United Nations

E/CN.6/1995/3/Add.3


Commission on the Status of Women

 Distr. GENERAL
27 February 1995
ORIGINAL: ENGLISH



COMMISSION ON THE STATUS OF WOMEN
Thirty-ninth session
New York, 15 March-4 April 1995
Item 3 (b) of the provisional agenda*

     *   E/CN.6/1995/1.


            PREPARATIONS FOR THE FOURTH WORLD CONFERENCE ON WOMEN: 
            ACTION FOR EQUALITY, DEVELOPMENT AND PEACE:  REVIEW AND
            APPRAISAL OF THE IMPLEMENTATION OF THE NAIROBI FORWARD-
                LOOKING STRATEGIES FOR THE ADVANCEMENT OF WOMEN

               Second review and appraisal of the implementation
               of the Nairobi Forward-looking Strategies for the
                             Advancement of Women

                        Report of the Secretary-General

                                   Addendum


                        II.  CRITICAL AREAS OF CONCERN

            C.  Inequality in access to health and related services

1.   In the Nairobi Forward-looking Strategies for the Advancement of Women,
health is one of the three sub-themes, along with employment and education, of
the three goals - equality, development and peace - of the United Nations
Decade for Women.  In designing measures for the implementation of the basic
Strategies at the national level, a number of areas for specific action were
identified.

2.   With the recognition of the vital role of women as providers of health
care and the need for strengthening basic services for the delivery of health
care came the need both to promote the positive health of women at all stages
of life and to recognize the importance of women's participation in the
achievement of Health for All by the Year 2000.  The Strategies stressed the
need to increase the participation of women in managerial and higher
professional positions, through appropriate legislation, training and
supportive action and to change the attitudes and composition of health
personnel.

3.   They also emphasized the necessity for providing health education to the
entire family and the need to combine promotional, preventive and curative
health, and access to water and sanitary facilities that involved women in all
stages of planning and implementation.  They stressed as well the need to
comply with the International Code of Marketing of Breast Milk Substitutes,
forbidding any commercial pressures that interfered with the priority of
breast-feeding, the application of vaccination programmes for children and
pregnant women and the elimination of any differences in coverage between boys
and girls, as well as the eradication of the marketing of unsafe drugs and of
practices detrimental to health and the provision of access to essential
drugs.

4.   The Strategies called for the provision of adequate nutrition for women
and children and the promotion of interventions to reduce the prevalence of
nutritional diseases such as anaemia in women of all ages, particularly young
women.

5.   They also stressed recognition of the fact that the ability of women to
control their own fertility was an important basis for the enjoyment of other
rights.  The Strategies called for the provision of appropriate health
facilities, adapted to women's specific needs, and the reduction of the
unacceptably high levels of maternal mortality.  The need was also expressed
to strengthen maternal and child health and the family-planning components of
primary health care, and to produce family-planning information and create
services, pursuant to the basic human right of all couples and individuals to
decide freely and informedly the number and spacing of their children.  The
urgency of developing policies to encourage delay in the commencement of
child-bearing was indicated, since pregnancy in adolescent girls had adverse
effects on morbidity and mortality, as well as the need to change
discriminatory attitudes towards women and girls through health education. 
There was a need for providing adequate fertility-control methods, consistent
with internationally recognized human rights, as well as with changing
individual and cultural values.

6.   The need to encourage participation of local women's organizations in
primary-health-care activities was part of the focus of the Strategies, as
were the application of gender-specific indicators for monitoring women's
health and the necessity of enhancing the concerns with occupational health
and the harmonization of work and family responsibilities.

7.   The Economic and Social Council, in its resolution 1990/15 (adopted by
the Council upon the recommendation of the Commission on the Status of Women,
at its thirty-fourth session), adopted the recommendations and conclusions
arising from the first review and appraisal of the implementation of the
Nairobi Forward-looking Strategies, contained in the annex to that resolution.

The following constitute the most detailed recommendations arising out of the
review process.

     "Recommendation XII.

         "15. Since the beginning of the 1980s, there has been a decline in
     the standard of health and nutrition of women in parts of every
     developing region due, inter alia, to a decline in per capita
     expenditure on health.  This is a particularly alarming situation since
     maternal and neonatal health are crucial to infant survival.  Infant and
     child mortality rates have been rising in a number of countries after
     having declined for decades.
     
