Our Grand Challenges
Thank you, Wolfram, for that warm introduction, and to both you and Emery Brown for inviting me to speak to the HST program this evening. I’m so sorry Emery could not be with us.
It is wonderful to be here. There has always been a special bond between HMS and MIT, and now that I am at Wellesley, I feel that we have a triangle of sorts—with Wellesley having a long and critically important partnership with MIT.
Since my medical school years—I finished HMS in 1985—the relevance and importance of the HST program has only grown. It’s easy to see why.
Both medicine and technology have evolved in ways that could not have been imagined 25 years ago. The opportunities are enormous—and so are the challenges.
As I sat down to prepare these remarks, I found myself thinking back to two important reports.
The first carries the title “Grand Challenges for Engineering,” and it recounts the findings of a distinguished committee of engineers that set out to identify what was described as “the most important, tractable engineering system challenges that must be met in this century for human life as we know it to continue on this planet.” The final list of 14 was wide-ranging—from making solar energy economical to providing access to clean water and better medicines.
They were published by the National Academy of Engineering in 2016—the same year I became president of Wellesley College—and greatly spurred my thinking, even figuring into my inaugural address.
This report drove home the critical need for work across disciplines, a need that extends far beyond engineering. Not one of the urgent challenges could be addressed by any single field. Each of them will require what is often called “T-shaped” expertise—a deep grounding in one area combined with a capacity to think, and work, on a far broader stage. Each of them requires conversations across difference.
So, that’s the first report.
The second report is very different. Its title is “Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering and Medicine,” and it emerged from a study that I co-chaired to assess the impacts of sexual harassment in academia on women in STEM fields. This was a joint effort of the National Academies of Sciences, Engineering and Medicine. You may have read about it last year—it got a lot of media coverage on its release.
To recap just a bit: What we found was alarming. Academic workplaces are second only to the military in the rate of sexual harassment. This includes gender harassment (put-downs rather than the “come-ons”), sexual coercion and unwanted sexual attention, and sexual assault. Our findings were especially disturbing given the place academia holds in the STEM pipeline.
At a point when talented women are poised to reap the benefits of their efforts, they are all too often derailed.
We concluded that wholesale change was needed—nothing less than, and I quote: “systemwide change to the culture and climate in academic STEM.”
So, what ties these two reports together—one focused on research challenges, the other on human behaviors?
It may surprise you to hear that I see them as companion pieces. To my mind, these are two critical fronts in a single battle. Because to solve the world’s most urgent challenges, we need all voices at the table.
My own field of women’s health is a case in point.
Let’s take a trip back in time.
Back when I began my medical career, women were rarely included in clinical trials—and in most of medical research for that matter. Investigators operated on the assumption that what was true for men would hold true for women for most conditions. That male biology was typical and women’s was, well, not.
There was just one problem with this approach: It was 100 percent wrong, totally at odds with science. We now know that women and men are different down to the cellular and molecular levels.
It is not just our sex organs, but our brains, hearts, lungs, and joints that are different. Simply put, to quote a 2001 report from the Institute of Medicine, “Every cell has a sex.”
The implications are enormous—all-encompassing. Men and women differ genetically, and these genetic differences are compounded by hormonal and reproductive changes across a woman’s lifespan.
We now know that the circumstances of women’s lives impact their health in unique ways—and, as we now know through the field of epigenetics, even changing their genetics. We know that the same disease can look different in a man than it does in a woman.
And—shockingly—we know that violence experienced by women in their early years is the single most powerful predictor of chronic disease as they age. When we fail to take such realities into account, we leave women’s health to chance. This is dangerous, does not encompass the best medicine, and all too often can be deadly.
So, here’s the question—the question that propelled my work, that led me to found the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital back in 2002: How could we mainly ignore over 50 percent of the population? Why on earth would we assume that their symptoms are atypical—and make those of the other near 50 percent the universal norm?
Now, it’s a simple and obvious question. And yet, for the most part, it went unasked until the 1990s.
This finally started to change after the elections of 1992, which led to an influx of women into the Senate in the wake of the Clarence Thomas/Anita Hill hearings.
This was known as “The Year of the Woman” and was in many ways a time not unlike our own, a moment where women were waking up to injustices and demanding action.
A turning point came the following year, when Congress passed a historic measure mandating the inclusion of women and minorities in phase 3 clinical trials conducted by the National Institutes of Health. Slowly, the medical research community began to shift.
Yet even today, we are far from where we should be. Consider that the majority of federally funded studies still do not report sex-specific findings, even if women were included in the research population.
Think about what that means: When you give an average as a result, that’s not really good for women or men. It doesn’t give the right answer for either of them.
I’m reminded of this quip from the 4-foot-11-inch former Labor Secretary Robert Reich: “Shaquille O’Neal and I have average height of 6 feet 2 inches.”
There’s an irony here: Even though we are on the cusp of the personalized medicine revolution, there is astonishingly little awareness of the impact of sex, the most basic genetic difference that we know of.
So why is this taking so long? Much of it has to do with who is asking the questions and making the decisions—with who is at the table. Or at the lab bench.
Back in the 1990s, Rep. Patricia Schroeder summed it up this way: “You fund what you fear. When you have a male-dominated group of researchers, they are more worried about prostate cancer than breast cancer.”
Now, prostate cancer is important! And so is breast cancer.
Which brings me to a critical point: Diversity is essential if we’re to have excellence.
Diversity is not a PC add-on. Rather, it goes to the core of where our commitments lie. It shapes the questions that we ask and how we move forward. It’s no coincidence that the push to require that federally funded studies take sex into account was spearheaded by women—notably Rep. Schroeder and senators Olympia Snowe and Barbara Mikulski—and women researchers and physicians, among whom I’m proud to count myself.
