Global Health & Environment
Spring 1999, Vol. 7, Issue 1

Women's Health in Global Crisis

Inside this Issue:

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Right to Health Commands Top Priority

by Claudia Morrissey, M. D., M. P. H., Advisor for International Women's Health, American Medical Women's Association, Washington, DC

"What are the most important things we can do as women to stay healthy?" inquired a group of 30 Bangladeshi women and their children gathered one recent, hot, and dusty afternoon at a satellite clinic. Although the scheduled lecture was on the importan ce of immunization, these women wanted to talk about their own health. This seemingly mundane scenario represents a profound change: women emboldened to value their health and seek ways to improve it.

As we approach the millennium, how can we support this awakening and enhance the state of women's health worldwide?

The Changing Global Picture

Data on the global burden of disease and death show that women in established market economies die primarily from diseases of affluence, with ischemic heart disease, stroke and other cardiovascular diseases (CVDs) responsible for up to 60 percent of al l adult female deaths. Breast, colorectal and lung cancers follow close behind, and depression tops the list as the most common cause of female disability.

Persistent among the leading causes of death in the developing world are those associated with underdevelopment: pneumonia, diarrhea, tuberculosis, malaria and measles. In sub-Saharan Africa, AIDS is the seventh leading cause of death for women, contributing to a drop in life expectancy to less than 40 in certain countries. Cervical cancer deaths in developing nations surpass those of all other cancers, with mortality rates three to six times higher than in developed countries, according to the World Health Organization (WHO). CVDs are also taking an increasing toll, as traditional diets and lifestyles become "modernized." In fact, WHO's 1995 report "Women, Aging and Health" notes that CVDs are the leading cause of death among women over 50 in the developing world.

The priorities and consequences of women's health change from infancy and childhood to adolescence, the reproductive years and the post-reproductive period. But, improving the health of women 15 to 44 "offers the biggest return on health care spending for any demographic group of adults (men or women)," calculates the World Bank. Targeted support is also essential to avert the consequences of disease and disability that result in a poor quality of life for many women in their post-reproductive years.

Motherhood, Mortality and Morbidity

For women aged 15 to 44, pregnancy-related complications are the number one killer and the leading cause of Disability-Adjusted Life Years (DALYs) lost. In fact, more than 99 percent of maternal deaths occur in women in the developing world, making the Maternal Mortality Ratio (maternal deaths divided by live births times 100,000) the health indicator with the greatest disparity between rich and poor nations.

Protecting maternal health in the developing world has only recently become a stand-alone development objective, reflecting the growing influence of women's advocacy groups and research findings identifying women as the "key actors" in development. Conceived in 1987, the Safe Motherhood Initiative (SMI) has served as a catalyst for increasing public awareness and testing approaches to improve maternal survival; it has challenged the world to halve the number of maternal deaths by the year 2000.

SMI's charge is a difficult one. More than 585,000 women die every year -- one every minute -- from five pregnancy-related complications: hemorrhage, sepsis, obstructed labor, eclampsia and the consequences of unsafe abortion. These deaths are largely preventable with known, low-cost therapies, but women continue to suffer because severe problems are not recognized, care is not sought, services are difficult to reach, or timely, appropriate care is not available at treatment facilities. In fact, the lifetime risk of maternal death is one in ten or less in 16 developing countries, compared to one in 9,000 in Switzerland. Asia contributes over half of all maternal deaths, but the risk of death is highest in Africa.

Risk is higher still for adolescents. A girl younger than 15 has five times the risk of dying from pregnancy-related complications than a women in her 20s; girls 15 to 19 have twice the risk. Social norms that favor early marriage and childbearing expo se more adolescents to this risk; and in many developing countries, including South Asia, Africa, Latin America and the Middle East, one-third to one-half of the women become mothers before age 20. Risk is also increased for the 12.5 million pregnant women who suffer from acute and chronic diseases and for women who have had a previous problem pregnancy.

In addition, abortions raise the stakes. Of the estimated 45 million pregnancies terminated each year, about half are performed under unsafe conditions, resulting in more than 200 deaths a day. Unsafe abortion accounts for at least 13 percent of global maternal deaths, and many developing countries spend a large proportion of their curative health care budgets on treating abortion complications that are easily prevented through access to family planning and safe abortion services.

