EXPERT OPINION: Women's Health : Indian Perspective - DR. M. G. MOKASHI

Women’s population world over is around 50%; in our country, it is below 50%. Other than motherhood, a woman has shouldered responsibility as a housewife. It is not just housekeeping; rather she should be a home minister. At times she is a decision maker; some other time she influences decisions. This has been irrespective of her education or earning capacity. She is a respected person in family. She represents culture and as a part of it, sacrifices for the family with love and understanding. She raises children, looks after their welfare, disciplines them and yet fulfils other household responsibilities, for which she has no monetary benefit, though her domestic role has saved family money. She is paid lesser than her male counterpart for comparable manual work. Thus she spends more cumulative hours of work in a day, inside and outside the home. Manu-smruti a code of conduct for Hindu religion declared, “Where the women are adored, even Gods like to stay therein”. If a man and a woman after marriage form a unit, she is called a better half. Also she represents ‘fair sex’. In spite of it, there has been some kind of discrimination against women, due to various reasons, in all the countries. Kaalidaasa the renowned Sanskrut dramatist observed that a woman was dependent on her father in childhood, on husband in her middle age and on son in old age. Rather, it was the social order that time, by the male dominant society. Women had to wait and fight for their equal rights, till the last century. Today, they have such rights by constitution. As per Hindu code they can be legal heir to ancestral property. They have equity for education and for employment. Today, in urban population they are well educated and appear in various types of professions and jobs.

Differences in male and female brain structure and functions: It is interesting to note that the male brain is 10% more in size and weight while female brain is more compact and dense in connections. Males have better sense of path direction/ map reading due to parietal lobe interpretation. Limbic system is more developed in females imparting emotional character. Due to large amygdale males present strong social and sex behaviour.* Males memorise general events while the females, the details of events too, attributed to Hippocampus. An analogy is that a male brain is like airport while female brain is like a runway in area**. In context with communications by corpus callosm, male brain is like a path while female one is like a 4-lane highway! More gray cells in males make them logical while female brain is intuitive due to more white cells. Males are less sensitive to pain perception. Males don’t mind much about mistakes; females are repenting but forgiving. Decisions of females are guided by external surroundings. In fact, such areas of differences were detected in case of 45 parameters.Our concern is mode of communication. For example brochures made for information in hospitals seem to be based on a unisex brain concept. How information should be delivered to a female spinal cord injury patient? Apparently, we have no separate theme.  

Hidden discrimination against women may not be denied. The very fact that sex determination in embryonic stage has been banned, is indicative of illegal MTPs/ abortions being practiced, in case of female embryo. This is an unfortunate, sad and heinous situation. Sometimes some woman relative is associated with such acts. Dowry a social evil (also a crime) is responsible for this trend. Incidences of suicide are come across in women, after marriage. And at times they are suspected to be homicide. Thus married women are under stress due to monetary demands from in-law’s side and due to taking that guilt on themselves, they endure the taunting, insults, mental and physical torture, by themselves, sparing parents of information, of such episodes. Divorces are on increase; whether it is good or bad is a different aspect but if it is a remedy to cut down suicides in women, it is an acceptable social diversion. It is tragic to note that some women are accomplices to provoke such suicides. Survivors of suicide have no betterment on family front. This social disease must be eradicated from root. Another fact is female physiology and pregnancy entrusted by Nature, in a woman from puberty till menopause. Too early childbearing has risk to baby as well as the mother. Premature birth rate can be on rise. Marriageable age has been legally fixed. Late pregnancy also carries risk of delayed labour and possibility of brain injury to newborn. After menopause, osteoporosis is a serious metabolic health problem to majority of women with risk of fracture to lumbar vertebrae and the femur bone, commonly.  Over and above diseases of uterus and hormonal imbalance, and the problems related to pregnancy, she has risk of other health disorders common to the population, at large. Incontinence after delivery and in old age is a common problem. Among cancers, cervix and the breasts are more affected. Such events and their preventive/ remedial results by occurrence are included in health indicators.

Health indicators are measurable events of results of health care policies and programmes from the population studies. WHO advocates use of certain indices to express and compare effects of strategies employed to improve country status on certain parameter like health, social conditions etc. WHO in 1958 defined Quality of Life (QoL) as "State of physical, mental and social well-being and not merely absence of disease or infirmity". WHO QoL Group (1991) favoured to include non-medical aspects of health through the notion of quality of life -" an individual's perception of (one's) position in life in the context of the culture and the value systems in which they live, and in relation to (one's.) goals, expectations, standards and concerns. It is a broad ranging concept, affected in complex way by the person's physical health, psychological state, level of independence, social relationships, and relationships to salient features of (one's) environment". Pakistani economist Mahbub ul-Haq introduced Human Development Index (HDI) and is used by UNDP since 1993. HDI indicates an average of 3 indices: Life Expectancy Index, Education Index (adult literacy rate and mean years of schooling) and GDP Index. According to HDI, out of 174 countries surveyed in 1999, India is in medium HDI category along with other 94 countries, ranked 132. Recent UN declaration in this respect is on the level of living itself. WHO termed it as Index of Standard of Living inclusive of income and occupation, socio-economic status, housing, drinking water and the sanitation.  Also sports and recreation, nutrition, and especially the level of health education together decide about the status of well-being. If our country has to improve ranking in HDI, Education Index must be improved which involves female illiteracy. Maternal mortality is being addressed. Further, unpaid or low-paid woman labour is an influence on GDP Index (Gross National Product). Almost 35 years ago, Bhutan's King Jigme Singye Wangchuk coined the term "Gross National Happiness as more representative of his 'Happy poor subjects' than Gross National Product". 

