WO RLD THE MAGAZINE OF THE WORLD HEALTH ORGAN IZATION HEALTH

Cover: WCC/P. Williams © In this issue Nations for Mental Health 3 BenedettoSaraceno ---- .-- Dispelling myths about heart disease 6 Ingrid Mortin Eliminating blinding trachoma 8 Bjorn Thylefors Noise can damage your hearing l O Andrew W. Smith Is the end in sight for river blindeness? 12 Doniel E. Etyo'ole

Globalizing human-animal companionship 28 Dennis C. Turner Weather, climate and health 29 David Bromley Health briefs 30 WHO Publications 31

World Health • SlstYear, No. 5 World Health is the officio! illustmted mogozine of the World Health © World Health Orgonization 1998 September- October 1998 Orgonizotion. It oppeors six times a yeor in English, French and Spanish, and All righ5 reserved. Articles ond photographs that ore not subject to seporate four times a year in Arabic ond Forsi. The Ambic edition is ovoilable from copyright moy be reproduced for non-(ommercial purposes, provided that IXI SSN 0043-8502 WHO's Regional Office for the Eostern Mediterranean, P.O. Box l 517, WHO's copyright is duly acknowledged. Signed articles do not necessorily Alexandria 21 511, Egypt. The Forsi edition is obtainable from the reflect WHO' s views. The designations employed ond the presentation of Correspondence should be addressed to the Editor, World Heolth Mogozine, Public Heolth Committee, Iran University Press, 85 Pork Avenue, Teheran material published in do not imply the expression of any opinion World Heolth Orgonizotion, CH· 1211 Genevo 27, Switzerland, or directly to World Health outhors, whose addresses ore given at the end of eoch orticle . l 5875·47 48, lslomic Republ ic af Iran. wha5oever on the part of the Organizotion concerning the legal status of any counhy, territory, city or oreo or of its authorities, or concerning the delimitation of i5 frontiers or boundaries. World Health • 51 st Year, No. 5, September-October 1998 3 Nations for Mental Health

Benedetto Saraceno

To answer the global challenge of mental and neurological problems, WHO has set up aspecial programme called Nations for Mental Health which targets the specific needs of those left out by existing health services, and seeks to alert policy-makers and the public to the broad issues at stake.

and cost-effective measures of early­ age education. Depression will become one of the major health problems of the future as up to 340 million people are expected to be affected. Most of the 800 OOO deaths attributable to suicide each year are due to depression, and it affects women twice as much as men. Schizophrenia is likely to affect up to 45 million people in the corning decades. Symptoms include disor­ dered thinking, perception and judge­ Children living in a slum in Kampala, Uganda. Substandard social conditions play a definite role ment, and this extremely disabling in the appearance of mental disorders. Photo WHO/L. Taylar condition imposes a heavy burden on families and communities. There are currently estimated to ental and neurological prob­ and behaviour. Those affected are be about 40 million people with lems are responsible for a often abandoned, left impoverished epilepsy worldwide. Many cases can great deal of suffering and or placed in institutions - all of M be prevented through prenatal care, disability throughout the world. The which place dramatic burdens on the safe delivery, brain inj ury reduction anticipated rapid growth of the popu­ individuals affected, their families and control of infectious and para­ lation aged 60 and over is likely to and their communities. sitic diseases. make the current estimated 29 mil­ Mental retardation, a disorder lion cases of dementia soar to some related to an incomplete develop­ 80 million in a few decades. ment of the mind, is projected to Unrealized potential Dementia results from processes in affect up to 100 million people in the the brain which mainly occur in mid-term future. Many cases can be Disabilities induced by mental prob­ elderly people, producing progres­ prevented, and its effects can be lems prevent a great many people sively impaired memory, thinking reduced through relatively simple from realizing their capabilities to 4 World Health • SlstYear, No . 5, September--October 1998 the full and from functioning com­ pletely in society. Besides these estimated figures for mental and neurological di sorders, large num­ bers also suffer from the effects of violence, displacement, poverty, isolation, stress and deprivation. Many belong to vulnerable groups such as women, children, the elderly, refugees and indigenous populations. All of these people, together with those suffering from acute or chronic mental illnesses that are inadequately managed, form a broad "nation" of underserved persons dispersed around the globe. Common to them all are stigmatization, frequent expo­ sure to human rights violations, and the need for strong family and com­ munity support. All too many lack accessible and appropriate care provided by local, flexible and com­ Mental disability will affect up to 100 million people in the not too distant future. Its effects can be prehensive services. reduced through simple and inexpensive measures. Photo WHO/T. Takahara Progress in medicine has led to dramatic improvements in physical health in most countries, but by contrast the mental component of South Africa, Sri Lanka and Yemen. rapid social and cultural changes health has not improved. Mental Mental health care operates within the society, such as shifting disorders tend to proliferate as a chiefly through human resources family structures, and increased result of complex and multiple bio­ rather than sophisticated technolo­ isolation and unemployment. logical, psychological and, most gies, so a country's development Although health care is organized importantly, social determinants. Yet level in this field is much less depen­ around a progressive and developing with recent advances in psychiatric dent on economic factors than it is in primary health care system, complete medications and specialized forms of other fields of medicine. Regardless with community-based preventive psychosocial interventions, the of a country's economic status, it is health services and comprehensive potential for improvement is greater primarily its spiritual traditions, outpatient services, health care than at any time in hi story. cultural characteristics and health workers do not at present have the To respond to this challenge, policy that determine the framework training or resources to carry out WHO has set up an Action for mental health care de] i very. preventive or care strategies to con­ Programme on Mental Health for Here are three examples of Nations front this suicide problem. U nderserved Populations, named For Mental Health projects. So the ai m of the Nations for Nations for Mental Health. It Mental Health project is to develop targets the specific needs of those culturally relevant ways of prevent­ missed by existing health services, The Marshall Islands ing and coping with suicide attempts. and seeks to strengthen mental health These include providing relevant planning and care at the national The Republic of Marshal I Islands staff with education and training on level by increasing the awareness consists of 29 low-lying coral atolls the causes of suicide, developing and commitment of policy-makers and five single islands scattered community-based strategies for and society at large with regard to across over 750 OOO square miles of suicide prevention, and trying to mental health problems. It also the Pacific Ocean, with about 60 OOO assist the individuals and families provides technical and financial inhabitants. The people all share the. involved in attempted suicides. The support to mental health demonstra­ same culture, but different dialects project will produce videotapes on tion projects, either by developing are spoken within different islands. the causes of suicide, the means of new models for "best practices" or Majuro island, located on Majuro preventing it and ways of dealing by using existing ones. Such projects atoll, is the capital of the Republic. with its consequences. In addition, a have already been set up in 12 coun­ The suicide rate in the Marshall national conference on suicide is tries: Argentina, Belize, Bhutan, Islands, particularly among young being organized. China, Egypt, Ghana, Marshall men, is alarmingly high, at 22.3 per Islands, Mongolia, Mozambique, 100 OOO, and is in part attributed to World Health • SlstYear, No. 5, September-October 1998 s

strengthening community-based mental health services and networks. So the project will provide mental health training and supervision to relevant personnel, in particular psychiatric nurse practitioners, who will run village outreach psychiatric clinics in each district. The profile of mental health in the community will be raised through media-based activ­ ities, information activities in schools, and making such groups as nongovernmental organizations, clergy, magistrates and the police much better informed about existing Everywhere in the world, the population aged 60 and over is expected to grow rapidly, with a consequent dramatic increase in mental and other health problems. and potential problems. The coun­ Photo WHO/PAHO/C. Goggero try's national mental health referral and record-keeping mechanisms will Some of the mothers will also be strengthened by updating report­ South Africa join a physical care group and will ing forms and building up the referral have home visits by a member of the system. Khayelitsha community is a rapidly project team focusing on their child's The intention is also to improve expanding settlement on the outskirts physical and medical progress. the quality of care provided by men­ of Cape Town. From 90 OOO in 1986, Infants will be measured and tal health services by incorporating a its population has soared to 300 OOO, weighed, and detailed enquiries will mental health component into the yet it is a town of an essentially be made about their health and devel­ national health plan, and by making temporary nature. Nearly a third of opment (including appropriate im­ guidelines available to all mental the residents live without services, munizations). health facilities. For acute psychi­ and electricity is available to only The project is expected to show_, atric cases, a special acute care about 10% of homes. Half of the that the community workers can be facility will be introduced into the adult population is unemployed; of trained for this work and that their general hospitals. • those with jobs, the great majority guidance will lead to changes in the earn less than the household subsis­ way mothers interact with their tence level. Fewer than half the babies and look after them. In the children of school age attend school, longer term, the project should im­ and nearly half of them are chroni­ prove the growth and development of cally malnourished. the children. The main goal of the project here is to prevent mental health disorders among children suffering from socio­ Belize econornic deprivation. Since these disorders often stem from depression Until recently, most psychiatric care in the mothers, the project adopts a in the Central American state of community-based approach incorpo­ Belize was provided through the rating a mother-infant interaction Dr Benedetto Saraceno is in charge of Notions Rockview Psychiatric Hospital. A for Mento/ Health , Department of Mental programme. Tms will involve about new plan to decentralize psychiatric Health, World Health Organization, l 2 l l 100 mothers participating in weekly care involves closing the hospital Geneva 27, Switzerland. home-based therapy sessions carried with a view to building up the com­ out by lay community workers over a munity care facilities and thus ensur­ period of 10 weeks after the birth of ing the effective treatment of all the baby, and then fortnightly for six mental health patients. The goal of weeks. the project here is to improve mental health and well-being through 6 World Health • SlstYear, No. 5, September-October 1998 Dispelling myths about heart disease Ingrid Martin

tries; and the numbers of deaths due economic standing and that the poor The prevention of heart to heart attacks are equal in poor and are, indeed, at higher risk of heart rich countries. It is estimated that in attacks. diseases in individuals calls for China and India combined, which In industrialized countries too, account for half the population of the where the epidemic began among the active promotion of health developing world, between five and the urban rich, though some decades in populations. And health six million deaths are caused each earlier than in the developing world, year by cardiovascular diseases. cardiovascular di seases are now promotion can start by putting more common in the relatively poor. right some wrong notions. When the worldwide heart disease Myth 2: Heart disease is a epidemic fully develops, the poorest countries and the poorest people problem of the rich within society will be the worst All societies include "early affected. adopters" and "late adopters" of isconceptions about cardio­ lifestyle changes. Early in the heart vascular diseases - heart di sease epidemic, affluent people in Myth 3: Heart disease is Mattacks, stroke and high developing countries had the means mostly a man's disease blood pressure - have existed for and the opportunity to adopt new many years and have in effect be­ lifestyles, involving behaviour such While coronary heart disease is, in come myths. Most of them stem as choosing foods rich in fat and general, less common in pre­ from factual observations during the calories, buying cars and using menopausal women than in men, in early phase of the current global tobacco. Since these goods have many parts of the world it is the most epidemic and have become deeply become affordable for mass con­ common cause of death in women, rooted in the minds of policy­ sumption "unhealthy" behaviour of even those aged under 65. Heart makers, health professionals and the this kind has become common disease, as well as its risk factors, public alike. Since these misconcep­ across all social classes. Today, varies to a surprising degree between tions adversely influence the alloca­ affluent people, especially the urban populations. For example, women tion of resources and undermine rich, have better access to health aged 35-64 years in Glasgow, actions to prevent and control car­ information concerning risk factors Scotland, and in Belfast, Northern diovascular diseases, they need to be in the media and they also possess Ireland, have hi gher heart attack firmly squashed. the means to modify their behav iour rates than men in some parts of in favour of a healthier lifestyle southern Europe, according to a (healthy diets, leisure-time physical recent WHO study on trends in Myth 1: Heart disease is a activity, abstinence from tobacco). cardiovascular di seases (the WHO problem of developed They constitute the "early adopters", MONICA Project). countries while the urban poor and rural com­ Hypertension and stroke are also munities - with limited access to major problems that affect women. Every year, cardiovascular di seases information and little time or money Gi ven the longer life expectancy of cause around 15 million deaths in for "healthy foods" and "fitness women, they contribute increasingly the world (30% of all deaths), and of clubs" - lag behind. As a result, to cardiovascular deaths and disabil­ these about two-thirds occur in risky behaviour develops, and risk ity after the sixth decade. The result developing countries. So the ab­ factors increase. is that, over their entire lifespan, solute number of deaths from these Recent studies from Latin women and men are equally affected causes is twice as high in developing America and South-East Asia, where by heart attacks and stroke - a fact countries as in the industrialized coronary heart di sease is particularly that has long been neglected by world. Over twice as many deaths common, indicate that many coro­ doctors and health professionals, and from stroke occur in developing nary risk factors are more prevalent by women themselves. Further­ countries as in industrialized coun- among those with lower socio- more, pregnancy-associated hyper- World Health • SlstYear, No . 5, September-October 1998 7 tension is an important health prob­ lem in the developing world, where it is the major cause of premature birth and perinatal death, and is also re­ sponsible for up to one-third of all maternal deaths.

