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Annals of African Medicine
Annals of African Medicine Society
ISSN: 1596-3519
Vol. 6, Num. 4, 2007, pp. 157–163
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Annals of African Medicine, Vol. 6, No. 4, 2007, pp. 157 – 163
REVIEW ARTICLE
Tropical
Parasitic Diseases and Women
O. O.Okwa
Department
of Zoology, Faculty of Science, Lagos State University, Lagos, Nigeria
Reprint
requests to: Dr. Omolade O. Okwa, Department of Zoology, Faculty of Science, Lagos State University, P. M. B. 1087, Apapa, Lagos, Nigeria. E-mail: okwaomolade@hotmail.com
Code Number: am07036
Abstract
Tropical parasitic diseases constitute the
greatest threat to the health and socio economic status of women as a gender
and social group. There are some gender specific ways in which parasitic
diseases affect women in contrast to men due to differences in exposure,
occupational risk, sociocultural behavior, gender roles and practices. These
parasitic diseases confer some social stigma, which affects the health seeking
behavior of women. Women are therefore important in the control of these
parasitic diseases and they are key agents of change, if they are included in
community control programs. Women need more attention in endemic areas as a
group that had been neglected. This deprived and excluded group have got vital
role to play, as discussed in this review.
Key words: Tropical parasitic diseases, women, Africa, sociocultural
Résumé
Les maladies parasitoses tropicales constituent une tres grande menace
pour la santee. Un probleme socio economique aux femmes comme un genre et en
tant quun groupe. Ils ya des manieres specifiques par les quelles ces maladies
attaquent les femmes contrairement aux hommes a cause de la facon differente
dexposition, occupation, reagisment culture et social Cette maladie entraine
une honte sociale et nuire la santee des femmes. Les femmes sont donc tres
importantes, et meme des elements cles a conbatttre cette maladie si lon les
incure dans programmes de la commisnaute. En tant au quun groupe exclusif et
negligee les femmes ont besoin de beaucoup dattention puis quelles ont un role
importante a jouer dans ce contexte.
Mots cles: maladies parasitoses tropicales, femmes, Africa, socioculture
Introduction
Gender
as described by Tropical disease research/World Health Organization (TDR/WHO)
is the sociocultural aspect of male female dichotomy as distinct from sex,
which denotes a physiological basis of male female differences. Gender refers
to qualities, behaviors and roles ascribed to different societies by men and
women.1
Gender
is determined not by biology but the socio political and economic context.2 Bundy,3 pointed out that there is a
gender related specificity and susceptibility in infection. Males and females
differ physiologically and do different things, thus there are gender
differences in average rates of parasite prevalence, incidence or intensity of
infection, chemical outcome and susceptibility.
Recent
research has drawn attention to the relation ship of gender and health and
highlighted the significant disparities that exist between men and women.4 Brabin5 reported that certain factors
are responsible for differential susceptibility of males and females to
diseases, that disease afflict males and females in different proportions and
women appear to have higher morbidity rates. Sex differences are most obvious
with regard to reproductive health and gender is therefore implicated across
all diseases. Many of the problems that women face with regards to tropical
diseases ie, Leprosy, malaria, Schistosomiasis, Filariasis (Lymphatic
filariasis and Onchocerciasis), Trypanosomiasis, Chagas disease, African
Trypanosomiasis and Leishmaniasis (which are diseases of poverty) are similar
to those they face, for other diseases.
Bundy,3 pointed out that certain factors are responsible for differential
susceptibility and specificity to infection. Gender inequality compounds this
problem. Bundy,3 stated that woman tend to have more episodes of illness and more physician visits, even when visits
due to gynecological and obstetric reason are discounted, in addition to
infectious diseases, poor water supply, inadequate sanitation and lack of other
health infrastructure.
Wide
ranges of other social and cultural factors negatively impinge upon (womens)
physical well-being and accessibility to appropriate health services.6 Limited access to education for women suggests that women are less likely than
men to have information about disease and their presentation. They lack control
of financial resources (often scarce) and therefore give their health low
priority. They are also less familiar with medical services and may be
reluctant to use them.5
This
review looks at the effect of Tropical parasitic disease on women and how
changes can be made ie, raising the status of women in terms of participation
in health and development projects.
