9

Occupational and Environmental Health

In this chapter an attempt is made to synthesize information on a topic that is elusive when examined from the usual perspective—that is, one that has been heavily skewed toward the developed countries and male subjects. Occupational and environmental health viewed through the prism of female health in Sub-Saharan Africa presents a challenging task of inference from what is known about social, economic, political, labor, and gender relations and the environmental health hazards typical of the region.

As Table 9-1 shows, however, there are already indications of a substantial number of adverse occupational and environmental factors that burden female health status disproportionately in the region. These factors—which include increased exposure to indoor air pollution, toxic wastes, and organic dusts from food processing; job overload; lack of job control; and ergonomic stressors, among others—are discussed in this chapter.

The approach adopted here first attempts to provide a conceptual framework for thinking about female work as a principal source of gendered occupational and environmental health problems. This is followed by a discussion of problems, trends, and emergent issues and their social determinants. The life span perspective is then employed in a systematic examination of the female health hazard profile, which, in turn, is related to adverse health outcomes in the region. Last, public health research implications are drawn from a consideration of the information presented. It must be noted at the outset that there are substantial cross-national differences in most of what is covered in this chapter. The approach adopted will attempt to be as inclusive of these variants as possible.

WOMEN'S WORK IN SUB-SAHARAN AFRICA

Any general consideration of occupational and environmental health is necessarily based on the nature of the work performed in the society at large. Africa, with a few regional exceptions, is a less-developed part of the world. The greater part of agriculture is subsistence farming, and cash crops account for a significant part of the monetary income derived. There is some mining or extractive industry, with petroleum featuring prominently in parts of the continent. Secondary industry is poorly developed, as are governmental and private sector services.

Although the Sub-Saharan region is vast and unevenly developed, it is nevertheless possible to set forth general categories of occupational and environmental hazards. This will allow the reader to combine different categories for any country within the region.

Women play a key role in production in Africa. Before characterizing that role, however, a number of



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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa 9 Occupational and Environmental Health In this chapter an attempt is made to synthesize information on a topic that is elusive when examined from the usual perspective—that is, one that has been heavily skewed toward the developed countries and male subjects. Occupational and environmental health viewed through the prism of female health in Sub-Saharan Africa presents a challenging task of inference from what is known about social, economic, political, labor, and gender relations and the environmental health hazards typical of the region. As Table 9-1 shows, however, there are already indications of a substantial number of adverse occupational and environmental factors that burden female health status disproportionately in the region. These factors—which include increased exposure to indoor air pollution, toxic wastes, and organic dusts from food processing; job overload; lack of job control; and ergonomic stressors, among others—are discussed in this chapter. The approach adopted here first attempts to provide a conceptual framework for thinking about female work as a principal source of gendered occupational and environmental health problems. This is followed by a discussion of problems, trends, and emergent issues and their social determinants. The life span perspective is then employed in a systematic examination of the female health hazard profile, which, in turn, is related to adverse health outcomes in the region. Last, public health research implications are drawn from a consideration of the information presented. It must be noted at the outset that there are substantial cross-national differences in most of what is covered in this chapter. The approach adopted will attempt to be as inclusive of these variants as possible. WOMEN'S WORK IN SUB-SAHARAN AFRICA Any general consideration of occupational and environmental health is necessarily based on the nature of the work performed in the society at large. Africa, with a few regional exceptions, is a less-developed part of the world. The greater part of agriculture is subsistence farming, and cash crops account for a significant part of the monetary income derived. There is some mining or extractive industry, with petroleum featuring prominently in parts of the continent. Secondary industry is poorly developed, as are governmental and private sector services. Although the Sub-Saharan region is vast and unevenly developed, it is nevertheless possible to set forth general categories of occupational and environmental hazards. This will allow the reader to combine different categories for any country within the region. Women play a key role in production in Africa. Before characterizing that role, however, a number of

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 9-1 Adverse Occupational and Environmental Factors in Sub-Saharan Africa: Gender-Related Burden Problem Exclusive to Females Greater for Females than for Males Burden for Females and Males Comparable, but of Particular Significance for Females Ergonomic stressors   X   Exposure to indoor air pollution   X   Exposure to organic dusts from food processing   X   Exposure to toxic wastes   X   Job overload   X   Lack of job control   X   Othera   X   NOTE: Significance is defined here as having an impact on health that, for any reason—biological, reproductive, sociocultural, or economic—is different in its implications for females than for males. a Other includes: ill-fitting personal protective equipment designed for men; working under recommended exposure limits for occupational hazards designed for healthy, well-nourished men in the developed countries working an eight-hour day; exposure to malaria prophylaxis and infection that pose serious risks for pregnant women; exposure to uncontrolled chemical and ergonomic hazards that pose risks for the fetus; effects of chemicals, indoor smoke, and injury hazards that extend to infants; work-time requirements that further compromise breastfeeding and infant nutrition; and lack of sufficient "off time" to allow for appropriate rehabilitation from injury or work-related disease, thus exacerbating hazardous exposures or increasing female work loads. methodological problems require attention. The most salient relates to how women's work in Sub-Saharan Africa is to be conceptualized. It is tempting to construct a table providing information about where women work by country, region, and sector compared with men. Given the unreliability of currently available information, this would run the risk of reifying such data, thereby allowing facile applications that are unlikely to be meaningful. The available data are not strictly comparable and show such wide variation among countries in Sub-Saharan Africa that they are neither likely nor reasonable on an individual-country basis. Nevertheless, the averages and range of percentages for the region as a whole are significant, and are provided below. Women's economic participation rates in Sub-Saharan Africa are high, clustering around 50 percent (UN, 1991). Nearly 80 percent of economically active women work in agriculture. About 40 percent of this group work unpaid on family farms, 30 percent are paid agricultural employees, and 30 percent labor on their own farms or in other informal work in the sector. While women make up a little over 40 percent of the agricultural labor force, they produce the bulk of the food in the region (Kerven, 1989). Men's participation in agriculture is restricted to cash-crop production and wage labor on plantations. Agriculture is thus the greatest single component of women's work outside the home. Women's labor force participation in Sub-Saharan Africa is higher than in most developing countries, and it is growing. This greater involvement of women in economic activities is thought to be a function of both improvements in their educational levels and the global economic crisis, which compels women to work in order to sustain their families (UN, 1991). The mounting proportion of female-headed households in the region also means that these women—up to 66 percent of them—are the main, if not sole, source of sustenance for their

