Women, health and development [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION JUNE 1980 Women, health and development k` r The World Conference of In- ternational Women's Year, held in Mexico in 1975, agreed on certain goals and strategies aimed at improving the social, economic and political status of women, and embodied them in a World Plan of Action. The General Assembly of the United Nations subsequently endorsed this World Plan of Action and .pro- claimed 1976-1985 the UN Decade for Women, so as to encourage member nations to identify priorities and develop strategies towards achieving the goals outlined in the Plan. In July 1980, at the mid-point of the Decade, a World Conference is to be held in Copenhagen, to evaluate progress made thus far, and to renew and refine the Plan for the remainder of the Decade. Within the overall Decade ob- jectives of Equality, Development and Peace, the sub-theme of Employment, Health and Education has been chosen for the Conference. In preparation for Copenhagen, the UN has carried out a survey of UN Member States to deter- mine what progress has been made, and what obstacles remain to be overcome in achieving the goals of the World Plan of Action. Of critical concern in this global analysis is the health of women. How are we to measure women's health? If we compare women and men, in all but a few countries women have a greater life expectancy; by this criterion Increasingly, all over the world, women are taking a greater part in decision-making. (Photo WHO/ UN) one might be tempted to assume that women enjoy a higher health status than men. Yet the results of the UN survey—to which 92 governments responded—indi- cate that, although modest improve- ments are undoubtedly occurring in such aspects of women's health as increased life expectancy and declining maternal and infant mortality, women's health status was reported by most countries as generally lower than men's. Maternal and infant mortality, moreover, are still unacceptably high in certain countries, and in particular groups. There are increasing disparities in health status and in the quality of health care between women in affluent coun- tries and those in poor countries. Socio- economic changes injurious to health and characteristic of underdevelop- ment—explosive rural/urban migration, unemployment and underemployment, the proliferation of slums, the spread of infectious disease, prostitution, violence, alcoholism and drug abuse, and the breakdown of traditional family support systems—all these features reduce the ef- fectiveness of measures taken by govern- ments to improve nutrition, expand health services and thus improve health status. For the majority of the world's nations this battle is being fought under increasingly adverse circumstances : the deepening world economic crisis, and the widening gap between rich and poor. In the country responses, life expec- tancy was reported to range from around 75 years in more developed countries to as low as 42 years in one of the develop- ing countries. Generally, lower rates were reported among women in lower Cover: On the threshold of womanhood. What part will this young girl play in the development of her community, the health of those around her? (Photo WHO/UNICEFIT, S. Satyan) IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Lalit Thapalyal World Health appears in Arabic, English, French, German, Italian, Persian, Portuguese, Russian and Spanish. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents Women, health and development by Lucille Mair .......... 3 Traditional patterns by P. K. Devi 6 Africa changes by Maaza Bekele 11 Fatigue by Krishna Ahooja-Patel . 14 A new frame of mind by Christiane Viedma 16 Communal garden in Laos by Ruth Seitz .......... 19 Women in the media by Esmeralda Arboleda Cuevas . 23 Listen to what women say! by Perdita Huston 27 News Page 30 Women, health and development by Lucille Mair Secretary-General of the 1980 World Conference of the UN Decade for Women Above: A scene at the World Conference of Interna- tional Women's Year, held in Mexico in 1975. Left and right: Women in poor rural communities, like these in Ethiopia and. Peru, are particularly dis- advantaged. Heavy physical work prevents them taking part in health programmes and also adversely affects their health. ( Photos WHOIUN1B. Lane, WHO/ UNICEF/ Campbell and WHO/ UNICEF1Mangurian ) socio-economic groups, among women in rural areas, and among some racial and indigenous groups. Similar wide dis- crepancies exist in maternal and infant mortality rates. And although improve- ments are reported by most countries, such generalizations disguise persisting or even worsening rates in some popula- tion groups, and obscure conditions of low-grade ill-health such as anaemia, malnutrition, disability, and infection resulting from too frequent or comp- licated pregnancies, or from unskilled abortion. Because of the vital importance of a woman's health and nutrition to her role as mother, to the survival of her children and to the well-being of the family, atten- tion to women's health is primarily focussed on child-bearing and maternal and child health care. But because child- bearing tends to occupy a diminishing period in women's lives, women's health problems must be seen in a total life concept, and health planning accordingly must encompass the changing roles of women in the family and in society. The unequal distribution of health care services emerges from the data as a global problem; the disparities between what is possible in rich and poor nations are paralleled by disparities within nations. The widespread tendency to spend the lion's share of health budgets on sophisticated high-technology treat- ment of illness has led to a widening gap between the facilities available for the affluent and those available for the poor. Moreover, sharp differences exist between the availability of health care in rural and in urban areas : some 80 per cent of the world's doctors work in urban areas, while the majority of the world's population lives in rural areas. In developing countries less than 15 per cent of people live within walking dis- tance of any health facility, and half the world's women (in some cases as much as 70 per cent) have their babies deliv- ered by traditional midwives (see "Chil- dren in the World" by M. McHale and J. McHale, University of Houston, 1979). Resource constraints are a major ob- stacle to improving women's health sta- tus, according to the evidence, and this problem is compounded by unemploy- ment and inflation. Inadequate infra- structure and poor communications create further obstacles; so do illiteracy, lack of awareness and information, and traditional constraints. Training and supervision are inadequate, personnel too few; policies are often not clearly defined, and there is a lack of co-ordina- tion between different agencies involved in health care. Even in developed countries, social and sexual equality between men and women has often only been achieved at superficial levels, and this is evident in the field of health. Women are now fac- ing problems caused by such spurious symbols of equality as alcoholism, drug- taking and smoking. They are also the first to feel the impact of a rapidly ex- panding technology which affects them in three major ways: the effects of new medical technologies; their exposure to new chemicals and processes in the home, in industry and in the environ- ment; and the social consequences of changing employment patterns and of their need to acquire new skills. But all such new phenomena tend to be export- ed from the developed to the developing world, and all women share in common a vulnerability to pressures from the irresponsible advertising of drugs or of high-prestige low-nutritional foods. Women in developing countries should not have to inherit the problems that have been experienced by women in 4 developed countries; they need protec- tion from exploitation and health hazards in the work-place and, for instance, from the known and unknown effects of nuclear testing. One contradiction which characterizes the situation of women's health in many parts of the world arises from the break- down of traditional practices on the one hand and, on the other, the adherence to traditional beliefs and taboos, with a consequent resistance to new ideas and a lack of community participation. This contradiction is nowhere more manifest than in the provision and acceptance of family planning services, which are still subject in many areas to legal, social and cultural constraints. Family planning, it seems clear, should be seen as a means of promoting the health, safety and welfare of mothers and their children, especially within the high-risk groups identified by WHO, but it equally clearly remains a controversial area (see "Risk Approach for Maternal and Child Health Care", wHo, Geneva, 1978). Women face the same health problems as men, but are additionally at risk because of discrimination on the basis of sex, because of their generally lower socio-economic status, and because of the additional physical demands of men- struation, pregnancy and lactation. The very large category of poor rural women are particularly disadvantaged ; the ex- cessive physical activity characteristic of their work patterns not only precludes their participation in health pro- grammes, but also adversely affects their health. How, then, can women's health status and health care be improved? In the first instance, it is essential to recognize the important role that women have played in the provision of primary health care in the home, and as traditional healers in the community—often unskilled, unac- knowledged and without reward. But if women's participation in the provision of health care is to be increased, there are two prerequisites : women need informa- tion and skills to provide better health care at the grass-roots level, and women need equality to allow them to partici- pate effectively at all levels of the health professions. Any programme of action to improve women's health must be comprehensive and dynamic. It must be directed towards the improvement of women's total social status, in keeping with WHO's all-inclusive definition of health. Women should not be seen as passive consumers of health care, but as active participants who perceive choices and make decisions about their health. Accordingly, a pro- gramme of action should aim at increas- ing their participation at the decision- making and planning levels, and not sim- ply in the lower ranks of the professions. Better data on morbidity are needed. Economic, social and cultural indicators should be developed to give a more accurate picture of women's health, and simple indices which can be used at the grass-roots level should be developed. Improved health status for women has fundamental implications for the devel- opment of society as a whole. Specific economic targets set by countries cannot be achieved without recognition of the significance of health care for women and their equal participation in all aspects of development. For the Mid-Decade Conference to fully carry out its responsibilities in the field of women's health, there needs to be the widest possible discussion before Copenhagen as well as at the Conference itself, not only of the issues and problems which face us, but of the practical strate- gies which can lead to solutions in this Decade for Women. ■ 5 Traditional patterns by P. K. Devi The health hazards faced by men and women are of two kinds biological and social. Women are con- sidered to be the weaker sex from the point of view of stature or physical size and capability for manual labour or muscular work. Yet in spite of physical handicaps, women are considered to have greater capabilities for survival and greater resistance to stress and strain than men. Once the hazards of reproduction and child-bearing have been eliminated, the increased life expectancy of women in most parts of the world illustrates this point. Health problems which women have to face because of social factors thus assume a critical role and can aggravate or supplement the health effects of biological problems. Social structures, cultural norms and value systems have, over the centuries, evolved certain patterns or so-called "traditions" affecting behaviour of groups of men and women or communities. All aspects of women's lives such as educational and economic status, urbanization, migration, changing costs and standards of living, and modifications in family and community structure influence or modify the effects of these traditional practices. Last October, during a field visit to a village on the out- skirts of Chandigarh, Northern India, we identified six families where three generations of women were living together in the same family house. Thus the senior-most woman of the house had the daughter-in-law and the daughter-in-law's daughter- in-law living with her. We were delighted to observe the freedom with which all the women discussed, among other things, impor- tant issues related to traditional practices and women's health. The second and third generation of women showed positive attitudes towards spacing of births, delaying the birth of the first child by one or two years after marriage, use of family planning methods, antenatal care and