Thinking about gender while responding to an epidemic: Must have or nice to have?
March 2020 is unique in that it is both Women’s History Month and the month when WHO declared the novel coronavirus disease (COVID-19) a pandemic. Lessons learned from previous disease outbreaks of other coronaviruses (MERS and SARS), Ebola, and Zika, have highlighted the lack of gender considerations in epidemic preparedness and responses, and its consequences. Julia Smith, Research Associate at Simon Fraser University, writes “the gender dimensions of outbreaks are both physical and socially constructed.” Physical in that diseases may affect people differently based on their sex. For example, Zika infections can be passed to fetuses during pregnancy, and traces of Ebola have been found in men’s semen long after they have recovered from the disease. Gendered social constructions refer to different roles, behaviors, and attributes associated with being male or female. This can be seen in the Ebola outbreak’s effect on women, who as frequent caregivers, both at home and in the healthcare setting, were at greater risk of exposure to the virus.
“Tyranny of the urgent” vs resilient health systems strengthening
Gender, as described in The Lancet’s series on gender inequities and health, is both an underlying factor in health systems functions and components, (i.e. laws, policies, and guidelines; human resources; data collection; service delivery, etc.), all of which have an effect on health outcomes. However, gender considerations are often not prioritized in disease outbreaks and fall to what Davies and Bennett call the “tyranny of the urgent,” which defers “structural issues in favour of addressing immediate biomedical needs.”
After the Ebola outbreak, global health stakeholders prioritized investments in building resilient health systems—systems with the “capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, [are] informed by lessons learned during the crisis.” While gender considerations have historically not been prioritized in health systems strengthening, there is a growing recognition of the need to use a gender lens when thinking of the “who, what, when, where, why, and how” in interventions to strengthen health systems and a country’s ability to effectively respond to health crises.
Using lessons from previous outbreaks to protect healthcare workers today
The global and national responses to the COVID-19 pandemic may already have fallen into similar patterns as previous disease outbreaks. Smith and Wenham of the Gender and COVID-19 Working Group note that as of early March 2020, global and national COVID-19 policies had yet to reflect gender analyses or considerations. Rather than wait for another report written at the end of this pandemic, offering us what will likely be all too familiar insights into the gender aspects of COVID-19, let’s glean what we can from the current, albeit rapidly changing, epidemiology of COVID-19 and current social dynamics to apply previous lessons to the present situation.
As in previous infectious disease outbreaks, particularly Ebola, healthcare workers, formal and informal, are the first line of defense against further disease spread. Globally, women comprise 67% of health and social sector employment, though are underrepresented in leadership positions, and are the main contributors to the unpaid and informal health workforce. Even among healthcare workers, the risk of contact with infected patients depends on their occupation, for example, male healthcare workers make up the majority of physicians, dentists and pharmacists, while females are the vast majority of the nurses and midwives. Close, personal care required for sick patients relies heavily on nurses and nursing assistants, thus leaving them at even higher risk among the healthcare workforce, particularly if there’s not enough available protective equipment (i.e. masks, gloves, etc.). Furthermore, in most contexts women are the caregivers at home, contributing to both further exposure during disease outbreaks. Consequently, the intersection of gender and healthcare workforce must be considered to effectively respond to an epidemic.
Global health programs such as the USAID-funded, Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program is supporting countries in strengthening their infection prevention control (IPC) capacity to improve epidemic preparedness and responses. IPC activities include patient placement, hand hygiene, and use of personal protective equipment. These activities are focused on ensuring healthcare workers adhere to guidelines and procedures, and prevent the spread of hospital acquired infections that may contribute to antimicrobial resistance and the spread of disease. Implementing partners and other stakeholders assisting countries to prepare for and manage the COVID-19 outbreak should resist the tendency towards the “tyranny of the urgent” and instead integrate gender considerations into COVID-19 responses to avoid exacerbating the effects of structural gender inequalities.
Gender considerations for healthcare workers
The following are suggestions on how healthcare leaders and implementing partners can increase gender awareness in preparing and responding to COVID-19.
Sex disaggregated data. At a minimum, programs and health facilities should collect, analyze, and report sex disaggregated data for COVID-19-infected patients and healthcare workers who become infected.
Disaggregate data for COVID-19-infected healthcare workers by occupation. It is important to track these data, knowing that staff who provide close, personal care, such as nurses and nursing assistants, may be at higher risk of exposure and therefore IPC activities may need to be tailored to those roles.
Contact tracing for infected healthcare workers. Investigate to see if an infected healthcare worker was infected at home or in the health facility. Women who are healthcare workers tend to be primary caregivers at home, so knowing whether infections are acquired at home or in the healthcare setting is key to understanding transmission patterns.
Planning to protect high-risk healthcare workers. Healthcare workers can be in the high-risk category—be older than 65 years, have asthma or HIV, or be pregnant. Health facilities and implementing partners offering technical assistance should have plans in place that reduce potential exposure to high-risk healthcare workers, while also maintaining privacy to workers’ health information.
Non-punitive leave for healthcare workers. Challenges in human resources for health vary significantly by context, particularly in low and middle income countries where there often is uneven capacity and high rates of absenteeism. Ideally, healthcare workers have paid sick leave and family leave, however, that’s not always the reality. At a minimum, healthcare workers who must take a leave of absence due to COVID-19 exposure or infection, should not be punished, as this disincentive may result in people coming to work when they should be at home.
Encourage upwards communication within healthcare settings. Clear and consistent communication with decision makers and healthcare leaders is essential during a crisis. Health facilities should have focal points by occupation to represent staff concerns, including issues around patient care and resource management, which should increase the voices of women, while also providing leaders with timely information.
Ensure community-based best-practice communication and outreach strategies reach household caregivers. This may include going house-to-house to inform caregivers and their households on best practices, ensuring information provided is both in local languages and in diagram form, and, where possible, providing households with soap, clean water and protective gear.
We are still learning and we should expect to keep learning for the long run. Weekly and even daily, our global response to COVID-19 is adapting as new data and lessons emerge. These suggestions represent only some of the ways that COVID-19 response efforts can begin using a gender lens during times of epidemic preparation and response. Though we’re nearing the end of Women’s History Month, let’s use this momentum in recognizing the need to increase gender considerations for healthcare workers, and apply them in April, which, coincidentally, will celebrate World Health Worker Week from April 5-11, 2020.
Useful commentaries on gender and COVID-19
- How Will COVID-19 Affect Women and Girls in Low- and Middle-Income Countries? Center for Global Development.
- The COVID-19 Outbreak: Potential Fallout for Sexual and Reproductive Health and Rights. Guttmacher Institute.
- The Coronavirus Is a Disaster for Feminism. The Atlantic.
- Coronavirus: Five ways virus upheaval is hitting women in Asia. BBC News.
This blog was written by Gloria Twesigye, Senior Technical Advisor for Research and Reporting, MSH with contributions from Carol Tyroler (Senior Gender and Research Advisor for Overseas Strategic Consulting, Ltd.), Luis Ortiz Echevarria (MSH), and Tamara Hafner (MSH).
ABOUT THE AUTHOR
Gloria Twesigye is the Senior Technical Advisor for Research and Reporting for the USAID-funded Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program. Gloria is a public health professional specializing in research and analysis, monitoring and evaluation, and data management in support of health systems strengthening programs focusing on access to medicines, maternal and child health, HIV/AIDS, tuberculosis, and malaria prevention. Contact at [email protected].