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa families. In some parts of Africa, notably in rural areas that provide male migrants and in periurban shantytowns, this proportion is very high, ranging between 50 and 70 percent of all households (Kerven, 1989). Women and families in both venues are affected by migration: rural families are affected by the emigration of spouses to the urban areas, while women who migrate to urban areas with their families are obliged to participate increasingly in the money economy of those areas, because the requirements of urban living, such as rent and transport, require cash payments. On average, between 15 and 20 percent of economically active women in Sub-Saharan Africa are in formal employment, with considerable variation across the region (UN, 1991). The overwhelming majority work in services, with very small numbers in manufacturing and other industry. Public and private sector wage labor tends to be monopolized by men. WOMEN AND WORK IN HISTORICAL CONTEXT The colonial experience had a substantial impact on the work of women, particularly their role in agricultural production (Gitonga, 1991; Lado, 1992). The social system in much of Sub-Saharan Africa, traditionally patriarchal in the precolonial period, was maintained during the colonial era. The division of labor within the family in much of Africa remains structured according to gender, with women specializing in food farming, processing, and trading outside the home. Land laws in Africa do not permit granting of title to women, even when they cultivate their own land or produce their own crops independently of a spouse. Men are presumed heads of households, and only they can obtain titles to cultivate, own, and occupy land. Sub-Saharan women, therefore, continue to cultivate land owned by men. During the colonial period, men took over cash-cropping agriculture and participated in the commercial plantation sector, while women remained tied to subsistence farming in ever-greater proportions. This preservation of the traditional exclusion of women from landownership sustained their dependence on men for communal or familial allocation of plots. The best fields went to cash-cropping, while plots for subsistence agriculture were generally more distant, more scattered, and less well prepared. This, in turn, led to production emphasis on crops that demanded less effort, but were also less nutritious, such as cassava, rather than more demanding and more nutritious crops such as yams. Technologies used in the women's agricultural sector have also remained undeveloped, and continue to involve considerable expenditure of human energy and time. The technical innovations that have been introduced have paradoxically expanded women's share of work, while decreasing their income, because of the preferential application of new technologies to cash-cropping and the male monopoly on access to credit and income. Women's progressive marginalization in the subsistence sector has meant that their productivity and control over resources has been reduced, while their total work burden has increased. This has had severe implications for the nutrition and health of the women and their families. Decrements and losses in women's food production and income have played a large part in the food crisis in Africa, and it is argued that macroeconomic policies are unlikely to be successful unless they explicitly address the role of women in both the subsistence and commercial agricultural sectors (Lado, 1992; Savane, 1980). The theme of the invisible (female) subsistence sector has been succinctly elucidated by Packard (1989a,b), and constitutes one of the indirect, nonbeneficial effects of industrialization in Africa. One of the major determinants of this invisibility has been the system of migrant labor. The migrant labor patterns typical of modernization in Sub-Saharan Africa that have resulted in the high proportions of households headed by women, described above, have also affected their children, especially girls. While they are in school, children have reduced economic value in the production of income or labor for family maintenance, and their mother's workload is correspondingly greater in these earlier years. It is not surprising that young girls are pressured to drop-out of school at about 12 years of age, or that they are expected to do more housework than boys. Women's work begins at a young age. These factors have forced many women to engage in informal sector activities in the processing and sale of food products and to participate at high rates in petty commerce, especially in West Africa (Bukh, 1980). The

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa relative absence of a productive, as opposed to a commercial, informal sector in Sub-Saharan Africa is noteworthy when compared with other parts of the world, such as Asia. Work in the informal sector consists of many short tasks that can be performed simultaneously, and it is optimal in a context of constant childcare. Such tasks—whether they are farming, petty trading, processing of crops, or commercial sex work—are typically small-scale activities with no access to capital, and yield little profit. The positive side of women's work, in both the formal and informal sectors, is that in addition to offering more flexibility in childcare, in many cases it affords opportunities for access to resources and allows women control over their own destinies, including economic survival for those fleeing oppressive marriages or without land. In the service sector in Sub-Saharan Africa, there are proportionately fewer women in clerical and service jobs because men dominate the public and private wage sectors, trade unions, and other employee organizations. This has been the case historically, even for paid domestic work. A higher proportion of the male work force (30 percent) than the female work force (20 percent) is in the service sector (UN, 1991). Within the manufacturing sector, the picture is similar to that of more developed countries (UN, 1991). There is gender segregation in different occupational groups; within the same occupational group, women's jobs are either less prestigious or less well paid for the same work. The maternity factor continues to discriminate against women in hiring and promotion. The stabilization and adjustment programs referred to in Chapter 2 have adversely affected women, who have been disproportionately squeezed out of public sector employment. The immediate cause for this diminution has been cuts in government health and social services expenditures. Deregulation has simultaneously accelerated a process, however slightly, of feminization of the wage sector in Sub-Saharan Africa (Standing, 1989). Women in ever-growing numbers may be performing the same work that males performed in the past in the public and private sectors, but do so under worse financial and social security conditions. Finally, the wage freezes associated with regional stabilization programs, combined with the effects of inflation, have driven up the number of working hours necessary to make ends meet. PROBLEMS OF DEFINITION There are considerable and overlapping problems of definition involving the nature of work, and whether it is paid or not. For this reason, a rigid, overarching definition of work is not very useful. This chapter employs the categories of formal, informal, domestic, and agricultural food production sectors in dealing with women's work in Africa. The main consequence of definitional fuzziness with respect to women's work is that much of their work is invisible, and this invisibility applies to all categories. Official statistics indicate that this dilemma applies worldwide, but the invisibility phenomenon is likely to be more pronounced in developing countries. The categories selected for discussion here have therefore been determined by their salience for women's work. Paid and unpaid work are, in general, difficult to distinguish in developing countries. Non-market-related unpaid work is almost exclusively the lot of women in Sub-Saharan Africa. The formal sector is characterized by employment at a wage or salary with Social Security benefits, and it is governed by a legal system of regulation dealing with employment contracts and working conditions. For women in Sub-Saharan Africa, this comprises mainly work in service and, to a lesser extent, clerical work. Women's participation in manufacturing is very low (less than 2 percent of the female work force), and takes place in industries generally perceived to involve "female" work. These include food processing and clothing and textile manufacturing (Naimi, 1991). Private and public sector service work also frequently involve "female" work. The informal sector is characterized by economically active people working on their own account (self-employed), without employees but with unpaid family workers, in the absence of regulation, including wage contracts (de Soto, 1989; UN, 1991). The growth of this sector is a widespread phenomenon in the developing world, notably in Asia and Latin America. For African women, this sector comprises petty commercial enterprises and small-scale production. It became a major growth sector in the 1980s and now constitutes a major source of women's employment in Africa. Examples include petty trading or home-based industries such as beer-brewing, soap-making, tailoring, and commercial sex work. The informal sector also makes a major contribution to family income. Women's contributions through this

