Tuberculosis: No Man’s Land?

Women are disadvantaged in most areas of healthcare, and stigma is major concern for women. TB, however, is one condition, where all evidence points to a higher burden of disease in men, a consistent pattern of underutilization of health services, and generally poorer health outcomes in men.

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Nov 12, 2019
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Women are disadvantaged in most areas of healthcare, and stigma is major concern for women. TB, however, is one condition, where all evidence points to a higher burden of disease in men, a consistent pattern of underutilization of health services, and generally poorer health outcomes in men.

Multiple systematic reviews have found that men are more than twice as likely to have active TB but are considerably less likely than women to be diagnosed and notified to national TB programmes. This represents a reversal of the usual pattern of disadvantage for women in use of health care. Understanding the sources of this gender imbalance is crucial to identifying and treating the missing millions of patients with TB globally.

TB is well known for interventions that are imposed from top-down, and for systems that are designed with the public health system in mind (e.g. DOT). TB services (e.g. National TB programs) simply do not seem to be convenient or anonymous for men, nor do they adequately address their fears and insecurities.

It is time for TB care to follow the principles of human-centered design, focus more on what people want, and align better with life circumstances. We need to understand men’s needs in specific contexts, listen to what men are saying and not saying, and design multifaceted and synergistic interventions that are grounded in realities.

Unlike the HIV community, the TB community has not done a good job of harnessing the power of survivors and patient advocates. Thankfully, this is changing. 

In this context, I see great value in a new book “Men and Stigma” by the Global Coalition of TB Activists. I was pleased to write the foreword. The book is timely because it helps raise awareness that men not only bear a higher burden, but also struggle to seek care and get adequate care.

The powerful stories of the male TB survivors in this book clearly illustrate the range of barriers they faced while dealing with TB. Their stories also provide valuable clues on how to overcome stigma and barriers, and how to design male-friendly TB services. It is important to make sure TB services are also female and child-friendly, and health systems do not need to choose between these. GCTA has published similar books on "Women and Stigma" and "Childhood TB and Stigma."

I hope TB program managers, donors, and implementers read this book. If we want to end TB, then we need to worry about the missing men with TB, listen carefully to those who have lived experience and can make sure live-saving interventions reach those who need them the most.


Acknowledgements: I am grateful to Ms Blessi Kumar of GCTA for inviting me to write the foreword for this book. Photo: Mr Jeffery Acaba, a TB and HIV activist from the Philippines, at the launch of the book in Hyderabad, India. Photo credit: GCTA

Go to the profile of Madhukar Pai

Madhukar Pai

Director, McGill Global Health Programs

I am a Professor and a Canada Research Chair in Epidemiology & Global Health at McGill University, Montreal. I serve as the Director of McGill Global Health Programs, and Director of the McGill International TB Centre. URL: http://www.paitbgroup.org/

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