Growing old in Latin America / Lee Sennott-Miller

Growing old in Latin America by Lee SennoH-Miller Research Assistant Professor of Family and Community Medicine, University of Arizona, Tucson, USA H ealth for All, the WHO goal for the year 2000, means much more than the simple presence or absence of disease. It represents a relative state of well-being or quality of life that cannot be achieved through medical services alone. Viewed in this broad perspective, the health of older women in Latin Amer- ica is largely a product of their experi- ence and culture. Although lifestyle and genetic factors play a part in health status, these are outweighed by the physical and emotional burdens placed on women in this region by virtue of their subordinate social and economic status. This low status is evident from the moment of birth when the midwife, on seeing the gender of the child, often quotes parents a bargain price for having helped to deliver a girl. Although not as extreme in Latin America as in some other parts of the developing world, girl babies may be neglected and young girls are routinely last in line when food is distributed. This practice is so widespread that a common proverb in this region captures it: "Cuando la comida es poca, a la nifia no le toca" - When food is scarce, young girls get none. When the girls become women, frequent pregnancies, childbirths and almost continuous lactation further deplete their meager stores of iron, and result in chronic anemia which, in developing countries, affects an esti- mated 60 per cent of pregnant women and 4 7 per cent of women who are not pregnant. Although moderate degrees of anaemia can be tolerated by women, their resistance to illness and fatigue is diminished, and their capacity to respond to physical and emotional stress is reduced. Making tortiUas for the family. Older women in Latin America and the Caribbean generally have less education and kwer skiDs than younger ones. WORLD HEALTH . April - May 1990 In addition to chronic undernut- rition, hard physical work for many women begins as early as six years of age and does not end until they die. As they approach middle age and the end of childbearing, many women find themselves giving financial support and care not only to the children they are raising, but to their grandchildren and aging parents as well. They may or may not have help. Among midlife women (those aged 40 to 59 years) between 20 and 30 per cent are without partners because of widowhood, divorce or abandonment. For women over 60, this figure rises to nearly 65 per cent in some urban areas. Thus, as women get older, the proportion who are heads-of- household increases. Older women in general have less education and fewer skills than younger ones, and few have worked in jobs that offer rights to social security or pensions. If they do have salaried work in industry or agriculture, as they age they may find themselves being replaced by younger, better educated and more pliable workers. Conse- quently, just when their income may be desperately needed to sustain the family, older women find themselves less able to supply the needed funds. What are the consequences of this complex situation for the women involved? Clearly, one result of the need to reconcile many conflicting roles, strategies, needs and demands is stress and the concomitant symptoms of anxiety, tension and depression. Of these, depression is the most serious because of its disabling consequences. Some ten medical conditions account for most deaths of Latin American women, although their ranking differs between women at midlife and those over 60, and between women in Latin America and those who live in the Caribbean. Among midlife women, cancer is the leading cause of death, followed by heart disease, stroke, diabetes and accidents. In the least developed and most rural countries of the region, infectious diseases such as pneumonia, influenza and intestinal infections are prominent causes of death. In the more developed and urbanised coun- tries, chronic liver disease (often the result of alcohol abuse) is an important cause of death. This suggests that in rural areas, the major causes of death are still likely to be related to the lack of basic sani· tation. In the more developed coun- tries, factors associated with the stress WHO/PAI-iO Growing old in Latin America of urban life, such as substance abuse, play an important role in mortality. Among women over 60, the risks of death from infectious diseases, intesti- nal and respiratory, are even greater, especially in the most rural countries. Nutritional deficiencies too become an important cause of death in this older group. Two types of cancer - breast and cervical - are most common. Again, the prevalence of these is related to the level of development. In the less developed countries, cancer of the cervix accounts for considerably more deaths than breast cancer. In more developed countries the reverse is true; median age-adjusted death rates from breast cancer are more than four times those for cervical cancer. Until recently, cancer of the cervix was thought to be a disease of poor, sexually promiscuous women. However, new studies have shown that the risk to women also may depend on the number of previous sexual partners of their husbands. This shifts the burden of guilt from the women exclusively, and has caused some scientists to label cervical cancer a sexually-transmitted disease. Unfortu- nately, its incidence is on the rise in many countries of the region. The patterns for breast and cervical cancer are so consistent and so clear- cut, that, unlike many other chronic problems, enough is known about them for medical science to intervene. Screening through Pap tests and mammograms (for cervical and breast cancer respectively) can aid early diag- nosis and prompt surgical treatment can effect a cure. Providing access to these examinations is, however, a major stumbling block. Most women now at midlife and older will not benefit from either the screening examinations or the risk factor edu- cation programmes begun by the Pan American Health Organization (PAHO) and others, but there is hope of reducing deaths from these leading causes in the future. "Women play a central role in determining the health of family members, and the education of women is a powerful - if not yet fully understood - factor affecting child mortality, nutrition, health and school achievement." T. Paul Schultz, Department of Economics, Yale University, USA The emergence of heart disease and stroke as major causes of death among older women can, in some respects, be 14 considered