     "Recommendation XIII.  Governments, international organizations,
     non-governmental organizations and the public in general should be aware
     of the decline in women's health in developing countries.  Improvement
     of women's health by the provision of appropriate and accessible health
     services should be a priority within the goal of health for all by the
     year 2000.

     "Women constitute the majority of health-care workers in most countries. 
     They should be enabled to play a much larger role in decision-making for
     health.  Governments, international non-governmental organizations and
     women's organizations should undertake programmes aimed at improving
     women's health by ensuring access to adequate maternal and child health
     care, family planning, safe motherhood programmes, nutrition, programmes
     for female-specific diseases and other primary health care services in
     relation to the goal of health for all by the year 2000.

     "The World Health Organization and other organizations of the United
     Nations system should further develop emergency programmes to cope with
     the deteriorating conditions of women's health mainly in developing
     countries, with particular attention to nutrition, maternal health care
     and sanitation.
     
         "16. Women's access to information and services relating to
     population and family planning are improving only slowly in most
     countries.  A woman's ability to control her own fertility continues to
     be a major factor enabling her to protect her health, achieve her
     personal objectives and ensure the strength of her family.  All women
     should be in a position to plan and organize their lives.

     "Recommendation XIV.  Governments, non-governmental organizations and
     women's movements should develop programmes to enable women to implement
     their decisions on the timing and spacing of their children.  These
     programmes should include population education programmes linked to
     women's rights and the role of women in development, as well as the
     sharing of family responsibilities by men and boys.  Social services
     should be provided to help women reconcile family and employment
     requirements.
     
     "Family planning programmes should be developed or extended to enable
     women to implement their decisions on the timing and spacing of their
     children and for safe motherhood.

     "The United Nations Secretariat, the United Nations Population Fund, the
     World Health Organization and other organizations of the United Nations
     system should develop collaborative programmes to link the role of women
     in development to questions related to population.

         "17. During the past five years, women's health, both physical and
     psychological, has been increasingly affected in many countries by the
     consumption and abuse of alcohol, narcotic drugs and psychotropic
     substances.  
     
     "Recommendation XV.  Governments and other competent national
     authorities should establish national policies and programmes on women's
     health with respect to the consumption and abuse of alcohol, narcotic
     drugs and psychotropic substances.  Strong preventive as well as
     rehabilitative measures should be taken.
     
     "In addition, efforts should be intensified to reduce occupational
     health hazards faced by women and to discourage illicit drug use.
     
         "18. The emergence, since the Nairobi Conference, of new threats to
     the health and status of women, such as the alarming increase in
     sexually transmitted diseases and the acquired immunodeficiency syndrome
     (AIDS) pandemic, requires urgent action from both medical and social
     institutions.
     
     "Recommendation XVI.  Greater attention is also needed with respect to
     the issue of women and AIDS.  Efforts in this regard should be an
     integral part of the World Health Organization Global Programme on AIDS. 
     Urgent action and action-oriented research are also required by social
     institutions at all levels, in particular the United Nations system,
     national AIDS committees and non-governmental organizations, to inform
     women of the threat of AIDS to their health and status."


                     1.  Women's health:  an overall view

8.   In the 1991 progress report on women, health and development of the
Director-General of the World Health Organization (WHO), 1/ presented to the
Forty-fourth World Health Assembly, it was recognized that women's health was
influenced by biological, environmental, social, economic and cultural
factors. 2/  It was further recognized that women's health, their status and
their multiple contributions were pivotal links between the health of a
population and its prospects of sustainable development - prospects which,
despite the remarkable progress of the 1960s and 1970s, had been dimming in
the 1980s. 3/

9.   Setting an agenda for women's health must begin with a recognition of
the fact not only that the health situation of women is different from that of
men, but also that the systems identifying and determining that health
situation are fashioned according to gender-biased models.  Gender
discrimination has tended to be hidden within the general issue of poverty and
underdevelopment.  In practice, women and girls suffer disproportionately
because of their low status in society.