Quality adjusted life years (QALY) is a measure, based on cost-utility analysis (CUA). This combines the qualitative and quantitative health care outcomes into a single measure of utility. If a treatment regime lengthens life by 10 years but at only half the quality of normal life, this would give 5 QALYs, as in case of a woman suffering from rheumatoid arthritis.Possibly a new Gross Wellbeing index may finally become the defining international statistical measure. Economists including Nobel Laureate Amartya Sen will launch the world's first concrete bid to measure happiness and wellbeing across the countries and continents to supplement the traditional UN and World Bank indicators of national income. Economist Sabina Alkire an expert of Oxford Poverty and Human Development Initiative group, says as a part of experiences of Kerala's 'Happy poor' led her to conclude that people can be 'non-poor in happiness but poor in food security'. Accordingly, with the help of her revered guru and former PhD guide, Amartya Sen she has fashioned questions on five topics, 1) Decent work, 2) Physical safety, 3) Empowerment, 4) Measure of shame, 5) Subjective humiliation. Women at times are deprived from topics 1,2,3 and subjected to 4, and 5 more than the male counterparts.

Before we review more details of some indicators, it is considered essential to focus on the following. Hindustan Times (17-12-2012) reported findings of surveys on ‘safety of women’ conducted along with NGO Akshara in Dec. 2011 and in 2012, recently. 95% women reported sexual harassment in some form. 68% women have done nothing when they experienced harassment. More than 40% incidences were at day time.  Cases of sexual harassment during bus travel were 46%, market place 41%, on the street 33%. 15% women have taken help of constable while only 4% cases were reported at police station. Major causes of not registering complaint were perceived as inaction and delay, over and above social stigma. 15 % took help of teachers or supervisors, in educational places. On-job incidences were either not in the questionnaire or not reported. Cases of physical assault and rape were 5% though 11% perceived fear of such events. Rape is a punishable crime. Incidences of rape in case of minor girls are also reported. In spite of various legal measures introduced to book those criminals, not many are punished. The women police have been assigned to register complaints and facilitate investigations. Unreported cases are suspected to be many due to social stigma since parents are unwilling to come forward and complain. So over and above physical health, social health is a pressing problem which can affect mental health. In a society boasting of cultural heritage, women feeling not safe, is a matter of grave concern. Even molestation attempt is traumatising and it affects dignity of a victim. That law should employ strictest measures is essential but there should be social pressure on the culprits. They should be boycotted from social matrix. Society should adopt a liberal outlook towards the victims and they must be integrated in the society, without stigma. It is a problem affecting the mental health.  

It is reported by National Service Framework, UK, 1999, that every year almost 1 in 6 adults of working age suffer from mental health problems, e. g. anxiety or depression.; The proportion of CHD patients having heart attacks is 3 times higher, while those having angina is 5 times. The risk of CHD is closely associated with social disadvantage; unskilled men being 3 times more likely to die than professional men, and their wives being twice as likely to die from CHD. The policy, Healthy People 2010, USA emphasizes the role of social environmental factors in healthy living and highlight the influence of 2 aspects of socioeconomic status - income and education on leading health indicators.Much of the morbidity and mortality in the developing world are consequent to extreme poverty; and women share high risk.From the following figures are for both the sexes, for prevalence of neurological burden of diseases. 20–30% of the populations are susceptible to neurological disorders.5 According to The World Health Report 2003, dementia contributed 11.2% of all years lived with disability among people aged 60 years and over: more than stroke (9.5%), musculoskeletal disorders (8.9%), cardiovascular disease (5.0%) and all forms of cancer (2.4%). It appears that social environment prevails upon the old wisdom and risk of mental disorders is dominant. Regarding other influence, the education having repercussions on health, adult literacy rate in India was 62% (2006). More than 38% segment over this average is expected from women population. Women with less education and unskilled jobs carry such a risk. It is worthwhile to review the United Nations (2000) Health Related Millennium Development Goals (MDG) and Indicators which are MDG 1: child underweight; MDG 4: child health and immunisation; MDG 5: maternal and reproductive health; MDG 6: HIV/AIDS

It is interesting to study existent available data from India related to health indicators. The latest statistical data between 2000 and 2010 are included. Life expectancy at birth was 65 years and at the age of 60 years was 16 years [more] in 2009. Healthy life expectancy (HALE) at birth (years) is 56 years. Adult mortality rate (probability of dying between 15 and 60 years per 1000 population) was 250 in male and 169 in female populations. So women lead a longer life [statistics for HALE not available]. 

