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New Haven freelancer Jennifer Kaylin is a frequent contributor to the Yale Alumni Magazine. |
The
Push for Women's Health February
1997 When Kaye Griffin moved to Connecticut from Texas in 1994, she had a hard time adjusting to health care that she found was far inferior to what she'd grown accustomed to at the Houston Medical Center. After venting her disappointment to a friend, she was told about a dynamic young doctor at Yale named Florence Comite, who specialized in women's health. But when Griffin called Comite, she got much more than she had expected. Yes, she found a new doctor whom she could trust, but in becoming the first patient to pass through Yale's fledgling Women's Health Initiative, she also found herself on the front line of the women's health movement. Three years later, Griffin is still a satisfied customer. "It is absolutely the perfect program for me," she says. "It treats me as a whole person, compared to the kind of fragmented medical analysis patients usually receive." As the superintendent of the Madison public school system, Griffin especially appreciates what she calls the program's "one-stop shopping" philosophy. "Like many working women these days, I don't have time to make lots of different appointments, running around seeing specialists and taking tests," Griffin says. "The Women's Health Initiative eliminates the need for all that. It's the kind of care that should be basic for everyone, but unfortunately it's not." Griffin's experience -- and indeed much of the women's health movement -- owes much to a study conducted, not at Yale, but at Harvard. In 1982, a team of researchers from the Harvard Medical School and from Boston's Brigham and Women's Hospital set out to determine whether a common medicine, aspirin, reduced the risk of heart disease. But the significance of their findings -- that an aspirin every other day might be beneficial in reducing the threat of a heart attack -- was almost eclipsed by another revelation the study made, albeit inadvertently. While the five-year probe was exhaustive in its collection of data -- 22,000 male physicians were studied -- no women were included, even though heart disease is the leading killer of women. Compounding the oversight was the fact that the study's conclusions were applied to women, although there was no evidence that aspirin would have the same effect on them as it did on men. An awareness that inequities existed in women's heath care had been growing for a long time. (When the Association of American Medical Colleges recently surveyed medical school graduates, 65 percent of them said they didn't feel they were adequately trained to treat major health problems in women.) But the exclusion of women from the now-famous "aspirin study" brought the issue national attention. The controversy ultimately resulted in the passage by Congress of the Women's Health Equity Act, which mandated the creation of an Office of Research on Women's Health to monitor the representation of women and minorities in all National Institutes of Health studies. The 1991 legislation also provided the impetus for the $625-million Women's Health Initiative, a 15-year study that will screen 160,000 postmenopausal women to explore ways of preventing breast cancer, heart disease, and bone fractures. But beyond these results, the aspirin study served as an alert to health care providers and medical schools around the country that women must be taken more seriously as both health practitioners and patients. At Yale the response was swift and wide-ranging. The Women's Health Initiative (now called the Women's Health at Yale, to avoid confusion with the national initiative) was just one of several programs to grow out of the heightened sensitivity to women's health needs. In fact, women's health has been assimilated so quickly at Yale that it has already entered a second phase. No longer is anyone debating the validity or value of allocating resources specifically to women's health; today, the most vigorous talk is about enhancing and expanding the projects that are already in place. Associate Professor of Medicine Janet Henrich, who co-founded the Women's Health at Yale program (WH-Y) with Comite, says that most of the progress in the field of women's health has occurred since 1992. "There's been an explosion in interest, activity, and knowledge," she says. "It's been the most exciting time in my professional career." "Yale is definitely in the forefront," says Gerard Burrow, dean of the School of Medicine. "Once we recognized that there was a need, we responded to it." Burrow adds that what's happening at Yale and elsewhere around the country was inevitable. "With at least half this year's medical school graduates being women, clearly there will be big changes." One indication of how times have already changed can be seen in the growing number of female students and professors at Yale's School of Medicine. Merle Waxman, director of the Office for Women in Medicine at Yale, says that there are now 48 tenured women on the School's faculty, compared with only 18 in 1986. Moreover, 58 percent of first-year students are women, up from 36 percent a decade ago. "This has a big impact on the way classes are taught. Everyone is more sensitized," says Waxman. "If a disease is discussed today, the professor had better explain how it presents itself in a man and how it presents itself in a woman, or else someone is going to raise her hand and ask." On the clinical front, the most visible health gain for women in the Yale community has been the WH-Y, which has gained national recognition and spawned imitations around the country. Comite says the program has three missions: to provide comprehensive clinical care for women; to educate the patients and the professionals who work with them; and to compile research data on health issues that specifically affect women. She likes to tell a story about how the WH-Y was launched. Comite had to present the idea to about 15 department heads, all of whom were male. According to Comite, they weren't quite persuaded, but when they mentioned the idea to their wives, she reports, "the women all said, 'What a great idea! Why isn't there a place where I can go to get all my medical needs taken care of? Why do I have to traipse around from this person to that person?'" The upshot was that their husbands all agreed to support the program. The typical WH-Y patient is a well-educated career woman between 40 and 60, who is either menopausal or about to become so. "Often they tell us things like, 'I turned 50, and this is my gift to myself,'" says program coordinator Lyerka Debush. Before arriving for her day-long appointment, a WH-Y patient fills out questionnaires that include a personal and family health history, an exercise history, a psychological health survey and a nutrition survey. Based on this information, tests are scheduled as needed. The patient is also given a physical examination and consultations with a physician and dietitian. Because patients have been fasting in anticipation of blood tests, they are served a full breakfast. An educational lunch forum run by the dietitian is provided while tests results are collected. In the afternoon, after the test results are evaluated, a follow-up consultation is held with the doctor. Other consultations are scheduled with a physical therapist, a mental health professional, and a nutritionist. The cost of this entire evaluation is $600, plus lab and diagnostic charges. Comite says the impetus for this integrated health care program came from the realization