Content Reviewer Dr. Subha Sri B RUWSEC, CommonHealth Language Editor Dr. Sumita Parmar Allahabad University, Allahabad. Description of The Module

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1 Paper-8 Module 26 Women and Non-Communicable Diseases. 1A. Personal Details Role Name Affiliation Principal Investigator Dr. Sumita Parmar Allahabad University, Allahabad Paper Coordinator Dr. Subha Sri B RUWSEC, CommonHealth Content Writer Ms Lalitha Venkatesan Independent consultant Content Reviewer Dr. Subha Sri B RUWSEC, CommonHealth Language Editor Dr. Sumita Parmar Allahabad University, Allahabad 2B. Description of the Module Item Subject Name Paper Name Description of The Module Women s Studies Women and Health Module Name / Title Women and Non-Communicable Diseases. Module ID Paper-8 Module 26 Pre-requisites Objectives The Reader is expected to have some knowledge of women and non-communicable diseases To make the reader understand the burden of NCDs, their effect on women and their interaction with gender

2 Keywords NCD, women, gender, diabetes, cardiovascular disease, tobacco Women and Non-Communicable Diseases Introduction Non communicable diseases (NCDs) also known as chronic diseases are ones that are not passed from person to person. They are of a longer duration and slow in progress. The WHO classifies four main types of non-communicable disease namely: cardiovascular diseases (heart attacks and strokes), chronic respiratory diseases (such as chronic obstructive pulmonary disease), cancers, and diabetes. According to WHO estimates, NCDs kill approximately 38 million people worldwide each year, out of which nearly three-fourths occur in low and middle income countries. Cardiovascular disease accounts for most NCD deaths. While people of all age groups and regions are affected by NCDs, we are going to analyze in further in this chapter, how NCDs affect women. Non-communicable diseases (NCDs), are chronic, costly but largely preventable diseases. These four diseases share common modifiable risk factors and are a major cause of poverty, a barrier to economic development. In 2009, the UN Secretary General Ban Ki-moon described the global NCD epidemic as a public health emergency in slow emotion. NCDs represent the biggest threat to women s health worldwide, increasingly impacting on women in developing countries in their most productive years. The costs of NCDs to families and societies are high and escalating, in terms of healthcare and lost productivity. For these reasons, NCDs have been identified as a global risk, and one of the most important threats to businesses and economies. Each year, millions of women and children die from preventable causes. These are not mere statistics. They are people with names and faces. Their suffering is unacceptable in the 21st century, No longer considered diseases of the rich and elderly, NCDs have significantly caused female death during childbearing years and for women with young families

3 in developing countries. More women per thousand die from NCDs all over the world, especially in Africa, than countries with high incomes. Although on an average women live longer than men, they live in poor health for many years as a result of NCDs. Apart from high death toll, NCDs cause serious complications and disability. NCDs not only affect the health of women and girls, it also affects the health and chances of life of their children. Being born to an undernourished or malnourished mother increases the chances of the infant suffering from under-nutrition, late physical and cognitive development, and NCDs in adulthood. TEN LEADING GLOBAL CAUSES OF DEATH IN FEMALES IN 2008 WERE Rank Cause Number of Deaths % 1 Cardiovascular diseases 9,127, Infectious and parasitic diseases 3,811, Cancer 3,566, Respiratory diseases 2,018, Respiratory infections 1,812, Unintentional injuries 1,408, Perinatal conditions 1,379, Digestive diseases 865, Diabetes Mellitus 723, Neuropsychiatric conditions 640, Cardiovascular disease remains a major area of concern and earlier known as the disease of the rich, now is widely prevalent in every section of the society. While socioeconomic development is said to be generally associated with better health, the improving socio-economic status in India has resulted in reduced physical activity, increased obesity and diabetes. Increased exposure to risk-factors smoking, drinking, unhealthy diet have been driven by rapid urbanization and globalization and is directly or indirectly responsible for the worsening scenario in the case of NCDs.

