Women Breaking Barriers in Public Health and Epidemiology

Dr. Mellissa Withers is a professor and public health researcher in the Department of Preventative Medicine at the University of Southern California (USC), where her day job includes teaching courses in global health and health research methodologies to undergraduates and graduate students at USC’s Keck School of Medicine. She also serves as Director of the Global Health Program for the Association of Pacific Rim Universities (APRU). APRU’s Global Health Program is headquartered at the USC Institute on Inequalities in Global Health, but the organization holds its annual Global Health Conference at universities throughout the Pacific Rim. China’s Zhejiang University, National Taiwan University in Taipei, Japan’s Osaka University, and the University of New South Wales in Sydney, Australia have each hosted in recent years.

Thus, while much of Withers’ work keeps her in Los Angeles, her perspective on public health issues and her actions in that arena transcend borders. For example, several years ago she found herself in the East Asian country of Mongolia, where she’d been invited to give a talk on maternal health at the National Center for Maternal and Child Health in the country’s capital of Ulaanbaatar. “While I was there,” she recounts, “I met with various people and I was in the office of the Assistant Director of the center talking about the challenges that Mongolia was facing in terms of maternal and child health and women’s health in general. I just happened to mention post-partum depression. I wanted to know how they were addressing that problem in Mongolia, and if they had programs or policies or any data on the prevalence of post-partum depression.”

Withers was surprised by the response. “I was told that post-partum depression was not really a problem in Mongolia. I thought to myself, that’s fantastic; maybe there’s something we can learn from this.”

After a bit more probing, it became apparent that medical professionals and health officials in Mongolia had not been screening for post-partum depression or collecting relevant data on how women in Mongolia fared in the weeks and months after giving birth. “Of course they didn’t think it was a problem because, how can you know that something is or isn’t a problem if you haven’t done any formal research on it?,” Withers reflects.

As a direct result of that interaction and with Withers’ assistance, the Center embarked on a program to study post-partum depression among Mongolian women. “I worked with them on that for about a year,” she says. “We screened women post-partum and, as it turns out, they had about an 18 percent incidence of depression.”

How does that align with what is typically found elsewhere in the world? “Between 10 and 20 percent is what you’d expect to find,” Withers notes.

As Withers’ experience in Mongolia illustrates, it is difficult to provide effective medical treatments much less implement successful preventative healthcare measures in the absence of reliable information regarding the nature, severity, and scope of a problem and its potential causal factors. Gathering information of this type on population-wide level is the essence of public health, a broad and diverse field that encompasses epidemiological research, biostatistical analysis, social and behavioral science research, health education and prevention initiatives, community organizing and advocacy, and, when necessary, medical interventions. Indeed, as we have seen in the wake of the SARS-CoV-2 virus and the Covid-19 pandemic, emergency medical interventions and critical care measures are, in a sense, the result of breakdowns in public health policy and failures to implement preventative measures.

Population-wide health research and the preventative health policies that result have their roots in the medical profession and in collective efforts to prevent various infectious diseases and illnesses through education, sanitization, immunization, and other mitigation strategies. Historically, these efforts were overseen by physicians, biologists, and medical researchers, three professions that were male dominated up through most of the last century. So, as largely successful efforts to eradicate diseases like measles, mumps, polio, and smallpox were gaining ground, and evidence-based preventative health education and awareness campaigns were taking hold in the second half of the 20th century, women were largely if not entirely relegated to supporting roles. However, by the start of the 21st century, that had changed significantly, and women were beginning to overtake men in many areas of medicine, healthcare, and public health.

In 2019, the Association of American Medical Colleges (AAMC) issued a report that found that for the first time in history the number of women enrolled in US medical schools had surpassed the number of men. That same year, a World Health Organization (WHO) report on Gender Equity in the Health Workforce found that women comprised roughly 46% of practicing physicians in the Region of the Americas and that 70% of healthcare workers worldwide were women. While data specific to public health professions is not readily accessible, a 2017 article in the scholarly journal Epidemiology noted “a higher prevalence of female than male doctoral students and epidemiology faculty, particularly at lower faculty ranks” and concluded that women were had come to play an increasingly significant role in the fields of epidemiology and public health over the past 25 years. Specifically, while women had constituted only “35% of American Public Health Association members by 1984,” they constituted “46% of members of the Society for Epidemiologic Research by 1996,” and the representation of women accounted for “66% of attendees of the Congress of Epidemiology in 2006.”

