In 2024, a major meta-analysis of cardiovascular disease in India found something that should have stopped clinicians in their tracks. Among elderly Indians, women had a 33% higher likelihood of developing CVD than men — yet they were significantly less likely to receive timely diagnosis or treatment. The reason was not mysterious. Families, doctors, and health systems were simply less responsive to women's symptoms. The women were there. The disease was there. The system looked away.
This is not a new story. It is not even a modern one. It is, in fact, among the oldest stories in the history of organised human knowledge — the story of medicine being built by men, for men, with women admitted as a special case governed principally by their capacity to reproduce.
What makes 2026 different from every preceding century is that we now have the data. We can measure the gap. We can count the deaths. We can track the years of suffering endured by women who were told their pain was normal, their symptoms were imaginary, their bodies were simply a noisier version of the default model that medicine had always studied. And we can trace that gap back through centuries of texts, traditions, and institutional decisions — from the Charaka Samhita to "modern medicine" — to show exactly how it was built.
To understand why women's health is in the state it is today, you have to go back — not to a single bad decision, a single bad actor, or a single era of neglect. You have to go back to the foundational assumptions baked into every major medical tradition that has ever governed human health. The assumptions differ in their cultural clothing but converge on the same essential claim: that the woman's body is defined by her reproductive organs, that her non-reproductive complaints are probably psychological, and that the male body is the default against which female bodies are measured and found to be a complicated variation.
This convergence is the predictable result of medical systems built by men, with access to medical education controlled by men, operating in societies where women's social value was tied to reproduction. When the people asking the questions have no personal stake in the answers, certain questions simply don't get asked.
What the Texts Actually Say
The Charaka Samhita — one of the three foundational texts of Ayurveda alongside the Sushruta Samhita and the Ashtanga Hridayam — contains an extraordinary clinical characterisation of women that deserves to be quoted directly. In its section on posology, women are described as "unsteady by nature, tender, wavering, easily disturbed and generally delicate, weak and dependent on others." This was not social commentary sitting beside the medicine. It was the medical justification for prescribing weaker, less potent treatments to female patients regardless of the severity of their conditions.
The structural architecture of Ayurveda's eight branches (ashtanga) makes the gendered prioritisation explicit. One of those eight branches — Vajīkaraṇa — is devoted entirely to male virility, sperm quality, and the enhancement of male sexual pleasure. There is no equivalent branch for female sexual or reproductive wellbeing. As scholarly analysis of the Samhitas concludes, "female diseases are peripheral to the medical science of Āyurveda."
The Charaka Samhita physician's oath includes an instruction that physicians should not treat "women unattended by their husbands." Women were simultaneously the objects of Ayurveda's reproductive concern and excluded from its epistemological community — there are no named female Vaidyas anywhere in the canonical texts.
Menstrual Taboo as Medical Prescription
The rajaswala paricharya — the behavioural code for menstruating women in the Charaka and Sushruta Samhitas — is where medical theory and religious taboo became most thoroughly fused. Menstruating women were instructed to sleep on the ground, avoid bathing for three days, refrain from seeing their husbands, and avoid religious spaces. These prescriptions were framed in dosha theory, but their practical effect was to encode Brahminical purity norms into the clinical system with the full authority of medicine.
The normalisation of menstrual restriction makes menstrual pain easier to dismiss, delays the recognition of pathological conditions, and shapes the environment in which girls learn to interpret their own bodies.
The barren wife was considered worthless. Manu lays down that women are created to be mothers, and men to be fathers. This leaves very little scope for elderly women, young widows, or female ascetics seeking medical help.
— Scholarly analysis of the Charaka and Sushruta Samhitas, WisdomLib
Unani medicine — rooted in Galenic humoral theory as transmitted by Ibn Sina's Canon of Medicine — entered India with the Delhi Sultanate and reached its classical form under Mughal patronage. It brought a more systematic engagement with gynaecology and obstetrics than the Ayurvedic mainstream, and medieval Islamic hospitals formally admitted men and women to separate but equivalently equipped wards.
In practice, the purdah system made accurate clinical examination of women structurally impossible. Women described their symptoms from behind curtains. Physical examination was conducted under extreme restriction, or not at all. A system that relied on pulse diagnosis, visual assessment of skin colour, and physical palpation could not function correctly under these conditions.
