In the eleventh seminar of the Lancet Commission on Gender and Global Health series, Commissioner Morna Cornell confronted the elephant in the room head-on by presenting an evidence-based argument for including men in gender and health discourses, policies, and programs. As Senior Research Officer at the University of Cape Town’s School of Public Health and Family Medicine, Cornell draws on her expertise in human rights activism and public health research to call for the inclusion of men’s health in the global health agenda, an endeavour informed by her background in HIV/AIDS advocacy in South Africa. This session was facilitated by Commission Co-Chair Sarah Hawkes and enriched by the participation of fellow commissioners as well as a highly engaged YouTube live stream audience.
“The most unequal country in the world”
Cornell began the session by situating herself in the South African context, noting that the sub-Saharan country has been labelled the most unequal country in the world. Poverty and extreme inequality fuel what Cornell referred to as “overlapping epidemics” within the country, which is currently battling a resurgence of COVID-19 among its largely unvaccinated population whilst struggling with a health system challenged by recent political upheaval. Endemic rates of unnatural death and increasing incidences of NCDs further exacerbate the situation for everyday South Africans, creating highly gendered health exposures and outcomes that remain poorly understood.
It is in this tumultuous milieu that one finds the world’s largest number of people living with HIV (PLHIV), a population of more than seven million people as of 2020. Reflecting on her experiences as the former Executive Director of the AIDS Consortium, Cornell recalled the bleak span of time throughout the 1990s when HIV “was literally a death sentence because we had no treatment”. Sustained activism pushed back against this write-off of PLHIV and would eventually contribute to South Africa having one of the most progressive constitutions globally, one which Cornell noted “entitles people living with HIV and their families to full and equal enjoyment of all rights and freedoms”.
The promise of rights, however, is not a self-fulfilling one. Realising these rights promised to South African PLHIV and their loved ones required advocacy, money, and most importantly, raised the underlying question: who deserves care? In the early years of treatment, as the profile of the global epidemic shifted and became increasingly heterosexually transmitted, women and children were described as “innocent victims”, i.e. deserving of care, and activists fought for treatment to prevent HIV transmission to infants and to keep mothers alive. In contrast, men were explicitly blamed for transmitting HIV and effectively relegated to the bottom of the list of those deserving of care.
Who deserves care – and who can afford it?
In 1996, Cornell attended the 11th World AIDS Conference in Vancouver, where a groundbreaking announcement offered the long-awaited glimmer of hope: triple-drug therapy to suppress virus replication. “Suddenly,” Cornell marvelled, “there was a possibility of life… if you could afford it”.
Within just two short years, however, the primary challenge facing HIV/AIDS activists shifted from the search for treatment to the distribution of treatment. 1998’s 12th World AIDS Conference, held in Geneva, aimed to bridge the treatment gap between richer and poorer nations, with the conference’s theme revolving around questions of equity and treatment access – a familiar struggle, Cornell pointed out, in the current COVID-19 pandemic. This inequity manifested in the stark contrast between stories coming from the Global North, where the term “Lazarus effect” had been coined to describe the near-miraculous experiences of those on treatment, and the Global South, where death tolls continued to rise while treatment remained out of reach for those who needed it most. Cornell recounted how this “massive and widening gap between the Global North and the Global South” sparked rage, suggesting that some lives matter more than others.
This rage gave rise to social justice movements and treatment activism, which saw “people living with HIV putting their bodies on the line in clinical trials without guaranteed post-trial access,” Cornell recalled. The courageous and tireless work of activists eventually led to the marketing of an affordable generic combination that drastically reduced triple-drug therapy costs. In 2004, the South African ART program began; today, it is the largest of its kind with over 5 million people on treatment by 2019 – “a remarkable achievement,” Cornell noted, “particularly in our context”.
Missing voices: Male mortality in the HIV/AIDS crisis
As is so often the case with complex challenges, the story did not end there. In 2002, while co-authoring the book Waiting to Happen: HIV/AIDS in South Africa, Cornell had identified a common thread running across all 90 papers: “What does it mean to be a man or a woman in South Africa? And how does this understanding impact on HIV risks?”
A deeper dive into these questions gave Cornell the first inkling that “our epidemic might be more about gender than biological differences” and steered her towards clinical research in search of answers. Cornell’s years spent working on clinical trials spurred her to pursue tertiary education for the very first time in her mid-forties. In her Master’s thesis, she found that men living with HIV had higher mortality rates on treatment than women. A literature review failed to generate much in the way of good evidence, and Cornell found that “the prevailing wisdom anecdotally blamed men for their own poorer outcomes,” with explanations like: men are reluctant to go to the doctor, only do so when they are older and sicker, and are unlikely to initiate treatment or remain in care. Reading these generalisations about men’s alleged health behaviours presented as fact did not sit well with Cornell and led her to test these claims in one of her PhD papers in a study of over 46,000 PLHIV with good – though routine – data.
