Samiha El Katsha, Susan Watts. Gender, Behavior and Health: Schistosomiasis Transmission and Control in Rural Egypt. Cairo: The American University of Cairo Press, 2002. xxii + 229 pp. $24.50 (paper), ISBN 978-977-424-728-6.
Reviewed by Jihad Makhoul (Department of Health Behavior and Education, American University of Beirut.)
Published on H-Gender-MidEast (December, 2005)
Schistosomiasis: A View From Within
Throughout Gender, Behavior and Health, El Katcha and Watts argue for and present a holistic view of the parasitic disease schistosomiasis in Egypt, with emphasis on a gendered analysis of infection and control. In fact, the book does what it sets out to do: provide an ecological analysis of the schistosomiasis pandemic that has plagued Egypt since the 1880s, looking beyond the immediate to the whole. This brilliant analysis covers the structural, historic, social, and medical aspects of the disease through two study communities--two agricultural villages situated in the central Nile Delta, seventy kilometers from Cairo--with a population of 7,600 to 8,000 each. The authors' practical, action-oriented research and intervention experience in the Nile Delta over six years is detailed in a narrative that gradually builds a case for a gendered analysis and consequently, better understanding, of this disease. Action research involves research participants in activities that aim at improving their own well-being; in their study, the authors involved men, women, health care providers and school teachers in collecting relevant data and building their skills. Their study also incorporates quantitative and qualitative findings from other research on the topic.
Readers will enjoy how the authors have deconstructed the complex public health problem of schistosomiasis, which has caused much death and disability in Egypt. They have contributed greatly to a better understanding of the multifaceted social aspects that underlie contagion, re-infection, control, and prevention. The picturesque descriptions guide readers through the gender-sensitive research trail and help them imagine and understand people's lives.
The authors' research findings and activities have helped fill the research and policy gaps they originally found in Egypt before they began their study in 1991. Despite many attempts to fight schistosomiasis in the country, including the launching of a National Schistosomiasis Control Program (NSCP) supported by local and international funds, the pandemic has not been totally controlled. New cases, especially among children, continue to appear. According to the authors, one reason for this is that the approach to prevention and control has always been top-down: local strategies are planned at the national level with little or no field testing or evaluation, and without regard for popular attitudes toward the disease. With this in mind, the authors seek to present a fresh picture of an old health problem.
To set the stage, they allocate the first eight chapters to background information on schistosomiasis in Egypt. The complex biological life cycles of the infectious agents, S. mansoni and S. hematobium, are clearly explained, as are the circumstances which led to the outbreak of schistosomiasis and national efforts to control it. The authors skillfully discuss aspects of Egyptian history prior to and after 1988 that have ramifications for the disease today. They take a critical look at the social structure of the Egyptian family, the introduction of irrigation canals (which globalized the agriculture, as traditional subsistence agriculture turned into cultivation of export-oriented crops which required year round irrigation, consequently increasing the farming population's exposure to contaminated water), and political decisions about national health services (chapters 4, 5, and 8).
Some readers may find the wealth of detail in the first eight chapters a bit tedious; perhaps the authors thought it necessary to prepare the reader for what follows. It is not until chapter 9, entitled "Gender, Human Behavior and Exposure to Schistosomiasis," that Katsha and Watts vividly and convincingly answer the questions and discuss the issues they raised earlier in the book. For example, residents of the communities under study continue to use the canals--the main source of schistosome cercariae, which burrow into human skin--despite knowing the risk of infection. Both the Rural Health Unit staff and the local residents use the term "dangerous" to describe schistosomiasis, but their actions do not reflect this understanding. According to the authors, their belief that the medication used in the mass control program, praziquantel, offers a cure may explain why they do not perceive schistosomiasis to be a real threat to their health. Also, the canals are central to a variety of domestic, social, and agricultural activities for all members of the family, which explains their continued use of them.
A number of the interventions and improvements surprisingly "required no extra staff, no extra equipment. Thus [they] could easily be introduced in all Rural Health units" (p.160). For example, epidemiological studies in Egypt reveal that in general, children under 15 years of age--the vast majority of whom are in school--have higher infection rates than the rest of the population. However, the authors' own research in the two communities showed a relatively small number compared to the population rates. Reviewing the school-based screening program there revealed problems such as inadequate knowledge of screening procedures at the health center, the logistics of obtaining stool specimens, and insensitivity to girls' need for privacy in the health center bathrooms. The names of the students who tested positive were read out publicly at school. "In view of these problems, it is not surprising that girls who were more sensitive to the violations of their privacy than were the boys, often decided not to go to school on the day the screening was to take place" (p.158). In a revised gender-sensitive strategy, the students were given containers to take home with them and the staff collected them from their houses to take back to the health center. Each child was informed privately of the results and small groups were discreetly escorted by the school nurse to the health center. Teachers volunteered to contact families whose children, many of whom were girls, were not attending school regularly and students volunteered to recruit siblings and friends.
Sensitive issues, such as female genital schistosomiasis, have been often overlooked by the NSCP, including physicians in the health centers that serve the communities under study. The authors uncover the reasons for this, such as the difficulty of diagnosis and the disease's resemblance to sexually transmitted disease, which is "surrounded by secrecy and silence" (p162). Treatment with praziquantel, as the authors reveal, has not met the needs of pregnant women, who become anemic if infected. Its safety for mothers-to-be has not been determined and hence to avoid complications, the Ministry has excluded them from treatment.
The lessons learned from this book are presented concisely in the concluding chapter. In brief, the authors emphasize that a bottom-up, participatory approach is necessary to develop a holistic view of schistosomiasis and its multiple determinants. To achieve this, an interdisciplinary research team is needed to conduct an anthropological and scientific analysis of behavior. Changing the water flow and covering canals, maintaining two-way communication between central and local health care facilities, as well as collaboration among various ministries, such as the Ministries of Agriculture, Land Reclamation, and Public Works, are examples of how structural change is necessary to support and uphold local interventions for curtailing schistosomiasis. These strategies are valuable weapons in the fight to understand and control not only schistosomiasis, but any public health problem.
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Jihad Makhoul. Review of Katsha, Samiha El; Watts, Susan, Gender, Behavior and Health: Schistosomiasis Transmission and Control in Rural Egypt.
H-Gender-MidEast, H-Net Reviews.
Copyright © 2005 by H-Net, all rights reserved. H-Net permits the redistribution and reprinting of this work for nonprofit, educational purposes, with full and accurate attribution to the author, web location, date of publication, originating list, and H-Net: Humanities & Social Sciences Online. For any other proposed use, contact the Reviews editorial staff at firstname.lastname@example.org.