The role
of women in self-help community directed treatment, a sort of control of health
of women by women and for women and their household at large are discussed.
Social Economic Effects of Parasitic Diseases on Women
The
sequel of untreated infection particularly for parasitic diseases which causes
gross disfigurement, (Filariasis, Leprosy, Onchodermatitis and Leishmaniasis)
further compromise womens health and carry social costs, including social
rejection, isolation, and divorce.7,8 The links between gender, work, health and illness are complex. Illness in
women affects their work capability, including both household and other
productive work in general, and sickness limits a women ability to work.
The
sexual division of labor and the sexual division of responsibility together
with local ecological, environmental, economic and cultural factors influence
exposure to infection and risk of disease. The links between women and health
encompass womens roles in the production of food and goods, as wage earners
and in biological, domestic and social reproduction through childbearing and
child rearing, through their care of the sick and more generally the
maintenance of domestic environment.9
Parasitic
diseases constitute the greatest threat to the health and Socio economic status
of women.10 Control of disease is part of
economic development because developed countries are those that have been able
to bring the parasitic diseases under control. Control of disease will lead to
improvement of human health and raise the quality of life and productive
capacity of people.11
Traditional
African societies are patriarchal as reflected in customs beliefs and religious
practices of the people. Under this system, women receive less attention then
they deserve. Discussions about womens health tend to conceptualize women as
mothers, wives, health providers, reproducers, food producers, processors,
fetchers of fuel and water. Womens health and well-being should rather be the
goal of specific programs.
Women
represent a strategic and important position as a social group in the control
of parasitic diseases, because they are at great risk.12 They could serve as vehicles of social mobilization, because they occupy an
important position in the domestic of Human societies and are very influential.
Hence, Women could help to ensure greater compliance in community based
treatment programs. The participation of the women (that is a process of
involving the deprived and the excluded) is a dynamic venture in disease
process which would help at proper knowledge and perception of disease. Women
could be used in drug distribution, vector control, family and community
support to increase compliance to treatment. This would help control bodies and
international efforts at controlling the diseases.
Women
are key agents of change and target group for any development program.13 If development involves improving conditions of living, then women should
always be included in development programs especially in the rural areas. They
should not be only victims but also beneficiaries of economic development.
Bushy,14 opined that women are great
human resource and must therefore be both the subject and object of national
development. Maintaining a healthy household and community is seen as a womans
responsibility, but women are often not included in village health committees.15 TDR news, reported that in many societies, the length and arduousness of a
womans working day means that her health problems are far advanced before they
become important enough to do something about. A womans health problems are
not serious until she cannot stand, walk or talk. A woman never gets sick, even
when she is ill to the point of death; she is expected to perform her duty.16 It seems women are being valued mainly in terms of their procreative and
productive roles. These barriers should rather be removed. Failure to do so is
discourteous, wasteful, short sighted and inhuman.
Millions
of women aspire to a better life and want to participate in societal
activities. Programmes have failed because women did not participate. In order
to achieve effective disease control, the peculiarities, needs and special
requirements of women needs attention.13
Reasons for Gender Difference in Infection Pattern
Differential exposure to infection
This
could arise as a result of gender differences in Occupational risks, socio
cultural behaviors, gender roles and practices. Differences in risk of exposure
accounts for differences in infection patterns. Exposure arises from four major
basic needs ie, occupational, recreational, socio-cultural and domestic.
Socio-cultural
practices and behavior result in differential exposure to infection. Gender
bias in infection prevalence is most marked where socio-cultural factors result
in only one of the gender being exposed to an infectious environment.17 The most obvious example of gender bias in exposure is where only one gender
enters the habitat of an intermediate host or vector of a parasite. Women have
more constant touch with water for various activities in terms of household
duties.18 Women were reported as
working twice as many hours than men worldwide.19 Fetching of the wood, water, childcare and agricultural labor are some of the
works of women, so they could be more vulnerable to infection.
