"Not just small men" - how healthcare is failing women, and what can be done

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Lucy Perez, Senior Partner, Life Sciences, McKinsey & Company; Global Leader, McKinsey Health Institute: Women spend 25% more time in poor health than men do, and this carries big economic consequences to the tune of a lost trillion dollars of economic opportunity each year

Robin Pomeroy, host, Radio Davos: Welcome to Radio Davos, the podcast from the World Economic Forum that looks at the biggest challenges and how we might solve them. This week: why do women tend to get worse health outcomes than men? And what are some simple, cost-effective ways to make that better?

Lucy Perez: So women spend 25% more time in poor health than men do. And many people think that that makes sense, that because women live longer than men, that they would spend more time in poor-health because it's concentrated at the end of life. But actually, that that big health gap happens during women's prime working years. It's actually much more pronounced between ages 20 to 60. And that is why it has such huge economic implications taking women out of the workforce.

Robin Pomeroy: A report from the World Economic Forum and the McKinsey Health Institute sets out three relatively simple ways that health systems around the world could improve women’s health outcomes, including when it comes to the massive killer: heart disease.

Lucy Perez: Women are 50% more likely to die in the year following a heart attack than men are. We're leaving opportunity on the table in terms of how we can help those women be in better health.

Robin Pomeroy: Follow Radio Davos wherever you get podcasts, or visit wef.ch/podcasts where you will also find our sister programmes, Meet the Leader and Agenda Dialogues.

I’m Robin Pomeroy, and with this look at how to improve the health of women, but also children and of men…

Lucy Perez: If we want better for everyone we really need to put that study of sex-based differences front and centre.

Robin Pomeroy: This is Radio Davos

Welcome to Radio Davos and on this episode, we talk about health and in particular women's health and to help with that I'm joined by my guest Lucy Perez. Hi Lucy. How are you?

Lucy Perez: I'm doing well Robin, thanks for having me.

Robin Pomeroy: Tell us what you do.

Lucy Perez: Many things, but the role that I have these days that we're here to talk about, I am a senior partner at McKinsey & Company where I'm also one of the global co-leaders of the McKinsey Health Institute.

At the McKinsey Health Institute, we have what I consider the best mission, how to add years to life and life to years. And one of things that we've realised in looking at how much progress we've made in terms of growing human lifespan is that we have not done the same when it comes to health span. The amount of time that we spend in good health.

And a big reason for that is because we have not been looking at sex-based differences and thinking about how male biology and female biology are different.

So I'm excited to spend some time today talking about how we can close that women's health gap.

Robin Pomeroy: And you recently published this report with the World Economic Forum, Care for Women, Investing in Care Delivery to Improve Women's Lives and Livelihoods. How do you pitch that report? What's the elevator pitch for it?

Lucy Perez: I will put that report in context first because I think that may be helpful for folks who are not familiar with this. We started a partnership with the World Economic Forum three years ago under the premise of understanding the economic impact of investing in women's health. As part of doing that work, we showed that women spend 25% more time in poor health than men do, and this carries big economic consequences to the tune of a lost trillion dollars of economic opportunity each year. And about a third of what drives that are gaps in care delivery.

And so this latest report is showcasing how we can address those gaps in care delivery to help women have many more days in good health and as a result have stronger economies for everyone.

Robin Pomeroy: Give us that figure again, how much more percentage of their life does a woman spend in ill health?

Lucy Perez: So women spend 25% more time in poor health than men do. And many people think that that makes sense, that because women live longer than men, that they would spend more time in poor-health because it's concentrated at the end of life. But actually, what we showed is that that big health gap happens during women's prime working years. It's actually much more pronounced between ages 20 to 60. And that is why it has such huge economic implications taking women out of the workforce.

Robin Pomeroy: Another reason you might say potentially it's logical is women give birth and this is a huge stress on the body.

Lucy Perez: It is a huge stress on the body but actually what we found is the majority of the gap ties to conditions that impact both men and women but that impact women disproportionately or differently.

Heart disease is a perfect example. Women for example are 50% more likely to die in the year following a heart attack than men are. And interestingly is because people often say or women present in atypical fashion. But the reality is women are 51% of the population. So is that really atypical? Or do we need to think differently again about male biology versus female biology and follow the science and what it shows us?

Robin Pomeroy: So interesting, right, atypical meaning not like a man.

Lucy Perez: Exactly.