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa sector in Africa are estimated at around 10 percent for industrial production, and perhaps as high as 90 percent for service provision. Incomes are lower than in the formal sector, although a recent South African study shows that informal sector workers can achieve incomes similar to those of waged domestic workers in the formal sector (Cooper et al., 1991), although informal sector activity is less secure. Low levels of investment in technology, poor economies of scale, high unit prices for raw materials, and limited access to large markets and marketing organizations mean low productivity and returns (UN, 1991). Overall, this is a major labor sector for women, ranking next in importance after domestic work and farm labor. The domestic sector involves unpaid home provisioning and maintenance activities. These include the preparation, processing, and cooking of food; cleaning; childbearing; childcare; care of the sick and aged; collection and head-portage of water and fuel; and back-portage of children. These tasks all consume large amounts of time and energy and must be constantly balanced against demands on women from other work sectors. As noted earlier, the expansion of women's work loads beyond the domestic sector has served to shift the burden of domestic work to female children. Because of the dominance of agricultural production in Sub-Saharan Africa, and because women play the largest role in subsistence agriculture, farm labor and food procurement are treated here as a distinct work category—the agricultural food projection sector—which includes both formal and informal, or domestic, activity (McGowan and Leslie, 1990; Raikes, 1989). Up to 80 percent of women work in agricultural production, a sector that can be further broken down into commercial/cash-crop, plantation, and subsistence production. In all three activities, women provide substantial inputs, but the bulk of their activity is on the informal end of the spectrum, in subsistence agriculture; family cash-cropping; and providing unpaid, usually seasonal, assistance for spouses performing wage labor on plantations. Their work also includes preparing, transporting, and marketing agricultural products for sale in the informal sector. The sum total of these dynamics within the sectors and subsectors described above is that virtually all women's work is effectively unpaid. Women participate little in the formal sector, either in the service or manufacturing industries, but dominate the domestic and agricultural production sectors and, to a lesser extent, commercial and productive activities of the informal sector. The bulk of women's work, then, falls under the rubric of social reproduction of workers in the family unit, as opposed to production. This helps explain its relative invisibility. Failure to take account of that invisible work leads to a serious underestimate of women's contribution to total output. It has been estimated that accounting for that work would have raised the figure for the world's annual recorded production by one-third, or $4 trillion, in 1985 (Sivard, 1985). Not counting women's work is particularly egregious in Sub-Saharan Africa, where women's work hours are extremely long. All over the world, women have been documented as working longer days than men. This distinction is more pronounced in the developing countries, and still more so in Sub-Saharan Africa, where extra hours worked by females have been estimated at 12 to 13 more a week than those worked by males. Time/budget studies have shown that women need to work between 60 and 90 hours a week just to make ends meet (UN, 1991). In some parts of East Africa, women work a total of 16 hours a day doing housework, caring for children, preparing food, and raising between 60 and 80 percent of the food for the family (Fagley, 1976). In Burkina Faso, women have about one hour a day to socialize, participate in community activities, and take care of personal needs (McSweeney, 1979). All of this adds up to a picture of long duration, high-intensity, and exhausting physical labor for women in Sub-Saharan Africa (Lukmanji, 1992). This has implications for the gendered nature of child labor. Although there is little documentation on child labor in Sub-Saharan Africa, it is clear that, given the nature of production, child labor constitutes a very significant proportion of total labor, and that female children make a disproportionately high contribution because of their involvement in domestic labor. Finally, the categorization of biological reproduction as a form of work is by no means unwarranted. While turning all aspects of life into work would be detrimental to the understanding and conceptualization of either, women's role in biological (as well as social) reproduction in the family context does free men for visible and paid work. This relationship can at times be brutally direct, as in the case of a woman who is unable to bear children and is forced out of the family to subsist as best she can in the informal sector—through prostitution, for example.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa THE NATURE OF OCCUPATIONAL AND ENVIRONMENTAL HEALTH PROBLEMS There is relatively little in the published literature on environmentally and occupationally related morbidity and mortality in developing countries, least of all for Sub-Saharan Africa. Still, work has been done and serves as a useful indicator of what remains to be done. The topic was substantively reviewed by Packard (1989a) in a seminal article on the broadly conceived health consequences of environmental and occupational exposures in Sub-Saharan Africa. Christiani and colleagues (1990) outlined research needs in the area of occupational health in developing countries more generally; Levy has more recently inventoried ongoing research in environmental and occupational health in the developing countries overall (Levy, 1992a); and a review by Rantanen (1992) emphasizes emerging trends in occupational health. A vigorous debate (Doll, 1992; Landrigan, 1992) has also arisen on the question of health, focusing on the general environment for countries at various levels of development. Finally, there has also been a recent trend toward greater governmental and nongovernmental involvement by the developed countries in developing-country occupational and environmental health issues in the form of the application of modern methods, which promise to provide more reliable data collection and analysis than were hitherto available. Beyond these studies, perhaps because of the extremely broad range of human conditions and adverse health outcomes encompassed under the rubrics "environmental and occupational health," relevant material is widely dispersed, even in the case of published academic work. Searches of the computerized occupational and environmental health data bases, including Medline and CCInfo-Disc, revealed very few references relating to any two or more of the following terms: Africa, occupational health, environmental health, and women. Not surprisingly, there is very little work, published or unpublished, that looks specifically at women, and most treatments of the subject of work are not differentiated by gender. Thus, ideas about female morbidity and mortality have to be based on inference, and the sources are mainly gender-blind material, on the one hand, and factors arising out of a general analysis of women's work in Africa, on the other. Unpublished work, conference presentations, work published in languages other than English, and internal reports of governmental and nongovernmental agencies have therefore been identified and assembled with more formal publications to permit as full a discussion as possible. As a result of this paucity of data, the nature of the problem is difficult to articulate succinctly, although it must be of great magnitude if for no other reason than the universal necessity to work in some way to stay alive. For poor people, and for women in particular, work loads, however defined, are extremely heavy and may be expected to give rise to a multiplicity of health effects over the course of a life span and through at least one subsequent generation. Emerging issues and trends must similarly be inferred through extrapolations from known exposures and from general considerations derived from sociodemographic and economic data. Occupational Injuries The emerging worldwide pattern of occupational health includes occupational injuries as a serious problem (see Chapter 8). An estimated 100 million occupational injuries, 180,000 occupational fatalities, and 10 million permanent disabilities occur globally each year, and between 70 and 80 percent of these events take place in developing countries (Rantanen, 1992). Rates of injury in those countries are thought to be between three and four times those of developed countries, and the most elevated rates are linked to young and inexperienced workers performing heavy work. Occupational Diseases The occurrence of occupational diseases is harder to estimate, but indications that are of increasing importance are noise-induced hearing loss, pneumoconioses, organic-dust-related lung diseases, metal toxicity, musculoskeletal disorders, and infections or infestations from exposure to contaminated water and animals (Rantanen, 1992).

