Tuberculosis and women: The case of Swaziland

Alice M Tembe, Swaziland
Tuberculosis, commonly called TB, is caused by microscopic bacteria called Mycobacterium tuberculosis. It can be pulmonary in nature, when it affects the lungs and is highly infectious or extra pulmonary when it affects some part of the body other than the lungs and is less communicable. TB can be latent (meaning the TB bacteria are in the person’s body but are not causing illness) and it can be active whereby the bacteria causes illness. Tuberculosis is transmitted through the air from exposure to bacilli in the sputum by inhalation through the mouth or nose via the trachea leading to the lungs.

In Sub-Saharan Africa, TB is the leading cause of death among people living with HIV (PLHIV) and in Swaziland over 50% of the PLHIV develop TB and die from it. In Swaziland women of child bearing age have a high prevalence of 41% of HIV (ANC Surveillance Survey: 2010) compared to the 19% among men of the same age group (Swaziland Demographic Health Survey: 2008) and this translates into increased risk of developing TB.

Contrary to the global evidence that men are more affected by TB than women, in Swaziland the burden of HIV has tipped the scale towards women.  HIV weakens the immune system and gives chance to the latent TB germ to grow, multiply and cause active TB. HIV increases the rate of TB occurrence in PLHIV and over two thirds of PLHIV in Africa lack access to effective TB diagnostics, prevention and treatment. It is interesting to note that the structural drivers of TB that increase women’s risk of infection in Swaziland are similar to those expressed by Dr Sarabjit Chadha, Project Director at the International Union Against Tuberculosis and Lung Disease (The Union), India. The gender disparities, influenced strongly by culture and religion, leave the burden of caring for the sick on women-- women who have lower literacy levels, low wage paying jobs (largely in the informal business sector) or economically dependent on their spouses. However, women are more likely to present themselves for medical care than men when they can and also adhere to the treatment better than men.

In Swaziland, men generally do not have strong healthcare seeking behavior, as seeking medical care is culturally considered a sign of weakness. Hence men present themselves quite late for diagnosis and the prognosis is usually bad before treatment is commenced. Thus there are more men with multi drug resistant TB (MDR-TB) and the chances of recovery are lower than that for women. This can be attributed to the practice that child bearing women are accustomed to regular visits to health centers and the taking of birth control and pregnancy supplementary tablets explains the higher rate of seeking healthcare and adhering to treatment. One 27 year old female MDR-TB survivor, who is still on treatment, noted that as women are considered ‘natural care givers’ they can manage medication easier than men.

True to the sentiments of Dr Chadha, TB programmes need to respond to the unique gender needs. Dr Chadha rightly points out that, “We need to target women more specifically. Right now our activities are not gender specific and we do not take cultural issues into consideration while devising any intervention. If there is a microscopy centre which is located 20 kms away from the village, it becomes much more difficult for a woman (as compared to a man) to reach it because (i) she is not educated (ii) she is economically dependent and (ii) she may not feel comfortable going out alone and accessing these services. So to accelerate and intensify case findings, we have to create awareness amongst the women. Basically she is running the family, so if anyone in the family (including the children or the husband or the in-laws) has cough for 2 weeks or more she could be the one who could influence positive action. Also, we need to bring the services to their doorstep rather than expect these women to come out and travel long distances to access health services. We need to have interventions which improve access.”

Currently, in Swaziland there are programs for men locally called, ‘kudla inhloko’, which translates loosely to eating the cow’s head. This is a traditional practice performed in communities where men sit around a fire to discuss community issues while roasting and eating a cow’s head. Further, a man’s pride is in the size of his kraal, so men take their cows to the dip-tank regularly and gather to catch up while they wait. It is during such natural social events that awareness dialogues on TB for men are conducted and mobile clinics can find them already mobilized into groups. This has since increased the men’s health seeking behaviour as they also get social support when they report back to the group. Treatment supporters have been trained among dip-tank managers and community leaders who are mostly males to sustain the Directly Observed Treatment (DOTS) programs.

Among women, particularly those working in the informal sector, textile industry, and those staying at home, mobile clinics visit their door-steps regularly to conduct awareness dialogues, sputum collection and medication refills with minimal disruption of their daily work and chores. Furthermore, peer educators are trained to sustain DOTS and provide a social support system when the mobile clinic is not around. This has increased early diagnosis, early treatment initiation, adherence to treatment and treatment success rate. At the national level, efforts are also being made by the National TB Control Programme (NTCP) to increase access to Isoniazid (INH) for PLHIV to reduce chances of TB development.

Women can do their bit to ensure proper ventilation at home, and even when they attend night vigils for funerals by opening windows and doors at least during daytime where possible to allow sunlight to minimize bacteria concentration. Maintaining general hygiene through hand-washing and keeping the immune system strong can go a long way in reducing the chances of developing TB.

Alice M Tembe, Swaziland
Citizen News Service - CNS
March 2013

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