Robin Pomeroy: All right, well this report, what you've done is identify three kind of concrete cases of what could be done to improve this.

And I'll just quote a bit, actually this is from your blog, I don't know if this is also a line taken from the report, you wrote a blog for the World Economic Forum - link in the show notes to that, well worth reading, it's a very concise kind of summary of what's in this report - but here's the line that should surprise people. "Investing in preventative care, such as integrated screenings and standardised reporting, could create healthcare system savings, delivering a three to six times return."

Lucy Perez: Those are massive numbers, right, very attractive when you think about that value of prevention and investing earlier to avoid downstream worse events.

So what we did is we said we wanted to take a look at three conditions that allowed us to understand what is happening today, what are those pain points that women experience in their care journey, and focus on things that happen to a lot of women.

So one of the things we did was look pregnancy. There's over 200 million births every year, right? Women who are going through pregnancy each year. There's also about 200 million women who are getting a mammogram each year. And in both of these circumstances, what we find is that we're leaving opportunity on the table in terms of how we can help those women be in better health.

So take the mammogram, right. It is well known as a breast cancer diagnostic. But what many people don't realise, it can also be a great indicator of heart health. Because in mammograms, we can take a look at breast arterial calcification. This is the buildup of calcium in your arteries there. And by looking at that, we get an indication of how much more likely that woman is to have a cardiovascular event. And because we can detect it earlier, especially if she's getting routine annual mammogram, we can intervene earlier and help prevent a cardiovascular event down the line.

So you're talking about an intervention that today maybe I'm going to use US numbers, cost you on the order of hundreds of dollars to avert something that can cause multiple hundreds of thousands of dollars to treat. That's how you get that very positive ROI.

Robin Pomeroy: So the situation is in countries where women are regularly getting mammograms, which is a screening of the breast for breast cancer. If you added a bit of, a bit extra...

Lucy Perez: I would argue it's not adding, it's literally annotating that mammogram. It's same test, right, the same image that's giving you that information that just needs to be annotated in a standard way, right? So you can compare and contrast over time against different populations. That's all we need to do.

Robin Pomeroy: Is it already happening? Are there clinics where they'll say, okay, we're going to screen you for cancer, but we'll also give you an idea of whether you're at risk of heart disease.

Lucy Perez: Indeed, there's a few places primarily in high-income countries that are indeed beginning to incorporate this, that they will also even have a standard of care for how to report on breast arterial calcification.

But the reality, it's very much the minority. And that's why we hope this work helps shine a light on it and reflect anywhere where a mammogram is happening, whether you're talking about a high-income country or a low-income country, but anywhere that a mammogram is taking place, that there's that opportunity to annotate for breast arterial calcification that then triggers a referral, sometimes to a primary care physician, sometimes to cardiologist, depending on the severity of that measure, so that that woman is better looked after.

Robin Pomeroy: Have you any anecdotal evidence of this? Do you know women who've actually experienced this?

Lucy Perez: I do. I mean, sadly, too many, right, that because the reality is I live in the United States, right? And there, routine mammograms are fairly common.

And so what do you often find is that in some instances, I have a friend who literally went for her mammogram last week and she was asking me, what should I ask about, right. Because she's been hearing me talk about preparing for launching this report. And I said, you should ask your doctor, the radiologist, to comment on your breast arterial calcification. And she did, and he asked why.

That speaks to the change that needs to happen, right? That everyone needs to understand this is an opportunity, a screening opportunity that we have that it's not costing anything additional and that ultimately can help save lives.

In her case, you know, after a lot of back and forth, right? It was clear he said she didn't have any meaningful breast arterial calcification, but what if she had had and she had missed that opportunity to then go consult with a cardiologist, for example.

Robin Pomeroy: Now you mention the differences between richer countries' health systems and poorer ones. Some countries won't have regular mammograms, won't be set up for that. In other countries where there's maybe a state healthcare system like most countries in Europe, I wonder if there's a reluctance to kind of seek out underlying illnesses that are there, because if they do detect that patient has potentially heart disease, oh no, well they've got to spend more than diagnosing and treating that.

You would be saying, well, they'll end up, if they don't, with a heart attack victim it's going to cost them a lot of money is that...

Lucy Perez: So this exactly the business case of prevention, right? That by intervening earlier, when you have that data, not only do you improve the odds for that patient of having a better health outcome, but you do it in a way that costs the health system a lot less.

