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Gavin: Hello, welcome to the final answer voice of 2022. I'm Gavin Cleaver, and we're very pleased to have you with us again today. We're handing over the reins to Tyee Sevier and Elisa Puku from the Lancet Regional Health Americas. And you're going to hear them talking with Professor Felicia Knoll. Professor Knoll is Director of the University of Miami Institute for Involved Study of the Americas and a professor of the Leonard M.

Miller School of Medicine. Thaisa, Elisa, and Felicia are going to be discussing the lack of gender diversity in medical leadership in Latin America and the gap in evidence of gender dimensions of the health workforce and how the majority of unpaid health care and caregiving is provided by women while men occupy leadership positions.

This is all based on Dr. Knoll's piece in the Lancet Regional Health Americas, which is entitled Feminization of Medicine in Latin America. More the merrier, we'll not beget gender equity or strengthen health systems. I hope you enjoy, and I hope you've enjoyed our 26th episode throughout 2022. We look forward to seeing you in 2023.

For now, here's Thaisavia and Elisa Bucu talking to Professor Felicia Knoll.

Taissa: Hello, I'm Teysa Vila, and I'm Elisa Pucull. And we're delighted to have Dr. Felicia Nall with us today to discuss a piece she authored and published in the Lancet Regional Health Americas entitled Feminization of Medicine in Latin America. the media will not beget gender equity or restrain health systems.

Dr. Nell is the director of the Institute of Advanced Studies in the Americas and professor at the Miller School of Medicine at the University of Miami. She is also a senior economist at the Mexican Health Foundation and founding president of Tomatillo Apecho, a Mexico based NGO that promotes research, advocacy, and innovation.

awareness and early detection of women's health issues in Latin America. She has dedicated more than three decades to academic advocacy and policy work in global health, focused on reducing inequalities and improving the condition of vulnerable groups, especially in Latin America and the Caribbean. So welcome Felicia.

We're delighted to have you with us today. 

Felicia: I'm delighted to be with you. It's amazing for our region to have this journal and to be able to be You know, part of helping to think through how it can promote health policy, reduce inequities, and really support also our researchers and early career researchers in the region.

Taissa: So for the first question, could you please explain what the idea behind the piece and where did the inspiration to write about it come from? So, there's actually a bit of a history to this. 

Felicia: The first piece goes back to 2015 of that history when the Lancet put forward a very innovative commission on women and health led by two colleagues and friends, Anna Langer and Afoz Nolais.

And in that work we looked at a model that had been developed by Julio Freg, which is all the different ways that women and health interact. So not only looking at the health of women, but women as. So not only as consumers of health and healthcare, but also producers of health and healthcare. And in that report, we were able to demonstrate how important it is to look at the gender aspect and to show, I think probably for the first time that the majority of health and caregiving is produced by people who identify as women.

It was sort of no surprise that caregiving is majority provided by women and we can talk about that in a bit. But it was certainly quite important to identify that the majority of paid people who work in the health sector are women as well. So in the end about, it's about the 70 percent is like at the key.

Number and we're actually just completing an update paper that we helped to submit to the Lancet soon on this. So like the magic number is about 70. It's about 70 percent of hours. It's about 70 percent of those who produce health care and it's about 70 percent of the total value. And when you add it all up the number that you know we shared in that report was Over 5 trillion and over 3 percent of global GDP and our new estimates, they're significantly higher than that, where we include discrimination.

And some are between eight and 11%. So just a huge subsidy to the health sector, but what also came out in that, and I think we'll speak about it later, is that there's tremendous underpayment. Due to discrimination and lack of payment for all of the health care that's provided particularly by women.

And that undervalues the whole sector itself, health and caregiving. But I want to take it sort of back a couple more steps because, you know, we are speaking about Lancet Regional Health America, thinking about Latin America. That it was actually work that I undertook arriving in Mexico in the early to mid 1990s with my husband, Dr.

Julio Franks. So Palu had done some of his thesis work on under and unemployment of physicians in Mexico. And he had shown, which is this really very important point at the time that there were just a plethora of Mexicans without healthcare and also doctors without work. And it was about 30 percent of physicians.

