Introduction

1While socio economic class, race and caste are recognised as significant factors which contribute to health inequity, gender is not. Women’s secondary social status and structural disadvantage contribute significantly to their susceptibility to diseases especially HIV. Another important factor to be reckoned is poverty. Gender and poverty interact very closely and prevent women from enjoying good health. Women in the lower strata are materially and nutritionally disadvantaged than men. They are often overworked and have little control over their time. The opportunity cost of seeking health care is often very high for women in rural areas. Community norms and values relating to women’s and men’s sexuality and While socio-economic class, race and caste are recognized as significant factors which contribute to health inequity, gender is not. Women’s secondary social status and structural disadvantage contribute significantly to their susceptibility to diseases, especially HIV. Another important factor to be reckoned is poverty. Gender and poverty interact very closely and prevent women from enjoying good health. Women in the lower strata are materially and nutritionally more disadvantaged than men. They are often overworked and have little control over their time. The cost of seeking health care is often very high for women in rural areas. Community norms and values relating to women’s and men’s sexuality and reproduction often perpetuate the already existing gender biases in health care. This article tries to highlight the multiple injustices suffered by women and stresses the need for the health care system and policy to be sensitive to the differential needs of women. Deliberate measures for a women-oriented health policy are required to overcome historical discrimination. This means change in perceptions, concepts, methods and interventions.

The Declining Sex Ratio

2The sex ratio, life expectancy at birth, death and infant mortality rates are the most commonly used measures to indicate the health status of a population. In India, the sex ratio has come down from 972 in 1901 to 927 in 1991. (Vide Table 12.1).

3This should be compared to the global sex ratio (excluding South Asia) of 106 females to 100 males (Mahbub Ul HaqHuman Development Centre, 2000: 120). The sex ratio of 933 females per 1000 males in the 2001 census is an improvement of six points over the 927 recorded in the 1991 census. But during the same period, the sex ratio of the child population in the age group 0-6 years came down to 927 from 945. The sharpest declines in the sex ratio of the child population are observed in Himachal Pradesh, Punjab, Haryana, Gujarat, Uttaranchal, Maharashtra and Chandigarh, according to the Census of India 2001 Report. Tables 12.2 and 12.3 are indicative of districts with the lowest child sex ratios and missing girls in the 0-6 age group, respectively. Female foeticide, female infanticide and gross neglect of girl children are said to be the major reasons.

4The basic aims of prenatal diagnostic tests such as ultrasonography, amniocentesis, chorionic villus biopsy, foetoscopy, maternal serum analysis etc. are the detection of foetal abnormalities, chromosomal abnormalities, genetic metabolic disorders and other congenital abnormalities. Unfortunately, due to the high cultural preference for sons in India, these tests are misused to determine the sex of the foetus and selectively abort the female foetuses. Commercially-minded doctors and technicians exploit the situation in the name of offering the clients their ‘needed’ service. Of late, the government of India has prohibited the conducting of such tests and severe punishment for violation has been introduced. However, that the law alone cannot mitigate the problem is clear from recent estimates which indicate that 200,000 abortions are performed after sex determination tests each year. If female infanticide is also taken into account, then the actual figure may increase to around 5 million a year1. As long as the doctors, technicians and the patients are all equal beneficiaries in the game, the crime may not come to light. In a vast country like India, monitoring and detection are difficult. Women are the worst sufferers since they are forced to undergo abortion even at late stages of pregnancy. Repeated pregnancies and abortions until a male child is conceived ruin their health. The cultural preference for a boy takes precedence over women’s physical and mental health. Motherhood, instead of being a pleasure, is a burden for the majority of women in India. The impact of the declining sex ratio on demographic imbalances and on women’s health status is simply ignored2.

5If a female foetus is fortunate enough to survive and be born, then an early death awaits her in the form of female infanticide. Since a girl child is considered to be an economic liability and economically unproductive to the natal family and because any investment for her is seen as a waste, girl children are ‘disposed of’ within a few weeks of their birth3. In 1998 in Tamil Nadu, according to records from public health centres, 3 226 infants were killed. (Tamil Nadu People’s Forum for Social Development, 2000: 133) In view of the practice of female infanticide, women are forced into repeated pregnancies until a boy is born or the desired size and composition of the family is achieved. The least interest is evinced in the physical and mental health of women.

