How the COVID-outbreak magnifies the call for more attention to women in global health

The COVID-19 pandemic has resulted in chaos around the world regarding containment of the spread, the organisation of care and minimising economic impact. While there are no winners in the fight against this virus, there are clearly losers, women being among these losers. Therefore, the COVID-19 outbreak magnifies the need for more attention to the role of women in global health. Following the transdisciplinary approach, this blog will emphasise several important fields that illustrate the current lack of a gender perspective in global health in the face of COVID-19: representation, health care, economics, education and safety.


Representation of women

Over the last months, national governments brought together their top experts in taskforces to set out a strategy to control COVID-19. An important task reserved for people with knowledge in the field of interest, in this case health care. While one would think gender has nothing to do with using expertise in times of crisis, the organisation Women in Global Health found that there is a massive underrepresentation of women in these taskforces: only 10% of the members of national emergency taskforces worldwide are female. Which is remarkable, as more than 70% of the workforce on the frontline of the corona-crisis is female.

Underrepresentation of women in taskforces is not only found on national levels; only 20% of the WHO Emergency Committee on COVID-19 and only 16% of the WHO-China joint mission on COVID-19 is female. This inequality in representation is further exemplified by the underrepresentation of women in the media during the COVID-19 outbreak. In April, Women in Global Health found that - despite the many female experts in the field of global health and security - only one woman was quoted for every three men in media coverage of the COVID-19 outbreak.

Only 10% of the members of national emergency taskforces worldwide are female, whereas more than 70% of the workforce on the frontline of the corona-crisis is female.

This underrepresentation of women correlates with the overall gender bias in the global health sector where women often are not represented in leadership positions. While it is well-established that women make up approximately 75% of the health workforce globally, various gender inequalities have been recorded. For example, in (leadership) opportunities, pay and management within the global health sector, research found a bias towards men. A textbook example of this gender gap is found in the fact that only 25% of member state chief delegates in the World Health Assembly are women.


While some could say that these are just numbers, this can have a massive impact on how the COVID-19 outbreak is managed. Governments, international agencies and media outlets informing the public currently miss out on the critical expertise of women. By neglecting the gender dimensions of health emergencies, including the role of women in health care, the WHO is not reaping the benefits the entire global health talent pool. Moreover, researchers agree that gender equality in the global health community promotes economic growth, improves nutrition, lowers fertility and reduces child mortality. For example, the wider consequences of epidemics on reproductive, maternal and child health are addressed in an earlier stage when women are part of taskforces. In addition, looking the WHO as an organisation but also the emergency taskforces, there is growing evidence that gender-diverse workplaces improve productivity, decision-making, innovation and employee retention and satisfaction.

Women are part of the solution to containing the virus, but they need to get a place at the decision-making-table first.

Simply put, the world misses out on the expertise and valuable addition of women in institutions and governments combatting the COVID-19 outbreak. Women are part of the solution to containing the virus, but they need to get a place at the decision-making-table first.


Health care

However, when investigating the role of women in dealing with a crisis such as COVID-19, we cannot just look at the topic of representation; most people would agree that health care itself is also a key topic. Looking at the health care sector, an emphasis on the gendered

nature of the health workforce and the indirect health risk that women face is crucial, and yet missing. As mentioned above, women represent the largest share of health care force working with COVID-19 patients and they ultimately put themselves at risk. Especially given the shortage of medical protection materials like medical masks, women face greater risks of contamination. This was also seen during the outbreak of the Ebola virus in West-Africa between 2014 and 2016: researchers found that as women had a predominant role as the caregiver within families and as health-care workers, they were more likely to be infected. Moreover, research has shown that women also – disproportionately – provide invisible care and conduct domestic labour in households and communities. Carrying out informal care and labour can also negatively affect women’s health and wellbeing. This unpaid health care is fundamental for global health, but is often not recognised by (international) institutions and governments. During a health emergency, these unpaid health care roles become even more important, but also more dangerous – especially if not seen or recognised.

A gender perspective should be included in crisis responses and the global health approach.

Aside from risks women face as carers, experiences from past outbreaks show that women’s health needs are largely unmet during health emergencies. During the Zika-virus outbreak in 2015 and 2016, resources meant for improving reproductive and sexual health were used in the emergency response instead, which contributed to a rise in maternal mortality in a region This phenomenon was also seen during the Ebola-outbreak in 2014: maternal mortality in West-Africa increased by 75% and the number of women giving birth in health clinics decreased by 30%. To be more specific: in Sierra Leone the decrease in use of life-saving health services caused 3600 additional maternal, neonatal and stillbirth deaths in 2014-15 (in the most conservative scenario). Moreover, during the Zika-virus outbreak, insufficient financial resources to travel to hospitals made it harder for women to receive health check-ups for their children. Focusing on the autonomy of women and the principle of equal access to health care, earlier epidemics have demonstrated the necessity for extra attention for women in health emergencies.

Given the crucial role of women in health care on the one hand; and the previous health emergencies showing an increase in maternal and child mortality and a decrease in autonomy of women in crises on the other hand, it is concerning that women have not been fully incorporated into the approach to counter COVID-19.


