Presentation to the California Public Health Association-North

Women's Health and Emerging Issues Conference

October 23, 1997

Women's Health in a Changing Global Context:
The Impact of globalization on women's lives and women's health

by Pamela Hartigan, Ph.D
Pan American Health Organization

Thank you for providing me with the opportunity to address you today. By way of introduction, I represent the Pan American Health Organization, or PAHO, the Regional Office for the World Health Organization in the Americas. PAHO is also the world's oldest international health institution, having been founded almost fifty years earlier than WHO, in 1902, as an inter-american organization. Back then, our concerns were infectious diseases. Today, we have vastly broadened our focus to include, amongst others, my particular area of concern which has been to integrate a gender perspective into our programs designed to influence the health of women and men in the Americas.

I have been asked to focus on women's health, and to comment in particular on how globalization is impacting on the lives and health of women throughout the world. I come at this topic mainly from the perspective of a single region, Latin America and the Caribbean, the one that I know best. But much of what I will say seems to resonate with those from other regions, and you may feel tempted in some instances to draw your own parallels with the situation of public health in California.

Let me begin by acquainting you with what we at PAHO have learned to date from grappling with the gender issue. Then, against that backdrop, let me end with some personal impressions of how globalization as a major force for economic and social change, may be aiding or abetting the situation of women and women's health. The process of expanding our institution's view of health, and in particular, emphasizing gender considerations in health, has been a gradual one. For many years, our focus on women's health did not go beyond pregnancy, birth and breast feeding. Moreover, we weren't particularly interested in women's needs, but more in the needs of the fetus they carried or infant they bore.

This began to change in the mid 80s with the growing awareness of the inequities faced by women in the development process. PAHO's emphasis on approaching health from a gender perspective emanates from its concern for equity in health. A prerequisite to attaining equity in health is acknowledging that different groups have different needs. A gender analysis in health contributes to equity because it provides the concepts and methods for responding more effectively to the health needs of men and women, as individuals and as subgroups within a population.

The framework of thinking that has emerged takes into consideration the fact that men and women play different roles in different social contexts, and because of that they develop different skills and abilities. These roles, skills and abilities are valued differently, and it is usually those associated with the masculine spheres that receive greater social recognition and are valued more highly than those associated with the feminine spheres. This differential value has direct implications for the degree to which men and women have access to and control over resources needed to protect their health. Collectively, these sexually assigned roles and responsibilities, and the abilities, values and decision-making capacity over resources that are linked to them, give rise to gender inequities.

There is no doubt that when we are dealing with health issues, we must consider the biological differences between the sexes which include anatomical or physiological and genetic differences. These differences are not only individual, but also are different among population groups of men and women. For example, in women osteoporosis is higher than for men. However, Indian women have much lower rates of osteoporosis than Caucasian American women, even though, by comparison, in both groups osteoporosis is still higher for females than for males in those respective population groups. What distinguishes these two groups has nothing to do with the characteristics of individuals but rather a mass influence acting on the population as a whole. Thus, the determinants of incidence are not necessarily the same as the causes of cases. We sometimes forget this.

But until very recently, the medical profession focused almost completely on these biological or sex differences as explanatory factors of differences in wellness or illness between men and women. From our now new perspective, while a gender approach in health recognizes the critical importance of biological factors to the health of the sexes, it emphasizes that a recognition of social factors is crucial to the analysis of differential health disadvantages and/or advantages for men and women. Ultimately, the probability of maintaining health, or becoming ill and dying from preventable causes is also a function of the gender roles played by men and women in society and the level of equity in the distribution of access to and control of resources in different societies.

Yet a knowledge gap remains in understanding how biological differences between the sexes interact with men and women's socially constructed roles and relations to produce good or ill health for one or both sexes. We at PAHO define a gender perspective as an approach which has as its purpose to identify, analyze and act upon inequities that arise from belonging to one sex or another. These inequities can create or maintain exposure to risk factors that endanger health; they can also affect the access to and control of resources, responsibilities and rewards in health work.

