PRB

(May 2004) Infectious diseases continue to cause ill health and deaths to millions worldwide, despite advances in public health over the last 100 years — advances that include the development of vaccines and antibiotics and improvements in sanitation. In many developing countries, women face particular difficulties in warding off infection because of social and economic obstacles to accessing health information and services. To reduce the impact of disease on women, some infectious-disease prevention programs are employing community-based approaches conducted by women.

The World Health Organization (WHO) estimates that in 2001, infectious diseases accounted for 26 percent of total mortality worldwide and caused 15 million deaths, many of which could have been prevented with drugs, vaccines, and access to uncontaminated food and water. Deaths from AIDS, tuberculosis (TB), malaria, diarrheal disease, and respiratory infections are responsible for much of the infectious disease burden. However, mortality presents only part of the picture. A number of other diseases cause severe disabilities and deformities in almost 1 billion people who live mostly in extremely poor and remote areas of less developed countries, says WHO. These illnesses range from the severely enlarged limbs of elephantiasis to dengue and Guinea worm, a painful and disabling parasitic disease.

In many less developed countries, women’s vulnerability to disease is heightened because of the interplay of economic, social, and biological factors. Often, a long history of discrimination against women has led to inequalities that perpetuate a lack of access to services and resources for them and their children and that increase the likelihood of risky behaviors. Anatomical differences also play a role in the transmission of infection. In the case of HIV, transmission through sexual contact is far more effective from men to women than vice versa. As a result of these factors, women in sub-Saharan African areas affected worst by HIV are 1.2 times more likely to be infected than men. The ratio is highest among young people, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). Women ages 15 to 24 are two-and-a-half times more likely to have HIV as their male counterparts. In the case of malaria, a disease that exerts its heaviest toll in Africa, pregnant women, particularly women in their first pregnancy, are the main adult risk group.

Because women bear children and typically play a primary role in caring for the home and other family members, infectious disease among women has a ripple effect. Pregnant women can mean sick babies and children, and illness among women can compromise the well-being of entire families. For example, pregnant women infected with certain sexually transmitted infections (STIs), including chlamydia and gonorrhea, face an increased risk of having ectopic pregnancies and of giving birth to infants with severe central nervous system damage, according to the Institute of Medicine of the U.S. National Academies. Women with certain STIs also experience an increased risk of infertility, cancer, and premature death, notes the institute in its book The Hidden Epidemic: Confronting Sexually Transmitted Diseases.

In addressing the impact of specific infectious diseases in different parts of the world, nongovernmental and other organizations are employing innovative approaches to disease prevention, working through women at the community level. For example, this approach has been used to address Guinea worm in Ghana and dengue in Puerto Rico.

Guinea Worm Project in Ghana

Through its efforts to control Guinea worm, the Atlanta-based Carter Center, in partnership with the Office of Global Health at the U.S. Centers for Disease Control and Prevention (CDC), has played a role in stimulating community-health change within Guinea worm-infected areas in Ghana.

Guinea worm (or dracunculiasis), a parasitic disease transmitted to people through ingestion of infected waters, traditionally affects poor rural communities that lack safe drinking water and adequate health care. The Guinea worm larvae go through their first stage of development once small water fleas known as Cyclops ingest them. When people ingest water contaminated with the flea, the male and female larvae mate, and a female worm develops. The worm can grow to lengths of up to 3 feet before it emerges from the surface of a person’s body, causing severe pain, fever, nausea, and ulcers, according to the WHO. Without adequate care, the ulcers may take long periods to heal and may be complicated by secondary bacterial infections, by stiff joints, and disabling shrinkage of limbs, says WHO.

As a result of a global eradication campaign whose partners include WHO, the United Nations Children’s Fund (UNICEF), and the CDC, the number of Guinea worm cases declined from an average of 10 million to 15 million at the start of the 1980s to an estimated 64,000 in 2001. Still, the disease persists in several poor rural areas of Africa. In Sudan, for example, a civil war has challenged prevention efforts.