that women were neglecting themselves. "Women spend two out of every three medical dollars for themselves and their families," she says. "Yet they put themselves last when it comes to their own personal health care. Most women, including myself, have so many demands on them that they are too busy and too tired to coordinate all the pieces of their own care." Henrich recalls that there was early resistance to the program. "It was hard to find funding because of the uncertainty as to what the service would provide," she says. "But it did exactly what we thought it would. We saw women with too many doctors and those who had been out of the health care system for a long time." Nevertheless, many other doctors responded with indignation. One internist expressed his opinions in a local newspaper. "A trendy program of this nature may appeal to a few radical feminists or to those who plan to work there, but I wonder how many mainstream women really believe that such a female-only program is desirable," the doctor wrote. Dean Burrow acknowledges the early opposition but says it's hardly surprising. "There was resistance to geriatrics and pediatrics initially, too," he says. "Some doctors argued that geriatric patients were just older people and that pediatric patients were just short people. That fact is that we've seen an awful lot of separate studies done of men. We're just trying to bring some balance into it." Asked whether he advocates gender blindness, he quips, "We've tried that. It's just that we've been more blind to one gender than to the other." Earlier this year, the WH-Y was selected by the U.S. Department of Health and Human Services as one of six medical centers to establish a National Center of Excellence in Women's Health that will serve as a national model for improving the health care of American women. With the national designation and $330,000 in federal support for women's health, the program has given new energy to interdisciplinary research on women's health. Much of that research is already under way at the WH-Y, which is one of 25 programs studying the effects of the hormone progestin on bone density. The goal is to find out more about how to prevent or delay the onset of osteoporosis, the weakening of bones that is often associated with aging. In addition to traditional scientific approaches to the ailment, the new efforts embrace alternative, or complementary, medicine, including research on the efficacy of a Chinese herb called dong quai, which has been found to alleviate hot flashes. The WH-Y is also conducting research on how patient education affects the outcome of treatment. One hypothesis under study is that the more knowledgeable a patient is about her disease, the more she will be able to communicate with her doctor and participate in her own treatment. A fourth study involves the nutrition of women in the Northeast. Subjects were asked to fill out food diaries, and the data was fed into a computer. Results from other studies indicate that zinc is linked to our sense of smell, the loss of which is often a problem for the elderly. In addition, the importance of selenium for balance, reproductive health, and overall well-being is being investigated. Beyond the WH-Y, the influence of the women's health movement can be felt elsewhere at the University. Yale University Press, for example, is publishing three books by Mary Jane Minkin, an associate clinical professor of obstetric and gynecology at the Medical School. The first one is a user-friendly no-frills reference book called What Every Woman Needs to Know About Menopause. It will be followed by books on obstetrics and gynecology. "We're very eager to be doing them," says Press director John Ryden, referring to Minkin's trilogy. "These are significant issues, and I expect we'll do more." Minkin says she decided to write the books because of the dearth of reliable information being written about women's health. "Women participate in health care much more then men," she says. "Men wait until the situation is acute, but women are involved with prevention, diet, taking the kids to the pediatrician, caring for aging parents. They are the healers, but when they want to go and read something, there's nothing out there." Minkin finds this situation surprising, considering how much progress is being made on other fronts. "When I was in medical school, I was the second female resident in Yale's ob-gyn program," she recalls. "Ob-gyn used to be viewed as the province of the dumbest students in the class. Neurosurgeons were at the top and ob-gyns were the bottom of the barrel. But that's all changed dramatically. I don't think you'd encounter that attitude anymore." One reason for the change of heart, Minkin says, is that there have been so many advances made in the area of women's reproductive health. "Fetal monitoring, the morning-after contraceptive, in vitro fertilization, laparoscopic surgery -- these are all techniques pioneered at Yale," she says. "It's a speciality that's much more stimulating to go into." A relatively new and extremely popular undergraduate course on women's health is further evidence of how attitudes at Yale have evolved over the past several years. When the course was first offered, three years ago, 170 students enrolled. It has since been capped at 100. "It's something students seem to profoundly want," says course coordinator Naomi Rogers. "I can't tell you the number of students who've told us the course changed their lives. That's not something you typically hear very much about an academic course." The reason for the popularity of the course, Rogers suggests, is its interdisciplinary nature. It provides a history of medicine, but it also delves into a wide range of contemporary issues, which are presented to students not by academics, but by the people who are directly involved. For instance, a woman who had been the victim of domestic violence was invited to speak, as was a mother of four who was a cocaine addict, a lawyer who teaches a course in medical ethics, an expert on eating disorders, and a representative from Planned Parenthood. "It's a very fluid course," says Rogers. "Every year the syllabus changes. This year we've included a lecture on geriatrics." Given some of the medical realities particular to their gender, it's easy to see why women are now up-ending the status quo. Because women live an average of seven years longer than men, they tend to develop more disabilities. Moreover, heart disease is more common and kills more women than all cancers combined; one of every eight American women will develop breast cancer in her lifetime. But while breast cancer may be the most common form of cancer in women, lung cancer is responsible for more deaths. The rate is soaring, and only 12 percent can expect to be cured. These health issues and others, such as osteoporosis and the burgeoning field of hormone replacement to minimize the symptoms of menopause, are only going to grow more critical in the coming years as baby boomers move into middle age. While increasing our knowledge of these medical conditions is important, those who are in the forefront of the women's health care movement hope that the efforts they make on behalf of women will benefit men as well. "It's not an anti-male issue," Comite stresses, "but we must be gender specific." Henrich, who is now involved in curriculum development at the Medical School, adds that a way must be found to make the changes permanent. "We need to see to it that the integrations we've accomplished don't fall out of fashion," she says. |
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