Robin Pomeroy: Let's look at the other one. So we've got three, as I mentioned, in your report. That's one you already mentioned, one of the other ones, which is pregnancy. So tell us how you could enhance women's experience there.

Lucy Perez: So when women are pregnant, that's actually the period of their life that they typically are most engaged with the health system, right? Much more frequently going to the doctor, getting tests.

And what we see is that it is not uncommon for many women to experience hypertensive disorders like preeclampsia or gestational diabetes during pregnancy.

Those women who experience that during pregnancy, it's almost like the canary in the coal mine, if you've heard that expression, right. They are twice as likely to develop more serious heart disease later in life. But what often happens is that those women, while they're being monitored, their condition is being treated. But the moment they give birth, and typically preeclampsia goes away, right, gestational diabetes has been managed, the health system almost forgets that she has had those conditions, and there's no proactive care management and monitoring.

So then years later, decades later, heart disease shows up in an aggressive form that had this been monitored much more routinely, right, if when she was going to the doctor, you're down the line talking about some symptoms, that doctor's able to make the connection to that gestational diabetes she had years earlier, you would again have a much healthier outcome and a reduction in the number of adverse events related to that underlying heart disease that went unchecked for so long.

Robin Pomeroy: And it's so important to know if you are at risk of heart disease, because it's a silent killer. I have a certain amount of personal experience. I have to say, I won't go into that here, but it can grab you out of the blue, and there are risk factors, genetic factors, whatever, but you're saying women with those conditions that can appear during pregnancy are, did you say, twice as likely as the average to have that? So they really should be looking into it.

Lucy Perez: I mean, heart disease is the number one killer of women globally, right? And so here you have a couple of instances where you're getting that alert, right, like that flashing red light. We should be paying attention a little bit more closely because we can help that women live healthier longer.

Robin Pomeroy: I'll cite these figures. I mean, you probably know them off the top of your head, but I'll just read from the report here. Improving follow-up and long-term care costs about $400 to $450 per woman, far lower than the cost of treating a major cardiovascular event, which you're talking about upwards of $100,000. In the U.S. alone, this could avert between six and 25 million dollars in avoided costs, roughly a three to five times return on investment, which was my initial question. How do you come to that figure? Well, that's how you do.

Let's look at the third one then, which is perinatal depression. Just tell us what that is and what you found there.

Lucy Perez: Yeah, as we did this work, we worked with a consortium of more than 20 health systems around the world representing five continents. Earlier, you were talking about how do we make sure we solve not just for those high income countries, but we wanted to make sure that we were representing a wide variety.

And I start by saying that because when we started this work you can say we had a bias towards we wanted look at postpartum depression. And one of the big learnings from doing this work with the consortium members is that actually we're thinking of it too narrowly because it doesn't begin postpartum and we should be thinking truly about perinatal depression and begin to look for the signs of depression earlier in pregnancy.

Robin Pomeroy: Perinatal would mean the whole period before, during, after.

Lucy Perez: Exactly. From the moment, basically, the woman is pregnant all the way, typically to the year after delivery is what we're looking at.

And it is really important because today, when you look at the data and the data that we have is most focused on postpartum, about 20% of women experience postpartal depression.

When you look broader, right, that number's naturally going to grow. And we know from some real-world evidence that indeed, in many instances, it'll manifest earlier than birth. And this becomes really important because by the way, this is a condition that has a lot of stigma associated with it. It also has a lot of validated tools for how we can screen and check if a woman is experiencing perinatal depression.

And so by giving it a voice, by making it standard and leveraging these tools that already exist that have been clinically validated and think about how they can be incorporated earlier.

Any one of these times that the woman is engaging with the health system during her pregnancy, we again increase the odds of helping her be healthier and her child because we see the correlation between the mental health of the mother and the health of that baby.

Robin Pomeroy: So it's a question of kind of integrating the mental health awareness and treatment and diagnosis into the wider health care for a pregnant woman.

Lucy Perez: Exactly, and de-stigmatising it, right? So that we're indeed making sure that we are identifying earlier, intervening earlier to get into those better health and economic outcomes.

Robin Pomeroy: It all makes perfect sense. So do you now go to health systems, and they all welcome you with open arms and say, thanks for finding ways to save us multi-millions of dollars on, or is it trickier than that to turn these kind of policy suggestions into reality?