Innate sensitivity and host resistance
Infection
status is determined not only by the degree of exposure but also by the degree
to resistance. Variations in individual susceptibility are encompassed within
each gender. Host resistance, whether innate or acquired may influence the
outcome of an infection event.5
Women and Their Health With Regards To Tropical Parasitic
Diseases
The
Tropical parasitic diseases to be considered are Malaria, Schistosomiasis,
Onchocerciasis, Lymphatic filariasis, Leishmaniasis, Guinea worm, Hook worm,
Trypanosomiasis
Malaria
Prevalence
of malaria infection increase in women during Pregnancy. Malaria causes anemia
and low birth weight babies. This is due to the loss of previously existing
immunity.20 This condition is often
serious among adolescent girls, who do not receive adequate treatment for
malaria because of social stigma associated with pregnancy in teenagers.2
According
to TDR,1 cultural expectations often
demand stoic acceptance of malaria due to low status of women in rural
communities. A woman may need her husbands permission before she seeks medical
care. In most cases women seek first to home remedies and traditional medicines
for their illnesses. If these fail and symptoms persist, they seek low cost
treatment in the form of over the counter drugs. Women consider this type of
treatment to be most effective for malaria.8
Women
often tolerate symptoms of malaria until they are critically ill because of the
perception that sick women are mean or lazy. Women are reproached when there
are malaria epidemics for having failed as custodians of health. Women need
information to help them recognize the symptoms of malaria in themselves and
family members eg, fever chills, headache.16
Malaria
in pregnancy is widespread. It endangers the health of women and prospects for
the new born. Health services are inaccessible to many of these children and
women. Women in malaria endemic areas run an increased risk of infection during
pregnancy. The placenta is a preferred site of parasite accumulation and
placental malaria is associated with low birth weight of the baby and anemia of
the mother. Resistance to placental malaria has been observed in women after
several pregnancies, compared to women in their first pregnancies. Co-infection
with HIV significantly increases the prevalence and extent of placental
parasitaemia, and the resistance to placental malaria normally seen in women
following several pregnancies is lost. Pregnant women with malaria infection
are usually anemic; this elicits the precarious state posed to this vulnerable
group due to the adverse effect of malaria in pregnancy.
Malaria
accounts for 6.5% of abortions, 15% of premature deliveries and 0.7% death in
utero. The situation is further compounded by poor socio-economic status of
most rural dwellers.21 Pregnant women and children
will continue to be two of the most important risk groups. Pregnant women are
especially vulnerable because of iron deficiency, a special problem in malaria
endemic areas. When children are sick from malaria, women usually bear the
psychological effects. Severe convulsions, fever and other symptoms affecting
children leave a psychological effect of fear and restlessness on the mothers.
Schistosomasis
The
prevalence patterns of Schistosomiasis are often complex in women because of
exposure and innate susceptibility.22 Women are exposed to Schistosomiasis because of their inevitable water contact
behavior. According to TDR / WHO,2 failure to consider gender difference in Schistosomiasis may lead to errors in
the design of experimental surveys and diagnosis. Infection may miss diagnosis
in pregnant women and girls at puberty because of low tumor necrosis factor
levels (TNF). Low TNF is associated with reduced schistosome fecundity and
schistosome eggs are found in the cervix, vulva, vagina, ova, fallopian tubes
and placental and this seems to show a correlation with infertility in women
living in hyper endemic focus of Schistosomiasis.
According
to TDR/ WHO,2 Female genital Schistosomiasis
(FGs) is held to be an important social and medical problem. The condition is
associated with pathological manifestations in the female lower genital tract
such as tumors and ulcers. There is also some evidence that it is associated
with complications as infertility, abortion, pre-term delivery and extra
uterine pregnancy (a life threatening condition). FGs may facilitate the spread
of some Sexually Transmitted diseases (STDs) especially Human immunodeficiency
Virus (HIV) although more work is needed to understand this interaction and the
relationship between urinary Schistosomiasis, infertility and implications of
the diseases on married sexual life of women. There is chemical, immunological
and epidemiological evidence that FGs might be a risk factor for the
transmission and the propagation of STDs and HIV, 75% of women living in Schistosoma
hematobium endemic areas (Africa and Middle East suffer from it. It could
be diagnosed as a sexually transmitted disease because of its varying clinical picture.