Let's look at some specific examples. In general, men die first. But if we put on our gender lenses, we find that they die from accidents, violent acts, cardiovascular disease, lung cancer, cirrhosis. To what degree are these illnesses related to attitudes and behaviors stereotypically defined as masculine, such as aggressivity and risk-taking, sometimes accompanied by too much alcohol? Are these deaths avoidable with a modification of gendered patterned behavior using population strategies of prevention that emanate from public health? We like to think so. On the other hand, we are very much aware that women live longer. But women's additional life years are not necessarily indicators of wellness and comfort. We know from the results of scientific research that in all societies, and despite the great strides made in modern medicine, women suffer greater morbidities than men, a fact which manifests itself in a higher incidence of acute conditions across the lifespan and in a higher prevalence of chronic illnesses and of short and longer term disabilities. As I pointed out earlier, osteoporosis affects women at a much greater rate than men; similarly depression, autoimmune diseases, malignant tumors, hypertension, obesity, and urinary incontinence. All of these are more frequent in women than in their male counterparts, and can seriously compromise their quality of life.

As emphasized previously, traditional approaches to women's health and illness have focused primarily on their biological role as potential reproducers, not on the socially defined roles and responsibilities that are assigned to them. By analyzing women's health from a physiological focus only, an opportunity is lost to i) shed light on the relational, historical and social contexts in which such problems occur, such as malnutrition, occupational risks and violence and ii) to design effective interventions that draw upon knowledge derived from an understanding of both biological and psychosocial factors. An example of the effect of this distancing of the analysis of women's health from the complex, diverse and dynamic realities of their lives has been the narrow approach to the provision of family planning services which provide contraceptives primarily to women, with little concern for women's health in general or even of human well-being as an end in itself.

The right of men and women to promote and safeguard their own health is a fundamental human right. But women are often denied the resources, both internal and external to them, that would enable them to exercise that right. The most detrimental factor to ensuring the health of women is linked to the growing numbers of them who live in poverty. In fact, the majority of the poor in the Americas and in the world are women. Women work longer hours than men, receive lower wages and have access to and control over less resources than men. Indeed, the socioeconomic situation of women relative to their male counterparts has deteriorated significantly in rich and poor countries alike, giving rise to the phenomenon now known as the "feminization of poverty".

Against this backdrop, and through a gender lens, what are the major health issues for women worldwide today? Although incidence and prevalence rates vary according to variations in countries' epidemiological profiles, the major health problems for women can be summarized thus, and not necessarily in order of importance:

How does globalization of the economy impact on the major health issues women face today? Globalization is the term we use to capture a diverse number of forces for change in the economy and society. It connotes: the liberalization and opening of markets; the breakdown of traditional systems of economic protection, cultural norms and social support networks; the communications and information revolutions; and broadly, the unification of people everywhere into one world. Clearly the structures that underpin every aspect of economic and social life are affected by globalization and the economic pressures of adjustment have both negative and positive consequences.

For example, let's look at the issue of environment and health. There is mounting evidence that exposure to contaminants released into the air, water and soil may be the primary cause of morbidities ranging from cancer and anemia to infertility, mental retardation, neurological, gastrointestinal and endocrine disorders, asthma, and compromised immune systems that may in turn, interact with infectious disease. This multitude of newly discovered environment-related illnesses adds substantial complexity to the already long list of traditional, environment-related infectious diseases, such as malaria, dengue, Chagas' disease, leishmaniasis and schistosomiasis, to name a few. If occupational risks other than exposures to toxic chemicals are included, then environmental health risks take on an even broader scope as accidents, musculo-skeletal disorders, hearing loss and stress-related psychological and cardiovascular ailments are added. What does globalization have to do with this? In some countries in our region, for example, trade liberalization policies have placed a premium on intensive agriculture for export. The consolidation of large landholdings for agribusiness and the relegation of subsistence farming to every smaller, less productive plots of land have increased concomitantly. Most of the rural population in Latin America and the Caribbean is poor or extremely poor. In 1990, approximately 61% of the rural population was poor and 20% were so impoverished that they could not meet their food requirements. The poor soil quality of their plots and their precarious location on steep hillsides and the edges of forested land often leads to further soil degradation of domestic food plots. Let's look at the gender-differentiated health risks that we know about.. there are many more that we don't know about. Here is where a gender analysis is an invaluable tool in assessing how biological differences between the sexes interact with men and women's socially constructed roles and relations, including the environmental contexts in which they live, to produce good or ill health for one or both sexes. Depending on the activities which rural men and women carry out in their biophysical environments, they will be exposed differently to harmful pesticides and their residues which are widely used in agroexport industries.