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Chemical Hazards Chemical hazards are major risk factors in developing countries, notably through the penetration of agrochemicals. Poisonings, acute or chronic, are not easily ascertained, but Rantanen (1992) estimates that there are some three million acute episodes of agrochemical poisoning each year, principally from organophosphate insecticides, 99 percent of which are in developing countries, with some 220,000 fatalities annually from this cause alone. Acute poisoning that is work-related becomes relevant for workers and their dependents because storage, distribution, formulation, application, and other handling problems of chemical materials abound, and access is very easy. In addition, containers and packaging are frequently reused in developing countries, where such materials are valuable, and warning labels are useless, either because they are written in foreign languages or because of worker illiteracy. Hazard control of any kind is problematic because engineering methods are generally beyond the means of producers in the developing countries, and the cheaper and easier option of providing personal protective equipment is often impractical. Environmental chemical contamination—especially of water sources—is yet another problem that affects the workplace and the domestic environment. It may be presumed that heavy work in hot climates engenders significant heat and ergonomic stress. In developed countries, the estimate is that up to 40 percent of all occupational diseases are somehow associated with ergonomic stress; there are no such estimates in developing countries. Toxic Emissions The major sources of environmental health problems are indoor air pollution from heating and cooking using biomass and other fuels; general air pollution from motor vehicles in urban areas; point source pollution from production sites such as factories and waste disposal sites; and general chemical contamination from the application of agrochemicals. Emergent trends show a proliferation in the relocation of hazardous factories to developing countries (LaDou, 1992) and in the export of hazardous waste from developed countries to be dumped in developing countries, especially Africa (Anyinam, 1991). Yet another trend is the export of chemicals, notably agrochemicals that have been banned for use in developed countries (LaDou, 1992). These trends are not well-documented by volume, rate, or health effects, yet the evidence is that the international trade in toxic substances is growing much faster than the international monitoring mechanisms and institutions that could manage the problem. Other naturally occurring toxins are produced by biologic agents such as mycotoxins on stored grains ( on peanuts), or exist in a natural state in inadequately prepared food (cassava). These can cause serious liver or nervous system disease, cancers, and birth defects. One example is lathyrism, a central nervous system degenerative disease caused by consumption of grass peas in Ethiopia, which has a community prevalence ranging between 0.5 and 3 percent (Haimanot et al., 1990). Conditions such as esophageal cancer, liver cancer, cardiomyopathies, and other neurological conditions may be partly or wholly attributable to environmental agents or to their synergistic interactions with other causative factors. The amount of thoughtful research required to tease out truly or plausible causal relationships is large. The most efficient resolution would be to extrapolate from known causal relationships in well-analyzed sites in developed countries to comparable situations in developing countries. LIFE SPAN APPROACH It is apparent from the age matrix for female health in Sub-Saharan Africa that environmental and occupational hazards produce a variety of effects throughout the life span, with, by definition, the most pronounced effect during the working years, between the ages of 10 and 49. There are problems with modeling a sequential life span approach quantitatively or epidemiologically because of multiple intermediate variables between initial causes and final outcomes. Analysis of such variables is rather