10.  While most of the world's poor suffer from poor health and nutrition, in
many countries, particularly those of South Asia, rates of malnutrition are
generally higher among females than among males of the same age group.  In
many countries, food is distributed within the household according to a
member's status rather than according to nutritional needs.

11.  Low health status is the outcome of biological as well as social,
political and economic factors acting together.  Many women suffering from
poor health status are found to lack knowledge, information, skills,
purchasing power, income-earning capacity and access to essential health
services.  Health must be considered in a holistic manner.

12.  Reliable and high-quality health services promote sustainable
development.  The greatest reduction in fertility rates have resulted from a
combination of women's improved economic and social status, education and
access to reproductive-health-care services.

13.  Despite the fact that in households and sometimes in the community,
women are the primary providers of health care, they often lack access to
outside health care for themselves.  For example, data show that in many
countries there are fewer women than men who are treated in hospitals, receive
prescriptions for medication, receive timely treatment from qualified
practitioners and survive common diseases.  Restricted access to health
services leaves women less capable of taking care not only of their own
health, but also of that of their children, thereby perpetuating a trend of
high child mortality.

14.  Ensuring women equal access to the benefits of public health care is
critically dependent upon gender-specific health strategies.  This is true
because men and women tend to suffer from different illnesses.  Women are far
more likely to suffer from reproductive role-related illnesses such as
sexually transmitted diseases, anaemia, and the complications resulting from
child-bearing.  Targeting these health problems clearly involves different
strategies for men and women.

15.  Under increasing economic pressure in the past four years, 37 of the
poorest countries have cut health-related spending by 50 per cent.  Some
countries report on the implementation of social compensation programmes to
offset the impact of structural adjustment policies.

16.  A major factor mentioned by many countries is the focus on primary
health care, promoted by most developing countries.  To provide equal care to
both rural and urban women, many countries have adopted the system of primary
health care including family planning, maternal and child care, vaccination
and reinforcement for the curing of diseases, including prevention of sexually
transmitted diseases and human immunodeficiency virus (HIV)/AIDS.

17.  In Asia and the Pacific, the focus of policy in the area of women's
health has generally been within the context of reproductive health. 
Fertility control and family planning have been the major set of issues around
which health policies and programmes have generally evolved in the past. 

18.  Some countries report that the fact that women have come to dominate the
teaching and health professions has resulted in the feminization of those
professions, and a consequent lowering within them of prestige and pay. 
Several national reports acknowledge the skills of women in the areas of birth
attendance and traditional medicine practices, and various areas of
self-healing, although these practices have not yet been duly incorporated in
the medical system.

19.  In many countries, there is not yet a policy for women's health, except
for reproductive health.  The reports often link improvements in the overall
situation of women's health to demographic trends and improvement in
infrastructure.  Health is considered an outcome of combined factors promoting
quality of life.

20.  Many countries note the contribution of specific health programmes, like
the expanded programme of immunization, to women's health, and the
contribution of local non-governmental organizations in health campaigns.

21.  Rural health centres are in general on the decline, and in much poorer
condition than urban ones.  For instance, one country reports that a person in
the rural areas consults the health centre about twice a year, versus four
times a year in the urban areas.


                           2.  Environmental health

22.  Sustaining the global cycles and systems upon which all life depends is
a first requisite of health.  The combination of population and production
growth and unsustainable consumption patterns has, however, heavily depleted
natural resources, threatening the environmental base upon which health and
survival depend.

23.  In developing countries, where populations are still expanding, pressure
on scarce resources has made it very difficult to improve living conditions. 
In 1990, an estimated 1.5 billion people did not have access to safe water,
and almost 2 billion people lacked sanitary means for disposing of excreta.

24.  Many countries have subscribed to the goal of universal access to safe
water for the year 2000.  Some reports indicate that improvements have been
made in sanitary education and in the application of low-cost technologies. 
One country refers to an initiative to save on wood energy, for example,
through cheaper production of charcoal and improved charcoal stoves.


                        3.  The life-cycle perspective

25.  In the case of women's health, the using of a lifelong perspective that
takes into account the whole life-span is of paramount importance, since
health conditions in one phase of a woman's life affect not only its
subsequent phases but also future generations.  It is also useful to look at
common issues or themes so as to identify a useful framework from which a
feasible agenda for action can be elaborated.