Meanwhile, only 65 percent of women receive even the most rudimentary of prenatal care, and 63 percent deliver at home. Skilled professionals attend only about half the births, leaving more than 60 million women to deliver alone, with a family member, or a traditional birth attendant. Lack of medical attention during delivery and immediately postpartum is especially dangerous as over 80 percent of all maternal deaths occur at these times.

Health, Disease and the Post-Reproductive Years

Females are living longer, however, making attention to the post-menopausal years an increasing priority. In fact, the World Bank projects that, by 2020, one in five women in the developing world will be 50 or older, increasingly neglected, and (to add to their undernutrition and diseases of poverty) plagued with a host of chronic conditions.

CVDs already represent a higher proportion of the female disease burden than do males in the 50+ age group. Further, deaths from cancers of the cervix and breast claim over 350,000 older women each year, osteoporosis afflicts one in 10 women over 60, a nd osteoarthritis is an increasing cause of disability for women in their post-menopausal years.

What Can Be Done?

Health protection for women 15 to 44 deserves first priority, thus avoidance of pregnancy-related complications and maternal mortality takes center stage. Programs are helping women, their families and communities recognize complications and develop emergency plans for accessing life-saving care (a shift away from a less effective focus on prenatal care, risk assessment and birth attendant training). WHO further recommends: delaying marriage and first births; ensuring skilled attendance to reduce risk at delivery; improving access to quality maternal health services, including emergency care; and addressing unwanted pregnancy and unsafe abortion.

A World Bank "package of essential services" for all women, regardless of age, also emphasizes:

Improving women's health in the developing world requires a coordinated effort -- from individuals to communities to governments -- and its most fundamental tenets are: zero tolerance for preventable female death and disability, and dedication to improving the status of women. As empowered citizens, women will no longer face the class and gender discrimination that puts them at risk, and they will feel entitled to live in good health, demanding high-quality, compassionate care throughout their lives. §

Tobacco Giants Woo Women the World Over

by Margaretha Haglund, President, International Network of Women Against Tobacco, and Chairman, Tobacco Control Programme, National Institute of Public Health, Stockholm

Jego lives in India. A mother, a wife and a smoker, Jego's health is at risk because of a tobacco habit she believes "can keep [her] physically fit." Recorded by the New Jersey-based International Network of Women Against Tobacco (INWAT), Jego's "Her estory" is not unique. More and more women are taking up tobacco as victims of misinformation, market expansion and commercial gain.

"Nobody can take my cigarettes away from me; not even if I get hurt

In fact, tobacco use is among the greatest health threats facing women around the globe today. Worldwide, about 12 percent of women smoke compared to about 47 percent of men, but tobacco-control advocates project that, without strong government and private-sector intervention, smoking prevalence among women will nearly triple over the next generation, with the number of women smokers rising from the current 187 million to more than 530 million. Eighty percent of these female smokers will live in the developing world, and half will die prematurely from tobacco-related causes.

In developing countries, only 2 to 10 percent of women smoke, compared with 25 to 30 percent in developed countries. Cultural stigmas help maintain this gap. But, while smoking may be socially unacceptable in some countries, bringing shame upon a woman's family, tobacco use in other forms among women in developing countries is extremely high. In Central and South Asia, only 3 percent of women presumably smoke manufactured cigarettes; but 50 to 60 percent chew tobacco in many parts of India. In Nepal and some areas of rural India, women also smoke bidis (0.2 g of wrapped tobacco) and chutta (a kind of cheroot).

Marketing Tactics & Consequences

As smoking decreases in the West, the tobacco industry is targeting the developing world, with particular emphasis on women and girls. Among other aggressive marketing and promotional campaigns, tobacco companies have unveiled Capri, Vogue, Kim and Virginia Slims -- "female" brand names with special appeal to women. With the fastest-growing cigarette market in the world and upwards of 30 million female smokers, the Chinese tobacco industry now features Camellia, modeled on the American brand More and specifically designed to lure women.

Accompanied by seductive advertising, these brands exploit ideas of female power, emancipation and slimness, and create new female demand. In an increasing number of less developed countries, smoking also is now linked with a cosmopolitan and affluent lifestyle; this, coupled with increasing urbanisation, career pressures and spending power, is convincing many young women to light up.

China has already found that a sharp increase in market share of foreign cigarettes was accompanied by increased smoking among girls. In Lithuania, in the five years since the sale of the former state-owned tobacco company, the proportion of female smokers has more than doubled from 10 to 20 percent. By way of contrast, in Sweden, because of stringent anti-tobacco measures, female smoking prevalence rates took almost 20 years to double.