hospital deliveries. Women be- longing to the older generations felt that there was no need to discontinue breastfeeding until the subsequent pregnancy was well on its way, though supplementary feeding should be started from the sixth month onwards. Women of all three generations expressed strong preferences for sons; the older women advocated two sons and the younger women at least one son. So it can be seen that cultural and religious traditions may not show the same pace of change, derived from educational or technological advances, as other areas of social organization do. But some significant changes have occurred though slowly over the last five or six decades in women's attitudes towards some of the key issues that relate specially to their roles as mothers and wives. Health problems peculiar to women vary tremendously from region to region and even in the same region, according to the social and economic classes of in- dividuals. Among the complex of such health hazards, we can identify three major areas which are still strongly un- der the influence of traditional practices, namely nutrition, fertility and reproduc- tion, and mental health. Nutrition Balanced nutrition is vital for the growth and development to the full potential of every individual. There is reason to believe that, because of dis- criminatory practices and strong prefer- ences for male children in many parts of the developing world, women are more exposed to malnutrition than men are, from childhood on. Among many popu- lation groups, infant mortality among girl babies is higher because of general neglect and the fact that, when food is 6 Two little girls tuck into their food in India. Among some population groups, unfortu- nately, when food is scarce, boys get more than their share of it at the expense of the girls. (Photo WHOIUNICEFIJack Ling) scarce, boys get more than their share at the expense of the girls. Field studies car- ried out in India revealed that girls are affected more commonly by kwashior- kor (severe malnutrition), but are less of- ten taken for treatment to hospitals and therefore succumb more often to the ill- ness due to starvation as well as neglect. Similarly they suffer from higher mor- bidity and mortality rates wherever cultural and economic reasons have brought about a strong preference for sons. Malnutrition involves a deficiency in all the staple foods as well as deficiency in calories. Deficient diets or suboptimal nutrition affect large masses of popula- tion, both men and women, in the under- developed countries. It appears logical that the man who provides economic support for the family gets the lion's share of what little is available for the whole family because, if he is not well, the whole family will suffer. Even the most illiterate people are aware of the need for additional nutritional support for growing children and for pregnant and lactating mothers. Thus the pref- erential treatment given to boys and men should not be interpreted as a deliberate attempt to deprive women. What is deplorable is that in societies where women also contribute to the family in- come, working on the land, for instance, or engaged in construction work, their economic contribution to the family does not receive adequate recognition. In fact, such women bear the dual responsi- bilities of working outside the home as well as taking care of the home and the children. The long-term consequences of chron- ic malnutrition in women are many. Their short stature and lower than aver- age weight because of inadequate nutri- tion during adolescence in turn leads to the low birth weight of their babies, which contributes to increased mortality and morbidity, inflicting a great deal of avoidable suffering on the whole family. "Those who skate closest to the margin of deprivation are the most powerless—the very young, the old, and everywhere, the women." Kathleen Newland Inadequate diet during pregnancy and repeated pregnancies at short intervals, before the body can build up its reserves, result in the birth of babies which are un- derweight, increases the risk of abortions and still-births, and generally contributes to increased pregnancy wastage as high as 30 per cent. Anaemia and malnutri- tion go hand-in-hand to reduce resis- 7 Traditional patterns tance to disease and contribute indirectly to the risks of death in childbirth. Throughout adolescence and the child-bearing years, women on average show a higher incidence than men of many nutritional disorders such as rick- ets and osteomalacia (vitamin D defi- ciency), goitre (iodine deficiency) and anaemia (iron, folic acid and vita- min B12 deficiency), as well as biochemi- cal and clinical features resulting from deficiency of vitamins A and B-complex. Effectively, women's needs for good quality food can never be met so long as poverty and food scarcity prevail. Ignor- ance and superstitious beliefs are less im- portant contributory factors to general malnutrition, but may lead to specific deficiencies, mainly of iron and vita- mins A and D, among more affluent communities. Since these women are more likely to seek medical care during pregnancy, such deficiencies lend them- selves to correction by appropriate sup- plementation and health education. Fertility and reproduction In all developing countries, traditional practices exert a considerable influence on such major issues as age at marriage, number of births and their spacing, nut- rition during pregnancy and lactation, breastfeeding, weaning, infant feeding practices and the acceptance of medical care and immunization. A world fer- tility survey report covering 15 develop- ing countries suggests that the average age at marriage is tending to rise, and in some Asian countries dramatically so. But early marriage is considered essen- tial for girls in the lower socio-economic groups and castes in India, in order to protect them from men of higher socio- economic orders who wield considerable economic power over these families. Early marriage deprives women of op- portunities for educational advance- ment, and this indirectly affects family health as a whole. In villages of India, newly married couples are strongly dis- couraged from postponing the first birth, and hence teenage pregnancies, with their attendant health hazards, are com- mon. Since the family size is affected by the strong preference for sons, it is ex- pected that a woman will have on aver- age four or five children in order to have two surviving sons. Breastfeeding continues to be an im- portant factor which determines spacing of births in the rural areas. Hence over a period of 10 to 15 years, the reproductive cycle of pregnancy and lactation takes a heavy toll on the mother's health, espe- cially if she also has to work outside the home to supplement the family income. Traditions have thus imposed a double penalty on women just because they are women. Pregnancy after the age of 30, particu- larly if the woman is having her fourth or fifth pregnancy, carries greater risks of complications and diseases peculiar to pregnancy. The combination of chronic malnutrition and too frequent births that is seen among the poor and the illiterate exacts a high toll in the form of an in- creased risk of maternal and neonatal deaths. As is true of any health hazard, the poorest are the worst hit. Under such desperate circumstances, it is not surprising that women in in- creasing numbers resort to abortion to get rid of unwanted pregnancies. Again, the worst sufferers of the undesirable consequences of abortion are the poor and the illiterate. The affluent and edu- cated know where, when and how to ob- tain safe abortion services, but millions of women lack the means or knowledge to take advantage of liberalized abortion laws in many countries. In other coun- tries abortion is forbidden by law, but those who can afford it are able to ob- tain it in safety, while the hospitals are crowded with gravely ill, poor and illiter- ate women suffering from the conse- quences of illegally induced abortions under poor hygienic conditions. Traditional attitudes are harsh towards unmarried or widowed pregnant women. Even in countries where low- cost safe abortion facilities are easily available, such women resort to crude methods in the hands of untrained quacks, since they are ashamed and afraid of the social consequences. Little wonder, then, that in most countries up to 50 per cent of maternal deaths are related to illegally induced abortions. In most societies, tradition encourages mainly natural family planning methods like periodic abstinence or the rhythm method. Because of strong political sup- port for family limitation and population growth curbs, and because of growing economic pressures, the old beliefs regarding the use of family planning methods are gradually being replaced by more liberal attitudes. Increasing empha- sis on education, especially the education of women, and their increasing economic independence will encourage more and more women, even in the rural areas, to adopt methods to limit their family size and thus overcome the barriers imposed by tradition. Mental health The increasing incidence of mental health problems among women all over the world may well be due to changing life styles and emotional conflicts to which women are subjected everywhere. Women seem less able to cope with tran- sitions where their traditional religious or cultural beliefs come into conflict with views and value systems which are forced on them because of changed circumstances. In India, traditionally, a girl who gets 8 Boys outnumber girls at this open-air class in Pakistan. Girls often miss the chance of going to school, or have their schooling interrupted by early marriage. (WHO/UN/B. Wolff) married is expected to sever all links with her parental home and family members, and to adapt herself to the ways and beliefs and traditions of the family into which she has married. Such adjustments are difficult, and the conditions appear particularly harsh on women since mar- riages are still arranged by the parents. The young, emotionally immature girl finds herself suddenly in a utterly strange household; it is hardly surprising that emotional problems are common at this stage. An Enquiry Committee which studied in depth the high prevalence rate of suicides in the State of Gujarat in India found that the incidence was high in women between the ages of 15 and 30 years. The Committee blamed a com- bination of physical, mental, social and domestic causes, but in particular child marriages, a lack of freedom of choice of partners, and family-to-family relationships. Women everywhere are burdened with "cumulative inequalities" as a result of socio-cultural and traditional practices which discriminate against them, and which are often taken for granted as though they were part of an unalterable, immutable scheme of things established by nature. Broadly speaking, the poor and the illiterate are more often the vic- tims of such traditions. In the words of Kathleen Newland : "Those who skate closest to the margin of deprivation are the most powerless—the very young, the old, and everywhere, the women." ■ 9

Africa changes The expectation is that a new woman and a new man will emerge from the revolutionary experience, free from colonial exploitation and equally free from exploitation on the basis of sex and social class by Maaza Bekele African countries are today experiencing a process of fair- ly rapid transition from rural subsistence economies toward more mechanized modes of production, industrialization and urbanization. This transition is taking place despite the fact that Africa's vast potential of human skills and natural resources are consi- derably under- or misused. Africa pos- sesses the largest number of the world's least developed countries and remains within the world economy primarily a supplier of raw materials to the devel- oped countries. It is the developed coun- tries which determine largely the terms on which this trade takes place. This leaves most countries (with the possible exception of the oil producers) with weak economies, and a people exposed to widespread poverty. Social and political unrest throughout the region is sympto- matic of the people's discontent. The struggle to achieve development with equity and justice is rife in Africa. Both men and women are engaged in this struggle. The question is whether African women, who are in a strategically weaker position than men (for reasons discussed below), will have equal opportunity to contribute the skills they possess to the development challenge on a fair and equal basis. Let us look quickly at the current sta- tus of African women as measured in terms of such social statistics as are avail- able. In 1975, Africa's female primary enrolment ratio (enrolment of all ages at the primary level as a percentage of the respective primary school-age popula- tion) was the lowest in the world-52 per cent, compared to 77 in Asia, 106 A father comforts a sick child in Ethiopia. The challenge which Africans, men and women alike, now face is the fight against poverty and the building of a just society. ( Photo WHO/UNICEF/P. Almasy) in South America, 107 in North and Central America, and 100 in Europe. Life expectancy at birth for all Africans was only 43.5 years, compared to 56.0 for Asians, 71.5 for Europeans