26.  For every 100 females delivered into the world, there are 105 males
born.  The female human being is biologically more resistant, and the surplus
of male infants is nature's way of balancing the sex ratio in the population. 
Ordinarily, the number of surviving girls soon surpasses that of boys. 
However, there are parts of the world where this male-to-female imbalance is
never overcome.

27.  Human intervention, in the form of neglect of girls, favours the
survival of males.  In several countries in the Asian and Pacific region, the
preference for sons over daughters has resulted in a differential treatment of
infants by sex.  The data show that there is a higher risk that girls, as
compared with boys, will die before age 5, in spite of the natural biological
advantage of girls.  In Bangladesh, the under-five mortality rate for girls
was recorded as 175 per 1,000 live births, as against 160 for boys, and in
Nepal, 187 for girls as against 173 for boys.  The pattern is much more
alarming in regions within large countries like India and China, known for
their strong preference for sons.  In India, there are 957 females aged four
years or under for every 1,000 males in the population.

28.  Preference for sons is most marked in South Asia and the Middle East,
but is not confined to those regions alone.  In Colombia, the number of deaths
of boys between the ages of one and two is 75 as against a figure of 100 for
girls in the same age group.  Recent empirical evidence suggests that excess
female mortality during childhood also occurs in Latin America and the
Caribbean, particularly in the less developed countries with low life
expectancy.

29.  Globally, at least 2 million girls per year are at risk of having to
submit to genital mutilation.  WHO estimates that 90 million women in the
world today have - at some time between the ages of 2 and 15, depending on
local custom, and most commonly between the ages of 4 and 8 - undergone one of
the procedures that fall under this category.  Most live in Africa, a few in
Asia, and, increasingly, due to migration processes, some in Europe and North
America.

30.  Many Governments have publicly denounced the practice.  Some have
translated their concerns into laws prohibiting female genital mutilation or
into programmes to persuade people to abandon the practice.  Several countries
report on the existence of harmful traditional practices and their impact on
women's health.  One report, on the other hand, highlights coexisting cultural
practices that are beneficial, including respect for and assistance to elders,
mutual assistance networks and breast-feeding.


                                4.  Adolescents

31.  More than 50 per cent of the world population is under age 25, and
80 per cent of the 1.5 billion young people between the ages of 10 and 24 live
in developing countries.  Although fertility levels have been decreasing in
many regions, the fertility rates of adolescents are very high and in some
cases increasing.  At present, it is estimated that close to 15 million
infants per year (10 per cent of total births) are born to adolescent mothers.

32.  Adolescents girls are more vulnerable to reproductive health problems
than young men.  The age of the first sexual encounter is declining
everywhere.  For example, a survey in Nigeria found that 43 per cent of
schoolgirls in the age group 14-19 were sexually active.  During the 1980s,
30.2 per cent of female adolescents in Jamaica and 12.7 per cent in Mexico
were sexually active before they were 15 years of age.  The proportion of
females under 20 years of age who used contraceptives at first coitus was
40 per cent in Jamaica, 21 per cent in Mexico and 8.5 per cent in Guatemala.

33.  The rate of pregnancy among girls in the age group 15-19 is 18 per cent
in Africa, 8 per cent in Latin America, 5 per cent in North American and
3 per cent in Europe.  In Venezuela, the number of births to girls under age
15 rose by 32 per cent between 1980 and 1988.  In the Caribbean, 60 per cent
of first births are to teenagers, most of whom are unmarried.

34.  One quarter of the 500,000 women who die every year from pregnancy-and-
childbirth-related causes are teenagers.  A survey in Bangladesh found that
maternal mortality in age group 10-14 was five times higher than in age group
20-24. 

35.  The sense of urgency in addressing the situation is justified by the
sheer numbers of girls involved.  In 1990, girls aged 15 or under constituted
40 per cent of the female population in Egypt and Morocco, 44 per cent in
Algeria and Mauritania, 45 per cent in Ethiopia and Mali, 46 per cent in
Djibouti and Somalia, 48 per cent in Nigeria, Uganda and the United Republic
of Tanzania, 50 per cent in Co^te d'Ivoire, and 52 per cent in Kenya. 
Increasing concern for the status of women and girls prompted the South Asian
Association for Regional Cooperation (SAARC) to declare 1990 the Year of the
Girl Child.

