Empowering Communities to Reduce the Impact of
by Rachel Wilson
(May 2004) Infectious
diseases continue to cause ill health and deaths to
millions worldwide, despite advances in public health
over the last 100 years advances that include the
development of vaccines and antibiotics and improvements
in sanitation. In many developing countries, women face
particular difficulties in warding off infection because
of social and economic obstacles to accessing health
information and services. To reduce the impact of
disease on women, some infectious-disease prevention
programs are employing community-based approaches
conducted by women.
The World Health Organization
(WHO) estimates that in 2001, infectious diseases
accounted for 26 percent of total mortality worldwide
and caused 15 million deaths, many of which could have
been prevented with drugs, vaccines, and access to
uncontaminated food and water. Deaths from AIDS,
tuberculosis (TB), malaria, diarrheal disease, and
respiratory infections are responsible for much of the
infectious disease burden. However, mortality presents
only part of the picture. A number of other diseases
cause severe disabilities and deformities in almost 1
billion people who live mostly in extremely poor and
remote areas of less developed countries, says WHO.
These illnesses range from the severely enlarged limbs
of elephantiasis to dengue and Guinea worm, a painful
and disabling parasitic disease.
In many less developed
countries, womens vulnerability to disease is
heightened because of the interplay of economic, social,
and biological factors. Often, a long history of
discrimination against women has led to inequalities
that perpetuate a lack of access to services and
resources for them and their children and that increase
the likelihood of risky behaviors. Anatomical
differences also play a role in the transmission of
infection. In the case of HIV, transmission through
sexual contact is far more effective from men to women
than vice versa. As a result of these factors, women in
sub-Saharan African areas affected worst by HIV are 1.2
times more likely to be infected than men. The ratio is
highest among young people, according to the Joint
United Nations Programme on HIV/AIDS (UNAIDS). Women
ages 15 to 24 are two-and-a-half times more likely to
have HIV as their male counterparts. In the case of
malaria, a disease that exerts its heaviest toll in
Africa, pregnant women, particularly women in their
first pregnancy, are the main adult risk group.
Because women bear children
and typically play a primary role in caring for the home
and other family members, infectious disease among women
has a ripple effect. Pregnant women can mean sick babies
and children, and illness among women can compromise the
well-being of entire families. For example, pregnant
women infected with certain sexually transmitted
infections (STIs), including chlamydia and gonorrhea,
face an increased risk of having ectopic pregnancies and
of giving birth to infants with severe central nervous
system damage, according to the Institute of Medicine of
the U.S. National Academies. Women with certain STIs
also experience an increased risk of infertility,
cancer, and premature death, notes the institute in its
book The Hidden Epidemic: Confronting Sexually
In addressing the impact of
specific infectious diseases in different parts of the
world, nongovernmental and other organizations are
employing innovative approaches to disease prevention,
working through women at the community level. For
example, this approach has been used to address Guinea
worm in Ghana and dengue in Puerto Rico.
Guinea Worm Project in Ghana
Through its efforts to
control Guinea worm, the Atlanta-based Carter Center, in
partnership with the Office of Global Health at the U.S.
Centers for Disease Control and Prevention (CDC), has
played a role in stimulating community-health change
within Guinea worm-infected areas in Ghana.
Guinea worm (or
dracunculiasis), a parasitic disease transmitted to
people through ingestion of infected waters,
traditionally affects poor rural communities that lack
safe drinking water and adequate health care. The Guinea
worm larvae go through their first stage of development
once small water fleas known as Cyclops ingest them.
When people ingest water contaminated with the flea, the
male and female larvae mate, and a female worm develops.
The worm can grow to lengths of up to 3 feet before it
emerges from the surface of a persons body, causing
severe pain, fever, nausea, and ulcers, according to the
WHO. Without adequate care, the ulcers may take long
periods to heal and may be complicated by secondary
bacterial infections, by stiff joints, and disabling
shrinkage of limbs, says WHO.