According to recent studies, pesticides have been associated with increased incidence of cancer among agricultural workers, contributing through genetic and epigenetic mechanisms. Pesticides may operate through the latter by inducing immunosuppression and causing decreased host resistance to infection, suppressed T cell activity or producing xenoestrogen compounds which mimic or modify natural hormones and may result in abnormal cell activity, boosting aberrant cell growth, which can result in cancer . Women, even if they don't work in the fields directly applying the pesticides, are the ones that wash the agrochemical drenched clothing. Agrochemicals and other contaminants penetrate the groundwater, presenting a further risk for family members. Even if there is some source of water that is ìsafeî from biological contaminants, rural water supplies will not be safe from chemical and heavy metal contamination. Livestock, vegetation and fish are likely to concentrate these wastes. There are a myriad of such issues which face us now. For example, the additional potential risk in rural areas represented by the disposal of hazardous urban wastes and the acceptance of toxic waste from other countries. Some of these wastes include lead and other chemicals and metals which may be transported across regional or national boundaries and deposited thousands of miles away from the sites at which they were emitted. Nutritional deficiencies are known to interact synergistically with a number of hazardous environmental exposures. For example, lead interferes with the proper metabolism of zinc, iron and calcium. Girls and women, as we know, have a greater need for iron-rich foods in comparison to men. Exposure to lead may be a major contributing factor to anemia in iron-deficient women. We also note with alarm that levels of organochlorine pesticides in maternal milk are 10 times higher in samples obtained in several Latin American countries than the levels found in the U.S. and Canada. Because of liberalization coupled with lack of regulation in developing countries, and pressure from aggressive and unethical sellers in developed nations, countries in Central and South America imported highly toxic chemicals for agricultural use. Even when large chemical corporations stopped exporting DBCP, for example, following the 1979 ban in the U.S., smaller manufacturers and distributors stepped in, paying royalties for every shipment sold. Many growers stopped buying the pesticides directly, but continued imposing the use of DBCP on banana plantations where they bought crops from local farmers.

In the urban areas, environmental health risks present an overriding concern for the health of men and women, boys and girls. It is important here to point out that even when the sexes in a same cohort group share similar economic and social situations and are exposed to the same hazard, their physiological structure may respond to it in different ways. How the sexes respond differently to similar risks warrants much more research. However, from a perspective of the gender division of labor, women are the environmental managers of the home. Urban inhabitants living in resource poor settings may share the risks of contaminated drinking water, airborne pollution in the form of dust particulates, illegal dumping of garbage and wastes, unsanitary removal of domestic sewage, and crowded housing, but how these situations are managed is gendered, as is the impact of environmentally-related illnesses within the household.

The globalization of economic production and trade with its reliance on free market behavior and the private sector did not fill the gap left by the progressive withdrawal of cash-strapped governments from a dominant role in health care delivery. The pull-back by governments was a pervasive consequence of the economic crisis of the 80s in the case of Latin America and the Caribbean and of the resulting need to enter into economic austerity programs as part of structural adjustment. The share of health expenditures in government budgets declined across our region and governments have been under pressure to reduce government payrolls and employment and to privatize health care delivery. Ironically, this has occurred at precisely the time when reliance on the private sector has been found wanting as an instrument for delivering health care to lower income groups in the U.S.. The effect on women in Latin America and the Caribbean was that they were obliged to take up a larger share of the burden of health care at precisely the same time they were also having to enter the remunerated work force in order to supplement incomes. With the resulting population shifts to pursue new economic opportunities there has been an erosion of the social networks that would have helped assume some of women's child care and household management tasks that we collectively describe as their reproductive roles.

In this vein, let's tease apart the above dynamics so as to look more closely at the forces that are dramatically changing the face of our region. First, let's briefly examine the specific aspects of economic adjustment that stimulated the massive insertion of women into the work force and the concomitant change in social support systems. Then, let's look at the ongoing reform of the public sector, including the health sector, and how it is having or can have an impact on women's health, and on women as caregivers.