Myth 4: Heart disease is a problemof old age Atherosclerotic cardiovascular dis­ eases (coronary heart disease and stroke) and hypertension increase with age. But research in industrial­ ized countries shows that about one­ third of heart attacks and one-quarter of strokes occur in people below the age of 65 . Many of the deaths due to Women are as vulnerable lo heart diseases as men. Hypertension particularly can be a serious problem when related to pregnancy, and is often a neglected risk after the menopause. cardiovascular diseases also occur Photo WHO/H. Anenden early, one-quarter of them below the age of 70. In the developing world, the situation is even more marked: even global action are key elements and longer periods of exposure to the up to half of all deaths attributable to in combating the advancing epidemic risk factors of heart disease because heart diseases occur in persons of cardiovascular di seases in the of improved socioeconomic condi­ younger than 70; and a great number developing world. Community tions. of working-age adults suffer from mobilization can best be attained The public health consequences these diseases. This has an enormous through educating the public, pa­ of an uncontrolled epidemic of car­ impact on the economic situation of tients, professionals and policy­ diovascular diseases in the develop­ individuals and families as well as on makers, based on the advice of health ing world would be disastrous. Not society as a whole, and hampers professionals. only would millions of productive efforts to alleviate poverty. years of life be lost, but the high costs of technology-intensive man­ Myth 6: Heart disease is no agement of these diseases would Myth S: Heart disease is not longer a public health issue impose a heavy financial burden on susceptible to community affected individuals, their families action There is a widespread mistaken and society as a whole. belief that the total burden of cardio­ The global epidemic needs a global The predominant factors contributing vascular diseases is diminishing. response now, in the form of an to the risk of cardiovascular di seases Despite declining mortali ty, heart international effort to create appear to be acquired, and to be di sease remains the dominant public awareness and stimulate action lifestyle-related rather than genetic. health problem in industrialized in all countries and all sectors of Ri sk factors can be modified within a countries. Eastern European coun­ society. • "healthy environment" that supports tries are at present experiencing the appropriate lifestyle practices, and highest mortality rates due to cardio­ most cardiovascular diseases are vascular di seases. A major cause for preventable. The prevention of heart concern is the projec\ed rise of these di seases in individuals calls for the diseases in developing countries in active promotion of health in popula­ the next century. It is predicted that I tions. by 2020 the number of deaths due to Dr Ingrid Martin is the Responsible Officer for Cardiovascular Diseases in the Cluster of Programmes that combine com­ heart attacks and stroke in the devel­ Noncommunicable Diseases, World Health munity mobilization with govern­ oping world will have doubled as Organization, 121 1 Geneva 27, Switzerland. mental regulation through taxation, compared with 1990. legislation and pricing policies have The reasons for this antic\pated proved to be effective in controlling acceleration of the epidemic ate tobacco and encouraging healthier increasing life expectancy related to diets in numerous industrialized a decline in infant mortality, un­ countries. From these experiences, it healthy lifestyle changes related to is clear that community, national and industrialization and urbanization, 8 World Health • 51 st Year, No . 5, Septembe r-October 1998 Eliminating blinding trachoma Bjorn Thylefors

One of the oldest diseases known to mankind, trachoma has always been a IIcommunity disease II associated with poverty, illiteracy, poor living standards and lack of personal and environmental hygiene. ASAFE strategy has been developed to tackle it.

A health worker explains to villagers thot they can ovoid trochoma through hygienic practices, such A "forgotten" disease as washing frequently and using latrines. Photo W HO Trachoma was one of the first dis­ eases to be tackled on a large scale rachoma is an infectious eye surgery of the eyelid to prevent by WHO, and from the 1960s on­ disease, caused by a micro­ blindness. Such surgery can easily wards successful campaigns for Torganism ( Chlamydia tracho­ be provided through a simple stan.: control of the disease were initiated matis) which spreads from eye to dardized technique, and it can be in many countries. This, together eye through contact with fingers, safely provided by trained nurses or with social and\economic i_mprove­ flies or the use of shared towels or other health auxiliaries. ments, led to the gradual disappear­ handkerchiefs. The disease leads to The trachomatous infection itself ance of the disease in many the formation of scarring on the can be treated with antibiotics, either populations, particularly in better-off inside of the eyelids, which after applied as an eye ointment or taken areas. There was still a problem, many years of repeated infections by mouth. As the infection usually however, in maintaining trachoma gives rise to inverted eyelids (trichi­ starts in early chjldhood, the main control in rural, underserved popula­ asis), when the eyelashes actually need for antibiotic treatment is for tions, where the low living standards rub on the cornea (the transparent children and for people who are often resulted in repeated infections. front of the eye). frequently reinfected through their This is the reason why trachoma Trachoma used to be common all contact with infected children. The tends to be a "forgotten" disease over the world in the early part of antibiotic ointment (tetracycline) has today, striking at the poorest of the this century. Today it is confined to to be applied relatively frequently poor. some 46 countries, mainly in Africa, and repeatedly for many years in Still, over the past few years the Eastern Mediterranean, South­ order to prevent blinding disease. there have been great improvements East Asia and the Western Pacific. It is, therefore, often difficult to in the methods and approaches to An estimated 146 million people still maintain such a treatment among the combating this affliction. A new have an active trachoma infection populations in need. On the other strategy known as SAFE has been and are at present in need of treat­ hand, antibiotics taken by mouth developed, with the following com­ ment. An additional 5.6 million are need to be used for at least two ponents: blind or are at immediate risk of weeks, which again is difficult to Surgery to correct in-turned losing their eyesight due to the maintain in the field. Furthermore, eyelids can be provided at the com­ disease. More than 10 million cases they tend to provoke side-effects in munity level, at a cost of less than of trichiasis are in need of corrective children. US$ 5; primary health care nurses or World Health • 51 st Year, No. 5, September-October 1998 9

The "SAFE" strategy was worked environmental improvements to out by several nongovernmental discourage flies from breeding. organizations involved in field work The WHO Executive Board and in collaboration with WHO. The the Slst World Health Assembly Iin same partners are now putting it into 1998 adopted a resolution on the effect. To develop this collaboration Global Elimination of Blinding further, a WHO Alliance for the Trachoma, and the WHO Alliance of Global Elimination of Trachoma was interested parties has set that goal for established in 1997. This brings the year 2020. It is hoped, however, together some 20 organizations, that this may be achieved well in foundations and agencies, and an advance of that date in order to increasing number of endemic or realize a long-held ambition of supporting countries. The Alliance eliminating the most important has already devised a simplified cause of preventable blindness in the method for assessing trachoma and world. • for mapping the disease so that priority areas for treatment can be readily identified. Furthermore, a standard surgical kit for eyelid surgery has been pre­ pared and tested, which can be bought for as little as US$ 80. A simple eye examination in the village suffices to detect the presence of trachoma. Collaboration has also been estab­ Photo WHO lished with a view to providing easier access in the future to the new antibi­ Dr B;orn Thylefors is Director of the Department of Disability/ ln;ury Prevention and otic azithromycin and to developing Rehabilitation, World Health Organization, other staff can be trained to perform possible alternative formulations. 121 I Geneva 27, Switzerland. this operation safely. Last but not least, strategies for Antibiotics are about to become large-scale use of antibiotics are available that may have greatly being developed in conjunction with improved effectiveness; interested WHO Collaborating azithromycin, a long-acting antibi­ Centres for the Prevention of otic, is of particular interest, since a Blindness. Health educational ma­ single dose by mouth is as effective terial is also being produced to pro­ as six weeks' use of ointment. mote face-washing for children and However, azithromycin is still not easily available to all those in need and, in the meantime, preventive campaigns must continue to use the tetracycline eye ointment. Facial cleanliness among chil­ dren is of great importance to keep flies away from the eyes and prevent severe infections. While it may be difficult in many areas to ensure good access to water for hygiene, it has been shown that it is quite easy to wash children's faces with very small amounts of water. Environmental hygiene is often a critical factor in communities where there is blinding trachoma. It is of the utmost importance to reduce the breeding of flies. This can be achieved to quite an appreciable extent through proper waste disposal and other measures, which the com­ munity itself is often capable of Supervised by an eye specialist, an older boy applies an ointment lo treat lrachoma in younger handling. children in his school in Morocco. Photo WHO/ UNICEF / E. Bubley 10 World Health • SlstYear, No. 5, September-October 1998 Noise can damage your hearing Andrew W. Smith

present, and the hearing loss be­ comes progressively worse if the exposure continues. The part of the cochlea that transmits high­ frequency sounds is particularly vulnerable. As a result, speech frequencies, especially consonants such as S, F, Sh and H which have a higher frequency than vowels, be­ come difficult to distinguish. High­ pitched children's voices are harder to hear. Increasing deafness leads to severe difficulties at work and in social interactions. Distressing tinnitus may occur. Extremely loud A young man has his hearing tested in India. In developing countries, noisy occupations and the sounds, such as those from artillery din of big cities are increasing risk factors for hearing damage. Photo WHO/A. Smith gunfire or near to a jet aircraft taking off, may cause acoustic trauma third of the total cases of hearing which produces worse damage to impairment. In developing coun­ many of the structures of the ear. The Romans compensated tries, especially those that are in the their armourers because they process of rapid industrialization, even more persons may be affected, Decibel levels recognized that the noise of and in those countries noisy occupa­ working with metal produced tions and the din of big cities are What level of noise is dangerous? increasing risk factors for hearing A simple rule of thumb is that noise deafness. Today, noise­ loss. may damage your hearing if you How does noise damage hearing? have to shout above the background induced hearing loss is still the In the cochlea, the organ of hearing noise to make yourself heard. The most prevalent irreversible in the inner ear, a large number of intensity of sound is measured on a tiny hair cells respond to sound scale of decibels. People exposed to industrial disease in many frequencies by producing nerve sound levels above 85 dB for eight countries. impulses which travel along the hours a day over many years will be auditory nerve to the brain, where at significant risk for developing t's an increasingly noisy world, the sound is perceived. Hair cells hearing damage. As the intensity what with traffic in cities, aircraft, are very sensitive to sound and they increases, the duration of exposure Iconstruction work, mechanized are easily damaged by excessive that can produce damage decreases. industries and occupations, home sound levels. At first the damage is For every three to five dB increase in appliances, rock concerts, personal temporary; this is a common experi­ sound intensity, the allowable daily stereos, motor racing and rowdy ence after exposure to loud noise - at duration of exposure is halved. toys. Everyone is aware of the a pop music concert perhaps - when However, people vary widely in increase in noise in our daily lives, one may have a mild hearing loss their sensitivity to any given noise and of the effect it may have on our and ringing in the ears ("tinnitus") exposure. This is partly due to indi­ sleep patterns and working abilities, for a few hours. vidual differences in anatomy and but fewer people are aware that As exposure to excessive sound physiology, but may also relate to prolonged exposure to harmful levels increases, more and more hair exposure to drugs or chemicals that levels of noise can permanently cells, and also the surrounding damage the hearing (certain antibi­ damage hearing. In fact, in industri­ structures, suffer permanent damage otics or certain industrial solvents, alized countries, excessive noise is and eventually cell death. Hair cells for instance). Age may be a factor. at least partially the cause of one- that have died cannot be replaced at Newborn infants, especially those World Health • SlstYear, No. 5, September-October 1998 11

