Throughout the duration of the course, we have analyzed and discussed how gender intersects with medicine and health. The objective being able to understand the role that gender plays and the five different theoretical models we can use in order to study and research these different intersections. In this post, I will use the critical medical anthropological approach to explain high rates of coronary heart disease (CHD) in women in India. Along with using my theory to approach and model the disease, I will also discuss the political, cultural, and social determinants that influence the ways in which coronary heart disease is approached and treated. The main determinants that affect India are: “ (a) lack of policies related to social determinants of CVD for control of primordial risk factors (smoking, smokeless tobacco, alcohol, physical inactivity, and unhealthy diet); (b) poor-quality preventive management – poor control of risk factors; (c) low availability and substandard acute CHD management; and (d) lack of appropriate long-term care of these patients and absent cardiovascular rehabilitative and secondary preventive programs” (Gupta 2016).
India is a large country located in southern Asia. As of 2013, India had an estimated population of 1.324 million people, and the population is steady increasing each year (UNICEF 2013). Of this populations, 48.17% is women. For women in India, “overall life expectancy has increased in India over time, women in fact have a higher life expectancy than men, and there have been substantial improvements in the management of conditions that were responsible for the largest number of deaths and disability amongst Indian women 25 years ago” (George Institute 2016). While this is a significant news for India’s heath and medicine, this increase in life expectancy also comes with downfalls. The main downside to the healthcare system present in India is the ack of knowledge and data on gender specific analysis, other than its data for women that focuses on reproduction and sexual health.
The lack of research and data on women’s health has negatively affected the health of women in India. “Non-communicable diseases have increased significantly” (George Institute 2016). The main non-communicable disease in India affecting women is cardiovascular heart disease (also known as ischemic heart disease). In India, “coronary heart disease and stroke are the leading causes of death in both economically developed and developing countries” ( Klag 2012). In India, 50% of cardiovascular disease results in death before the age of 70%, where this statistic is much different in developed countries (Klag 2012). This percentage is much lower in developed countries with a much smaller value of 25%. Both men and women are greatly affected and impacted by the heart disease, but it has now become the leading cause of mortality patterns among women in India (George Institute 2016). Coronary heart disease “is a chronic illness with acute manifestations. Two clinical aspects are angina pectoris (pain) and myocardial infarction (heart attack). CHD refers to illnesses caused by the narrowing of the coronary arteries” (Endler 2001).
Cardiovascular heart disease has been traced to what are as follows: smoking 59%, obesity 41% , hypertension 22% , positive family history 17% , diabetes 10% , and hypercholesterolemia 8%” (Dehghani 2015). Smoking is a large social issue within India. Most people are affected not because they are smokers, but because people who live in their homes smoke and they take in secondhand smoke. While not as dangerous, it still has a significant impact on one’s health. Obesity, hypercholesterolemia, and diabetes have been traced to a lack of healthy food choices being available. In India, eating healthy can be extremely costly and almost impossible for poorer families. Positive family history can be traced to women who have babies. Their children often times are more likely to have CHD later on in life. Understanding these connections is very important for India due to the act that in the last 30 years, coronary heart disease has all but doubled, but has declined by 15% in developed nations, such as the United States (Dehghani 2015). “India is going through an epidemiologic transition whereby the burden of communicable diseases have declined slowly, but that of non-communicable diseases (NCD) has risen rapidly, thus leading to a dual burden. There has been a 4-fold rise of CHD prevalence in India during the past 40 years” (Krishnan 2012). This has been significantly in the women’s aspect.
The main social determinant in India being a lack of policies related to social determinants of CVD for control of primordial risk factors is a main contributor to CHD. As discussed, relation of smoking, history of hypertension or diabetes, waist/hip ratio, dietary patterns, physical activity, consumption of alcohol, blood apolipoproteins (Apo), and psychosocial factors to myocardial infarction have all been studied and can be attributed to CHD. “…Advertisements on internet and television have led to more aggressive marketing of tobacco products and unhealthy food items… India is the third largest country in the world in both tobacco production and consumption. Of the 1.1 billion smokers worldwide, 182 million live in India” (Beaglehole 2003). India has no current policies in place to prevent tobacco usage. The government in India often times receives a large percentage of any money made by the tobacco company and often has a large hold on its taxes as well. The government is less likely to begin preventative smoking policies or work towards creating a way to create awareness. The diet in India that was previously rich in fruits and vegetables, has been replaced with diets rich in calories and animal fats that are low in carbohydrates because they are easier to come by and cheaper in cost. In India, family plays a very large and consistent role in all people’s lives. Women are at the forefront of this since they send most of their time in the home taking care of children. The Human Development Report 2015 recorded that “women across the world undertake most of the unpaid housework and care giving work in their homes” (Human Development Report 2015). This is the very similar case in India. Women’s household roles impact their health significantly. Exposure to smoking in the home and limited engagement in work contribute to an increased rate of non-communicable disease.
