It is a usual sight in the Delhi Metro woman’s coach. A woman propped on her heels, the light of her smartphone shining on her face with her laptop bag hanging off her shoulder. And right next to her, stands another, sifting her flat chappals to balance the weight of her heavy jhola bag that carried all she ever had, the rays of the sun bouncing off her sweating forehead. The boundaries are stark , invisible yet so palpable in this small coach that women on either side fail to find their common ground. A ground that is very real, from where the society and family lie perched on a pedestal higher than their own, where beyond the apparent economic and educational differences between them, their search for an identity brings them to this common ground.  An identity that transcends all boundaries; that will give them the voice to claim forgotten stories.

Tales of women driven to desperation by society and expectations, both unrelenting and unforgiving in their demands are an echo of the costly alienation of these women, in its most grotesque form. Rapes, honour killings, acid attacks, depression and lack of choices – are the stories of the sub continental woman- both rich and poor. And while committed activists speak out, report and write articles resisting a deliberate collusive silencing at both the local and global level, what is quite often missed out is a conversation on holistic woman’s health.

While activists have campaigned for mental health services, breast and cervical cancer, reproductive health and maternal health, their focus of efforts paints a very worrisome picture for the Indian woman – one that threatens to perpetuate the prevailing mindsets further reinforcing the traditional identity thrusted upon the woman– that of being  the breeder and nurturer incarcerated in the homes and hovels of both urban and rural dwellings.

According to a report published by the NCD Alliance, collectively, Non Communicable Diseases are the leading cause of death for women worldwide. They cause 65% of all female deaths, amounting to 18 million deaths each year.  Yet the alarming numbers have failed to attract the attention from activists, committed social health workers and even educated urban women themselves. No longer diseases of the rich and elderly, NCDs are a significant cause of female death during childbearing years and for women with young families in developing countries.

ncdBut open conversations in the public domain are missing. The mores of filial respect dictate boundaries that never permit the public into private, or vice versa; the women being pushed further and further into an isolation where their health needs are accorded the least priority. This gets reflected in the long held misconceptions that Cardiovascular Diseases(CVD’s) are male diseases despite them being the most significant cause of death among women worldwide. There is a wide gap between the perceived and actual risk of CVD among women with very few women actually considering it to be the greatest threat to their health.

What is it that is holding back the Indian woman, both in the rural and urban settings, from seeking preventive and curative healthcare in NCD’s? While most of us might blame illiteracy and financial instability to be barriers between the rural women and the healthcare system, it is despite these setbacks that rural women have shown more interest in seeking healthcare for themselves, when provided access to. The puzzle of the educated, financially independent urban woman hesitant or ignorant of her own healthcare is fraught with complexities that will need a deeper understanding of  women being sidelined and bearing the sentence of being sidelined, both in the family and society.

Much of this centres around the perceptions that have incarcerated the woman – both urban and rural- into predefined set norms built on a foundation of culture, traditions and expectations. Marriageability of girls and women provides the main route to economic and social recognition in both urban and rural areas. Women with NCD’s face discrimination in terms of marriageability, employment, insurance and education. As a two fold result, families shy away from revealing the health status of their daughters and discourage them from seeking diagnosis and treatment. Those who are vocal about it are more likely to be divorced, separated or abandoned by their husbands, leaving them financially vulnerable.

The traditional division of labour in the Indian household that has unfairly distributed the share of responsibilities towards children, old parents and in-laws and the household to the women has left them with little choice, time or care towards their own health, resulting in an ignorant behavior. Threats to their health never make it to conversations over the dinner table. As the principal care givers in households, the burden of NCD’s in the family also affects them indirectly compromising their educational and income earning opportunities.  Over time this has reinforced among women a decreased health seeking behavior, despite them being at an equal risk of NCD’s.

While the rural women’s limited access to and control over financial resources forces her to prioritise her own health care needs much lower than those of her family’s, in urban settings, the financial empowerment has not translated into an increased health seeking behavior among women. Interestingly, the barrier lies in the deeply entrenched patriarchy that surfaces in subtle forms in the urban households. A woman’s independent decision making power over her own health is overshadowed by an explicit approval and validation from the male head. Lurking doubts in a woman’s mind regarding her own health, emanating partly from her lower socio-cultural and educational status in the family and partly from a lower awareness about NCD’s in the society, begs a male to lead the woman on her health care journey.

Geographical distance is a significant barrier to accessing healthcare for almost all women in rural settings and remote locations, but the constraints with regard to mobility or access to private or public transport haunt both rural and urban women. Social expectations requiring women to remain at home, not travel alone for fear of crime or violence discourage women from walking into health camps or centres unaccompanied by their husband or father.

The long held perception that sports is “unfeminine” coupled with the social norms surrounding dress and the curtailed physical mobility for many girls and women in developing countries has restrained women for long. This is not just a direct infringement of freedom of choice, but also rendering the women more vulnerable to NCD’s.

With tobacco companies targeting girls and women with zealous well funded marketing campaigns that promote tobacco use with independence, beauty, femininity and sex appeal, women’s ability to make well informed decision regarding their health is further compromised. The belief that it relieves tension and facilitates weight loss thrives on deepening insecurities around body image and beauty. The “nutrition transition” towards an increased intake of high calorie food rich in saturated fat, sugar and salt owing to rapid urbanization has significantly impacted the health of not just the girls and women, but their families who adopt similar dietary and lifestyle habits.

Women, being the healthcare providers in formal health care settings and within the household, are adequately placed to impact the burden of NCD’s at the global level significantly. Yet, women’s own health care needs are not catered to adequately – in terms of access, comprehensiveness, responsiveness. The global response to the NCD epidemic has often missed out on the significance of girls and women, given the pivotal role they play in family nutrition and lifestyle habits. As an important key of intervention, activists, policy makers and health care professionals must steer their focus towards this invisible epidemic that kills 18 million women worldwide every year. We, as family members, have a moral responsibility to initiate conversations with our mothers, wives, sisters and daughters regarding their health, both preventive and curative. But before health programs and movements take up the cause, it is imperative for women themselves, to claim their identity in the society as more than just a facilitator in the household.