36.  Some countries report an increase in the life expectancy of girls over
that of boys.  One country reports that owing to the availability of medical
facilities and health units in all villages, life expectancy at birth for
girls increased from 2 to 66 per cent, or at a rate of 127 per cent, from
1981-1982 to 1992-1993.

37.  Many countries indicate strong policies of readmitting teenage mothers
into secondary schools.  Many have included courses on family-life education
at school.  One country reports a peer approach counselling programme at the
Young Women's Christian Association (YWCA).


                            5.  Reproductive health

38.  The health of women in the years 15-45 is influenced predominantly by
their reproductive and maternal roles.  Despite progress in a number of key
areas, the morbidity and mortality rates of women due to reproduction remain
unnecessarily high in many areas of the globe.  Maternal mortality is the
indicator that exhibits the widest disparity among countries.  Of the 150-200
million pregnancies that occur world wide each year, about 23 million lead to
serious complications such as post-partum haemorrhage, hypertensive disorders,
eclampsia, puerperal sepsis and abortion.  Half a million of these end with
the loss of the mother.

39.  Ninety-nine per cent of these deaths take place in developing countries. 
The incidence of maternal death ranges from almost non-existent to very high
(the rates in some poor countries reach as high as 1,600 times those in
industrialized countries).  Scattered information suggests that in some
countries, one fourth to one half of all deaths of women of child-bearing age
result from pregnancy and its complications.

40.  Maternal mortality rates in central and eastern Europe, apart from
Romania and Albania, are about twice as high as the average for Europe as a
whole.  In Romania and Albania, maternal mortality has fallen dramatically
since the legalization of abortion, as previous rates were largely due to
unsafe abortions.  Unsafe abortions are among the top causes of maternal
mortality in all countries except Azerbaijan.  Azerbaijan's exceptional status
might be due to the way it defines such practices.  In the Russian Federation,
nearly 200 abortions are reported for every 100 births.

41.  Comparing new information on maternal mortality with that available five
years ago suggests that pregnancy and childbirth have become safer for women
in most of Asia and in parts of Latin America.  Nevertheless, data are still
too scattered and more needs to be done to have a more complete picture. 
However, frequent child-bearing, which can seriously compromise the health and
nutrition of a woman's children, continues to be characteristic of large
numbers in many areas of the world.

42.  One reason for the lack of progress is the tendency to look for rapid
solutions to deep-seated problems.  It has been found that safer motherhood
requires a massive and simultaneous attack on all the elements contributing to
the problem, including those under the headings of legislation, social
services, rights of women.  As regards the health sector alone, the system's
entire infrastructure - including community mobilization, pre- and post-natal
care, clean and safe delivery with trained assistance and above all timely
referral for management of complications - needs strengthening in most
countries where maternal mortality is high.

43.  International commitments setting goals for reduction of maternal
mortality by 50 per cent for the year 2000 have been endorsed by most
countries.  Many countries mention the Safe Motherhood Initiative, adopted by
WHO, the United Nations Development Programme (UNDP), the United Nations
Population Fund (UNFPA), and the United Nations Children's Fund (UNICEF) in
1987.  Many countries report that the increased provision and improvement of
existing maternity services at all levels of the health system is the most
effective means of reducing maternal mortality.  In addition, quality
reproductive-health-care services, including family planning, together with
good primary health care represent important interventions.  Many countries
report increments in health care to address the matter of maternal mortality. 
Several reports mention a national programme for maternal health, with
campaigns on reproductive health and family planning.  Several countries
report the inclusion in their expanded programmes of immunization of
antitetanus campaigns.


                                 6.  Fertility

44.  Fertility levels, measured by the total fertility rate, have continued
their tendency to decline in all regions.  World fertility fell by
10.5 per cent, from 3.8 to 3.4 births per woman, between the periods 1975-1980
and 1985-1990.  The total fertility rate varied from 8.5 (the highest) in
Rwanda, to 1.27 (the lowest), in Italy.