and 62.3 years for South Americans. In addi- tion, whereas life expectancy at birth is normally (in both developed and deve- loping countries) higher for women than for men, an inverse relationship had al- ready appeared in one of Africa's largest countries. Crude birth rate was also higher in Africa at 45.6, compared to 43.4 in Asia, 38.8 in South America, 33.8 in North and Central America, and 16.8 in Europe. The proportion of dependent children aged 0-14 years was higher than Africa's 44.7 per cent only in Asia, which had 64.2 per cent. Female participation rates in the mod- ern, industrialized, usually urban sector are not readily available. Indications from country studies, such as one con- ducted in Kenya, are that there is a high correlation between female educational levels and the probability of gaining employment. Highly educated, wealthier women who also have good connections are usually able to get work. But the large, under-educated mass of urban poor women remain for the most part in the informal sector, in daily or seasonal (low) wage employment, in domestic work; and where there are no other opportunities they turn to prostitution. The picture appears to be rather gloo- my. Nevertheless the women of Africa have made not insignificant progress over the past 15 to 20 years. Female pri- mary enrolment ratios have risen from 27 in 1960 to 52 in 1975, and secondary from 1 to 7 in the same period. Life ex- pectancy at birth (for all Africans) rose from 35.9 to 43.5 years, and the crude birth rate per 1000 decreased from 47.3 in 1955-60 to 45.6 in 1970-75. It is expect- ed to reach 38.6 by 1995-2000. In addi- tion, in the 1950s and 1960s it was rare to find African women in executive and ad- ministrative positions in either the public or private sector. In the 1970s they became increasingly more visible. It is significant, for example, that at the Inter- national Conference for Primary Health Care held at Alma-Ata, USSR, in 1978, Africa had the highest proportion of female delegates. It is on the basis of the progress that has been made, coupled with their rela- tively high status in society, that the posi- tive participation of women in African development can be built. African wom- en need not, should not and almost cer- tainly will not become passive recipients of whatever passes under the name of development. While African women cannot be treat- ed as a homogeneous group in view of differences in historical experience, cul- tural traditions, ethnic and religious fac- tors, as well as geographical influences, yet there are many circumstances which they share in common. In the role of wives and mothers they are accorded high status. Even under the iniquitous system of apartheid, black women are held in high esteem within family and community. As women grow older, their wisdom and counsel are sought and re- spected. Many render a lifetime of ser- vice, attending the births of infants and giving ante- and post-natal care, includ- ing birth spacing advice. Women are usually their children's first teachers and where no other opportunities exist they continue to teach their adolescent daugh- ters whatever they know. Women pro- vide health care within the family and have major responsibility for satisfying food and nutritional needs. However, it is usual for the husband and/or father to dominate social and family life, with the exception of the matrilineal societies in West Africa where households may be under a female head and may consist of several of her relatives other than the conjugal family. Largely because of male dominance in 11 Above and facing page: Woman harvesting millet in Chad and market vendors in Upper Volta. Only in recent years has the important productive role of African women in agricul- ture and commerce gained recognition. (Photos WHO/ILO and WHO/ UNICEF/ B. Wolff) the home and in society at large, the true value of women's contribution outside the home tends to be blurred. It is only in recent years that the important role Afri- can women play as productive agents, particularly in agriculture and com- merce, is gaining recognition. In the vast rural hinterland where some 70-80 per cent of African people live, it is estimated that 60-80 per cent of agricultural labour is performed by women. It is predomi- nantly women who produce, process, preserve, store and market food crops; they husband animals and fetch and carry water and firewood. They also par- ticipate in sowing, weeding, harvesting and transporting cash crops—coffee, cocoa, tobacco, tea—which are the mainstay of many African economies. Women also hold a dominant position in commerce and trade in many coun- tries. In West Africa, four out of five women are engaged in this sector, includ- ing trade in agricultural goods, import and export of manufactured items and trade across borders with neighbouring countries. Generally throughout Africa women are engaged in some sort of trade, mainly to supplement family income, sometimes to provide the sole means of household support and often to have an independent source of income to sustain them following divorce, desertion or widowhood. (Some African women wear their entire fortune in jewellery which can be easily converted into cash). Even where women are required to remain in seclusion they are known to trade from their own back doors. African women, therefore, regard themselves as fully engaged in economic and social tasks which already contribute significantly to whatever development is taking place. In pre-colonial days they considered their tasks complementary to those of the men as families and com- munities strove to sustain and improve the conditions of life. In the liberation struggles women have participated and continue to participate on an equal basis with men even on the battle-front. As Stephanie Urdang from Guinea-Bissau put it, the expectation is that a new wom- an and a new man will emerge from the revolutionary experience, free from colo- nial exploitation and equally free within newly emerging societies from exploita- tion on the basis of sex and social class. But there are danger signals and the reality appears to be different, particu- larly in those countries where the prevail- ing modes of development are highly skewed in favour of a minority elite, and where economic dominance of the old colonial power remains. In particular, development policies in the agricultural sector do not reflect women's special concerns and needs. In some countries women have limited access to land, while land for food crops is sometimes usurped. Farm mechanization may decrease the work done by men (especial- ly in the production of cash crops) but in- crease women and children's work. Women participate actively in building feeder-roads to shorten the distance to market. Ironically, the same road brings the middle-man to the farm gate to pur- chase at lower prices—and sometimes from the male head of household—what women have produced. But the most severe constraint rural women face is the lack of access to suitable technologies and the money and credit needed to enhance their productivity and relieve drudgery. At best women's output remains constant despite increasing in- vestments of time and energy. The effect on women's health and that of their fam- ilies can be disastrous, particularly when they are de facto heads of households due to male migration, a phenomenon which is today widespread throughout Africa. In the peri-urban slum, life can be even more difficult for female migrants cut off from traditional community and family support. Even the settled urban poor woman is being pushed out of petty trade and small-scale processing enterprises by the industrialization process. Nor are jobs easy to obtain in new ventures, part- ly because openings are few due to capi- tal-intensive modes of production. In general, women are not equipped to bar- gain in the modern sector and enterprises exploit their need and their special skills : food processing, weaving, spinning, etc. Employment for most women is on a daily, seasonal or piece-work basis, an aspect not covered by protective legislation and minimum-wage laws. Moreover, supervision on the shop- floor, which could deter exploitation, is almost non-existent. Nor are there usual- ly basic hygienic facilities, day-care, or opportunities to breastfeed infants brought to the factory gate by older siblings. Women's health status is further en- dangered by high fertility, with much of their lives spent in a continuous cycle of pregnancy, births and dependency of their children. Although there is a high incidence of infertility in certain West African countries, which gives cause for concern, the more general rule is for women to have up to seven dependent children in the household. The effect on women's physical and emotional health of poverty, overwork and inordinate re- sponsibility, coupled with high fertility, 12 has not been adequately studied. Nor has there been a strong focus on the psycho- social effects of changing status and role in the wake of the African transition. Nevertheless it is known in the villages and urban slums that the level of mater- nal morbidity and mortality is high com- pared to other causes of ill-health and death. There is also severe wastage of in- fant and child life which women keep on trying to replace, since children have great value—social, cultural and eco- nomic—in African society. Because of the poor health of the mothers, many are born and some survive whose weight at birth is such as to put them at great dis- advantage in later life. African women are acutely aware of the fact that they face severe threats. It is largely through their own efforts that their voices are beginning to be heard. The major channels are women's organ- izations. Traditionally such organiza- tions have had as a major aim self-help and other aspects of social and economic support. But they are changing character in many countries and are becoming more closely integrated into the main- stream of the development process. In Ethiopia, for example, women partici- pate on equal basis in peasants' and ur- ban associations and in trade unions. They are being transformed from philanthropic institutions into agencies which focus attention and promote women's role in the Ethiopian revolution and in nation-building. They participate in political activities, assume leadership roles and take in hand arrangements that make it possible, for instance, for large numbers of women to participate in the mass literacy campaign. A survey conducted in 1977 by the Economic Commission for Africa's Training and Research Centre for Wom- en revealed that in more than one-half (26 out of 49) of independent African countries machinery exists at govern- ment level for the integration of women in development. Many institutions have grown out of national commissions for the International Women's Year. Some exist in the form of Women's Bureaux, sometimes attached to the Ministry of Health or Social Affairs, others are sep- arate wings of a political party, while others have the status of an independent ministry. Three priority concerns stand out in their reported activities : (i) devel- opment of women's skills and income- earning capacity through appropriate ed- ucation and training with special atten- tion to neglected areas such as science and technology; (ii) improvement of the health status of women and their families by enhancing their knowledge about health and health care and ensuring ac- cess to appropriate services, including day-care; and (iii) mobilizing women to participate actively in the decision- making process, as a way of overcoming negative attitudes and ensuring that women are not left in a position of dependence. International agencies are also begin- ning to focus more specifically on wom- en's problems and needs and to screen projects in the light of their effects on women's social status, their economic ac- tivities and their health. The health sec- tor, in particular the primary health care philosophy and strategy, is a natural ally in the cause of African women, in that the aim of ensuring social justice and equity in the process of development is identical to the goals of women's organizations. The issues are becoming increasingly clear. The challenge which Africans, men and women alike, face is fundamentally a fight against poverty and the building of a just society. What is special for women is that for this fight to succeed they must remain full participants. And African women can do this, because they have status in society and an improved health and education profile. They have an ac- cumulated pool of skills and experience which can be employed for the benefit of society at large. In addition they have the political rights they have won in the post- colonial period and, above all, they are playing an increasingly more important role in the social, economic and political decision-making process. Therefore in all respects options are still open in Africa. African women do not need to be left behind and to repeat the experience of women in western industrialized society who were left behind in the process of change and development. ■ 13 „. • • • • 4* 11.