Onchocerciasis
Most
studies on Onchocerciasis reported significant differences in infection among
gender.12 Higher prevalence was usually
found in the gender more exposed to Simulium fly bites. Though, Okwa23 attributed resistance to fly bites in women to hormonal effects and the
protective mode of African dressing. According to Brabin,5 there is little substantial evidence that Onchocerciasis is less frequent in
females on the basis of exposure only. Gender differences are most marked in
savannah areas of high transmission where worm burdens are lower from early
childhood in females as are ocular lesions. In forest areas, gender differences
are less marked and ocular lesions similar in males and females. Brabin5 also stated that gender differences are most evident under conditions of high
transmission but women appear to be less resistant to infection.
Petralanda et al24 reported that a serum from
breast milk of women with Onchocerciasis contains heat labile antigenic
products of filarial parasites. This could lead to transmission of
Onchocerciasis to the offspring. Onchocerciasis in pregnancy may likely affect
immune responses to Tetanus Toxin vaccination and birth weight of
children. Increased resistance in women could also influence the risk of
transmission of infection from mother to child in highly endemic areas. Amazigo25 reported that Onchocerciasis was believed to reduce Reproductive rates of women
in a rural farming community in Nigeria.
Onchocerciasis
has great socio-economic and psychological complications for women by lowering
their chances of getting married due to the disfiguring skin lesions. In a
study, women expressed greater concern than men about their physical
appearances.26 Prior to 1990, the social
implication and cultural aspects of Onchocercal skin disease (OSD) had been
totally neglected especially where women were concerned. The beauty of the skin
is culturally and socially extremely important. OSD is now recognized as a major
health problem. It carries with it a severe social stigma compounding the pain
and suffering of those infected with the disease.27
Ivermectin
is the favored and current drug for the control of Onchocerciasis. It would
also be necessary to integrate Ivermectin treatment into maternal and child
health care (MCH). Pregnant and lactating women are usually excluded in
Ivermectin distribution. They are advised to seek treatment one month after
delivery. In areas of high fertility, women may thus be continually excluded
from treatment and hence the chance of a better life. Such women may also
constitute a reservoir for the disease. Pregnant women in a study by World
Health Organization (W.H.O) received treatment.27 No
adverse effects were apparent, hence Merck, Sharpe and Company the
manufacturers of Ivermectin, has now changed the exclusion criteria for
pregnant and lactating mothers.
No
immediate negative effects were found in women that inadvertently took the
drugs. Utilization of health services by women is a complex behavior phenomenon
affected by factors as availability, distance, and quality of care, social
structure, health beliefs and low status of women. The low status among the
women studied; characterized by high average parity, full time childcare and domestic
responsibilities, no doubt influence their failure to report for treatment.
Scarce resource affected womens mobility and treatment seeking behavior. When
a woman fails to turn up for a treatment program, she would always have good
reasons related to her gender. Health workers treatment of patients has been
recognized as a major problem and important reason why people in developing
countries prefer self-treatment or seek traditional healers when they are sick.29 Women are really especially vulnerable to poor treatment by health workers.
Women will learn from health workers if treated with respect. The low social
and economic status and low self-esteem of some women especially in rural areas
reinforce their attitude that their health is not a priority. It was
recommended that the coverage of women excluded during Ivermectin campaigns
could be resolved by adopting community based distribution approach, where
community members such as leaders of womens groups ie, traditional birth
attendants (TBAs) and community health workers (CHWs) would participate in the
treatment program.
Lymphatic filariasis
This has
been known to be very prevalent among women. There is a social stigma
associated with the disease. There is ignorance of cause and treatment, and women
are silently bearing the brunt of the disease, which they hide underneath their
dressing. Social discrimination and divorce was high among these women in a
study, conducted in Africa. Prostitution was usually the after effect of such
neglect.13 These sets of prostitutes
were of the lowest cadre and the high-class prostitutes often refer clients
with Sexually Transmitted Disease (STDS) to them.26 Lymphatic filariasis is also a social and economic burden on African
communities and women are mostly affected. It could result into immense
swelling and growth and strong feelings of shame, fear, embarrassment and
suicidal thoughts.
