Priority Disease Groups for Women
Table 10.4 presents conditions with excess burdens for women divided into the four groups defined earlier.
[Table .]
Conditions Specific to Women
In developed countries, advances in medical technology have almost eliminated the burden of disease resulting from maternal conditions. Three types of cost-effective intervention packages for maternal conditions are the prevention of pregnancy by means of effective family-planning methods; the prevention of complications (for example, hemorrhage); and the prevention of death or disability resulting from complications through emergency obstetric care. Proven technologies also exist for screening and early detection of some neoplasms, although their implementation has been uneven. Problems pertaining to conditions in this category are not simply related to the availability of medical technologies, but also to the behavioral and social factors that influence women's exposure to risks and underuse of services as well as the economic and institutional factors that influence the availability and quality of services, especially in developing countries.
Even though the international women's health movement has promoted significant advances in the quality of care for reproductive health and maternal conditions in the past 25 years, the main challenges in relation to conditions specific to women include reaching poor and socially excluded women with basic maternal and reproductive health services; strengthening the adoption of preventive health behaviors in developing countries; extending the quality of care to other conditions specific to women, including neoplasms; and educating and empowering women to promote their own healthy behaviors.
Conditions Associated with Women's Greater Longevity
The main group of diseases with excess burdens for women associated with women's greater longevity are Alzheimer's disease; musculoskeletal disorders, such as osteoarthritis, rheumatoid arthritis, and osteoporosis; and cardiovascular diseases,3 which together account for 12 percent of total DALY losses for women worldwide. LMICs account for about 80 percent of the DALYs resulting from these conditions, likely because of the lack of medical care during the early stages of these diseases.
Alzheimer's disease and other dementias account for 1.5 percent of total female DALYs, and this burden is almost twice as high as that for men. About 46 percent of this burden is concentrated in HICs and 54 percent in LMICs, but DALYs lost per capita are much greater in the HICs than in more densely populated LMICs. Because of population aging, during the next 50 years the number of people with Alzheimer's disease is expected to more than double, with more women affected than men (McCann and others 1997). Studies of the effects of estrogen therapy on Alzheimer's disease have been inconsistent: estrogen may increase the risk of both dementia and other diseases such as stroke in postmenopausal women (Shumaker and others 2003).
As concerns musculoskeletal disorders, osteoarthritis affects 9.6 percent of men and 18.0 percent of women age 60 or older worldwide and accounts for 1.5 percent of total female DALYs. Osteoarthritis is related to aging and is most common in overweight women over the age of 45. Demographic changes in developing countries, especially middle-income countries, indicate that osteoarthritis prevention and treatment needs will increase during the next decade. Most prevention and treatment are linked to regular exercise, healthy weight management, physical and occupational therapy, and pain management with over-the-counter medications.
Because cardiovascular diseases are generally thought of by society as "men's diseases," women tend to delay seeking treatment for cardiac-related events (Seils, Friedman, and Schulman 2001). However, cardiovascular and cerebrovascular diseases account for about 8.2 percent of total female DALYs, more than half of which is caused by cerebrovascular diseases.
In addition to age, smoking, and obesity, another risk factor that exposes women to a greater burden of cardiovascular diseases is depression, which is associated with increased morbidity and mortality from heart diseases and is highly prevalent in women (Linfante and others 2003). Also, women's symptoms of heart disease tend to be different from men's, increasing the difficulties of diagnosis (Seils, Friedman, and Schulman 2001). Finally, evidence suggests that physical activity significantly reduces the risk of cardiovascular events; however, women tend to exercise less than men (Manson and others 2002). Whether this observation can be generalized to all age groups and whether it occurs because of biological factors or social norms deserve further attention.
Conditions Arising from the Interaction of Sex and Gender
In the group of conditions resulting from the interaction of biological and social factors, unipolar depressive disorders have the most significant gender ratio and most unequal burden of disease in every region except East Asia and the Pacific. Unipolar depressive disorders account for 4.2 percent of women's global burden of disease. Even though the DALYs lost per capita are similar in LMICs and HICs, these disorders represent a higher share of women's total burden of disease in HICs (7.3 percent) than in LMICs (3.9 percent). Another important consideration is the high comorbidity between depression and other psychiatric disorders (for example, anxiety disorders). Neuropsychiatric disorders account for 11.8 percent of women's total global burden of disease and 23.5 percent in HICs.
The exact contributions of biology and society in the etiology of depression are unknown. Some believe that genetic causes account for about half of the risk for mood disorders (Zubenko and others 2002), whereas others suggest that gender roles, stressors, social relationships, and personality traits may play a larger role than hormones and neurotransmitters (Bromberger 2004). As concerns biology, aside from genetic predisposition, the fluctuation of sex hormones, especially estrogen, during women's reproductive life is believed to be an important risk factor for depression (Bromberger 2004). As concerns social factors, poverty; lack of proper nutrition and education; stressful and insecure life circumstances; and domestic and sexual violence and the concomitant feelings of loss, entrapment, and lack of control are likely at the root of depression (Bromberger 2004; WHO 2000).
Treatment for depression includes medication and psychotherapy or counseling, and instruments are available to assess the severity of depression, including prenatal and post-partum depression. In developing countries, severe depression and anxiety disorders go mostly untreated (76 to 85 percent of serious cases receive no treatment), partly because of ignorance, social barriers, and stigmatization, which may affect women's access to treatment (WHO 2004). A main challenge, therefore, is increasing women's access to treatment for depression in developing countries by creating systems that help them overcome social stigma and economic and social barriers.
In addition to treatment, prevention of depression and other mental illness needs to address women's role in society and the control they have over their lives and circumstances. According to the World Health Organization, pertinent factors are related to having sufficient autonomy to exercise some control in response to severe events, access to adequate resources to be able to make choices, and social supports (WHO 2000). The promotion of healthy behaviors, including exercise, is also crucial for prevention.
Gender-based Conditions
The main characteristic of gender-based conditions is that they have no biological referent and can, therefore, be prevented by means of behavioral change. The role of social components in this category explains excessive health burdens for women in particular world regions. For example, women are disproportionately affected by fires in South Asia, an outcome of the violence caused by dowries. Too often women die in what are called "cooking fire accidents," whereas in reality they are murdered so that their husbands may remarry and obtain another dowry.
Another characteristic of the diseases and injuries in this category is that they are often underreported because of stigma and social pressures. As a result, the data probably underreport the true extent of the problem. FGM and domestic violence are two examples. In 2000, estimates indicated that 100 million to 140 million girls and women had undergone FGM and that more than 2 million girls were at risk. At least 28 African and Middle Eastern countries practice FGM for social, cultural, or religious reasons (WHO 2000). Unfortunately, global burden-of-disease data do not report the resulting DALYs lost. Regarding violence against women, 10 to 50 percent of women report having been physically abused by an intimate partner, and 12 to 25 percent report attempted or completed forced sex. Although men experience more absolute DALY losses from violence, women are also seriously affected. In 1998, interpersonal violence was the 10th-leading cause of death for women age 15 to 44 worldwide.
Given the complexity of these health problems, comprehensive interventions are necessary. Changes are needed in the following areas:
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legislation and law enforcement
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public policies and programs in areas such as health, education, and police and legal services
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training of service providers and creation of gender-sensitive services, especially at the community level
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education of the general public to create awareness, behavioral change, and promotion of advocacy groups
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better data collection, research, and understanding of the individual and social mechanisms sustaining these problems.