• • • 1 .411,0 4" - kik Fatigue In all societies, whether in urban or rural areas, most women work harder and for longer hours than men. Yet the fatigue factor has not been considered as an important determinant in health studies by Krishna Ahooja-Patel Because of the "social blink- ers" through which we tend to look, some of the serious problems affecting women's health have remained hidden behind the barriers of traditional habits of thought. That women are always at work across a whole range of occupations which con- tinually demand a higher input of energy and longer hours is a "hard reality" that has not yet come fully into the line of social vision. There exist large areas of darkness about the emerging outline of what women do or achieve and about the intensity and duration of their work performance. The reasons for this misty vagueness are interlinked with society's view and women's own view of what they contrib- ute to the treasury of human endeavour. Since neither their work effort, nor its performance nor its achievement receives social recognition or economic rewards, women themselves both underestimate and undervalue their work capacity. The result of this optique is that they remain physically fatigued and psychologically overburdened throughout their work/life cycle. This in turn is considered to be "normal" both by themselves and by society. The sum total of this "normal- cy" is that the constant and cumulative fatigue affects not only their work capac- ity, productivity and creativity but also in the final analysis their self-develop- ment, health and contribution to society. What is the nature and size of this problem? What are the processes by which women become fatigued? In what way does it affect their work capacity and work performance, both within and outside the household? How does fatigue become an agent of various maladies? And finally, can a healthy society afford to keep half of its population incapaci- tated through exhaustion? These are some of the points which need to be ex- amined to bring this important problem from the subterranean to the surface. Women as producers There has been very little research on the physical effects of women's work in the production process and its influence on their mental health. Whether this work is classified as paid or unpaid, mar- ketable or non-marketable, its links with work environment have not yet been ad- equately analysed. For example, what is the cause-and-effect relationship of job dissatisfaction, cultural alienation and social stress on women, by contrast with male workers with whom they share some general characteristics? The specif- ic concern for their health arises from the fact that more women than men are working in low-wage, low-skill and low- status jobs. The nature of these jobs, whether they work as typists, sales clerks, telephone operators, nurses' aides, waitresses or cleaners, requires addi- tional physical efforts which seriously endanger their health and cause excessive fatigue. As more and more women (many of them married and with small children) work outside the home, the totality of their daily tasks multiply and thus proportionally increase their work- load. As more scientific and technologi- cal equipment is brought into the facto- ries, more and more of them find them- selves in monotonous, repetitive and un- imaginative jobs on the assembly line. Similarly in rural regions, as mechan- ization is introduced on farms, the resid- ual work for women (picking, collecting, packaging and its variants) increases in intensity, covers larger areas and demands higher input of energy resources. Over and above this work are the routine daily tasks of fetching water over long distances and carrying heavy loads of produce to the market with chil- dren in their arms or strapped to their back. It needs to be noted that while the changing seasons increase or decrease the workload of male farm workers, women's work off the firm and in the household goes on around the clock irre- spective of the calendar. And in this cal- culation the socially obligatory "per- sonal services" to the male of the house- hold are not even considered as physical- ly tiring. The available information gleaned from time-budget and time-use studies in 14 • ' , ...I • -_ ;1,1 4"'"' w. the church or the family (mostly male members of the house) which decides what their destiny is or will be. Women as consumers Women at work often have to match their efforts with men. But they suffer far more from constant and cumulative fatigue. (Photo WHO/ILO) urban and rural areas shows that in all societies, compared to men, most women work harder and for longer hours and have relatively less leisure, recreation and rest. More important still, since they are generally outside the decision- making processes, they do not have any meaningful control over the nature of their work or environment. Women as reproducers Apart from the servicing jobs, mainly manual and menial, which create heavy demands upon women's energies and physical resources, they are further drained throughout their life by the reproductive processes. Their exhaustion from these processes derives from social norms, values and traditions which over- burden women's sexuality. Neglect of their health occurs at various stages; it begins early in childhood and continues throughout the reproductive ages. Wom- en themselves add to this through negli- gence by being always the last to recog- nize their ailments, consult a doctor or treat a disease. Not surprisingly, there- fore, statistics tell the sad tale that wom- en in poverty situations rarely seek medi- cal help (even if it is available), and that larger numbers of them in "affluent" societies are increasingly relying on the modern miracle of drugs to treat eco- nomic anxiety and social frustration. In many areas of Asia, Latin America and Africa, a large proportion of a wom- an's life is devoted to child-bearing and child-rearing. In a poor state of health which must simultaneously cope with frequent pregnancies, anaemia, malnu- trition and a number of other health hazards, survival becomes a game of chance. The demands on her depleted en- ergies depend on the value that her fami- ly and her society places on her repro- ductive role. Several studies on family planning, analysing women's preferences on breastfeeding, pre- and post-natal care and birth-control devices, reveal that those interviewed have constantly pleaded that "they are tired". The fati- gue factor—an important determinant of decision-making in the reproductive process—is frequently not taken into account in various programmes and projects. Thus, the creative role of women as the generators of the human race (described by economists as "capital goods") becomes even more of a physical burden when it is down-graded from being a privilege to being a punishment. The main point to note here is that women do not have any control at any stage of the reproductive process, and then it is always a third party—the state, Another dimension of "personal ser- vicing" by women is their role as food- gatherers, food-preparers and food- distributors. They are responsible for almost all household tasks related to consumption. In the words of Galbraith, they "select, transport, prepare, repair, maintain, clean, service, store, protect and otherwise perform (such) tasks ..." Since housework is not industrialized or developed into a major enterprise and since it continues to be in the private domain where the division of labour is inequitable, it is usually not included in the broad definition of "gainful activity" and is both economically undervalued and socially underrated. Its significant feature is that the continual and repeti- tive nature of its tasks, performed mostly in isolation, results over a long period in physical and mental fatigue. Even where experiments have been made in commu- nal services, women are usually allotted "inside" work while men are given "out- side" jobs. In industrialized countries, although various machines and gadgets may be available to relieve women of heavy mus- cular exertion, they often complain of in- adequate leisure and rest. There exists, of course, an inbuilt bias in the design of household equipment which requires regular cleaning. A number of studies have attempted to assign economic values to household tasks. Their results show that, as part of daily routine, wom- en carry heavy loads which permanently twist their spinal column and endanger their health status. And yet, fatigue as a factor has not been considered as an important determinant in health studies. As modern medical science advances towards preventing and curing more and more human maladies, women's fatigue as a social disease will have to be taken into account. Otherwise, as a result of the multiple roles played by women, there will probably be more accidents at work and a higher rate of absenteeism, or else a whole generation will be born of ailing mothers and the health providers of the family and community will be seriously handicapped. For human prog- ress and development, it is essential that the untapped human potential of women should at last be released. ■ 15 At the midway point of the United Nations Decade for Women, where do we stand? Mr Kurt Waldheim, Secre- tary-General of the United Nations, has this to say in a report to the UN Commis- sion on the Status of Women : Although women represent about one-half of the human race and are responsible for two- thirds of all the hours mankind works, yet they receive only one-tenth of world income and own less than one per cent of world property. These bald figures speak louder and more clearly than any amount of fine phrases. If we really want to re-distribute the world's riches and create a New International Economic Order, it is not enough merely to examine a country's gross national product, but also to dis- cover what is happening at the people level. Only then do we see that, as far as women are concerned, little progress has been made. At WHO, two resolutions in turn have been adopted—the first in 1975 and the second in 1976 on the lines of the conclu- sions reached by the World Conference of International Women's Year held in Mexico. Their objective is to further the participation of women in development, not only as consumers but also as pro- viders of health services through the pri- mary health care approach P1-IC being the ideal vehicle to promote health through development and development through health. But how can this be done? Certainly not by creating a programme whose op- erations would be guided by an outflow of paper from the Geneva headquarters and which would never get to grips with the immense complexity of the problems. A multi-disciplinary working group was first created at headquarters to study how to integrate into all the Organiza- tion's programmes elements dealing with the participation of women in health and development activities. The Director-General, Dr Halfdan Mahler, has taken direct responsibility, through the Regional Directors and Regional staff, for promoting efforts to initiate country-specific activities concerning women in health and devel- opment. Subsequently a "focal point" and supporting staff have been designat- ed at headquarters to stimulate and promote such activities in the various programmes. "Focal points" also exist in all the six Regions of WHO, and their activities will be launched and will become effective at the country level. The aim has been to create a new frame of mind within all WHO programmes and projects; when- ever and wherever a new task has to be undertaken, this new way of thinking will raise the question : Is consideration being given to the health and quality of life of women of women, that is to say, not only as mothers and keystones of the family but also as equal partners in development? For if they naturally con- stitute the majority of beneficiaries of the family health and maternal and child care services, they should also form at least 50 per cent of the beneficiaries of the other health services. A new frame of mind Whenever and wherever a new task has to be undertaken, we have to ask ourselves the question: is consideration being given to the health and quality of life of women? by Christiane Viedma 16 A maternal and child health clinic in Iran. Because of their role in the _Mindy, women are the most effective health care providers and educators available to society. (Photo WHOIUNICEFIJ. Liftin) Because of their role within the family, women can have a great impact on health and are the most obvious, and perhaps the most effective, health care providers and educators that are avail- able to society. If they are to be incorpo- rated more extensively into health work, new development patterns will have to be evolved which will give them the freedom to carry out their role to the fullest extent. How can we foster this kind of action? By informing ourselves about women's needs ; by listening to them; by encou- raging them to say what they expect from the services, to offer the planners the benefit of their experience as providers of health care, and above all to participate in decision-making. A proposal to this effect has been made to the Director-General by the African Regional Office. In many Afri- can villages there are primary health care activities which are largely if not entirely staffed by women. A list of these women will be drawn up and from them will be chosen a panel of experts in primary health care ; they will meet regularly to exchange ideas and experiences and will exercise the functions of coordinators and eventually of consultants in this field. The project will involve nine small com- munities of not more than 500 inhabi- tants during the first year, 15 the second year, 21 the third year, and so on. The primary objective is to promote the fullest possible participation of wom- en in the African Region in taking deci- sions about social and economic devel- opment through the primary health care approach. The activities which are in- tended to accelerate this participation in the villages involve many sectors, among them local health problems, drinking water supplies, environmental hygiene, promotion of cottage industries, anti- illiteracy programmes, agriculture, org- anizing cooperative programmes and daily work schedules including running creches and baby-minding schemes, and professional training. For this project, WHO will provide rainwater tanks, bicycles for the health workers, essential drugs, vaccines and refrigerators for storing them. UNICEF will provide kits for the use of traditional midwives who have been given some degree of training. The countries them- selves will be responsible for choosing the localities and giving the necessary logistic support. Two factors are expected to emerge from projects like this. Firstly, it is hoped that the participation of women will im- part new energy to development in all sectors and will result in a substantial im- provement in the quality of family life. Secondly, such projects should enable women to advance resolutely towards the goals of equality, development and peace. ■ 17 Air.. 1=-* 1 7i.st 4,01 Ok. L '%•-- .444 • 4-14, '4! 