Errors of Omission and Commission

6Girl babies are discriminated against as far as good food and treatment of diseases are concerned. They are not breastfed for a prolonged period in order to conceive again and give birth to male babies. Poverty forces the parents to practise discrimination in attending to the nutritional needs of children. While boys are given milk, eggs and fish because they are considered as potential breadwinners, girls are denied such nutrition due to non-affordability. Hospital records indicate a higher admission of boys when compared to girls, not because girls do not fall sick, but simply because the girl children are treated with local or traditional medicine unless the situation becomes grave, while boys are rushed to hospitals soon after symptoms of a disease. According to one estimate, every year 12 million girls are born; but, despite being biologically stronger than boys, 3 million girls do not survive to see their fifteenth birthday. About one-third of these deaths are in the first year of life (UNICEF, 1995-a: 57-59) According to UNFPA (1999), 18 percent more girls than boys die in India before their fifth birthday. “In South Asia, most deaths among children under 5 are due to infectious diseases such as pneumonia and diarrhoea combined with malnutrition. While there is no evidence of gender differences in the rate of contraction of such diseases during childhood, there is a higher mortality rate of female children in the under 5 age cohort reflecting the tendency to neglect female children”4. In the adolescent age, especially at the time of puberty, girls require special nutrition, but unfortunately in India many families can illafford rich food for their girl children. Even in affluent families, either due to ignorance or indifference or to the habit of eating modern junk food, the need to provide them with rich food is not at all considered seriously. In India, nearly 40 % of the girls are married before the age of 18 and suffer severe anaemia and malnutrition. A majority of women suffer from chronic energy deficit due to insufficient daily calorie intake, that is, 500-700 calories less than the recommended daily adult minimum intake of 2 250 calories5. This has serious consequences on the health of offspring. Research studies indicate a reduction in inter-generational height and early onset of menopause. According to a paediatrician working at a premier institution in Delhi, hospital records for the past thirty years indicate a decrease in the average birth weight from 3 kg to 2.5 kg (Mahbub-Ul-Haq, 1996) According to the ICMR, nutritional anaemia is common among girls and one-third of the women are found to have haemoglobin levels below 8 gms/dl.

7Population education and family life education, especially on sexuality, is almost non-existent in India. The failure on the part of parents and social institutions to provide information on sexuality and reproduction leaves the young at high risk of contracting the HIV infection. Survey results at the international level indicate that young people are more and more likely to be sexually active outside marriage and even before marriage as a result of economic conditions, peer pressure, mass media influences, migration and other social changes6. A social stigma is attached to pre-marital pregnancy and contraceptives are denied to young unmarried women. Abortions are difficult to arrange and young unmarried women who are pregnant therefore often attempt ineffective or harmful remedies that endanger their lives. Another important factor to be reckoned is violence against young girls.

Violence against Women

8There is a phenomenal increase in crime against women. According to the National Crime Records Bureau, dowry deaths rose from 5,513 in 1996 to 6 917 in 1998, cases of rape from 14,846 to 15,031, torture from 35,246 to 41,318, molestation from 28,939 to 31,046, sexual harassment from 5,671 to 8,123. (Sharma, R.D., 2001). Rape is the most heinous transgression in the list of crimes. Doctors in government hospitals, especially in the rural areas, refuse to conduct a medical examination of rape victims unless they are brought by the police. The Supreme Court raised serious objections to this in one of the cases brought before it. “This” the court says “results in a delay in the ultimate examination of the victim by which time the evidence of the rape may have been washed away by the complainant herself or be otherwise lost”. Nevertheless, sensitivity to this problem is least among doctors in India.

9Small children below fourteen years are inducted into prostitution either by force or through trafficking, alluring with them assured jobs. A government of India survey suggests that at least 25,000 children are in prostitution in the six main cities of Delhi, Calcutta, Mumbai, Madras, Bangalore and Hyderabad alone. Private estimates put the figure at 500,000 minors in prostitution. The rehabilitation of such children has been found to be a difficult task involving behaviour correction, assurance of steady income, marriage, housing and family acceptance. Normalcy is not restored by merely sending them back to their families. The experience of social workers in this field reveals that very few children rescued from brothels have been able to begin a full and healthy life again (UNICEF, 1995-b: 16).