45.  Sub-Saharan Africa is the only region of the developing world that has
not yet undergone a widespread decline in fertility.  A decline has started in
three countries of the area:  Botswana, Kenya and Zimbabwe.  Ethiopia reports
a fertility rate of 7.5 births per woman in 1992.

46.  The total fertility rate continued to decline in all subregions of Asia
and the Pacific throughout the post-Nairobi Conference era.  Between 1985 and
1992, it dropped from 2.42 to 2.19 in developing East Asia and from 3.69 to
3.37 in South-East Asia.  In South Asia, it fell from 4.71 to 4.36 and in the
Pacific Islands, from 4.92 to 4.61.  The developed countries of the region,
namely, Australia, Japan and New Zealand, which had already achieved a total
fertility rate of 1.71 by 1985, experienced a further decline to 1.56, by
1992.

47.  In the Caribbean, many countries have experienced nearly a 50 per cent
drop, from about 6.0 to 3.0, in total fertility rate levels within the last
30 years, and the rate is expected to decline further in the next decade.

48.  Although fertility rates have gone down world wide, many women still
lack access to information and services, or cannot make use of them because of
economic limitations or cultural norms.  Only 27 per cent of couples use
contraception; 140 million women in developing countries become pregnant
although they did not want a child.  Every year, over 20 million women
terminate unwanted pregnancies through unsafe abortions, as a result of lack
of access to relevant care and services such as family planning, costly
contraceptive methods, lack of information, and restrictive legislative
practices.  Of these, 15 million survive, but with a wide range of long-term
disabilities.  Some 60,000-100,000 die.

49.  One country reports that in 1992, for the first time since the
introduction of family planning, the gender-differential participation ratio
became 55 to 45 in favour of men, owing to a broader public awareness of the
relative seriousness of the side-effects of contraceptive measures taken by
women.  Some countries consider that with respect to utilization of
contraceptives, universal coverage has been reached:  only 4 per cent of
sexually active women are without any such coverage.  The protection and
monitoring of maternity programmes have been further reinforced in the last
years.  One country reports the establishment of family counselling services,
with a counsellor-to-woman ratio of 1.4:2,000.


             7.  Cervical cancer and sexually transmitted diseases

50.  Cancers of all types among women are increasing.  Those affecting women
more frequently in both developed and developing countries are stomach cancer,
breast cancer, cervical cancer and colorectal cancer.

51.  Cervical cancer is the most common form of cancer in women in most
developing countries and the second most common form of cancer in women in the
world as a whole.  There are an estimated 450,000 new cases (a realistic
figure including undiagnosed early cases would go as high as 900,000), and a
death toll of 300,000, each year.  

52.  Breast cancer is one of the major causes of female mortality in
developed countries.  The number of women developing breast cancer and dying
from the disease is growing steadily every year.  As in cervical cancer, early
detection plays a major role in reduction of mortality.

53.  Prevalence rates of sexually transmitted diseases are higher among
females than among males in those aged 20 years or under.  In one
industrialized country, 6 million women, half of whom are teenagers, acquire a
sexually transmitted disease.

54.  A number of countries report the launching of national awareness-raising
campaigns.  Several countries report the establishment of national programmes
of early detection of breast cancer.


                                 8.  HIV/AIDS

55.  AIDS emerged as a major health problem in the mid-1980s, in both the
developed and the developing countries, threatening to undermine major gains
in the reduction of morbidity and mortality.  A decade ago, women seemed to be
on the periphery of the AIDS epidemic, but today almost half of newly infected
adults are women.  Women are more susceptible to contracting the disease for
biological reasons and because of their lower social status.

56.  WHO estimates that well over 14 million adults and children have been
infected with HIV since the start of the pandemic, and projects that this
cumulative figure may reach 30-40 million by the year 2000.  It is estimated
that over half a million children have been infected with HIV from their
infected mothers.  The epidemic incapacitates people at the ages when they are
needed most for the support of the young and the elderly.  WHO estimates that
by the year 2000, 13 million women will have been infected with AIDS. 