4.` 1r - „1„. : w Communal garden in Laos In an effort to equalize opportunities for men and women, rich and poor, Laos has granted basic literacy and political involvement to people like Souvanna, a 37-year-old widow by Ruth Seitz Souvanna's hands deftly plucked weeds from the rows of yellow-green lettuce. The relaxed face of this Lao widow showed that she enjoyed nurtur- ing the land to produce food. The task of raising vegetables tradi- tionally falls on women in Laos, and it becomes an arduous one when poultry, pigs, children and even ants ruin their fenced plots of earth. Village women spend much time chasing these invaders. Souvanna Suksaengsumran explained why vegetable-growing is easier for her. "This garden of four hectares belongs to seven families. We share the work and the produce. Instead of having a plot near to home—and therefore near the animals—we requested a site from the Ministry of Agriculture." Each day this 37-year-old mother or one of her four children bicycle to their communal garden. They stake tomatoes, plant seeds in raised beds every few weeks so that greens can be harvested year round, and enrich the soil with a mulch of rice husks. We had walked about a kilometre from Souvanna's house on the outskirts of Vientiane and had crossed a narrow bridge—only wide enough for pedes- trians and bicycles—over the Mekong River to an island of gardens. The river had flooded several months before and, as it receded, families had planted dry- season gardens on its banks extending down into its fertile bed. The vegetable plots and papaya groves on the plateau of the island were also lush. "We pump water out of a well and fill a reservoir for watering the land", Souvanna explained. The November light was fading, and Lao men and wom- en hurried to finish their dipping and sprinkling before night fell like a curtain. Children hand-pumped while they checked the hose that carried the water supply by gravity flow to a concrete- lined reservoir. Souvanna stepped down into the water on wooden slats fastened to the side and dipped her sprinkling cans into the pool. Balancing her load, she moved quickly up the vegetable rows with the water streaming in showers from both sides of her lean, strong body. Souvanna Suksaengsumran, elected head of a 27-household community in Laos. Left: Souvanna fills her sprinkling cans in the communal reservoir. (Photos B. Seitz c ) The garden of these seven households was organized by the participants them- selves. An elected head determines what work needs to be done, while another person is put in charge of dividing and selling produce. Half is sold at Nong Duan market, four kilometres from the island plot; the other half is divided into seven shares for the members. When the tomatoes are just beginning to ripen, all are sold; only surplus pickings are shared. Souvanna said that the week before I visited the garden she had received about three kilos of tomatoes and 15 kilos of greens. One of her favou- rites is swamp cabbage, a green that is high in nutrients. Her nephew, Soradetj, pointed out the water buffalo that the group hired for ploughing. "None of us owns one", he said, "but when our garden is organized under the proposed 'Office of Gardens', we will have some government benefits, including tools and seeds." Since their intensive cropping requires much fertiliz- er, no doubt he hopes this too will be available. Souvanna pointed to a sweet potato vine, and observed : "This vegetable is important if we lack rice." A shortage of this staple grain is more than a fearful dream in Laos, one of the poorest coun- tries in the world. An overwhelming majority of the people are subsistence farmers, but the country continues to have an annual rice deficit of 100,000 tons. Prime Minister Kaysone Phomvihan has encouraged voluntary collectivization in an effort to reach the country's priority of self-sufficiency in food production. To this end, Souvanna's family partici- pates in a district rice-growing venture, with over 3,000 households sharing the work and reaping a harvest that is still slim. Besides planting and threshing, she helps to repair irrigation canals three times a month during the slack period. At present, the people do not intensively cultivate the glutinous rice that is their daily fare. The little landlocked country of Laos looks to hard-working women like Sou- vanna Suksaengsumran for far more than raising food. When the communist 19 Communal garden in Laos Left: Duck soup is on the menu for the family's noonday meal. In Laos, the mothers have always carried much decision-making power within the family; today they have also gained community responsibility. The administrative unit which Souvanna heads is empowered to settle neigh- bourhood disputes, handle requests for marriage permits, and provide a channel for revolutionary teaching. Right: More than 3,000 households share the work of harvesting the rice crop in response to the government's call for voluntary collectivization. The object is eventually for the country to reach self-sufficiency in food production. ( Photos B. Seitz c ) Patriotic Front formed the Lao People's Democratic Republic in 1975, nation- building started from scratch. Thirty years of war and foreign domination had scarred the land and the people; in its underdeveloped state, such basics as a health care system, a transportation net- work and production-marketing links were absent. But before any systems could be devel- oped, the new revolutionary government realized the need to free its 3.2 million people from illiteracy. The female half of the population had been particularly cheated. According to a government source, when Laos was a colony in the first half of this century, 99 per cent of the women were illiterate. By 1975, some progress had been made, but still only one out of three could read and write. Souvanna explained why she went through girlhood without going to school. "Our family worked as labour- ers; we got a share of the harvest as pay. I was the youngest of five, and if I helped also, we got a little more. So I worked in the rice fields while the rich children went to school." But the longing to understand the deli- cate Lao script never died inside Sou- vanna. "After I got married, I didn't think about myself because I worried how I would be able to pay for my children to go to school." Her worries increased when her husband died of cancer. "But since the Revolution, they go to school free and I do also. Since I started in 1976, I haven't paid anything." Sou- vanna's eyes lit up. Clearly, a sense of wonder still surrounds this educational opportunity. For the past four years, she has studied reading, writing and arith- metic for two hours, several evenings a week, at the Bung Kha Nyong pagoda. "Now I can make a market list and read the newspaper", she said with pleasure. The programme is so arranged that someone attending three nights a week can complete two courses in one year, after finishing primary school. Govern- ment employees volunteer to teach even- ing classes at the advanced level twice a week. The government's policy is embodied in the slogan : "Those who are illiterate must learn; those who know already must share." Slowly but persistently, Laos is tearing down this barricade to individual and societal development. The government claims that 80 per cent of the population is now literate. The goal is for every citizen up to 45 years to have basic literary skills by 1981. In Laos, a mother has always carried much decision-making power within the family—and has usually held the purse. But since the Revolution, Souvanna and other women have also gained communi- ty responsibility. The smallest adminis- trative unit in Laos is the nuoy, which may have only ten households. Several nuoys make up a village or ban, and the commune or tasseng is the next level. Three years ago Souvanna was elected to head her nuoy, which settles neighbour- hood disputes, handles requests for mar- riage permits and provides a channel for revolutionary teaching. At a recent seminar in her nuoy, the leader reviewed the three cleanlinesses : Live cleanly. Eat cleanly. Drink cleanly. These directives have special implica- tions for Lao women. As regards the third, for instance, government posters now urge women to boil the water they carry home each evening for drinking. And sanitary agents encourage commun- ities to hang a bucket above the well so as to avoid ground contamination by the various containers used by villagers. Souvanna knows that the well 100 meters from her house is relatively safe, but she and her nuoy have not yet done anything to keep it so. She explained that the new regime strongly discourages the chewing of betel nut. "Mothers feel it is good for their health because they feel dizzy and 20 weak." Many market women still twirl the orange-coloured stimulant in their mouths. Khemphet Pholsema, a leader of the Lao Patriotic Women's Associa- tion (LPWA), an arm of the Party, com- mented : "We don't force women, but ed- ucate them to change their ways of think- ing." She pointed to another "traditional yoke to progressiveness among women", which prevents them upgrading their abilities to produce as much as men. "If we followed the superstition that it's dangerous to work when certain events occur, we would be idle for ten days a month." Mobilizing Lao women for productive labour is the main function of thee LPWA, which claims a quarter of the country's women as members. Women in govern- ment have organized day-care centres in each ministry, and village women like Souvanna arrange for child care at their production base. "During the rice harvest, some of us take care of the children at one home so others can do collective work." The 40 Association members in Sou- vanna's nuoy of 27 households also serve as a neighbourhood welfare agency. "We give rice, clothes and other necessities to two old men in our nuoy who have no children." In addition, the proceeds from marketing vegetables raised by the fami- lies in Souvanna's nuoy help to provide for the needs of the poor and the bereaved. A widow herself, she com- ments: "This system is good." Although over the past four years food production and the eradication of illit- eracy have taken precedence over health education, women have played a part in the slim progress made in medical ser- vices. For example, commune or tasseng dispensary workers are training village health workers with the aid of a clearly illustrated manual. Both WHO and UNICEF are promoting this government effort. For many years Lao grandmothers, the meretow, have gathered around sick people to give advice. Their suggested cure may be unrelated to the cause of the sickness. "Stay away from cucumbers", they may advise a fever-wracked person. However, some traditional practices are healthful and sound. For instance, Souvanna breastfed each of her children and drank the nourishing milk of the young coconut during pregnancy, and she imagines that her daughters will do the same. When her youngest child, seven-year-old Tienchay, gets a fever and headache, Souvanna immediately thinks of malaria. She chooses one of two sources of medical treatment—a tasseng clinic about 300 metres from her house or a mojah, a Buddhist monk who knows herbal remedies. For malaria, he may recommend that Yaphagnayen, a prep- aration from the roots of several trees, be taken with honey. Most of his cures are free—as indeed are the medicines at the clinic. But there may not be any malaria depressant available because commercial drugs are scarce. "It's hard", said Sou- vanna, aware that many necessities are lacking in a struggling