10Since more and more women are leaving the homes for regular jobs, sexual harassment at the work place is assuming serious proportions. Women are discouraged from continuing in their jobs or from working efficiently to get promotion. As a result of professional jealousy and the feeling that women are grabbing their jobs, men indulge in such ignoble behaviour. Notice is often not taken of the mental harassment suffered by women.

11If communal violence against women is also considered, then the atrocities are beyond human imagination. The physical and mental trauma suffered by women due to the violence meted out to them at home, at the work place and by society in general has long-term health consequences which have also been conveniently forgotten by health researchers.

The Pangs of Motherhood

12The next stage in the life cycle of a woman is the reproductive stage, which is perhaps the longest of all the stages. Maternal mortality in India, which is defined as the number of maternal deaths per one lakh live births, is one of the highest in the world. India, which accounts for 15 % of the world’s population, accounts for over 20 % of the world’s maternal deaths. At the national level, it is estimated that there are 453 deaths per 100,000 live births. The inter-state differentials are startling, with the lowest ratio of 87 deaths for Kerala and an alarmingly high ratio of 738 deaths for Orissa. Other states with high maternal mortality are Madhya Pradesh, Uttar Pradesh, Rajasthan, Assam and Bihar (UNPF/UNFPA, 1997: 55). The Human Development Report 1995 reports that the maternal mortality rate for 1980-1992 was 460, as compared to 2 for Ireland and 10 for all industrial countries. Even the average for all the developing countries, 351, is substantially lower than that of India. According to a World Bank study (1996), the average Indian woman is 100 times more likely to die of maternity-related causes than a woman in the industrial world; about 15 % of the pregnant women in India develop life-threatening complications during pregnancy7. One of the most often quoted studies is from Rajasthan showing that for every single maternal death there were 60 episodes of morbidity, of which 18 were directly related to pregnancy and birth (Datta, et al., 1980). One reason for such a high incidence is lack of institutional care. In 1992, the proportion of deliveries receiving skilled attention varied from 97.1 % in Kerala, 85.3 % in Haryana and 77.7 % in Tamil Nadu to lows of 33.2 % in Uttar Pradesh, 24.6 % in Rajasthan, 22.9 % in Orissa, 27.6 % in Madhya Pradesh, 27.5 % in Bihar and 30.3 % in Assam (UNPF/UNFPA, 1997: 48) In rural areas, where the majority of our population live, only 40.6 % of all deliveries received skilled attention at the time of delivery, compared to 83.9 % in the urban areas.

13Another contributory factor to high MMR is abortion. Abortion, which was made legal in 1971, is resorted to even in advanced stages of pregnancy. The Medical Termination Act permits abortion only up to twelve weeks and, in special circumstances, up to sixteen weeks, after seeking a second medical opinion. Unfortunately, abortions are resorted to in India even in the fifth month of pregnancy and such abortions are invariably carried out by untrained quacks. It is said that 20 % of India’s maternal mortality is directly due to unsafe abortions, with six lakh women dying annually. (Shiva, M., 1991: 34-36) According to Kapur’s (1993) study, in India one woman dies of septic abortion every ten minutes8. This refers only to legal abortions, with almost as many deaths for illegal abortions. Illegal abortions outnumber legal abortions by a ratio as high as 11 to 1. Adoption of traditional or drugstore methods to control fertility are common, since sexual accommodation is viewed as the wife’s duty and sexual pleasure as a man’s prerogative. It is a pity that the physical and mental trauma suffered by the woman from repeated abortions causes little or no concern to other family members. There is almost no ethical or religious guilt on the question of abortion.

14Anaemia is another culprit in the high MMR. About 50 to 80 % of the mothers suffer from anaemia due to iron deficiency. It is found that nearly 30 to 40 % of the new-born babies have a low birth weight due to maternal anaemia and malnutrition9.

15The high infant mortality is another indicator of the low health status of the pregnant women. Table 12.4 indicates the prevalence of IMR in different countries. Because of high the IMR, women are forced to have repeated pregnancies to achieve the desired family size. In a country where social security measures are almost non-existent, children’s support during old age is necessary. Due to the high IMR, a premium of two or three children is rendered inevitable and ruins the health of women in the low-income groups.