To put the current state of affairs in perspective, as recently as 1970, fewer than ten percent of practicing physicians in this country were female. Dr. Mary Guinan illustrates the impact this had in the field of public health in her 2016 memoir Adventures of a Female Medical Detective. When Guinan, a graduate of the Johns Hopkins University of School of Medicine, was accepted into the Centers for Disease Control and Prevention’s elite Epidemic Intelligence Service in 1974, she was the only female physician among the 39 students in her class. When she subsequently attempted to join the WHO’s smallpox eradication efforts in India, she was told that the WHO “wasn’t taking women.”

An epidemiologist by training, Guinan went on have a distinguished 20-year career at the Centers for Disease Control and Prevention (CDC), where she was part of the team tasked with initial investigation into HIV/AIDS epidemic (Glenne Headley played Guinan in the 1993 HBO docudrama And the Band Played On). In 1990 she became the first woman to hold the post of Associate Director for Science at the CDC and she is the founding dean of the School of Public Health at the University of Nevada Las Vegas (UNLV).

Guinan’s career in many ways paralleled the rise of women in public health professions and she is one of many women who populate the ranks of the profession and who are attaining leadership roles in the field. But, as in many professional fields, there is still much progress to be made in the realm of gender equity. The same 2017 Epidemiology journal that found a greater number of women than men among epidemiology doctoral students and faculty concluded that “leadership positions in medical schools, hospitals, academic journals, and health care companies are still disproportionately male.” Similarly, the WHO’s Equity in the Health Workforce report from 2017 noted that, “Overall, an average gender pay gap of around 28% exists in the health workforce. Once occupation and working hours are accounted for, the gender pay gap is 11%.”

The numbers cited above are an accurate reflection of what the women interviewed for this story have to varying degrees, seen firsthand as they’ve risen through the ranks in their professions. However, as USC Professor Dr. Mellissa Withers explains, the representation of women in public health fields can vary greatly by level and by specialization. “A lot of the students in academic programs are women,” explains Withers. “For example, in my PhD cohort at UCLA there were ten of us and only one was male. But the focus of the program was community health sciences. You tend to see women over-represented in community-oriented public health programs, whereas in biostatistics, epidemiology, and environmental health, it’s more evenly balanced in terms of men and women.”

Dr. Marie Stoner, a researcher with RTI International’s Women’s Global Health Imperative who has a PhD in epidemiology, concurs with Withers. “Public health programs in general are predominantly women,” she estimates. “In some areas of public health it may be as much as 90% women from what I have seen. And yet, a lot of the leaders are men and in the research methods classes you see that many of the most prominent role models are male. So, there is a definitely a gendered aspect in terms of representations in different specializations. Epidemiology has more men than some of the other fields and I think that has to do with the quantitative and statistical components of epidemiology.”

“In epidemiology,” Stoner adds, “one of the things that you notice is that a lot of the people who are regarded as really great researchers and methods leaders are men. In fact, leaders in methods are almost all men.”

Dr. Michelle Williams, the current chair of the American Public Health Association’s Women’s Caucus, teaches at George Mason University (GMU), where she is an Assistant Professor in the Department of Global and Community Health. She too notes that women are well represented in public health classes but not necessarily in leadership positions. “From what I see as a professor in the classroom,” she says, “the majority of the students are women. But, when you look at leadership positions, the department chairs are predominantly male. The faculty at many schools are predominantly female and yet the deans are mostly men. Even when I was working at the health department in Tallahassee it was very much the same way. The majority of the people who were the lower-tier employees were women, while men occupied the higher positions. Unfortunately, I think it’s like that in many fields, so I don’t think public health is unique in that way.”

Dr. Sarah Gareau, a Senior Research Associate at the University of South Carolina’s Institute for Families in Society (IFS), has also noticed these gender disparities and suggests that inherent bias is almost certainly at play. “There are, even in public health, masculine and feminine stereotypes that you start to notice,” she explains. “You do see a lot of women going into more community-based work, just as I did early in my career. In fact, we know that there are more women than men out there on the ground doing community work in public health, nursing, and social work. We also know that there are a lot of women who are studying public health in school. But, in many cases, the dean of the school of public health, the executive director of a public health agency, and the legislators who have to sign off on public health initiatives are men.”

Dr. Gareau goes on to note that this dynamic has even surfaced in the midst of the Covid-19 pandemic. “We see that at the national level,” she says. “I have immense respect for [National Institute of Allergy and Infectious Diseases director] Dr. [Anthony] Fauci and the importance of immunology and epidemiology. At the same time, there are mutual aid efforts all over the US where individuals are doing community-based work to help others through the pandemic who may be struggling to pay rent or buy food. That’s not what you primarily hear about on the news. The news is all about vaccines and immunology and these other more masculine areas of public health. Public Health Awakened, which is a women-led national network of public health professionals who are currently pushing for equity and justice in how we address the pandemic, is not what you’re hearing about on the news right now.”