The Galenic humoral framework classified women as constitutionally "cold and moist" and men as "warm and dry." Since warmth and dryness were associated with intellectual capacity and strength in this system, the constitutional description of women was hierarchical, not merely descriptive. Female physiology was, by the theoretical architecture of Unani, an inferior variant of the male norm.
Their story can also teach us a lesson today. In both medical and non-medical literature, one often finds statements in which male authorities make absolute claims about what is, or is not, permissible. Not infrequently, such statements serve the purpose of curtailing women's freedom.
— Pormann, "Female Patients and Practitioners in Medieval Islam," The Lancet
When the British established medical education in India, they did not arrive with a clean slate. They imported the biases of a Western medical tradition that had spent the better part of a century formally excluding women from clinical research, and layered those biases onto a subcontinent whose own traditions had their own distinct architecture of female marginalisation.
The most consequential colonial intervention was the systematic dismantling of the dai tradition — India's community of birth attendants. The campaign against dais was framed as modernisation. What was destroyed was a multigenerational body of empirical, experiential, women-centred obstetric knowledge. The colonial replacement — institutional hospital delivery — was unavailable to the vast majority of rural women. They were left with neither.
Calcutta Medical College admitted only male students initially. The medical knowledge system that emerged from colonial India was doubly male-filtered: imported from a Western tradition that excluded women, and practised by an Indian professional class from which women had been formally barred. Indian women entered formal medical education only through the sustained advocacy of figures like Anandibai Joshi (first Indian woman to obtain a medical degree, in the United States, 1886) and Kadambini Ganguly.
Modern allopathic medicine promised to be different. It promised evidence, rigour, reproducibility. What it delivered, for most of the twentieth century, was the same default in scientific clothing: male subjects, male norms, male-calibrated everything — with the added authority of peer review and institutional prestige.
In 1977, the FDA issued guidelines recommending the exclusion of "any premenopausal woman capable of becoming pregnant" from Phase I and Phase II drug trials, in response to the thalidomide tragedy. The policy lasted sixteen years. Eight of the ten drugs withdrawn from the US market between 1997 and 2000 were pulled primarily because of women's health risks that pre-approval, male-dominated trials had failed to detect.
The NIH Revitalization Act of 1993 mandated female inclusion in federally funded research. The NIH's Sex as Biological Variable (SABV) policy in 2016 required sex-disaggregated analysis. Progress was real. But a five-year internal NIH review found that less than half of studies including both sexes actually reported results disaggregated by sex. Inclusion without analysis is, as researchers have noted, inclusion theatre.
Cardiovascular disease is the leading cause of death in women globally. In India, the figures carry their own particular weight: Indians account for 60% of the world's heart disease burden despite representing under 20% of its population. And within India, 2024 data shows that Indian women have a higher prevalence of CVD than Indian men — 38.85% versus 31.06% among the elderly — yet women have higher mortality from cardiovascular disease because of, as researchers put it plainly, "differential access to health care between the sexes."
The canonical description of a heart attack — crushing chest pain radiating to the left arm — was derived almost entirely from research on men. Women, especially those under 55, are significantly more likely to present with atypical symptoms: jaw pain, severe fatigue, nausea, back pain, shortness of breath. The Framingham Heart Study, whose findings have shaped global cardiology for seventy years, found that premenopausal hormonal protection made younger women "low-risk" for CAD — a conclusion that became, as a 2023 Indian cardiology review documents, "the root cause of major gender bias in CAD," misleading physicians into treating younger women's chest pain as psychological.
The concepts that women are less affected by CAD came from landmark Framingham Heart Study findings. The prognosis of women with angina appeared more favourable, which created gender bias that persists to this day.
— Vijayalakshmi et al., Indian Journal of Cardiovascular Disease in Women, 2023
Endometriosis affects an estimated 42 million Indian women — roughly 1 in 10 women of reproductive age, a prevalence comparable to diabetes. The ICMR's 2023 Endometriosis Burden Study found that the average Indian woman waits 7.2 years for a correct diagnosis, occurring in a country with only one endometriosis specialist for every five million women.
