Older Women's Health Struggles for Recognition

When Raisa, a 56-year-old Moscow resident, visited her internist complaining of abdominal pain, he told her it was a natural consequence of post-menopausal aging, and declined to perform any tests on her. Several months later, when she was able, through "connections," to get another physician to perform an ultrasound on her pancreas and liver, she found out that her pancreas was enlarged and she did, in fact, need medical attention.

Raisa's experience reflects the situation in many CEE and NIS nations: the health concerns of mid-life and older women are pushed aside while those of reproductive-age women command the few resources that are provided for women's health.

"In many countries of the world, women's health is still not a priority for policy makers, and when it is put on the agenda, this is usually in the context of maternal and child health," according to WHO's report, "1995 Highlights on Women's Health in Europe." "The elderly woman does not receive particular attention from the health services, and since women generally have less access to economic resources than men, many old women, especially when living alone, are subject to conditions of extreme poverty."

Issues linked to menopause, such as estrogen replacement therapy and osteoporosis, as well as breast and cervical cancer, diabetes, cardiovascular disease and nutritional intake, are important concerns for older NIS/CEE women, but the level of public and clinical knowledge in these areas is frequently inadequate, access to health services is limited, and the research base is thin. These deficits are especially worrisome in light of the gender imbalance among the elderly - in Kazakstan, Belarus, Estonia, Latvia and Ukraine, for example, the population's proportion of over-65 women is double that of men.

Although the health status and needs of older women vary widely from Central Asia to Central Europe, it is a subject that deserves more attention region-wide, said Viviana Mangiaterra, MD, WHO Europe regional adviser for women and child health.

"This target age is not a priority in these countries, and all efforts are concentrated - in country and at the international level - on abortion and reproductive health issues. The fact that there is not enough attention to their needs is already a problem, in my opinion," she explained. "It is evident that economic difficulties are particularly heavy for this group of women, as well as the access to primary health care - the cost of drugs which are often available only in the black market is just an example of it.

"Breast cancer screening should be a priority... because I'm sure it would indicate an important public health problem. Lifestyle indicators could also be interesting to collect for this group, including mental health, alcoholism and tobacco abuse indicators."

Different Nations, Different Issues

Diane Holmay, RN, director of the Center for Women's Health at Franciscan Skemp Health Care in LaCrosse, Wisconsin, has led discussion groups for three years with Russian women of all ages as part of AIHA's Dubna-LaCrosse partnership. In Russia, she said, older women historically have not thought about what their health needs might be as they age because their life expectancy has been relatively low. But she has noticed a shift in attitude even in the few years she has been visiting Dubna.

"Three years ago, they didn't have a whole lot of interest in things like estrogen replacement - a lot of women didn't plan on living through menopause. But now they are a little more willing to plan for the future."

The older women who have participated in Holmay's groups have shown an interest in learning how to prevent osteoporosis and acquire better nutritional habits. Many of the women in Dubna are anemic, with inadequate calcium and protein intakes, Holmay said, and high smoking rates and alcohol consumption are prevalent as well. Because transportation is not widely available in the city of 60,000, access to care is difficult even for urban-dwellers.

Another problem she sees is that older women are hesitant to self-advocate. "There is a sense that their health comes second to their families... If foods are limited, for example, it is clear they would feed their husband and children first."

On issues such as menopause, the knowledge level in Russia can be uneven as well. Mark Perloe, MD, of Georgia Baptist Medical Center in Atlanta, Georgia, coordinated a Russian women's health care conference two years ago with AIHA partner St. Petersburg Medical University in the name of Academician Pavlov. He noted that patient and physician focus groups revealed an approach to menopause that differs from the US standard: "There were some professors who very strongly believed that menopause is a natural condition and does not require therapy ... and there was a real lack of education and information that women had about this. It's not talked about in the family setting or in any other setting."

In neighboring Ukraine, the most significant health issue facing older women may be their reluctance to seek preventive care, according to Liliya Slobodianyk, MD, head of the Outpatient Clinic for Women at the Center for Maternal and Child Health Care, Left Bank in Kiev. Although the clinic provides gynecological and breast exams, pap smears and colposcopy (examination of the vagina and cervix using an endoscope) for older women, these services are rarely administered.

"Older women seldom visit the outpatient clinics, and it is difficult to persuade them to have [preventive] oncological examinations," Slobodianyk said. "As a result, disease is detected in the later stages. We also have problems providing treatment for vaginitis, perimenopause and osteoporosis prevention."

But in most CEE and NIS countries, the ability to develop health care initiatives for older women simply boils down to a question of resources. Croatian health professionals, for example, are busy treating acute conditions in both sexes as their health system slowly recovers from the recent war there. "There is no distinction between men and women... They have very few dollars, and the priority is on acute medicine," said Victor Lee, MD, medical director at St. Leonard's Center in Centerville, Ohio. Lee spent several weeks last spring studying geriatric populations in hospital and community settings in Zadar and Biograd, Croatia, as part of the Zadar-Franciscan partnership.

"Things like flu shots and mammograms are not being done," he said. "They are too busy treating pneumonia and broken hips."