Tropical Diseases Essay, Research Paper

Women’s Health and Tropical Diseases: A focus on Africa

Why focus on Africa?

Over one-quarter of the world’s population are at risk from parasitic infections and the majority of these infections are confined to the world’s poverty belt of the tropics and sub-tropics — largely in Sub-Saharan Africa. Women constitute nearly 67per cent of the total population of Africa, and to achieve better global health condition, a focus on African women is thus necessary. Low income levels are associated with debilitating disease patterns. Thirty-eight of the world’s 63 low-income countries are in Africa. Of its 500 million people, 40 per cent have less than US$1 a day to live on, 68 per cent have no proper sanitation and 52 per cent no access to safe water (Lancet, 1997). In a recent WHO report, analysis of the poverty data (UNDP 1994) illustrates the role of poverty in co-determining the health status of the populations (WHO/TF/HE/TBN/97). The report referred to above concludes that “levels of both total and rural absolute poverty” are substantially higher in the ten low performers (countries with highest negative deviation from estimated life expectancy) compared to ten high performers (countries with the highest positive deviation from estimated life expectancy). Interestingly, nine out of ten are in Africa. Of all geographic regions, Africa has the highest tropical diseases morbidity and mortality ratios (Sai and Nassim 1991).

Efficient services and special effort by health providers is needed to enhance the health status of populations in this region. Planning for health services, improving the efficiency and engendering services in any country depends primarily on information about the main causes of ill-health and death in defined areas. Data on cause-specific mortality and morbidity, in particular, data disaggregated by gender and sex crucial for effective planning are scanty for most countries in sub-Saharan Africa (Heggengougen 1996). Gaining solid and longitudinal understanding across the life span based on reliable, consistent and quality data has been re-echoed as perhaps the first action for tackling major causes of ill-health (Stephens 1996).

Given the paucity of data available to health planners in Africa, the question to ask is – can program planners achieve a reform of the health sector and or improve it? Do we have data to show where services are required? And can services and human resources be made available where they are most needed but nonexistent?

Why focus on Tropical Diseases?

Tropical diseases are to a large extent poverty-borne diseases. It has been estimated that half a billion people are suffering from tropical diseases -malaria, schistosomiasis, African trypanosomiasis, chagas disease, Leishmania (Kala Azar) and leprosy (WHO, 1993) and that a high proportion of this population live in sub-Saharan Africa. Tropical diseases produce large burdens of disability and some act synergistically with some non-parasitic diseases to produce severe disability sometimes leading to death.

Equally important is the focus on parasitic and infectious diseases. In the last decade, especially with the advent of AIDS, information on STDs, HIV, teenage pregnancies is becoming more available, but data on tropical diseases some with lifelong impact on health and economic development remains ambiguous.

In the absence of a vaccine or a ‘magic bullet’ for the treatment of tropical diseases like malaria and with increasing travel from non-endemic to endemic countries malaria, will become a huge problem to developed countries. Already an increasing number of imported cases including strains resistant to available drugs are being reported (Globe and Mail, 1997).

The Health of Women and Tropical Diseases

As Heggenhougen (1994) aptly notes “a Sub-Saharan female has a dramatically poorer chance of survival relative to her developed-world sister than does a Sub-Saharan male compared with his developed-world brother”.

With many tropical diseases (malaria, onchocerciasis, trypanosomiasis), exposure to the bites of infective vectors is closely related to work patterns of males and females, to individual and community behaviour (Robert, 1963) and is central to transmission.

Until recently, the theory has been that because males assumed the greatest responsibility for farm labour, their exposure and infection rates would be considerably greater than those of the female members of the family.

Historical changes in economic and agricultural roles of men and women leave women with the major responsibility for subsistence farming (Okonjo, 1988) and family welfare. Adolescent and adult females in Africa now make the greatest contribution to agricultural production (FAO, 1984). These changes in roles have increased exposure of females to infective bites of flies which transmit tropical diseases and increase their role in the transmission of diseases.