The number of women smokers will continue to rise as the female population in developing countries expands and as women's economic status improves. The health consequences of this imminent tobacco epidemic are not yet evident; however, women are at sp ecial risk from passive smoking, as some 50 to 60 percent of men in emerging nations smoke and extended families in developing countries live in close proximity. Lung cancer, the fifth leading cause of cancer deaths among women worldwide, is likely to rise to number one (as it already is for men). Today too, the vast majority of rural women have extremely limited access to health care. Poor, sick and pregnant women exposed to tobacco smoke are at especially high risk.

The Prevention Challenge

Since China accounts for 25 percent of the world's female population, preventing a rise in smoking among girls and women in China alone would be "the greatest single opportunity for prevention of noncommunicable diseases in the world," says tobacco-control expert Judith Mackay. However, most current tobacco-control programmes fail to address the specific needs of women. In part, they don't understand the economic consequences or the gender or class complexities that call for special tactics targeted to disparate populations. In India, for example, middle-class women smoke cigarettes and poorer women chew tobacco or smoke bidi. These populations differ dramatically in education, literacy and living conditions, and they require very different intervention approaches.

Simultaneously, many women in Asia and South America work for tobacco companies. In Indonesia alone, tobacco manufacturers employ about 15 million people, mostly women. Many of these women recognize that smoking diverts family money from food and education. Low-income smokers in India, for example, spend up to 60 percent of their income buying cigarettes or chewing tobacco, while Philippine smokers of 20 cigarettes a day fork over 35 percent of their median household income for their habit. However, these women are often the economic mainstays of their families and have seen their living standards improve while working for the tobacco companies. Any policies to move to other crops or products must take into account this intense love-hate relationship.

The next century will bring the full burden of the tobacco epidemic to bear on young girls and women in Asia, Africa and other developing nations. Halting this epidemic requires special measures to inform, motivate and protect women, including disseminating information, providing school health education, protecting against economic dependence on tobacco, and imposing restrictions on the marketing and advertising of tobacco to women and girls. Established in 1990, INWAT is using these multifaceted approaches to combat the complicated effects of tobacco consumption on women and girls worldwide. §

Downward Health Spiral Hits Women in CEE-NIS

by Eleonora Kapitonova, M.D., Ph.D., Head, Clinical Department, Gomel Branch of the Research Institute of Radiation Medicine and Endocrinology, Gomel, Belarus

Political and economic changes are but one culprit in the devastating, decade-long health spiral plaguing Central and Eastern Europe and the Transcaucasus. Reinforcing the downward trend (and the widening health gap between Europe's eastern and western halves) are cuts in public health budgets, medicine shortages, undernourishment, unfavorable working conditions, unemployment, poverty and war. Women and children are particularly hard hit by the unfortunate epidemiological trend.

Women live longer than men and have lower mortality rates at all ages and for all causes of death, but the conclusion that they are healthier is sadly unwarranted according to the World Health Organization's (WHO) report, "Investing in Women's Health." In fact, the "lower" death rates in women give a false picture of their health and well being, and in the case of CEE/NIS, may divert attention from the critical nature of women's health issues.

History and Trends

By the early 1980s, considerable advances had been made in the former Soviet Union in medical care, particularly in the area of mother-and-child care. An extensive network of maternity consultation centers and children's polyclinics was established, and immunization levels were often higher than in Western European countries. At that time, in Belarus, for example, both infant and maternal mortality rates were at a record low, and diseases such as diphtheria, tuberculosis and syphilis were practically eradicated.

But less than a decade later, the situation changed. Between 1989 and 1994, infant and maternal mortality rates increased in Belarus, rising from 11.8 to 14.8 per 1,000 live births and 21.8 to 26.0 per 100,000 live births respectively. More than half of these deaths were caused by the ill health of women rather than complications associated with pregnancy, concluded a 1995 UNICEF report "On the Condition of Children and Women in Belarus." In fact, WHO puts maternal mortality in the NIS at about twice that of the CEE and four times the European average. Abortion remains a major cause of these still-high levels -- and a principal form of birth control -- across the region.

As infant and maternal mortality rates increase, average female life expectancy in the region declines. In Lithuania, for example, life expectancy dropped from 76.3 years in 1990 to 75.86 in 1991. Overall, average life expectancy for women in the NIS and CEE is six and five years less than the average for women in Western Europe: 79.89 years in the EU versus 73.9 and 74.91 in the NIS and CEE.