Economics

As can be seen in the current discussion in regard to measures to prevent a second wave of COVID-19, health crises also spark discussions on the economy. In the economic field, one can identify a similar disproportionate risk for women. Since the 1960s, the movement of women from reproduction to production had a huge impact on the nature of women’s health. Meaningful participation in economic decision-making at all levels has a positive impact on women’s (experienced) health. But with the outbreak of COVID-19, the risk of regressing to gender dominant roles in the home increases, which has a negative and reversing impact on women’s economic empowerment.

The risk of regressing to gender dominant roles in the home increases, which has a reversing impact on women’s economic empowerment.

Why? First of all, due to school closures many dual-income-families have to decide who will (temporarily) reduce their working hours to take care of the children. Globally, women are paid less than men: for every dollar a man earns, a woman earns 77 cent. This is also observed in the global health workforce: as mentioned before, women make up the majority of this workforce, but there is a 28% gender pay gap. Additionally, this is in the positive scenario that women are participating in the labour market, something that cannot be taken for granted: while 94% of men between the age of 25 and 54 work, only 63% women work and this is often part-time. As women’s jobs are less time-consuming and less profitable, their jobs are often considered a lower priority. Therefore, it is likely that in an emergency, women put their job on hold to care for and educate the children. Secondly, the current restrictions put in place by governments to contain COVID-19 (for example travel restrictions and closure of the catering industry) target women disproportionately. For example, women are over-represented in hospitality, a sector highly affected by the restrictions.

It is likely that in an emergency, women put their job on hold to care for the children.

This impacts the economic empowerment of women now, but also in the long-term. This expectation is supported by evidence from previous health crises. Looking at the Ebola-outbreak, academics found that the crisis had deep, long-lasting effects on gender equality: while everyone’s income was affected, men’s income returned to pre-outbreak rates faster than women’s income. Moreover, due to declining rates of childhood vaccination, many children contracted preventable diseases later on, forcing their mothers to take time off or terminate their work.


By failing to provide special attention to the economic position of women during the current health emergency, the economic empowerment movement of many women can be reversed, with myriad associated health consequences. This not only has major effects on women today, but can have long-lasting effects on gender equality and economic freedom in the long run.


Education

While in The Netherlands, the Outbreak Management Team (OMT) is doing everything they can to keep schools open, the discussion on school closures continues worldwide. The school closures due to COVID-19 are likely to have a differential impact on women and girls compared to men and boys, for many reason. Girls’ access to education is associated with a decrease in child and maternal mortality rates, decrease in child stunting, decrease in child marriage, increase in girls’ lifetime earnings and an increase in national growth. But earlier health emergencies show that school closures have major impact on girls on the short and long term. During Sierra Leone’s Ebola-outbreak, school closures resulted in “a reported increase in adolescent pregnancies”. Similarly, in villages highly disrupted by Ebola, girls were “10.7 percentage points more likely to be become pregnant, with most of these pregnancies occurring out of wedlock”. Some even give a higher estimate of 65 percent. In addition, many girls did not return to schools in Sierra Leone once they reopened. A painful discovery was the increase in numbers of unwanted sex and transactional sex in the years after the crisis which is likely to be related to school disruptions.


While it is well-established that education has a (long-term) positive impact on health; and that earlier health emergencies have shown the major negative impact of education disruption on women, the argument for the protection of girls seems to be non-existent in the discussion on school closures.


Safety

The disruption of education caused safety risks for girls in Sierra Leone. But there are additional reasons for why more attention should be given to the safety of women and girls in an epidemic. In times of self-isolation there is a higher chance of the occurrence of domestic violence. There is a widespread consensus that the risk of gender-based-violence escalates during times of crisis, such as wars, disasters and epidemics. For example, in the wake of an earthquake in New Zealand there was an 53 percent rise in intimate partner violence. That the current crisis causes an increase in domestic violence was already noticed in China in April: compared to the previous year the number of domestic violence cases reported to the police tripled.

In times of self-isolation there is a higher chance of the occurrence of domestic violence.

Additionally, in times of crisis, it is harder for victims to seek help. While some victims might need medical help for their injuries, medical facilities around the world are closed or overloaded. Victims who try to escape their abuser have few places to go. Where some women used to find refuge at their parents’ home, they now do not want to potentially expose their elder parents to the virus. Moreover, research found that travel limitations hinder women’s ability to seek shelter. For example, when in Bangladesh travel restrictions were put in place, women experienced increased intimate partner violence as they spend more time with their (potential) perpetrators.


Conclusion

Issues of representation, health, economics, education and safety are examples of the many ways a health emergency influences the lives of women and girls across the world. In the Thirteenth General Programme of Work, the WHO stated to pay particular attention to vulnerable groups, like women, during an health crisis. However, looking at the numbers on representation of women in COVID-19 taskforces worldwide and the lack of attention given to issues as care by and for, the economic position of, the education for and the safety of women (the WHO only made a statement about this in mid-April!), one could conclude that currently, insufficient attention is given to the impact of the COVID-19 health crisis on women. Now, during the current crisis, but also in future health emergencies, a gender perspective should be included in crisis responses and the global health approach. This COVID-19 outbreak just magnified the existing female deficit in global health. Therefore, I hope that this will be the last crisis to exemplify the need for including a gender perspective in the global health agenda, workforce and organisations.


Written by Bente van Oort, Master student Global Health