Cardiovascular disease is widely seen as a man’s issue in India, even as women are at heightened risk of negative health outcomes. Gendered expectations around lifestyle habits and family responsibilities make it doubly harder for women to seek preventative, emergency and follow-up care.
After two days of chest pain and excessive gas, Mariman Khatoon finally consulted a doctor. An initial check-up revealed that the 60-year-old had had a heart attack and needed an angioplasty—a surgical procedure to widen blocked or narrowed blood vessels supplying the heart, which usually involves inserting a stent.
Khatoon’s right artery was completely blocked; her left artery was 70% blocked, which doctors believed had caused a previous heart attack that went unnoticed. She required two surgeries to place stents in her heart.
Khatoon lives in Govindpuri, a lower-middle class suburb in Delhi. Her story is typical of many women in India with heart-related problems who delay seeking medical care.
“In general, women approach health facilities very late,” says Dr Varsha Koul, an interventional cardiologist and Khatoon’s treating doctor at Batra Hospital & Medical Research Centre in Delhi. “In almost all cases of heart attack and heart failure, women never approach us within the golden period of one and a half hours [when it is possible to reverse the effects of a heart attack]. Thus, they come with damaged hearts which cannot be fully recovered.”
“There is a general perception in India that women are less affected with hypertension—it’s a myth.”
Yet another problem that Khatoon shares with many of her countrywomen is stress, which is often driven by family and social pressures. Chronic stress is a primary risk factor for heart disease. “My daughter has crossed the marriageable age,” Khatoon says. “That worries me, and I want her to get married. Our finances are also not stable. These things give me a lot of tension.”
Her husband sells fruit in a small roadside shop, or ‘thadi’. Her son works as a clerk in an office. The family of seven has a monthly income of INR25,000 (US$305). It was the son’s insurance cover through his job that helped pay the INR2.5 lakhs (US$3,000) required for Khatoon’s treatment. Six months on, she suffers from sleeplessness, headaches, and poor appetite as a result of the delayed treatment.
Despite heart disease being the leading cause of death among women in India, cardiovascular disease (CVD) remains under-recognised, under-diagnosed and under-treated. Risk factors and effective treatments are well-understood, yet the gender dimension remains unaddressed.
Towards a deeper understanding of women’s risk
It is believed, especially in low- and middle-income countries (LMICs) like India, that CVD mainly affects men and not women. Yet a growing body of evidence points to risk factors for Indian women approaching dangerous levels.
A 2022 study by the Public Health Foundation of India that analysed hypertension—a major modifiable risk factor for CVD—among men and women showed that the risk among women increases with age. “There is a general perception in India that women are less affected with hypertension—it’s a myth,” explains co-author Dr Ambarish Dutta from the Public Health Foundation of India.
“While the prevalence is low at younger ages, our study showed that after 50 years of age, Indian women are much more prone to hypertension than their male counterparts. This aspect has not been looked into before with large nationally representative Indian data, and should be a cause for concern.”
Indeed, data from the fourth round of the Indian National Family Health Survey shows 31% of men aged 50-54 are hypertensive, compared to 38% of women. It is striking that in the 65-69 age group, the proportion reaches 39% for men and 51% for women. The Longitudinal Ageing Study of India, another prominent data set detailing health in the country, reports similar conclusions.
There is some scientific explanation to this pattern, Koul explains. “Women have the hormone oestrogen, which provides protection from CVD. But in the post-menopausal stage, oestrogen levels decline, leading to increased risk of CVD.”
What is especially noteworthy, Dutta says, is “the pattern found in our study is similar to what we see in high-income Western nations, even though the lifestyles are very different. For example, women in India have lower consumption of alcohol and smoking, which are risk factors for hypertension and other CVDs, but that does not reflect in them having lower rates of those diseases.
“It is possible that psychosocial stress and financial burden may be negatively compensating for less substance abuse, but this is a matter of further research.”
How gendered expectations influence health
Lifestyle patterns perhaps help explain the gender difference in the incidence of CVD, explains Dr Devaki Nambiar, a programme director at the George Institute for Global Health India.
"As women are primary caregivers in the family, there is a tendency among them to ignore chronic diseases such as hypertension and diabetes."
“The nutrition pathways for women and men are very different in India,” she says. “Since childhood, there’s more focus on providing more nutrition to male children, and chronic undernutrition is seen among young women. This continues in older ages as women eat [after the family] or leftovers, compromising nutrition. This impacts chronic disease, including CVD.”
Women also tend to give less priority to exercise, which is exacerbated by lack of access to parks and other public spaces, she says. “Concerns of safety and security add to the already existing reservation against exercise,” Nambiar says.
As one of the few female cardiologists in India, Koul has been able to gain a deeper insight into the lives of her female patients. “They go through a lot of household-related tensions and worry about finances being spent on their treatment. They want to be discharged [from hospital] sooner, as they get anxious about day-to-day management of the house. For them, their health is really a secondary consideration.”
