Women are the biggest consumers of medicines worldwide. Their health needs match those of men and even exceed them because of the physical demands of pregnancy and childbirth. Yet throughout the world their needs are trivialised, ignored or neglected.

Salmah died last Friday during childbirth. The bidan or the village midwife and the other women present struggled hard but in vain to ease the prolonged labour. Salmah was only 14. But deaths like hers are not uncommon in Indonesia. Teenage mothers face higher risks during childbirth from problems such as toxaemia, prolonged labour and cervical lacerations.

It's not only teenage mothers who face greater health risks. Overall women throughout the world fall ill more often and are less likely to get proper treatment.

'The health care system depends on women,' said Dr. Halfdan Mahler, director general of the World Health Organization (WHO) in 1985.¹ But what is society doing to take care of the health of its women?

A woman's biology allows her to live, on average, six or seven years longer than a man: a fact that is sometimes taken as showing that women are in good health and that all is well with them. But that is far from true. Women are in poor health, especially in the developing world. In India, Bangladesh, Bhutan, Nepal and Pakistan, where the status of women is particularly low, where they are malnourished, where they bear many children, and where they perform hard physical work caring for their families and land they die earlier than men.²

Childbearing exerts a major strain on women's health especially in poor countries. Every year around half a million women in Asia and Africa die in childbirth. Globally a further 25 million women fall seriously ill each year after giving birth.³ Women in many poor countries of Asia, Africa and Latin America often bear more than five children and the risk of death or illness following childbirth increases with every pregnancy. Teenage pregnancies, common in many developing countries where girls marry young, are twice as likely to result in the mother dying in childbirth as pregnancy in women in their twenties.

Many Third World women are weakened by hard physical labour on their family's farms and two-thirds of them are anaemic during pregnancy from poor nourishment. Even when they are not pregnant nearly half the women in the developing world are anaemic, not as a result of a specific illness but from general 'maternal depletion' — too much work, not enough food and too many pregnancies too close together.⁴

In poor countries health services have in general failed to have much impact on the number of women who die in childbirth nor on the number of infants and young children dying each year. According to the WHO only one-third of women in the developing world have access to a trained health worker. Half are attended at delivery by untrained traditional midwives ill-equipped to deal with problematic births, sepsis and so on.⁵

In countries such as the UK and USA pregnancy and childbirth is a much safer business but more and more women have lost control over the experience to modern technology and drugs. Tales of unnecessary Caesarian sections and episiotomies abound in the US and parts of Europe. Many women are simply deprived of the experience of a natural delivery.

Contraception has been mooted by some as the way to improve women's health in developing countries, by reducing the toll on health of pregnancy. The WHO states that: 'Access to family planning services is the key to women's health and to their well-being in all other aspects of their lives'.⁶ And it is true that where pregnancies are unwanted, where illegal abortion is a possible consequence then family planning services could prevent deaths (in Latin America half of all deaths among pregnant women are due to abortion).

But it is not quite that simple. Families in poor rural countries often want to have a lot of children, to offset those that die in the early years of life, to provide a workforce for their fields and homes and to take care of them when they grow old.

Family planning programmes in developing countries have often become population control programmes instead; they introduce contraception not to give women freedom of choice over when they have children and how many they have but simply to reduce the number of children born. For that reason permanent or long-lasting methods are encouraged irrespective of the possible health hazards.

Millions of female consumers all over the world have been touched by the side-effects of contraceptive methods: of thrombosis (clotting of blood in the blood vessels) from the Pill, of pelvic infection and occasionally sterility from intra-uterine contraceptive devices (IUDs) and of menstrual chaos from long-acting injectable contraceptives such as Depo-Provera.

The tragic consequences of women using the Dalkon Shield IUD in the 1970s are well-known today. Women and consumer groups have fought a lengthy battle against the manufacturer of this particular IUD, logging the grisly episodes of pelvic infection and heavy bleeding that have sometimes accompanied its use.⁷

And other IUDs are not free from problems. Around 200,000 women in the US alone are sterile from using IUDs.⁸ The risk to women using IUDs in the Third World as a long-term contraceptive is high because health services are rarely adequate in giving women the regular medical checks that are needed.

