Data Point | The gender disparity in healthcare

The Data Point is a bi-weekly newsletter in which The Hindu’s Data team decodes the numbers behind today’s biggest stories.  

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The difference in the anatomy between various genders implies that diseases and their symptoms may affect them differently. Moreover, some diseases affect certain genders more than others, while a few are gender-specific conditions. Thus, it is imperative to look through a gendered lens for a better understanding of diseases.

Equal representation of genders in clinical trials, and impartiality and unbiasedness in testing and diagnosis help in creating a healthcare system that addresses the needs of all genders.

Yet, various studies conducted in the U.S. reveal that in some fields of medicine such as oncology, psychiatry, neurology and cardiology, the disease burden was higher among women while their share in clinical trials was not proportionate. 

In a study where 1,433 trials were conducted from 0.3 million people in the U.S. between 2016 and 2019, the average share of women was  41.2%. In psychiatry, where women comprised 60% of patients, the share of women participating in clinical trials was 42%. Similarly, the difference was significantly high in the case of cardiovascular diseases (41.9% female participants vs. 49% female patients) and cancer trials (41% female participants vs. 51% female patients)

Gender disparity is also observed in research funding. For instance, according to the National Institutes of Health (NIH) data, the 2023 research funding estimate for substance misuse (a condition more prevalent among men) was $2,583 million while that for depression (a condition more prevalent among women) was $664 million. Similarly, research funding in 2022 for HIV/AIDS, a disease more prominent among men (DALY of 0.361 million in 2015) was $3,294 million, while that for inflammatory bowel disease (IBD), a disease dominant among women (DALY of 0.475 million) was $203 million. (expand DALY somewhere)

To know more about the gender gap in clinical trials and research funding, click here

Women faced the challenge of a gender gap in testing, diagnosis and treatment, which arose from a lack of comprehensive research about conditions dominant among women and biases toward women in healthcare.

In a multicentre observational study published in 2023, it was revealed that the median time taken to diagnose IBD from the onset of a symptom was more prolonged in women than in men. For instance, it took about 12.6 months to diagnose Crohn’s disease (a type of IBD) for women, while it only took 4.5 months for men. Similarly, it took 6.1 months for women and 2.7 months for men, in the case of ulcerative colitis.

NIH data also revealed that funding given for women’s reproductive disorders was significantly lower than that for conditions with a similar disease burden. 

Polycystic ovary syndrome (PCOS) is a common endocrine-metabolic abnormality among women with a worldwide prevalence of up to 21%, depending on diagnostic criteria. Yet, while diseases with equal or lesser disease burden like rheumatoid arthritis, tuberculosis, and systemic lupus erythematosus, were awarded funds worth $454.39 million, $773.77 million, and $609.52 million respectively, the funding for PCOS research between 2006 and 2015 was limited to $215.12 million. 

Thus, a limited understanding of disease further delays diagnosis, especially for diseases affecting women’s reproductive system. 

In the Indian context, the taboo towards menstrual health in society, which extends to the health sector adds to this problem. Endometriosis, a disease that affects roughly 10% (190 million) of women and girls of reproductive age worldwide according to the WHO, is highly underreported in the country. 

Despite persistent visits to multiple gynaecologists over a decade, my journey to obtain a proper diagnosis for endometriosis was marked by significant delays. My experiences of enduring intense menstrual cramps, accompanied by nausea and bowel disorders, were consistently dismissed by doctors who attributed them to natural menstrual processes. Prescription of painkillers became routine without a genuine effort to comprehend the severity of my discomfort or suggest diagnostic scans for underlying issues. Only after my insistence, despite initial reluctance from doctors, did I finally receive a diagnosis. Regrettably, by that time, the lesions within my ovaries had grown larger than the organs themselves.

Even with a diagnosis, treatment options remain limited due to the narrow understanding of this condition. While invasive surgeries like laparoscopic procedures and hormonal medications seem to be the only options, these treatments come with significant side effects and cannot guarantee the complete eradication of recurring lesions.