the dangers of excessive noise, the need to avoid prolonged exposure and the proper use of hearing protec­ tors. Noisy industries should develop hearing conservation programmes for their workforce. These pro­ grammes should include regular inspection and monitoring of sound levels, strategies for noise reduction through engineering solutions and ear protection, regular screening of employees for hearing impairment, health education for the workforce, counselling, and compensation schemes for those affected. All this should be backed up by government legislation, which should apply to all Damaged-ear cell cilia in the ear of a cat which has been exposed for two hours to a loud noise. Photo by courtesy of Ors M.). Mulroy and M. C. Liberman, Massachusetts Eye and Ear Infirmary, industries, not just those believed to HaNard Medical School, USA © be noisy. If uniform regulations are enacted to award compensation for that are premature, have increased health professional s, and those in occupational hearing loss, this susceptibility to noise exposure, yet high-risk situations. The last group would stimulate employers' interest may be placed in noisy incubators. would include workers in noisy in developing effective hearing Elderly people suffer from a large occupations, such as firefighters, conservation programmes. burden of hearing loss; this is gener­ police officers, factory workers, Noisy products need to be la­ ally due to presbyacusis (deafness of farmers, construction workers, belled as such, and people should ageing), but can be made worse by military personnel , heavy industry have greater access to hearing pro­ previous occupational noise­ workers, musicians and entertain­ tectors which are cosmetically and exposure. This is one reason why ment industry personnel, but it also functionally acceptable - just as is men generally have worse hearing includes young people who are the case with sunglasses. There than women in later life. exposed to high levels of "leisure should also be wider availability of Noise-induced hearing loss has noise". It is vital to promote the basic hearing tests - again, just as been known about for a long time. value of conserving normal hearing, many people readily have their The Romans compensated their eyesight tested. armourers because they recognized Much can be done to conserve that the noise of working with metal NOISE CAN DAMAGE our wonderful and valuable sense of produced deafness. Today, noise­ YOUR HEARING hearing in our increasingly noisy induced hearing loss (NIHL) is still world. The main tasks are to raise the most prevalent irreversible indus­ Noise Sources Decibel Effects public awareness and to provide trial disease in many countries, and level more opportunities for noise reduc­ more compensation is paid for noise tion and hearing conservation. Jet take-off Eardrum than for any other occupational rupture Accurate data are needed on the size hazard. and sources of the problem, espe­ Live rock There is no known cure for music cially in developing countries. And NIHL, although researchers are more research is needed into the basic mechanisms of noise-induced looking for one, and the onl y strategy Steel mill 110 Pain threshold is to prevent it. This is done through hearing loss and into ways, firstly, of health education, individual protec­ preventing it and then, eventually, of Busy street 90 tion strategies, occupational safety Hearing damage treating it. • measures and reduction in sources of Factory 80 excessive noise. Annoying Conversation 60 in office Quiet Dr Andrew W. Smith is Medical O fficer, Reducing the risks Prevention of Blindness and Deafness, World Health Organization, I 2 I I Geneva 27, Health education on this subject Whisper 20 Switzerland, and unti/January 1996 was convenor of the Hearing Impairment Research needs to be targeted at the general Group at the Liverpool School of Tropical public, those in influential positions, WHO/A. Smith Medicine. 12 World Health • SlstYear, No. 5, September-October 1998 Is the end in sight for river blindness? Daniel E. Etya' ale

nchocerciasis, commonly known as river blindness, is a Oparasitic disease caused by a filarial worm known as Onchocerca volvulus. The adult worms have a lifespan of some 9 to 14 years and the females produce millions of microfilariae (baby worms), which migrate to the skin of the infected person and cause itching, and to the eyes, where they can cause blind­ A young Indian child in the Amazona region is given ivermectin to combat onchocerciasis. Wide coverage of all communities concerned ness. When a female blackfly bites with this treatment may make river blindness a disease of the past by the an infected human and then moves year 20 10. Photo WHO/TDR/M. Edwards on to bite someone else, the parasite is transmitted to a new victim. one million people today are either lariae and not the adult worm, it must These flies breed in fast-flowing blind or severely visually handi­ be taken for many years. streams, and it is near the breeding capped, and some 40 OOO new cases Three major regional control sites that transmission of the disease of blindness occur each year. In the programmes are now in operation, is most intense. worst affected communities, over all of them closely associated with People who are exposed to the one-third of the adult population and WHO. In Africa, besides the OCP, bites of infective flies early in life nearly all the male workforce over which covers 11 countries, there is are especially at risk of being se­ 40 years of age may already be the African Programme for verely infected and losing their blind, and their life expectancy is Onchocerciasis Control, APOC, sight. Men are more exposed than often reduced by ten years. In West covering 19 countries. The women to these bites, especially Africa, many villages and fertile Onchocerciasis Elimination fishermen and farmers who work river valleys have been abandoned Programme of the Americas, OEPA, close to the river. for fear of this scourge. covers six countries of Central and Onchocerciasis afflicts more than Latin America. In OCP, controlling 18 million men, women and children the blackfly vector has been the in 37 countries, principally in sub­ Control measures main strategy, supplemented where Saharan Africa and Latin America, appropriate with ivermectin. Both but also in south Yemen. About 125 There are two main ways of control­ APOC and OEPA rely on mass million people in the world are ling this disease. The blackfly may treatment with ivermectin. Provided considered to be at risk, and over be eliminated by spraying insecti­ these two programmes can sustain 99% of those infected live in Africa. cides in the breeding sites - a com­ wide coverage with ivermectin There are two main forms of the plex and expensive method of vector treatment of all targeted communi­ disease: the blinding type, mostly control that has nevertheless been ties for at least 12 to 15 years, it is found in the savannah belt north of used very successfully since 1974 reasonable to believe that, by the the Equator and the Congo River by the Onchocerciasis Control year 2010, river blindness will have basin; and the non-blinding type, Programme (OCP) in West Africa. become a scourge of the past in all responsible for relentless itching, Alternatively, the parasitic worm the countries concerned. • with a disfiguring skin disease. Both itself can be targeted by a drug. forms cause great suffering, low Since 1987 there has been a safe and economic output, poor school per­ effective drug called ivermectin formance and social stigmatization. (Mectizan ®), donated by the manu­ The most severe consequences of facturer, Merck & Co, which is onchocerciasis are irreversible eye suitable for large-scale treatment and Or Daniel E. Etya'ale is an ophthalmologist with Prevention of Blindness and Deafness, changes, resulting in impaired vision needs to be taken only once a year. World Health Organization, 121 1 Geneva and ultimately in blindness. About But because it kills only the microfi- 27, Switzerland. World Health • SlstYear, No. 5, September-October 1998 13

Gender issues J1t Violence and reproductive health Juliet Heller

akhungu's mother was pin­ abort girl foetuses. In others, mid­ ning all her hopes on her wives bring a bucket of water when Mdaughter's education to raise attending births, in case it is a girl. the family's social standing in her In the United Kingdom, one woman Kenyan community. But her daugh­ in ten is severely beaten by an inti­ ter dropped out of school at 14 when mate partner every year. Each year, she became pregnant. Much as 10 OOO Nepali girls are sold into Makhungu now loves her son, she prostitution in neighbouring India. still cannot wipe from her mind the Under Pakistani law, a woman fact that he is a product of gang rape reporting a rape who is unable to by classmates who attacked her as prove the offence can be imprisoned she walked the three kilometres for adultery. Millions of girls un­ home from school. dergo genital mutilation every year, Violence against women is a a dangerous and painful practice that A girl refugee in Croatia remembers her war global epidemic, according to The can result in shock, infection or experience. Violence during armed conflicts intimate enemy: gender violence and death. Rape of women and girls has often has life-long consequences for women, reproductive health, a report pub­ which ore linked to their sexuality and reproduc· been used as a weapon of war in the live health. lished by the London-based Panos recent conflicts in Central Africa and Photo WHO/ UNICEF/0 Gorenak Institute, an international develop­ the Balkans. ment agency. Women everywhere Gender violence is closely tied to that two out of five battered wives are more in danger from their part­ a woman's sexuality, fidelity, preg­ faced greater abuse while they were ners, fathers, neighbours or col­ nancy and childbearing. This is pregnant - a finding that "flies in the leagues than from strangers. And the what makes it a reproductive health face of the myth in Chile that mater­ abusers come from all nationalities problem, as well as a physical and nity is a time of special care and and strata of society. emotional one. Research shows that protection," according to psycholo­ Despite the evidence, violence physical and sexual abuse can be gist Soledad Larrain, who carried out against women in the home was not important factors in teenage preg­ the research. Mental, as well as declared a breach of human rights nancy, and in the spread of sexually physical, abuse can affect pregnancy until 1993, at the UN World transmitted diseases, including outcomes. "If the stress and trauma Conference on Human Rights. HIV/AIDS. Violence can also lead of living in a violent neighbourhood Throughout 1998 and leading up to to unwanted pregnancies, pregnancy can induce pregnancy complica­ 10 December, the 50th anniversary complications, miscarriages, low­ tions," says Lori Heise, of the Centre of the Universal Declaration of birth-weight babies and maternal for Gender and Health Equity in Human Rights, gender-based vio­ deaths. Washington DC, "it is reasonable to lence was the subject of keen interna­ Pregnancy is a vulnerable time assume that Living in the private hell tional debate. for women, but many surveys show of an abusive relationship could as that assaults against women actually well." escalate during and after pregnancy, Domestic violence also takes a Sex and childbearing or during arguments over family terrible toll on women's sexual planning. This can cause miscar- pleasure and self-esteem. Worse Violence against women takes many . riage, early labour and delivery of a than the physical pain is the emo­ forms and can happen throughout a premature or low-birth-weight tional anguish of being forced into woman's life, even before she is infant. sex. "I don't want to have relations born. No country is immune from Studies in the United States show with him because I don't enjoy it," this basic problem. In some coun­ that 25% of battered women are says a Chilean woman of her hus­ tries, pregnant women who are under struck during pregnancy. And a band. "I don't feel anything. With pressure to have sons commonly study in Santiago, Chile, revealed the insults and blows, how could I?" 14 World Health • 51 st Year, No. 5, September-October 1998

