Multiple Disadvantage: India, Women's Health and Tuberculosis

Poverty, we know, affects 70% of women worldwide compared to 30% of men. Regrettably some of the Indian women feel they do not deserve any better in life. Some of them often say they are unsure of their status within society when their status at home is so poor. However women are not without a voice in their defense. Certain villages have effective mahila mandals (women's groups) working. These groups give women a great deal of support on difficult social issues such as wayward husband's or awkward mother-in-laws. Such groups, like some of the women's political and religious groups in Bangladesh, may in future tackle some of the social factors around diseases such as tuberculosis. Young people are perhaps more comfortable with learning new behaviours around status and influence, which are never presented to them as a threat to their highly valued culture in all its many forms.

As regards the pattern of early marriage in both Moslem and Hindu rural families, young brides are encouraged to begin a family early on. Early marriage reduces a woman's financial independence - which she would be able to use to good effect were she to develop the disease. With little status within her husband's home, a young wife is traditionally under the strong influence of the mother in law and other relatives of her husband. (This influence continues until the young wife is young no more - and her seniority wins her respect within her husband's family.) The young wife has many duties around child care, cooking and caring for her husband and his relatives, and she will attempt to carry on with them and unfortunately delay seeking treatment. She may even go to a traditional healer for help. Therefore it is a resourceful young wife with tuberculosis who fights back the fear that her husband's family might return her to her parent's village and accesses treatment. Such a resourceful woman should therefore be assured of confidential care as well as support through the long treatment programme. Men with the same disease do not experience such fear and uncertainty about getting support and treatment -research in countries of the South show that they use health services more than females do.

The provision of subsidised treatment at NGOs, however breaks down with multi-drug resistant tuberculosis. This condition is costly to diagnose and to treat: in India the cost is approximately Rs 6500 (£100) a month. Rural Indians can scarce afford this treatment. This condition presents a huge problem across India and all the health agencies involved see money as the most immediate solution to multi-drug resistant tuberculosis.

Clearly tackling tuberculosis in India raises many questions about the socio-economic and political structures within society, as well as demanding an understanding of religious and cultural factors. Tuberculosis in India cannot be tackled without tackling behaviours in the society, such as the low status of the female. Women are the greater victims of the stigma around the disease.

Certainly a husband or father with tuberculosis puts an enormous strain on the family whenever it threatens his wage-earning powers. But what needs to be realized is the very high social cost to a family when the mother is affected by the disease. Her need to attend treatment programmes takes her away from her children; the cost of treatment cuts into the family budget, and a child is at a 3-10 times greater risk of dying within two years if he/she looses their mother than those with both parents alive.

From the example of India it is clear that the tuberculosis programmes of the future will not just use the medical model but will tackle all the factors operating on women with respect to the disease side by side.

Research has shown that in their reproductive years, 15-49 they are at greater risk of developing the disease after infection than are men at the same age. Females often experience differential access to food throughout their lifetime. Young females leave school at aged 14-16 years and many struggle to read and write and understand infection pathways for certain diseases. They do not understand the full benefits of good nutrition for health and usually do not acquire socio-economic independence. As regards the pattern of early marriage in both Moslem and Hindu rural families, young brides are encouraged to begin a family early on. Early marriage reduces a woman's financial independence - which she would be able to use to good effect were she to develop the disease. With little status within her husband's home, a young wife is traditionally under the strong influence of the mother in law and other relatives of her husband. Starting a family early is encouraged by her husband's family. She is likely to ignore her symptoms and trust they go away: her husband will most likely get the support of his family to get treatment and get cured. Despite her educated guess that she might have tuberculosis, and a little money to spend on medicines, she is still likely to struggle to get to a health facility for diagnosis and then for repeat treatments and checkups. The mother-in-law is a very strong figure within the marital home and every wife is dutiful towards her - even when she is neglectful about her daughter-in-laws health needs who will try and carry on with her many duties.

What is unfortunately too common in India is a selection of GP's, pharmacists and quacks who provide tuberculosis medication with a limited understanding of prescribing, leaving their customers with incorrect and incomplete courses of treatment, with a high risk of multi-drug resistant tuberculosis.

Indian women who have limited social and economic capital, and who are afraid to declare they have the disease, often approach a herbal doctor e.g. Kabiraj or a spiritual healer e.g. peer fakir or saddhu. Such local people are often easier to reach from their villages and do not charge so much. For example the peer fakir might give the woman a necklace or amulet containing herbs, seeds, powder and perhaps a holy sentence.

Women in India must have a better status within society - a position of reasonable socio-economic freedom whereby she can access treatment and afford it. Their health will improve also with their increased utilization of health facilities, a phenomena associated with her greater education.

It is vital to alert women to the dangers of late presentation to medical facilities and on a false reliance on herbal doctors and spiritual healers.

For those health professionals caring for women recently arrived from the Indian subcontinent these words of caution are given:

1. Tuberculosis is a disease of shame for the woman and she will need much reassurance to take away feelings of guilt and shame.
   
2. Household and familial duties are still required of the woman, even if she is suffering from tuberculosis.
   
3. She may continue to have no real understanding of why she has the disease and how it is spread, and will therefore benefit from a fuller explanation than normal of why all the procedures and precautions are carried out.
   
4. Saving a woman from possible morbidity and death will be the greatest gift to her children.