The East-West Divide

Diverging trends between CEE/NIS and the rest of Europe extend to disease-specific mortality. According to WHO, even the lowest 1990/91 female death rate in CEE/NIS from cardiovascular disease (Lithuania: 72.95 per 100,000) was still more than one and one-half times the European average and more than twice the average for Western Europe. And the highest rate (Turkmenistan: 165.11 per 100.000) was more than three and five times the European and EU averages.

The mortality gap between the East and West from cancer is less striking, but nonetheless serious. For example, standardized death rates from breast cancer were lower in CEE/NIS than the rest of Europe (about 14-15 deaths per 100,000 compared to 18-20) from 1981 to 1990. But, breast cancer is more likely to reach an advanced stage in CEE/NIS; in Ukraine one-half of all new cases of breast cancer are advanced. And the rates for cervical cancer in CEE are three times higher than in Western Europe. Given the lack of screening services and prevention programs, cancer rates continue to rise in CEE/NIS -- while they fall across Western Europe.

Meanwhile, the democratic reforms that have helped create fresh opportunities for young people have also unleashed new social challenges and risk factors that seriously impair the health of girls and women in CEE/NIS. Among these are unemployment, poverty, alcoholism, depression and suicides, which are particularly high in Lithuania, Latvia and Russia, according to a 1997 UNICEF regional monitoring report. Sexual violence is also on the rise, and prostitution has increased markedly, resulting in the wide spread of sexually transmitted diseases and drug and alcohol abuse.

Ecological risk factors are also high on the list of health concerns for women in the region. Radiation exposure resulting from the Chernobyl accident is estimated to have affected the health of some six million residents, with the female populations o f Belarus, Ukraine and Russia suffering the most. In fact, many young women in these countries have decided not to procreate because they fear giving birth to unhealthy babies. However, Chernobyl is not responsible for most infant -- or adult female -- deaths or disability. Malnourishment, alcoholism, smoking and stress are among the main culprits.

Need for Reform

Epidemiologically speaking, patterns of female mortality in CEE/NIS are following the negative trends seen earlier in this century in Western countries. But, ecological, medical and prevention-oriented nongovernmental organizations have awakened to this dilemma. They are working to reform public and governmental attitudes towards female health, and are cooperating with governmental services in the region to implement health policies that take into account women's societal contributions and health needs. Meanwhile, a growing focus on mother-child health and disease prevention in aging women may open the door to shifting responsibility from the traditional polyclinics to a public health network, incorporating a primary medical care system, and implementing prevention programs that look to the future and minimize expensive hospital treatments. §

Bias Blocks Female Health Promotion in India

by Kamala Krishnaswamy, M.D., and M. P. Rajendra Prasad, M.B., B.S., M.Sc., National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India

A large proportion of India's 450 million women are in ill health. Most of them don't have to be, but social, cultural and economic factors prevent them from receiving the care they need.

Introducing distinct gender bias at early ages, India's male-dominated society, especially in the northern states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh, is a principal factor in the hindrance to health promotion of Indian women. According to the World Bank, one symptom of this bias is the persistence of excess female mortality in India up to the age of 30.

Gender discrimination shows up in the appropriation of food, health care and education, and it ensures that Indian women experience more bouts of illness than Indian men, are less likely to receive medical attention before they are in critical condition, and suffer unusually high rates of rape, burning and beating, the World Bank reports. Low social status and intense physical labor also account for Indian women recording some of the highest maternal mortality rates -- and lowest literacy rates -- in the world.

According to the World Bank, the more than 400 maternal deaths per 100,000 live births in India are primarily the result of infection, hemorrhage, eclampsia, obstructed labor, abortion and iron-deficiency anemia (found in 50 percent of pregnant women and 50 to 85 percent of adolescent girls in the country). Early marriage and childbirth, high fertility levels and closely spaced pregnancies exacerbate the situation. Calorie inadequacy, goiter, and vitamin A- and B-complex deficiency also contribute to maternal morbidity, and promote chronic energy deficiency (a body mass index of less than 18.5 kg/m2), low birth weights and a national shortfall in child development, reproductive performance and overall public health.