Gender issues :.t.-·· home the idea of "Zero Tolerance" Zimbabwean television is making a for all forms of violence against series about domestic violence." The women. One recent incident illus­ group also lobbies the government to trates the kind of impact their work enforce new laws and to recognize can have. In March, when a cam­ marital rape as a crime. paign was launched on the Channel Island of Jersey to raise awareness about domestic. violence, using a Fighting back painted bus as a mobile headquarters, a woman came forward to tell her An historic case in China last year story. "I am a victim of domestic resulted in a young woman success­ violence and I want to be the first on fully suing her abusive husband. She that bus," she said. She later de­ had been so badly kicked and hit that scribed how she felt ten feet tall after she had to spend ten days in hospital. being able, for the first time, to speak In court, her husband claimed that out about her experiences. wife-beating was a private matter, When democracy was restored in but the judge ruled against him. The Chile in 1990, a National Women's case provoked intense debate in Service called SERNAM was set up China and provides a precedent for Mother ond child in Combodio. Violence to tackle domestic violence. The similar cases in future. ogoinst women not only threatens their own phone lines to the family violence In Kenya as well, a Masai health, but also the health of their family. Photo WHO/ UNICEF/ ). Isaac hotline never stop ringing, and the woman has defied cultural tradition police force has been "sensitized" to and taken her husband to court for handling domestic violence cases. violence. Agnes Siviankoi, who In cultures where there is a strong The number of complaints has sky­ endured 13 years of abuse, says: "I preference for sons, some women are rocketed since an Intra-Family have done the unthinkable in my beaten when only daughters are born Violence law (VIF) was introduced community. I am fighting for the (even though sex is determined by in 1994. It was widely seen as a rights of Masai women who will the male sperm). A village woman massive communication success. know now what steps to take." from Veracruz State in Mexico told "Just leaving a VIF brochure on the According to Millie Odhiambo of researchers: "My husband was very night table can have a dissuasive the International Federation of angry with me because I had only effect," says lawyer Luz Rio Seco, Women Lawyers (FIDA), who are given birth to three girls. Five of Santiago's Women's Institute. fighting to criminalize wife-beating, months after the last birth, he beat me In Zimbabwe, a four-bedroom the case is unprecedented. She violently and told me that he was house in a Harare suburb has become comments: "Most cases go no fur­ going to kill me. He threw me on the the secret destination for women and ther than the police station, where ground and kicked me for having had children fleeing domestic violence. you are prevailed upon by your another girl and said he was going to The Musasa project, the country's family, your community and your give her away." first such refuge, provides coun­ social and economic standing to selling and documents the scale of the drop the accusation." • problem by carrying out surveys of Zero tolerance abuse among local women. Over 25 % of married women surveyed The intimate enemy. gender violence However, the tide could at last be reported that they had been beaten by and reproductive health is available turning as women around the world their husbands; many had endured from th e Panos Institute , for £5. It can challenge their society's tolerance of this for over ten years before seeking also be found on Panos's website wife-beating and other forms of help. http :// www.oneworld .org/ panos . gender-based violence. Getting these Musasa has made a real impact, intimate issues into the public arena especially through the media, says is the objective of the Zero Tolerance Njovana, the project coordinator. "At Trust based in Edinburgh, Scotland. first the media thought we were there The Trust's most effective campaign to create havoc in other people's message, stated on posters around the homes. Journalists were very abusive country, is simple but potent: "No towards women activists ... . But a Juliet Heller is with the Panos Institute, 9 White newspaper recently wrote a very Lion Street, London N l 9PD, England Te/.- Man Has The Right." T-shirts, 0171 278 l l l l; Fax 0 17 1278 0345, postcards and leaflets help to drive complimentary profile about me, and e-mail.· ;[email protected] .u k. World Health • 51 st Year, No. 5, September-October 1998 IS

A priority health issue

iolence against women has levels of the health sector will be serious consequences for their Physical, psychological and developed on this basis. Vmental and physical well­ being, including their reproductive sexual violence inflicted on and sexual health. These include Access to information unwanted pregnacies, gynaecological women is on important public disorders, disabilities, depression, health problem requiring A database on violence against suicide attempts, injuries and many women and health has been set up, other problems. Most of the violence urgent action. which contains both statistical and women suffer occurs in the home and bibliographic information. The is inflicted on them by men they statistical part has initially focused know. Much needs to be done in Objectives on the prevalence of such violence in order to understand and measure the families, rape and sexual assault, and magnitude and the nature of the WHO is conducting a multi-country their consequences for the health of problem and its health implications, study on Women's Health and women and families. It is planned to as well as to find ways to prevent Domestic Violence which has the expand this to include other forms of violence against women and mitigate following objectives: violence against women. The data the harm it does. • to obtain reliable estimates of the will be used to ascertain whether WHO is focusing on building a extent of violence against women there is sufficient information to knowledge base for policy and ac­ in several countries; develop programmes to identify tion, and defining the role of the • to document the health conse­ information gaps or areas for further health sector in preventing violence quences of domestic violence research, and ultimately to provide a against women and providing care against women; basis for policy-making and plan­ for those who suffer it. • to identify risk and protective ning. In the long term, WHO aims to factors for domestic violence WHO seeks to ensure greater determine effective strategies, in against women, and compare recognition among health providers collaboration with other organiza­ them within and between settings; and planners, and within health tions, for preventing violence and • to explore and compare the strate­ professional organizations, of physi­ decreasing morbidity and mortality gies used by women who experi­ cal, psychological and sexual vio­ among women who have been ence domestic violence. lence against women and its abused. implications for health policies and Specifically, WHO is taking Further objectives are to develop a programmes. A poster and an ex­ action to: sound methodology for measuring hibit on violence against women as a • increase knowledge about vio­ violence against women across public health problem have been lence against women and share cultures, and to draw up ethical and produced, together with an informa­ this knowledge with policy­ safety guidelines for research in this tion pack entitled Violence against makers and health providers; area. By actively involving women's women: a priority health issue. • identify prevention and interven­ organizations working in this area as This is available in English, Spanish, tion strategies that can reduce members of the research team, the French and Russian. The report of a violence against women and study will develop collaboration and workshop organized by WHO and mitigate its consequences; build research capacity in countries. the International Federation of • improve the capacity of health WHO is working to define what Gynaecology and Obstetrics entitled workers to identify and respond can be achieved by the health sector Elimination of violence against to women suffering mental and to prevent violence against women women: in search of solutions is also physical abuse; and to provide appropriate care for available. For further information • support the formulation of anti­ those experiencing abuse. It also please contact the Violence and violence policies by national supports the documentation of exist­ Injury, Team of Prevention of Social governments; ing interventions, and the develop­ Change and Mental Health, World • serve as an advocate for greater ment and testing of new ones for the Health Organization, 1211 Geneva recognition of the problem of prevention of such violence and the 27, Switzerland. Fax: violence against women; management of its health conse­ +41(22)7914332, e-mail: quences. Guidelines for different [email protected], or http://www.who.int/frh-whd/. • 16 World Health • SlstYear, No . 5, September-October 1998

Gender issues . ?:{~i· Health and the ageing male Alexandre Kalache

While women experience greater burdens of morbidity and disability, men die earlier, yet the reasons for such premature mortality are not fully understood. The rapidity with which the worldwide population is ageing will require asharp focus on gender issues if meaningful Men's life expectancy has greatly increased, but is still shorter than women's. Researchers are trying to find out why. Photo WHO/PAHO/C Gaggero policies are to be developed.

t is impossible to understand focus on it was essential in order to they are "indestructible machines" ageing and health without a extend services to millions of women which require minimum mainte­ I gender perspective. Both from a throughout the world who were nance. As a result, many men come physiological and from a psychoso­ exposed to neglect and an unneces­ into contact with the health sector cial point of view, the determinants sary burden of diseases. It was only when they are children and at of health as we age are intrinsically therefore largely due to very appro­ the end of their lives. Too little, too related to gender. There is increas­ priate advocacy, often led by non­ late. By the time they "return" to a ing recognition that unless research governmental organizations, that the doctor, diseases that could have been and programmes - on both clinical importance of women's health gradu­ prevented or adequately managed if science and public health - acknowl­ ally gained prominence in many - detected earlier may have already edge these differences, they will not although not yet all - countries. This progressed to an irreversible stage, be effective. While women experi­ achievement must not be eroded; on leading to premature death. It fol­ ence greater burdens of morbidity the contrary, it requires consolida­ lows that a life-course perspective is and disability, men die earlier, yet tion. required on gender and health: our the reasons for such premature health, at the end of our lives, is the mortality are not fully understood. result of past experiences, in terms The rapidity with which the world­ Men's health must not be of both lifestyle and encounters with wide population is ageing will re­ neglected the health sector. quire a sharp focus on gender issues if meaningful policies are to be An equivalent movement has yet to developed. Yet so often gender in champion men's health. The reality Women live longer the health context is taken as being remains that men, particularly in synonymous only with women's adulthood, receive comparatively It is well known that, in general, life issues. little attention from the health sector. expectancy at birth is considerably This perception has its roots in Astrid Stuckelberger, a researcher higher for females than for males. In the successful campaigns orches­ based in Switzerland who devoted most of the industrialized world, that trated by women's groups in the her doctoral thesis to gender differen­ difference is between 6 and 8 years. 1970s and 1980s. These campaigns tials in health, offers an interesting However, in some countries the were imperative. The health status insight into the debate. She argues difference can be greater than 12 of women had been neglected that in many cultures men, from early years. In the Russian Federation, for throughout history, and a sharper childhood, are made to believe that example, life expectancy at birth for World Health • SlstYeor, No . 5, September--October 1998 17

7

Gender issues ;/~ ~ ,...... "'"""

Life expectancy at age 65 for women and men in a range of countries

France 21.4

Japan 21.3 Swit,"'-1

Coooda Spain Swtden Italy

USA

Gtrmuy

Grot(I United Kiogdom Colonoliia

CJ,ile

,... It is ;ust as essential far men as far women to receive due attention from Argeatlna health services throughout their life span. Photo WHO/L. Taylor Mexko Repoblk for men. of Korea China-Rural In the light of this, public aware­ China-Urt.on ness of established medical knowl­ Latvia edge· needs to be increased and basic Hungary clinical, socioeconomic and epi­

Bolgaria demiological research intensified. RvsSKII This challenge will necessitate a Federatioo o w..... Kuwait quantum leap in international re­ [) Men Turkmenistan search efforts, supported by new 10 12 14 16 18 20 22 partnerships between intergovern­ Years mental, governmental, commercial and voluntary sectors. WHO/Ageing and Health Programme All these considerations were a female in 1995 was 71.6 years addressed by the WHO-co-spon­ compared with 58.3 years for males. Maintaining independence sored First World Congress of The Other Eastern European countries Ageing Male, which took place in show similarly wide disparities, Despite the enormous medical Geneva on 4-8 February 1998. while in some countries in the progress achieved during the past Members of the International Eastern Mediterranean and South few decades, the last years of life are Society for the Study of the Ageing Asia the difference is negligible or still usually accompanied by increas­ Male discussed the current state of even reversed; for instance in ing ill health and disability. The key knowledge of ageing in males and Kuwait, life expectancy at birth is 75 factor in healthy ageing is the abi lity the social, economic, medical, epi­ years for females and 74.4 for males. to maintain independent living for as demiological and political chal­ By and large, these trends are long as possible. Effective pro­ lenges to be met. The Geneva maintained in older age. Only in grammes promoting healthy ageing Manifesto which was issued is Kuwait can older men expect to live and preventing disability in older published on the following page. longer than their female counterparts. people will make more efficient use The WHO Ageing and Health In Eastern Europe - contrary to what of health and social services, and Programme is currently developing a is observed at birth - the difference will improve the quality of life of programme of activities that reflect in life expectancy among older men older persons by enabling them to gender and life-course perspectives. and women (2 to 4 years) is similar remain independent and productive. Further details can be obtained to that in other countries. This indi­ In addition, interventions such as through the WHO Web site cates that the factors which lead to hormone replacement therapy may (http://www.who.ch/hpr/ahe ). • much shorter life expectancy for help to prevent the preventable and males compared with females at delay the inevitable. Evidence is earlier stages in the Russian available that such interventions Federation and other countries in the may slow the progression of disease Dr Alexandre Ka/ache is in charge of Ageing region no longer apply to individuals in women. There is an urgent need and Health, World Health Organization, once they reach old age. to obtain comparable information 121 1 Geneva 27, Switzerland. 18 World Health • SlstYeor, No . 5, September-October 1998