Dr. Marie Stoner, an epidemiologist whose work is in the area of global women’s health, likes to emphasize that there are many different types of work that fall under the large umbrella of public health. As she explains, “There are people in the field who do health policy and think about larger level initiatives and programs that federal and state governments are putting into place. There are people in the field who do health economics and analyze the costs of different types of interventions. There are epidemiologists who focus on the quantitative analysis side of understanding disease within populations. And there are also specializations like maternal and child health. So there are a lot of options in public health. You can work in academia, at pharma companies that are testing drugs, at nonprofit organizations. Understanding that can be important.”

Indeed, the women interviewed for this story illustrate this diversity and represent several salient public health specializations, as detailed below.

The first school of public health in the US – The Johns Hopkins University School of Hygiene and Public Health – began matriculating students in the midst of the influenza epidemic of 1918 and by 1936 there were ten schools offering degrees and certificates in public health. But it wasn’t until the second half of the 20th century that the number of schools offering Master of Public Health (MPH) degree programs experienced significant growth, a trend that continued into the first two decades of this century.

In 2003, according to a National Institutes of Health (NIH) report, there were 32 accredited schools of public health in the US; as of 2021, the Council on Education for Public Health (CEPH) listed 64 American schools of public health with formal accreditation. This development, in and of itself, has created more opportunities for women to advance in the field, as awareness about careers in public health has grown and the range and number of jobs in the field has continued to increase.

Dr. Subasri Narasimhan is a newly appointed Research Assistant Professor in the Department of Global Health at Emory University Hubert Department. She completed a postdoctoral research fellowship at the Center for Reproductive Health Research in the Southeast (RISE) after earning her PhD in Community Health Sciences at the Fielding School of Public Health at the University of California, Los Angeles (UCLA). However, it wasn’t until midway through her undergraduate program at the University of North Carolina at Chapel Hill (UNC-Chapel Hill) that she remembers becoming aware that public health was a career option.

“When I was a junior in college,” Narasimhan recounts, “I interned under a child development specialist who taught me about qualitative research and interviewing people for research purposes. I worked on a Fragile X syndrome project as part of that internship. That was the first time I had any contact with the concept of public health and the idea that you could talk to people – in this case with parents – in order to develop a better understanding of what support and coping skills they might need when they have a child who is newly diagnosed with a disability.”

“At that time,” she continues, “I don’t think I really understood what public health was, even though I went to a university that has a very good graduate public health school. But I think that was still early on in terms of when people were starting to think of public health as a career apart from medicine.”

After completing her bachelor’s program at UNC-Chapel Hill, Narasimhan would go on to earn her MPH at UNC’s Gillings School of Global Public Health.

Narasimhan’s experiences are not unique. Dr. Sarah Gareau also discovered public health while in her bachelor’s degree program through an internship opportunity. “As an undergrad, I volunteered with a program that served children infected and affected by HIV/AIDS,” she explains. “So, early on I had an interest in and a passion for political advocacy in the realm of public health. I’m just not sure I realized at the time that it was a thing that you could go to school for and turn into a career.”

It was primarily by chance that Gareau, an undergraduate student at Ursuline College in Ohio, learned that she could channel her passion for health advocacy into a career in public health. “Even as an academically strong student at the undergraduate level, I was never even told that something like epidemiology existed or that you could get a master’s degree in public health,” she says. “It was only because Kent State was nearby that I became aware of public health. At Kent, they had a doctorate program in health education, only it wasn’t offered through a school of public health, it was offered through a college of education. I realized on my own that health education was what I was leaning towards, but that if you were interested in community health education rather than being a health education teacher, continuing education in a public health program made more sense. So, it was easy for me to see that if you happened to go to a flagship university where, as an undergraduate, you were told about all these things, you started out with a big advantage.”

After earning a doctoral degree in public health (DrPH), Gareau would go on to serve as a founding director of the MPH program at North Carolina’s Lenoir-Rhyne University, a program that is among the more than 100 MPH programs currently accredited by the CEPH.