As a result of a global
eradication campaign whose partners include WHO, the
United Nations Childrens Fund (UNICEF), and the CDC,
the number of Guinea worm cases declined from an average
of 10 million to 15 million at the start of the 1980s to
an estimated 64,000 in 2001. Still, the disease persists
in several poor rural areas of Africa. In Sudan, for
example, a civil war has challenged prevention efforts.
and health organizations like the Atlanta-based Carter
Center have worked with male volunteers within rural
villages to reduce the local incidence of disease by
keeping infected persons out of the water, using a
simple cloth or nylon filter to remove the water flea
from drinking water, treating ponds with larvicide,
educating community members to promote behavior change,
and providing safe water sources. However, the men often
have been unable to identify all sources of water
accessed by the community because they are not the ones
involved in clothes washing and other day-to-day tasks
requiring the use of water. Therefore, the Carter
Centers efforts took a new turn. The center is
currently working with the Ghana Red Cross Womens Club
to reduce local infection. The collaboration involves
community women, the people most familiar with
water-associated household practices.
In 1999, female volunteers in
393 villages conducted door-to-door surveillance of
Guinea worm, distributing filters, identifying potential
water sources, ensuring the women did not enter infested
waters, and providing other community members with
information. As a result of these efforts, the incidence
of Guinea worm decreased by 36 percent between 2002 and
2003, Monique Petrofsky of the CDCs Office of Global
Health told the CDC-sponsored International Conference
on Women and Infectious Diseases in February 2004. Other
districts had a 56 percent increase in cases during the
Dengue Project in Puerto Rico
Dengue, which thrives in poor
and crowded urban areas of tropical countries, ranks as
the most significant mosquito-borne viral disease in the
world, according to WHO. Transmission to humans occurs
through the Aedes aegypti mosquito that dwells around
homes in water-storage containers and discarded items
associated with poor water supply and waste disposal.
Dengue hemorrhagic fever, a more severe form of the
illness, causes internal bleeding, and infected persons
can progress to shock and death within hours after the
onset of symptoms, says WHO.
WHO estimates that up to 50
million infections occur every year in more than 100
countries. Eliminating dengue is challenging for many
reasons, including the absence of a vaccine, the minimal
impact of pesticide spray, and the primary role that
manufactured containers play in the life cycle of
infected mosquitoes. For these reasons, prevention has
been the best approach.
Because women often are most
knowledgeable about household surroundings, CDC recently
partnered with the U.S. Head Start program in Puerto
Rico to establish a novel prevention strategy that
relies on community health workers known as promotores.
Local women, who were nominated by fellow community
members to be leaders, received training to help promote
behavior change within the community. These promotores
made house-to-house visits, interviewing heads of
households and inspecting areas around homes to ensure
the absence of containers and other manufactured objects
that could serve as breeding grounds for the mosquito.
The promotores also engaged in a number of community
education activities, including painting a bridge with
dengue prevention messages, organizing a childrens
parade to provide the community with dengue-related
information, and creating a dengue prevention exhibit at
a local supermarket.
The education efforts
resulted in positive behavior change: 20 percent more
households turned containers upside-down to prevent
larval infestation in the intervention community than
did those in other communities, the CDCs Hilda Seda
told the participants at the February conference.
Although much remains to be
learned about the best ways to promote health among
women, novel infectious-disease interventions that
result in positive health behavior shifts in
hard-to-reach populations are gaining attention.
Devoting resources to such intervention strategies might
serve not only to level the playing field for women with
regards to infectious disease, but may also serve to
strengthen the positions and the self-esteem of women
entrusted with helping to improve and save the lives of
family members and peers.
is a medical writer and editor in Atlanta, Georgia.
Thomas R. Eng and William T.
Butler, eds., The Hidden Epidemic: Confronting
Sexually Transmitted Diseases (Washington DC:
National Academy Press, 1997).
Joint United Nations
Programme on HIV/AIDS (UNAIDS) and WHO, AIDS Epidemic
Update: December 2003 (Geneva: UNAIDS and WHO,
Mary Kay Kindhauser, ed.,
Communicable Diseases 2002: Global Defence Against the
Infectious Disease Threat (Geneva: World Health
Monique Petrofsky, "Successes
with Guinea Worm Work" (presentation made at the
International Conference on Women and Infectious
Diseases, Atlanta, Feb. 27-28, 2004).
Hilda Seda, "The Role of
Women in Dengue Prevention: Results of a Pilot Study in
Puerto Rico" (presentation made at the International
Conference on Women and Infectious Diseases, Atlanta,
Feb. 27-28, 2004).
World Health Organization
(WHO), Scaling up the Response to Infectious
Diseases: A Way Out of Poverty (Geneva: WHO,