Leishmaniasis
The
infection with Leishmaniasis in women depends on species and strains of Leishmania.
L. tropica has a preference for women than L. donovani. The genetic
background of the woman also has a role to play.3 Leishmaniasis/HIV infection is seen as an emerging disease and this have grave
consequences on women and their offspring.29 Women have been traditionally thought to be less frequently infected by
cutaneous Leishmaniasis because the disease is generally believed to be found
mainly in slyvatic areas, where the infected vector is present.16 Consequently, Leishmaniasis was viewed only as an occupational hazard mainly
for men owing to the rural nature of their work. According to Velez et al,30 in a study, a similar proportion of infection was reported for both sexes as
opposed to the preponderance of males generally reported, even with Montenegro
skin test. The prevalence rates between males and female were similar.
In some
foci, women suffer from Leishmaniasis than men and have less access to health
care services. Research has now revealed that women also suffer as much as men
but report to the health centers less. This is disastrous because a silent
enduring of the suffering leads to deterioration in quality of life, given the
chronicity of the lesions. Disfiguring scars on womens faces leads to social
stigma and inability to get marry.
Womens
treatment for cutaneous Leishmaniasis in 1995/96 in Tunisia, Colombia and Costa
Rica, where coffee plantation poses an occupational risk as an agricultural
main stay of the economy was investigated. Women who lack access to proper
treatment of cutaneous Leishmaniasis suffered physical effects (pain and
secondary infections and aesthetic effects (scars that impair their social
relations). Men reject partners with Leishmaniasis, because they fear catching
the disease, women tend to rely more on self treatment or seek traditional
cures, using plant ointments, very hot baths with salt or wax and acid burning.
The disease becomes more advanced as they go for treatment at the clinics
usually as a last resort. In the case of visceral Leishmaniasis, there is
problem of detection in females. This is a serious problem that affects
infected girls who are not diagnosed, so do not receive treatment. This implies
a large loss in years of life, considerable human suffering and a high cost for
the country.30
The
women stay at home looking after the house and if the condition is not
permanently incapacitating, consults a traditional healer in her village about
her lesions or applies medicines that her husband brings her from the pharmacy.
To her, going to the health center demands several hours and sometimes a day,
more so after diagnosis, treatment consist of injections which last 20 days.
Men seek to cure themselves with a lot of money and make numerous trips to
health centers in towns. Women, who are not as rich, cannot make these
expenditures. They cannot be replaced in their domestic labor, nor will men
undertake this expenditure for the health of women.
Women
with ulcers and scares on the face considered themselves less attractive. Their
prospects for marriage are diminished and their capacity to retain a man
lowered. This disfigurement could also lead to possible impairment in the long
term and affect womens social relation, status and socio-economic mobility.13
In
treatment seeking, women appear to try more kinds of treatment than do men, no
gender difference were observed in the length of time between the development
of lesions and seeking treatment. It was concluded that women consult official
services less and are under represented in the assessment of the disease and
there is always a false estimation of the number of cases by sex. Inequalities
in access to treatment for women have to be corrected and ensuring that
community education includes an emphasis on Leishmaniasis and the fact that it
is not disease that affects only Men.
Women
who lack access to proper treatment of cutaneous Leishmaniasis would suffer
physical, aesthetic and much social effects as well. The lesions will also
diminish the working capacity of women with consequences for their mental
being, children and household chores. Women affected by Leishmaniasis would
express suffering and seek a cure for the disease through self-treatment and
visits to local healers.30
Guinea worm
Guinea
worm causes women to be sedentary. Women are forced to concentrate on more
sedentary jobs leaving food crops unharvested. The hallmark of the disease is
crippling incapacitation whose seasonal occurrence coincides with planting and
harvesting seasons resulting in loss or great reduction in agricultural output.
Womens role in agriculture is greatly hampered. Their agricultural roles as
harvesters are stopped. Brieger et al31 reported that women lose as much as US$70 yearly in Nigeria, at guinea worm
illness.
