Despite significant progress being made in the fight against Tuberculosis (TB), as we mark this year’s World TB Day and six months on from the first ever United Nations High Level Meeting on TB, it continues to be the world’s deadliest infectious disease, with around 4,500 people losing their lives to it every day. Men are disproportionately affected by TB. More men than women are diagnosed and die from TB globally, and more men than women have undetected TB. Yet while strategies to tackle the disease have become more gender-sensitive, they tend to focus on women and girls and not men and boys. Without the inclusion of men and boys, as well as a greater recognition of how gender and poverty intersect to prevent diagnosis and treatment of TB, efforts to end this deadly disease will be hindered.
The burden of TB in men
The burden of TB is higher in men than in women, and men are substantially less likely than women to be diagnosed. Those men who do access care are less likely than women to complete TB treatment or access care for post-TB complications. These findings were published in 2016 in a seminal meta-analysis of 56 TB prevalence surveys including 2.2 million participants in 28 countries. Moreover, we know that men can account for around two-thirds of ongoing TB transmission in low and middle-income countries (LMICs) . But here’s the surprising thing: despite this robust evidence, the “missing men” were not mentioned in early drafts of the Political Declaration of the UN High Level Meeting on TB. It took strong calls from civil society and academic and professional bodies to ensure that the epidemiological evidence informed the final wording of the Political Declaration.
“Masculinity” as a driver behind the epidemiology
TB and its spread varies from country to country and is determined by a complex and interconnected set of factors. The reasons behind the higher burden of TB in men also vary and the evidence base for their relative importance is patchy. However, there is evidence that some male behavioural “norms”, driven by perceptions about masculinity are behind this higher burden. These include:
- Care seeking and an unwillingness on the part of “strong” men to seek help for symptoms.
- Employment where predominantly male manual labourers work in confined, silica-contaminated atmospheres in the mining and construction industry that promote aerosol transmitted infection.
- Crime and prisons, which are frequently over-crowded and male dominated, with a global prison population that more than 95 per cent male.
- Homelessness, mental health and addiction and the growing number of people – and particularly vulnerable men – who live on the streets and use homeless shelters which are often identified as hotspots for transmission and outbreaks.
- Sex and the narrative that men have multiple partners and are at risk of contracting HIV, for which they are, again, less likely than women to access care.
- Smoking and alcohol consumption and the fact that more men smoke and consume more alcohol than women, with both important risk factors for the development of TB.
Convincing as these behavioural factors are, they come with an implicit suggestion that the problem and the issue lies with men, and that it is up to men to look at themselves and change. Moreover, are men not, after all, traditionally in positions of power and agency in society? So, what’s stopping them? Yet, the truth is that the dominant and pervasive notions of masculinity driving these behavioural factors are sustained by political and economic systems and societal norms. They have not been constructed by men on their own. Instead gendered norms are constructed, reinforced and policed in societies by both men and women.
Poverty, Gender and TB
Which brings us to the real driving force behind TB and the higher burden of TB in men: poverty. It intersects with gender to amplify TB transmission and disease. If you juxtapose poverty with each of the examples of masculine behaviour given above, it is both a cause and a consequence of the behaviour. TB is, in turn, both a cause and consequence of poverty: hence the vicious cycle of amplification.
Catastrophic social and economic causes and consequences of TB disproportionately impact upon the poorest TB-affected households in LMICs. This is devastating but can also be changed. There is evidence that intersectoral socioeconomic support interventions such as targeted cash transfers can mitigate against the huge economic consequences and costs of being an individual or household affected by TB.
As a result we need a socio-economic, developmental approach to bringing an end to TB.
Don’t forget the men
The STOP-TB Partnership, which comprises over 1700 partners in more than 100 countries, recently issued its call for Wave 7 of their TB REACH grants. The grants aim to improve TB case finding and treatment outcomes , and are supported by Global Affairs Canada and Canada’s Feminist International Assistance Policy. The special theme is “empowerment of women and girls to lead key approaches in the TB response”. The first two steps in the suggested approach espouse a broader approach to gender, based on evidence from the context and epidemiology:
- Understanding how gender affects the TB response and how the epidemic affects gender issues in affected communities;
- Designing responsive interventions to address identified gaps.
However, the third step – promoting gender equity through TB programs that empower women and girls – implies that empowerment of women and girls is the solution, despite the glaring gap of unidentified and untreated men with TB.
Empowerment can be defined as “the process of becoming stronger and more confident, especially in controlling one’s life and claiming one’s rights”. It is hard to see how a focus on strengthening women and girls’ abilities to control their lives and claim their rights will tackle any of the issues relating to masculinity outlined above and address the problem of the missing men in TB, unless there is also engagement with men and boys.
Empowerment of women and girls to tackle the social and economic challenges (especially poverty) TB poses is a vital catalyst for progress towards the Sustainable Development Goals. However, it must be combined with tackling challenges faced by men and boys in their communities to respond to the compelling epidemiological evidence and accelerate progress to End TB. It’s time to address the intersection of poverty and masculinity to End TB.