For India’s homeless women, TB care is shaped by gender norms and economic precarity Premium

Reshma's struggle with tuberculosis as a homeless woman highlights the gendered challenges in accessing healthcare and TB treatment.

There are two explanations for how Reshma (name changed) died. In one, she is a disease statistic. A 30-year-old new mother, living on the pavement in Jaipur, died from contracting tuberculosis. The bacteria settled in her lungs, immunity weakened, medicines failed. 

The other story is not as linear or logical. Reshma’s family cast her out when the diagnosis came belatedly. She fought disease and destitution on the streets, between the stifling summer sun and crisp cold at night. The absence of proper treatment, and minimal food, however, allowed the TB pathogen to evade her immune defence.

Reshma’s story – as a woman and as a person without shelter – isn’t singular. A new study, supported by the Dr. Amit Sengupta Fellowship on Health Rights (ASFHR), captures the gendered lens of a clinical disease and challenges rigid mortality numbers. In addition to economic precarity, patriarchal norms decided if Reshma’s cough was accurately diagnosed, when she reached a health facility, how often she followed the six-month drug regimen, and if she would go on to develop drug-resistant TB infections. Experts suggest that stigma and isolation further wrinkle women’s access to care in a system becomes hostile to people lacking institutional agency or autonomy. 

The recent survey illustrated how this cycle of inequity plays out, documenting 17 cases of homeless people living with TB in Jaipur. Overcrowded and unsanitary conditions accelerated TB transmission; malnutrition and weak immunity further increase their risk of contracting TB. HIV coinfection, alcoholism, smoking and tobacco chewing also worsened their TB infection. Lack of shelter further complicated access to healthcare – homeless people were less likely to receive a timely diagnosis and treatment, and in turn, more likely to develop drug-resistant strains of the disease.

The study found a pronounced impact on women like Reshma, who feel unseen by both the community and the medical system. India in 2022 accounted for the world’s highest cases of tuberculosis, per this year’s World Health Organisation Global Tuberculosis Report. Local estimates show the overall occurrence of TB among the homeless population was around 85 cases per 1,000 population Within them, the prevalence of TB among homeless females was 1.5 times higher than homeless males.

Anupama Srinivasan, Assistant Director of REACH, explains that women’s experiences often play out in a blind spot. “We do not as yet know enough about the specific experiences of homeless persons with TB… Homeless women are one step beyond that.”