Cornell found that men being older and sicker when they started treatment explained some, but not all, of the excess mortality and found no evidence to support claims about men being less likely to adhere to treatment regimens and more likely to die after being lost to care. Finally, a self-described “Aha!” moment led her to compare the gender difference in mortality on ART to the gender difference in mortality among the HIV-negative population. Against all expectations, Cornell found that HIV-negative men faced an even greater mortality risk than HIV-positive men on ART. In her own words, “being in HIV care seemed to protect men on treatment against some health risks, and over time on antiretrovirals the deaths were less and less likely to related to HIV or ART and more likely to reflect background risks”. In South Africa, she added, these background risks are predominantly from violence, road traffic accidents, and suicides.
Over the years, Cornell has found increasing evidence of gender inequity in HIV programs across sub-Saharan Africa. On the one hand, women have higher incidence rates and are thus prioritised – appropriately, as Cornell pointed out – for targeted funding and programming, resulting in better access to treatment and lower mortality. On the other hand, men are much less likely to be tested and start ART, are indeed sicker and older when they begin treatment, and thus have a higher risk of death – a hidden truth that only becomes evident when data are disaggregated.
Beyond women’s health: Understanding gender inequity in global health
Piecing together separate instances of gender inequity in health, Cornell painted a bigger picture in which men’s health is systematically underrepresented in global and national policies despite a growing body of evidence documenting their poorer access to and outcomes in health care. She asserted that this is not indicative of a conscious desire to exclude men. The early focus on women’s health was appropriate given the nature of patriarchal power dynamics but has had the unfortunate side effect of conflating gender with women. Today, this conflation of gender with women manifests itself in the language we use, the groups we target for interventions, and the funding priorities we set. In addition, the conflation of gender with women also reinforces the gender binary and runs the risk of excluding trans and non-binary people from discourses, policies, and programs on gender and health.
These patterns suggest a collectively-held implicit bias, which Cornell defines in accordance with Merriam-Webster as “present, but not consciously held or recognised”. While neither intentional nor malicious, this bias has significant and wide-ranging ramifications as it perpetuates “a sense, somehow, that men are less deserving of care than women and that men are individually responsible for their own poorer health outcomes”. Referring to a 2013 paper by Commission Co-Chair Pascale Allotey, Cornell echoed her assertion that “a female bias in gender research constrains debate and limits our opportunities to intervene effectively” and argued that such bias may even provide some explanation for the limited success to date in mainstreaming gender and health.
Bridging the past and present, Cornell acknowledged that historically, men as a group have held greater social power than women as a group – but men are neither homogenous nor all-powerful. She argued that we need to consider how men and women are born with biological sex and then immersed into a gendered system; and how their gendered pathways to health or ill health can be influenced by race, class, sex, age, and (dis)ability among many other factors. An intersectional approach to gender and health would also consider historical contexts such as the impact of colonialism and apartheid on marginalised men, whom Cornell pointed out “are not necessarily privileged in health and may face higher morbidity or mortality than women” based on recent disaggregation of COVID-19 data.
Towards a paradigm shift: Next steps for the Lancet Commission
Situating her presentation in the context of the work awaiting the commissioners, Cornell called for the Commission to take into account the issue of scale in global health, to confront “issues that impact on large numbers of people, particularly those who live in extremely unequal societies where making a difference can impact on many lives”. Cornell argued that the road to Universal Health Coverage (UHC) can only be realised through a paradigm shift away from the current view of men’s health as “an optional add-on”, a practice that undermines men’s right to health as well as the efficacy of public health responses. She urged the Commission to “highlight the historical neglect of men’s health, check for implicit bias not only in ourselves but also in the policies and websites of international health agencies, major donors, and national programs, use an intersectional lens that is context-specific, and ensure that we do not perpetuate outdated thinking about gender”.
In closing, Cornell acknowledged that such a paradigm shift will be a challenge. However, reflecting on her personal journey in public health, she said that “change is not easy – but it is possible,” a lesson learned from her years in HIV/AIDS activism and the hard-won victory of seeing millions of people once sentenced to death now living healthy lives on ART.
Tiffany Nassiri-Ansari sits on the Secretariat of the Commission and serves as a Research Assistant at UNU-IIGH.