57.  The AIDS pandemic is most devastating in sub-Saharan Africa.  WHO had
estimated that by 1992, 1.5 million adults in the region would develop AIDS,
and more than 7 million would be infected with HIV.  In this region, HIV
transmission is predominantly through heterosexual relations, and among the
infected population, almost the same proportions of men and women are
represented.  In the 15 countries in Eastern, Central and Western Africa where
by 1990 above 1 per cent of the adult population was infected, the already low
level of life expectancy at birth (about 50 years in 1985-1990) is projected
to remain unchanged through the year 2000.  Because as many women as men carry
the virus, WHO estimates that child mortality may increase by as much as 50
per cent through mother-to-child transmission in much of sub-Saharan Africa
during the 1990s.  In Ethiopia, the trend between 1987 and 1993 (2.4:1
compared with 1.4:1) indicates that the male-to-female ratio is narrowing.

58.  At the beginning, transmission of HIV in North America, Europe and
Australia occurred basically through homosexual contact, but increasingly
heterosexuals and drug-users are becoming the agents of transmission,
especially in North America.  According to WHO estimates, 1.6 million cases of
HIV and close to 350,000 cases of AIDS might occur by  1992.  In Latin
America, the Caribbean and the urban sections of Brazil are the areas most
affected.  It is estimated that currently about 1 million people in the region
may be affected by HIV.

59.  Asia and the Pacific has exhibited the highest growth rate in HIV/AIDS
among women, many of whom are married women with a single partner.  India and
Thailand are the countries worst affected.  There are no estimates available
for the region as a whole, but the estimate for India is up to about 1
million, and for Thailand about 400,000.

60.  A Global Programme on AIDS was established by WHO in 1987.  By 1990,
more than 150 countries had established national AIDS committees to coordinate
national control programmes.  Part of the problem that has to be faced
concerns the reluctance of national authorities to acknowledge the existence
of HIV infection, and its real magnitude.  Another challenge is the
discrimination against people with HIV/AIDS, a response often connected with
the stigma attached to sexually transmitted diseases, and the mistaken belief
that HIV can be transmitted through casual social contacts.

61.  The Global Programme on AIDS strategy stresses a gender-specific
approach, emphasizing women's social, physical and economic vulnerability.  In
most countries where HIV/AIDS has become a serious threat or is expected to
become one, national AIDS committees have been established to formulate
prevention programmes.  Several countries are devoting resources to research,
guidance, educational material and technical assistance.  National campaigns
of education and prevention have been developed in many countries.  Several
have included prevention components in school curricula.  A few countries
report close collaboration with non-governmental organizations in training
peer leaders as a way of improving service delivery.


                      9.  Health consequences of violence

62.  Although grossly underreported, violence against women has assumed
alarming proportions, as can be seen in section D below.  Only recently have
domestic violence and rape been viewed as a public health problem, yet they
are a significant cause of female mortality and morbidity.  Violence against
women leads to psychological trauma and depression, injuries, sexually
transmitted diseases and HIV, suicide and murder.

63.  Accurate figures on the prevalence of domestic violence and rape are not
available, but from existing data it is known that rape and domestic violence
account for about 5 per cent of the total disease burden among women aged
15-44 in developing countries.  In industrialized countries, where the total
disease burden is much smaller, this share rises to 19 per cent.  In these
countries, assaults have been reported to cause more injuries to women than
vehicle accidents, rape and mugging combined.

64.  In Asia, non-governmental organizations have played a pivotal role in
publicizing the situation.  They have collaborated with Governments in many
countries in efforts involving the provision of legal aid and legal
counselling to victims of violence, and the running of trauma centres and
shelters for abused women.


                     10.  Health issues related to ageing

65.  Life expectancy for women has risen by eight years since 1970 in the
low- and middle-income countries, and by five years world wide, though this
gain has been less than that enjoyed by men.

66.  In the years to come the number of women over age 65, in both
industrialized and developing countries, will increase; and the total number
of these women will rise from 330 million in 1990 to 600 million in 2015. 
Women over age 50 constitute more than one third of the entire female
population of the United States of America.  In addition, women constitute
about 59 per cent of the United States population aged 65 or over, and 72
per cent of the population over age 85.  In contrast, in Lithuania, female
life expectancy decreased, as it did in Poland and some of the newly
independent States.