And then we started working together, I asked the question, What about gender? And it turned out that the vast majority of those physicians that were without work or were qualitative or quantitatively underemployed were women, overwhelmingly so. Well, we're over double the rates that we saw for men. And that led to a whole stream of research.

And it turns out that it affects nursing and many other careers in the health sector. But what we see is that gender, particularly being a woman Clearly implies a whole set of barriers, but I think what's so key for us in terms of policy is this idea, particularly we saw during the pandemic and post pandemic now that we have so many people in our world and in our region who lack access to health care.

And part of that is a lack of human resources to produce and deliver that health care. A good proportion of resources are there and under or unutilized because they sit with women who don't have ways to work in our health sectors that are dignified, decent, and allow them to have a work life balance.

So that's why we did this paper. And I think we have something about Latin America, these data that we have to project and ask globally. 

Taissa: Yes, absolutely. And fancy you already. Pushed it to Latin America. My follow up question is, do you look in your work about what is it specific to Latin America that makes gender inequity so persistently present?

Is there any difference comparing to the whole world and what's behind that? 

Felicia: It, you know, it's a great question. I've been thinking a lot about this. I think that one of the terrible constants that we have in our world as an eight constant over time and over space is discrimination against women, discrimination based on gender.

So I don't think we can say that that is unfortunately or fortunately unique to our region, to Latin America. But what are some of the differences? We have seen an incredible Increase in female labor force participation in our region that in some countries is higher than anywhere else in the world.

We've seen incredible increases in educational attainment and you know, near parity, if not beyond parity of women who study in certain professions, including medicine. And as we showed in the paper somewhere around 2019, we end up with more women studying medicine than men. That isn't a constant throughout the world.

So what does it say about our region is that we have an incredible potential to solve this problem, but also a really pressing need to put in place the gender transformative policies that have acquired in medical education and overall in the health sector, but also in how we manage and incentivize The time of families, men, women and others to provide child care to be able to ensure that this population has appropriate access to care.

Not all regions in the world can boast that opportunity as yet. We have that. It means we have something we can do for ourselves and something we can, I think, use. To project out where the other that, you know, sadly characterizes our region is that it's one of the most inequitable in the world and include some of the poorest countries in the world.

We go from, you know, Haiti to Chile and within countries, we have places that are as poor as anywhere else and deprived as anywhere that I've seen anywhere in the world and in the poorest countries of the world, and at the same time. Areas that are able to provide medicine that rivals. And I say, this is someone who has battled cancer in Mexico, rivals what you can get in Boston.

Those inequity belie opportunities, but also the moral compass that we have to use to evoke change. And I think gender, women, medicine, healthcare is absolutely essential. And just, you know, again, to highlight, you know, we're talking about a paper that focused quite a bit on medicine and physicians and doctors, but this belies the entire health sector.

It's about how we treat nursing as an occupation. It's about how we pay our nurses, it's about professionalizing that, and nursing, and it's about having many, many nurses who don't get to work as nurses and work as anything else from nannies to taxi drivers to being out of work. So it's really pervasive throughout the entire sector.

It's 

Taissa: a complicated issue that throughout the whole region, and I would say it's even more cultural. I can add this. So following up in the opening paragraph, you talk about gender focused transformative policies that can contribute to strengthening health system. Achieving universal health care.

There's coverage that is so important in our region. And could you tell us more about how you see this connection, how those policies could come into play? 

Felicia: Yes, absolutely. Let, let's And we can get back to your point about culture, which as long as both of you are willing to also share as women who live, who identify as women who live in Latin America, because you're, you're, you're living it and can walk the talk, then we can talk about culture, machismo and other points.

But going back to to the policies and universal health coverage, let's start with caregiving, right? Which women who are professionals, women who are physicians, women who are nurses are also overtaxed with the caregiving responsibility for children. And for the elderly, and I should probably have mentioned this and said something about Latin America as well, that this is a region where epidemiologic transition and demographic change has been rapid and extremely compressed.

So we see this generation of women who are. Becoming highly educated, for example, as physicians and have the responsibility still overwhelmingly for both children, but now also for those who have chronic and noncommunicable diseases and for an older population, Austin in countries that have just really not done very much to think about.