In a recent review, Amazigo (1994) observed that certain health conditions and problems associated with the highly prevalent tropical infectious diseases (e.g malaria, schistosomiasis) are shared by males and females at almost equal prevalence rates but they have each particularly serious consequences for females because of their reproductive functions. These problems exacerbate risk during pregnancy and childbirth.

A few tropical infectious diseases cause gross disfigurement. Leprosy, lymphatic filariasis, schistosomiasis, leishmaniasis and onchocerciasis are all diseases that disfigure the body – (SLIDES), hence, men and women are affected but differently socially, economically and psychologically. Studies demonstrate that these diseases are particularly cruel for adolescent females and women because of their effects on marriage prospects (Amazigo and Obikeze, 1990), education and self esteem ( Ovuga et al, 1996). The results of multi-country study on the social and economic effects of onchocerciasis demonstrated that school-age girls whose parents have severe onchocercal skin disease (OSD) are 2.6 times more likely to drop out of school than their counterparts from non-OSD families (TDR/WHO,1997).

Some if not all tropical diseases have direct health effects that go beyond the immediate female victim. Malaria in women leads to low birth weight either by premature delivery or impaired growth in utero (TABLE) and in pregnant women provides an opportunity especially in Plasmodium falciparum infection for parasites to invade the fetus itself (McGregor, 1983). In women with onchocercal itching the duration of breastfeeding was reduced by more than 9 months for 25 per cent of the infected women who breastfed infants after the onset of disease condition (Amazigo, 1994).

Women have thus been subject to government attention in the provision of health services not for their own sake, but largely for their roles as mothers and for being responsible for family members health (Rathgeber and Vlassoff, 1993).

In this discussion paper, infectious and parasitic diseases (malaria, tuberculosis, onchocerciasis ) selected were chosen because they have deleterious impact on women and the size of their burden as measured in Disability-Adjusted Life Years (DALYs) (Murray and Lopez, 1994). Even when infections from them do not proceed to mortality they generate considerable morbidity in men and women.

MALARIA

The threat from malaria is a global and not an African issue. One billion people are at risk from malaria and between 1-2 million deaths per year are due to malaria and 90 per cent of the deaths are in Africa. Given the global warming and increased international travel, urban malaria is now a major public health problem in Africa and persons from developed countries who have no immunity are at great risk.

On March 13, 1998 a new global initiative was announced by the new Director General of WHO, Dr Bruntland to Roll Back Malaria. The program aims at reducing malaria deaths (2.7 million deaths per year) by 50 per cent by year 2010 primarily through control activities including rebuilding health care services. The Roll Back Malaria is initiative a new opportunity to the African region to control malaria but several issues need to be carefully considered in implementation of this new attack to avoid past mistakes which resulted to both insecticide and drug resistance.

In the search for new insecticides it will be useful to explore the potentials of traditional herbs in use in the communities by local people as mosquitoes repellents (e.g local herb, Nchawu – which the Igbos of Nigeria burn to ward off mosquitoes). Also, such local coping mechanisms, and or capacities should be explored.

In the last two decades, it is estimated that 40 per cent of fevers are due to malaria (Brinkman and Brinkman, 1991), therefore, strategies for the control of malaria have shifted with a major focus on reducing mortality and morbidity with prompt and presumptive treatment of fever.

There has also been increasing recognition that the success of any control strategy would depend on a number of factors including the behaviour of patients especially mothers and caretakers of young children, the need to understand treatment seeking behaviours (Oaks et al, 1991) the choice of treatment. Research studies have shown that women’s choice and time of treatment are dependent on such factors as:

a) cost;

b) access to health facilities ;attitudes of providers, cultural beliefs about the cause and treatment of malaria.