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 9-2 Environmental Hazards and Typical Outcomes by Phase in the Life Span Phase Outcome Hazards Intrauterine Birth defects, prematurity, low birthweight Hookworm, malaria Infant/child Nutrition effects, chemical poisoning, accidents Pesticides, indoor air pollution Adolescent Obstetric problems, infertility, miscarriages Arduous work, lathyrism Young adult and middle-age Acute poisoning, injuries (with breakdown of family life because of migrancy and female-headed households) lead to poverty and overwork with nutrition effects, commercial sex work Pesticides, indoor air pollution, arduous work, HIV Old age Chronic poisoning from toxins interacting with age effects, nervous system and psychiatric problems, infections from children Childcare complex, and dependent upon very sophisticated statistical technology, as well as high-quality, plentiful data. These data are generally unavailable, even in developed countries. Nevertheless, a more qualitative approach may be taken to the life span phases in Table 9-2. There is a degree of reversibility, and some adverse health outcomes in females at selected life phases determine the hazardous exposures health determinants in those in other life phases. It is therefore possible to think of bi-directional effects between the various phases in Table 9-2. McGowan and Leslie (1990) provide a useful basis for conceptualizing life span/life cycle effects together with some illustrative examples. They deal substantially with the effects of childhood health and nutrition on adult work capacity and the reciprocal effects of adult health, nutrition, and mortality on all aspects of female work. They note particularly the physical stunting, anemia, and possible mental retardation or visual impairment caused by nutritional deficiency in early life. The impact of these difficulties on work has yet to be adequately studied or documented. There are also consequences of other environmental and occupational exposures on subsequent health status to be considered. These include infections such as polio, chemical poisonings, burns and other disabling injuries, water-related infestations, and blindness from onchocerciasis. The close domestic association between mother and infant leads to chemical and injury exposures both within and outside the home that begin early in life (Gitonga, 1991). For females, the indoor pollution they experience as infants and as children continues into adulthood, and domestic-work-related exposure compounds respiratory problems. Similar considerations may apply to agrochemical exposures. Reciprocally, adult morbidity and mortality of occupational and environmental causation will adversely affect the nutritional status of younger females and will considerably increase their work load. The effects of adult female morbidity and mortality for those in the informal and agricultural production sectors, as well as for those in female-headed households, have major health implications for female children. Chronic diseases and malnutrition limit work capacity considerably. The most common problems for adult women are anemia, fevers caused by malaria, gastrointestinal disturbances and nutritional depletion from frequent pregnancies, and pregnancy and lactation. All these factors may be considered to be work-related in the sense that they may be caused by biologic agents related to occupation, or work overload in relation to nutritional intakes. Work may thus be thought of as including the physiological work of reproduction and lactation.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa NATURE OF THE EVIDENCE An Occupational and Environmental Health Hazard Profile for Women Women's very substantial working lives provide a framework for considering a hazard profile for each of the four work sectors. Injury rates have risen with increasing mechanization and as chemical use has become more widespread (Jinadu, 1987, 1990; Odelowo, 1991; Schmauch, 1991). Mechanized transport is a case in point (Hicks, 1987), but mechanization can also decrease accident rates in the workplace (Asogwa, 1988). An important effect of increased work loads and exhaustion is a higher injury rate. Patriarchal and male dominance and increased pressure for production are likely to lead to domestic violence and to sexual violence at work. Violence is also related to work in the informal sector such as commercial sex work, home brewing, and running a tavern. Petty trading may also expose women to robbery and criminal violence. Alcohol consumption also plays an important role (Lerer, 1992). Fatal agrochemical poisoning, notably with organophosphates and paraquat (Adebe, 1991; Levin et al., 1979; London, 1992), is increasingly important. Physical Factors Given the heavy physical nature of women's work in Sub-Saharan Africa, heat-related illness may be anticipated, ranging from heat rash to heat exhaustion and heat stroke, with possible chronic effects, especially in hot climates. The role of adaptation to heat requires investigation to determine its interaction with the range of heat-related illness. Heavy weights carried while transporting fuel and water require high levels of energy expenditure, energy that is limited by nutritional status, which in turn limits the availability of food at home for those not engaged in work. Chemical Factors The nature of work in Sub-Saharan Africa clearly involves substantial exposure to chemical hazards (Institute of Occupational Health Information Office, 1986). Much processing work liberates dust, usually of an organic variety from vegetable and other food products. Indoor smoke pollution from burning biomass fuel for energy constitutes a principal respiratory hazard for women performing domestic work. Smoke particulates have been measured at time-weighted averages well above permissible ''nuisance dust" levels in African huts (Grobbelaar and Bateman, 1991) and can cause chronic obstructive pulmonary disease and chronic bronchitis (Myers, 1989). Wet work conditions result in impairment of the integrity and functions of the skin and can enhance the absorption of chemicals, and hence their reactivity. Agricultural water sources are frequently polluted with biologic and chemical agents. The single largest chemical category, however, is agrochemicals, which includes chemicals used as insecticides (including antivector spraying), herbicides, fungicides, nematocides, and avicides. The hazard of acute poisoning by agrochemicals is well known for organophosphate insecticides and for the herbicide paraquat. In addition, chronic toxicity is thought to result from long-term exposure to herbicides containing dioxin and organochlorine and organophosphate insecticides (London, 1992). Apart from the difficulty of ensuring safe work practices with agrochemicals, substantial pollution of water sources is very likely to occur in an environment of poor subsistence farming in the absence of a regulatory system. Finally, toxic waste—usually heavy metals, organic chemicals, and radioactive materials —has been dumped in increasing quantities in Sub-Saharan Africa. Poor periurban and possibly rural communities may be particularly at risk for exposure. Women searching for fuel, usable garbage, or water are likely to be preferentially exposed. Biological Factors Many biologic agents, whether infectious or allergenic, are present in the working environment of women. Their role as informal and formal health care providers involves exposure to a range of infectious agents. These