Caregiving for those populations. Some have done something on child care, very, very few Costa Rica, for example, might be one of the only have to theoretically have significantly put in place policies to deal with caregiving for chronic and non communicable diseases and the older generation.

So the first point in terms of gender transformative policies is something isn't specific to medicine, but includes medicine, which is to try to build in the incentives to be able to provide quality caregiving. Which means it includes training, for example, but also to incentivize people of all genders, men, women and other to have the opportunity to both work and to provide care.

And we talk about that actually in the Lancet Women in Health Commission, because I believe, I really do believe it's an opportunity. In many cases, men are penalized more in the workplace. If they do caregiving and then women we need to incentivize both and make sure that this is considered a part of life for everybody who would like and wants to provide caregiving for their own families or for, for their communities.

So I think that's one, and you know, there are a set of incentives that can be put in place paid leave. Not only for, again, for childcare, but also for care of the elderly or those who are suffering from illness. Then I think we need to talk about the actual, the health sector itself. And let's, you know, think about medicine for a minute.

We've seen a change over time in the demands that are placed on students of medicine for the number of continual hours that they serve in internships and residencies. But it's still not easily compatible. With having a family and particularly if you're still taking on the majority of the caregiving burden.

So what we can do in terms of applying a gender lens to medical education, I think is hugely important. And then there are a series even of issues that have to do with producing the tools that are required so that women can effectively provide care. And, you know, we've mentioned in the paper even during, during COVID to be able to have the sorts of protective equipment that would fit a smaller body that would be appropriate to people typically who have a different body structure.

Then many of the, the dominant men in particular profession. And I think all of those from the, the largest that affect the entire population to that should be very specific to inter occupational or intra occupational needs is what we need to think about when we, when we think about changing and changing policies in ways that will counteract what we're seeing throughout the health sector.

Yeah, there's, we talked a lot about in this paper about stewardship and leadership. And what it means to have the majority of learners being women, but the vast majority of leaders being men. And one could say, why is that important? And, and I know we'll talk about this a little bit later, but it is quite key to think about the policies that are required to ensure that leaders.

Are gender balanced as well. I think that's, that's, that's quite essential. Now, the other piece, if we have a few moments to focus on it, and I produced with some colleagues including Erna Langer, Beverly Essie, and others, a piece of work a commentary on universal health coverage and packages.

And the gendered nature of health and caregiving, and this is quite a fundamental critique to what I think global health leaders have accepted as a very progressive and dominant paradigm for the future of health systems, which is we should all strive for universal health coverage. We should think about progressive universalism.

We should take these cost effective packages very seriously. But when we thought about it a bit. All of that is based on a lot of free or underpaid labor. What makes many of these packages cheap is the fact that you have community health workers or nurses or underpaid physicians and unpaid caregivers in the families who are overwhelmingly women.

If we valued as we should that care appropriately, which would also ensure that we develop the policies that are required to improve, for example, the training for that kind of work, then these packages wouldn't be nearly so cheap. They're cheapened, it cheapens healthcare, and it cheapens women in a way that goes beyond health.

And I think we have to take a very fundamental look at why best buys are so cheap, why packages are so cheap, and within universal health coverage, to what extent we're relying on under and unpaid labor as part of the feminization of the health workforce, beginning with physicians. 

Taissa: I'm personally very keen on the studies on unpaid work for women because We don't talk enough about that and about not only when we think about universal health care, but if we start to critically read many or possibly most of the policies that we have in health related, if we're sticking to this topic, we'll see that they are overwhelmingly not considering.

Mostly women, because we know it's women who do that, but unpaid healthcare provision. And my tricky question to you on that point is that there's a link between who we are warming as teachers, then who we're putting as leaders and who makes study that turns out to be a policy and changing this vicious cycle.

Is it? One way out for us 

Felicia: without question. I mean, this is why I was mentioning this idea of learners and leaders and building, you know, a little bit on a recent follow up paper to another Lancet commission on health professionals for the 21st century. That came out in November, the song lock paper did that led by Julio Franken and Lincoln Chen that offer us a whole series of lessons about transformative education, post COVID pandemic, taking advantage of technology to be able to think about the wonderful and impressive ways in which we can increase access in the post pandemic world.