Self-medication is a common approach by people when they experience signs and symptoms of malaria. Given the high incidence of malaria in Africa, the lack of or near absence of laboratory facilities at peripheral levels for clinical (biomedical) diagnosis, malaria has remained a problematic issue. Studies for a better understanding of the criteria used by women and village health workers in predicting malaria are highly desirable. Such studies, will afford experts insights into malaria transmission modes and have already been identified in Nigeria (Okonofua et al, 1992), Liberia (Jackson, 1985) and in Zimbabwe.

The transmission of malaria is not, and should not be seen as a matter for only health professionals. Because women are the primary care takers control initiatives as the Roll Back Malaria should focus on and harness the benefits of participatory planning by involving women from the outset in the determination of the needs and priorities of malaria control, planning and implementing measures that are feasible and acceptable to improve health. The role women can play in malaria control partnership programme will be discussed later in this paper.

In order to establish sustainable control programmes, strong partnerships between local women’s groups and health services is necessary. It must be recognized that as stake holders, the lead role must be shared by both in the control of malaria at least until Africa can boast of adequate number of trained health staff and availability of functional facilities at the peripheral levels. Presently, the acute lack of both staff and facility at the peripheral level underscores the need for the role of women in the home treatment of malaria and in control to be encouraged. In order to circumvent this anomaly, active involvement of communities, in particular, women’s groups to the fullest extent possible, should be an integral part of policy in malaria control for every country in the subregion.

TUBERCULOSIS

Tuberculosis is the single biggest infectious killer in women. It kills nearly 2 – 3 million people yearly. It is primarily a lung infection caused by inhalation of droplets containing tubercle bacilli of cough spray from tuberculosis patients. Mycobactarium tuberculosis and M. Africanum are two predominant causative strains in Africa.

In many Sub-Saharan African countries especially Central and East Africa, the incidence of TB has increased with the advent and increasing occurrence of human immunodeficiency virus (HIV) seropositivity. In a number of these countries one in three people with HIV die from TB due to neglect, they also infect hundreds of HIV-negative persons with TB bacteria.

Surprisingly, policy makers in most Sub-Saharan African countries are still unaware that TB is a great threat, that 95 per cent of the eight million new TB cases every year occur in developing countries, Africa with an incidence of 272 per 100,000 population which is approximately a ten-fold incidence rate compared with an incidence rate of 27 per 100,000 for European countries.

Equally sad is the observation that many policy makers have continued to neglect TB despite current knowledge that untreated TB follows a rapidly fatal course in HIV infected persons – hence Chreiten (1990) reference to both diseases as “the cursed duet”. The presence of Mycobacterium tuberculosis leads to accelerated replication of HIV; evidence that AIDS and

TB accelerate each other has been documented (Pope et al, 1993). Worst still, in HIV sero-positive TB patients, because of poor health status, there is increase incidence of adverse reactions to available drugs and poor response to therapy compliance to TB therapy is as low as 30 – 45 per cent in Sub-Saharan Africa.

According to WHO Global Tuberculosis Programme (GTP) recent reports over 900 million women are infected with TB world-wide and they are also at greater risk from HIV infection.

Directly observed treatment short-course (DOTS) is the WHO/GTP recommended strategy for the detection and treatment of TB, a strategy described in the 1993 World Development Report, as one of the most cost-effective strategies. In a collaborative TB control programme of the Ministry of Health in Guinea and the WHO, Guinea’s TB cure rates using DOTs are today recorded as over 80 per cent.

Because patient compliance is the most important determinant for success in the treatment of tuberculosis health sector initiatives must be designed to promote compliance by women. Given that stigma attached to Tuberculosis often leads to isolation and divorce of women health policies should emphasize on community directed programmes with inputs from different community groups, in a fashion acceptable within the specific cultural setting of the population.

Partnership with women for health reform

There is no gainsaying the fact that women play crucial roles both in family and society’s health care. It is imperative that such roles remain focal points for health care reforms to ensure their full participation.

Experience has shown however, that sustaining women’s participation in health-related projects is difficult.