Lucy Perez: Well, the reality is that health systems are very complex, as I think we all know and experience it every day.

And that was one of the things that we wanted to do with this work, is really understand, where are those discontinuities in care? Because if this were easy to do, it would have happened already, right?

There's a lot of good intent towards improving health outcomes overall. In this case, we have the evidence, so we know what it takes. But what has been really challenging is to connect the dots, right? It is to think about what is, for example, the diagnostic tool that I'm putting in place. I'm thinking the screening that I may do, for example for perinatal depression. Then what do I need to activate? Think in the case of the mammogram so that when the breast arterial calcification score is high, how do I help make that transfer happen of the data, the information of connecting the patient to the right cardiovascular specialist?

Those things are not easy to do.

Typically in health systems, they're part of different departments, different budgets. And so what we've tried to do working with the consortium members is actually integrate in one place. What is the suite of changes that need to happen?

And by the way, recognise that health systems really vary in terms of the resources they have. Some are very tech enabled, right? So you can think about what's the clinical decision support tool that you want to code to facilitate those transfers. Others are much more manual, right, in terms of how things happen.

So in the work that we did, we really try to solve for different levels of maturity, resources, sophistication that health systems have, so that we can bring not only a perspective on, look at all the value at stake, but look at the changes that need to happen in terms of the capabilities you have, the processes that you need to change, and the technology that you want to put in place to facilitate that more seamless journey.

Robin Pomeroy: People get excited about technology, don't they? Particularly artificial intelligence at the moment. I wonder. If some of that enthusiasm and hype maybe overshadows some kind of simpler, more human things to say, well, OK, you came here for cancer, but let's also remember we've got some great information now that might relate to heart disease.

It doesn't take a huge leap in technology to arrive at a system that just works better with what you already have. Do you think sometimes kind of sensible policy gets kind of drowned out by some of the excitement over AI, which we can use AI to look at that mammogram and find this, that, and the other. Yes, but if you're not using it to deliver this outcome for patients, what's the difference?

Lucy Perez: I mean, clearly there's a lot of enthusiasm about AI, right? I don't think you can have any conversation in health these days without touching on it.

But essential to AI is the quality of the data, right, that you're feeding the models.

When it comes to women's health for too long, we've actually almost forgotten to ask the question of sex as a biological variable.

And that is foundational because even during COVID, there were data sets that were not coded for sex. If you don't do that coding you don't know if there's a sex-based difference.

And so when you go and ask about what are those basics that need to happen, that is number one. Are we collecting? Are we counting? The women who are, for example, participating in the trial that are in the health system and then doing the study and asking the question of, are there sex-based differences?

Because back to what we were talking about earlier with the atypical presentation, that rationale that is, you know very misinformed when talking about the different outcomes in cardiovascular disease. If we're not tracking that data from a sex-based perspective, we cannot have the doctor who's using clinical decision support software is looking at how that woman manifests when she shows up to the emergency room and he may think she has indigestion because the symptoms are not matching the male physiology, right?

And so I get very excited about, especially in places like these where we have the evidence, how is that evidence translating into better clinical decision support tools, that for example, one of those first variables should be, oh, I'm talking to a female patient. What should I be looking for? It may be different than what I would be looking for if I'm looking at a male.

Robin Pomeroy: So Lucy, tell me kind of how your journey towards this happened. Did you have an aha moment when it was like, oh my goodness, this has just not been taken into account by clinicians, by researchers, the fact that women are different from men in a lot of these things. Was there a moment, is there an incident that happened? Did you read a paper? Did you have a personal experience? You thought, hold on a minute, that woman found out she didn't have indigestion. She had a disease or whatever it was.

Lucy Perez: Part of it at first is a collection of small moments that happened, but then indeed, I will speak to two things that happen.

One is I've always been very passionate about health equity. And one of the things that always struck me when we were looking at health equity is that we didn't really talk about sex and gender as a variable in health equity And so that made me very curious to start looking at the data. And so many years ago.

Robin Pomeroy: So what were you talking about then when it came to equity?

Lucy Perez: There's much more focus on racial disparities or geographic disparities, which are extremely important, right? But back then what struck me was, why are we not also talking about sex and gender, right. And so that took me down a path with some colleagues in having conversations about this.

I'm a scientist by training, you know, I have a PhD in organic chemistry, so asking questions is something that comes very, very naturally. To take a look at some of the data, around conditions that are unique to women and unique to men and understand, do we see any differences in how they're diagnosed or does the sex of the doctor doing the diagnosis change the answer?