Although women have always played a major role in agricultural production in the region, more recently they have massively entered other areas of the remunerated labor force in both the formal and informal sectors of the economy. Between 1960 and 1990 in Latin America, the number of economically active women tripled whereas the number of males was less than doubled. The number of women who have to perform remunerated work, what we call, productive roles, because of economic necessity is clearly increasing. However, with greater levels of education, women are also choosing jobs and careers that were formerly regarded as the domain of men. Nevertheless, when unskilled women enter the labor force, they work in the informal sector. In Latin America and the Caribbean between 1990 and 1995, 84 of every new 100 jobs were in the informal sector which in 1995 employed 51.6% of the population. This sector includes any work that is not regulated by labor laws or would be but is not registered. The activities carried out by these women and men are highly diverse and include street vending, food processing, home-based subcontracting to larger enterprises, handicrafts, shoe-shining, appliance repair, non-licensed transportation services, marketing articles from chewing gum and pencils to contraband, scavenging, prostitution, and so on. One of the effects of the changing market-place has been the increase of home-based occupations as a way to cut costs for export oriented companies. By contracting out work, the company is not subject to regulations that must be in place in factory settings to ensure worker safety. In addition, home based workers are not covered by health insurance that would provide them with preventive or curative care. Women are massively employed under these arrangements. Moreover, average incomes for women in the informal sector are far lower than those of their formal sector counterparts. In contrast, men working in the informal sector earn higher average incomes than male formal sector workers in many Latin American countries. The gap in men and women's income earning ability reflects inequality deeply rooted in labor market segmentation. Moreover, the need for women to balance reproductive and productive roles puts women in the informal sector at a disadvantage in comparison to men . Street sellers, for example, mostly men, are able to work at peak times, are mobile and sell cooked food on the main roads. Housebound women sellers work longer hours than the street vendors and earn less. The extent to which women can balance their double roles depends on the types of households they live in. More specifically, their capacity to cope is determined largely by the extent to which other females are resident in the household to whom domestic chores are delegated. Although elder daughters may take over these roles within nuclear households, women have the greatest leeway to balance their multiple roles in extended households. When they are unable to delegate to other women, working women may be forced to lock up young children while away from home. These women often start their day at 4 or 5 a.m. making cooked food to be eaten while they are away and then do additional domestic chores on their return in the evening. While women's roles are rapidly changing, most men continue to be caught in the macho trap. Despite the fact that one-third, and in some countries, one- half of households are headed by women, the stereotype of the male as provider and the woman as housewife persists in the minds of many, including women who may be the main income earners. As a result, men contribute far less than is necessary to household management tasks, including child rearing. So who is watching the children while women work? This is a source of tremendous anxiety for working women worldwide, but more for poor women. In a number of studies carried out in our region examining the impact of economic adjustment on vulnerable households, women consistently spoke of depression and high rates of anxiety, linking them to the helplessness they felt at having to leave home to work and not knowing the whereabouts of their adolescent children. This anxiety heightens with increasing levels of street violence and youth gangs. A number of studies have talked about the erosion of social capital, one of the most important assets of resource poor families because it decreases vulnerability and increases opportunities. Social capital refers to the norms, trust and reciprocity networks that facilitate mutually beneficial cooperation in a community. Social capital erodes with community violence, whilst at the same time, violence is an indication of the erosion of social capital. The issue here is that women's gender roles are undergoing rapid change but most men are slower to accept the changes and many feel threatened by them. As globalization erodes entrenched social beliefs, it can be positive for women as their choices expand. However, as Arthur Schlesinger Jr. points out in a recent article in Foreign Affairs, ìresistance will be reinforced by the defensive reaction around the planet to relentless globalization - a reaction that takes the form of withdrawal from modernity. Globalization is in the saddle and rides mankind, but at the same time drives people to seek refuge from its powerful forces beyond their control and comprehension.î A militant expression of this cultural backlash is the upsurge of religious fundamentalism. ìPeople retreat into familiar, intelligent, protective units. The faster the world integrates, the more people will huddle in their religious or ethnic or tribal enclaves.î