Of equal concern to women is the use of hormonal injectable contraceptives such as Depo-Provera widely promoted by family planning agencies for population control in developing countries. Although it has practical advantages, the contraceptive can cause depression, headaches and menstrual chaos and there is a theoretical greater risk of cancer.⁹

But women's health needs are not solely confined to their reproductive functions. They are just as vulnerable to infections and other diseases as men — often more so. In the words of Sister Patricia Travaline, a health worker in Bangladesh: '… simply by being born female, a woman is more at risk of falling ill.' In addition, she adds, 'being poor and living in a rural Third World country increases that risk. '¹⁰ As yet there are few statistics which compare men's and women's rates of illness. Fortunately this is changing. Over a quarter of the 76 countries which report to the WHO now monitor health data separately for women and men.¹¹

Many times a woman's sickness is overlooked by a medical profession too ready to see a woman's health solely in terms of her gender. In developing countries medical officials have literally failed to see illness in women. Development consultant Barbara Rogers asked some (male) health experts in West Africa in the late 1970s why their statistics for onchocerciasis (river blindness) only referred to men. One replied that 'it was really a man's disease'. Another admitted he had never noticed that the documentation was only about the men.¹²

Women's health problems are often trivialised by (male) doctors. In developing countries a woman's health is simply not considered important by society. Malnutrition affects more women and girls than males because custom dictates they eat last. Yet far fewer women and girls end up in hospital for treatment than males. In India, studies by the National Institutes of Nutrition show that malnutrition among female infants and women is now worse than ever before.¹³ Yet it is men and boys who end up in hospital. One study has shown that while four or five times as many girls as boys suffer kwashiorkor (a disease of malnutrition) only one girl was hospitalised for every 50 boys.¹⁴ Boys and men are seen as more important, more productive; women and girls are of little economic value and so their health is of less consequence.

Drug company advertising plays a significant role in promoting these views of women and their health problems. Companies spend on average about 20 per cent of its sales turnover on promoting its products both to doctors and to the public.¹⁵

A common image of women in drug advertisements aimed at doctors is of silly, emotional hypochondriacs at the mercy of their sex organs. It's a convenient one for it offers an abundance of 'illnesses' which need a pharmacological 'cure'. Women are the biggest consumers of medications worldwide from contraceptives to mood-altering drugs.¹⁶ As such they are major targets in drug advertisements.

Every stage of a woman's life, from menstruation to the menopause, is turned into a sales pitch by the drug industry. Sometimes general pain-killing drugs are sold in two versions, one labelled 'PMS' to signal its use for women suffering from menstrual pains. Spurious female conditions — such as the 'empty-nest syndrome' (when a woman's children have grown up and left home, supposedly leaving her life empty) or the 'irritable postmenopausal woman' are dreamt up in order to sell more medications.¹⁷

Other events also call for promotional attention. Puberty hails the 'need' for deodorants and a barrage of sanitary options. Catching a man calls for cosmetics and perfume. Keeping him requires skin products and vitamins to hold unsightly wrinkles at bay.

In the US and UK, women are twice as likely as men to be given mood-altering (psychotropic) drugs such as tranquillisers.^{18 19}

This pattern is emerging in the Third World too. It is often an easy way out for the doctor who does not have the time, or perhaps the interest, to help get to the root of the patient's problem. Being born a woman does seem to increase the risk of mental illness: there are more women than men in mental institutions in the UK, more women than men diagnosed as schizophrenic in Sweden. But the statistics do not mean that women are psychologically weaker than men. It is more likely that it is the role in which society places women that creates their mental anguish. Tranquilising women into accepting the mould society has cast for them is easier than helping them break it. But the side-effects of these tranquilisers, or 'housewives' pills' as industry calls them, include headaches, blurred vision and drug dependency.²⁰

Women are not only utilisers of health services and medicines they are also health providers, especially for their families. As wives and mothers, women purchase children's medicines and general health products from tonics to anti-diarrhoea preparations. Here women are especially vulnerable to the pharmaceutical industry's advertising ploys, since naturally they want to do the best for their family.

In developing countries with poor public health services families resort to self-medication because it is cheaper than paying the doctor's fees. Women buy medicines for their families over-the-counter from drug stores, chemists, even supermarkets — sometimes with no more guidance than the gilded promises from an advertisement hoarding.

Although access to information and safe goods are two basic consumer rights, all too often people only find out the full details of a drug's hazards when it's too late. Frequently doctors themselves do not know all the side-effects of a drug they prescribe nor do they know when not to prescribe a preparation. They too, especially in the Third World, depend too much on what the pharmaceutical industry chooses to tell them.

Numerous pharmaceuticals sold in developing countries which are banned in the West or strictly controlled in their use become a hazard in unregulated markets.

Tragedies happen. Mothers in Thailand, Indonesia, India and the Philippines, persuaded by promises of thriving health for their malnourished children gave them anabolic steroids. These are powerful growth hormones whose use is severely restricted in the West, and whose side-effects include hirsutism (excessive growth of hair on the face and body) and irreversible sex changes in young girls.²¹ But no one had told the mothers: the advertising held only the promise of healthy growth by means of a raspberry flavoured liquid.

The consumer movement has done wide research on pharmaceuticals and the Health Action International (HAI) network is campaigning for the market to be regulated internationally and for countries and their doctors to adopt a more rational approach to the use of drugs.²²

Women have a special need for education about health because of their dual role as consumers — on their own behalf and again for their families. As frequent health providers to the community they need more information and more support too. Traditional midwives for example form the crux of healthcare for pregnant women in large parts of Africa, Asia and Latin America yet few have had any training to help them perform this role better.

