The socio-cultural challenge in public health interventions: the case of tuberculosis in India

Abstract

As per H. Graham, public health policies need to be reconfi -gured to improve population health and to address inequali-ties in the social distribution of health (Graham 2004). These refl ections draw upon the fact that social determinants are central to programs and policies regarding prevention and control of diseases such as HIV/AIDS, malaria and tubercu-losis (TB). While there is ample literature demonstrating that social factors promote and/or undermine the health of women, men, families and populations, there is limited knowledge about the social processes underlying the unequal distribution of health among specifi c populations, which in turn is at the root of persistent social disparities (Anderson 2000; Marmot 2000; Marmot 2005). The aim of these thoughts is to promote a better understanding, thereby a systematic account for how gender and other social processes operate in causing health inequalities in the case of TB management and control. While epidemiological evidence indicates that in low or mid-dle-income countries TB is more prevalent among men than women, studies show that this may be explained by gender differences in the social pattern of interactions (Eastwood & Hill 2004; Uplekar et al. 2001). In addition to differences in exposure and risk of infection, there is a difference in the pro-gression from infection to disease as well as in the tuberculo-sis notifi cation rates in men and women (Holmes et al. 1998). Approximately three million women worldwide contract TB annually and it is estimated that TB accounts for nearly 17 million Disability Adjusted Life Years (DALY) for women with about 750 000 dying of TB every year (Vlassoff et al. 2000; WHO 2002). Not only may women have higher rates of progression from infection to disease and a higher case fatality in their early reproductive ages, but consequences of the lat-ter are felt at the household and community levels (Needham et al. 2001). As a disease of poverty, the social implications of TB are heightened among women living and working in resource poor areas, such as those found in urban slum settle-ments in Mumbai. Delays in seeking help that arise from gen-der disparities to access and entitlements to care have been demonstrated to play a signifi cant role in Maharashtra (Vlas-soff et al. 2000; Vissandjee et al. 2002). Research in Kerala suggests that stigma has adversely affected participation in programs such as DOTS (Directly Observed Treatment with Short course regimen), resulting in poorer treatment outcomes (Balasubramanian et al. 2004; McMurray 2007). Social dis-crimination on the basis of TB disease status may result from various factors, such as perceived danger and contagiousness, as well as adverse judgments which may attribute the condi-tion to immoral behaviour and blame the victim for acquiring the disease. Social determinants of support and rejection in-fl uence the ways that people in the general population without TB interact with people who are symptomatic (Narayanan et al. 2003). In Western India, sex with prostitutes and menstrua-ting women were perceived to be associated with the onset of TB, leading to increased stigma and cross-gender mistrust (Holmes et al. 1998; Uplekar et al. 2001; WHO 2006). Res-ponses to TB unveil the moral basis of risk and vulnerability to this disease, suggesting a causal web of interactions lin-king ethnicity, culture and gender as social determinants of health and patterns of socialization (Narayanan et al. 2003). In this regard, fi ndings of a multi-country study indicated cri-tical links between the interests of TB control, gender studies, and the socio-cultural contexts of poverty, restricted access to needed resources, and interactions between illness and victi-mization (WHO 2006) .