...,.-..,,_~· Gender issues ·.' \,~- · ',rt?.~ The Geneva Manifesto Achieving healthy ageing for men

n 1950 worldwide life decades, the last years of life ore still will make more efficient use of health expectancy at birth was 47.8 accompanied by increasing ill-health and social services, thus reducing I years for women and 45. l years and disability. Hence, the soari ng pain and suffering, improving the for men. Thanks to major contribution s elderly population will ra ise major quality of life of elderly people and from medical research and heal th soc ial, economic and ethical issues enabling them to remain independent care, among others, by the year worldwide and may strain to the limit and productive and to contribute to 2000 it w il l be 67.8 years for health services as w ell as socioeco· the well-being of society. women and 63.7 years for men , and nomic and political infrastructu res. Of paramount importance for the it is projected to increase further to O ne of th e key factors in healthy prevention and reduction of disability 79. 3 years for women and 7 4 .4 ageing is the ability to ma intain in older age ore healthy lifestyles and years for men by the year 2050. independent living for as long as healthy environments and the provi· Life expectancy for men is signifi· poss ible. Ageing may be associated sion of education for healthy ageing. cantly shorter than that for women in w ith impaired general vigour and an In addition, interventions, such as every region In Europe, it is 8 years accumulation of debili tating diseases, hormone replacement therapies, may shorter, in North America 6.7 years w hich may reduce productivity. These improve these debilitating diseases by and in Africa 3 years. This gender include cardiovascular diseases, preventing the preventable and delay· disparity has ma jor soc ial, persona l mal ignant neoplasms, chronic ob· ing th e inevitable. Evidence is avail· and socioeconomic consequences. structive pulmonary diseases, various able that such interventions may slow In 1950 the world population was dementias (for example, Alzheimer the progression of card iovascular 2.5 bil lion. This year it will exceed 6 disease), anxiety and mood disor­ disease and osteoporosis and th e billion and is projected to stabilize at ders, degenera ti ve and metabolic onset of Alzheimer disease in women. l 1-1 2 billion by about the year diseases (such as arthritis, orthrosis, There is an urgent need to obtain such 2050. In 1950 there were 128 diabetes, and (osteoporosis) and information in men . mil lion elderly people (aged 65 years visu al and hearing losses. Therefore, In view of the above cons idero· and over) in the world, constituting the promotion of healthy ageing and lions, there is a need to increase 5 . l % of the global population. By the prevention , or drastic reduction , public aw areness of established 2000 their number w ill increase to of il l-health and disability of older medical knowledge and to intensify 419 million , correspond ing to 6.8% people must assume a central role in cl inical, socioeconomic and epidemio­ of the population of the world . The the formation of national health and logical research. Th is would make the United Nations project that the in· social policies. An effective pro­ best use of existing knowledge as well crease in the proportion of the elderly gramme promoting healthy ageing as developing new and improved population will accelerate in strateg ies for prevention and the first half of the twenty-first trea tment of age-related century and that, by the year disease. 2050, 14.7% of the total A comprehensive op· population (almost l .5 proach to this new chal· billion people) will be in old lenge of the twenty-first age. century will necess itate a The largest elderly male quantum leap in multidisc i· populations of th e world by plinary and internationa lly the year 20 l O will be 97 coordinated research ef­ million in China ( l l % of the forts. Such effo rts shou ld be total male population), 49 supported by the establish­ mil lion in India ( l 8%), 37 ment of new partnerships mil lion in the European between governments, Union (20%) and 23 million industry and phi lanthropic in the United States ( 16%). agencies. The endorsement As many as 26% ( 17 mil­ from intern ational organiza­ lion) of Japanese men will tion s, in particu lar the be aged 65 years or more. World Hea lth In spi te of the enormous Organization, should be In order to promote healthy ageing and prevent disabilities in old medical progress achieved actively soug ht. • people, there is an urgent need for more relevant dato about men as during the past few well as about women . Photo WHO/ UNICEF / H. Davies World Health • SlstYeor, No . 5, September--October 1998 19

Gender issues ·-'.'J:~i~ Prostate cancer Karol Sikora no symptoms, the reported incidence of cancer rises dramatically. With­ out the test, many would die of other causes without knowing they had cancer. The reported incidence of prostate cancer thus reflects both the age of the population and the avail­ ability of PSA testing.

The symptoms

The prostate gland surrounds the urethra - the tube connecting the bladder to the outside world. Any enlargement of the prostate will reduce the flow of urine by constrict­ ing the urethra. Cancer usuall y first causes symptoms by simply reduc­ ing the flow of urine, which leads to poor stream size, dribbling and the need to pass urine several times during the night. There may also be blood in the urine. Of course, be­ nign prostate enlargement is very The alarming I 00% increase in prostate cancer in the USA and many European countries is directly linked to men 's increased life expectancy. Photo WHO/Zalar common and causes the same symp­ toms. The only ways to distinguish one from the other are by a biopsy There are two main factors at and by PSA. As men everywhere are living work. The first is the increasing age Prostate cancer cells can spread of the population. The majority of through the bloodstream and tend to longer, so the prevalence of prostate cancers occur in men older form deposits in bone, especially in than 70; therefore, as more people the spine, a process called metastasis prostate cancer is rising live longer - and 30 countries are (meaning change of place). This can sharply. Blood testing can predicted to have a greater than be picked up easily by carrying out a 100% increase in septuagenarians bone scan, using a radioactive tracer detect the disease but there over the next 25 years - they are that attaches to damaged bone to are doubts whether mass more likely to get thi s disease. The produce a "hot spot". Patients often second factor is the increased avail­ complain of a constant, dull back­ screening of elderly men ability of a sensitive blood test- the ache due to irritation of the sheath prostate-specific antigen (PSA). covering the bone. The cancer can would pay dividends. This test measures a protein secreted also spread to the pelvic lymph by prostate cancer cells and accu­ nodes, inducing renal failure by rately reflects the amount of cancer blocking the ureters as they descend he figures are alarming: a re­ present; it can also detect the disease from the kidneys. The disease can ported 100% increase in in patients who have no symptoms. also metastasize further afield to Tprostate cancer over the last A little-appreciated fact about affect the liver, lung and brain. decade in the USA and in many prostate cancer is how common it is. For patients with the disease European countries. What does this Post-mortems on men over 70 years confined to the prostate gland, the mean? Is there some novel cancer­ old have consistently shown a preva­ biggest dilemma is whether or not to causing agent that is selectively lence of over 50%. So if a test like have treatment. Many are going to creating havoc for modern man? the PSA is used to screen men with die of something else before any 20 World Health • 51 st Yeor, No . 5, September-October 1998

Gender issues · · -·.?;I~tJ: . " ... ' ... --~ :\.~ ·-

The guidelines for pain manogemenl developed by WHO in the 1980s provide a relatively inexpensive yet effective method for relieving concer poin in 70-90% of patients: the "three-step analgesic ladder" shown above. A sensitive blood lest exists to detect prostate concer. However, os this type of concer often The method is based on o progressive remains con fined to the prostate gland and without symptoms until the patient has died from increase in the strength of drugs administered, another cause, there is controversy about applying this test routinely. from non-opioids (aspirin and paracetamol) to Photo WHO/PAHO/C. Gaggero mild (codeine) and finally lo strong opioids (morphine) until the patient is free from pain - hence the concept of an "analgesic ladder". problems arise, especially if cancer is The drugs are not given "as required ", but must be taken every four hours "by the clock". detected by screening with PSA. Drugs and hormones Additional drugs - adiuvonts - can be used This has led to considerable contro­ for specific indications: to treat the adverse versy about the use of screening. Prostate cancer cells need a supply effects of analgesics, to enhance pain relief, or to treat psychological disorders such as anxiety The evidence is inconclusive as to of androgens - the male sex hor­ or depression. whether routine annual PSA testing, mone - to grow. If the level is re­ Further information con be found in Cancer pain relief !Second edition) - with a guide to as recommended by the American duced, the cells die. There are opioid availability, World Health Cancer Society, either prolongs life several strategies to reduce the level Organization, 1996. Graphic by WHO or reduces di sability-adjusted life of male sex hormone in a patient. years lost. A review recently pub­ The most radical is simply to cas­ li shed by the UK Department of trate the patient surgically, since the pain ladder. Freedom from cancer Health firmly concluded that, at testes are what produce the hor­ pain should by now be a basic present, there is no place for such mones. There are several drugs that human right, although too often this screening programmes. can achieve the same effect, block­ aspect of care tends to be ignored. Prostate cancer that remains ing the pituitary gland from produc­ In future, new tests based on localized can be removed by surgery. ing stimulating hormones to the molecular markers will become Several types of operation are feasi ­ testes. A range of drugs is also available to distinguish the aggres­ ble, but a common problem is their available to block the effect of an­ sive, rapidly spreading form of the potential to interfere with the intri­ drogens within cancer cells. Such disease, which needs active therapy, cate nerve control system at the base approaches are effective even in from the slowly emerging form, of the bladder, resulting in inconti­ patients in whom the disease has which can be left untreated and nence and the inability to ejaculate spread, but unfortunately the cancer simply monitored by repeated PSA sperm. An alternative to surgery is often becomes androgen-indepen­ tests. Such logical guides to individ­ radiotherapy. This uses beams of dent, allowing the cells to grow in ual cancer treatment strategies are high energy radiation, applied over a the absence of the hormone. likely to become commonplace for a period of several weeks, to selec­ Chemotherapy with a wide range of wide range of tumours in the next tively kill the cancer cells. The drugs used successfully for certain decade. • rectum is very sensitive to the effects other cancers has not produced good of radiation, so diarrhoea and some­ results here. times some small ulcers may occur Many patients with prostate as side-effects. Both surgery and Dr Karol Sikora is Chief of the WHO cancer wi ll suffer pain from the bone Programme on Cancer Control ond is based radiotherapy work best if the cancer metastases. This can be relieved at the International Agency for Research an remains localized. effectively by simple palliative Cancer, 150 cours Albert-Thomas, 69372 Lyon Cedex 08, France. He is also Professor radiotherapy and the use of anal­ of Clinical Oncology al Hammersmith Hospital gesics according to the WHO cancer in London. World Health • SlstYeor, No. 5, September-October 1998 21