Poor-quality preventive management, while present, they are hard to implement at a widespread rate. The healthcare systems within in India, while improving, are still very poor compared to other nations. Major barriers include low-detection rates, inadequate awareness, poor use of evidence-based prevention, and low adherence rates (Gupta 2016). Low-detection rates are extremely difficult due to many people living in the rural areas of India or lacking proper insurance for health care. Inadequate awareness stems from a lack of resources. Women in India typically have lower literacy rates than men. “The literacy for rate for males (15-24 years) is 88.4%, which is higher than the % for females at 74.4%” (UNICEF 2013). These rates can be attributed to the fact that women often marry young in India and leave school to stay with their husbands’ home and be proper wives. Evidence-based prevention can be extremely difficult when they are helping a population that has next to no research in general on women as a whole. Adherence can also be extremely difficult to come by Without programs to hep people be well informed, people are not going to stay on a track that their health care provider hands them, especially if they do not see the affects immediately.
Low availability and substandard acute CHD management and lack of appropriate long-term care of these patients and absent cardiovascular rehabilitative and secondary preventive programs is also extremely next to impossible to find in India. The availability of proper health care is almost completely absent within India. This is mainly due to “the shortage of a trained workforce is observed at all levels of health care… There is an uneven distribution in numbers and in quality of the healthcare workforce, not only between rural and urban India, but also between and within different regions and states” (Gupta 2016). For women, they are in the home more than men and less able to travel. Due to this, women are less likely to ever seek out a doctor for help. If they live in a rural area, they are even more less ikely than their husband to see a health care provider. This has helped in aiding the increased number of women that are now suffering from cardiovascular heart disease in India.
One might use the critical medical anthropological theory to explain an increase in cardiovascular heart disease in woman in India because it focuses on how these assumptions and behaviors (social determinants) by people who have power (the men and government) impact the health of people without power (women). (ANP 270 Lecture 1.4). The fact that women are seen as child-bearers that should stay at home and take care of the family, they are more likely to face social determinants that put them in a more likely position to have cardiovascular disease than the men that have power over them, their husbands. The government has put them at even higher risk by failing to implement policies that would help to relieve negative social determinants. This aided by the lack of an effective health care system has put women at risk. Possible alternatives that can be explored are lifestyle modification (LM), developing an independent women’s health research and implementation agenda, providing incentives for behavior change to promote achievement of these goals, and getting a better understanding of issues around the barriers to delivering quality healthcare to women to help with the cultural lifestyle aspects present in India. Enforcing lifestyle modification and offering incentives could help in changing behaviors within the home that put women at a higher risk, while providing them with money to invest in healthier food options that would lower obesity, diabetes, etc. rates. This also gives women more power within the home by giving them money. Women are generally not seen as the breadwinners within the Indian culture, so by handing them money to provide food, you offer them the opportunity to be just as much involved in providing for the family as their husbands. The research and implementation agenda would create a research base into the disease itself and offer more opportunities for prevention. The lack of current knowledge and research into the disease itself means that there in next to no way to have evidence-based prevention. The agenda would help in creating a basis for prevention. Overall, the intervention would help women to become more aware of there bodies as well by providing education and resources.
In conclusion, India has many issues when it comes to gender equality. Inequality within the country is deeply rooted in their own cultural views and ideologies of the roles that women play within the family and household. In order to effectively give women more power over their bodies and homes, there needs to be more preventative and educational opportunities available to women. While these cultural ideas and norms will not be able to be changed today, or even tomorrow, some more awareness needs to be made in order to combat cardiovascular disease. With noncommunicable diseases already on the rise, and fear of an epidemic in India, the government needs to make a better stance and begin to create systems that will not only benefit women, but all people. Factors such as prevention, implementation of policy, and education will help to create a framework necessary to begin alleviating and taking control and combating cardiovascular heart disease.
Beaglehole, R., & Yach, D. (2003). Globalisation and the prevention and control of non-communicable disease: The neglected chronic diseases of adults. The Lancet,362(9387), 903-908. doi:10.1016/s0140-6736(03)14335-8
Dehghani A, Bhasin SK, Dwivedi S, Malhotra RK. Influence of Comprehensive Life Style Intervention in Patients of CHD. Global Journal of Health Science. 2015;7(7):6-16. doi:10.5539/gjhs.v7n7p6.
Endler, N. S. (2001). International Encyclopedia of the Social & Behavioral Sciences. Toronto: York University. doi:https://doi.org/10.1016/B0-08-043076-7/03811-0
George Institute. (2016). Framing Women’s Health Issues in 21st Century India – A Policy Report. The George Institute for Global Health India, May 2016. Retrieved August 16, 2018, from https://www.georgeinstitute.org/sites/default/files/framing-womens-health-issues-in-21st-century-india.pdf.
Gupta, R., Mohan, I., & Narula, J. (2016). Trends in Coronary Heart Disease Epidemiology in India. Annals of Global Health,82(2), 307. doi:10.1016/j.aogh.2016.04.002
Human Development Report (2015). UNDP (United Nations Development Program) from http://report.hdr.undp.org/.
Klag, M. J. (n.d.). Goldman’s Cecil Medicine (Twenty-Fourth Edition)(24th ed., Vol. 1). Elsevier. doi: https://doi.org/10.1016/B978-1-4377-1604-7.00051-8
Krishnan MN. Coronary heart disease and risk factors in India – On the brink of an epidemic? Indian Heart Journal. 2012;64(4):364-367. doi:10.1016/j.ihj.2012.07.001.
UNICEF. (2013, December 27). Statistics. UNICEFwww.unicef.org/infobycountry/india_statistics.html.