16The health hazards posed by contraceptives need some analysis. It is an open secret that the family welfare programme in India is demographically driven and not women-centred. From simple methods such as diaphragms and jellies, it has now come to IUDs, Norplant and clinical trials of Depo Provere and Net En. It has been medically proven that greater risks are associated with hormonal methods. The issues range from the adverse side-effects of contraceptives to the ways in which family planning is promoted and services are delivered. Also present in this debate are certain thorny issues like induced abortions, forced sterilization and whether contraceptives should be made available to unmarried adolescents and in particular women. The main criticism of the feminists against family planning is its disproportionate reliance on irreversible and long-term methods that restrict women’s control and on hormonal preparations that cause health risks to women. The needs of individual woman should be addressed first and foremost and societal benefits should occupy the back seat. “A contraceptive can be safe or unsafe depending on who is using it and the quality of the service system delivering it. Moreover the concept of safety must reflect client concerns. Safety cannot be defined simply as the absence of life-threatening complications but must be assessed from a woman’s perspective. So-called minor inconveniences or side-effects such as menstrual bleeding disturbances, headache or weight gain may not threaten life, but may be of extreme concern and often significantly affect a woman’s quality of life”. (Sen, G., Germain A., & L.C. Chen. 1994: 227).

17WHO and the Population Council accept that women who use Norplant experience heavy and irregular menstrual bleeding and suffer other side-effects. such as headache, dizziness, nervousness, weight gain, vomiting, change of appetite, excessive facial hair growth, functional ovarian cyst, infection and pain at the implant site. Moreover while implantation involves only a twenty-minute surgery, removal is more difficult and complicated and facilities are lacking in many developing countries (Karkal, M., 1993).

18We need to look at the question of informed consent here. A woman cannot make a free choice about contraception if she is not presented with all the options that are available to her. She must be fully and fairly informed of the respective risks and benefits of each method. The provider, while presenting the facts, should be unbiased. In a country like India, where the doctor–population ratio is abysmal, where is the time for doctors to speak to each and every woman about the ranges and comparative benefits of contraceptives? It is again the educated, informed and financially well-off women who seek such information on their own initiative. There is no denying the fact that contraceptives have provided an opportunity to prevent unwanted pregnancies and enabled women to take up a career outside the home. But women are still not able to protect themselves from STD transmission, especially when STD transmission is much greater from man to woman than the other way around. Access to family planning services is another factor which should be considered here. An evaluation of family planning programmes in eighty-eight developing countries concludes that services are routinely made available to women at reasonable cost in only fourteen countries. (Ross J.A. et al. 1992: Table 11) Other assessments have pointed out that many family planning programmes fail to offer a wide selection of methods, lack high stands of medical practice, are insensitive to cultural conditions, do not offer sufficient information about proper use or possible side-effects and neglect women’s other reproductive needs (Bruce J., 1990).

19Women’s organizations all over the world have been continuously waging a war against anti-women population control policies and pressing their demands for (a) greater control by women over their own reproduction (b) no interference with natural bodily functions and processes in the name of contraceptives (c) provision of protection from STDs (d) reduction of the power imbalance between men and women at home, work place and community (e) greater male involvement in family planning and (f) methods that can be easily reversed. Women’s groups are not against family planning or birth control, but population control at the cost of women’s health is objectionable to them. Too much emphasis by the government on female sterilization with no attempt to involve the men is also not acceptable to feminists.

20Another worrying phenomenon in the reproductive health care of women is its professionalization and commercialization. “Sedation, induction of labour, superficial interventions like episiotomies, increased use of forceps and Caesarean sections are fast becoming normal procedures, apart, that is, from other costly and unnecessary tests like ultrasounds and amniocentesis”. (Voluntary Health Association of India 1992) Caesarean sections are on the increase because doctors are very busy and cannot wait for the normal delivery to take place or because women are less inclined to suffer labour pain. In the same way, unnecessary hysterectomies (removal of uterus) are performed once the woman complains of excess bleeding. Even menopause is not taken in a normal way. “Even menopause - the second major change in a woman’s life after menarche - is being medicalized. It did not take long for the market to be flooded with sedations, tranquillisers and hormones to combat the depression and hot flashes associated with menopause. Seen as a deficiency disease, oestrogen was advertised to keep women ‘feminine forever’, despite its proven link to cancer of the breast, uterus, cervix and vagina and no link with combating depression. What is required is only a recognition that menopause like menarche is only another stage in a woman’s life that requires understanding but no treatment”10. In this age of market economy, the attractive advertisements mislead people and influence their thinking to the extent of making them addicts to modern medicine.