I cannot come to California and not discuss the impact of the maquiladora system on women's health. In fact, I suppose that when we hear the word ìglobalizationî most of us think of the maquila or assembly operations which are usually foreign owned operations set up in developing countries to cut costs by paying low wages, avoid collective bargaining and eschew environmental regulations in their countries of origin. These assembly plants are estimated to have created between 20 and 30% of new job opportunities in Mexico and the Dominican Republic during the late 1980s. Girls and unmarried women make up some 70 to 77% of the workers at these plants region-wide. Their average age is 16-25 years. Most of the women are relatively unskilled and work in the maquilas is their first remunerated employment. An oft-cited maquiladora manager stated his reason for female preference: ìBecause of their mothering instincts, women are.. more responsible than men; they are raised to be gentle and obedient, and so they are easier to deal with. They are also more nimble and meticulous and they don't get tired of doing the same thing nine hundred times a day. We hire them because we know we'll have fewer problemsî. Why women ìcauseî fewer problems is again a gender issue. They are less likely to complain, because most women have been socialized to endure hardship in silence, and they are less likely to organize than men, proof being that women's participation in labor unions is considerably less than that of men. Environmental health risks can include neurotoxic effects from exposure to organic solvents. Other occupational risks include repetitive motion injury and associated tendinitis, dermatitis, hearing loss, and acute respiratory infections. Menstrual and hormonal abnormalities have been found repeatedly in these industries. Stress is also an occupational hazard for assembly plant workers. As stated in a recent study by the International Labor Organization, ìContrary to a widely held view, the greatest levels of stress are not found among leaders or those called upon to take decision-making positions but are found among workers tied to assembly line production for whom machines impose the pace at which they must work. It is women who are found in greater numbers among these workersî.

So what do women in the formal and informal sector do when they need health care? However objectionable the conditions are in the maquila industries, they may be better than what is available elsewhere in the countries. And many of these assembly plants now have on-site health care facilities for workers. In the case of the informal sector workers, and remember that this is the sector where most women are employed, there is no worker protection. The remuneration women receive is not enough to provide them with access to affordable health insurance schemes. When women become ill or wish to seek preventive care, they must incur out of pocket expenses to gain access to the public or private health system, as in the former, user fees are increasingly imposed by the strapped public health sector. However, regardless of whether workers use the public or private health care, the medications they need have always had an economic cost. As the public health system continues to shrink, the social safety nets which, although precarious, at least existed in many countries, have continuously eroded. Even where still free, men and women's access to the public health system will be constrained by the time they must spend going to the clinic and waiting their turn.

The macroeconomic adjustment policies adopted by the governments of the region to alleviate the debt crisis of the 80s have been associated with cutbacks in public social services, the elimination of subsidies for basic goods, higher prices for drugs, transportation, housing , water and electricity, and the privatization of public services. The impact of these changes has not fallen equally on all households. The heaviest burden of the impact has fallen on the sectors with the lowest income, and within these sectors, women have been seriously affected due to their disproportionate representation among the poor, their comparatively greater need for health care because of their reproductive function, and the additional burden of providing care once offered by the public services, a responsibility which women have been forced to assume as part of their social role as caretakers of household members.

Macroeconomic trends and policies are normally analyzed in a language that appears to be gender-neutral. Attention is directed to average indicators of productivity or efficiency with no mention of sex. However, the appearance of neutrality conceals a profound gender bias for it ignores the process involved in the reproduction and maintenance of human resources and the contribution of this process to the economy. The economy has been defined chiefly in terms of market for goods and services. Essential activities that are unremunerated, such as childrearing, the transportation of water and fuel, the processing and preparation of food, the household management tasks, the care of elderly, sick and disabled family members do not appear in national accounts. This, in most societies, is ìwomen's workî . The United Nations Development Programme has estimated that if these unpaid activities were treated as market transactions at the prevailing wages, they would yield huge monetary valuations - a staggering $16 trillion, or about 70% more than the officially estimated 23 trillion of global output. Of this 16 trillion, 11 trillion is the non-monetized ìinvisibleî contribution of women.

The gender division of labor is critical to an examination of equity in access to medical and social security services of any population group, particularly the low income groups. In the majority of our countries, eligibility for social security coverage derives from an individual's employment status, present or past. In addition, the possibility of obtaining and keeping private health insurance depends to a large extent on the employment and remuneration of the potential subscriber.