For all our progress, medical research continues to shortchange women. And when research is inadequate or misleading, it distorts health care decision-making throughout the health care system. That’s been the case with women’s health for far too long—and while we have made some important progress, we still have a long way to go.
Let me share a few data points from recent years.
A study by Stacie Geller and Molly Carnes looked at 782 randomized trials in 14 leading U.S. medical journals in 2015—107 were the primary report of a NIH-funded randomized clinical trial conducted in the U.S. and including both sexes.
What they found in these 107 students was that we have made progress—81 percent enrolled ≥30 percent women.
- Only 26 percent reported at least one outcome by sex or included sex as a covariate in statistical analysis
- Seventy-four percent didn’t include sex in the analysis.
- Seventy-two percent did not mention whether sex was included in their analysis, didn’t report any sex-specific outcomes, and didn’t provide explanation.
- Two percent explained why they didn’t include sex in their analyses.
- The authors noted that there had been no statistical improvement compared with a similar study performed in 2009.
- It is clear that we are not making full use of federal dollars in biomedical research!
On a far more positive note, the NIH has taken notice.
After a damning report from the Office of Management and Budget, in January of 2016, the NIH announced its new policy on including sex as a biologic variable, which requires investigators to factor sex into the design, collection, and analysis of data, and reporting of vertebrate animal and human studies in order to strengthen science.
This is a matter of the quality and integrity of science.
And the NIH will also require the inclusion of adequate numbers of women in all phases of clinical trials to achieve meaningful results.
The NIH stated that they are also committed to working with other stakeholders, for example federal agencies such as the FDA, journals, and professional societies, to ensure that there is more robust implementation.
In sum, the sex as a biologic variable policy is an important commitment by the NIH and could be an important step if implemented rigorously.
If implemented rigorously, the policy will require investigators to examine if there are known sex differences in their area of investigation in order to understand how best to include sex and gender as important variables.
Just asking the question could be transformative in both pre-clinical and clinical research.
Will the policy fulfill its promise? That remains to be seen. It will likely depend in no small part on who is at the table.
I was reminded of this yet again by an article published in the recent Lancet issue devoted to advancing women in science, medicine, and global health. Vincent Larivière and colleagues analyzed some 115 million scientific publications covering public health, clinical medicine, and biological research by the authors’ gender over 30 years. Their findings showed that:
- Studies with a female first or last author were more likely to report research findings by sex.
- The effect was strongest when both first and last authors were women.
We’d do well to attend to these results, and their larger implications. Our life experiences shape—and often drive—what we focus on.
* * *
As president of an eminent women’s college, I think a lot about such things.
When I left the Connors Center for Women’s Health—the organization that I’d founded and to which I’d dedicated more than 20 years—some were quite surprised. They saw my move to Wellesley College as an abrupt shift. But for me, the move to women’s education could not have been more natural.
Throughout my career, I’d been spurred on by a number of powerful questions. Yet, ultimately, all were facets of a single inquiry: How do we create the conditions for women to flourish and reach their full potential, both in service to them and in service to the world, and in doing this, improve conditions for all?
I’ve talked about what happens when women’s voices go missing in medical research. But the point I’m making is much broader. Across sectors, there is an abundance of research demonstrating that performance improves when women hold their share of key leadership roles, medical research being just one example. Regardless of the specific arena, women often have special insights into—and concern about—issues related to women.
We also see this in the realm of technological innovation, where the impact of gender or sex may show up at two points in the production cycle.
First comes the idea or invention.
I think of the woman-led company that has developed the Bloomer smart bra, which uses medical-grade washable sensors to collect cardiac monitoring data that can be communicated to the wearer’s physician—and used to collect large-scale information to feed the growing industry of artificial intelligence in medicine.
Great idea! Data gathering that is gender friendly and geared to filling in the considerable gaps in our knowledge of women’s heart health.
But of course, it’s not just enough to have an idea—that idea needs to get funding in order to get to market. Here too, women face obstacles. You may have seen a March 1 New York Times story that explored this issue. The headline said it all: “When Women Control the Money, Female Founders Get Funded.” Now consider that as of October 2017, women made up just 8 percent of investing partners at the top 100 venture capital firms.
It’s not hard to appreciate why female founders received only 2.2 percent of the $130 billion in venture money invested in the U.S. last year.
* * *
For all of these reasons—and many more—there is good reason for concern when women go missing in leadership roles, from the corporate C-suite to the research lab. And let there be no mistake, women are still going missing. To cite just a few statistics from medicine:
- In academia, women [make up] 38 percent of American medical school faculties but concentrated in lower ranks.
- In 2014, women accounted for just 16 percent of deans, 21 percent of full professors, and 15 percent of department of chairs.
- Women in academic medicine are paid less, even accounting for specialty, with women earning about 90 cents for every dollar earned by their male counterparts. (Freund and Carr. Academic Medicine August 1, 2017)
* * *
So, faced with such statistics, how do we move forward? What more can we do to assure that all voices have a place? And here I should be clear: While I’ve focused on women in this talk, my concern extends to everyone who is unfairly marginalized, to all who have struggled to gain respect and share their gifts.
Race, religion, disability, gender, national origin—these are but a few of the traits that hold people back and in so doing deprive the world of much-needed talents and insights.
When I ask myself this question, several worlds come to mind: curiosity, kindness, and humility. If we’re to work together at the intersection of our shared knowledge and pasts, these qualities are essential.
Can we be curious not just about our disciplines, but also about each other?
Can we show the sort of kindness that transmutes diversity into true belonging?
Can we have the humility to know that each of us has biases and blind spots?
Our answers to these questions will go far to shape the future. To decide our fate as we confront the world’s grand challenges.