The
impact of guinea worm disease on women is profound. The inability of the
infected mother to continue to work and care for her own personal and childs
need has far reaching consequences. She is unable to work and earn money for
adequate feeding so under nutrition and malnutrition sets in for both mother
and child. This results in weight loss for both. She is unable to meet the
husbands sexual needs. The husband may seek attention elsewhere outside the
matrimonial home, thereby threatening the stability of family life. The
continued support of the husband especially at a time like this, when her disability
makes her more dependent is threatened.32
Hookworm
Women
exhibit higher rates of hookworm morbidity because they suffer compromised iron
balance needing more iron than men do. They are therefore predisposed to iron
deficiency anemia by hookworm. Pregnancy and breast-feeding are aggravated by
hookworm morbidity that causes abortion, stillbirths and miscarriages, thereby
causing psychological and emotional stress.10
Hookworm
also has economic impact on women who show a disinclination and inability to
work and productivity is undermined. Poverty and ignorance are two important
epidemiological factors in hookworm disease and women are most affected. They
are the gender that is more ignorant about nutritional factor and the very
group that cannot afford to raise their nutritional levels especially with
regards to iron content.32
Trypanosomiasis
In rural
areas, the cost of treating sleeping sickness is high; they include drugs, user
fees and long hospitalization.
Women rely on their husbands to provide funds for treatment and so they often
seek for treatment at a late stage of the diseases if at all.8
Women
also fear lumbar puncture taken for diagnosis as rendering one permanently weak
with chronic back pain and been rendered unfit for marriage as men cannot
tolerate weak women, hence women may not find husbands or divorce on this
ground.13 The belief that
Trypanosomiasis is closely linked to STDs especially Acquired Immune Deficiency
Syndrome (AIDS) and that they are been perpetuated by women exist. This is in
fact called womens diseases in some places. This makes women suffering from
Trypanosomiasis to avoid seeking treatment. They fear the shame, stigma and
ostracization. In certain parts of Cameroon, women with Trypanosomiasis receive
scarifications on their bodies when they visit Traditional healers. The
ugliness of these scars puts off potential male suitors. Bucksbaum et al33 reported that swollen glands in the neck are also symptoms of Trypanosomiasis
and this adds to the social stigma. Much of the laziness attributed to women in
some Trypanosomiasis areas is no doubt due to this disease. Trypanosoma
cruzi the causative agent of Chagas disease infects 10 18 million people
in America, half of who are women who eventually transmit it to their newborns.34
Conclusions and Recommendations
There
should be increased awareness and understanding of the importance of gender in
determining health outcomes and the crucial role that women play in health care
within families and the wider society. In addressing womens health needs,
reports of women, development and health projects emphasizes the importance of
training women as health workers, skilled community workers, formal health
educators and peer group educators in ways that fit in with local, cultural,
social and economic factors. This would meet the need for a greater number of
health workers in a variety of fields.
Community
participation development projects need to be designed to include women and
their interest and to consider the ways in which such projects will affect and
be affected by issues of gender. Womens effective access to health care
involves the interrelationship of many complex factors. This can only be
assured if services are considered available, affordable, appropriate and
acceptable by women.
Access
to information and knowledge are also key issues in womens access to health
care. One of the reasons for the lack of success of health projects is failure
to understand womens normal patterns of time and use in the community and to
accommodate for this in planning. Womens work within and outside the home, and
in pregnancy and lactation, both reflects womens status and has a direct
impact on their health.
The
gender concepts help to explain the differential treatment of male and female.
Discrimination against females was found to start from birth and continue
throughout life to the extent that infanticide, early marriages and slavery are
directed at the female children. Women themselves are not innocent of this and
can correct these themselves. To eradicate this, mothers should be educated to
stop showing preferential treatment to their male children right from birth.
They should bring up female child as also important so that they would build up
high esteem as a woman.
More
female health workers are needed especially in the rural areas where women are
in purdah, only female health workers can have access to such women. These
women are inhibited from showing body parts, to sharing intimate problems with
the opposite sex. The social and economic conditions of womens lives affect
their children in a complex process of interaction and for this reason it is
necessary to look in more detail at the precise interaction.
The
effect of Tropical disease on women shows a vivid picture, it is therefore high
time to begin to portray and measure womens health in a way, which actually
considers womens health for its own sake.
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