Traditionally, humanitarian and health organizations like the Atlanta-based Carter Center have worked with male volunteers within rural villages to reduce the local incidence of disease by keeping infected persons out of the water, using a simple cloth or nylon filter to remove the water flea from drinking water, treating ponds with larvicide, educating community members to promote behavior change, and providing safe water sources. However, the men often have been unable to identify all sources of water accessed by the community because they are not the ones involved in clothes washing and other day-to-day tasks requiring the use of water. Therefore, the Carter Center’s efforts took a new turn. The center is currently working with the Ghana Red Cross Women’s Club to reduce local infection. The collaboration involves community women, the people most familiar with water-associated household practices.

In 1999, female volunteers in 393 villages conducted door-to-door surveillance of Guinea worm, distributing filters, identifying potential water sources, ensuring the women did not enter infested waters, and providing other community members with information. As a result of these efforts, the incidence of Guinea worm decreased by 36 percent between 2002 and 2003, Monique Petrofsky of the CDC’s Office of Global Health told the CDC-sponsored International Conference on Women and Infectious Diseases in February 2004. Other districts had a 56 percent increase in cases during the same period.

Dengue Project in Puerto Rico

Dengue, which thrives in poor and crowded urban areas of tropical countries, ranks as the most significant mosquito-borne viral disease in the world, according to WHO. Transmission to humans occurs through the Aedes aegypti mosquito that dwells around homes in water-storage containers and discarded items associated with poor water supply and waste disposal. Dengue hemorrhagic fever, a more severe form of the illness, causes internal bleeding, and infected persons can progress to shock and death within hours after the onset of symptoms, says WHO.

WHO estimates that up to 50 million infections occur every year in more than 100 countries. Eliminating dengue is challenging for many reasons, including the absence of a vaccine, the minimal impact of pesticide spray, and the primary role that manufactured containers play in the life cycle of infected mosquitoes. For these reasons, prevention has been the best approach.

Because women often are most knowledgeable about household surroundings, CDC recently partnered with the U.S. Head Start program in Puerto Rico to establish a novel prevention strategy that relies on community health workers known as promotores. Local women, who were nominated by fellow community members to be leaders, received training to help promote behavior change within the community. These promotores made house-to-house visits, interviewing heads of households and inspecting areas around homes to ensure the absence of containers and other manufactured objects that could serve as breeding grounds for the mosquito. The promotores also engaged in a number of community education activities, including painting a bridge with dengue prevention messages, organizing a children’s parade to provide the community with dengue-related information, and creating a dengue prevention exhibit at a local supermarket.

The education efforts resulted in positive behavior change: 20 percent more households turned containers upside-down to prevent larval infestation in the intervention community than did those in other communities, the CDC’s Hilda Seda told the participants at the February conference.

Future Directions

Although much remains to be learned about the best ways to promote health among women, novel infectious-disease interventions that result in positive health behavior shifts in hard-to-reach populations are gaining attention. Devoting resources to such intervention strategies might serve not only to level the playing field for women with regards to infectious disease, but may also serve to strengthen the positions and the self-esteem of women entrusted with helping to improve and save the lives of family members and peers.

Rachel Wilson is a medical writer and editor in Atlanta, Georgia.

References

Thomas R. Eng and William T. Butler, eds., The Hidden Epidemic: Confronting Sexually Transmitted Diseases (Washington DC: National Academy Press, 1997).

Joint United Nations Programme on HIV/AIDS (UNAIDS) and WHO, AIDS Epidemic Update: December 2003 (Geneva: UNAIDS and WHO, December 2003).

Mary Kay Kindhauser, ed., Communicable Diseases 2002: Global Defence Against the Infectious Disease Threat (Geneva: World Health Organization, 2003).

Monique Petrofsky, “Successes with Guinea Worm Work” (presentation made at the International Conference on Women and Infectious Diseases, Atlanta, Feb. 27-28, 2004).

Hilda Seda, “The Role of Women in Dengue Prevention: Results of a Pilot Study in Puerto Rico” (presentation made at the International Conference on Women and Infectious Diseases, Atlanta, Feb. 27-28, 2004).

World Health Organization (WHO), Scaling up the Response to Infectious Diseases: A Way Out of Poverty (Geneva: WHO, 2002).