Gender equity is must for tackling TB

Shobha Shukla, CNS (Citizen News Service)
According to the WHO Global TB Report 2016, of the 10.4 million new TB cases in 2015, 5.9 million were men (56%), 3.5 million were women (34%) and 1.0 million were children (10%). The global male:female ratio was 1.6:1. Also there were 1.77 million deaths in 2015 due to TB: 1.06 million (59%) were men, 0.50 million (28%) were women and 0.21 million (13%) were children. While the TB bacteria might not differentiate between its male and female preys, men and women do face different risk factors for TB and different barriers to successful TB diagnosis and treatment.

The recently concluded 48th Union World Conference on Lung Health held in Guadalajara, stressed upon the need of integrating gender in TB programming in order to effectively combat the epidemic.

Elizabeth Pleuss, Public Health Advisor, United States Agency for International Development (USAID) dwelt upon gendered differences in the experience of TB. Evidence from various countries indicates differences in susceptibility as well as in enacted/ perceived stigma in TB for men and women.

Who is more susceptible to TB?

Women are more likely, than men, to spend time caring for sick relatives; in sub-Saharan Africa, women are more likely to be HIV positive. Also, women generally exhibit more robust immune responses due to sex hormones. Men, on the other hand, travel more frequently than women and spend more time in crowded settings. They are more likely to smoke and drink and also more exposed at work, especially in mines. All this makes them more vulnerable.

TB stigma lurks...

TB not only diminishes marriage prospects of women more than men, but also increases their chances of divorce, if already married. They are also subject to social isolation and experience more stigma from the family. Men experience greater stigma in their workplace and community, strengthened by the belief that the body should be resilient and not succumb to disease. They also worry more about income and job impact.

Pleuss listed some common barriers/ delays in accessing treatment, like stigma, financial restraints, physical or logistical barriers, poor health literacy, and provider and system-level barriers.

She added that women are less likely to produce quality sputum; they are likely to have extra-pulmonary TB (so diagnosis becomes difficult); their health is inherently a lower priority than men’s health; they have a lower level of knowledge of TB; they are financially dependent on men and require permission from them to seek healthcare. All this prevents them from accessing timely care. Men delay care due to fear of costs or financial barriers; inflexible clinic hours and do not want to leave work to seek treatment.

"To make TB control programmes more effective, we need to address the different barriers women and men face to access TB care. Earlier care-seeking will result in earlier treatment initiation and hence in increased treatment success, thereby reducing TB transmission”, said Pleuss.

Jeremiah Chikovore, of Human Sciences Research Council, Durban, stressed upon acknowledging that men and women co-construct each other. Men face unique challenges at their workplace - absence of comprehensive TB education; limited protection of workers’ rights; some workplaces do not offer security to allow people time off to seek healthcare; and informally employed men are concerned about the opportunity losses associated with missing work. Men with TB report emotional and physical suffering, and feel isolated and stressed by their incapacity to work. Related failure by men to meet role expectations breeds a sense of vulnerability in them.

Chikovore advocated for:
  • health systems strengthening to accommodate men and engender a collaborative atmosphere; 
  • enhancing health promotion activities at workplaces; 
  • strengthening social security and reducing out-of-pocket expenditure, and implications of missing work to attend to health; 
  • addressing knowledge about TB; and
  • recognising the special vulnerabilities of men and women.”
Vishnu Mahamba of KNCV, shared some of the lessons learnt through their Challenge TB Project in Tanzania. He recommended “Gender specific programming so as to improve access of TB services i.e. specific needs and vulnerability; implementation of male-specific risks reduction interventions, including TB screening, TB prevention and awareness programmes; need of country level TB guidance materials and tools that address gender specific-aspects of TB for both men and women.”

Dr Niyati Shah, Senior Gender Advisor, USAID, insisted that gender is one of the social determinants of health and that addressing gender norms and inequities is critical to achieving expected outcomes, reducing risk and vulnerability, and increasing demand for access to, and uptake of services. Gender related power, control and stereotyping directly influence men’s and women’s access to health and ability to have their needs addressed.

Gender equality is relevant to both women and men. It is not about who the beneficiaries are, but how the programmes are designed and  implemented. Programmes promote gender equity if they engage women as active actors in their own health and well-being, and if they address the underlying structural barriers.

According to Shah, men’s health is also negatively affected by harmful notions of masculinity. Both women and men benefit from more equitable relations, addressing men and their masculinity, as well as women and their empowerment. Transgender men and women are also subject to gender norms, stigma, and inequities and face related barriers to health knowledge and services.

The process of integrating gender considerations should run throughout the programme cycle and be broadly encompassing - from providing privacy for women to provide sputum samples for TB diagnosis to reforming property rights to allow women to inherit land, which could make a significant difference in their income and thus ability to access treatment and care services.

The goal should be for all programmes and interventions to be gender accommodating at the very least, and ideally gender transformative, she said.

Shobha Shukla, CNS (Citizen News Service) 
15 October 2017
(Shobha Shukla is the Managing Editor of CNS (Citizen News Service) and has written consistently on health and gender justice for several years. With support from the Global Alliance for TB Drug Development (TB Alliance) this article is part of in-depth thematic coverage of the 48th Union World Conference on Lung Health, provided by Shobha Shukla and her CNS Correspondents Team. Follow her on Twitter @Shobha1Shukla or visit www.citizen-news.org)

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