economy. Herbal plants do provide a useful al- ternative at times. "Most of us know a few of them", commented Souvanna. "For example, I boil the roots of the guava to make a tea to stop diarrhoea." In an effort to equalize opportunities for men and women and rich and poor, Laos has granted people like Souvanna basic literacy skills and political involve- ment. As of yet, few economic improve- ments are among the benefits. The pro- duce that this widow takes to the market buys few goods, and such things as school notebooks fall into the category of luxuries. However, she remains committed to group production, hoping that her effort will increase the tasseng rice yield and the kilos of vegetables that she receives from the collective garden. She has a firm will to haksaat—a Lao verb that means "to love your own nation". ■ 21 . gt - ;• 24,...6 • , t els „- • ; Women in the media An alarming gulf separates the traditional stereotypes transmitted by the media from the real women of today. All concerned with women and the media should seek reforms—and the time for action is now! by Esmeralda Arboleda Cuevas The closer we draw to the World Conference marking the mid-way point of the UN Decade for Women, the clear- er it becomes that we need a more accu- rate image of woman than the one reflected in the mass media. What, fun- damentally, is that image? A provisional answer has been given by UNESCO. Citing allegations by militant feminists that the media propagate and perpetuate a stereotyped image of women, which in turn serves to perpetuate their inferior social status, UNESCO reports that, whereas theoretical analysis of female sociology has paid considerable atten- tion to women's position and role in society, few studies of an empirical nature have actually considered the rela- tionship between women and the media. All we find are a handful of reports, or even literary essays, of a fragmentary character—not the kind of material from which to derive a clear and rounded pic- ture of the image of women put forward by the media. No doubt one reason for this is, first and foremost, because that image is in a constant state of flux. But the available data suggests a portrait that is traditionalist rather than truly repre- sentative of the modern age. The University of Louvain in Belgium did indeed carry out a study showing A wedding in Bolivia. Are the mass commu- nications media perpetuating a stereotype image of woman as wife, housewife, mother, sex symbol? (Photo WHO/UN/Rothstein) that the newspapers invariably define a woman through her relationship with a man, emphasizing either her role as mother or wife or else as a sex object. If women are written up in news items, it is because they are women, and even when they are shown as engaged in activities outside their traditional role—as women politicians, activists or sports stars—they are still described in the same old tradi- tional terms. This same outlook is also thrust willy- nilly on the readers of newspapers. The women's pages constantly offer articles about cooking, fashions, news of high society or those forms of entertainment that have always been considered as of prime interest to women. It is even sad- der to record that women journalists are contributing so little to the development of "the new woman". One can only hope that the growing numbers of women reporters should at least help to increase the chances of painting a new picture. Women's magazines depend heavily on advertising and therefore tend to per- petuate the images that conform with an essentially masculine society. So they go on showing women as housewives or in roles that have only the slightest influence on the future of society. The pages of these journals imply that certain products are absolutely vital to improve one's home or one's personal charm, and take for granted that these two elements are the be-all and end-all of female existence. Radio and television Despite the immense possibilities that radio offers as a popular means of com- munication, critics and research workers who study the functions of the media give little serious thought to the ways in which radio could contribute to improv- ing women's condition. Even in indus- trialized societies, radio perpetuates an image that is based on the partial vision that man has of woman. Two studies confirm this, one of them carried out in the USA in 1975 and the other made in the UK, two years later. In the United States for in- stance, there is no tie-up at all between women and the radio programmes. More than a third of the radio stations included in the study broadcast no pro- grammes for women, and those which did allocated only 1.4 per cent of their time to them. The picture is even grim- mer in the countries of the Third World; the use of radio for teaching purposes or as a factor in development has proved to be both ineffective and inadequate, mainly because of differences of opinion between those who prepare the pro- grammes and those who are trying to im- prove economic and social conditions, the level of education and the transfer of information. Television has more impact than radio, or at least so it appears from studies that have been made of women's attitudes. But here too, apart from some 23 slight progress in programmes aimed expressly at women, all television programmes still present the same old stereotyped image. News programmes for the most part ignore the participation of women in society, no doubt because there are fewer of them in the ranks of journalists and of television news read- ers, but also because television pays little attention to subjects that are truly femi- nine. Entertainment programmes for the most part show woman as a purely deco- rative object or else as a wife with nothing in her head but housework; vir- tually always she is a passive individual, dependent on a man at the economic, emotional and physical levels. The film image Cinema as a means of communication is failing to convey the changes that are now taking place in the roles allotted to each of the sexes—changes that more ac- curately reflect their true behaviour in society. The Louvain University study comes to the conclusion that further in- vestigation is necessary, and suggests a closer look at the history of the cinema, film criticism and related theories with a view to stimulating programmes that will devote greater attention to the new wom- an. This in turn would promote a new approach to the image projected on the screen. Training in this field and more job prospects should be opened up to women by the film industry: this would help to counteract the absence of female film directors and scriptwriters—an absence which no doubt accounts for the distorted image of woman given by the cinema. But we ought to be thankful that the feminist movement has aroused considerable interest, both in theory and practice, in improving that image, partic- ularly in Western countries. Impact of advertising The information we have available on advertising—the medium of communica- tion whose image of woman has the most impact and whose influence on the pub- lic at large is the most powerful—indi- cates that the woman is generally seen as the consumer most susceptible of being persuaded. Women are used to sell both male and female products, and with this aim in mind the role they are accorded is once again that of housewife, mother, wife or decorative sex symbol. However, two recent trends suggest that some sort of adaptation to the new social conditions is beginning. The first is a decrease in the number of housewives shown in advertisements, and the second the increasing stress placed on the wom- an's physical appearance. The first ten- dency could be seen as a positive factor, but the second wipes out any hope of seeing advertisers concern themselves, however slightly, with improving the sta- tus of women. In fact what has happened is that the advertising industry has ac- knowledged that the housewife image no longer works and has ceased to bring in commercial returns. New images replace 24 Women in the media Left: In the industrialized countries, the image of woman offered by the media is either of a secretary ( to a male "boss -) or of a . filmstar sex goddess. (Photos WHO/ ILO and WHO/J. Mohr) Right: Even today in some parts of the world, custom obliges the woman to wear the veil in public. Nevertheless, various national and interna- tional bodies are striving to improve the image of woman in all aspects of development. (Photo WHO/UNICEF/T.S. Satyan) it—but the woman is as much exploited as ever, mainly as a sex object. Very often, while pretending to support the cause of women's liberation, the industry perpetuates the same old traditionalist view. Even in such industrialized countries as the United States, where the media are supposed to offer a less stereotyped im- age, progress is slow. In television plays, for instance, women tend to be always about 20 years of age, while men are around 30 or 40. Women are invariably shown as secretaries, nurses, housewives, while men appear as lawyers, doctors and so forth. Furthermore, the pro- grammes screened during family viewing time offer stereotyped portraits of women to a greater degree than the programmes that are transmitted later in the evening. Action now! An alarming gulf separates such tradi- tional stereotypes transmitted by the media from the real woman of today, who is the product of the dynamic evolu- tion of our times. It is essential for all those concerned with women and the media to try to bring about reforms. Since all strategies for change take a cer- tain amount of time and demand a great deal of effort, the time for action is now. The few limited movements in various parts of the world which are trying to bring about a definitive change need to be headed in the same direction, whether they stem from groups interested in human rights or from feminist organiza- tions. Everyone should support the eff- orts that various national and interna- tional bodies are making. The focus of these efforts rests with the United Nations and the specialized agencies, which are striving to improve the image of woman in all aspects of development. A positive first step would be for all those who are interested in this question to join forces in making a critical evalua- tion of the situation, and to draw up a set of clear guiding principles which would promote further action and serve as a legal basis for future situations. In the foregoing context, let me under- line the importance of the mandate con- ferred on me by the United Nations Eco- nomic and Social Council. Through a close analysis of the existing documenta- tion and from the replies to a question- naire sent to member states and to all interested non-governmental organiza- tions, I hope to draw up some general directives on how the media can be in- duced to modify the image of women in a positive way. These guidelines will be ad- dressed to women working in the press, radio, television and the cinema. They will deal with the role of women in tele- vised news reports and news features, in entertainment programmes, in works of fiction and in advertising. To do this, we hope to establish a cordial working collaboration between the mass com- munications media and public education in general. ■ 25

Listen to what women say ! 66 I have come to believe that the strongest single barrier to humane, commonsense development—which takes into account the potential of women's involvement—is the attitude of men 99 writes Perdita Huston Just about the time I had come to believe that we could do away with the separatist jargon of "women in develop- ment"—because it had served its pur- pose as consciousness-raiser and prod- der—I went to a meeting. In fact two meetings : one in New York, the other in Washington. At each meeting, a man— known for his good intentions and long- time involvement in development issues, a person who has great influence on the allocation of funds and programme design—destroyed my faith in the pro- gress I thought had been made in these past years. Each clearly demonstrated to an audience of women from both deve- loping and developed nations that he had no grasp of the common sense of "wom- en in development" efforts, nor that he had any humility whatsoever to learn from or even listen to the women present. In sum, I'm discouraged. Right there, in the modern buildings consecrated to serving the poorest of the poor, you find leaders displaying as- tounding ignorance on the very basic question of the survival and the partici- pation of one half of the world's popula- tion. I've come to believe that the strongest single barrier to humane, com- mon sense development—which, among other things, considers the potential of women's involvement in development efforts—is the attitude of men. Evidently, some men continue to think of women as type-cast in the moulds of passive, ignorant childbearers. The poor "We want to be heard!" Women raise their voices in India. (Photo WHO/R. Rai) must be ignorant or they wouldn't be poor, right? As a result, only a minute quantity of the funds allocated to devel- opment assistance have ever been used to find out more about what the "ignorant poor" think, want, need or aspire to. Our great assistance leaders walk in darkness, ignorant themselves about the human beings they are charged to serve. If