21One neglected dimension of maternal health care in India is the non-treatment of reproductive tract infections (RTIs). If not properly attended, these can have deleterious consequences on women’s health. Infections of the lower reproductive tract, if untreated, may cause pelvic inflammatory disease and infections of the upper reproductive tract may cause difficulty in pregnancy, chronic pain and even infertility. The incidence of RTIs is found to be high in India. Community-based studies in rural West Bengal and Gujarat and urban Baroda and Bombay show that the prevalence of clinically diagnosed RTIs ranges from 19 % to 71 %, and in rural Karnataka it is 70%11.

Mental Health of Women

22In India, mental health is not viewed as a problem at all. The need for maintaining good mental health has hardly been recognized. Davar (1999) is of the view that the role of ‘housewife’ and ‘motherhood’ has been associated with high levels of distress mainly because they are highly demanding. (Davar, B.V., 1999) Coupled with this is the feeling of helplessness due to lack of authority, autonomy and bargaining power, in spite of their contribution to the development of the family. Thus women are subjected to a great deal of stress and strain. In the case of working women, women’s outside careers cause friction in the home and women are overburdened, especially if other members in the family do not share in the domestic chores. Discrimination, harassment and threat of violence by superiors or male colleagues at the work place contribute further to the misery of women. These sociological factors are often ignored and the depression suffered by women is conveniently attributed to their menstrual cycle and physiology. While economic and social compulsions have brought many women to the world of paid work and raised their aspirations and expectations, societal attitude is not at all responsive to their changing roles. A survey conducted among 500 working women in Delhi by Hamara Parivar, a family welfare programme, reveals that 78 % the respondents suffered some depression due to sociological pressures and breakdown of personal relationships (Kumar, A. & A. Soni, 2000: 39)

Women and HIV

23At the end of 1999, 34.3 million people worldwide were living with HIV/AIDS; 15.7 million were women, an increase from 12.1 million in 1997. Women represented more than 40 % of the 5.4 million people infected in 1999 alone. (UNAIDS, 2000: 6) The higher incidence of the HIV infection among girls and women is necessarily linked to the gender power relations, the inability of women in insist on safe sex practices by their male partners and the economic power enjoyed by the male. This is to be viewed in the context of the biologically easier male to female transmission of the HIV virus and the non-availability of a contraceptive which women can use to protect themselves without expecting the male to use the condom. HIV among women is not only a health issue but also an economic and development issue. Women’s roles as mothers, care-givers and wage earners are affected by this disease. It also has tremendous impact on future rates of infant child and maternal mortality, life expectancy and economic growth12. Many women with HIV/AIDS become infertile or die before the end of their reproductive years. Moreover, the AIDS epidemic has left 13.2 million orphans, threatening the very family structure that is the foundation of the social fabric. In India, one in every 3 300 children under 15 years of age has lost his/her mother or both parents to AIDS13. The cumulative number of reported cases of death due to AIDS in the country as reported to the National AIDS Control Organisation (NACO) up to 31 Dec 2000 was 1 722. Based on the available data from the nation-wide sentinel surveillance, an estimated 3.7 million people were infected with HIV in 199914.

24Women, who are often monogamous wives infected by their husband, are especially stigmatized. This stigma also affects the provision of health care. A majority of the hospitals are said to have either turned away HIV-infected patients or serve their needs only reluctantly. There is a general feeling that treating patients with HIV is a waste of time, which is a highly ethical question. The Indian government, supported by a World Bank loan of US$ 200 million, has started clinical trials of the anti-HIV drug AZT on pregnant women. “As usual they have come up with a technological fix. There is little emphasis on prevention or any attempt to tackle poverty” (Raj. D. 1998: 2). Whether women are the culprits or not, they bear the brunt.

Health Problems of Ageing Women:

25Many ageing women suffer from gastroenteritis, hypertension, arthritis, diabetes and asthma. The medical system has failed to address the specific health problems of older women, which include arthritis, osteoporosis, cancers, and malnutrition and anxiety syndromes due to loneliness. Since they are economically dependent and their mobility is highly restricted due to their age, they suffer neglect and no follow-up in cases of prolonged treatment. Even if they do not have any disease, they are over-burdened with domestic chores. While there is a specific retirement age for men, women are forced to attend to kitchen work and childcare until their death.

