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. .-.-:-:-:-:-:-:-:-:-:-:-.-.-. . .. -:-::::-:-:-:-:-:-:-:-:-::::::::-:-.- ::--- :::-. ~ .-:-:-:-:-:-:-:-:-:-----------:-:-:-:-:-:-:-:-:-:-: . -:-:-. .-::-:-::::: ::-:: :'::-:-::-. -:-:::::::::::::::-:- :::-. :-. -:. : - .:.-:-- -: - - .. ::- -.-.- .- ' 2----:-.- -:-:--:-- ::: Looking Ahead ithin the memory of living Americans, there was a time \/ \/ when women generally spent the bulk of their years, and ~ ~ essentially their entire adult lives, bearing and nursing large numbers of children. Pregnancy happened outside of individual con- trol but had the power to shape a person's identity, consciousness, and daily life. Death struck both young and old routinely, unpredictably, ca . . . prlclously. Today, the average American woman spends only 11% of the time between her menarche and her menopause about 4 years in ac . Eve childbearing. Half have given birth to their last intended child by 30.i And the reproductive period, instead of consuming two-thirds of a life- time as it formerly did, now typically accounts for well under a half. Many women now spend more years after their menopause than their foremothers spent as adults. Few Americans now die in childbed or from infantile conta- gions. Sexually transmitted infections causing syphilis, gonorrhea, and cer- vical cancer no longer threaten certain death. No one need now sustain large numbers of closely spaced, undesired pregnancies or ransack her own body for the nutrients to feed an inexorably growing brood. American women who enjoy normal health and take reasonable care of it can now 209

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I N H E R O WN R ~ G HT look forward to options and opportunities their grandmothers or great- grandmothers could not even have imagined. Almost 60 years of active adulthood beckon today's healthy young girl. Indeed, the major ills that women face today arise in large part from the drastic reshaping of female lives that medical science has made possible within a current octogenarian's lifetime. We now live long enough to succumb to osteoporosis and Alzbeimer's. We delay childbear- ing long enough to raise our risk of breast cancer. We eat richly enough to encourage cancers and cardiovascular disease. The current "epidemics" of the later years are, in a sense, the price we pay for the longer lives that most women now have the chance to live. Despite this unprecedented progress, however, a lifetime of good health is, for far too many American women, nothing more than a "chance" that passes them by. A badly distorted health care system denies simple preventive care to countless people, but meanwhile almost indis- criminately provides vastly expensive therapies to repair predictable disas- ters. We transplant bone marrow in the terminal stages of breast cancer but bar the modestly priced mammograms that could have caught the disease early. We heroically rescue tiny infants with months of intensive care but withhold the simple prenatal care that might have assured them safe and timely delivery. We perform hundreds of thousands of abortions on young girls each year but block their access to the cheap contraceptives that would have prevented their pregnancies in the first place. The research community, furthermore, fails to give adequate attention to issues vitally affecting female health. What can be done to lessen the painful and damaging social pressures that threaten the futures of so many adolescents? How can we organize care that helps the elderly preserve their dignity? Why can't we face the issues of sexuality frankly and openly enough to stem the spread of AIDS? How can we move forward in the search for more useful contraceptives? When will the ail ments and experiences characteristic of women move out of the medical and scientific ghetto in which they have long languished and into the mainstream of thought and practice? The women who will see the year 2000 have lived through a period of truly millennial change. They may well live to see other changes equally as great-perhaps now inconceivable lengthening of the life span, 210

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C HAPTER 10 ~ LookingAhead perhaps unimaginable control over fertility, perhaps the conquest of cur- rently common diseases. Or they may witness, on the other hand, the uncontrollable rampage of HIV, or the ineluctable fall of more and more uninsured or inadequately insured Americans into medical penury and despair, or a rising tide of violence that will critically deform our society. Just as the lives we live today were beyond the dreams of our ancestors, so the lives our descendants will live may well be beyond ours. What will not change, however, are the three forces that have shaped both this book and every female life: the interlocking pressures of physiology, gender, and social role. Women will continue to face particu- lar physical and health challenges. Those challenges will differ from the ones faced by men. And the life demands and experiences that women encounter will continue to shape their responses. As our nation's consciousness of women's health issues contin ues to rise, as women themselves take greater responsibility for their well- being and make greater demands on society for redress, and as more and more women gain positions of influence in the health professions, our health care system and the research enterprise that underlies it may re- spond increasingly effectively to these realities of female life. Or, bound in outdated biases and organizational principles, they may not. The outcome will depend on American women's ability to understand the issues that affect their health and then see that society responds. IN CONCLUSION This book represents many months spent pondering the changes of this century and immersed in the scrupulous research data assembled by IOM committee, conference, and staff members. Perhaps author's prerogative will permit it to end with what those excellent scien- tists would doubtlessly call a pair of anecdotal observations. My paternal grandmother, Esther Malka Pomerantz Lieff, born in the 1880s, died of cervical or uterine cancer long before I could know her and well before anyone knew of the lifesaving power of the Pap smear. More than 50 years later, that simple test warned my gynecologist that her granddaughter needed a hysterectomy to escape her fate. My maternal grandmother, Sarah Florin Jacobs, born in the 27]

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I N H E R O WN R ~ G HT 1890s, was stricken by blinding abdominal pain while preparing dinner for my grandfather in her seventy-ninth year. She died of a ruptured gallblad- der the next day. In the quarter century that I knew her, she never once bestowed a gift without saying to the recipient, as I now wish for the reader, "May you use it in good health." NOTE 1. Forrest (1991), 5. 212