This, and I have to know that this, this can't be said in a way that takes away from the suffering and loss. That's so many families in our region because our region is so heavily affected by COVID. I'm in so many ways that that that loss is there and it's real. However, needs to and doing justice and almost dignifying that mean taking advantage of these new opportunities with technology to be able to provide more and better care in the future.

It is really key. And that that that new paper talks about that. And my question is very much around how can that help us to close the divide between women and men as learners and as leaders in our health sector and Latin America again can be a beacon of figuring this out. Now, why does it matter again?

The leaders are overwhelming men. Well, many. Are enlightened and very able, willing, and I would say determined and dedicated to promote gender equity and equality broadly within our region and globally as well. It is. Different to live it than to just learn about it. And so I think we do need to have a balance.

And I think as our world comes forward, that balance is really going to be a gender balance today. We talk very much about women and men. It's going to be a different gender conversation as we go forward. But, but the point is to have. Leaders doing the research leaders implementing and making the policy decisions who have lived and understand what it means to embody certain experiences and as they practice their profession medicine as they speak to patients.

who are women and of other genders and work with those patients. And as, as they seek to think about how education needs to move forward. The other is, and this is very much an economist point of view, but well, I'm not an economist economist in many ways, certainly not very neoclassical or, or a conservative or traditional as an economist.

One thing that I, I do believe in very strongly is that we want to have as much talent to draw on as we can. So one of the economic arguments as to why discrimination is bad is that it really limits your talent pool. It limits the diversity for which you can draw new knowledge, new experiences, and new ideas to move all of our societies forward.

If you take any segment of the population, ethnicity, religion, gender, color, and leave them out, you lose access to an incredible body of talent that can help that group and all others to move forward as a society. And, and I think that's what we're doing in the health sector by not recognizing that we are underpaying or not paying at all women who have studied to be able to close.

The divide and access that we know characterizes Latin America and many other parts of the world, if not all parts of the world. I'm not sure if that answers your question. 

Taissa: So, I was thinking here about the female leading roles and how you talk about women not being nominated for Ministers of health and this is a problem in our region to say, and it's, I think it's really tricky to, to try to find this balance here in our region.

And to really change this situation and make them be more highlighted. So when, when you, we think about the pandemic and how women were affected they could, they could be transformed and nominated to leading roles. So can you, can you explain even more about this? About how could could we change this in our 

Felicia: region?

I can try at least. So I think there are two areas that maybe we haven't looked at enough when we do look at this paper. One is the leadership of medical schools and universities. And these were actually very easy data to come by. They were publicly available. That's who were able to put them into a viewpoint.

And we were able to show that this is where we knew that the leaders of education were not gender balanced compared to the lawyers. But we also knew that ministers of health, national and subnational, are often drawn from those who are deans of medical schools. Or leaders of universities and that's those who have been ministers or leaders in a health sector and political scene will often go back to a position as a leader in an educational institution.

So being able to insist with our educational institutions, some which have a very long history, like the national thing when I'm in Mexico, the national university in Mexico. And yet. Have never appointed a woman as dean or president of the university. So I think this is an area where we can drive and insist on change.

And it's also where we can depend on our students, right? Students today, and I say this from the University of Miami sitting here at the University of Miami, they do have a voice. They may not be undertaking the election, but they're also and more and more also like sitting within the groups, at least having a seat at the table saying, what do we want from our leaders?

What kind of a fairness selection do we want to be able to have when we think about new deans and leaders of universities? And so there's a voice for our students to insist on more gender transformative policies and leadership in the education sector. As well. Now, the other is, and this I've been, I'd wanted to do this analysis for a long time and so that's, I'm so grateful that Lance Regional Health America has let me do this, you know, years of living in Mexico and going to visit the National Academy of Medicine.

Before I was elected as, as a member, which is relatively recent, I would go, you know, as a visitor when there was a presentation or when there was a particular event and including when my husband was secretary. And I would go into this amazing room. I mean, it's a beautiful room within one of the areas of the.

Mexican social security is huge real and there's this enormous wall, right? And the profiles, the portraits of the presidents, like go back to the 1800s, right? I was looking along this wall and I mean, there were men members of my family members of people I respected, my own physicians were up there and not a single face of a woman like rose and rose and rose.