4 There are several myths that have led to neglect of NCDs in women. Firstly is a view that the only health-related issues of women are defined through their reproductive capacity, in spite of the fact that two thirds of death and disability in women are caused by chronic diseases, violence, and other injuries. Secondly, NCDs, especially CVDs, have been considered primarily as diseases of men. Although age-specific NCD death rates in women lag behind the rates in men by about 10 years, the absolute number of NCD deaths in women is similar to that of men. Another myth is that NCDs in women are an issue only in high-income countries. But most NCD deaths in women occur in low- and middle-income countries and the rates in these countries are much higher than the high income countries. NCD deaths are frequent in people under the age of 70 years, including women, and many of these deaths are slow and miserable. A large proportion of NCD deaths, especially before old age, are avoidable with cheap, cost-effective, and in some cases, cost-saving interventions. INDIAN SCENARIO NCDs account for nearly half of all deaths in India. Overall, the leading cause of death was cardiovascular disease, followed by COPD. In the study, it was also noted that urban areas had lower number of deaths from communicable, maternal, perinatal, conditions, but a much higher number from NCDs. GIRLS AND WOMEN S VULNERABILITY TO NCDS WHO identifies four main shared risk factors for NCDs: namely tobacco use, unhealthy diet, physical inactivity and alcohol use. These risk factors are largely modifiable and responsible for the majority of new cases of NCDs. Vulnerability to these risk factors has been driven by rapid urbanization, economic development and globalization, most significantly in emerging economies like India and China. NCDs are created by our social and physical environment and are linked closely to the way our cities and transport systems are designed, the way we work, and the way we produce, process and consume. In many low- and middle-income countries, the low socio-economic, legal and political status of girls and women have increased their exposure and vulnerability to the risk factors of NCDs. Sixty percent of the world s poor are women, twice as many women as men suffer from malnutrition, and two-thirds of illiterate adults

5 are women. These underlying determinants are putting girls and women at a disadvantage in their capacity to protect themselves from the main NCD risk factors. RISK FACTORS FOR NCDS Tobacco Use Tobacco use is one of the most serious avoidable risk factors for premature death and disease in adult women. While evidence suggests that men s smoking rates may have peaked and are now in slow decline, smoking rates are increasing among youth and young women in several regions of the world. WHO estimates that the proportion of female smokers will rise from 12% in 2010 to 20% by Deaths due to tobacco use among women are similarly projected to increase, from 1.5 million in 2004 to 2.5 million by Women s health is also jeopardized by exposure to second-hand smoke, especially in countries and cultures where many women do not have the power to negotiate smoke-free spaces, including in their own homes. Girls and women are among the new targets of tobacco companies, particularly in emerging economies. Through marketing campaigns that associate tobacco use with independence, beauty, femininity and sex appeal, and through the availability of more affordable tobacco products, the tobacco industry is compromising girls and women s ability to make informed choices about tobacco use. Many women remain unaware of the health risks of tobacco use and believe that it relieves tension and facilitates weight loss. In India, tobacco is consumed in many forms, both smoking and smokeless. India is also the second largest consumer and producer of tobacco in the world. According to studies, the prevalence of tobacco use in women is 20 percent, as against 48 per cent in men. Smoking results in 1 in 20 deaths among women. Poor diet and Nutrition Urbanization has led to change in dietary patterns and an increased intake of energy-dense foods, high in saturated fat, sugar and salt. This nutrition transition is fuelling levels of overweight and obesity and is impacting significantly on the health of girls and women. According to WHO projections in 2008,