Eyes can be more at risk in males Andre-Dominique Negrel

girls and women, because they are more frequently involved in such activities. Epidemiological studies have shown that men's chances of suffering eye injuries can be two to eight times as high as those of women. This difference only seems to disappear after the age of 70, when the lifestyles and occupations of both sexes become very similar. The causes and rates of occur­ rence of eye injury vary widely with age, and reflect people's activities at different stages in life. The age groups in which incidence is high are from S to 25 years and from 70 years onwards. The risks vary greatly from one country to another, and even from one area to another, and there are also seasonal varia­ tions. As with other health prob­ lems, the poor are more at risk than the rich because of their living and Men's industrial and mechanical activities put them at special risk of incurring eye in;uries. working conditions. Photo W HO/PAHO/C Gaggero Preventing serious visual loss from eye injuries calls for two strate­ gies. The first consists of positive Epidemiological studies have shown that men's chances of eye health promotion and protection. This includes public education suffering eye injuries can be two to eight times higher than (especially for boys and male ado­ those of women. This difference only seems to disappear after lescents) and legislation, such as the mandatory use of seat belts, protec­ the age of 70, when the /ifestyles and occupations of both tive devices in hazardous activities, and safety codes for the manufacture sexes become very similar. of toys. The second, which is of equal importance for saving eye­ en are much more likely than Many eye injuries are a direct sight, is to ensure prompt medical women to suffer injuries to result of particular jobs and other intervention, followed by special­ Mthe eyes, particularly during activities, so the pattern of their ized surgical repair once injury has childhood and adolescence. These occurrence often reflects a nation's occurred. • injuries range from minor bruises to socioeconomic situation. Certain severe open-globe injuries with population groups are at increased immediate loss of vision. From a risk either because they are more public health point of view, the exposed to hazards or because they importance of eye injuries is that are less able to protect themselves. they may lead to permanent visual Some hazards arise from every­ impairment (in most cases affecting day activities such as work, sport, just one eye), with long-term conse­ play and travel; others from the Dr Andre-Dominique Negrel is an ophthalmologist with Prevention of Blindness quences for well-being and employ­ violence of war and crime. Boys and and Deafness, World Health Organization, ment. men tend to be more vulnerable than 1211 Geneva 27, Switzerland. 22 World Health • SlstYear, No. 5, September-October 1998

Smoking: men are still the main• v1ct1ms • • Barbara Zolty

ach year about 2.8 million men around the world die from Esmoking. This translates to almost 8000 deaths each and every day. As startling as these figures are, current trends indicate that the number of deaths worldwide will actually escalate, and by the year 2020 tobacco use will be killing more people than any single disease. For the individual, the risks of smok­ ing are just as real. Half of those regular smokers who start smoking Eight thousand individuals die every da y as a result of smoking - and 80% of them are men. during adolescence will eventually Nevertheless, anti-tobacco measures do work and - if adopted worldwide - could save millions of lives. Photo)&P Hubley be killed by tobacco; half of them in middle age and half in old age. slowing among men in developed It is estimated that, on average, At present, 80% of tobacco countries, smoking rates among men 47% of men around the world deaths occur among men. This does in developing countries have in­ smoke, compared with 12% of not mean that tobacco is not a prob­ creased rapidly, and it is likely that women. In the 87 countries for lem among women, but simply smoking-related deaths will increase which data are available, smoking reflects the fact that, in most coun­ too. Increased smoking among rates among men range from around tries, men have been smoking in women is also a cause for concern. 25 % or less in countries such as large numbers for longer than Unless tobacco use among women Bahamas, New Zealand and Sweden women. Where reliable data are and girls can be reduced in devel­ to over 65 % in the Dominican available to assess trends, the epi­ oped countries and prevented from Republic, Latvia, the Republic of demic of tobacco use among men becoming established in developing Korea, and the Russian Federation. has usually been followed, some countries, women could well form In countries around the world, decades later, by a similar epidemic the second wave of the tobacco tobacco use is rising among young among women. This pattern has epidemic. people. At the same time, the age at been repeated in the industrialized which people start smoking is going world throughout the century, and down. If people do not begin to use there is every reason to believe that From rich to poor countries tobacco before the age of 20, they the same will eventually hold true in are unlikely to start smoking as the developing world as well. There are around 1100 million adults. The tobacco industry knows With the development of the smokers in the world today. Some this, and even though it may publicly manufactured cigarette, men in 900 million (82%) are men and, of claim that it does not want young developed countries first started these, 700 million - more than two­ people to smoke, their own docu­ smoking regularly in the 1920s, with thirds - live in the developing world. ments show a long-standing interest per capita consumption rising By the mid-2020s, the transfer of the in young people. For its very sur­ steadily to its peak in the 1970s. As tobacco epidemic from rich to poor vival, the tobacco industry needs to consumption levels rose, smoking­ countries will be well advanced, recruit new smokers every year to related deaths followed, allowing for with only 15% of the world's smok­ replace those who die from tobacco­ the 30-40-year delay that typically ers living in rich countries. It is related diseases. Those new smok­ occurs between smoking initiation feared that health care facilities in ers are most often teenagers. and the resulting health developing countries will be hope­ consequences. Although the in­ lessly unable to cope with the results crease in smoking-related deaths is of this epidemic. World Health • SlstYeor, No. 5, September--October 1998 23

~~· Gender issues . ,j~~-

Although life expectancy for smoke throughout their lives, 100 Health risks both sexes is predicted to rise in million will eventually be killed by many countries, the gap between. tobacco and half of these deaths will Tobacco is a known or probable men and women is widening, mainly occur before the age of 70. More­ cause of about 25 diseases, yet the due to the large numbers of men who over, more girls will probably start sheer scale of its impact on the smoke and die of tobacco-related to smoke following the invasion of global disease burden is still not . . diseases. However, the number of Western-style advertising which fully appreciated. For example, 1t 1s women and girls who smoke is also portrays smoking as glamorous, known to be the most important rising, and this will lead to an in­ modern, and "liberating". cause of lung cancer. Less known is crease in the number of tobacco­ the fact that tobacco kills more related deaths among women. people through many other diseases, Tobacco is one of the greatest Economic costs including cancers in other parts of public health challenges facing Tobacco is detrimental to the eco­ the body, heart disease, stroke, countries of central and eastern nomic health of countries. To the emphysema and other chronic dis­ Europe. In 1995, there were about direct health care costs of tobacco­ eases. Evidence is also mounting 700 OOO deaths in these countries, or caused illnesses must be added such about the serious health conse­ about 25 % of the world total. In costs as disability, reduced produc­ quences of environmental tobacco marked contrast to countries of tivity and income lost due to early smoke, both for adults and children. western Europe, where half or less morbidity. According to a World Research shows that the risks of smoking-related deaths occur in Bank study, tobacco use causes a net from smoking are substantially people under age 70, in central and global loss of US$ 200 billion per higher than was previously thought. eastern Europe about three-quarters year, and half of those losses occur With prolonged smoking, smokers of such deaths occur in middle age in developing countries. Other costs have a death rate three times higher (35-69 years). resulting from tobacco use are more than nonsmokers at all ages, starting In China, about three-quarters of difficult to quantify, such as a re­ from young adulthood; and smokers a million deaths each year are caused duced quality of life for smokers and in their 30s and 40s are five times by smoking, and most of these are those exposed to environmental more likely to have a heart attack among men. About 63% of Chinese tobacco smoke, and the suffering than nonsmokers. men smoke, compared with only 4% caused by the loss of a loved one. In the mid-1990s in developed of Chinese women. The most com­ Drastic measures are needed at countries, about 25 % of all deaths mon causes of death in China are once to reverse the tobacco epidemic among men, and more than one-third already stroke, heart disease, cancer and avert millions of preventable of deaths among middle-aged men and respiratory diseases. deaths. There is some reason for (age 35-69), were caused by smok­ If current rates of smoking per­ optimism. International experience ing. In 1990, it was estimated that sist, tobacco will kill a third of all shows that comprehensive tobacco smoking caused 42% of all cancer young men alive today in China. Of control policies and programmes deaths among men in developed the 300 million males in China under work. They include such legislative countries and 21 % in developing the age of 30, about 200 million will and fiscal measures as complete countries. become smokers. If they continue to bans on tobacco advertising and sponsorship, restrictions on smoking in public places, and higher taxes on tobacco products. These must be complemented by widely available smoking cessation courses and strong anti-tobacco educational programmes. Countries that have adopted such policies and pro­ grammes have seen tobacco con­ sumption fall. If such measures were adopted on a large scale by countries around the world, millions of lives and billions of dollars would be saved. •

Ms Barbaro Zolty is Technical Officer with the Young people ore a favourite target for the tobacco industry. Mad of those who start smoking in Tobacco-Free Initiative, World Health their teens will become lifelong smokers. Photo WHO/ H. Anen en Organization, 12 1 1 Geneva 27, Switzerland 24 World Health • SlstYeor, No. 5, September-October 1998

Early death and alcohol

Peter Anderson

death indicates that a sharp improve­ ment occurred in 1985-1986, fol­ lowing the anti-alcohol campaign launched in the former Soviet Union in June 1985. That campaign led to a sharp decline in alcohol consump­ tion and an associated reduction in the numbers of deaths from acci­ dents, suicide and homicide (exter­ nal causes), and from cardiovascular diseases. When major economic changes were introduced under perestroika, the anti-alcohol mea­ sures were lifted and alcohol con­ sumption increased sharply during the 1990s. At the same time, prema­ ture deaths started to increase. The transition to o free market economy in the Russian Federation and other eastern European Deaths from accidental poisoning in countries hos been marked by a sharp increase in olcohol·reloted deaths in men. This is of least the Russian Federation rose from 28 portly due lo the abandonment of the anti-alcohol campaigns launched in the 1980s by the former Soviet Union ond ifs neighbours. Photo Keystone © to 51 per 100 OOO population be­ tween 1992 and 1994. Out of every 23 additional cases of accidental Up to one-third of the recent increase in registered mortality poisoning, 20 were due to alcohol. The role of alcohol in deaths from cardiovascular diseases among adult men in Moscow may from accidents, suicide and homi­ cide is generally not hard to under­ be attributed to alcohol consumption, and this proportion may stand. Its role in deaths from well be similar elsewhere in the Russian Federation and in diseases classified as "diseases of the circulatory system" is shown by neighbouring countries. the following data. The centre in Moscow which monitors cardiovas­ ne of the most striking features in the world, but there is an increas­ cular diseases has estimated that the ofWHO's European Region ing divide between the "haves" and share of routinely registered sudden Oduring the late 1980s and early the "have-nots." About one-third of deaths in total deaths from heart 1990s has been an increase in the gap the population in the eastern part of disease among males aged 25-64 in life expectancy between the west­ the Region - 120 million people - years increased from 43% in 1987 to ern and eastern parts of the Region. are living in extreme poverty, if this 69% in 1993. Twenty per cent of the On average, a child born in the east­ is defined as an income of less than sudden deaths in 1993- 1994 resulted ern part of the Region today can US$ 4 a day. from alcohol intoxication, with expect to live some 10 years less than Why was there such a sharp blood alcohol concentrations of 3.5 a child born in the countries of the increase in premature death in the g/1 or higher found in the victims. European Union. Of course, this is eastern part of the Region, particu­ Another 10-30% of deaths which not only a health issue. It reflects larly between 1992 and 1994? Since showed alcohol concentration of less social, economic and political condi­ this change coincided with the initial than 3.5 g/1 could also have been tions, and there are signs of a reversal phase of transition to a free market caused by alcohol intoxication prior of the trend; more recent figures show economy, it seems logical to blame it to death. Further, the number of an improvement in life expectancy in on the economic difficulties stem­ sudden deaths which were caused by the eastern part of the Region. ming from the transition. However, alcohol poisoning increased during The European Region includes increased alcohol consumption is 1992-1993 with the result that 56% some of the most economically and also to blame. of the increase in sudden death technologically advanced countries An analysis of the trends in early erroneously attributed to cardio- World Health • 51 st Year, No. 5, September-October 1998 25