And not one woman's face now recently, just a few years ago, they did elect a vice president and then a president, the first woman in the history of the National Academy of Medicine. But I was just so struck when I got there and saw that wall. And I thought, you know, how is this possible? It was just such a gendered environment.

And, you know, gradually there were more women coming in as, you know, academics into the National Academy of Medicine being, being elected in but not in the leadership. And this turned out to be true across Latin America. And again, these were data, like, these were not hard to get. They're publicly available.

And it's just shocking that we have institutions that go back sometimes hundreds of years and have never had. A leader who is a woman and we're, you know, somewhere between five and 15 percent now are women and white. Why do we care about that? You know, you could say this is really a somewhat an outdated institution perhaps, but it's not, it's, it is also where.

Groups come together to socialize, to talk to each other, to identify opportunities, to be able to say, you know, there is a deanship open in this university, we are looking for a director of a hospital in state X, right? That's where people come together and talk. That's that social network that really is important.

For being able to push careers forward and women just weren't there. And we need to open that up without question. So I think there are some spaces within the health sector aren't usually thought about. It's not just how many ministers of health do we have? It's how many deans, it's how many presidents of universities, it's how many academicians in our national academies of medicine.

And I would also say we need to think at the subnational level, particularly in our region and particularly in our largest countries, right in Brazil and in Mexico, where some of the states. Are the size of countries in our region and in our world, frankly, and so there is a concentration of need and a concentration of power that's important and subnational left for what we also need to look.

It's not just who is the national minister of health or who is the president of the National University. It's state by state to evoke change, and I truly believe particularly post the pandemic. That we need to think in our region about subnational leadership and change as well as national and more and more as things evolved politically in our region.

I think that subnational can be a beacon of change, a catalyst to consider open a space break through a glass ceiling when we need it in gender and in many other issues. 

Taissa: If we think about there is a huge gap on the physicians that we, we know that your work showed us don't have problem in forming physicians or forming nurses.

Our gap is exactly putting your foot at the door of the university and getting to a leadership hall. This is like, this is where our. Problem is, but then if we go back to teaching and how many teachers that were lead of the departments that you had, there were a woman. So even that, if you look at, and it's like a first step in your career, you were the, you know, department had already there just see that they are overwhelming man.

We do need to change the university level, and then we can change dean level, and then we can move up, and I just, I'm just curious to see, do you have any concrete things that you would say, say, so tomorrow, if I could change this University of Miami, this would be a policy that I think would make a change.

It is a 

Felicia: bit of a vicious circle actually, right? That if you because I think we are seeing change in our region at the level of department heads and even more balance in under and underemployment that women are doing better over time from the data that we're beginning to see. But the vicious circle is that if you don't have.

Also gender balance in the higher levels of leadership and stewardship, then what women need to do to get there is even more difficult. Like we know things like women end up taking on more administrative tasks and women end up working many, many more hours that than men, when you think about unpaid work and paid work.

And one thing that, one thing I say to my students now I don't know if this can change tomorrow, but it can change with how. Our students look and, and, and demand change, right? So you know, when I was a student and thinking about going into the labor market, I was like, you're, you can be super woman and you can do it all.

You can work longer hours. You can have everything you want in your life. It's not a limiting factor. You don't have to give up your career in order to be able to have a family. You can do it all. Well, yes, we can. As long as we don't want to sleep. Right. So as long as we don't care about our own health, of course we can do it all.

Right. So I think we let societies off very easy and saying we can be super women, we can really do it all that maybe that was step one, you know, step now is for our students and early career professionals to say, Yes, we can do it all. And we want to share in the joy of caregiving and the responsibility of caregiving as well as in the labor market.

And I, I think that our, our students and our early career researchers and professionals can actually insist and demand that that that's sort of one. Other things that we can do in Lancet is already doing, which is really amazing, which is that we have to not accept in our conferences in our selection boards or in anywhere else that we're making decisions or presenting ideas that we have one single face, right, that looks very male.

We have to change that. Now, we haven't mentioned it, but I think it is really important to do so. That it isn't only about women and men, there's an intersectionality issue right there are different faces of women and different faces of men, as well as other genders, but mostly what I'm speaking about is being able to have diversity of representation.

