Wearing a heavily embroidered, bright pink dress, Sadorzi sat waiting for a doctor at Mirwais Hospital in the southern Afghan city of Kandahar.
She had travelled more than 100 kilometres to seek treatment for tuberculosis, after doctors in her hometown said they could do nothing for her.
For months, her son had been buying over-the-counter drugs to try to cure her cough, fever, weight loss, and night sweats. When her son finally took her to a doctor, she was told that she likely had drug-resistant tuberculosis (DR-TB), meaning she’s resistant to at least one or more of the most important drugs used to treat TB.
“I can’t eat anything. I can’t do anything. All my body is in pain,” the 50-year-old told The New Humanitarian as she opened a plastic bag full of antibiotics and cough medicines – none of which have worked.
Before the COVID-19 pandemic erupted, tuberculosis was the world’s leading cause of death from infectious diseases, killing 1.4 million in 2019, according to the World Health Organization. While men are more likely to develop TB than women across the world, the opposite is true in Afghanistan.
Women represent about 38 percent of TB infections globally, but in Afghanistan they’re some 54 percent. In almost every age group, women like Sadorzi are more likely than men to develop the disease, as well as resistance to the drugs that treat it.
“In the community, we’re seeing that more females are affected,” said Dr Anthony Oraegbu, a TB expert with Médecins Sans Frontières in the southern city of Kandahar. Here, MSF runs the only DR-TB treatment facility in Afghanistan’s entire southern region, as well as an outpatient clinic at the hospital.
“I can’t eat anything. I can’t do anything. All my body is in pain.”
There’s no consensus on why tuberculosis hits more women than men in Afghanistan. Health experts say deep gender inequality could be one major factor, as women are more likely to be confined in poorly ventilated homes, and less likely to access healthcare.
Afghanistan’s protracted war and the coronavirus pandemic are further complicating efforts to address TB – and raising fears infection rates could rise. Conflict displaced some 380,000 people last year while the virus spread, and women in particular have missed out on healthcare, aid groups say.
Tuberculosis is a disease often rooted in poverty. It is spread through the air via coughing, spitting, and speaking, and spreads more easily in cramped, overcrowded spaces.
In 2019, some 10 million people worldwide were diagnosed with tuberculosis, including almost half a million who developed drug resistance. Afghanistan had 72,000 infections, with 2,400 cases of drug resistance.
Public health experts fear tuberculosis could swell as the pandemic has kept people at home, and sidelined services for other crucial health problems – from preventable diseases to malnutrition and maternal health.
The WHO says there were “substantial reductions” in reported TB infections in 2020, a sign that cases are going undiagnosed and untreated. The Stop TB Partnership – a coalition of health agencies, governments, and community groups – estimates the knock-on effects of COVID-19 could cause an additional 1.4 million TB deaths worldwide by 2025.
COVID-19’s effects on Afghanistan’s tuberculosis problem aren’t yet clear. But researchers with a project funded by the US Agency for International Development, or USAID, said that fewer people have been screened for and diagnosed with TB, and people on TB treatment have had difficulties getting medication.
“These challenges can lead to decreased adherence, increased treatment failure, increased drug resistance, and other adverse outcomes,” the researchers reported.
With men making up the majority of global tuberculosis cases, it’s unclear why women appear to be more at risk of contracting the disease in Afghanistan.
Oraegbu believes women may be more likely to get TB – and to develop drug-resistance – because they lack access to healthcare, are more likely to be confined to the home, and are more likely to take over-the-counter drugs that breed resistance. Of the Kandahar clinic’s 56 currently enrolled patients, 36 are women.
“It’s not easy in a conflict environment when women do not have the financial power to seek healthcare,” Oraegbu told TNH. “There’s this perception that TB is a disease of men. We need to change that perception here because women are really disadvantaged.”
Wrishmeen Sabawoon, a visiting researcher at the University of Tokyo who previously studied TB in Afghanistan, also pointed to gender roles: Women are more exposed to the bacteria that causes tuberculosis because they are largely stuck indoors amid high air pollution from cooking stoves. This, coupled with undernutrition, means many women exposed to TB go on to develop the disease, he said.
At the same time, however, gender inequality or conflict aren’t unique to Afghanistan.
Kamran Siddiqi, a professor of global public health at the UK’s University of York who has researched gender and TB in South Asia, said it’s important to examine the reasons behind Afghanistan’s tuberculosis gender disparity so that funders and policymakers recognise it as an important issue.
“What is required here is a sound epidemiological study that takes a large cohort of women and follows them up to see who gets TB and why,” Siddiqi said.
Conflict, stigma, and lengthy treatment
Treatment for tuberculosis can last months. It’s a long road for anyone, but even more of a barrier for women who may need their family’s permission to travel hundreds of kilometres through Taliban-controlled areas to reach treatment centres like MSF’s in Kandahar, where they must stay for weeks at a time.
“A woman cannot start or continue treatment if she doesn’t have someone to come with her, to be with her,” said Oraegbu.
Women like Sadorzi are from the exact community TB experts in Afghanistan are most concerned about: poor, rural, nomadic communities who move with the seasons or to flee conflict.
Her home province of Zabul has become a Taliban stronghold in recent years. And there have been frequent clashes between the armed group and government forces in parts of southern provinces like Kandahar.
“A woman cannot start or continue treatment if she doesn’t have someone to come with her, to be with her.”
Further compounding the way women experience the disease differently is the role stigma plays.
For centuries, TB has been associated with notions of shame, guilt, isolation, and rejection. In Dari, one of Afghanistan’s two official languages, tuberculosis translates to the word sil, which has deeply negative connotations and is associated with blood, coughing, and weight loss.
The deep-rooted stigma associated with TB means women are more likely to conceal their condition for fear of social isolation, and miss out on proper treatment until it’s too late.
For women who do manage to access healthcare, a tuberculosis diagnosis is only the first step. While treatment at the MSF clinic is free, families often forgo income during the lengthy process.
Hiayat, 35, and her baby daughter lay in a bed at the Kandahar clinic. Both mother and child were diagnosed with drug-resistant tuberculosis.
“I’m really glad we are supported, but we have nothing to do here,” Hiayat told TNH shyly as she played with her baby on her lap. Hiayat, like Sadorzi, uses one name.
Before this, Hiayat had suffered from a terrible cough, chest pain, night sweats, and vomiting for months on end.
Her family saw doctors in Ghazni, Hiayat’s home province in central Afghanistan, and the Pakistani city of Quetta, before she was finally diagnosed with drug-resistant TB. Neither she nor her husband understood what it meant.
“My relatives call me every day asking for the money I borrowed.”
“I wondered: What should I do?” said her husband, Mohammed. “I have no money to support my family, no money even for food.”
The family will stay in Kandahar for the next two months while their condition stabilises, before they continue treatment at home for another nine months.
While Mohammed is relieved his wife and daughter are finally getting the care they need, he’s worried about the future.
He borrowed roughly $200 to take his wife to Pakistan, and he’s not earning any of his farming income while he accompanies Hiayat in treatment.
“My relatives call me every day asking for the money I borrowed,” he said. “I feel very bad because I have two sick family members and I have this big loan to repay. It’s a huge pressure.”
With little work available in Ghazni and Afghanistan’s economy stumbling, Mohammed believes he’ll inevitably have to leave home again.
“When my family gets better, I will go to another province to work and earn money to feed my family and pay back the loan,” he said. “Maybe I’ll come back here to Kandahar.”