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa include viruses (HIV and hepatitis B) and bacteria (TB). Those working with livestock are exposed to toxoplasma and brucella. Because much agricultural and domestic work takes place outdoors and involves water, the gamut of water-related infections and infestations pose significant differential risks to women. These include malaria (Kaseje et al., 1987), onchocerciasis, trypanosomiasis, and schistosomiasis. Biological causes of work-related illness are likely to be more prominent here than in developed countries, where they account for only 5 percent of such illness, because immunizations are costly and impractical, and the community prevalence and incidence of hepatitis B infection are much higher. Many poisonous insects, spiders and other arachnids such as scorpions, and snakes pose hazards for agricultural workers. Women's work as the principal food processors brings them into substantial contact with organic dusts, which are frequently contaminated by fungi and bacteria. Separately or in conjunction with infectious agents, these contaminants may have considerable toxic and allergenic potential for both respiratory and skin problems. Work Organizational Factors Psychosocial Organization of Work Although not proven in the developing countries, Karasek's (1979) job-strain model is useful in conceptualizing the components of hazards related to work organization. In this model stress may be thought of in two dimensions—job load and job control (decision latitude). Job Load There are unreasonable male expectations of work from women, including those working full time in the formal sector. Perhaps the most striking aspect of the organization of women's work is the extent of their overload (Lado, 1992; Lukmanji, 1992; McGowan and Leslie, 1990). Overwork comprises two dimensions: intensity and duration. As mentioned above, women frequently work at the extreme limits of their physical capacity in intensity and energy required, while the long hours must inflict substantial physical, mental, emotional, and social wear and tear. Because women have very limited access to other productive resources, their need to increase their production can only take the form of harder work, longer hours of work, or both. Nevertheless, there are absolute limits to an increased work load without the introduction of labor-saving technology in the domestic, subsistence, and informal sectors. Job load or demand is therefore a major and increasing stressor in the context of Sub-Saharan Africa. Job Control It is relatively clear from the foregoing that women in Sub-Saharan Africa exercise little control over their work in all four sectors. Decisions about what work they will do, how they will do it, and when it will be done are largely resistant to alteration or choice by women, given the degree of overload. In addition, patriarchal structures do not allow females the autonomy and decision making authority that derive from ownership of land. According to the Karasek model applied in developed country contexts, this combination of high load and low job decision latitude is maximally stressful and might be expected to generate a number of stress-related adverse health outcomes. Other psychological sources of stress include: gender discrimination in hiring and promotion affects job satisfaction and strain sexual harassment at work sexual and other violence at home and at work in the informal sector insecurity of job tenure, income, or work conditions in both formal (especially temporary and seasonal work) and informal sectors multiple-role-balancing because of multiple responsibilities pressure of piecework in cottage industries

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa absence of male support in dealing with family or social problems because of migrancy worry about childcare for women in the formal sector worry about family and individual health problems. Sources of stress abound in the context of women's work in Sub-Saharan Africa. It has been estimated that up to 20 percent of women have mental health problems requiring expert attention in South Africa (Klugman and Weiner, 1992). The Physical Organization of Work Ergonomic stressors are ubiquitous in developing countries (ILO, 1987), but they have not yet been studied to any great extent. Women are subject to such stressors to a considerable degree in the course of their work. These problems originate in their physical size and strength in relation to heavy work and in the protracted periods spent in posturally stressed positions bending over fields; in portage of heavy loads including children, fuel, and water; in extensive distances traveled on foot; and in time spent standing. Formal and informal health care involve them in lifting other people, while work in the manufacturing sector reproduces ergonomic stresses typical of home work, often under less favorable conditions. In the formal manufacturing sector, machinery is usually made to foreign specifications. Additional Considerations Unique to Women in Sub-Saharan Africa In addition to a gender-blind consideration of the occupational and environmental health hazard profile in the African setting, special considerations are appropriate for females. Some important gender differences are: Personal protective equipment is designed to fit men. Recommended exposure limits for occupational hazards are designed for healthy, well-nourished men in the developed countries working an eight-hour day. Malaria prophylaxis and infection pose serious risks for pregnant women. Uncontrolled chemical and ergonomic hazards pose risks for the fetus, as they would in developed countries. The effects of chemicals, indoor smoke, and injury hazards for women extend to their infants. Work-time requirements may further compromise breastfeeding and infant nutrition. Rehabilitation from injury or work-related disease may be impossible to come by (Burger, 1990; Leger and Arkles, 1989), thus exacerbating hazardous exposures or increasing female work loads. Adverse Health Outcomes of Occupational and Environmental Hazards This section needs to be read in conjunction with the life span/life cycle outlined above. Reproductive health is covered in detail in Chapter 4 and will not receive any special emphasis here. For many years now the approach to occupationally and environmentally caused disease has been limited to a few extreme examples where relatively rare exposures have led to clearly defined adverse health effects that were unlikely to have been caused by other agents. This concept has recently been broadened to encompass direct and indirect determination of health by multiple factors (Schilling and Andersson, 1986). The causative categories are listed in Table 9-3. Indirect (Group) Health Effects As Packard (1989a) and Chinemana (1985) point out, this concept needs still further broadening in developing countries to reach beyond the confines of the developed world and its formal employment sector. A broader