Meanwhile, India's own 1991 census showed that a mere 39.3 percent of Indian women above age seven are literate, compared with 64 percent of Indian males. In fact, due to the increasing population, there are more illiterate females in India today than there were a decade ago, the World Bank contends, with literacy levels for females as low as 21 percent in some northern states. Barriers to educational opportunity and attainment necessarily -- and negatively -- affect Indian women's reproductive behavior, use of contraceptives, access to health services and overall status in society. Uneducated and living on the streets because of poverty, many young girls fall easy prey to criminal prostitution rings and drug trafficking, leading to severe emotional and mental problems -- and posing an even greater challenge to improving maternal and child health.

The government is the main source of preventive health care in India, and is responsible for immunization and family planning. Its Family Welfare and Integrated Child Development Services (ICDS) programmes attempt to meet the health and nutritional needs of women, but spending on these initiatives, as well as general health care, represents only about 1.3 percent of India's gross domestic product, according to 1996 World Bank statistics. Not surprising, then, that current efforts to expand ICDS, introduce supplementary feeding programmes, and empower women with nutrition and health education are in jeopardy. And thus far, prevention of the epidemic of non-communicable diseases currently plaguing Indian women is not on anyone's priority list. The non -profit and for-profit sectors (including traditional practitioners and local healers) pick up some of the slack, providing 80 percent of all health care and most of the curative care in the country, while nongovernmental organizations run a number of effective, but small-scale, programmes targeted to women.

But improving women's health in India requires more -- much more, including: sustained government support, strong policy objectives and a gender-sensitive shift that will give rise to an accepting environment and the necessary allocation of resources. Also on the list according to the World Bank: integrated family planning and maternal and child health care services; accelerated anemia prevention and control efforts; trained fieldworkers; and wider availability of temporary contraceptive methods and medical termination of pregnancy.

India has come a long way in recent decades, but women's health issues have remained near the bottom of the country's long "To Do" list. The time has come to cross gender lines, re-prioritize, and draft a new list! §

Osteoporosis Afflicts Growing Number of Chinese Women

by Xihe Zhao, Professor, Institute of Nutrition and Food Hygiene, Chinese Academy of Preventive Medicine, Beijing

As the number of elderly women grows in China, so does the prevalence of osteoporosis-a condition that leads to reduced bone mass and fractures. In fact, osteoporosis is rapidly becoming a public health problem of major proportions in the country.

Triggered by reduced bone density and micro-architectural disruption of bone tissue, osteoporotic fracture is one of the most common afflictions of older people, especially postmenopausal women. Profound physical impairment and reduced quality of life are the common results. Insufficient calcium, inadequate exercise, smoking and excessive alcohol consumption increase osteoporosis risk, according to the World Health Organization. A number of major prevention and prevalence studies in China are attempting to understand how these factors influence the onset of osteoporosis in Chinese women. Simultaneously, the Chinese government endorses weight-bearing exercise and calcium supplementation -- both now increasingly practiced among older, urban Chinese women.

Insidious Onset, Increased Fracture Risk

Bone density increases during childhood and adolescence and peaks at about 25 to 30 years of age; it is then maintained without much change before falling at about 40 to 45 years in women and 55 to 60 years in men. Women lose about 15 percent of their bone mass in the first 10 years after menopause, but the rates of bone loss vary between individuals. When bone mass becomes too low, structural integrity and mechanical support deteriorate significantly.

Along with the introduction of bone densitometry, bone density has been measured extensively in China since the mid 1980s. The peak bone density of women is lower than that of men. How this and lifestyle decisions contribute to osteoporosis is the thrust of an ongoing, large-scale national prevalence survey.

Also being studied in relation to osteoporosis is vertebral fracture. A population-based study in 1993-94 in China estimated the prevalence of vertebral fractures in postmenopausal women in Beijing compared with Caucasian women in the United States. Researchers found that Beijing women had lower spine bone mass density than U. S. Caucasian women and were less likely to suffer vertebral fractures. In fact, while the prevalence of vertebral fracture increased from 4.9 percent among 50- to 59-year-old Beijing women to 36.6 percent in Beijing women 80 or older, the age-standardized prevalence of vertebral fractures among the Chinese participants was 5.5 percent less than among the U.S. females. The study revealed an inverse relationship between the bon e density of the lumbar spine and the risk of vertebral fracture: the lower the bone density, the higher the risk of fracture.