The pattern of work for women in the labor market has three characteristics that differentially affect their access to social security and health insurance benefits: their concentration in low-paying jobs that either have no coverage, such as in the informal sector, or generate a very low contribution, a very low pension, and virtually no possibility of access to private health insurance; ii) the high proportion of women in part time jobs that are excluded from the benefits schemes; iii) an interrupted work history, associated with gestation and childrearing, which reduces time of service and affects the amount of pension that a woman receives and even her eligibility for a pension.

The cumulative effects of a lifetime of this work pattern become dramatic as women age. Old age for women, in contrast to men, is disproportionately marked by widowhood, poverty and lack of social welfare benefits. In the U.S., for example, where the proportion of women wage earners is relatively high, the percentage of women over 65 living below the poverty line was twice that of men of the same age in 1993. The average income from social security that retired women received was 63% of the figure for retired men. Furthermore, the number of women receiving a pension was one-third that of men.

Thus, social security and pension schemes are undergirded by an inequitable foundation, and one of the dimensions of that inequity is gender discrimination. This notion of discrimination encompasses sins of omission as well as deliberate acts. That is, ignoring the work pattern of women is tantamount to disproportionately marginalizing them from direct access to the benefits of the system.

Within the different national strategies for health sector reform currently in place in our region, certain strategies tend to be more frequent, mainly: decentralization, cost recovery in the public sector, selective privatization, the adoption of basic packages of health care, the introduction of new forms of hiring, the targeting of public expenditures, and the control of drugs. Some apparently gender-neutral formulations referring to objectives such as ìcost reductionî, ìeffectivenessî and ìefficiencyî frequently include a gender bias because they imply transfers of costs from the remunerated economy to the economy based on the unpaid labor of women. Thus, the underlying premise of some measures is that governments can cut costs by cutting services - for example, shorter hospital stays, reduced care for the elderly, because most health care occurs in the home.

The concept of equity, which is the backbone of this analysis, is based on the notion of need. This assertion implies that the distribution of the system's resources and benefits should be guided not by impartial criteria of equality but by considerations of need. In other words, it is not a matter of men and women receiving identical quotas in the distribution of resources and services. What matters is that they receive such resources differentially according to their needs. The empirical determination of the health needs, biological and gender based, of men and women, and the degree of correspondence between these needs and the basic health services offered, comes a basic planning tool.

I have tried to cover a lot of ground in this presentation, beginning with identifying the major challenges in women's health. However, most of the challenges to women's health today come from outside the health field, as I have tried to point out in the discussion on environmental, labor-related and public sector reform issues. This is why engaging in a consideration of the complexities of these linkages becomes such a vast, fascinating, yet daunting endeavor. One of the exciting aspects of globalization is that we are finding common ground for these discussions and thus strengthening our responses to the challenges we face in our own communities. This is a critical time to act. Markets continue to expand as governments recede, regulations erode and social obligations are shirked. The challenge for the 21st century is to steer a balance between a market economy which fosters strong inequities and is insensitive to environmental hazards and poverty, and democratic systems which are founded on the belief that women and men should have access to and control over the resources they need to ensure that they are able to exercise their rights, including their right to health.

Thank you for providing me with the opportunity to address you today.

Pamela Hartigan, Pan American Health Organization (PAHO

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References

Hartigan, P. Environment, Gender and Health: Incorporating a Gender Perspective in Environmental Health. PAHO, Washington, D.C., 1997.

PAHO, Women, Health and Development Program. Gender, Health and Development: A Facilitator's Guide to Training, Washington, D.C., 1997.

Human Development Report 1995. Published for the United Nations Development Programme (UNDP). New York: Oxford University Press. This section of the discussion that lists the major health problems for women is taken from "The Health of Women and Children in the Americas: It's Time To Look through a Gender lens" by P. Hartigan, published in Directions, Partners of the Americas, Washington, D.C., 1996.

Carlson, B.A. and Wardlaw, T.A. A Global, Regional and Country Assessment of Child Malnutrition. New York: UNICEF Working papers, No. 7, 1990.

The World Health Report 1997: Conquering Suffering, Enriching Humanity. Geneva, World Health Organization, 1997.

Gomez, E. Women and Health In Latin America and the Caribbean: Old Issues and New Approaches. Pan American Health Organization, Washington, D.C. 1995.

