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Women and Tropical Diseases WOMEN AND TROPICAL DISEASES The International Development Research Centre is a public corporation created by the Parliament of Canada in 1970 to support research designed to adapt science and technology to the needs of developing countries. The Centre's activity is concentrated in six sectors: agriculture, food and nutrition sciences; health sciences; information sciences; social sciences; earth and engineering sciences; and com­ munications. IDRC is financed solely by the Parliament of Canada; its policies, however, are set by an international Board of Governors. The Centre's headquarters are in Ottawa, Canada. Regional offices are located in Africa, Asia, Latin America, and the Middle East. Le Centre de recherches pour le développement international, société publique créée en 1970 par une loi du Parlement canadien, a pour mission d'appuyer des recherches visant à adapter la science et la technologie aux besoins des pays en développement; il concentre son activité dans six secteurs : agriculture, alimenta­ tion et nutrition; information; santé; sciences sociales; sciences de la terre et du génie et communications. Le CROI est financé entièrement par le Parlement cana­ dien, mais c'est un Conseil des gouverneurs international qui en détermine l'orien­ tation et les politiques. Établi à Ottawa (Canada), il a des bureaux régionaux en Afrique, en Asie, en Amérique latine et au Moyen-Orient. El Centro Internacional de Investigaciones para el Desarrollo es una corporaci6n publica creada en 1970 por el Parlamento de Canada con el objeto de apoyar la investigaci6n destinada a adaptar la ciencia y la tecnologia a las necesidades de los paises en desarrollo. Su actividad se concentra en seis sectores: ciencias agri­ colas, alimentos y nutrici6n; ciencias de la salud; ciencias de la informaci6n; ciencias sociales; ciencias de la tierra e ingenieria; y comunicaciones. El Centro es finan­ ciado exclusivamente por el Parlamento de Canada; sin embargo, sus politicas son trazadas por un Consejo de Gobernadores de caracter internacional. La sede del Centro esta en Ottawa, Canada, y sus oficinas regionales en América Latina, Africa, Asia y el Medio Oriente. This series includes meeting documents, internai reports, and preliminary technical documents that may later form the basis of a formai publication. A Manuscript Report is given a small distribution to a highly specialized audience. La présente série est réservée aux documents issus de colloques, aux rapports internes et aux documents techniques susceptibles d'être publiés plus tard dans une série de publi­ cations plus soignées. D'un tirage restreint, le rapport manuscrit est destiné à un public très spécialisé. Esta serie incluye ponencias de reuniones, informes internos y documentos técnicos que pueden posteriormente conformar la base de una publicacion formai. El informe recibe distribucion limitada entre una audiencia altamente especializada. IDRC-MR-314e February 1992 Women and tropical diseases Edited by Pandu Wijeyaratne, Eva M. Rathgeber, and Evelyn St-Onge Cosponsored by the International Development Research Centre, Ottawa, Canada and the UNDP/World Bank/ WHO Special Programme for Research and Training in Tropical Diseases (TOR) IDRC ~C A N A D A Material contained in this report is produced as submitted and has not been subjected to peer review or editing by IDRC Communications Division staff. Unless otherwise stated, copyright for material in this report is held by the authors. Mention of a proprietary name does not constitute endorsement of the product and is given only for information. ISBN : 0-88936-623-3 Contents 4 Foreword - Pando Wijeyaratne, Eva M. Rathgeber, and Evelyn St-Onge 5 Leprosy in Women: Characteristics and Repercussions - Marian Ulrich, Ana Maria Zulueta, Gisela Caceres-Dittmar, Celsa Sampson, Maria Eugenia Pinardi, Elsa M. Rada, and Nacarid Aranzazu 24 Adam's Rib Awry: Women and Schistosomiasis - Edward H. Michelson 41 Women and Malaria - R. Reubin 54 Leprosy - M. E. Duncan 81 Does Schistosomiasis Infection Impair the Health of Women? - Melissa Parker 100 A Synoptic Inventory of Needs for Research on Women and Tropical Parasitic Diseases with an Application for Schistosomiasis - Hermann Feldmeier and lngela Krantz 134 Clinicopathologic and socioeconomic impact of Chagas disease on women: a review - Anne Zajac 149 Materno-Fetal Malaria: Multiple Dyadic Dilemmas - E. F. P. Jelliffe 176 Women and Malaria: Social, Economic, Cultural, and Behavioural Determinants of Malaria - Irene A. Agyepong 194 La Mujer y la Enfermedad de Chagas Congenito en Santa Cruz, Bolivia: Aspectos '] Epidemiologicos y Socio Culturales - Esperanza C. Azogue 4 Foreword This collection resulted from a global call for papers addressing the theme of women and tropical