6 approximately 1.5 billion adults globally were overweight, and out of these more than 200 million men and nearly 300 million women were obese. A staggering 43 million children under five years are currently overweight, and at this age girls are more likely to be overweight than boys. At the other end of the malnutrition scale, under-nutrition in women is also critical for the global NCD epidemic. Due to the concept of fetal programming, maternal under-nutrition during pregnancy increases the risk of the infant developing chronic conditions such as diabetes and cardiovascular disease later in life. This is profoundly important in countries such as India and throughout much of Africa, where high levels of under-nutrition co-exist with rapid changes in nutrition in young adulthood. Indians are moving away from traditional diets that are high in carbohydrates and low in fat to modern diet, which are high in fat and low in energy. Macronutrients such as fats/oils play an important role in the development of NCDs. Also, fruits and vegetables, which are highly protective against several NCDs are inadequately consumed by Indians, especially women, as in most communities the woman serves the entire family and eats what is left over. As a result she does not get enough nourishment from the food that she is supposed to. Physical Inactivity Urban living is often associated with lower levels of physical activity than rural living, increasing the risk of overweight and obesity, diabetes, cardiovascular disease and certain cancers. Evidence worldwide suggests disparities between the sexes in physical activity levels, particularly during the school years. Adolescent girls in many low- and middle-income countries are less active and place less value on participating in physical activity. Physical mobility for many girls and women in developing countries is curtailed by the social and cultural context they live in. They are restrained from practicing regular physical activity and sport, whether through the lack of safe and supportive environments, a shortage of income and leisure time, negative cultural stereotypes of body image, social norms surrounding dress and mobility or due to the common perception that sport is unfeminine. Access to and participation in physical

7 exercise is not only a right in itself, it is also a catalyst for a number of development goals and the empowerment of women and girls. In India, although reliable estimates of physical activity levels are unavailable, it is estimated that one-third of women have inadequate physical activity. High income groups have been noted to be physically inactive and in urban areas women have high work-related sedentary lives. Harmful Use of Alcohol Global alcohol consumption has increased in recent decades, with most or all of this increase occurring in developing countries. In many societies, women are both expected and assumed to drink less than men. As a result, early detection and treatment of alcohol-related complications in women is limited and alcohol treatment programmes tend to be based on the needs of men. This is exacerbated by women developing the problems associated with alcohol consumption more quickly and at lower doses than men, leaving them at risk of developing NCDs. Alcohol is a risk factor for cancer of the esophagus, liver cancer, cirrhosis of the liver, motor vehicle accidents etc. Rising affluence, exposure to different lifestyles etc., has led to more Indian women falling prey to alcohol addiction, although it is believed that only 11% of the total women population consume alcohol. Differences in prevalence of serious morbidity between men and women (for 1000 population, 2005 statistics) Condition/Disease Male Female Hypertension Coronary Heart Disease Cancer Paralysis As can been seen in this table the incidence of heart disease in women is almost equal to that of men and the incidence of cancer is much higher. Hypertension also happens to be one of the leading causes for heart attacks and is more prevalent among women than men. It is also believed that more men than women get

8 properly treated for hypertension. Another myth, that hypertension, one of the leading causes of CVD, is again believed to be a condition associated with men. Even in cases where women get treated, most of them are unaware of serious repercussions and are not very diligent about taking their medicines. Estimated Deaths ( 000) By Cause, Female in India, WHO, 2004 Ages 0- Ages Ages 60+ Disease/Condition 14 Malignant Neoplasms Other Neoplasms Diabetes Mellitus Endocrine disorders Neuropsychiatric Cardiovascular Diseases Respiratory Disease Congenital Anomalies Maternal/Perinatal Conditions WOMEN AND CANCER Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells. If the spread is not controlled, it can result in death. Cancer is caused by both external factors (tobacco, chemicals, radiation, and infectious organisms) and internal factors (inherited mutations, hormones, immune conditions, and mutations that occur from metabolism). These causal factors may act together or in sequence to initiate or promote carcinogenesis. The development of most cancers requires multiple steps that occur over many years. Breast cancer is the most common cancer among women worldwide, with an estimated 1.4 million new cases diagnosed in About half of these cases occurred in developing countries. Despite being largely treatable through early

