Glass Walls As Well As Ceilings: Gender Specific Barriers to Access for Health Interventions.
Of the approximately 3 billion people who live on less than $2 a day, infectious diseases represent a potent and serious source of ill-health. Each year, diseases such as tuberculosis (TB), schistosomiasis (bilharzia), malaria and HIV/AIDs claim almost 9 million lives.  Of the victims, many of whom are under the age of 5; almost all are acutely impoverished and reside in lower and middle income countries where infectious diseases remain key drivers of disease burden.
The recently adopted Sustainable Development Goals rightly recognised the huge impact of these debilitating afflictions on the capabilities of people worldwide to live the healthy, happy lives, and the 2030 Agenda for Sustainable Development, within the remit of Sustainable Development Goals 3, called for “ending the epidemics of AIDS, tuberculosis, and malaria” amongst others.  Despite the renewed interest in combatting these diseases, and the sustained progress in tackling some of them (with TB mortality having fallen by 47% since 1990 for example) there is still significant distance to cover.  Given the scale of the problem, constraint of resources is a serious issue- it is estimated that there was a global funding gap of $1.4 billion for the treatment of TB in 2015.  Evidently then, despite progress, significant work remains in reducing the burden of infectious diseases worldwide.
Overlaid on this issue of resource constraint is another dimension that is currently neglected, both within academic literature and in practice: that of gender. The intersection of gender and infectious disease epidemiology is far reaching, having ramifications for both vulnerability to illness, and access treatment. Whilst there is a significant biological component to the former, both facets have a significant social dimension that reflect the social construction of gender is itself and are thus impacted by a number of different factors, including age, marital status, and extent of impoverishment as well as many others. Together these factors, and the asymmetries with which they impact men and women have consequences for the way in which infectious diseases manifest, and in turn, must be central considerations when designing and structuring treatment programmes.
Inequality between genders can operate at many levels, ranging from widespread societal norms and biases within communities through to inequality of individuals within family units. Whilst these asymmetries are found across genders (men for example, due to their traditional role as breadwinner in the household are far more likely to contract occupational exposure derived diseases for example), the focus for this piece will be predominantly on women, and the way in which inequalities surrounding them limit or hinder their ability to access health services.
Perhaps one of the most pertinent examples of gender asymmetries driving poor health outcomes lies with HIV/AIDS. While HIV/AIDS has significant stigma attached to it worldwide, this stigma is not always evenly distributed across genders. Research based in India, highlighted that whilst almost everyone faced discrimination upon disclosure of their positive status, men were treated much more positively than women.  Contraction of HIV amongst women was irrevocably associated, whether true or not, with prostitution/sex work, a highly stigmatised profession in India, something commonly described as “becoming bad” in some demographic groups. 
Not only do women often face more stigma with regards to HIV, but they are also in many cases less likely to receive the treatment they require, as found in Kenya, where despite an increased vulnerability to HIV and concomitantly, a higher prevalence; women were less likely to access voluntary counselling and testing services compared to men.  This was in part due to the stigma associated with the disease, and also due to the asymmetry in decision making power between marital partners. This inequitable distribution of power within the household represents a serious barrier to treatment access, something corroborated by research conducted by The International Community of Women Living With HIV/AIDS. They found that gender represented a significant barrier for access to treatment and that this was primarily due to the fact that women often had to obtain permission from their husband or another male family member to seek HIV care. Additionally, accessing treatment required asking male members of the family for money. These were all based on the initial assumption that they had disclosed their positive status to their families, which was often not the case due to the stigma associated with the disease. The combination of fear of the stigma associated with the disease and the gender derived barriers to access therefore represent a significant factor in limiting women’s ability to access treatment for HIV.
The question remains as to what can be done. In “Gender, Equity: New Approaches for Effective Management of Communicable Diseases” Theobald et al identify two core approaches to address gender equity in health.  First is the requirement for the integration of gender into monitoring and evaluation strategies. The second refers to gender sensitive training and resources, in order to develop ways to more readily deal with gender based asymmetries in health and treatment access. Ultimately, strategies seeking to enhance gender equity in the control and treatment of diseases must recognise the different barriers faced by women and men, particularly in the impoverished. Whilst this will vary according to the disease and the social context, it is imperative if everyone afflicted with serious infectious diseases are to be properly, and promptly, treated.
It is evident that the integration of gender based considerations into the treatment of communicable and infectious diseases is vital. It is an essential change to make if we are to reshape the structure and delivery of programming to combat infectious diseases in a more equitable, and just way. Additionally, from the viewpoint of efficiency, marginalising large proportions of the population has negative ramifications for program coverage, as well as the epidemiology of the disease at large. Regardless, it is clear that for men and women, gender is a significant determinant of susceptibility to communicable diseases and greater considerations of this will ultimately help facilitate more equitable, effective, and sustainable treatment of infectious diseases that allows everyone, irrespective of gender, to lead healthier and happier lives.
Charlie Whittaker is a PhD student at The John Innes Centre, studying climate change and molecular epigenetics. Outside of academic science, his primary interests are global health, food security and the intersection of the two.
Global Report for Research on Infectious Diseases of Poverty, WHO, 2012. http://www.who.int/tdr/stewardship/global_report/en/
Global Health 2035, Sustainable Development Goal for Health. http://globalhealth2035.org/our-work/sustainable-development-goal-health-0
Global Tuberculosis Report 2015, WHO, 2015. http://www.who.int/tb/publications/global_report/en/
Executive Summary, Global Tuberculosis Report, WHO, 2015. http://www.who.int/tb/publications/global_report/gtbr2015_executive_summary.pdf
Bharat, Shalini. “Facing the challenge: household responses to HIV/AIDS in Mumbai, India.”AIDS care 1 (1999): 31-44.
Cornish, Flora. “Challenging the stigma of sex work in India: material context and symbolic change.”Journal of Community & Applied Social Psychology6 (2006): 462-471.
Taegtmeyer, Miriam, et al. “Using gender analysis to build voluntary counselling and testing responses in Kenya.”Transactions of the Royal Society of Tropical Medicine and Hygiene 4 (2006): 305-311.
Theobald, Sally, Rachel Tolhurst, and S. Bertel Squire. “Gender, equity: new approaches for effective management of communicable diseases.”Transactions of the Royal Society of Tropical Medicine and Hygiene4 (2006): 299-304.
International Community of Women Living with HIV/AIDS (ICW). 2004. ICW Vision Paper 2: Access to Care, Treatment, and Support. London: ICW