A large number of women living in S. Asia suffer on-going sex discrimination regarding their education, reproductive health, economic freedom and social independence. Naturally this has a bearing on their health. But can such socio-economic and educational discrimination explain the horrific numbers of women with tuberculosis worldwide?

Jackie A. Jackson discusses the issues.

900 million women are infected with tuberculosis and the disease is the leading cause of death among women of reproductive age. In fact it now appears that women with tuberculosis may have experienced a weakness in their body's defences, at the time of their infection, that is never shared by men. How these biological factors interact with the socio-economic and educational factors mentioned above is not well understood, but I will attempt to describe how some of them operate for the women of S. Asia.

I visited the K. S. Roy Hospital, Calcutta in December 1997 where 600 people were in-patients; many were children and drug addicts and 60 had multidrug -resistant tuberculosis. The hospital often uses chemotherapy regimes that are now out-of-date in Great Britain, since the Government cannot always afford the new, shorter regimes. In 1998 Paul Nunn of the World Health Organization (WHO) Tuberculosis Unit declared the Indian tuberculosis programme to be "a sham", and at the present time the Indian Government is working with the WHO to provide more co-ordinated treatment programmes.

I was introduced to 24-year-old Kakuli, a Hindu woman from a poor village. She said that her husband was a kind man who tried to earn a regular income and be a good head of the family. She had been brought with her newborn to the hospital with exhaustion, night sweats and productive cough. Both were severely malnourished, found to have pulmonary tuberculosis, and had remained in the hospital for over a year. Besides their medication they were given good diets, rest and accommodation - things that Kakuli had found hard to provide for herself as a mother-to-be.

Perhaps Kakuli's risk of infection was made higher by her being pregnant at the time. Some biologists have found that changes in a woman's hormones during pregnancy can change her immune response. Others wonder if men and women succumb to different strains of the mycobacterium, or whether their different nutritional and hormonal states determine their susceptibilities. Kakuli's low socio-economic status and possible harsh living conditions were probably important risk factors, just as her social position in a very traditional family would have had some influence on her access to good food and early medical help. Also in many S. Asian societies tuberculosis is treated with suspicion and fear, preventing early diagnosis and treatment. Kakuli's delay in getting treatment is not unique. For many women, the need to decide between either disclosing their disease status in order to get treatment or keeping quiet and preserving family honour, is leaving them in a very vulnerable position. Such behaviour encourages the spread of the disease. Women of lower class and socio-economic status seem to suffer a bigger disease burden than richer, more educated women in less traditional communities. Besides having greater protection by having better living conditions, a woman from a higher class will have fewer difficulties in getting confidential treatment and completing the intensive regime.

Many of the rituals and customs surrounding marriage and family life in the communities of S. Asia combine to give some women poor self-esteem, low social status and a physical disadvantage. When a woman's position in her husband's household is low she has reduced access to food and medical care, and she will be reluctant to admit how ill she feels and demand treatment. Instead she is likely to continue in her wifely and/or daughter-in-law duties and so act as a dangerous source of infection. Depending on the community in which the woman lives, will dictate whether she is outcast or not, after being pronounced infected. A woman outcast from her husband's family would lose her social status and possibly family protection. Due to the high cost of the medication and the loss of her working days a young wife in the husband's family is treated as a liability, and the woman feels very vulnerable. Also if the relevant clinic is not nearby this woman must be able to overcome the obstacles of transport and cost.

For a woman carrying a taboo disease several conditions need to exist before she feels comfortable disclosing her health status. She must know that her information is confidential and that she will not experience bad treatment. It is quite common for young, unmarried women, who suspect they have the disease, to decide not to go forward for diagnosis or treatment. The reason behind this is her fear of not being able to get a husband: remaining unmarried would bring great shame on her. Thus a woman's physical experience of tuberculosis is made all the more difficult by the deadly chain linking the disease to family honour and shame. One of the best ways to break the chain is to set up woman-only services.

Woman-only services have been demanded by sufferers of another taboo disease in another part of the world: namely women in the United States who have the Human Immuno-deficiency Virus (HIV). I believe that women with tuberculosis in S. Asia share some of the same problems that the Americans are seeking to overcome. In fact the International Centre for Research on Women is committed to promoting confidential and friendly women-only services worldwide for women who are HIV+ve. Key features of the service are easy access, social support, and appropriate advice and treatment. The United Nations Development Fund for Women (UNIFEM) declare women to be a vulnerable group, and seek to protect them from sexual discrimination, poverty and ill-health in the next century. Their proposals for the future health facilities of tomorrow's women in their AGENDA 21 document sound very similar to the women-only tuberculosis clinics that I feel are needed in S. Asia. UNIFEM describes the facilities as 'women-centred, women-managed, and affordable, accessible services'. All the lessons learnt from the many failures in tuberculosis care support this argument. If some women in S. Asia clearly experience the double disadvantage of being female and being subordinate to other community members then it behoves the S. Asian Governments and world-wide agencies for health to provide even more specific services for them.

[For further information regarding the K.S. Roy Hospital, please contact Mr & Mrs Jackson, IIMC (UK), 10 Widmore Drive, Hemel Hempstead, Herfordshire, HP2 5JJ; Tel/fax: 01442 25018] .

Jackie A. Jackson RGN, MA,BSc, PGCE, Joint UK Co-ordinator, The Institute for Indian Mother and Child (UK). UK Reg Charity 1066834