social development (which I assume "development" in the broadest sense is all about) necessitates a trust in people, why is it that our planners rely on statis- tics and scientific analysis rather than on the expressed needs of the people they serve. Why don't they listen to people? The most blatant example of this failure to consult those Who are the recipients of assistance programmes is in population policy. It was only in recent years that anyone dared to challenge the firmly-held view that the population ex- plosion was all women's fault: "Women are ignorant and have no meaning to their lives unless they have lots of chil- dren"... But, lo and behold, when wom- en began to be questioned about their attitudes towards family size (provided they were asked by women), we learned that they did not want to have as many children as they were bearing. We learned that their legal, economic and social status was so linked to their hus- bands' that they had no choice but to fol- low their husbands' will. If he is not pleased with her, she can be cast off. How then can a woman refuse to obey her husband in any facet of her life, least of all the crucial issue of fertility? If her husband wants to prove to everyone that he is virile, his wife must produce anoth- er child; she is obliged to go on with childbearing whether she likes it or not. Yet the policy planners call her "igno- rant" because she has been told about contraceptives but has chosen not to use them. The fact is that she has no choice in the matter whatsoever. She must do her husband's will. In a world conscious of cost-effective- ness, this blindness to the very origin of a problem is shameful. Hundreds of mil- lions of dollars have been spent on "motivating women" to have fewer chil- dren. Women are told constantly that the control of fertility is their problem. Yet, if anyone had ever bothered to listen to them, they would have realized that it is not necessarily a woman's decision. And so the cycle of bureaucratic ignorance continues. To put the situation in a nutshell: we have overlooked the role of men in popu- lation programmes, and now have come to realize that we have left women out of development strategies. Supposing the planners did indeed lis- ten to women, to the vast hundreds of millions of women who are poor, illiter- ate and malnourished, what would they learn? First they would learn that illit- eracy is not a barrier to common sense and wisdom. They would learn that women know what they need and want: they want to participate in the advance- ment of their societies, they want to learn how to provide more effectively for their families. The planners would learn that women are perhaps the most relevant agents of change we have to work with in our endeavours to create a more humane global society. 27 Listen to what women say! Left : Especially where women share in hard physi- cal work, the labour laws must be made equi- table to both sexes. Everywhere, the woman is still expected to carry the household burdens in addition to her day's work outside the home. Right: While most societies are undergoing a rapid transition, improvements in the women's status are taking place with desperate slowness. Just as ire hear pleas for greater North-South dia- logue, so we must continue to plead fbr an lin-- proved dialogue on the roles and the potential of women in today's world. ( Photos WHO/ UNICEF and WHO/ UN) They would learn, too, that the legal constraints, customs and traditions which govern women's lives are the greatest barriers to women's participa- tion, and that these barriers are perpe- tuated by men who fail to comprehend the factors of change which are afoot in the world, men who choose to ignore women's contributions and women's potential. In one provincial capital of Kenya, a 19-year-old woman of ,rural origin who had attended school until the age of 16 told me she was enrolled in a six-month child-care course in preparation for em- ployment in a nursery. We talked in the training centre at the end of the day; it was cold and we huddled together as I listened to her story and to her vision of the future. "My mother had 11 children. She is my father's only wife. She works in the field and grows the food we eat. She plants cabbage, spinach and corn. She works very hard, but with so many chil- dren it is difficult to get enough food or money. We are a big family and I have to help. "My life is very different from my mother's. She just stayed in the family until she married. Life is much more diff- icult now because everybody is depen- dent on money. Long ago, money was unheard of. No one needed money. But now you can't even get food without cash. Times are very difficult. That is why the towns are creating day-care centres—so women can work and have their own lives. I have to work because, without it, I will not have enough money for today's life. These are the problems I face and try to think about. How shall I manage to improve this life so that I can live a better one? "If I had a chance to go to the univer- sity, I would learn more about health ed- ucation. I could help women that way. If I were in a position of authority, I would really try to educate women. Right now, girls are left behind in education. It costs money and parents think it is more im- portant to educate boys. But I think that if people are intelligent, there is no differ- ence. Girls and boys should be educated the same. I would make rules and teach women who are not educated and who have never been to school. And I would change the laws so that men would un- derstand women and their needs and not beat them as they do." A strange look came into the woman's eyes as she added : "I only hope that I will have a mature husband who will understand and will discuss things with me." This young woman's words sum up many issues of which I heard less fortu- nate women speak. Her words address the issues of women's crucial role in agri- culture, of education, family law, family planning, tradition faced with change, the need for cash-labour skills, women as agents for change, women as citizens (not just mothers, wives and labourers), the altered relationships between men and women, communications between men and women, family violence, stereo- typed roles and the consequent need for non-sexist education, the distribution of food the list is endless. These are the crucial issues of equitable development for all people. In sum, this young woman spoke of the factors of change that are afoot in today's villages. Other women in the rural villages of less-developed nations speak of the spe- cific needs for training and education. An illiterate 25-year-old Tunisian wom- an told me : "I have seven brothers and sisters at home. I came to this training centre because I don't want to lead a life like my mother's. I want to have know- ledge. My mother had a disagreeable life because my father held her under his thumb. He had great authority over her because she had no education. If I can get an education, I will be more at ease than she was. I never went to school, so I am trying to learn something here at the centre. My father did not want me to come. He listens to those around him who say, 'Why send a daughter to school to have her eyes opened and to know what happens in the cities. They must continue to stay with their eyes closed.' My father can read Arabic but he is learned only in the Koran's teachings. "If I were in a position of responsibili- 28 ty, I would be sure that women had ac- cess to education. That is what they need first of all—education. Women have need of health education, hygiene educa- tion, and family planning. Women are just as capable as men and I hope that women—through their education—will come to be more equal to men. In a cou- ple, education and culture are the most essential things. If both are educated and learned, they will please each other, be closer to each other. I want my daughters to go very far with their education. I want them to work and to have a good future. I have learned to read a bit here, but I want to learn so much more. I want to know about everything." And what is this young woman's mes- sage? That development is a family af- fair, that fathers, husbands and brothers have to realize women's potential, that couples must work together, that women want to participate to help each other and society, that they can be a major force for better communities if they are trained in health care, hygiene and par- ticipation, that leadership is crucial if this process is to take place. These were just two women, both fair- ly young, both articulate. But I heard the same words and reasoning repeatedly during interviews with 200 rural women in Sudan, Egypt, Kenya, Tunisia, Sri Lanka and Mexico, women of all ages and degrees of literacy. They all spoke of the same issues, and pleaded for a chance to participate, a chance to partake in the development process, a chance to be heard. But who listens? The first barriers they encounter are within the family. Fathers, husbands or brothers want them to stay put, to "remain here where we are, like beasts". The community often looks down on women who seek to move out of tradi- tional roles. Some, desperate for a chance to earn and survive, are forced to the cities where they fall prey to the dangers of slum life and exploitation, whether economic or sexual. A second barrier is women's legal sta- tus. Be they traditional wives, heads of households, migrants or labourers, wom- en have little legal protection in many countries. They become risk-takers because survival forces them to step out of traditional roles and thereby endanger their status. That women are forced to take such risks with their lives and their families' security documents the lack of foresight in development planning. I had assumed that policy planners were im- bued with the quality of foresight. Yet foresight and long-range planning to provide entire populations with the tools essential for adjustment to rapid change seem to be at a minimum. Until assistance agencies are willing to devote funds to project-oriented research on women, studying women's real roles and their potential as change agents in societies in transition, we will all remain in darkness and the poor families of the world will continue to suffer. The fact is that power and resources remain in the hands of men, that most development planners are men, that the fathers of daughters who are forbidden training or education are men. Just as we hear pleas for an improved global dialo- gue between North and South, so must we continue to make our plea for an improved dialogue on the roles and the potential of women in today's world. But here we confront the real prob- lem : leadership. If, indeed, we are to create such a dialogue, strongly commit- ted and enlightened leadership is needed. Leadership that is able to analyse the social movements afoot and is willing to listen to how people—including wom- en—are affected by those movements. Leadership which realizes that legal codes must be changed to provide equi- table family law governing inheritance rights, land-ownership, divorce, choice of partners and of fertility. Labour laws must be made equitable to both sexes. Facilities for child care are needed every- where because women, forced by eco- nomic need, are entering the work force in greater numbers. Without child-care facilities their children will be at a disad- vantage and the mother's health will deteriorate, since she is still expected to carry the household burdens in addition to her day's work outside the home. Cer- tainly the industrialized nations have paid only lip service to the need for child- care services; let us hope the developing countries will be more enlightened in their planning. Leadership must understand that the family is being pulled hither and yon by the pressures of rapid progress and that development planning has to be concep- tualized around the notion of the family as a unit. And women are a crucial part of that unit. As I said earlier, the point had arrived where I thought we might now drop the term "women in development" and turn to look at the basic social unit of society, the family, and how it was being affected by rapid change. But we had better wait. Until such time as leaders, planners, fa- thers, sons, brothers and husbands begin to recognize the roles, the contribution and the potential of women for the world's future and its very survival, we will, alas, have to keep harping away at the separatist jargon. Women must be part of development. To listen to them is to understand why. ■ 29 000 000 000 000 000 000 000 000 000 000 00000• 000 *00 000000 4,6 0 ikee 00 * 41 0 4, 6. 