Dr. Marie Stoner, who earned her doctorate in epidemiology, was leaning toward a career in medicine as an undergraduate at The College of William and Mary when she was drawn to neuroscience and then epidemiology. “I was essentially a pre-med student,” she says. “But I gravitated to neuroscience because I was particularly interested in the psychological aspects of health. As I learned more and more about public health and was exposed to the concepts and the thinking behind public health, its appeal grew for me because it felt like an interesting blend of medicine and the psychology of how people make decisions about health. I also like the more quantitative scientific part of it as well, which is probably why I chose epidemiology.”

Dr. Stoner has taken note of the fact that, in addition to an increased number of schools offering graduate programs in public health, there are more opportunities for students to be introduced to the field as undergraduates. “It seems like there are more undergraduate programs that are offering intro courses in public health,” she points out. “Between that and the increased public interest in public health, we’re at a good place for people in the field to reach out to college and even high school students, just to explain more about the field and the options in public health.”

The early academic and career experiences of Dr. Megan L. Smith, an Assistant Professor who teaches in the Department of Community and Environmental Health at Boise State University, are particularly instructive in terms of the crucial role awareness can have in a young woman’s career decisions. “As a young person and particularly as a young woman, I didn’t really know what careers were available to me,” she recalls. “Given my experiences and where my family was situated, I was aware that women could be nurses and women could be teachers. I decided I wanted to be a teacher.”

Dr. Smith did indeed become a K-12 teacher. She enjoyed it. Her favorite grade was seventh. “At that age the kids are starting to be able think deeply and critically and question their world and they are still hungry for knowledge,” she explains. But it was her area of focus that is particularly surprising given that she would eventually find her way to a career in public health.

“I initially became and English and drama teacher,” she says. “But I had an opportunity early on to either teach high school English or middle school math and science. So, here I was in a newer teaching position in a small mountain town and they’re offering me the opportunity to teach at the middle school level, but the subject area was math and sciences. I thought to myself, ‘I could probably do that.’ So, I added a math and science credential, and I went to work teaching life sciences and pre-algebra at the middle school.”

As a math and science teacher, Dr. Smith saw early signs of gender disparities. “Many of the young women in my classes had already begun to internalize the idea that they were not well suited to become mathematicians or scientists. So, I was seeing a drop off for women who just didn’t seem to identify with being good at math or science.”

Dr. Smith was also confronted with challenges that her training in education hadn’t fully prepared her for. “I had been super well prepared to create excellent lessons,” she points out. “What I was less prepared for were all the additional needs my students brought with them to class every day. In my first year of teaching, I had a student go missing for two days and I saw students who had issues with incarceration and other things that are so challenging for young people. So I had students bringing these things to my classroom and there I was trying to teach math… I wanted to study adolescents and how we could better prepare them and help them deal with the problems and challenges I had seen.”

To achieve that goal, Dr. Smith got her PhD in Human Development and Family Studies, a field that is adjacent to public health. Her doctoral dissertation examined the social and behavioral health aspects of substance abuse and sexual risk behavior in high school students, and a West Virginia University School of Public Health faculty member was on her dissertation committee. “By the end of my PhD program,” she explains, “I had realized that the work I was doing and the work I wanted to do was in the area of public health.”

“I don’t think things are naturally going to change in public health or any other field in terms of gender disparities,” explains Dr. Michelle Williams, who in her role as chair of the Women’s Caucus of the American Public Health Association has prioritized public health issues that “impact women but that aren’t necessarily headline news and that aren’t yet part of the mainstream discussion about women’s health.” She goes on to stress that change is “going to have to result from individual women acting very deliberately and understanding their career goals and what it is going to take to get there. If you do want to be the dean of a college or the president of a university or the head of a CDC office, you have to plan it out and be deliberate about how you navigate your career. That’s how things will change.”

Change, as the adage goes, happens slowly and then all at once. That may be an apt description of the situation public health finds itself in, especially given the boost in profile the Covid-19 pandemic has given to the field and the number of women who are already active in public health education and policy. “We want women to see themselves in all facets of public health,” stresses Dr. Megan L. Smith. “I came to Boise State to teach public health in the Community and Environmental Health Department. And, despite the fact that there are lots of women who come through our graduate program, we had all male teachers in the research and statistics courses. So, there are lots of women coming into the program, but the people they would see teaching research and statistics were men. I have a fabulous graduate director who saw this and who knew that I had taught statistics in the past. So he moved me into that first research core, and I am now teaching statistics to our graduate students.”

“That,” she continues, “was an intentional move. We want women to see themselves in all facets of public health. In fact, we have a woman here who is an epidemiologist as well, so we are trying to be conscientious about decisions regarding who the students see teaching particular subjects. We don’t want to create those artificial silos that tend to discourage women from engaging in areas of public health that have traditionally been dominated by men.”