Bulletin of the World Health Organization, "Control of Cancer of the Cervix uteri". Geneva, The World Health Organization, 64(4):607-618, 1986. "The Alan Guttmacher Institute. Today's Adolescents, Tomorrow's Parents: A Portrait of the Americas. New York, 1990.

Blastein, N., Chelala, C., Diaz, A., Solis, J.A.., Yunes, J. (eds.). "Maternal and Child Health: Goals for 1995 and indicators for monitoring progress." In: Interagency Coordinating Committee for the Americas. World Summit for Children. PAHO, Washington, D.C. 1994.

Ibid. PAHO. Cervical Cancer: A Preventable Disease. Women, Health and Development Program, Washington, D.C. June, 1994.

Desjarlais, R., Eisenberg, L., Good, B. and Kleinman, A. World Mental Health: Problems and priorities in Low-Income countries. London, Oxford University Press, 1995. For a full discussion on this, see Heise, L., Violence against Women: The Hidden Health Burden, World Bank Discussion Paper No. 255. Washington, D.C. The World Bank, 1994.

PAHO. Division of Health Promotion and Protection, 1997.

La SituaciÛn de la Mujer y la Nina en AmÈrica Latina y el Caribe. ComitÈ Coordinador Interagencial para las AmÈricas, UNICEF, 1996.

Davis, D.L., Blair, A. and Hoel, D. "Agricultural Exposures and Cancer Trends in Developed Countries", Environmental Health Perspectives, Vol. 100, 39-44, 1992.

Repetto, R. And Baliga, S. Pesticides and the Immune System. World Resources Institute. Washington, D.C. 1994.

Albert, L. "Residuos de Plaguicidas Organoclorados en Leche Materna y Riesgo para la Salud", BoletÌn de la Oficina Sanitaria Panamericana, 91(1), 1981. Schemo, D.J. "Pesticide from U.S. Kills the Hopes of Fruit Pickers in the Third World". The New York Times. Wednesday, De. 6, 1995. Economic Commission for Latin America and the Caribbean (ECLAC). The Equity Gap: Latin America and the Caribbean and the Social Summit. Santiago, Chile, 1997.

Moser, C. Household Responses to Poverty and Vulnerability: Confronting Crisis in Cisne Dos, Guayaquil, Ecuador. The World Bank. Urban Management Program, 1997.

Fernandez Kelly, P. Political Economy and Gender in Latin America: The Emerging Dilemmas. Woodrow Wilson International Center for Scholars, Washington, D.C., 1994. For a full discussion on the concept of social capital, see R.D. Putnam, "The Prosperous Community: Social Capital and Public Life", American Prospect, Spring, 1993: 35-42 and Putnam, R.D., Making Democracy Work: Civic Traditions in Modern Italy, Princeton, N.J.: Princeton University Press, 1993.

Schlesinger, Jr., A. "Has Democracy a Future?" in Foreign Affairs, Sept./Oct. 1997, Vol. 76, No. 5, p. 2 -12.

Fernandez-Kelly, op. cit. Jessup, D. Worker Rights and Trade: Democracy's Next Frontier. Paper presented at the Conference on U.S.- Latin American Trade and Women: Breaking Trade and Gender Barriers. University of Texas at San Antonio, 1994.

Abramo, L. "ReconversiÛn Productiva, cambio tecnolÛgico y empleo femenino en AmÈrica Latina" en Repercusiones de la ReconversiÛn Productiva y del Cambio TecnolÛgico sobre el Empleo y las Condiciones de Trabajo de la Mujerî, OIT, 1993, p. 19. UNDP. Human Development Report, 1996.

Older Women's League. "Mother's Day Report" on the Economic Status of Older Women, 1995.

McLean, S., and Burrows, N. The Legal Relevance of Gender. London, Macmillan Press, 1987. For a further analysis of the presence of gender biases in the health and social security systems of the Region, see "Gender Equity in Health Care Reform", PAHO, Subcommittee on Women, Health and Development, 17th Meeting, April, 1997.

Gomez, E. "Introduction," in Gomez Gomez, E. (ed.), Gender, Women and Health in the Americas. Washington, D.C., PAHO/WHO Scientific Publication No. 541, 1993.