Similar results were found for hip fracture. In the first population-based study of hip fracture rates in China conducted from 1988 to 1992, the hip fracture rate among Beijing women 50 or older was 88 per 100,000. This figure was much lower than in Hong Kong women in 1985 (353/100,000) or among U.S. Caucasians in 1983-84 (510-559/100,000). In fact, despite lower bone density and calcium intake (less than 400 mg/day for most women) than U.S. female Caucasians, Chinese women have among the lowest hip fracture rates in the world. Experts attribute this, at least in part, to a shorter femoral neck length, higher amounts of physical work, and lower alcohol and animal protein consumption.

Given recent socioeconomic developments, ensuing diet and lifestyle changes, and increasing life expectancies, however, the incidence of hip fracture is on the rise in many Asian countries. In Hong Kong, hip fractures increased more than twofold in th e last two decades. From 1988 to 1992, rates in Beijing women jumped 34 percent, and they are expected to continue to climb. Faced with these prospects, researchers are working hard to identify risk factors for osteoporosis and develop effective intervention approaches for its prevention. §

WHI Targets Prevention in Older U. S. Women

by Jacques E. Rossouw, M. D., Deputy Director, Women's Health Initiative, National heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland

In the United States, women outlive men by some six years, but over their lifetimes they have as much cardiovascular disease and cancer as men, and they suffer more osteoporotic fractures and arthritis than men. Heart disease now accounts for one in three deaths in U.S. women, cancer for one in five, and stroke for one in 12, and these percentages go up steeply with age.

Finding Predictors of Disease in Older Women

The National Institutes of Health launched the Women's Health Initiative (WHI) in 1991 to explore the determinants of health in older women and test a number of promising, though unproven, prevention approaches that may reduce their burden of cardiovascular diseases, certain cancers and osteoporosis. The environmental, lifestyle and genetic factors that predict disease are being studied in 93,000 postmenopausal women ages 50 to 79, currently involved in an observational study. Exhaustive questionnaires and examinations were administered to the study population during 1993-1998, and the women will be followed until year 2005 for disease incidence. More than 1.5 million vials of blood have been stored for later analysis to see whether risk factors -- predictors of disease -- can be identified in blood or DNA.

At the core of the WHI are three randomized controlled clinical trials of prevention approaches: hormone replacement therapy (HRT) to prevent coronary heart disease (CHD); low-fat dietary pattern to prevent cancers of the breast, colon and rectum; and calcium and vitamin D supplementation to prevent osteoporotic fractures. WHI chose to test these approaches because these conditions are among the main diseases that burden older women, and if these preventative approaches work, they will find wide applicability to many populations of older women.

Finding Prevention Approaches That Work

Measures to prevent CHD such as cholesterol lowering, blood pressure control, and smoking cessation work as well in women as in men. However, one approach -- hormone replacement therapy -- is of special interest for women.

Women develop CHD some ten years later than men, and this delay in onset is commonly attributed to the higher levels of estrogen in pre- compared to post-menopausal women. Also, women who receive HRT after menopause have lower rates of heart disease. But women who receive HRT may also differ from those who do not in other ways, so there is some question as to whether it is the hormones or the innate characteristics of those who take them that lead to lower heart disease rates (i.e., there may be a "s election bias"). If the lower CHD risk among hormone users is explained by their unique characteristics or lifestyle, then HRT may be irrelevant to the disease and will not work in the general population. The randomized controlled clinical trial method has been designed to overcome this possible selection bias, and the WHI includes a randomized trial of HRT compared to placebo in more than 27,000 women, who will be simultaneously followed for CHD risk.

Similarly, while a diet low in fat and high in fruits, vegetables, grains and cereals is regarded as healthy, there is no proof that such a diet in fact reduces the risk for breast cancer or cancer of the colon and rectum. So the WHI includes a random ized trial of more than 48,000 women, some of whom will be guided to change their diet, and some of whom will stay on their usual diet. Finally, the initiative includes a randomized trial of more than 40,000 women, some of whom will take a calcium and vi tamin D supplement, and some a placebo, to see whether the supplement will reduce the risk for fractures.

In each of these randomized trials, both the potential benefits and the potential risks will be carefully documented. And when the data are published, women will know whether HRT, a low-fat dietary pattern, or calcium and vitamin D supplements are lik ely to help them lead healthier lives as they grow older. §

Changing Trends Forecast New Female Health Policies

by Paul Dolin, D.Phil., and Filippa W. Bergin, LLM, World Health Organization, Geneva

In 1990, infectious and parasitic diseases accounted for five of the ten leading causes of female disability and premature death in the developing world, and maternal conditions amounted to 15 percent of disability-adjusted life years lost among women of childbearing age. Health policies in developing countries reflect these conditions, giving priority to measures that control infectious diseases and improve maternal and child health.