9 detection, it is the leading cause of cancer death in women worldwide. For women in developing countries, access to affordable treatment and effective early detection remains a significant challenge. Lung cancer is the second leading cause of cancer death for women, despite being one of the most preventable types of cancer. Cigarette smoking accounts for 50% of lung cancer cases in women worldwide. As smoking rates in women continue to rise quickly in most parts of the world, it is becoming apparent that without effective action cancer of the lung may be the most common cancer in women worldwide in years. For people living in developing countries, health is often an interrelated and interdependent mix of infectious and chronic illnesses. Cervical cancer is a classic example. It has been proved that human papilloma virus (HPV) infection, one of the most common sexually transmitted infections (STIs), is a necessary cause for cervical cancer. Cost-effective procedures are available to detect and treat cervical pre-cancer, and safe and effective HPV vaccines now exist which can prevent up to 70% of cervical cancer. However, 85% of cervical cancer deaths occur in lowincome countries, where access to screening and treatment are virtually nonexistent, and adolescent girls are not receiving the crucial HPV vaccination. Among women, cancers of the breast, lung and uterus have shown a rise. Lung cancer in women is also increasing because of environmental exposure to smoke. Also, women have shown a general increase in incidence of ovary, thyroid, and gall bladder cancers. There has been a decline in the incidence of cervical cancer due to the increase of institutional deliveries, resulting in improved maternity care, including genital hygiene. WOMEN AND CARDIOVASCULAR DISEASE Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels and include coronary heart disease (leading to a heart attack), rheumatic and congenital heart disease, cerebrovascular disease (leading to a stroke), hypertension, heart failure, and peripheral vascular disease. Important modifiable risk factors of heart disease and stroke are unhealthy diet, physical inactivity and tobacco

10 Cardiovascular disease (CVD) is the largest killer of women worldwide and increasingly impacts on women in developing countries. It is estimated that by 2030 the number of annual deaths caused by CVD will rise from 17.1 million to 23.6 million. Yet due to long-held misconceptions that CVD is a male disease, there remains a significant gap between perceived and actual risk of CVD in women. Very few women perceive it as the greatest threat to their health. Cardiovascular disease is the leading cause of death among women, regardless of race or ethnicity, accounting for deaths of 1 in 3 women. Mortality rates for coronary heart disease have fallen for both men and women but the rate of fall is much less in women than men. A greater proportion of women than men with myocardial infarction die of sudden cardiac death before reaching the hospital. The worldwide INTERHEART Study, a large cohort study of more than 52,000 individuals with myocardial infarction, have revealed that women have their first presentation of coronary heart disease approximately 10 years later than men, most commonly after menopause. Despite this delay in onset, mortality from coronary heart disease is increasing more rapidly among women than men. Basic health interventions that educate people on healthy lifestyle choices can be effective in reducing mortality rates, improving child health, and reducing the risk factors associated with CVD. However, poverty limits women s ability to make healthy lifestyle choices. As such, women in low and middle income countries living in poverty are particularly vulnerable to CVD. In South Africa the proportion of CVD deaths in women between 35 and 44 is 150% higher than that of women in the United States. There is also a significant gender gap in the diagnosis and treatment of CVD in women, which is not reflected in current guidelines. Warning signs for women are different than those for men, contributing to an under diagnosis of CVD in women. More women-specific clinical research is needed to address this issue, as the majority of studies to date have been carried out on men. According to the Working group of disease and health burden: NCDs Ministry of Health and Family Welfare, Cardiovascular disease in the Indian population is one of

11 1. Early occurrence Indians acquire the disease at least 10 years earlier than their western counterparts 2. Higher case fatality a comparatively higher proportion die after a heart attack in comparison to the western countries 3. Occurrence of disease at a lower risk factor threshold. CAD in women continues to be a major public health problem that represents a leading cause of death and disability. Women have a higher frequency of angina/chest pain than men; however, women have a lower prevalence of obstructive CAD compared with men with similar symptoms. Nevertheless, young women with obstructive CAD experience a significantly worse outcome compared with men with regard to prognosis after myocardial infarction, and older women with obstructive CAD often have greater co-morbidities that influence their outcome adversely after acute myocardial infarction or myocardial revascularization than do men. Women presenting with acute coronary syndromes (ACS) are also less likely to receive effective acute diagnostic and treatment strategies than men. Better understanding of gender differences in manifestation and detection of myocardial ischemia is a critical initial step to improve outcomes for women. WOMEN AND COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE) Chronic respiratory diseases are chronic diseases of the airways and other structures of the lung. Some of the most common are asthma, chronic obstructive pulmonary disease (COPD), respiratory allergies, occupational lung diseases and pulmonary hypertension. Gender differences exist in prevalence, severity, risk factors and death rates of chronic obstructive pulmonary disease (COPD). It is strongly associated with tobacco use and the use of solid fuels for cooking, light and heat which have gendered dimensions. When exposed to similar levels of tobacco smoking, evidence has found that women are more likely to suffer adverse respiratory consequences at lower levels of exposure and sooner than men, resulting in the development of COPD.