Gender issues . ; . ·-}~

A man being treated for alcohol dependence of A street kiosk selling different kinds of vodka in Moscow the Narcological Hospital No 17 in Moscow. Photo Keystone/European Press Photo Agency/AP / A Nemenov © Photo Keystone/AP /0. Nikishin ©

vascular disease could be attributed Taking together the deaths from The widespread availability of to alcohol poisoning. all external causes and deaths from alcohol, together with low prices Since sudden deaths account for cardiovascular diseases, we may during the first phase of transition to close to half of all deaths from conclude that 40 out of every 100 a market economy, may account for cardiovascular diseases among men extra deaths between 1992 and 1994 what has happened. before the age of 65, it can be esti­ are attributable to alcohol consump­ Recent tax rises in the Russian mated that about one-quarter to one­ tion. Federation have helped to bring third of the observed recent increase There are those who dispute such about a welcome reversal in the in the registered cardiovascular relationships and point to the comparative price of alcoholic mortality among adult men in recorded statistics for alcohol con­ drinks, but the situation in other Moscow should actually be attrib­ sumption, which in general are much countries is not yet known. Mean­ uted to alcohol intoxication. The lower in eastern Europe than in the while, a fuller understanding of proportion is probably the same for west. However, not only is developments in Russia in recent such deaths in other parts of the unrecorded alcohol consumption years could be of benefit to all Russian Federation and in neigh­ much higher in eastern Europe, but countries. • bouring countries which have com­ the pattern and type of alcohol parable mortality trends and alcohol consumed differ considerably be­ Or Peter Anderson is Regional Adviser, Tobacco or Health, of the World Health consumption. tween eastern and western Europe. Organization 's Regional Office for Europe, 8 Scherfigsvej, DK· 2 I 00 Copenhagen 0, Denmark.

Vodka prices in the Russian Federation compared with food prices

4kg 4kg

The price of vodka in the Russian Federation fell sevenfold between 1985 and 1995, then increased again by almost 50% between 1995 and 1997. This fluctuation was translated into patterns of alcohol consumption and alcohol·related sudden deaths. Figure by WHO/ EURO/A. Nanda 26 World Health • SlstYear, No . 5, September-October 1998

. { 3 .

Gender issues_,.~-::/~;. Gender differences in mental health Michele Tansella

or many years, doctors have serious crimes) than women, as known from clinical experience indicated by their higher rates of Fthat women receive more ser­ arrest and imprisonment, and are vices for mental disorder in primary more likely to commit suicide and to care settings than men. On the other become homeless. More than 90% hand, psychiatrists and clinical of those who commit suicide have a psychologists are aware that this mental disorder, and between a difference is less apparent in special­ quarter and a half of single homeless ist mental health services, and par­ men are suffering from a severe ticularly in hospital-based services. mental disorder. Men come to the attention of health . services less often than women, but are more likely to be referred for Young and adolescent boys suffering from Disability rates specialist psychiatric care. extreme psychological stress fend to react with However, such findings simply aggressive ond antisocial behaviour. The World Bank and WHO recently indicate the extent of treatment, not Photo WHO/ UNICEF/ 8 Press drew up tables of the burden associ­ the need for treatment. The clini­ ated with different diseases, in terms cians should therefore look beyond of disability-adjusted life years. their clinical practice and acknowl­ Depressive disorders account for edge that they need help from epi­ Surveys carried out in the almost 30% of the disability from demiologists, and from epidemio­ general population show little neuropsychiatric disorders among logically based research, if they are women, but for only 12.6% among to understand which sex, or which difference between males and men. On the other hand, alcohol and demographic group within each sex, females in the overall drug dependence accounts for 31 % has the greater risk of experiencing of neuropsychiatric disability among psychological distress and mental prevalence of mental men, but for only 7% of the disabil­ illness. ity among women. In a recently Surveys conducted in the general disorders. But the pattern of published book called World mental population do not show much differ­ the disorders, as well as that health: problems and priorities in ence between males and females in low-income countries (Oxford the overall prevalence of mental of psychological symptoms, University Press 1995), Robert disorders. But there is evidence that differs considerably between Desjarlais and others reviewed 15 the pattern of the disorders, as well studies on psychiatric disorders and as that of psychological symptoms, men and women. psychological distress carried out differs between men and women. over the last decades in many parts The difference varies in different During adolescence, the difference of the world, including Africa, Asia, phases of life, from childhood to becomes smaller because girls the Middle East and Latin America. adolescence and adulthood. Males experience more emotional prob­ They found "a consistency across are more vulnerable to developing lems, with fearful, anxious or over­ diverse societies and social contexts: I psyqhiatric disorders arising from controlled behaviour. symptoms of depression and anxiety insuit to the central nervous system In adulthood, men have more as well as unspecified psychiatric during their development. Most problems related to alcohol, drug disorder and psychological distress studies show a higher prevalence of abuse and antisocial behaviour, are more prevalent among women, mental health problems in young while women suffer more from whereas substance disorders are boys than in girls, the former experi­ anxiety, depression and eating disor­ more prevalent among men." encing more conduct disorders, with ders. Moreover, men are much more It is difficult to use gender as a aggressive and antisocial behaviour. likely to commit crimes (and more category to analyse the risk factors World Health • SlstYeor, No . 5, September-October 1998 27

. ., ~~ Gender issues ·.. ,:,?;;u~ .. of mental disorders without knowing deal with chronic sources of social • enact or enforce legislation to the relative weight of the various stress in the form of low-quality improve women's status; biological and psychosocial factors housing, dangerous neighbourhoods, • address women's need for equi­ that make men and women differ higher risk of becoming victims of table employment and economic from each other. On the one hand, violence and of encountering prob­ development; there are clear-cut biological factors lems in parenting and child care. • expand education for women and (for example the endocrine system) The incorporation of a gender­ girls. and, on the other hand, factors re­ related perspective into psychiatric lated to roles, stereotypes and social research may have important impli­ In addition to these measures, in­ circumstances of people's lives. cations for theory, clinical practice creased investment in research and What really matters? and public health policy. Some of service provision to improve psy­ It is more helpful to think of two the implications for public health chological well-being and to reduce main groups of causes of mental policy of higher rates of emotional rates of alcohol abuse, violence and disorders: physical and biological on distress, anxiety and depressive suicide in men is desirable, and will one side (such as genetic compo­ disorders in women were summa­ help indirectly to meet the needs of nent, birth trauma, maternal infec­ rized in the recommendations from their wives and children. tions at a particular point in a the 1991 Conference on Women's As for the clinical implications, pregnancy); and social, situational Health organized by the National no doubt the clinician would benefit and interactional on the other side Council for International Health from an increased knowledge of (such as stressful factors but also (NCIH). They included the need to: gender-specific factors that may buffers that serve to diminish the • establish standards for women's predict and influence the prevalence, impact of unfavourable external health and well-being, and then course and outcome of mental disor­ events). Again, the relative contri­ measure progress towards those ders. We need more hard data before bution to mental disorder made by standards; such knowledge can be provided. the biological/physical or by the • develop ways to monitor the Again, to quote Desjarlais' social/cultural sets of factors is impact of structural adjustment report: "Women are often neither unclear. programmes on women's welfare encouraged nor permitted to voice and establish programmes to their feelings and complaints. When mitigate their adverse effects; they do, they are likely to be dis­ Social stress counted or dismissed." The results of studies on gender differences in Desjarlais and his colleagues, after mental disorders may therefore have reviewing the proposed explanations immediate implications for training. of observed gender differences in Health care professionals must be psychiatric illness, conclude that trained to empower women when "poverty, domestic isolation, power­ they are interviewed in the clinic. lessness (resulting, for example, Over the next decade, we should be from economic dependence or low able to see to what extent psychiatric levels of education) and patriarchal medicine is able to increase our oppression are all associated with a knowledge and to improve the higher prevalence of psychiatric prevention, care and treatment of morbidity (exclusive of substance psychological suffering and psychi­ abuse) in women. In short, a consid­ atric disorders in both women and erable body of evidence points to the men. • social origins of psychological distress for women." They quote extensively a classical research study which found depression to be more prevalent among working­ class than middle-class women living in London, and other studies Professor Michele Tansella is Professor of which reported poor women experi­ Psychiatry, Institute of Psychiatry, University of Verona, and Director of the WHO encing more, and more severe, life Women tend to translate stressful situations into Collaborating Centre for Research and events than does the general popula­ anxiety, depression and eating disorders. In Training in Mental Health and Service fact, depression accounts for 30% of the Evaluation. His address is lstituto di Psichiatria, tion. Still others reported that poor disability stemming from psychiatric conditions Ospedale Policlinico, via de/le Menegone 10, women are more likely to have to in women. Photo WHO/ UNICEF / M. Halevi 371 34 Verona, Italy. 28 World Health • SlstYeor, No. 5, September-October 1998 Globalizing human-animal companionship Read a book on companion animals: Wilson, C. & Turner, D.C. Dennis C. Turner (eds.) 1997. Companion Animals in Human Health, Sage Publications, Inc ., 2455 Teller Road , Thousand Oaks, CA 91320-2218, USA; e-mail :[email protected] (Price: $45 hard cover; $21.95 paperback) Ask for a copy of the IAHAIO Geneva Declaration or of the Prague Guidelines on Animal-Assisted Activities and Therapy: available in various languages from AFIRAC , 7 rue du Pa steur Wagner, F-75011 Pari s. • Th e w hole story of animals and hum an health in a nutshel l: World Health , Ju ly-August 1998.