In an article titled, “Male-centric medicine is affecting women’s health” in The Hindu, the author explains that women are less likely to receive appropriate medications, diagnostic tests and clinical procedures even in developed countries such as Canada and Sweden as the stereotype of the “hysterical woman” continues to haunt women even when they need urgent clinical interventions. 

Therefore, it is crucial to implement appropriate interventions, create awareness within the medical community to mitigate bias and push for gender-sensitive clinical trials and equitable allocation of research funding. These measures are imperative to ensure equal and unbiased healthcare for all individuals, regardless of their gender among other identities.

Fortnightly figures

  • 10.3% was the decrease in India’s merchandise exports in May 2023 at $34.98 billion from $39 billion in May 2022. Imports contracted at a slower 6.6% rate to $57.1 billion, lifting the trade deficit to a five-month high of $22.1 billion. This is the sixth time in the last eight months that goods exports have declined year-on-year, although May’s decline was lower than the 12.6% fall recorded in April.
  • 110 million people have had to flee their homes because of conflict, persecution, or human rights violations, the UN High Commissioner for Refugees (UNHCR) said. The war in Sudan, which has displaced nearly 2 million people since April, is but the latest in a long list of crises that have led to the record-breaking figure. Last year alone, an additional 19 million people were displaced, including more than 11 million who fled Russia’s invasion of Ukraine in the fastest and largest displacement of people since World War II.
  • 1 lakh people were shifted to approximately 1,500 temporary shelters set up as part of the disaster management efforts by the Gujarat State against Cyclone Biparjoy before the cyclone made landfall. Cyclone Biparjoy caused widespread damage in Gujarat’s Kutch-Saurashtra region as it made landfall late on June 15, Thursday. The Gujarat government also shut schools and other educational institutions for the next day as the State received heavy downpours in the aftermath of the cyclonic storm.
  • 4.25% was India’s retail inflation in May from 4.7% in April this year, a 20-month low. The price rise in food items faced by consumers moderated to 2.91%. This is the third successive month that inflation has remained below the Reserve Bank of India’s (RBI’s) upper tolerance limit of 6% after a prolonged streak above it. Base effects from May 2022 when retail inflation was over 7% also played a role in lowering the inflation rate this May.
  • ₹1.13 lakh crore was the third instalment of tax devolution released by the Centre to States, according to the Finance Ministry. This surpasses the normal monthly devolution of  ₹59,140 crore. The additional advance aims to enable expedited capital spending, financing of development/welfare-related expenditure and increased resource availability for projects and schemes of the States.

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Fentanyl Test Strips Are Saving Lives, but They’re Just the Start

Feb. 15, 2023 — In December, Texas Gov. Greg Abbott did an about-face on an issue that has been a flash point in the debate over decriminalization of drug paraphernalia: the use of test strips that can detect fentanyl, the synthetic opioid. Abbott had previously opposed legislation legalizing the test strips, but he cited a stunning 89% increase in fentanyl deaths in Texas the prior year. 

“It’s an extraordinarily deadly problem,” Abbott said in a press conference where he explained his change of heart.

More than 100,000 people died of drug overdoses in the United States from September 2021 to September 2022, according to the CDC. Almost 70% of those were from fentanyl and other synthetic opioids. Now, the death toll is causing lawmakers across the country to change their tune.

A Policy Shift

Fentanyl test strips were developed in 2011 to test for the drug in urine by law enforcement, for parents wanting to know what their kids were taking, and for users wanting to know what was in the drugs they previously took. A Johns Hopkins University study in 2018 found that the strips could accurately detect fentanyl in drug residue. Soon after, California and Oregon were among the first states to provide their public health departments with free strips to distribute at needle exchanges.

The strips are simple to use and effective. When dipped in water that contains dissolved drug residue, the strips indicate immediately whether trace elements are contained in a substance, such as heroin, cocaine, or ecstasy. As little as 2 milligrams of fentanyl can be deadly depending on a person’s weight, tolerance, and past usage. 