67.  Of these elderly women, many will suffer from the chronic diseases
associated with ageing such as osteoporosis and dementia, or from the
consequences of neglect such as malnutrition, alienation and loneliness. 
Reporting on health conditions of the elderly female population is still
scanty, especially in the developing countries.  Osteoporosis affects 10
per cent of women world wide above age 60.  In one industrialized country,
osteoporosis is responsible for 1.3 million bone fractures per year.  Most of
the women affected become totally dependent as a result of the illness.

68.  When women do seek care for their health problems, the result is often
overprescription of tranquillizers - especially to older women - instead of
further investigation.  A North American study found that physicians
prescribed psychoactive drugs 2.5 times more often to women over age 60 than
to men in the same age group.

69.  Many industrialized countries are concerned with the rising demand for
health-care services on the part of their growing population of elderly
people.  Some developing countries are restating the importance of the
traditional family and community networks in caring for the elderly.


                               11.  Malnutrition

70.  Adequate nutritional intake is particularly important for girls and
women.  Discriminatory feeding practices in childhood sometimes lead to
protein-energy malnutrition, anaemia and other micronutrient deficiencies in
young girls.  Higher rates of malnutrition generally exist among females than
among males in the same age group.  In many developing countries, food is
distributed within the household according to a member's status rather than
according to nutritional needs.

71.  Problems caused by malnutrition in girls are responsible for subsequent
problems during childbirth, like obstructed labour, fistulas and birth
asphyxia.  Because women need more iron than men, and because they tend to
receive a lower share in the distribution of food, globally 43 per cent of
women and 51 per cent of pregnant women suffer from anaemia.  A third of women
of reproductive age who are not pregnant have anaemia.  In developing
countries, 56 per cent of pregnant women are anaemic and up to 7 per cent
suffer from severe anaemia.  Virtually all adolescent girls in developing
countries suffer from iron deficiency.

72.  Because their mothers lack iodine, 30,000 babies are stillborn every
year, and over 120,000 are born cretins.  Iodine deficiency is the most common
and preventable cause of mental retardation.  At least 25 per cent of
adolescent girls are affected.  This deficiency leads not only to goitre but
to brain damage as well, and also affects women's reproductive function.  In
developing countries, stunting caused by energy-protein malnutrition in girls
affects 43 per cent of all women aged 15 or over.

73.  Many countries mention the adoption at the World Summit for Social
Development of the goal of a one-third reduction in iron-deficiency anaemia by
the year 2000.  Some countries have improved their nutrition surveillance
system.  Many report a direct impact of structural adjustment programmes on
the nutritional situation.


                              12.  Mental health

74.  Community-based studies and treatment studies indicate that women are
disproportionately affected by mental health problems and that their
vulnerability is closely associated with their marital status, their work and
their roles in society.  Epidemiologic evidence is accumulating that links
mental disorders with alienation, powerlessness and poverty, conditions most
frequently experienced by women.

75.  Several reports indicate a tendency in health services to shift their
emphasis from the provision of curative services to the prevention of ill
health.  Although most health measures still focus on physical ill health, 
well-being-related measures are becoming increasingly important.  


                             13.  Substance abuse

76.  Over the next 30 years, tobacco-related deaths will more than double, so
that starting from the year 2020 well over 1 million adult women will die from
tobacco-related illnesses annually.  Women are smoking in increasing numbers
in developing countries and are a special target of cigarette advertising
world wide.  In France, a recent survey among students showed that girls today
smoke more than boys.  There is also a rapidly growing trend among girls
towards the use of other drugs.

77.  Some 30 million women have contracted diseases due to alcohol intake. 
Alcoholic cirrhosis is the cause of 300,000 deaths among women each year.  The
ill-treatment of 50 per cent of battered wives is alcohol-related.

78.  Illicit drug-abuse problems among females have been underestimated, as
statistics in many countries are not gender-disaggregated.  A few countries
report a new bio-psycho-social approach in health services, distinct from the
focus only on maternal and child health.


                                     Notes

     1/  Document WHO/FHE/WHD/92.5.

     2/  Ibid., para. 16.

     3/  Ibid., para. 10.


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Date last updated: 06 December 1999 by DESA/DAW
Copyright 1999 United Nations