On this World Tuberculosis Day, let's talk about the situation of female TB patients and survivors in India.

Women and tuberculosis – does gender matter?

India has about 2.7 million tuberculosis (TB) cases currently, and patients have, for years, grappled with an unsympathetic society. Not only are they a victim of the disease, they are also dogged by social stigma, misinformation, and abuse. Women are particularly vulnerable, especially in rural India.

The situation has now prompted a group of women, all survivors of TB, to launch a campaign aimed at spreading awareness about the disease and supporting female TB patients who have been socially stigmatised because of their condition. The “Bolo Didi” campaign was born when filmmaker Rhea Lobo, a TB survivor herself, made a two-minute film based on the stories of fellow survivors and released it on YouTube. Women who had contracted the disease began reaching out to her on Facebook and via WhatsApp. The campaign also reflects a tragic situation unique to India: women from presumably well-off backgrounds, with access to Facebook, YouTube and WhatsApp, are also at the receiving end of society’s scorn. Although the number of male TB patients outstrips that of women patients, the latter bear the brunt. One can only wonder at the helplessness among women from a less privileged social background.

But wait a minute, isn’t TB a gender-neutral disease? Or is it a condition that women are particularly vulnerable to? In other words, does gender matter when it comes to TB? To answer that question – whether TB gains particular significance when the victim is a woman – we could perhaps look at the findings of a US study of gender trends in TB, and how people approach the issue.


Global Findings

The study in question sifted through 88 surveys covering more than three million participants in 28 countries, from the Americas to south-east Asia, and its findings were published in the September 2016 issue of the American health journal PLOS Medicine.

According to the study, people are under the misconception that gender issues in health pertain only to women, while in truth the focus ought to be on the incidence of a disease, particularly those that are infectious, and their distribution.

Though global health initiatives have tended to treat gender issues in health as being synonymous with women’s health, in the case of TB this was way off the mark. The reason: globally, more men than women die from TB. What’s worse, the time taken to diagnose men was 1.5 times longer. According to the study, this meant that men are less likely than women to achieve a timely diagnosis.

Based on its findings, the study made two key recommendations:

  • First, greater effort and investment were needed to improve awareness of TB in men as an individual and public health issue. The reason: undiagnosed TB is the key driver for transmission in communities.
  • Second, policies on gender and TB should consider the high prevalence of TB in men and ensure investment in male-friendly diagnostic and screening services. This would reduce undiagnosed TB, it said.

But does this mean that TB is not a major issue for women? If so, why is there a need for an initiative such as ‘Bolo Didi’? What exactly does TB signify for women, not just in India, but worldwide? Here’s what the United Nations Development Programme (UNDP) and the World Health Organization (WHO) have to say on the issue.

UNDP Study

In a 2015 discussion paper the UNDP admitted that, globally, more men suffer from TB than women. For instance, 60% of the estimated 9 million cases diagnosed in 2013 were found to be male. Deaths among men were higher too: about 66% of the estimated 1.5 million cases.

Having said that, the UNDP paper says it isn’t as if women were deemed relatively less vulnerable when it came to TB, and cited trends to support this:

  • Among infectious diseases, TB accounted for the most number of deaths among women globally
  • More women die annually of TB than of all maternal mortality causes combined
  • Women co-infected with TB and HIV are more likely to die of TB than co-infected men
  • In countries with high HIV prevalence, more women are afflicted with TB than men

The study also looked at how TB affected women from three angles: (a) biological differences and TB vulnerability; (b) impact on pregnant women, and (c) gender and access to services.

Biological differences: While men were more vulnerable to pulmonary TB than women, a diagnosis was more difficult among the latter. Also, TB seemed to progress faster in women of reproductive age than among men of the same age group. Women are also more prone to have TB infections outside the lungs, such as genital TB, which is difficult to diagnose and can be a significant cause of infertility.

Impact during pregnancy: Pregnant women diagnosed with TB are twice as likely to have premature babies, and their babies are six times more likely to die within a few weeks of birth. TB can also be transmitted from mother to child.

Access to services: Social factors often prevent women from accessing treatment centres; for instance, family members may refuse to pay for services, or may not attach importance to her health problems. Also, women patients are more stigmatised than male counterparts; if married, it could lead to marital problems, or if unmarried, it might be difficult to find a suitable groom. Healthcare infrastructure is often skewed against them, especially vulnerable populations such as female prisoners, who are more TB-prone than male prisoners – services may simply not be provided, even when they are provided to male inmates.

WHO Report

A WHO fact sheet on TB, released in November 2015, notes that while TB deaths are more prevalent among men, the disease “can have particularly severe consequences for women, especially during their reproductive years”.

The fact sheet mentions that an estimated 3.2 million women fell ill with TB in 2014, of whom 4,80,000 died. It points out that TB is one of the top five killers among adult women aged 20-59.

The disease was particularly dangerous for mothers, making perinatal deaths six times more likely and doubling the risk of premature birth and low birth weight. If a pregnant woman tests positive for HIV, TB increases the risk of maternal and infant mortality by almost 300%. Studies in India have shown that the risk of vertical transmission of HIV to the unborn child is doubled if the mother also has TB.

Describing TB as ‘a disease of poverty’, WHO identified some factors that make women more vulnerable to TB in the developing world:

  • Gender inequities
  • Rising tobacco use and diabetes among women
  • Stigma and discrimination against women
  • Cultural and financial barriers

According to the fact sheet, the disease mainly affects women when they are economically and reproductive active; and when they succumb, the impact goes beyond the patients and is strongly felt by their children and families.

Last Words

If you are reading this, it is perhaps safe to assume that you or members of your family have the means to build the immunity required to fight the disease in case anyone gets infected. And if this happens, the TB will probably be “passive” to begin with, which is relatively easy to kill at this stage.

On the other hand, if you are weak, your immunity system will also be so irrespective of your gender. In that case, the TB may revive and become active. This is when you must be careful. So it is imperative that you pay attention to your health; if you have a violent spasm of coughing, or spit blood, for instance, get yourself examined by a qualified medical practitioner.

Also keep in mind that the people who work for us – the maid, the driver, or the building security guard to name but a few – are more vulnerable than us, given their living conditions. It is up to us to inculcate the importance of hygiene among them to preempt spread of the disease.

If they or any of their family members catch it, one must teach them TB is curable, but that the patient must take every single medicine prescribed to be cured. Fortunately, medicines are available at government health centres for free.