Encouraging young women to take courses and train in epidemiology and other more technical/quantitative areas of public health is something that Dr. Sarah Gareau would like to see more of, especially when the Institute for Family Studies she is affiliated with is looking for new hires. “What we desperately need in the field and what we are constantly struggling to find at IFS are employees who are passionate about the core values of public health and who also have these hard-to-fill marketable skills. I can find a GIS specialist, I can find a database manager, and I can find a computer programmer who can provide the analysis that we need. But it’s hard to find people with these skills who are also passionate about public health, who are prepared to ask the kind of questions that are critical in public health, who have that instinct to question when something doesn’t look right.”

“On the other hand,” she emphasizes, “the people who do get it and who know the kinds of questions to ask and the ways that data can be used to inform policies that improve people’s lives need to be able to do the IT work as well. Those are the people who are hard to find.”

As director for the Global Health Program of the Association of Pacific Rim Universities (APRU), Dr. Mellissa Withers has noticed the subtle and not-so-subtle ways women can be marginalized in public health. “I’m in charge of organizing an annual international conference on global health,” she says. “Each year I work with the conference’s host university, which rotates among the participating countries. When I get the list of proposed panelists and speakers it is always predominantly men. I try to aim for a more gender-balanced panel and to make sure we have adequate representation of women as speakers, but we’re not there yet.”

Dr. Withers also points to the importance of female mentors and role models in public health. “There is,” she says, “a lack of female role models in leadership, which can cut down on your opportunities to be mentored by a woman in a leadership position. That can lead to imposter syndrome, where you just don’t feel that you’re good enough professionally as a woman. I remember reading an article several years ago about how if someone is looking at a job posting and there are 20 criteria that candidates are expected to meet, men will apply for the job even if they don’t meet a couple of the criteria, whereas women who lack just one qualification will not apply. I think that the lack of self-confidence that characterizes imposter syndrome is a real thing.”

The need for female role models is echoed by Dr. Subasri Narasimhan, who also stresses the importance of cultivating diversity among women in leadership roles in public health. “I felt that I had great mentors who were women of color,” she recounts. “That helped me to see that this is possible for me, that I can come up through the ranks in this field. But that’s not a common experience. One common scenario is that once a woman of color becomes a faculty member at a school of public health and once a woman of color attains a leadership position, that person gets a lot of mentorship requests. That’s great to see, but it also indicates that there remains a huge demand for that kind of mentorship from new, entry-level professionals that was not previously being met, at least not by mentors who come from diverse backgrounds.”

The Women’s Caucus of the APHA is one locus that can provide guidance, support, and potentially even mentoring for women in the field of public health. Dr. Sarah Gareau, former chair of the Women’s Caucus and a current member of the APHA Executive Board, admits that she is biased, but points to the APHA’s Student Assembly as a good place to start. “You can join the Student Assembly either for free if your institution is an agency member or for a low cost otherwise. The Student Assembly can provide all kinds of opportunities for networking, which can be a good head start on advancing your career in public health. Also, the APHA is such a broad organization that it can serve as a resource for helping you decide on an area of public health you might like to land on.”

In addition, Dr. Gareau suggests making contact with the public health agency or department one’s state of residence. “Each state has a public health association,” she explains. “We have the South Carolina Public Health Association here, and that’s how I eventually made the leap to leadership within APHA. In fact, it’s probably why I am on the board today. My mentor told me that I should think about going to the state public health association meeting and I very quickly became involved in developing programming for the statewide conference, and that led to similar involvement with the APHA. So that would be the other suggestion because those state meetings are friendly and welcoming even for undergraduates. From there, you can get connected to the national work.”

Finally, Dr. Gareau recommends that students in public health programs try stepping outside of what may be their comfort zones and take one or two courses in some of the more technical, data-heavy areas of public health. “I realize that I am stereotyping,” she concedes, “but women in public health are often interested in doing qualitative, advocacy, and non-profit community work. Because of that, a number of things happen. For one, we don’t see as many women going into areas of public health that are seen as being more masculine – areas such as big health data analytics. Secondly, if you’re used to doing community work and dealing with limited resources, you may not be the best advocate for yourself.”

“It’s complicated,” she concludes. “I know that if someone had told me as an undergraduate to take computer science courses, I would have just looked at them and said, ‘What are you talking about?’ But my advice is to do it even if it’s not your favorite thing because the skills you learn will be helpful down the road. It doesn’t mean that you’re going to be stuck in IT for the rest of your life, but you are going to be able to speak the language that can take you further in the public health field.”