12 Women are more likely to take responsibility for cooking and other activities around the home that require the burning of solid fuels. Women and children are also more likely to spend time within the home, where the fuels are burned. The concentration and length of exposure to solid fuels increases the risk of COPD, leaving women and children vulnerable to this disease and resulting in an estimated 1.5 million premature deaths each year. Asthma is another chronic respiratory disease. Asthma can be controlled through appropriate management, yet a significant proportion of patients, the majority of whom are women, continue to have symptoms, face lifestyle restrictions and require emergency care. Asthma is more often under-diagnosed and under-treated in female adolescents than in males, and asthma onset during adulthood is more common and more severe in women than in men. Lack of access to essential medicines is one of the primary causes for poorly managed asthma in low-income countries and can lead to disability, absenteeism and poverty. Estimated Number of Patients with Chronic COPD in India (in lakhs) Male Female T o t a l Year Urban Rural Urban Rural Urban Rural Source: Working group of disease and health burden: NCDs Ministry of Health and Family Welfare The above table shows an increasing trend, while more men than women are projected to suffer from chronic COPD, the majority of cases are likely to be from rural areas, where women are constantly exposed to fumes from cooking or passive smoking. WOMEN AND DIABETES

13 Over 300 million people worldwide have diabetes, and approximately half of these are women. As a result of increasing lifespan, the number of women at high risk of diabetes is rising. The health toll diabetes takes on women is significant, particularly in terms of diabetes-related complications such as heart disease. In the past 30 years, the all-cause mortality and cardiovascular mortality rates for women with diabetes have not declined, unlike those for men. Women with type 2 diabetes are less likely than men to receive measures for prevention and control of cardiovascular disease. Diabetes is an important maternal health issue. Preconception planning is crucial for women with type 1 and type 2 diabetes. Uncontrolled or undiagnosed diabetes in pregnancy is associated with the delivery of macrosomic or large-forgestational-age (LGA) infants. This can result in life threatening and costly complications for the mother, such as obstructed labour, and complications that threaten the life and health of the newborn child. Gestational diabetes (GDM), a form of diabetes that develops in one in 25 pregnancies worldwide, is associated with perinatal complications. Women with GDM and their offspring are at an increased risk of developing type 2 diabetes later in life. Approximately half of women with a history of GDM go on to develop type 2 diabetes within five to ten years after delivery. Moreover, there is increasing evidence to support the theory that some diabetes is triggered by events in the womb. There are strong links between maternal malnourishment, the offspring s birth weight and the child s consequent propensity to early insulin resistance. This is particularly important in countries like India and throughout much of Africa where high levels of under-nutrition co-exist with rapid changes in nutrition in young adulthood. In India, the prevalence of diabetes in increasing in both urban and rural areas, particularly among the marginalized and the poor. According to NFHS-3, prevalence of self-reported diabetes between the ages was 2.2% among women and 2.7% among men. This largely indicates gaps in awareness. The International Diabetes Foundation estimates that the overall prevalence of diabetes in India is per thousand. BARRIERS FOR GIRLS AND WOMEN WITH NCDs