disease research. In 1989-1990, a joint initiative was undertaken by the Special Program for Research and Training in Tropical Diseases (TDR) of the World Health Organization (WHO) and the Health Sciences Division and the Gender and Development Unit of the International Development Research Centre (IDRC). Health researchers were invited to submit papers on women and tropical diseases in a competition sponsored by the two agencies. The papers were reviewed by an international expert panel consisting of health and social scientists from Switzerland, Australia, the United States, Sri Lanka, and Canada. They included Steering Committee members of TDR's Socioeconomic Research Program and IDRC staff. Criteria for judgement included scientific merit, relevance to gender issues, innovative ideas, research recommendations, review of the literature, and knowledge of the field. During a meeting held in September 1991 at Litchfield, Connecticut, the group chose the paper entitled "Leprosy in Women: Characteristics and Repercussions" by Marian Ulrich et al. of Instituto de Biomedicina, Caracas, Venezuela for the five thousand dollar prize that was offered. However, numerous other submissions of high quality were received from researchers in Latin America, Africa, Europe, and North America. A selection of the top ten papers, as judged by the panel, is included in this volume. Although the general quality of the papers was excellent, the competition highlighted a gap in research on gender and tropical diseases. It is clear that there is a need for further research and for more collaborative work between biomedical and social scientists. For this reason, TDR and IDRC will sponsor a second competition in 1992 with the hope of advancing understanding of this important interdisciplinary field. This collection of papers represents an important first step toward the stimulation of further work on gender and tropical diseases. The papers have scientific validity and interest in their own right but they also are important indicators of the current state of the literature on this subject. As such it is anticipated that they will serve to inspire further interdisciplinary research on gender and tropical diseases. It is hoped also that the collection will inspire more collaborative work and networking among researchers working in the biomedical and social sciences fields. Pandu Wijeyaratne1 Eva M. Rathgeber Evelyn St-Onge 1Editors are with Health and the Environment, Health Sciences Division; Gender and Development, Social Sciences Division; and Health Systems, Health Sciences Division of IDRC, respectively. 5 Leprosy in Women: Characteristics and Repercussions Marian Ulrich, Ana Maria Zulueta, Gisela Caceres-Dittmar, Celsa Sampson, Maria Eugenia Pinardi, Elsa M. Rada, and Nacarid Aranzazu Instituto de Biomedicina, Apartado Postal 4043, Caracas lOlOA, Venezuela Health is often measured in terms of low monality; nevenheless, merely being alive is not a measure of the quality of life. H. Mendez Castellanos Summary Physiological, socioeconomic, and cultural factors play important roles in the response of women to M. leprae and in the impact of leprosy on their lives. They appear to develop stronger immunological responses to M. leprae than men, as suggested by lower incidence and less severe clinical forms of disease in most areas of the world, as well as stronger reactions of cell-mediated immunity after prophylactic vaccination. Ethnic or genetic factors, pregnancy, intercurrent infection, and malnutrition might be included among the factors that modulate this response. With the introduction of multidrug therapy, leprosy control throughout the world is no longer an unrealistic goal. Active vaccination may constitute the other factor necessary for eventual eradication of the disease. Women in leprosy-endemic areas of the world, with few exceptions, suffer from marked economic and social dependency and inferiority, which can only be heightened by the social stigma associated with leprosy. Nevertheless, they bear an enormous responsibility for the health of their families, often as head of the household, and they possess a unique capacity to influence community opinion. The incorporation of women at all levels into active roles in health care programs may constitute one of the decisive factors in the success or failure of leprosy control. Introduction Among tropical diseases, leprosy bears a social stigma with its roots buried deep in historical tradition. Other diseases, of which mucocutaneous and diffuse cutaneous leishmaniasis and onchocerciasis (river blindness) are examples, cause profound incapacity and disfigurement, but none is associated with the ostracism and sense of fear and repulsion inspired by leprosy throughout much of the world. While
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