States across the country have been legalizing fentanyl strips in the hopes of saving lives. Georgia passed a bill in July. Alabama, Tennessee, Pennsylvania, Wisconsin, South Carolina, and New Mexico all did the same. A similar bill has been introduced in Florida’s legislature. These states join some 30 others that have decriminalized the strips and made them available to drug users.

When the strips first came on the scene, they were used to remove fentanyl entirely from the drug supply. But today that’s not as true as it once was because fentanyl is now so prevalent, says Aaron Ferguson of Austin, TX, who advocates for safer drug use through the Urban Survivors Union. The organization hands out strips to people who are thought to be more likely to use some type of precaution to prevent against fentanyl overdose. For example, he recently distributed the strips and naloxone, a medication commonly used to reverse opioid overdoses, to a mother who knew her son was using opioids and wanted him to be safe.  

A Poisoned Supply

“We’re in a drug poisoning crisis,” says Jacqueline Goldman, a research assistant at the Brown University School of Public Health. The crisis has deepened not necessarily because more people are using drugs, Goldman says, but rather “more people are dying from them because they’re so potent.”

Compared to other Western countries, the United States has always had a “puritanical” view of harm reduction strategies to cope with drug use and abuse, says John McIlveen, PhD, the top opioid treatment official for the Oregon Health Authority. “Now is an excellent opportunity to change the narrative,” he says, “because the drug supply is no longer just contaminated with fentanyl, it is fentanyl.”

Because fentanyl is readily available and so potent, people from all walks of life are prone to overdose. “If there’s any silver lining, it’s that views are shifting and we’re finally seeing more acceptance of the test strips and other harm reduction methods that save lives,” he says. 

Losing the Battle

 Even as the strips become more widely decriminalized, they remain an imperfect solution. While the strips are accurate at  detecting fentanyl and its analogues, they don’t tell you how much the substance contains. 

According to Ferguson, the high expense of drugs and the legal risk of obtaining them means that users may be unlikely to toss out a supply of drugs even if a test strip shows signs of fentanyl. And there’s also the risk of a false positive result. A May 2020 study published in the International Journal of Drug Policy found that the strips returned a false positive 10% of the time. This means that the test reads positive when it contains no fentanyl. 

More concerning is the risk of false negative results, especially in pressed pills. The CDC calls it the “chocolate chip cookie effect.” Fentanyl clumps in pill form so when you cut into the pill to test the drug, it’s possible that a portion is free of fentanyl when the pill contains it. The International Journal of Drug Policy study found that false negatives occur in 3.7% of cases. 

What’s more, fentanyl’s potency means that some users are addicted to the high it provides and may be seeking it out rather than avoiding it, says McIlveen. The more the drug supply contains fentanyl, the more users become addicted to it because it’s 50 times more powerful than heroin 

The drug supply is also constantly changing and it’s hard for the strips to keep up. New contaminants like xylazine, a powerful sedative used in cattle and horses, have recently overtaken the opioid marketplace. Xylazine can’t be detected using the strips.

Nora D. Volkow, MD, director of the National Institute on Drug Abuse, says fentanyl test strips need to be available for free throughout the country along with a steady stream of other harm reduction tools, namely naloxone. 

“Currently, an opioid user may see someone overdosing and they don’t have enough naloxone on hand to stop it from happening,” she says. 

Other medications like buprenorphine and methadone help wean patients off fentanyl and other opioids, but they’re not available in many parts of the country. Patients may get a prescription from their doctor, but the pharmacy in their area can’t fill it because they don’t have the medication. 

There are some effective treatments for saving people, such fentanyl test strips, naxolone, syringe service programs, buprenorphine, and methadone, but states are not providing them consistently. In West Virginia, for example, 62% of convictions were for drugs and the state also had the highest number of drug overdose deaths in the nation. The hope is that in the future, more resources will point toward harm reduction rather than incarceration. 

“Discrimination and stigma have resulted in laws that are interfering with the survival of people who take drugs,” Volkow says. 

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