Discriminatory Health System and Health Administration:

26Women feel bad if attended by male health providers. Very few female doctors are available in the rural areas and hence women are hesitant to seek health care.

27In reproductive health, almost all the contraceptives are provider-controlled rather than user-controlled (sterilization, IUDs, implants, injectables). Women are at the mercy of doctors. The health care policy is still very silent on reproductive tract infections suffered by nearly 40 % of the women of developing countries. The insensitivity of the community at-large to the air pollution problem suffered by poor women in the kitchen is a classic example. In view of the multiple jobs performed by women, the stress levels suffered by them are on the increase. Unfortunately, mental health assumes least priority in our health care system. Even research studies are highly biased. The higher rates of depression among women is attributed to their biology, that is, menstruation, pregnancy and menopause, rather than to the social, economic, political and cultural discrimination suffered by them. It is the humiliation suffered by women in the hands of men at home, work place and community that causes depression, and medical research fails to analyze the impact of these factors on the mental health of women.

28In addition to everything else, health data is not disaggregated by sex. Another moot question is the reliability of such data. In societies where gender biases exist in health-seeking behaviour, female morbidity data can be underestimated. Health researchers are of the view that health problems that affect women have received less attention and funding than research on health problems that affect men. The only exception is contraceptive research.

29The health inequity deliberately perpetuated by the government needs serious consideration. While the poor are forced to run from pillar to post for quality health care, the mushrooming of private hospitals run on commercial lines almost like five star hotels accentuates the deprivation suffered by the poor people. There are 1 531 public health centres without a doctor and out of 22 991 public health centres in India, only 1 023 have a woman doctor. (Government of India, 1998) The inadequacy and failures of the public health system in India have driven people to seek health care from private health care providers15. Indiscriminate privatization is likely to accentuate the misery of the poor, above all the women of the poorer families.

30Some of the other health concerns of women which are not elaborated here are the following:

• In the case of infertility of couples in almost all-social strata, the blame is placed squarely on the women. New reproductive technologies force women to undergo various tests and suffer tension, anxiety and repeated visits to hospitals/clinics. Adoption was the recourse some time back, but with the introduction of new techniques, there is a never-ending pressure on women to try them, without regard for their physical discomfort and mental health.
• People in general, and women in particular, are torn between the indigenous and allopathic systems. In the case of common and frequent ailments, local medicine is invariably tried because of time and financial constraints. Seeking allopathic treatment is still not very common in rural India. In the name of modernization and globalization, modern medicine is being thrust on the people and some of the traditional healing techniques which had been passed on by women over generations have witnessed a sudden death.
• It is a pity that the system does not locate the health problems of women in the general context of oppressive man-woman relations. The effect of gender division of labour on women’s health (women are often overburdened with unpaid, unrecognized domestic work), the societal view of treating women as child-bearing machines and the domestic and communal violence to which they are subjected are often ignored. Women’s health is not viewed in a holistic perspective.
• Poverty causes havoc to women’s health. This is also conveniently forgotten.
• Medical research on the whole remains silent on bioethical issues relating to abortion, female foeticide and female infanticide. These issues are highly controversial and topical in the context of cloning and advancements in human genetics.

Conclusion

31Women’s health must be built up from infancy and childhood through to adulthood. Women’s health should not be identified with maternity health alone. A focus on adolescent health is the immediate necessity. This means providing information on sexuality, fertility and conception to youth, the development of self-awareness and a positive self-image among women and the empowerment of women through education and employment for self-dependency. A multi-pronged strategy is absolutely necessary. Violence against women should be reduced through immediate and severe punishment. There should be no prolonged legal battle, which further aggravates the mental agony of the women victims. Child prostitution should be put to an end by vocational training for women on a mass scale and life education for all youth. The public health system, especially in the rural areas, should be strengthened and the big private hospitals should be compelled to attend to the needs of the poor at least two days a week and the big industrial corporations should be involved in the building of community hospitals. Women’s health should be given special attention in order to set right the gender inequity found in health care in India. Unless and until women are empowered with knowledge, skills and material resources, they will continue to be exploited. They are entitled to all the privileges that are enjoyed by men. Unless society is awakened to this reality, women’s issues in general, and health issues in particular, will continue to be marginalized.