A 2024 PMC qualitative study of Indian women with endometriosis recorded diagnostic delays ranging from zero to 21 years. Three converging factors were identified: a complete lack of awareness about the condition before diagnosis; misdiagnosis with pelvic inflammatory disease or fibroids; and, most damaging, healthcare providers dismissing symptoms — often suggesting the pain would subside after marriage or childbirth.
"I had a doctor who told me repeatedly to get married and have children — it would cure my endometriosis." This was not a historical anecdote. It was a participant aged 30, speaking about recent experiences in the Indian healthcare system. The instruction to manage a chronic inflammatory disease through reproduction is not an outlier — it is a documented, recurring clinical response that reflects the persistence of the view that women's non-reproductive pain is most relevantly addressed through their reproductive function.
In the UK, the picture is striking for a different reason: diagnosis times have been getting worse. A 2024 Endometriosis UK survey of 4,371 patients found the average diagnosis time had risen to 8 years and 10 months — an increase of 10 months since 2020. If a high-income country with advanced medical infrastructure cannot close this gap, India — with 170 times the number of affected women and a fraction of the specialist density — faces a challenge of an entirely different order of magnitude.
Even though endometriosis is as common as diabetes, affecting one in ten women, it takes years to get a proper diagnosis. The pain ruins life — and we still routinely tell women it is normal.
— Dr. Manali Shilotri, Gynaecologist, Horizon Prime Hospital, 2024
A Nature review published in March 2025 states the case plainly: "The medical field has treated women as 'smaller men' for too long." Of 86 commonly used drugs examined in a comprehensive pharmacokinetic review, 76 exhibited clinically relevant sex-based differences. Meaning, women experience adverse drug reactions at nearly twice the rate of men globally.
The physiological basis is well established. Women have different liver enzyme activity (notably CYP3A4 and CYP2D6), different gastric emptying rates, different body composition, different renal clearance, and different hormonal modulation of drug targets. These affect the efficacy and safety of drugs across every major therapeutic class.
The sleep drug zolpidem is the canonical case. Its standard dose was calibrated on male pharmacokinetics. Women were experiencing significant next-morning cognitive impairment and impaired driving at the same dose. A 2023 review in Frontiers in Pharmacology documents that it took the FDA until 2022 — twenty years after the drug's approval — to require a sex-differentiated dose. For two decades, women were being routinely overmedicated by a drug never properly tested on their bodies.
A 2025 Nature analysis notes that approximately 80% of non-clinical studies use only male animals. If a compound is optimised in male cells or male mice during early development, any sex biases in those models are carried into every subsequent phase and into the prescriptions written by doctors told the standard dose is universal. Only 4% of COVID-19 clinical trials actively sought to recruit women — despite clear evidence of sex-differential infection rates, drug responses, and mortality risks. (Nature, 2025)
India's situation is distinct not because any one of its medical traditions was uniquely cruel to women — all of them shared variants of the same foundational failures. It is distinct because those failures have compounded across millennia without being systematically addressed, and because the modern health system that was supposed to break the cycle imported the biases of Western medicine on top of its own.
The Post-Independence MCH Tunnel
India's public health system after independence addressed women's health almost entirely through the lens of Maternal and Child Health (MCH). The Janani Suraksha Yojana, launched in 2005, achieved real results: India's maternal mortality ratio declined from 398 per 100,000 live births in 1998 to 97 in 2023 — a reduction of over 75% in 25 years. That is a genuine achievement.
But the MCH framework meant that healthcare investment and research were organised around the pregnant woman — not the woman. NCDs now account for 53.5% of female deaths in India, up from 33% in 2000. The health system successfully reduced the number of women dying in childbirth, while the same women were dying in growing numbers from cardiovascular disease and cancer in a system that had barely begun to study these conditions in the context of female physiology.
Without actions that specifically target women, public healthcare spending is effectively pro-male. In a setting with entrenched gender biases, gender-neutral policies will not suffice and may aggravate existing disparities.