14 Girls and women living with NCDs experience specific challenges in accessing cost-effective prevention, early detection, diagnosis, treatment and care of NCDs, particularly in developing countries. Entrenched poverty, gender inequality, the stigma associated with NCDs, women s family responsibilities and the costs of seeking care are all significant barriers. These factors are compounded by health systems that may fail to respond to the specific needs of girls and women with NCDs. Health System Barriers Women provide the bulk of healthcare worldwide, both in the formal healthcare setting as well as in the informal sector and in the home. Yet women s own needs for healthcare are often poorly recognized and catered for in terms of access, comprehensiveness and responsiveness. Health systems in many communities are not responsive to the needs of women. In many places cultural taboos make it impossible for women to seek medical care from male health providers but there is, at the same time, a shortage of female health professionals. Moreover, the reality for millions with NCDs is a basic lack of NCD programmes and services. Healthcare systems in low- and middle-income countries are still geared towards infectious diseases and delivering acute care, and need to be reformulated to integrate NCDs. Integrating NCDs in health systems would drive a different type of health system that would prioritize prevention, patient education and longer term monitoring. These changes would benefit patients with all conditions and diseases, and makes economic and human sense. Economic Barriers Resources matter for the effective care and management of NCDs. Globally, women account for 60% of the world s poor. In some parts of the world, women and girls are often more burdened by the poverty of their household and their environment than men and boys. Women s lack of access to and control over resources limits their ability to pay for healthcare for NCDs. Women in low-

15 income families often prioritize spending on their family s well-being than on their own health. Socio-Cultural Barriers Even when affordable healthcare services do exist, women s socio-cultural status in many developing countries translates into reduced access to and control over health resources and health literacy. Many young women and girls are unable to make decisions about care for themselves or their children without the explicit approval of their husband or another family member. And for many, the discrimination and rejection experienced because of their disease results in management issues and the development of often-preventable life-threatening complications. Higher rates of illiteracy among women than men also mean they have less access to written information about NCD risk factors, prevention and treatment. In some societies there are also persistent beliefs that girls are naturally stronger than boys so treatment is sought earlier for sick boys. Geographical Barriers Geographical distance can be a significant barrier to accessing healthcare for women, particularly for those living in remote rural settings. Women tend to be less mobile than men, as they are less likely to have their own form of transport, and may be unable to afford public transport. These constraints may be reinforced by social expectations requiring women to remain at home and not travel alone, particularly due to fear of crime, violence and harassment in public or on public transport. The travel time to access health care is great for women, who are usually responsible for most of childcare and household duties. This dissuades them from traveling long distances to access healthcare. CONCLUSION According to the WHO, In line with WHO s Global action plan for the prevention and control of NCDs , India is the first country to develop specific national targets and indicators aimed at reducing the number of global premature deaths from NCDs by 25% by A National Multi-sectoral Action Plan that outlines actions by various sectors in addition to the health sector, to

16 reduce the burden of NCDs and their risk factors, is in the final stage of development. India has several major national institutions dealing with NCDs at a national level, such as Indian Council for Medical Research (ICMR), All India Institute of Medical Sciences, and Public Health Foundation of India. India is gradually developing a broad array of public programs targeting NCDs. The India Public Health Standards for NCDs, is now being developed, which will contain recommendations for services, human resources, drugs, investigations, and equipment that should be provided for NCDs at various health care levels. There are three major components: health promotion for general population; disease prevention for those with high risk; and assessment of the risk factor burden. The National Cancer Control Program has twenty-five regional cancer centers. The National Trauma Control Program intends to address the growing number of road traffic injuries. The four components of its program are pre-hospital trauma care; hospital care; rehabilitation of the injured; and injury prevention. In the area of smoking, India has adopted the Framework Convention on Tobacco Control (FCTC) and has prepared a tobacco action plan. A comprehensive law, the Cigarette and Other Tobacco Products Act, 2003 (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution), aims to reduce the exposure of people to tobacco smoke; prohibit advertisements; prohibit sale to minors; and regulate the contents of tobacco products. Prevention efforts for tobacco are also developed and planned for integration into the NRHM and the NPDCS. In order to achieve the NCD goal for the year 2025, the prevention and control of NCDs need to be integrated into existing health systems and initiatives, particularly within maternal health programmes. Gender-responsive health systems have to pay adequate attention to different gender needs and priorities. All sectors should collaborate to identify and promote actions outside the health sector that can enhance health outcomes for women. Greater involvement of girls and women in identifying problems and solutions and implementing policies in the fight against NCDs should be initiated. NCDs and common risk factors should be included in the country s development goals.

17 References siteresources.worldbank.org/ncd_i N_Policy_Feb_2011.pdf 4. planningcommission.nic.in/aboutus/.../wg_3_2non_communicable.pdf 5. _report_chapter1.pdf