There also needs to be a shift in education to encourage women to keep healthy for themselves. 'Women are encouraged to keep healthy not for themselves but for others,' contents Charmain Kenner, a writer on health education. She gives the example of a film on cervical cancer entitled, Think of us in which women are told to go for a smear test because their families need them to stay healthy.²³

Keeping healthy for others is a tall order. The shift towards primary healthcare — preventive medicine which includes improvements in nutrition, water and sanitation — means more work for women. They will have to carry more water from the well if hands are to be washed several times a day. If water needs to be boiled, women must fetch the wood for the fire to heat it.

What this means is that there will be no improvements in healthcare for women unless there is an improvement in their status. Reaching a woman with primary health services will not mean that she or her baby daughter are suddenly valued more by their family. The benefits — of the use of oral re-hydration salts to treat diarrhoea for example — are still going to be directed first towards an ailing baby boy rather than his sickly sister in a society which rates boys more highly.

At present, much medical research on women's health misses the point. Their real needs — for better nutrition (in the developing world especially), for a redistribution of their workload and an understanding of their difficulties — cannot be treated with pills. The pharmacological buzzing around women's hormonal 'conditions' — concern with cures rather than causes — is a distraction which will not improve their health.

Part of the problem is that women are seen as passive not active consumers. In its Alma Ata report in 1978 on Primary Health Care, the World Health Organization commented that 'women can contribute significantly to primary health care especially during the application of preventive measures, but men can 'contribute by shaping the community health system'.²⁴

Women's health will only improve when they have more control of the health services, ensuring that their needs as people as well as potential or actual mothers are met. Their health will improve when men take a greater share in the household work. Their health will improve when they are not expected always to put other people's needs before their own.

Notes

1. Mahler, H. 'Women — the Next Ten Years', in World Health, April 1985, p.3.
2. 'World's Women', data sheet of the Population Reference Bureau Inc., Washington D.C., 1980.
3. Taylor, D. et. al. Women: A World Report, Methuen/New Internationalist, London, 1985, p.42.
4. The State of the World's Children 1986, Oxford University Press/UNICEF, Oxford, 1986, p.37.
5. WHO quoted in Women: A World Report, op. cit., p.43.
6. In Point of Fact, WHO, Geneva, July 1985, no.27, p.1.
7. Ehrenreich, B., Dowie, M. and Minkin, S. 'The Charge: Gynocide', in Mother Jones, November 1979.
8. Pappert, A. 'The Rise and Fall of the IUD', in Adverse Effects: Women and the Pharmaceutical Industry. International Organization of Consumers Unions, Penang, 1986, p. 170.
9. Duggan, L. 'From Birth Control to Population Control: Depo-Provera in Southeast Asia', in Adverse Effects: Women and the Pharmaceutical Industry, op. cit., p. 161.
10. Quoted in Women and Health in Africa. Evaluation and Planning Centre for Health Care, London School of Hygiene and Tropical Medicine, London, 1985, no.6, p.28.
11. 'Review and Appraisal: Health', presented to the World conference to review and appraise the achievements of the United Nations Decade for Women: Equality, Development and Peace, Nairobi, Kenya, July 1985, A/CONF.116/5.
12. Rogers, B. The Domestication of Women: Discrimination in Developing Societies. Tavistock, London, 1980, p.56.
13. Mukhopadhyay, M. Silver Shackles: Women and Development in India. Oxfam, Oxford, 1984, p.27.
14. Bhatia, S. 'Status and Survival', in World Health, 1985, p.13.
15. Tiranti, D. 'A Pill for Every Ill', in New Internationalist, no. 165, November 1986, p.4.
16. Cottingham, J. 'Women and Health: An Overview', in Women and Development, Isis Women's International Information and Communication Service, Geneva, 1983, p. 144.
17. 'A Portrayal of Women in Drug Advertising: A Medical Betrayal', in Journal of Drug Issues, vol.6, no.1, 1976.
18. Ingleby, D. Critical Psychology. Penguin, London, 1981.
19. 'Sex Differences in Psychotropic Drug Use', in Social Science and Medicine, vol.12B, pp. 179-186.
20. Chilnick. L. D. (Ed.) The Pill Book. Bantam Books, New York, 1982, p.155.
21. Yee, L. W. 'The Marketing of Anabolic Steroids in the Third World', International Organization of Consumers Unions, Penang, May 1983.
22. Health Action International, various documents.
23. Kenner, C. No Time for Women. Pandora, London, 1985.
24. Quoted in Blair, P. Programming for Women and Health. Equity Policy Center, Washington, 1980, p.40.