0 *se e4D 40 000 000 00* 00* 000 000 000 000 000 000 000 000 000000 00* 000 000 *00 000000 000 000 000 000 000 00* *00 000 000 000000 000 000 00• 000 000 000 000 000 000 000 000 Primary Health Care principles applicable to Europe The primary health care (PHC) approach which evolved as a response to the overwhelming health and socio-economic pro- blems of the developing coun- tries has several principles that apply equally to the industrially developed countries with their highly organized systems of medical care, according to Dr Leo Kaprio, Director of WHO's Regional Office for Europe. Four examples of such prin- ciples cited by Dr Kaprio* are: health care should be related to the needs of the population; consumers should partici- pate, individually and collec- tively, in the planning and im- plementation of health care; Photo WHO/D. Henrioud Scotland: Community doctor provides "front-line" care. the fullest use must be made of available resources; and (d) the PHC is not an isolated approach but the most local (that is, community-based) part of a comprehensive health system. While the PHC approach in Europe—with its fundamental medical emphasis—is different from that envisaged for the Primary Health Care in Europe by Leo A. Kaprio; published by WHO Regional Office for Europe, Copenhagen, Denmark. developing countries, these prin- ciples are not only relevant to the European situation but are being put into practice in several countries. In the European Region over the last 100 years, Dr Kaprio says, the total health care system, including "front-line" PHC (as it is understood in Europe) has evolved in parallel with social and economic de- velopment, reflecting not only advances in medical science and the (often parochial) out- look of many health profes- sionals but also, especially at the local level, the true wishes of the population. He adds: "The growth of front-line care has not always progressed smoothly and evenly in all countries. Over-emphasis on sophisticated hospital-based care, for example, has often been detrimental to primary care. Therefore, the new worldwide emphasis on PHC is particularly welcome in the European Region." The Declaration of Alma-Ata describes PHC as "essential health care based on practical, scientifically sound and socially acceptable methods and tech- nology made universally acces- sible to individuals and families in the community through their full participation and at a cost the country and community can afford... It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community." Egypt : Fight against diarrhoea! diseases A nation-wide effort is being made to combat diarrhoeal dis- ease in Egypt, according to information received at WHO headquarters. It is the country's major cause of death in the age group 0-5 years, accounting for 43 per cent of deaths, or approxi- mately 100,000 deaths each year. Diarrhoea and malnutrition are closely inter-linked, in that the disease attacks the mal- nourished child, and leaves the patient further malnourished and an easy prey to a subsequent attack. An important aspect of Egypt's anti-diarrhoea combat, therefore, is nutrition education to encourage breastfeeding and supplementary feeding from home-prepared available foods, and also food aid. Every effort is made to detect protein energy malnutrition at an early stage. Besides, the programme lays stress on proper waste disposal and supply of safe drinking water, personal cleanliness and food hygiene practices, control of diarrhoea and other commu- nicable diseases and immuni- zation against diseases of child- hood, and family health in- cluding the importance of spa- cing between births. One of the most important components of the programme is oral rehydration therapy (ORT) to treat diarrhoea. Since the cause of death in diarrhoea! disease is the loss of body fluids and salts, death can be prevented by replacing them either through an intravenous drip or by a simple drink of salts and sugar: 3.5 g of sodium chloride (table salt), 2.5 g of bicarbonate (baking soda), 1.5 g of potassium chloride, 20 g of glucose or 40 g of sucrose dissolved in a litre of drinking water. The suitability of ORT in the management of diarrhoea was established in a pilot project carried out by Egypt in the second half of 1977 with the aid of UNICEF and WHO. It was observed that mild to moderate cases could be ma- naged effectively with ORT, and that there was a definite increase in weight among the orally rehydrated children as compared with those receiving only traditional treatment. It was concluded that ORT was a very effective and simple method within the technical skills of every mother, with guidance from a nurse. UNICEF has been a major contributor of packets of oral rehydration salts (ORS), and is now helping to install a pro- duction line in a state-owned company which is already pro- ducing ORS packets under the trade name of "Rehydran". The packets are also produced locally by medical practitioners or phar- macists in the pharmacies of the primary health care (PHC) units. It has been calculated that at least 5 million packets of ORS will be needed yearly to cover the children that could be reached by Egypt's 3,000 PHC units. A rural health unit serves a population of 5-15,000 and an urban centre over 50,000. The training and reorientation of health workers is going on simultaneously. Paediatricians in district hospitals teach them in short courses how to diagnose diarrhoea, judge the degree of dehydration, manage a diarrhoea patient, and demonstrate to mothers the preparation of the oral fluid. Much thought is given to the education of the mothers in child feeding, especially during and after diarrhoea. The trainees also learn how to weigh the child, maintain a case record sheet, and obtain community participation in preventing diar- rhoea. Health education about the programme is carried out through all the mass media and also group meetings and person- to-person contacts. Demonstra- tion sessions are held to let mothers see how the solution is prepared and administered, and how the child should be fed. The packets of ORS carry clear and simple instructions advising the users, for instance, to dis- solve in one litre of water— "not more, not less", and to discard the left-over solution after 24 hours. The effectiveness of the pro- gramme is evaluated by using standard forms to record treat- ment, deaths and monthly supply of ORS. How UK keeps an eye on spread of disease Excellent progress in the first three years of operations of UK's Communicable Disease Surveillance Centre (CDSC) has been noted by the WHO Weekly Epidemiological Record. Set up on 1 January 1977, CDSC was created to extend the epidemiological functions of UK's Public Health Laboratory Service (PH LS) beyond epide- miological research to embrace national responsibility for com- municable disease surveillance and control, and a commitment to training community physi- cians in communicable disease epidemiology. CDSC is thus a service unit rather than a research or aca- 30 demic unit with three main functions: surveillance; inves- tigation; and training and teach- ing. Records of the past three years show that CDSC epide- miologists have been involved in surveillance of all commu- nicable diseases and have taken part in many field investigations. The Unit's work gives a very clear picture of the communi- cable disease pattern in the UK. Among communicable dis- eases acquired abroad, the viral haemorrhagic fevers have ass- umed particular importance. Photo WHO/T. Farkas Technician in UK health lab pipettes virus suspension. Even though no confirmed cases have been reported in the country since 1976, the dis- ease has been under surveill- ance. An analysis by CDSC of published material on Lassa fever and Marburg disease and of the British experience in 1976 and 1977 concluded that community spread of these diseases in the UK was very unlikely. Malaria increased in the UK from about 100 cases a year in the 1960s to 1,909 in 1978. This was the result of world- wide increase of malaria pre- valence and increased passenger traffic between the Indian sub- continent and West Africa and the UK. Of the 1,909 cases in 1978, 349 (18 per cent) were of falciparum malaria and 10 deaths were reported. Two cases of human rabies in England were reported to CDSC in 1978. In both cases the disease was acquired in the Indian sub-continent. In another incident, in which a rabid cat attacked an English holiday- maker in a hotel abroad, over 30 persons who had had contact with the cat were traced through holiday tour operators and press publicity. About 250 cases of typhoid were reported each year, over 90 per cent of which acquired the infection abroad. Of approxi- mately 100 cases of paratyphoid, 90 per cent were infected abroad : half due to S. para- typhi A infections and half due to S. paratyphi B. The surveillance of Legion- naires' Disease began in the UK after the identification of the first cases in Nottingham in August-September 1977. Since then more than 200 cases have been reported by laboratories, most of which were investigated by CDSC epidemiologists. Other diseases under CDSC surveillance included smallpox, food poisoning and salmonell- osis, campylobacter enteritis, influenza and other virus in- fections, rubella, whooping cough, tuberculosis and sexually transmitted diseases. Writers focus on women's problems Information officers of a number of UN agencies, in- cluding WHO, attended a meet- ing in Paris last April of the regional coordinators of a net- work of women writers spe- cializing in women's questions. A number of non-governmental organizations were also re- presented. The network project, orga- nized by UNESCO and financed by the UN Fund for Population Activities, was started in January 1978 in response to the Plan of Action adopted at Mexico in 1975 at the International Women's Year Conference. Its aim is to facilitate the ex- change of news and other in- formation pertaining to women and creating a sharper aware- ness of the new role that today's women are called upon to play in society. It is hoped also to accelerate the integration of women, as equal partners of men, in the development process, and to fight the pre- judices and stereotyped atti- tudes that have kept women outside the mainstream of society. Of the five regional networks envisaged, the network for the Arab countries is still at the planning stage, but the four others are already functioning actively. The African Women's Features Services have produced 20 or so articles, the Caribbean Women's Features Syndicate about 50 and Depth News Women's Features Services (Asia) about 80. The Oficina Informative de la Mujer (Latin America) has over 400 texts to its credit and reports a press pick-up of 200 per cent. The articles issued so far present a vivid picture of the difficulties the average woman faces in her daily life, the weight of prejudice that frus- trates her efforts and her struggle, conscious or otherwise, against discrimination. Health, an es- sential factor in any development process, comes up frequently with its special implications Women's Decade symbol: Off to a flying start. for women. A writer speaks, for instance, of the tragedy that the birth of a premature infant means for the working class in some countries, another tries to show that cancer of the uterus is a disease of underdevelopment. Other articles touch on the thousands of deaths among women caused annually by abortion, the problems of family planning and nutrition for mother and child. In the next issue In July, World Health will include an account of an eye hospital in Sudan which trains local health workers for community care, a plea by a behavioural scientist for a broader concept of health, and a report on the health delivery system in Laos. Authors of the month Mrs Lucille MAUI, formerly Ja- maica's Ambassador to Cuba and Deputy Permanent Repre- sentative to the UN, is Secretary- General of the 1980 World Con- ference of the UN Decade for Women. Professor P. K. DEVI is Head of the Department of Obstetrics and Gynaecology at the Post- graduate Institute of Medical Education and Research in Chandigarh, India. Dr MAAZA BEKELE, formerly Head of the Social Services De- partment with Ethiopia's Plan- ning Commission, is a consultant with the Family Health and Mental Health Divisions of WHO. Dr Krishna AHOOJA-PATEL is a staff member of the Interna- tional Labour Organisation in Geneva and Editor of the ILO news bulletin Women at Work. Mrs Christiane VIEDMA is the Deputy Editor of World Health. Mrs Ruth SEITZ is a freelance journalist specializing in devel- opment topics. She is based in Manila. Mrs Esmeralda ARBOLEDA CUE- VAS is the Special Rapporteur to the UN on the impact of the mass communications media on the changing roles of men and women. Ms Perdita HUSTON is the Re- gional Director for North Africa, Near East, Asia and the Pacific of the United States Peace Corps. She is the author of "Third World Women Speak Out", pub- lished last year for the US Over- seas Development Council. WORLD HEALTH 1980 Subscription Rates US$ Sw. fr. One year 15.— 25. Two years 27. 45. Three years 36. 60. ORDER FORM Please enter my subscription to "World Health" as follows: I enclose cheque/international postal order in the amount of • Name: Street' City: Country World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. World Health is also distributed through the network of international bookstores and subscription agencies. For payment in national currencies, please contact your usual bookseller. One year ❑ Two years ❑ Three years ❑ LQ, a. fl f; -, 4 ....-.. k' I ilril,lrl, '''cil t C- c C CI .:) _ _. •., 44,, t 1 ....k . . 4 ,,.; t 4 e.. Na. ' , ' l ' CI 1 8 mil. nt ci , , n-' 1 If ', ,, I' r-r.,,Y to aqs cl . Pek:t•Qt 4 Learning to read and write in Bolivia. Will these girls enjoy a better social s'atus than their mothers in the years t9 come? (Photo WHO/UN) Pr in te d in S w itz e rla nd Ir ne ri m er ie s R du n ie s S .A . La u sa n ne