The pandemic is deepening existing inequalities, including gender inequality, say Roopa Dhatt, Samira Ouedraogo, Sarah Hillware, and Ann Keeling, but the US can help build a more equal world

Dear Joe Biden and Kamala Harris 

You will be taking charge of the US administration at a critical time for both the US and the world. The global covid-19 pandemic has infected more than 50 million people and 12 million Americans, caused the deaths of more than one million people, and is far from over. As we grieve lost family and friends, frontline health and other key workers battle stress and exhaustion, and the livelihoods of millions have been destroyed; this is the right time for America to rejoin the global community in health and lead the way.  

The pandemic is deepening existing inequalities, including gender inequality, and that makes us all more vulnerable. We propose seven areas for action where the US can lead and offer support in building a stronger and more equal world:

First, make good on your promise to reverse moves to withdraw America from the World Health Organization (WHO). In this pandemic and beyond, the world needs a strong coordinating body with a clear mandate in global health security. US citizens cannot be safe from covid-19 until it is eradicated everywhere. Countries with vulnerable health systems and resource constraints will be unable to vaccinate their citizens unless the vaccine is free of cost or heavily subsidised. We ask you to lead the way in managing the pandemic in the US and also, through active membership of WHO and other multilateral bodies, to ensure that any vaccines, treatments, and diagnostics reach even the most marginalized women and girls. 

Second, the pandemic has shown that we all rely for our health and lives on health and social care workers, the majority of whom are women. Health and social care workers have been applauded for their service and sacrifice and have put themselves in harm’s way, many working without adequate personal protective equipment. Moreover, in many countries frontline female health workers are underpaid or even unpaid. Women in the health and social workforce now need a new social contract, which ensures that they are paid fairly and have decent work conditions. This is everybody’s problem since there is a looming global shortage of 40 million health and social care workers.

We at Women in Global Health, a global movement of 24 chapters with 35 000 supporters from more than 90 countries, ask America to lead the way and promote a new social contract for women in health and social care in the US and to support low and middle income countries to do the same. With gender equity in the health workforce, women will deliver a strong foundation for health systems and, therefore, for everyone’s health. 

Third, although women make up 70% of the health and social care workforce and 90% of nurses and midwives, women hold only 25% of senior leadership posts. The same pattern has been repeated in decision making for covid-19, with 85% of 115 national covid-19 taskforces having a majority of men as members. Although women are experts in the health systems they deliver, their knowledge, expertise, and talent are marginalized in health leadership, with serious consequences for women and for health systems. 

Some decisions made in response to covid-19 have cost the lives of women. One projection estimates that a 10% decline in maternal and reproductive health services in low and middle income countries during the pandemic could lead to an additional 1.7 million women experiencing major obstetric complications while not receiving the care they need, resulting in 28 000 additional maternal deaths and 168 000 additional newborn deaths. We ask America to lead the way in ensuring that women have an equal say in decision making in the US and global covid-19 taskforces, along with any bodies planning post-pandemic reconstruction. 

Fourth, the lives of women and adolescent girls are also lost when sexual and reproductive health and rights are curtailed. The current administration reimposed “the Global Gag Rule,” which bans foreign NGOs receiving US government funding from using money from any source to provide abortion services, counselling, or referrals, or to advocate for liberalisation of their country’s abortion laws. The current administration went even further in applying these restrictions to nearly all US federal global health assistance, affecting around US$9 bn US foreign assistance. In practice, the lack of access to contraception and safe abortion increases the number of unwanted pregnancies, unsafe abortions, and, therefore, deaths among women and adolescent girls. 

We ask America to lead the way in ensuring sexual and reproductive health and rights are realised, especially for women and adolescent girls, in the US and globally. We ask you to end the Global Gag Rule permanently so it is not reintroduced by a future administration.

Fifth, restore US funding to the United Nations Population Fund (UNFPA), especially since the pandemic threatens to reverse gains for women in their maternal health and sexual and reproductive health and rights. UNFPA provides critical support to governments in this area, including in humanitarian contexts, benefitting the most vulnerable women and adolescent girls and their newborn infants. With maternal death rates in the US scandalously high (two to three times higher) among low income Black and Latina women, this is an area where America can lead the way both at home and globally. Women and adolescent girls can have no right to health without sexual and reproductive health and rights and access to safe abortion.

Sixth, above all else, the pandemic has demonstrated the case for universal health coverage (UHC) as the foundation for global health security. People in lower income groups are least likely to have health insurance, most likely to be working in frontline roles and living in crowded housing, and to have underlying health conditions. All these factors increase their risk of infection and death. In the US, data show significantly higher covid-19 death rates among Black and Latina people compared with white and Asian people. Racial and ethnic disparities have also been found in other countries. 

In 2019 the world’s governments met at the UN High Level Meeting on UHC and agreed to achieve universal health coverage by 2030. Countries were behind reaching this goal even before the pandemic and will now need leadership and support to accelerate progress. UHC has yet to be realised in America, but the US can lead the way both at home and globally to achieve universal health coverage. This will transform the health and lives of the poorest people, particularly women and girls, and increase global health security for future health emergencies.

Seventh, in the year that the Black Lives Matter movement sent the issue of racial inequality to the top of the political agenda in America and highlighted racial and ethnic inequalities across the world, we celebrate Kamala Harris as the first woman—and a woman of color—to be elected to the executive branch in the US. She will be an inspiring role model for girls and women all over the world. It will, however, take deliberate action at all levels to reverse centuries of systemic discrimination. America can lead the way in taking an intersectional lens to address systemic inequalities at home and starting a global conversation that leads to transformative change. 

We welcome America back into the global health community. Expectations are high and the need is great. We want you to lead change for women and girls in the US and beyond and to champion gender equality and equal leadership for women at all levels of health. Millions of women work in global health and they need decent work and an equal say in decision making so that they can use their talent and expertise to achieve global health security and health for all.

Roopa Dhatt, executive director, Women in Global Health. Twitter @RoopaDhatt

Competing interests: None declared.

Samira Ouedraogo, researcher , Chair of Women in Global Health Francophone West Africa, Burkina Faso. Twitter @SamyOuedraogo

Competing interests: None declared.

Sarah Hillware, deputy director, Women in Global Health, USA. Twitter @SarahHillware 

Competing interests: None declared.

Ann Keeling, senior fellow, Women in Global Health, UK. Twitter @annvkeeling

Competing interests: Dr Keeling reports personal fees from the World Health Organization outside the submitted work.