Poverty is an underlying factor of poor healthcare among women in India. In the case of 65-year-old Kamni Begum, only one-quarter of her heart was functional by the time her family travelled 250km to bring her to a Delhi hospital.
“She had fainted three days earlier, and before that she had vomited and complained of anxiety,” says her daughter-in-law. “We took her to a nearby hospital and the doctors said that she had a heart attack. There is no tertiary care hospital in our district, so we brought her to Delhi.” Begum did not take any medication, but tests revealed that she had been suffering from hypertension and diabetes for a long time.
“As women have less financial opportunities, men are usually considered breadwinners of the family, so their health issues are taken more seriously and acted upon more promptly than women’s,” says Dr Yogesh Jain, a rural doctor based in central India and a commissioner in The Lancet Commission on Non-Communicable Diseases and Injuries (NCDIs).
“As women are primary caregivers in the family, there is a tendency among them to ignore chronic diseases such as hypertension and diabetes.”
Dr J.P.S. Sawhney, chairperson of the Department of Cardiology at Sir Ganga Ram Hospital in New Delhi, says gendered expectations around household management influence attitudes to healthcare among working women, too.
“No woman in India is unemployed as they manage household chores seven days a week,” he says. “Working women are dually employed—they work in offices and come back home to manage the household. There is no consideration in offices about their family duties and family also doesn’t show compassion for hours spent in the office.”
Bias in favour of men’s treatment
Even after women experience a cardiovascular event, they are less likely to access follow-up care, compared with men. A 2021 study published in Health Care for Women International that examined the gendered nature of treatment and rehabilitation among stroke patients in India found bias in favour of men’s treatment, where men accounted for a larger chunk of hospitalisation and rehabilitation expenses.
The difference in continuity of treatment, or follow-up care, was especially stark. While more than 92% of men went to hospitals and rehabilitation centres for follow-up care, the figure was 59% for women.
“Follow-up care, especially rehabilitation, is extremely important among stroke patients,” says co-author Professor Bevin Vijayan from Azim Premji University. “Stroke leaves parts of the brain damaged and recovery, which involves relearning lost skills, takes a long time.”
Given that older people are at higher risk for stroke, women are at greater disadvantage since their need for rehabilitation to regain full functioning is often overlooked by the family, as younger women take over domestic duties.
This discrimination even permeates scientific research, Sawhney says. “Women are under-represented in the clinical trials of CVD medicines. Due to this skewed data, we treat women by extrapolating data of men.”
An examination of 11 clinical trials showed that the proportion of female participants ranged from 19% to just 31%. “We need to move to more focused evaluations in females,” he says.
Closing the gender gap with practical solutions
A long-term strategy to reduce gender-based disparity in cardiovascular health care is to ensure “equality between men and women at all levels” in India, Jain says. “Work in the household should be equally divided between men and women so that women can spend time taking care of themselves. It will also rid them of the stress of being the sole caregiver in the family.”
“Whenever a man is diagnosed for hypertension, his wife should be tested for the same as there is a high likelihood of her having the same issue.”
As an immediate measure, Jain recommends the government proactively screen women for risk factors such as hypertension and diabetes through outreach programmes. “After screening, the government needs to ensure follow-up and treatment for those who need it.” Dutta also suggests that “whenever a man is diagnosed for hypertension, his wife should be tested for the same as there is a high likelihood of her having the same issue.”
“We need to take a life-course approach in health systems,” Nambiar says. “The government must promote exercises among girls at school and create spaces for them to talk about their issues freely.”
She says community groups may be an effective complement, especially to counter the lack of follow-up care among women. “India has a robust culture of self-help groups, where women from the same locality come together as a collective,” Nambiar says. “They hold weekly or fortnightly meetings.
“These spaces need not be reserved only for economic activity. Women can be encouraged to discuss health issues such as non-communicable diseases (NCDs) and learn from each other’s experience. Such collectives can also promote exercise among the members.”
Making public spaces available for exercise can also encourage healthy lifestyle habits, Nambiar says. “In Kerala, the top floors of many primary health centres have been converted into gyms. As these are available free of cost, many people, including women, make use of them frequently. Parks in Delhi have open gyms, and women exercise there in the afternoons after finishing household work.”
Equally important is investing in research and clinical trials that focus on women. “It is now clear that women need attention when it comes to CVD,” Dutta says. “We need to research the risk factors that impact them the most and find solutions. We also need better clinical trials that have a larger representation of women.”
In the policy space, women’s health concerns are generally relegated to maternal and child health and the cancers of women—cervical and breast. The focus must shift towards comprehensive healthcare with gender-specific prevention, screening and treatment efforts. India really needs a change of heart for women’s health.