By the year 2020, a very different disease profile is forecast, however. Depression, ischaemic heart disease, stroke and chronic obstructive pulmonary disease are projected to be the leading causes of female disability and premature death in developing countries. This forecast closely mirrors the current (and projected) disease burden in developed countries, which experienced an epidemiological transition to non-communicable and chronic conditions several decades ago.

Demographic trends, too, will impact health policy priorities in the new millennium. Already down, the total fertility rate (the number of births per women of childbearing age) is projected to drop to 2.3 by 2025. Simultaneously, under-5 and maternal mortality rates are expected to halve, while life expectancy is rising. In fact, by 2025, there will be more than 800 million people aged 65+ in the world, two-thirds of them in developing countries. Increases of up to 300 percent in the geriatric population are anticipated in many developing countries, especially Latin America and Asia. According to the World Bank, one in five of these geriatrics will be women 50 or older. Health policy and programmes need to be modified, developed and implemented to reflect these future trends.

Health Agenda for the Millennium

Brazil created the first comprehensive women's health policy in 1983. Since then (especially in the last four years), many governments of industrialised and developing countries have shown sustained commitment to advancing women's health.

Current women's health agenda, however, focus largely on reproductive health and domestic violence, both of which are highly influenced by factors related to gender-based discrimination. These agenda need to go further and address other neglected determinants of women's health, such as the impact of occupational health, the growing influx of non-communicable conditions, and the role of ethical, political, financial and societal issues in the policy-making process.

Reorienting health services so that they are community-based, gender-sensitive and responsive to women's needs and rights are important components of a comprehensive health policy to protect women's health. In international fora, governments have readily endorsed the principles to protect reproductive and women's health and rights. The next challenge is to turn these principles into policies and programmes at the national level. An increasingly difficult task, however, is setting priorities -- while resolving the conflict between epidemiologically based decisions for populations and the needs, and rights, of individuals.

Disability and disease trends are also important. For example, depression -- projected to become a leading cause of female morbidity and mortality -- can be treated by drugs or through cognitive recognition techniques; however, public health spending on preventive strategies is limited, especially in developing countries, where mental illness often carries a stigma and goes untreated.

In addition, as the incidence of pulmonary diseases (and lung cancer) rises, health policies and intervention programmes must make tobacco control a priority not only in developed countries (where female smoking rates are already high), but in the developing world, where tobacco companies are actively targeting women and girls. Policies must also address health problems facing older women, including cardiovascular diseases (the leading cause of death in women over 50 in developing countries), cervical and breast cancer, osteoporosis and osteoarthritis.

Setting Priorities

Strengthening women's health services is the first priority. This means expanding and improving essential services involving contraceptive choice, maternity care, nutrition assistance, and the screening and treatment of sexually transmitted diseases and cervical and breast cancers. A second priority is prevention -- early intervention to protect women's health. In this case, policies must focus on interventions that produce behavioural change: in-school reproductive and sexual education; public information and services to prevent unwanted pregnancy and sexually transmitted diseases; and programmes to discourage smoking and substance abuse.

Reducing gender discrimination worldwide and ensuring equitable access to services are also critical, especially in developing countries. This requires cultural intervention to build an environment where women are encouraged to use health services and given the financial wherewithal to do so. In short, women need to be empowered, and female participation in policy decision-making and service provision is key.

The Political Agenda

Governments in developing countries face a special challenge. While their efforts to further reduce the burden of infectious and parasitic diseases and promote safe motherhood initiatives must continue, policies and programmes must be directed to meet the projected change in disease profile, especially the growing non-communicable disease burden.

It's a difficult task, requiring not only financial resources but public will. To boot, there is the reality that, while policy is a necessary step, it is, in and of itself, not sufficient. Governments topple, famines strike, privatisation occurs, financial markets collapse -- and often it's back to Square One.

Reforms have occurred worldwide in recent years to strengthen women's health and rights. Bolstered by these positive changes, international support and mainstreamed language, the women's health agenda must continue to march forward. And as countries progress in their policies and attitudes towards women's health, further advances will necessarily occur. §

The opinions expressed are those of the authors and do not necessarily reflect WHO policy.

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