Carolina Flores

As many as 45 million women in the world, most of them in sub-Saharan Africa [1], suffer from a painful sexual health condition. This scourge of women’s health may cause bleeding and pain (especially during sexual intercourse) [2], decrease fertility [3], and make women more susceptible to STDs [4,5]. The lesions, often acquired in childhood, can and do persist through adult life [6, 7]. Yet this condition is fully preventable: all we need is a cultural shift towards valuing women’s lives everywhere in the world.

You may be surprised to learn that I am not talking about female genital mutilation (FGM) [a]. FGM has received plenty of attention in mainstream media in the last few years, leading to a number of global campaigns pledging to stop this practice [8, 9, 10]. The problem I am talking about is female genital schistosomiasis (FGS), and you are very unlikely to have heard of it in the mainstream media. For example, whereas a quick search in The Guardian returns about 382,000 results on FGM, there isn’t a single article mentioning FGS.

While it is true that ending FGM mainly requires a shift in local traditions and views of women, this is by no means easy to achieve [11]. In contrast, wherever we are, we can all work on the cultural shift needed to end FGS. What we need is to value all human lives equally, and act in accordance – both individually, through giving, and politically, through campaigning for global justice.

And you should care about ending FGS, even if it is the first time you’ve heard about it. Here is why:

Female Genital Schistosomiasis is caused by infection with the S. haematobium, a parasite which infects people exposed to affected water. It is often contracted in childhood, with serious symptoms observed in girls as young as 3. [12] This parasite then continues its life cycle inside the human body. When its eggs lodge in the female reproductive system, the body’s reaction leads to a host of unpleasant lesions. [13, 14]

The most characteristic ones are ‘sandy patches’ (thickening and scarring of tissue), breaches and open wounds in the mucosal surface and skin. [13, 14] Scars in tissue are a lifelong condition once contracted. [6, 7] Other associated symptoms are stress incontinence [15], irregular bleeding [16] , discharge [4], and pain during intercourse [2]. It may also be associated with infertility [3] and severe acute diseases such as ectopic pregnancy [17].

It can lead to cancer and death at a young age

The internal injuries I mentioned above are not only painful, but they also facilitate the implementation of HPV [4, 5], which can lead to cervical cancer. As FGS favours a rapid propagation of the virus and eases the spread of malignant cells, it contributes to a higher chance of developing cancer more quickly.[18, 19]

Because girls often contract FGS at a young age, this type of cancer occurs shockingly early in sub-Saharan Africa. For example, a study in Tanzania found that 18% of women with FGS and cancer were younger than 25, whereas only 5% of women with cervical cancer and without FGS were in the same age group. [20]

There is evidence that what applies to HPV also applies to other STDs: FGS makes it far easier to contract them. This means that STDs will spread more where more women have FGS, worsening the sexual health of the whole population.

It makes HIV transmission much more likely

FGS is associated with a 3-4 fold increase in acquiring HIV/AIDS during sexual intercourse, which means that FGS may be one of the most important co-factors in HIV transmission in Sub-Saharan Africa’s HIV epidemic. It has been estimated that 16 million women will acquire FGS and that, if cured, 120 000 new cases of HIV could be averted through regular FGS treatments in the next decade [21, 22, 23]

More research needs to be done on the topic, but we now know that FGS causally contributes to HIV transmission by increasing the number of HIV-receptive cells in a woman’s reproductive system. A woman infected with both diseases poses an additional risk of infecting her partners, as the dual infection leads to increased HIV levels in genital ulcers. [23]

Finally, HIV in a woman with FGS is very likely to have a fast progression to AIDS. As with HPV, this is because FGS facilitates virus replication. All of this tends to happen at a very young age, because FGS is often contracted before women become sexually active.

You can read more about some recent research on the HIV-Schistosomiasis interaction 

It is a factor in gender inequality, poverty and social exclusion

It should be no surprise that suffering from disruptive symptoms since childhood, with a higher risk of contracting life-threatening illnesses, contributes to staying in poverty. But there is more to FGS than the health problems mentioned above.

Though men also contract schistosomiasis, these infections have a disproportionate impact on women’s quality of life through FGS symptoms. This is compounded by the social stigma associated to the disease, by other disruptive symptoms of schistosomiasis [24], and by the association between schistosomiasis and being unable to go to school or to work [25]. All together, suffering from FGS compromises women’s agency and makes it very difficult to escape poverty.