Of those that we represent those who are in need of the care that we can give or that can be given. Right. And so we need to think about that intersectionality as we're thinking about about gender in terms of change. And that is something that I think has been a very, it's been a very painful set of discussions and realizations in the United States, but it is beginning to come forward.

I'd ask you to also comment on whether or not we're there in Latin America. I'm not so sure we are. I think we, you know, too often accept that most of the faces we see on the podium in the National Academies of Medicine or presentations are pretty light and pretty male. And that we need to think about how to change that as well more than we have been doing in the past.

But to, you know, sort of go back to your question, what would I, like, immediately do is, and try to, in our global health process, incentivize our students To demand better demand more. And for our, all of our students to think that they can demand the right to caregive as well, to be part of their families, or as I said, their communities, they may, it may not be their own family members, but caregiving and being part of creating a society that's healthier isn't only about having a child and caring for one's own child.

There are many other aspects and, and how do you build in. The possibility of all people being able to to have that opportunity and give that gift, I think is really important in making our societies much healthier places to live in and to be in. I mean, important to 

Taissa: address as well. I was thinking here and following up a bit on Taishi's question and cultural aspect that we mentioned before, and I think it's.

Really important to address because culture is part of the society and we, we know that machismo is present, very present in Latin America. And it's a structural, it's a structural problem. We know that there is structural racism, there is structural race and machismo as well. So should we start the universities at, as, The person who worked with education before, I think it's something that should start early age and try to develop changes in that even in a society level and as people who are healthcare givers and work with health can we.

Try to change a bit on those aspects of the society. Can we, can we do that in a cultural level as well? Change a bit. The last question. 

Felicia: Well, and also I, I'm going to let both of you also comment on this as women who lives and work in, in, in Brazil. Right now I, you know, I straddled Mexico and Miami.

But so I also I would love to hear your opinion on this, but I, I thought we might bring up one point that I think is, is, is absolutely fundamental, which is violence against women and violence against children. And as you might know, we are blessed to have a Lancet commission on gender based violence and maltreatment of children that I am honored to, to co chair with Dr.

Flavia Mastro. Why do I bring this now? You know, I can say. We have to think about changing textbooks and educating in a different way from primary school on, even from preschool on. But the other thing I really want to say is that while we are talking about at least one in three women who have suffered serious physical, sexual, Or verbal abuse while we're talking about at least one in five Children and in poor areas, much more than that, that have also suffered severe forms of abuse.

There is almost no way that we can speak about change, unless we look at that. I think it's a driving force. It's a determinant because there's the intergenerational transfer of violence. A young boy sees it, learns it, and very sadly, too often applies it. There's some amazing research about how to change that process and Gary Barker, who was featured in the Lancet Region very, very recently has done really amazing research on this in Latin America, particularly in Brazil, on, on how you change and break that intergenerational transfer of violence.

But let's just talk about the children and the women who have lived through this. All of the evidence shows that no matter how you try to power through it, no matter how much support we can offer in terms of treatment, it affects your ability to study, your ability to work, your ability to live. And so you never are able to achieve your full potential when you've gone through something like that.

Because at the very least, you have to invest an immense amount of your time in, in work to alleviate that kind of trauma, right? At the very least, and, and that's the very, very, like, that's the best scenario that we can speak about. If you survive. Exactly. And if you get help. And we're talking about intense amounts of support, psychological, psychiatric, physical, and others to be able to reenter the labor market, to be able to complete school, to be able to undertake testing, to be able to be in an environment with aggressors and abusers, often almost impossible not impossible, almost.

We can change this. There is. So no other risk factor other than air pollution, I would say, that affects as many people in our world as violence against women and children, and it is rife in Latin America. When I did my doctoral research with street children in Bogota, I was Shocked is the understatement to, to just hear the standard practices to, to teach children how to behave in certain ways, boys and girls.

And we dealt with the tip of the iceberg, what happened as a result, which was what do we do to support street children, right? But what did we do to change the situation in their homes? And this is where I think so much can be done with. Communication and particularly what we can communicate today, we can communicate the message that this is not a way to educate Children, that this is not a way to teach or train.

And this is completely unacceptable behavior in our societies. And I think the more we can share that message, the more we can change a culture of something that we've called machismo. Almost in its least awful form, but that has affected the lives of women and children in our region in unthinkable ways.

