Doyal and Hoffman discuss women’s health in South Africa in the context of continuing poverty and gender inequality.
Most discussions of women’s health in South Africa have focussed on two interconnected areas: sexual and reproductive morbidity and mortality and HIV/ AIDS. This is not surprising given the extent of these problems and the harmful effects they continue to have on so many women’s lives. However it is important that they are put in the context of broader changes in South African life and the additional health hazards these developments may pose for women.
Old and New diseases
Historically, societies experiencing economic growth have gone through what is called a ‘demographic transition’. This is reflected in a shift from ‘diseases of poverty’ (mainly infections and problems associated with reproduction) to the so-called ‘chronic diseases of affluence’ including cancer, heart disease and mental health problems. This in turn leads to increased life expectancy and a growth in the proportion of older people in the population, as we can see in countries such as the US and the UK.
However in many developing countries like South Africa the pattern has been much more complicated. Here the population is now experiencing a double burden with the new ‘modern’ diseases appearing on top of the old ones, which remain unresolved as a result of continuing poverty. When the newly emergent HIV/AIDS pandemic is added to the equation, the picture is one of a ‘triple burden’ of ill health. As a result, the last decade in South Africa has seen a decline in the life expectancy of ordinary South Africans rather than the expected improvement.
These burdens are bearing down especially heavily on women because: (1) they remain at the centre of the continuing crisis of maternal morbidity and mortality and (2) they are over-represented among those living and dying with HIV/AIDS. As a result of these crises, the increasing significance of chronic diseases for women has usually been overlooked. Yet a glimpse at the future shows the dangers of the failure to take these problems seriously.
Mortality rates among South African women aged 15-54 have increased rapidly over the last few years. About half of these deaths are due to HIV and 16% to infections and maternal causes. However most of the remainder (24%) are due to the growing incidence of non-communicable diseases. These chronic problems are not always fatal but they can be a major cause of illness and disability. The challenges they pose for poorer women in particular and for those in older age groups will be illustrated here with reference to cancers of the breast and cervix, coronary heart disease and mental health problems.
challenges of Women’s cancers
Deaths from cancer of the cervix have traditionally been associated with poverty while breast cancer is more common among women in richer populations. This is reflected in patterns within South Africa where cervical cancer has always been a much greater problem among black women, particularly those in rural areas compared with white women (70.2 per 100,000 compared with 11.3 per 100 000, in 2000) By contrast, white women have had much higher rates of breast cancer.
Cancer of the cervix now ranks 15th as a cause of premature death among South African women yet it is a largely preventable disease. The lifetime risk of dying from cancer of the cervix is 1 in 34 for black women and 1 in 93 for those who are white. Around 84% of all women diagnosed with the disease are black. This group of women usually present at a relatively late stage (late diagnosis), and hence cure rates are low. This reflects in part the overall lack of primary care services especially in rural areas. But it also stems from the absence of effective health information strategies.
In the past decade screening policies have been introduced that offer opportunities for a limited number of Pap smears to women over the age of However there have been significant problems both in ensuring the availability of services and in promoting their uptake. Also, when the disease is diagnosed, access to specialist care can also be very limited especially in rural areas.
In recent years breast cancer rates have been increasing among South African women as a whole and have now surpassed those of cancer of the cervix. Among white women the rate now stands at 17.9 per 100,000 while it is around 13.4 among black women. The rise in breast cancer has been especially marked among the many black women who are moving into the towns. Though the reasons for this are clearly complex, it seems to reflect a reduction in protective factors such as late menarche, early age of first birth, long lactations, large families and physically active lives.
These trends are likely to increase with greater urbanisation and many of these migrant women will find it especially difficult to access expensive screening and treatment facilities. Recent data from a number of different hospitals showed that only 22% of black patients presented with early cancer (stages I and II) in contrast to around 69% of those who were not black. Conversely stages III and IV were most prevalent in black women (77.8%) compared with non-black women (30.7%). This clearly has a major effect on survival rates.
Cardio-vascular disease is about women too
The last two decades have been marked by an increase in the incidence of cardio-vascular disease (CVD) among women in many of the world’s poorest countries. Moreover these problems are increasingly found not just in older women but also in those who are pre-menopausal. This pattern can be observed in South Africa where the rate of CVD has increased to the point where one in four women below the age of 60 has some form of heart condition. For women between the ages of 15-44, CVD ranks third in the size of the disease burden whereas it is sixth for men in the same age group.
Evidence from around the world shows that CVD is usually thought of as a white male problem. This also applies in South Africa where the growing incidence among black women has received very little attention. The major reasons for these growing numbers include increased smoking, high rates of obesity and lack of physical exercise. Yet very little money has been put into gender-sensitive strategies for health promotion or detection and treatment of risk factors or early signs of clinical disease.
Gender, poverty and mental health problems
Problems related to mental health have received very little attention in developing countries in general and South Africa in particular. This reflects in part the fact that they are not major causes of death. However they are responsible for a huge burden of distress and disability especially among the poor.
Very little information is available on mental health problems in the South African population as a whole. However a recent study from the Medical Research Council indicated that severe depression is the second leading cause (after HIV) of years lost due to disability among South African women. Both depression and anxiety disorders are much more common among women than among men. This reflects the continuing gender inequalities in South African society and their links with poverty.
Low socio-economic status, unemployment and lack of education are all important factors underlying female depression. These are found especially among the rural black women who make up half of the poorest people in the South African population. For these women, depression and anxiety are often exacerbated by low status and lack of autonomy in decision-making. There is also growing evidence of the links between gender violence and mental health problems, including post traumatic stress disorder. Finally it is important to signal the fact that the HIV epidemic itself is a major cause of depression both among those (predominantly women) who are affected and also those caring for others.
Action for Women’s health
The unfinished agendas of poverty related illness and lack of reproductive services remain a major issue for women and require a comprehensive response. Similarly the growing HIV epidemic demands further intersectional responses that meet the needs of both women and men. But at the same time it is essential that appropriate attention is paid to the increasing burden of chronic diseases that are especially likely to damage the health of those older women who are picking up so much of the growing burden of caring for others. Taken together, these problems will require increased provision of gender sensitive health promotion strategies, as well as improved primary care and better access to higher level services including both diagnosis and treatment. This will need to be done against the background of wider initiatives on both gender and socio-economic inequalities.