Here is the happy ending to this post: there is effective treatment for schistosomiasis ( praziquantel), and it is given for free by pharmaceutical companies in a program coordinated by the World Health Organization (

http://www.who.int/schistosomiasis/strategy/en/

). If we add the cost of organizing and monitoring distribution, we get the result that treating a child costs US$1.23 (through the 

 recommended charities). What are you waiting for?

http://www.who.int/neglected_diseases/integrated_media_urogenital_schistosomiasis/en/

[Morice, P. et al. (1996) [Genital bilharziasis and female infertility.Review of the literature and three case reports]. Contracept. Fertil. Sex24, 56–61](

[Kjetland, E.F. et al. (2008) Female genital schistosomiasis – adifferential diagnosis to sexually transmitted disease: genital itchand vaginal discharge as indicators of genital S. haematobiummorbidity in a cross-sectional study in endemic rural Zimbabwe.Trop. Med. Int. Health 13, 1509–1517](

[Mosunjac, M.B. et al. (2003) Cervical schistosomiasis, humanpapilloma virus (HPV), and human immunodeficiency virus (HIV): adangerous coexistence or coincidence? Gynecol. Oncol. 90, 211–214](

[Kjetland, E.F. et al. (2008) Prevention of gynecologic contact bleedingand genital sandy patches by childhood anti-schistosomal treatment.Am. J. Trop. Med. Hyg. 79, 79–83](

[Silva, I.M. et al. (2005) Therapeutic failure of praziquantel in thetreatment of Schistosoma haematobium infection in Braziliansreturning from Africa. Mem. Inst. Oswaldo Cruz 100, 445–449 

[a] Interestingly, the two may be historically related. A recent paper (

https://www.researchgate.net/publication/236052203_Female_genital_mutilation_and_female_genital_schistosomiasis-bourouwel_the_worm_Traditional_belief_or_medical_explanation_for_a_cruel_practice

) suggests that FGM may have started as a misguided attempt to cure visible symptoms of FGS. In fact, the areas with high prevalence of FGS and of FGM overlap.

WHO: Effectiveness of interventions designed to reduce the prevalence of female genital mutilation/cutting

El-Adnani, M.S., Saleh, K.M., 1982. Extraurinary schistosomiasisin Southern Iraq. Histopathology 6, 747–752

Poggensee, G., Feldmeier, H. (2001) Female genital schistosomiasis: facts and hypotheses. Acta Tropica 79, 193-210

Eyrun F. Kjetland, E. F, Leutscher, P. D. C., Ndhlov, P.D. (2002) A review of female genital schistosomiasis. Trends in Parasitology Vol. 28, No. 2, 58-65

Kjetland, E.F. et al. (2005) Simple clinical manifestations of genitalSchistosoma haematobium infection in rural Zimbabwean women. Am.J. Trop. Med. Hyg. 72, 311–319

Bland, K.G. and Gelfand, M. (1970) The effects of schistosomiasis onthe cervix uteri in the African female. J. Obstet. Gynaecol. Br.Commonw. 77, 1127–1131

Ville, Y. et al. (1991) Tubal schistosomiasis as a cause of ectopicpregnancy in endemic areas? A report of three cases. Eur. J. Obstet.Gynaecol. Rep. Biol. 42, 77–79

Moubayed, P., Ziehe, A., Peters, J., Mwakyoma, H., Schmidt,D., 1995. Carcinoma of the uterine cervix associated withschistosomiasis and induced by human papillomaviruses.Int. J. Gynaecol. Obstet. 49, 175–179.

Ylitalo, N., Sorensen, P., Josefsson, A.M., Magnusson,P.K.E., Andersen, P.K., Ponte´n, J., Adami, H.O., Gyllensetein,U.B., Melbyl, M., 2000. Consistent high viralload of human papillomavirus 16 and risk of cervicalcarcinoma in situ: a nested case-control study. Lancet 355,2194–2198.

Moubayed, P., Lepere, J.F., Mwakyoma, H., Neuvians, D.,1994. Carcinoma of the uterine cervix and schistosomiasis.Int. J. Gynaecol. Obstet. 45, 133–139.

Hotez, P.J. et al. (2009) Africa’s 32 cents solution for HIV/AIDS. PLoSNegl. Trop. Dis. 3, e430

Feldmeier, H. et al. (1994) Female genital schistosomiasis as a riskfactorfor the transmission of HIV. AIDS 5, 368–372

http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0001396

King, C.H. and Dangerfield-Cha, M. (2008) The unacknowledgedimpact of chronic schistosomiasis. Chronic Illn. 4, 65–79

The scourge of women's health you've never heard of

Shocking images of starving children are one of the staple images of extreme poverty. But childhood malnutrition is not limited to such extreme hunger: in fact, millions of children appear normal but are chronically malnourished. The problem of hidden hunger extends widely and has got serious consequences.