areas there are many dog and cat The emotional benefits that people derive from .the companionship of onimols translate into measurable improvements in their physical health. Photo WHO/D. C. Turner owners who derive the same benefits of contact with dogs and cats in their n September 1998, the physical activity, lower intake of homes as described above; on the International Association of medication, shorter hospital stays, other, large segments of the human IHuman-Animal Interaction fewer complaints about minor health population are confronted with Organizations (IAHAlO) organized problems and measurable improve­ problems caused by unsupervised or the 8th international conference on ment in emotional well-being, in­ untamed dogs, cats and other ani­ human-animal interactions, "The creased social contact with other mals. These problems include Changing Roles of Animals in people, increased self-esteem and zoonoses, injuries, annoyance and Society", in Prague, Czech communication skill s (especially pollution. Nevertheless, experience Republic. This conference was among children), reduced levels of has shown that by taking an inclu­ cosponsored by WHO and attended apathy, confusion, depression and sive approach to companion animal by 800 delegates from 42 nations. loneliness (especially among elderly issues, including education about WHO and IAHAIO called a joint persons), and increased social and zoonoses prevention, animal popula­ Discussion Forum in Prague to plan emotional support in times of crisis. tion management and welfare, and a training programme for developing Recognizing these benefits of responsible pet care, these problems countries on dog and cat population contact with companion animals, the can be solved to everyone's satisfac­ issues, emphasizing zoonoses pre­ national members ofIAHAIO unani­ tion. Both human and animal health vention and encouragement of mously adopted "The IAHAIO and welfare are improved. This is responsible animal care. Geneva Declaration" in 1995 with the approach that the WHO/IAHAIO In the industrialized and urban­ five fundamental resolutions which Discussion Forum, with significant ized world, companion animals - in have, in the meantime, been en­ input from the World Society for the particular, dogs and cats - can play dorsed by over 65 organizations, Protection of Animals, took in an important role in improving the institutions and government agen­ Prague. Plans for a joint training health and quality of life of their cies throughout the world. Research programme are currently being owners (see box). Scientifically and applied programmes in this field finalized and it is hoped that this will controlled studies, many of which have advanced so much over the past be offered for the first time by late were presented at the 1995 IAHAIO two decades, that in 1998, "The 1999 or early 2000, either in South conference in Geneva and the 1998 IAHAIO Prague Guidelines on America or South-East Asia. • conference in Prague, have demon­ Animal-Assisted Activities and strated the fo llowing benefits to Animal-Assisted Therapy" were Dr Dennis C. Turner is President of IAHAIO, the people who have dogs and cats in ratified to ensure the quality of such International Association of Human-Animal modern societies: lower heart rate programmes by international recog­ Interaction Organizations and Programme Chair of the conference Prague '98 and blood pressure in stressful nition. (cosponsored by WHO} . His address is: situations, faster recovery from In many developing countries, P.O. Box 32, 8816 Hirzel, Switzerland. physical and/or emotional stress, however, one finds a more complex IAHAIO's address is. IAHAIO, c/o Delta Society, 289 Perimeter Road East, Renton, lower cholesterol levels, increased situation. On the one hand, in urban WA, USA 98055-1329. World Health • SlstYeor, No. 5, September-October 1998 29 Weather, climate and health David Bromley

xtreme weather conditions and changes in climate have the Epotential to damage health, though their full impact is only now becoming known. Studies show, for instance, that marked changes in the incidence of di seases take place in parallel with the weather conditions of the El Nifio cycle. And as the global climate warms up due to In certain parts of the globe, such climate factors as prolonged drought have a direct bearing on greenhouse gas emissions, there are people's health and survival. Photo WHO/UNICEF/P Singh likely to be rises in death and illness from both infectious and noninfec­ di seases such as cholera and dysen­ hundred million more people will be tious diseases. tery starts to change. put at risk of dengue, with Recent years have seen growing Diseases brought about by El 20 000-30 OOO more dengue deaths interest in the effects of El Nifio and Nifio and other major weather events a year by 2050. other extreme weather events on cause a great deal of suffering and A large amount of the current human health. "El Nifio", a term for death, but their period of impact is greenhouse gas emissions originates the Christchild in Spanish-speaking usually limited. However, world­ from the burning of fossil fuels and Latin America, is used to describe an wide climate change caused by causes considerable air pollution - anomaly in the flow of ocean waters global warming could lead to un­ both indoors and outdoors. A recent along the west coast of South precedented effects on human health study predicted that by 2020, if America, which can occur around resulting from complex ecological current trends in greenhouse gas Christmas time. It happens when the mechanisms that affect fresh water emission continue, there will be cold water of the coastal current is supplies, food resources and the risk 700 OOO avoidable deaths a year replaced by the eastward flow of of infectious diseases. Studies because of exposure to additional air warm water from the equatorial indicate that a relatively modest rise pollution. The health effects of Pacific. El Nifio events occur every in global temperature of 1-2°C atmospheric particulate matter three to five years. would enable mosq uitos to extend produced by the burning of fossil El Nifio has local effects, like a their range to new areas, spreading fuels include heart disease and decline in fisheries, but is also asso­ malaria and other infectious diseases respiratory illness. Researchers ciated with changes in distant re­ to new populations. calculate that up to 8 million deaths gions. Droughts in south-east Asia, Some 2.4 billion people are related to atmospheric particulate Australia and parts of Africa, and currently at risk of malaria. That matter could be saved in the first 20 heavy rainfall and flooding in arid number could go up by 45-60% by years of the next century if carbon areas of South America have been the year 2050 if current climate emissions are cut significantly. observed during El Nifio years, predictions are correct. The esti­ WHO is a member of the "cli­ while the Indian summer monsoon mated number of annual deaths from mate agenda", a United Nations sometimes weakens and winters in malaria would rise from the present interagency programme which western Canada and parts of the 2-3 million to 3.5-5 million. There integrates all major international northern USA become milder. are already signs that malaria is on climate-related activities. WHO has Disasters triggered by drought are the increase in highland regions a major role to play in linking the twice as frequent worldwide during where it was not found before, monitoring of health impacts with El Nifio years. though how far global warming or the monitoring of climate, and in Extreme weather disturbances other ecological factors are to blame assisting Member States to use affect human health mainly through is not yet clear. prediction and forecasting models to natural disasters. However, they Dengue, another disease that is reduce the human impact of climate also have a big impact through spread by mosquitos, currently change and climate variability. • outbreaks of infectious diseases. As threatens about 1.8 billion people. temperature and humidity change, An estimated 50 million people are the incidence of insect-borne dis­ infected each year, with about David Bramley is an editor in the Department of Information Management and eases such as malaria and Rift Valley 25 OOO deaths. A rise in temperature Dissemination, World Health Organization, fever, and epidemic diarrhoeal of 1-2°C could mean that several 1211 Geneva 27, Switzerland. 30 World Health • SlstYear, No. 5, September-October 1998 Health briefs

Indian actress campaigns for sale WHO foresees rise in ageing-related motherhood illness s a result of marked declines in premature mortality and fertility rates Aworldwide, life expectancy has risen sharply, leading to a steep increase in the number of people reaching older age. There are currentty 580 million older people (aged 60 years and above) in the world, with 355 million in developing countries. By 2020 the corresponding figures will have risen to 1OOO million and over 700 million respectively.

Although most older people enjoy good health, the rapid population ageing indicates that more people will enter the age of higher risk of developing chronic diseases, including circulatory diseases, cancers and diabetes. It is predicted that these noncommunicable diseases will be responsible for over three-quarters of all deaths in developing countries by 2020.

In some Asian countries, noncommunicable diseases, such as circulatory diseases, cancer and diabetes, are now the major causes of death. In India, Indonesia and Manisha Koirala participating in WHO's 50th anniversary celebrations. Thailand, for example, hypertension has been found to affect up to 15%of the Photo. WHO/ SEARO © adult population. Similar trends are found in Latin America; in Argentina, Cuba and Uruguay, for instance, circulatory diseases and cancers are already responsible ne of India's top film stars, Manisha Koirala, has joined the global effort to for over 60%of all deaths. In Cuba, the prevalence of hypertension has reached Opromote safe motherhood . The actress says she sees her new role as nearly 35%in men and 27%in women. twofold - to make people aware of the problems that can occur in pregnancy and childbirth, and to raise funds to deal with them. Other age-related disorders that are expected to rise are mental health problems and visual impairment. The number of people affected by senile dementia, for Ms Koirala began her campaign for safer motherhood at a press conference in example, is estimated to increase from the current 29 million to 55 million by New Delhi in September 1998. Speaking at the invitation of WHO, she said it 2020. In most countries of Asia and Africa, cataract accounts for over 40%of all was shocking that so many women in India die in childbirth. "I want to create blindness. With the predicted increase in the rates of diabetes and smoking, awareness among men and women about safe motherhood," she said. She which are risk factors for the development of cataract, in developing countries, also described the situation of many mothers in her home country, Nepal, as the burden of blindness from cataract may soon reach even higher levels. "very, very bad" . Through its Ageing and Health Programme, WHO is committed to promoting Manisha Koirala has appeared in some 30 Hindi and Nepali films, including the health and activity throughout the life span. Individuals are able to influence how they age by adapting to ageing-associated changes and by adopting healthy extremely popular Bombay in which she played a mother of two. Joining her at the September press conference, Delhi's health and education minister Dr Harsh lifestyles. World Health Day 1999 will focus on active ageing and will promote Vardan said that, for every 100 OOO live births in India, between 400 and 800 intergenerational solidarity and life-long development. women die during pregnancy or childbirth or soon afterwards.

No fewer than 585 OOO women die worldwide every year as the result of pregnancy or childbirth, according to WHO's Maternal and Newborn Health/ Safe Motherhood programme. Millions more are incapacitated, and some are disabled for life. World Health Day 1998, which was celebrated on April 7 in countries all around the world, focused on safe motherhood with the theme "Pregnancy is special - let's make it safe". In India on that day, Prime Minister A. B. Vajpayee urged "the entire society" to get involved in helping to make motherhood safer. World Health • SlstYear, No . 5, September-October 1998 31 WHO publications Publications can be ordered from Distribution and Sales, WHO, 1211 Geneva 27, Switzerland.

measures for selected disorders in acoherent scientific and conceptual framework. WHO highlights prevention of mental It encourages health policy-makers, professionals and others to support and use these measures in helping to overcome the world's growing burden of mental disorders illness. ore than 1500 million people throughout the world suffer from mental, Mneurological and psychosocial disorders, yet many of these problems ore The book's clear message is that prevention of mental, neurological and preventable. Mental retardation, epilepsy, suicide and professional "burn-out", psychosocial disorders is both feasible and affordable. But the book also stresses for example, ore all amenable to strategies of primary prevention that intercept that, while the medical profession clearly hos on important port to ploy, many their causes before they affect - and often devastate - people's lives. Simple other ports of the community con help in preventing mental disorders. and effective ways to do this already exist but ore too often being ignored. Primary prevention of mental, neurological and Primary prevenffon of mental, neurological and psychosocial disorders is a new psychosocial disorders (ISBN 92 4 1545 16 XJ costs Sw. fr. book from WHO that brings together a number of tried and tested preventive 35.-/US $31.50 {Sw.fr24.50 in developing countries}.

Announcement LETTER TO THE EDITOR to readers Getting the message across Dear Editor, As a result of financial con­ Communicating effectively is on important skill for people working in the field of straints, publication of World public health. But the basic idea regarding where to start and what to talk about Health will be suspended as con be very confusing for most health core providers. from the end of 7 998. The Sick people and their relatives ore often not well informed about disease November-December issue, conditions. Medical practitioners generally ovoid talking much about adisease, described below, will therefore its treatment, and its prognosis. It is not that they lock knowledge, but they generally lock the communication skills and attitude to answer queries, or to be the last for a while. We thank soothe people's apprehensions. This lock of communication creates problems all our readers for their loyalty and con do more harm, without conferring any benefit. and support, and look forward It hos been repeatedly pointed out in medical literature, and in government to continuing to provide useful policies, that everyone should be well informed about health. This is only possible if physicians develop skills to explain effectively. One suggestion is that this skill and up-to-date health informa­ con be developed in each physician if special sessions on communication skills tion through WHO's other and effective communication ore organized regularly for students in medical publications. colleges. Information available in libraries and at Websites is often only useful for specialists, and downward dissemination of this information is only possible if those specialists In the next issue hove the inventiveness and the desire to translate it into more understandable Specialists warn that AIDS is strengthening its grip language and transmit it to the public. This con only be done by increasing the on the world despite recent advances in AIDS drug awareness and proficiency of the specialists regarding effective communication. research and an expanded comm itment to combat th"e disease by some countries . Th e N ovember­ Dr (Mrs) VandanaJoshi, Lecturer at the State Institute of Health December 1998 issue of World Health w ill descri be Management and Communication, City Centre, Gwalior, India efforts to counter AIDS on all fro nts, and particularly 474002. among the most vulnerable communiti es. • Printed in Great Britoin byG reenShires Print limited, Kettering, Northamptonshire, England. Photo WHO/UNICEF/C. Andrew