Maternal Mortality ratio is 200:100,000 live births in India in 2010. In India, 4.4 million children under the age of 5 died from infectious diseases in 2010, nearly all such deaths were preventable. Child death traumatises a mother, inside out. Infant mortality rate (probability of dying between birth and age 1 per 1000 live births) is 48. Under-five mortality rate is 63. Distribution of causes of death in children aged <5 years was prematurity in 14% while neonatal sepsis in 6%.1 in 10 adults is obese and by applying rule of equity, women won’t mind sharing half the burden, at least and at length the waist line!

WHO in World Health Report 2003 "Shaping the Future" has enlisted Goals = G, Indicators = I. I have emphasised on data on maternal and child health, presently since the two are interconnected from it. ‘Healthy People 2010’ a document prepared by the US Dept. of Health and Human Services in Nov. 2000. It is a Prevention agenda for nation. Overreaching goals are 1. Increase Quality and Years of Healthy Life. 2. Eliminate Health Disparities. There are 28 Focus Areas identified, each having its own goal; further the Goal Statement and Objectives are listed. Healthy People 2020 continues in this tradition with the launch on December 2, 2010 of its ambitious, yet achievable, 10-year agenda for improving the Nation’s health

The following goals/indicators from ‘Healthy People 2010’ are relevant to women’s health.

Under Long-Term Care and Rehabilitation services, Arthritis, Mean days without severe pain, Activity limitations due to arthritis and personal care limitations, appear. Osteoporosis with Cases and Hospitalisation for vertebral fractures and Chronic Back and activity limitations, are included. In relation to cancer, Pap tests, Colorectal screening, Mammograms are enquired. 

Disability and Secondary Conditions: [6-1 to 13] include PWD and Feelings and depression; Social participation and emotional support; Satisfaction with Life; Employment parity, Inclusion in Regular Education; Accessibility of Health and Wellness programmes;     

Family planning: [9] Intended pregnancy; Birth spacing; Contraceptive use and Failure; Emergency contraception; Male involvement; Adolescent pregnancy; Abstinence before age of 15 years, Pregnancy prevention, education and Sexually transmitted disease ( STD ) protection; Problems in getting pregnant and maintaining a pregnancy are the indicators. But the threat of STDs and AIDS is really alarming due to low to moderate incidence-high mortality, thereby low prevalence situation, and certain radical measures demand inclusion. Cover of condom is a short term medical measure but perfunctory as a social remedy; it may not conceal the underlying facts for a long. It is like relaxing, being seated on a time-bomb. Eventually it would explode and the effects may be much more devastating.

Maternal, Infant and Child Health: G 16 includes Fetal, Infant, Child, Adolescent / young Adult Deaths; Maternal deaths, Illness and Pregnancy-complications; Perinatal care and Childbirth classes; Obstetrical care-very Low Birth Weight Deliveries at level III hospitals; Caesarean deliveries; Weight gain during Pregnancy; Low, very low birth weight, premature birth; Infants put to sleep on their backs; Developmental disabilities; Spina bifida and other neural tube defects. Prenatal substance abuse; Fetal Alcohol syndrome; Breastfeeding; Newborn bloodspot screening; sepsis among infants with sickle cell disease, Special Care Needs

A woman is a natural caring person due to love of a mother, or a sister, a wife or a daughter and plays a significant role as a carer for the family in their health problems. In the process, her own health is neglected. This may be by way of irregular food intake and or under nourishment, disturbed sleep, fatigue and exhaustion, anxiety all leading to stress in life. Further, a duty-bound woman carer in family refrains from drawing attention to her health problems. Poverty adds to such problems depriving her from investigation and treatment. At times one comes across a 60+ wife supporting her around 70 years stroke affected husband, on her murmuring, limping and painful hip or knee joints without a trace grimace. The picture is sad and indicates social structure too. Grown up children can’t spare time; some are forced to earn for livelihood for the family. Some are busy with their careers. Paid carers cannot be afforded for long-term. ‘Get well’ cards culture is convenient but useless for a patient who needs physical and emotional support. A woman carer in family may provide emotional backing but is unable to provide physical support, simply due to weight of a growing child or an adult.     

Women’s contribution to family welfare is acknowledged but that towards economy is largely unrecognised since it is in honorary capacity if not to name it as ‘unpaid services’. A woman in the family is the last person to report of her health problems, and that too when they are unbearable with a result that early diagnosis and early intervention are not possible. She is the first person to cater care to other family members while the last one to give opportunity to others to care for her. Here lies her greatness and the weakness of the system, too. This is not reflected in the health indicators but we have to look for and introduce new indicators to relieve women from this tendency and come out with their problems sooner than later. If they are healthy, family is healthy and thereby the society too.  

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