Tuberculosis (TB) response for women is grossly inadequate. By Shobha Shukla

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In developing countries TB remains the third leading cause of death among women of reproductive age (15-44 years), disproportionately affecting pregnant women and the poor. This calls for immediate action to address the suffering caused by TB and to eliminate the disease as a leading killer of women.
According to Carol Nawina Nyirenda, a patient advocate, "As women, we usually carry the dual burden of being infected and at the same time caring for our infected and affected family members and loved ones."
Diagnosis and treatment of TB presents a unique challenge in the case of women, due to biological differences and gender inequalities. While men are more likely to have latent TB, women are more likely to develop the active disease. Poverty is a major factor for developing active TB, and as women account for 70 percent of the world’s poor, they are disproportionately affected by the disease.
According to Ann Ginsberg, Chief Medical Officer at TB Alliance, TB has a profound effect on women and their families. The burden of the disease is obviously more on the woman of the house. She has to bear the physical, mental and economic trauma of the disease. The woman may be sick herself or have sick children or a sick husband to take care of them. Women suffering from TB are often unable to care for their children and have trouble performing household chores. They may have to walk miles to get the treatment which has severe side effects. The health of children with an infected mother is also greatly affected. In addition there is no one to bring money in the family, as the disease leads to a loss of work and loss of wages. So the women end up taking the brunt of much of that.
Women's social roles/status places them at a higher risk of contracting TB. Cramped and unhygienic living conditions and poor nutrition levels facilitate the spread of the disease. In developing countries, women often cook indoors, in confined spaces, using biomass fuel. Studies show that they are more likely to develop active TB, as the smoke from such fuels can weaken the respiratory systems and impair the immune system’s ability to fight off bacteria.
Poor women are also at an increased risk of being coerced or forced into sex work. Millions of women are forced into commercial sex work each year, especially in the developing countries. They are then at an increased risk of contracting TB, as also HIV from their clients.
TB also poses a considerable risk for pregnant women. Discontinuing TB medication prematurely is hazardous to pregnant women and their babies and can lead to the development of drug resistant TB. If left untreated, women may transmit TB to the newborn infant.
Women suffer much more from the impact of TB, due to stigma and discrimination, coupled with a lower socio-economic and educational status in low-income countries. Very often they are afraid to reveal their ill health to their family and community members. Positive TB diagnoses may force women into divorce and/or, make them unsuitable as a marriage partner. In India, even in well off families, women are programmed to put family above self. They traditionally eat last, of whatever is left, and often neglect their illness until they become too sick to lead normal lives.
All these factors prevent women from timely accessing qualified health services, causing delays in treatment and the continued spread of disease.
Even clinically, TB in women is more difficult to diagnose, perhaps due to biological differences, as indicated by studies in several countries. On top of this, social factors compound the problem in some regions. A study in Pakistan reported that women felt uncomfortable producing the mucus needed for sputum-smear microscopy, the standard diagnostic test for TB in resource-limited settings. Some women used saliva instead, which greatly affected test results.
A lack of political will, inadequate financing, poor information about the disease and social stigma remain barriers to reducing the burden of TB among women. Routine TB screening should necessarily be incorporated into maternal and child health programs in countries where TB is endemic.
Ann Ginsberg feels that the current TB regimen is too long and complicated for patients to follow. It is crucial that we have new treatment regimens which are shorter, simpler, and hopefully better tolerated by the patient. Only then can we save the lives of millions of women and reduce the burden the disease has on their families.
Developing even a single drug takes as long as 10 or even 20 years in case of TB. But we are looking here for new multi drug regimens. The goal of the new CPTR Initiative is to bring together the sponsors of these different new drugs that are in the development stage, the regulatory authorities, and other key stakeholders, including funders, to really change the paradigm of the clinical process. In this way, instead of having to develop multiple new drugs one at a time (which may take decades before we have a better drug regimen), one can go from pre clinical development to approval of a new regimen in a few years. New drugs will impact in many ways on eradication of TB. They would especially impact the lives of women and children in a positive way.
(The author is the Editor of Citizen News Service (CNS). She has worked earlier with State Planning Institute, UP, and teaches Physics at India's prestigious Loreto Convent. Email: shobha@citizen-news.org, website: www.citizen-news.org)

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