a sign of improved health in Latin America. Infant mortality is decreasing, water supplies and environmental sanitation are improv- ing, and this trend contributes to an overall increase in life expectancy. As more people survive into adulthood, chronic conditions emerge. Patterns of heart disease and stroke are not as clear-cut as those involving cancer. The attack on these conditions in developed countries usually focuses on improved treatment of early epi- sodes, control of hypertension and assistance in modifying risk factors such as smoking, obesity and stressful lifestyles. Although treatment has improved in Latin America and the Caribbean, lifestyle changes do not seem to be keeping pace. In fact, the abuse of cigarettes and alcohol is on the increase among women in the Region. Women are also prone to hypertension, obesity and diabetes, particularly in the Caribbean. The stressful social factors mentioned pre- "Street vendors have sometimes been found dead in their hiding-places. They are too old and have worked too hard, . and can take it no longer." Right: One result of frequent pregnancies is that women's resistance to illness and fatigue is diminished. viously also do not seem amenable to· easy solution. These signs point to an increasing rather than decreasing impact of these chronic conditions on older women. Two conditions - diabetes and occupational illness and injury - merit mention particularly because of their long-term impact on the health of midlife and older women. Although diabetes is a significant cause of morta- lity among older women, its disabling effects - including blindness and poor circulation - are felt for many years before death occurs, and they are uniquely disabling. Given the impor- WORLD H EA LT H, Aprii -May 1990 tant role played by older women in the family, these disabilities can be devas- tating since they reduce the woman's ability to care for her family as well. Occupational illness and injury are emerging as important health prob- lems as more midlife and older women join the work force. Accidents were among the top five causes of death for midlife women in 11 out of 18 countries surveyed and, in five coun- tries, for women over 65 as well. Women workers are most often found in textile, footwear, food production, electronics and handicrafts industries. Conditions in these industries can be quite hazardous because of exposure to noise, light, heat, toxic chemicals and radiation. Chronic illness may be the result. In spite of increasing rates of employment of midlife and older women, the domestic workload described earlier has not decreased. Instead, the paid shift has simply been added to the unpaid work of maintain- ing the home. Researchers refer to this as the "doble jomada," the double shift. In some rural areas, a third shift of work in the fields or family gardens is also necessary to sustain the family. The pressure of this overwork causes premature aging. it is not unusual to find women of 50 or 55 years of age disabled by such work-related prob- !ems as arthritis and hypertension. Even if they are eligible for a pension through salaried work in industry or agriculture, symptoms of premature aging are not recognised as disability, and women must continue to work or find other means of support. The plight of those with no hope of pension support is illustrated in a study of domestic workers conducted by Ximena Bunster and Eisa Chaney and reported in their book, Sellers and Servants. They describe the plight of older women street vendors, who must guard their wares night and day, and have sometimes been found dead in their hiding places. They are too old and have worked too hard, and can take it no longer. Dona Olga, one of Bunster and Chaney's informants, and a peddler who has sold various products for 30 years explains: "Each day you have to struggle, you have to be on your feet running after your customers. As a young girl, you don't feel tired because peddling seems like a game. You have a good laugh every now and then and the illusion that everything is going to be fine. When you become older and more mature, you realise that there is no hope, that days are all the same. You tire early sitting and selling, run- ning after customers. Sometimes we don't even know what time it is, nor Growing old in Latin America the day of the week, and the buzzing noise of the people in the market become intolerable." Little of the above, of course, addresses the issue of the health of midlife and older women in Latin America, only their illness and death. One would think, given the litany of wrongs and injustices, pressures and burdens to which women are subjec- ted, that their health and the quality of their lives would have deteriorated irrevocably when they reach old age. Living fully That this is apparently not the case is one of the most heartening findings of our research. Older women in Latin America and the Caribbean are still able to age successfully, to love and live fully, and to remain hopeful for the future. Two changes would be most helpful to them, and they are unre- lated to traditional notions of health or medical care. If it were possible to guarantee women financial security in their old age, through an extension or expan- sion of the social security schemes currently operating in the countries concerned, it would improve the qual- ity of their lives enormously. By this I do not mean to offer them charity, rather to recognise the unpaid work that they have done all their lives as equally critical and worthwhile to the national economies as that done by those whose salaried employment entitles them to pensions. Nothing enhances well-being more than the knowledge that there will always be a roof over one's head and food on the table. The second change is more difficult to achieve and is far from realisation even though it has been part of official policy of most countries in the Latin American region for many years. This is the goal of equality, which would give women the same access to resources and rights that men enjoy. Two elements are critical to pro- mote change. Firstly, power rela- tionships and the traditionally subordinate roles of women must not be regarded as "written in stone." Secondly, informal groups - the fun- damental bases for association among women in these countries - must be used to build institutions over which women have control, so that they can gain experience in the use of their enormous but latent talents. These two changes would go far toward improv- ing the physical and mental health of midlife and older women in Latin America and the Caribbean. • 15