And this paper, right, what we showed was that actually conditions that are unique to women are diagnosed much less frequently than those that are unique to men.

And then when you double click on what was the sex of the provider doing that diagnosis, you see that men tend to diagnose male-specific conditions in the same rate that women diagnose male specific conditions. But when you're looking at women's specific conditions, male doctors diagnose them a lot less.

And so that was probably one of, for me, like seeing that data, it really struck me.

Then the next thing was having a friend who suffered from endometriosis, really wanting to learn more about this condition because until I got to, in a way, live it side by side with her, frankly I didn't know much about it. And now I'm embarrassed that I didn't know more about it earlier because endometreosis impacts one in 10 women. It's actually the same numbers as diabetes. One in 10 woman suffer from diabetes. But yet, you look at diabetes, and we have so many options to treat, right? We don't, you know, there's still plenty of room for more innovation, but you know there's multiple products in the marketplace, more than 500 drugs in clinical development. And yet, do you look at endometriosis and you say, okay, same numbers, one in 10 women and yet no approved drugs and only about 20 clinical drugs in development. It's a very stark difference.

And so that was the beginning of wanting to know more. And I think then the big insight for me was it is about so much more than the conditions that are unique to women. And that is when you realise, for example, heart disease was probably the most shocking to me that we just don't talk enough about those sex-based differences in heart disease. And again, that's the number one killer of women.

And when you start going through the data, you just find over and over again, that sex-based differences are much more prevalent than not, but yet for so long we've operated in a world that assumes there are no sex-base differences. So if we want better health outcomes for everyone, because by the way, sometimes it is to men's disadvantage on the sex-based differences. So if you want better for everyone we really need to put that study of sex-based differences front and centre.

Robin Pomeroy: Endometriosis, we did an episode of Radio Davos on that. Oh, it's going back two or three years now. If you're listening to this and you have never heard of endometriesis. A lot of people haven't, but as you say, it's very, very common and it's chronically under-diagnosed. Most women almost never get it diagnosed first, second, third time they visit the doctor. I'd invite people to go back and listen to that episode.

I wonder, when you have conversations about this issue now, does it ever kind of butt up against, you know gender politics and kind of identity politics.

Do you find that there's kind of a pendulum that shifts away that actually it's a bit sensitive now to talk about women's health or are we, and I hope you're going to say, no, that's not the case, people are grown up and sensible and we talk about this normally. Is there a political aspect to this?

Lucy Perez: What I would say is, for too long, I mean, you were talking about doctors, right, and the biases they may bring to the table. It is not surprising because medical schools were not teaching sex-based differences, right? We just, again, we were not asking the question.

What you're finding now increasingly is a recognition that women are not just small men, right. For too long when we thought about it is we have to adjust the dose because women average, they're physically smaller than men and that takes care of it.

I think, fortunately, what we're seeing now is that people are understanding we're talking science. We're talking human biology. Women are different from men, not only in terms of their reproductive organs, but it's genetics, right? It's hormones. It's so many more variables, and it's actually really fascinating scientific questions that are getting asked now, why is it that women are more likely to suffer dementias, right.

And when you think about what's going to be a massive cost burden to society, dementia is very high on that list. It is hard to imagine that we're going to solve and think about the cure for dementia without taking into account the understanding of sex-based differences.

So while it is true that there's a lot of debates, you know, I think the majority of folks recognise that we are talking about we need to do good science. With good science, we feed good clinical care that takes us to better health outcomes and stronger economies.

Robin Pomeroy: People can that report, links to it in the show notes to this episode. Where can they find out more about the work you and the McKinsey Health Institute do?

Lucy Perez: They should check us out online, McKinsey Health Institute, which you can find at mckinsey.com. And we hope that folks will also look for ways to take action, right? Because I think what's really important in this space, I mean, the first step towards action is educating yourself, right, building awareness about closing the women's health gap. But then all of us have a role to play, whether it's the next conversation you're having with your doctor where you're asking about those sex-based differences. Or the ways where you think you want to contribute economic ally or in other ways to advancing the science and the innovation that will help us close the women's health gap, I would just encourage all our listeners to take action.

Robin Pomeroy: Lucy Perez, thanks very much for joining us on Radio Davos.

Lucy Perez: Thanks so much, Robin.