TB care and control under gender lens

Tuberculosis care and control came under gender lens when participants attending Western Regional Consultative Meeting of Partnership for TB Care and Control in India (PTCCI) shared their perspectives on TB and women. This regional consultation was held in Indore, Madhya Pradesh during 5-6 March 2013. If we look at data, number of new TB infections in India was more in men than women. However statistics on male: female ratio in new TB cases is different too in some parts of India.

Dr SK Yelurkar, Deputy Director (TB), Maharashtra shared two examples from his state where TB rates were alarmingly high in women. In Maharashtra, there are two corporations, Malegaon (district Nasik) and Dhuendi (district Mumbai), where more than 75% of TB patients are female. These two corporations are overcrowded slum areas and most residents are Muslim. “To investigate further why more women than men are getting diagnosed with TB here, the state Director has asked us to conduct operational research in these two corporations and hope we will be able to address key issues here in the fight against TB” said Dr Yelurkar to Citizen News Service – CNS.

Another noted TB physician agreed that perhaps clinicians are not consciously looking for TB in women. Professor (Dr) Salil Bhargava, Professor, Department of TB and Chest Diseases, Medical College Indore said “Although we have been treating TB patients for so many years we have not looked at gender because there are multiple factors that affect a person. I will come back to you after few months and share my experience of analyzing TB patients according to their gender. Possibly women may remain asymptomatic for longer duration as they perhaps come to the clinics late, they might be neglected while they are being treated, or they may not come to us as frequently regarding adverse events related to their drugs during their treatment.” Professor Bhargava is right on spot: we need to look at gender so that programme can address those structural drivers that put women at greater risk of TB.

On the eve of this regional consultation, Dr Sarabjit Chadha, Project Director – Axshya, International Union Against Tuberculosis and Lung Disease (The Union) said to Citizen News Service – CNS: “Structural drivers like poverty, social stigma, less health seeking behaviour, malnutrition, are factors that not only increase the risk of women developing TB, but also lead to delay in diagnosis in women affected by TB. Women, especially in rural settings, do not have a similar health seeking behaviour as men, and normally end up accessing the health system much later in the sequence of the disease.  Also, issues of poverty and malnutrition are more relevant in case of women because of gender inequality. If you look at women and men as a part of the family, it is again related to equality--the family might take the boy to a doctor for his treatment but that would not be the case for the girl child. This could have serious implications. Malnutrition again is a serious issue. Women do not have as much access to food as men and this could be because of cultural norms as in many families a woman is supposed to eat last after feeding others. Malnutrition predisposes women to TB.”

Dr Vikas Arora, a consultant with World Health Organization (WHO) at Revised National TB Control Programme (RNTCP) in Madhya Pradesh agreed with Professor Bhargava and Dr Chadha, and further elaborated gender-based inequalities and discrimination deeply entrenched in our patriarchal societal structure. Dr Arora said: “Women are more at risk of TB because they are more likely to get delayed treatment. Till the time a woman is able to do work in the house and care for her husband, children and other family members, she is less likely to be taken to the hospital. Only when she gets bed ridden she is taken to the hospital. Once she starts feeling better and resumes her household chores, there is more chance that she may be withdrawn from the treatment. That is why women are more at risk of suffering from TB.”

Not just TB, but with increasing rates of tobacco use, particularly smoking forms, women are at greater risk of other co-morbidities such as Chronic Obstructive Pulmonary Disease (COPD). “It is an established fact that COPD and TB are a dual epidemic that affects men due to higher tobacco consumption rates. COPD and TB rates are rising in women too particularly in rural population, because of exposure of women to tobacco smoke, secondhand tobacco smoke, indoor air pollution (in form of smoke of biomass based cook-stoves), which makes women more prone than men to TB and COPD” said Dr Prakash Tyagi, GRAVIS, Jodhpur, India.

What about information, education and communication materials on TB – are they gender sensitive? Dr Sandeep, RNTCP consultant to Gujarat said: “We conduct advocacy, communication, and social mobilization (ACSM) activities such as patient-provider meetings or community meetings, but so far we have not been able to focus on vulnerable groups such as minority groups. If we conduct ACSM activities for minority groups it may help improve TB responses for the group.”

Although ACSM activities are not yet calibrated according to the vulnerable groups, there are significant advancements made in state of Gujarat in engaging women living with HIV in TB programme. Dr Dixit J Kapadiya, Gujarat state TB-HIV coordinator said: “In Gujarat, Gujarat State Network of Positive People (GSNP) is managed by women living with HIV. We invite GSNP people to our meetings and share with them the list of people who are co-infected with TB-HIV who are not able to adhere to the daily observed TB therapy. The GSNP people follow up with these people and try their best to bring them back to the programme. State level networks of people living with HIV help a lot in bringing patients that are not able to adhere to Daily Observed Treatment Shortcourse (DOTS) back to the programme.”

Another participant Josesph from Indore said that “women are the unofficially appointed Carer in the family – she is the one who will be caring for anyone in the family with TB (or other illnesses). So naturally she will be most exposed to TB. Most of the women who come from lower socio-economic background are often living in over-crowded, poorly lit and ventilated areas which further increase their risk of contracting TB.”

Sunita Prasad, from Eli Lilly and Public-Private Mix (PPM) lead for the Partnership for TB Care and Control in India highlighted another key issue: “We will like to share our work in Gujarat –SEWA sends out team of women from village to village and house to house looking for patients and those who have not been able to adhere to the treatment. Another aspect which comes to our mind is that these women get much more exposed to infections be it in the community or hospital. We have seen nurses, volunteers and other workers who are not informed enough about infection control. We need to do something there as well.” Undoubtedly standard infection control education and practices should be advocated.

Speaking about how can we make TB responses gender sensitive and more effective for women, Dr Chadha said: “We need to target women more specifically - right now our activities are not very gender specific. Let’s say there is a microscopy centre which is located 20 kms away from the village. Men, because they go out for work, can cycle or they can take a public transport and somehow access it. But for a woman it becomes very difficult because (i) she is not educated (ii) she is economically dependent and (iii) she may not feel comfortable going out alone and accessing these services. So one thing for accelerating, intensifying the case findings would be to create awareness in 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. The second thing is that we need to bring the TB health 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. This could be related to sputum collection, transportation or active case finding—all of which will help in reducing delay for TB diagnosis. The third thing is that the program recommends directly observed treatment and this may be an issue although in India with the ASHAs (accredited social health activists) coming in, the programme has become a little more gender sensitive. But if the community DOT provider is a male, women may not feel comfortable going to this person. So, all these factors need to be considered (and not ignored) when devising an intervention.”

Let us hope the long neglected health issues in context of women get more spotlight at this year’s International Women’s Day, 8th March.

Bobby Ramakant, Citizen News Service – CNS
March 2013

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