Hidden hunger includes both low weight for age (excluding acute malnutrition, which cannot be considered hidden), and micronutrient deficiency, which is very often associated to low weight for age. The scale of the problem is huge: one out of six children in developing countries is underweight, that is, 

What are the consequences? To start with, 

 children still die of malnutrition every year [2]. The picture is bleak: a shocking 45 [3] to 

 [4] of childhood deaths worldwide are attributable to under-nutrition. Hunger remains the biggest killer of under-five children. Furthermore, malnourished children are both more likely to contract diseases and to die from them. Of childhood deaths from disease, the following percentages can be attributed to under-nutrition [5] :

52.3% for pneumonia – 1 000 000 children

It is important to note that this is not limited to children who are extremely underweight. Though the effect is more pronounced in such cases, if we combine the risk associated with moderate malnutrition with its high prevalence rates, we find that much of the burden of deaths as a result of under-nutrition in young children is attributable to moderate, rather than to severe, malnutrition.

But perhaps the most invisible form of hunger is micronutrient deficiency, which, though not even necessarily associated to low body weight, can seriously reduce span and quality of life. These are some of the consequences of particular micro-nutrient deficiencies [6]:

As for the economic consequences of hunger, start by noticing that it is the main factor in causing childhood stunting, which affects a quarter of all children worldwide [7]. This has got consequences to motor and cognitive development, and to educational achievement, which in turn reduce productivity in adulthood. This and the increased health costs it causes make hunger a heavy burden on the economy. Under-nutrition and micronutrient deficiency cost up to 

 to the global economy [8], and it is estimated that childhood malnutrition costs USD25 billion a year to Africa alone [9]. In contrast, it is estimated that addressing childhood and maternal hunger worldwide would cost only USD10 million [10].

There has been some progress in reducing hunger over the last decades, with the number of undernourished people having decreases by 17% in the last two decades [11] but this is widely acknowledged to be unsatisfactory. For example, the stunting of early childhood growth as a result of malnutrition has decreased only 1% [12] in the last two decades. In comparison, TB cases have declined by 40% [13], and malaria cases by 30% [14]. Also, the improvements there have been are unevenly distributed geographically: for instance, in North Africa and South Asia the improvements have been modest, and in West Africa, the situation has actually worsened [15].

Solving this problem will have to involve agricultural partners, governments, and NGOs, and will likely require economic growth and improved social policy in the affected countries. As components of a solution for this problem, the following have been suggested [16]:

create more nutrition-sensitive programmes that include small farmers and families

increase women’s control of land ownership and farming decisions

widen access to agricultural credit and subsidies to encourage domestic food production

focus more on the energy supplements to pregnant women. In the Gambia, an intervention of this type lead to a 39% reduction in low birth weight cases, one of the important reasons for low body weight for age later on in childhood, and a 40% reduction in infant mortality [17].

Assessing the cost-effectiveness of interventions in these areas is possibly worth investigating. But for now the best opportunity for effective giving to target hidden hunger is micronutrient fortification, as Giving What We Can has acknowledged in recommending Project Healthy Children [18]. Adding important nutrients such as folic acid, iodine, iron, vitamin A, and zinc to staple foods is very cheap, at just a few cents per year per person, and greatly contributes to eliminating the problems caused by micronutrient deficiency. The Copenhagen Consensus has estimated that every UDS1 spent on food fortification results in USD9 benefits to the economy [19].

Micronutrient fortification is not a complete solution to the problem of hunger, but it seems to be the best place to start. The problem has a large scale and, when we consider the suffering it causes, much more should be done to alleviate it. Hidden hunger needs to be brought to light and approached integrating economic and agricultural policy, education, and large-scale health interventions like micronutrient fortification. If you want to start making a difference today, you can donate to Project Healthy Children 

Undernutrition as an underlying cause of child deaths associated with diarrhoea, pneumonia, malaria, and measles

FAO: Understanding the true cost of malnutrition

Voa News: Unicef on the cost of Africa's child malnutrition

Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?

WHO: Prevalence and trends of stunting among pre-school children, 1990-2020

Project Syndicate: Africa's hidden hunger

What works? A review of the efficacy and effectiveness of nutrition interventions

Giving What We Can: Project Healthy Children

Project Healthy Children: Food fortification overview

The World's Hidden and Deadly Hunger

Carolina formerly managed the Giving What We Can blog. She studied Maths and Philosophy at St. Hugh's College, Oxford.

Carolina recently finished reading Maths and Philosophy at St Hugh's College, Oxford.

Carolina Flores

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The scourge of women's health you've never heard of

The World's Hidden and Deadly Hunger