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 9-3 Classification of Work-Related Diseases Cause Example Direct Hut lung and indoor smoke pollution Contributory Tuberculosis and overwork or dust Aggravating Psoriasis and excessive water contact Easy access Acute agrochemical poisoning approach facilitates a deeper understanding of the panoply of historical and current (direct, or individual, and indirect, or group) effects of environmental and occupational hazards. Beyond formal sector activity, and the male workers from this sector who are the traditional subjects of study in the developed countries, indirect effects (Packard, 1989a) are borne by those in other employment sectors, who furthermore may not receive much of the benefit from industrialization. Packard provides examples for the most important production sectors in Sub-Saharan Africa. Typical examples are the migratory diseases such as tuberculosis and sexually transmitted diseases, including HIV; the consequences for female subsistence farmers in rural areas of permanent male disability from high-risk mining activities; and increased exposure of women to malaria and schistosomiasis as a result of new irrigation practices used in large-scale agricultural developments. Other health effects for females may be linked to mining developments, which customarily have been based on forced removal of peasant producers from their land and by the undermining of subsistence production by considering the wage to be a mere supplement. This led to worsening socioeconomic conditions at both poles of the migratory oscillation. Migration facilitated the transmission of infectious disease (Packard, 1989b). The absence of Social Security has meant that the burden of disability from work-related accidents and disease in former miners has been made invisible by relocation to the rural areas (Davies, 1993). Women's work has increased as a consequence. Depending upon the kind of mining operation, additional environmental hazards may ensue. For example, asbestos mining has led to high community prevalences of asbestos-related disease, including cancers (Felix et al., 1990; Myers et al., 1987). Agricultural developments have led to the recrudescence of malaria and the growth of pesticide-resistant vectors because of irrigation and land use patterns. Economic disruption of communities through the elimination of small procedures has led to marginalization and a change in the employment sector mix leading to unemployment, urbanization, and wage dependence. Developments in manufacturing usually have resulted in draining the rural areas of person power and resources, with consequent transfer of wealth from rural to urban areas. All these factors are critically important in the consideration of the health of females in Sub-Saharan Africa, because there is a marked female preponderance in the rural areas in countries where the migrant labor system operate Direct (Individual) Health Effects When it comes to occupational and environmental health outcomes in females in Sub-Saharan Africa, there is little documented research (Naimi, 1991; National Workshop on Health and Safety of Women in the Workplace in Zimbabwe, 1988), but it should be borne in mind that even in developed countries female workers are infrequently studied. Health problems in the informal sector have been studied only in India (National Commission on Self-Employed Women and Women in the Informal Sector, 1988). The pattern of disease, however, may be predicted with a fair degree of confidence. Neurological disease, both central and peripheral, must exist because of the direct effects of acute and chronic poisoning with agrochemicals. The consequences of interactions among toxins, infections, and poor nutrition may

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa be expected to contribute to cancers of the esophagus, liver, and urogenital system. Occupational infections and infestations such as hepatitis B, HIV, TB, brucellosis, toxoplasmosis, fungi, malaria, trypanosomiasis, onchocerciasis, schistosomiasis, hookworm, and guinea worm constitute an important part of the disease spectrum. Protein-energy malnutrition and anemia will compound many health problems. Overwork and excessive exposure to contact with infectious children and adults may result in lowered resistance to infection. Major cardiovascular diseases in Sub-Saharan cardiomyopathy may have important occupational and environmental etiologies. A wide range of chest conditions constitute important components of female morbidity. Chronic bronchitis, chronic obstructive pulmonary disease, asthma, and restrictive conditions such as anthracosis (Grobbelaar and Bateman, 1991) are known to be particularly prevalent in women. Concomitant tuberculosis is an important aggravating factor. Dermatoses would be aggravated by domestic and agricultural exposure to water and wet conditions. This would be complicated by contact with allergenic exposures. Based on clinical evidence, Olumide has argued (1987a,b) that domestic water exposure may lead to hardening of the skin, thus offering some protection against other work-related dermatoses. In contrast, evidence from the workplace for women in the food industry, where the prevalence of dermatoses is very high, indicates that this is unlikely to be the case (London et al., 1992a,b,c). Although undocumented, musculoskeletal disorders, along with venostasis problems that are frequently aggravated by pregnancy, must be an enormous problem. These range from the later effects of bone deformation from poor childhood and adult nutrition, through the consequences of bearing heavy weights from an early age, to the complications of childbirth, to chronic osteoarthritic conditions affecting multiple joints. Work-related musculoskeletal disorders are certain to occur frequently given the nature of women's work, which involves excessive maintenance of unnatural postures with consequent postural stress, the application of considerable force to work movements, and frequent repetition of movements. Postural stress is very likely to involve the lower back, upper limbs, and neck for women in the two most important sectors, domestic work and subsistence agriculture. Stress-related conditions have been documented for women workers in the developed countries (Doyal, 1990; Hall 1990, 1992). In Sub-Saharan Africa, diabetes, which is thought to be stress-related, has been found to be associated with high work load (McLarty et al., 1990). Finally, occupational health services provided either directly or by primary health care services are likely to cover only a negligible proportion of women in Sub-Saharan Africa. Rehabilitation services that promote recovery from injuries and occupational disorders are also rare. It is therefore to be expected that there is substantial underassessment of work-related adverse health outcomes. CONCLUSIONS In conclusion, the state of occupational and environmental health of females in Sub-Saharan Africa is determined by the major groupings of factors below. Nature of Women's Work and Problems of Definition Women are very substantial contributors to the world of work in Sub-Saharan Africa; their efforts are out of proportion with their counterparts in other parts of the world. They contribute equally with men according to official statistics based on visible—and therefore recorded—work. Women's work is not so easily defined, however, and attempts to categorize components run into difficulties with overlaps between paid and unpaid work, formal and informal sector settings, and production sectoral consideration. Since formal sector work for women is limited in Africa to service and clerical work and other "female work," the bulk of women's work falls within the zone of poor visibility or invisibility. Much of women's work is unpaid, whether in agricultural production, domestic work-related to social reproduction, or informal sector activities. Informal sector activity has been growing rapidly and makes a very large contribution to provision of services. The increasing number of female-headed households, a product of the very prevalent migrant labor system, intensifies the workload for females further in both rural and urban settings. There has been a steady increase in women's workload historically. This has been the product of patriarchal