And I, we're, we're trying to do research on this now for the commission, but I think that we can explain a significant amount of the gender wage gap, at least the pre market gender wage gap. Because of violence 

Taissa: against 

Felicia: women. 

Taissa: I tend to think that because we normalize machismo as part of a Latin society, we call Latinos are machismo is intrinsic to a Latin society.

It sometimes feels to me that we started to accept violence against women as a definition of machismo and the definition of society, so maybe just by. Just by normalizing this word and giving it, like, a sense that it's not so bad is already terrible, and it's something that we should start, like, start from there, like, let's not use this word anymore, because it's making something unbearable, like, like it is okay.

Felicia: See, it's interesting. When I am all my time in Mexico, I was struck that and my, my girls use this word all the time that something that's really neat, Padre, right? The father, like Padresimo is something that's really cool, really neat. It's, you know, father like, Padresimo, it's the male. And the word madre can be used either very positive or extremely negatively.

But from the time that kids are little over Mexico, they say things are fathers, things are padrísimo. And I always say, no, madres. It, it, it really is part of our language, right? And, and what becomes entrenched through language as being good, bad, or acceptable. So I. I, I completely agree with you.

And if we go back to medicine and the medical profession we, we do have evidence that there's harassment and discrimination and abusive language and inappropriate behavior, you know, all through the medical profession. We also know that things like when we send particularly our young female students out to do their social service, they're often at tremendous risk.

There is no protection for them physically or otherwise where they are. We will not achieve real change if we can't make safe environments for women to be 

Taissa: able to work. That's really important to address because. Like you said, we are both from Brazil and we see the differences in treatment among men and women with subject gaslighting and other issues that happen all the time, not only in the medical community, but in research and in education as well.

And for example, a difference that we can see is. the amount of time on paternal leave. So a father can have five days of paternal leave and a woman four months. And we know that according to hope that they, they should breastfeed up until like six months, at least for six months, at least, at least not until at least.

So this, this starts. Early in the beginning and we see girls that are ashamed of menstruating and other problems as well that surround this whole issue of having these gender inequalities in 

Felicia: the region. So long as women have access to leave to care for children and men don't, women are going to be underpaid compared to men.

And, and I've had people say to me, you know, that I know that woman X will take time off and man Y will not. And therefore we are going to hire man Y especially if it costs us the same to do so. What will equalize that and, and allow us to have a balance between, I said that the joy of caregiving and the opportunity to work is having that be a gender neutral policy.

In terms of access, breastfeeding isn't gender neutral, but we can facilitate it in different ways. And, and we can include access along a period of time that where we, we link access for women to access for men. I think that's the only way that we're really going to evoke change, but that has also to do with valuing caregiving.

Like so long as we don't value that, it's, it's going to be hard to ensure that employers are forced to give to all those opportunities to be able to, to undertake to undertake caregiving. And, you know, I mean, I, I agree with I agree with all that you're saying, and this is why I think we can, for medicine, do something very special.

Taissa: Well, Felicia, thank you tremendously. It was really, really nice talk. And Yeah. Thank you for unpacking your amazing amount of work and connecting all the dots for us. It was really good. Thank you. And the same, I'm, I 

Felicia: am so again, I'm just, I'm so pleased that we have now a Lancet for our region, the Americas, and that we can have this outlet for being able to publish and change to the Lancet for the Americas and particularly for, for Latin America and the Caribbean.

Really grateful that, that both of you are leading this journal that that says an awesome lot about what we can do to evoke change. So thank you for all you're doing and for being partners with those of us who do research in the region. I know, and I hear it from my, my colleagues and my students, but we're so excited to have this opportunity.

Gavin: That's it for this episode of The Lancet Voice. If you want to carry on the conversation, you can find Jessamy and I on Twitter, on our handles at Gavin Cleaver and at Jessamy Bargainall. You can subscribe to The Lancet Voice if you're not already. wherever you usually get your podcasts. And if you're a specialist in a particular field, why not check out our In Conversation With series of podcasts, tied to each of the Lancet specialty journals, where we look in depth at one new article per month.

Thanks so much for listening, and we'll see you again 

next time.