— Dupas & Jain, 2021, cited in International Growth Centre, Women and Health in India, 2024
The Access Gap That Never Closed
Studies of hospital attendance patterns in India consistently find that women are underrepresented in non-obstetric outpatient visits relative to their share of the population. The opportunity cost of healthcare time falls disproportionately on women; male family members are more likely to prioritise getting male patients to care; and women themselves, after generations of having their symptoms normalised or dismissed, are less likely to present with non-acute complaints.
The IGC's research found that women in India have worse diagnostic outcomes than men even for symptomatic conditions where objective diagnostic criteria exist — because men and their families are simply more responsive to perceived ill-health signals. The "responsiveness gap" operates before the patient ever reaches a clinic, at the household level, in the daily decisions about who matters enough to get medical attention.
When you look across all five traditions and ask which one marginalised women most severely, the answer is more complicated than a simple ranking.
Ayurveda's marginalisation was the most structurally embedded. It had the longest uninterrupted influence on the Indian subcontinent, encoded female inferiority directly into its theoretical framework, excluded women from formal medical knowledge production entirely, and fused medical prescription with religious taboo in a way that proved extraordinarily difficult to disentangle.
Unani's marginalisation was significant, but partially offset by its institutional architecture. Its bimaristans were in theory gender-inclusive; its clinical literature contained more systematic gynaecological content than Ayurveda's. What undid these theoretical advantages was the purdah system — the social barrier that made the formal machinery of Islamic medicine inaccessible to the very patients it was supposed to serve.
Modern allopathic medicine's marginalisation is the most consequential today — not because it is the most extreme but because it is the one currently operating, and because it has the scientific capacity to do better and consistently chooses not to at the institutional level. A tradition that has the pharmacokinetic data showing women metabolise zolpidem differently and takes twenty years to adjust the dose is operating from indifference.
The Question We Keep Not Asking
There is a through-line connecting the Charaka Samhita's description of women as "unsteady and wavering" to the Indian emergency room where a woman with cardiac symptoms is more likely to be told she is stressed than sent for an ECG. The through-line is not malice. It is something more durable: the assumption, built into the structure of every medical tradition, that the default body is male, and that female biology is a complication to be managed around rather than a subject to be understood on its own terms.
India's 25-year reduction in maternal mortality is real, meaningful, and worth celebrating. That capacity exists. The question is whether it will now be directed at the full range of women's health — at the 42 million women with endometriosis waiting 7.2 years for a diagnosis, at the women with cardiovascular disease who are 33% more likely to have it than men but less likely to be treated for it, at the millions taking drugs calibrated on male bodies and prescribed as universal.
The ancient texts cannot be rewritten. The colonial intervention cannot be undone. But the clinical trials can include women and disaggregate their results. The diagnostic thresholds can be recalibrated. The medical school curricula can teach the sex-specific symptom presentations that the current generation of physicians was never taught. The policy framing can move from maternal and child health — which is about the woman as mother — to women's health, which is about the woman as a person with a body that deserves to be understood.
The cost of not doing this is not abstract. It is 19,000 maternal deaths a year, 42 million women with a decade-long diagnostic delay, and a cardiovascular epidemic in a female population that medicine still hasn't fully admitted is there.
Key Sources
India — Clinical: Padhi et al., "Inequalities in CVD Among Elderly Indians," Current Problems in Cardiology (2024) · Vijayalakshmi et al., "Gamut of CAD in Indian Women," IJCDW (2023) · ICMR Endometriosis Burden Study (2023) · PMC qualitative endometriosis study, India (2024) · SRS Maternal Mortality Data (2023)
India — Policy: International Growth Centre, "Women and Health in India" (2024) · Balsarkar, "Significant Decline in MMR in India," JOGI (2023) · Dupas & Jain, "Women's Healthcare Access in Developing Countries" (2021)
Global — Clinical: Jenkins et al., The Lancet eClinicalMedicine (2025) · Guzikevits et al., PNAS (2024) · Nature, "Women Poorly Represented in Clinical Trials" (March 2025) · Frontiers in Pharmacology, sex differences in ADRs (2023) · Endometriosis UK Diagnosis Time Survey (2024)
Historical: Charaka Samhita; Sushruta Samhita; Cleghorn — Unwell Women (2021); Dusenbery — Doing Harm (2018); Criado Perez — Invisible Women (2019); Pormann, The Lancet (2009)