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa relations that put women's agricultural production needs in second place, lack of control over production resources and their own work, and unreasonable male expectations of work from women, including women employed full-time in the formal sector. Other socioeconomic determinants include effects of structural adjustment policies, inflation, and migrant labor. Together these elements led to an inability to cope with the totality of work in all sectors, which resulted in the shifting of the domestic burden to female children, and a consequent intensification of child labor. Women's resultant overwork has been well quantified as excessive in terms of both duration and intensity. Morbidity and Mortality The scant published literature on environmentally and occupationally related morbidity and mortality in Sub-Saharan Africa is gender-blind. Occupational health services provided either directly or by primary care services are likely to cover only a negligible proportion of women in Sub-Saharan Africa. Rehabilitation services that promote recovery from injuries and occupational disorders are also rare. It is therefore to be expected that awareness of environmentally related health problems is low, and that there is substantial underascertainment of work-related adverse health outcomes. At the same time, given the nature of women's work, the impact of environmental and occupational hazards occurs throughout the life span. As Table 9-4 illustrates, there may be substantial effects of determinants of morbidity and mortality in adult women on children or in the opposite direction. These are especially pronounced in female-headed households. Occupational and environmental exposures to toxic substances or drugs can have devastating effects on the fetus, resulting in either fetal death or long-lasting morbidity or disability in the offspring. Likewise, occupational insults are more likely to occur in younger females (and males), who are in the workforce in greater numbers; these conditions and their sequelae thus can have effects on health status that can extend substantially across the life span. These hazards, in addition, interact with each other and other causes of ill-health to produce a wider range of adverse outcomes. It may be inferred from published work on males that substandard housing, poor nutrition, ubiquitous infectious agents, and overwork, together with other environmental hazards such as chemical toxins, combine to determine a wide range of adverse health outcomes for women. These must include respiratory, dermatologic, neurologic, and work-related musculoskeletal disorders. TABLE 9-4 Ages of Occurrence of Injuries in Sub-Saharan African Females In Utero Infancy/ Early Childhood (birth through age 4) Childhood (ages 5–14) Adolescence (ages 15–19) Adulthood (ages 20–44) Postmenopause (age 45+) Maternal exposures to toxic substances Indoor air pollution Indoor air pollution Indoor air pollution Indoor air pollution Indoor air pollution       Job overload Job overload Job overload       Lack of job control Lack of job control Lack of job control       Ergonomic stressors Ergonomic stressors Ergonomic stressors       Othera Othera Othera a Other includes: ill-fitting personal protective equipment designed for men; working under recommended exposure limits for occupational hazards designed for healthy, well-nourished men in the developed countries working an eight-hour day; work-time requirements that further compromise breastfeeding and infant nutrition; and lack of sufficient "off time" to allow for appropriate rehabilitation from injury or work-related disease, thus exacerbating hazardous exposures or increasing female work loads.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa RESEARCH NEEDS Because relatively little is known about occupational and environmental health in Sub-Saharan Africa, and even less is known of the status of women, research implications are daunting and somewhat unfocused. This means that the first priority of research is to undertake a substantial body of descriptive work relating to women's work in Sub-Saharan Africa. This may be expected to yield areas that require nore in-depth study. The broad components of this descriptive work would involve the study of representative tasks performed by women in all sectors identified above. Work hazard and risk assessment for selected adverse health outcomes should be conducted on this basis. A mix of in-depth, participant observation, and quantitative methods (Cooper et al., 1990) will be required to adequately characterize environmental and occupational exposures, as well as conditions relevant to health. Given that most analytic studies have been undertaken in developed countries on male subjects, there is considerable room for attention to female subjects in relation to many exposures and outcomes. Several priority topics are suggested. These include: Effects of pesticides and other home chemicals on peasant farmers and on others in plantations and monocropping production. This applies across the life span, and also to the chronic effects that have barely been studied. Ergonomic stressors in relation to musculoskeletal disorders, including the impact of bearing heavy weight at different ages and the effects across the life span and life cycle with regard to degenerative osteoarthritic problems. Respiratory damage, notably from chronic bronchitis, and reduced lung function across the life span. Appropriateness of occupational exposure limits given gender and the multiplicity of other environmental stressors. The mental health impact of psychosocial stressors that are related to work and environment. In particular, an examination of the physiological, psychological, and social effects of chronic fatigue arising from the intensity and duration of overwork is required. Validation of many routinely used developed country measures (Nell et al.; 1993) for wider application across cultures and across settings (informal versus formal sectors). Many invalid assumptions are made about the utility of research measures across cultures. This is more obvious for neuropsychologic measures, but it applies equally to questionnaires, respiratory function measurements (Myers, 1984), and other seemingly more objective measures (Bachmann et al., 1992). Research needed to inform public health policy. Only limited work has been done for developing countries generally (Christiani et al., 1990), for Africa (Khogali, 1982; Levy, 1992a,b; Myers and Macun, 1992), and for women (McGowan and Leslie, 1990). In addition, it is important in these studies to investigate interactions between exposures related to productive work, the physiologic work of reproduction, and other general determinants of women's health status such as nutrition, anemia, and physical size. REFERENCES Adebe, M. 1991. Organophosphate pesticide poisoning in 50 Ethiopian patients. Ethiop. Med. J. 29(3):109–118. Anyinam, C. A. 1991. Transboundary movements of hazardous wastes: The case of toxic waste dumping in Africa. Intl. J. Hlth. Serv. 21(4):759–777. Asogwa, S. E. 1988. The health benefits of mechanization at the Nigerian Coal Corporation Accid. Anal. Prevent. 20(2):103–108. Bachmann, O. M., J. E. Myers, and B. N. Bezuidenhout. 1992. Quantitative vibration sense testing in workers exposed to acrylamide monomer. Am. J. Indust. Med. 21:217–222. Bukh, J. 1980. Women in subsistence production in Ghana. Pp. 18–20 in Effects of the Penetration of the Market on Rural Women's Work. Geneva: International Labor Office. Burger, E. 1990. Rehabilitation of mine injuries. Nursing SRA 5(3):18–21. Chinemana, F. A. 1985. Effect of work on health—community perceptions in Zimbabwe. J. R. Soc. Hlth. 105(6):216–218.

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