nursing shortages and the aging labour force. It is no accident that the bulk of the nursing labour force is, for the first time, over age 50. This never happened before because we made many nurses quit when they were young. Initially, they were forced to leave when they got married. Later, married women could stay, but they had to leave when they became pregnant. Older nurses tended to be single women who worked as supervisors and often lived in a residence that provided them with food and clean clothes. Yet we not only continue to organize nursing as if they were all as young as they were in the past, but we have also intensified the work, speeding up the pace and increasing the demands.

It is not surprising, then, that health care work is now the most dangerous occupation in terms of illness and injury, especially given that the women who provide care feel responsible--and are held responsible--for the care deficit, often putting in unpaid extra hours to provide the necessary care. We cannot understand and address these problems without understanding that almost all nurses are women.

This takes me to my second example of why gender matters and why we should begin with women. Nurses do not make up the majority of those who work in health services, even though they are the focus of much current concern. Indeed, the largest proportion of those employed in health and social services are those usually described as ancillary workers, the mainly women who cook, clean, do laundry, do clerical work, and provide personal care. Their work is often dismissed as unskilled and, increasingly, is not even counted as health care work.

Yet these workers do work once done by nurses and work that is so critical to care that nurses must do it if the ancillary workers are not there. Think C-difficile and SARS. Cleaning, as well as laundry, have proven to be critical components in preventing the transmission of infectious diseases. And think how crucial accurate records are to care. Drug reactions and tainted blood are just two examples. The costs of poor cleaning, bad food, faulty records, and bad personal care can be enormous, not only to the individuals who need care, but also to those who provide care—and indeed to the economy as a whole.

To understand the dismissal of such work as unskilled, and thus easy to privatize to contractors, it is necessary to understand how the skills traditionally associated with women’s work are rendered invisible and undervalued. And with these workers, the dismissal of women’s skills is often combined with the dismissal of the skills immigrants and those from racialized groups bring to the job. We also need to understand the ways women’s power is limited by the structures of care and care work, and by defining care as a “labour of love.”

The majority of these ancillary workers are personal care providers. In long-term care and home care, they make up the majority of health care workers. And most of those they care for are women. This female majority may help explain why long-term care and home care have received so little attention and support, placing Canada well below Norway and Sweden in public spending on such care--that is, below countries that have placed a high value on gender equity and women’s rights. As is the case with nursing, the conditions of their labour are the conditions for care. Within health care, they are among those with the highest risk of illness and injury, suggesting that care itself is at risk.

Like cooking and cleaning, laundry and clerical work, personal care work is associated with women’s work in the home and with women’s natural capacities. As we send people home “quicker and sicker,” and keep more people at home with more complicated care needs, where we expect mainly women to provide the care with little formal training and support, we reinforce the notion that this is unskilled work that can be done by any women. The work and the skills become hidden in the household. So do the risks to providers and to those with care needs. Indeed, in spite of our talk about accountability, we have very little information on the health hazards faced in the home by either providers or by those with care needs.

Unless we start to recognize and value this work, and make these workers members of the public health care team, we may well face more pandemics and personal tragedies for patients, as well as growing injury and illness rates for the women doing the work. This means supporting unpaid care work, as well, through training and through the provision of alternatives. And to do so means understanding that this is women’s work.

In addition, it means understanding what makes women sick or injured, how they experience these problems, and the ways they are treated during and after care. It also means understanding differences among women in relation to their health, their care, and their care work. As resources become increasingly unequal, so do differences, not only between women and men, but also among women.

In sum, planning for care means planning with women in mind, not only for the sake of the women, but also for the sake of the system as a whole. Such planning could make care more efficient as well as more effective.

(Pat Armstrong has served as chair of the Department of Sociology at York University and director of Canadian Studies at Carleton University. She is a partner in the National Network on Environment and Women’s Health and the co-author or editor of many books, including “Women and Health Care Reform in Canada” and “Caring For/Caring About: Women, Home Care and Unpaid Caregiving.”)