In this blog, Zlatina Dobreva discusses the lessons learnt from Dr Clare Wenham’s book launch event, Feminist Global Health Security, Chaired by Dr Justin Parkhurst. The global and national health security response to infectious diseases has failed to deliver gender mainstream policies. Applying a feminist perspective to the COVID-19 response would enable a quicker recovery.
“Clean your house and don’t get pregnant!” – was the overwhelming message to women across Latin America during the Zika epidemic in 2015-2017. Absolving themselves from blame, governments put the burden of the epidemic and its long-term consequences on women. Drawing on a literature review of Zika-related national and international policies and interviews with policymakers, practitioners, and women advocates, in her book Feminist Global Health, Dr Claire Wenham (Assistant Professor of Global Health Policy at LSE) analyses these policies to understand how women and/or gender were considered and incorporated. She argues that global health security, defined as the collection of national and global actions to minimise the spread of infectious diseases across geographical regions and international boundaries, prioritised the state, the economy, and state structures, but failed to take into account the everyday reality of women. Her feminist critique of the Zika response, and an LSE panel discussion with Gustavo Matta (Public Health Researcher at Fio Cruz, Rio de Janeiro), Naila Kabeer (Professor of Gender and Development at LSE), and Sophie Harman (Professor of International Politics at Queen Mary, University of London) on the need for gender mainstreaming in global health security, reveal important lessons for policymakers in the context of COVID-19.
Does global health security really “get gender”?
The “Me Too” movement trickled down to global health security in terms of gender representation. Global Health 50/50 and Women in Global Health were some of the initiatives that began advocating for more diverse and inclusive organisations. Their work remains hugely important as we see an improved commitment to gender equality among organisations from 55% in 2018 to 79% in 2021. However, the real elephant in the room, Dr Wenham argued, is the disconnect between the discourse at the global level and the impact that global health security policies have on women. It is not an issue solved through better representation. Two of the most powerful women at the time were leading the Zika response – Dr Margaret Chan (the former Director-General of the WHO) and Dilma Rouseff (Brazil’s former President). Nevertheless, global health security actors and governments failed to adopt gender-inclusive practices and to ultimately recognise the value of having a gender-inclusive framework in their response.
‘Where are the women?’
A good example of how national and international policies prioritised the security of the state over the individual is the Zika response. According to Dr Wenham, women suffered from “conspicuous invisibility” despite their greater susceptibility to the infection. They were visually at the forefront of the outbreak, but the national and global response failed to incorporate policies that addressed the challenges women faced and prioritised only a subsection of women, fuelling rather than abating the threat of future outbreaks.
Women’s images featured and were highly visible across the national and international media. However, women were constructed as “mothers”, holding babies with microcephaly. Consequently governmental interventions supported mothers primarily. Actions focused on ensuring there was no stagnant water in houses and fumigation of mosquitoes. Even the military was involved to ensure government guidance was followed – Brazil mobilised 60% of its troops to support vector control efforts. In contrast, the security of women from infection who were not mothers but were at risk of getting pregnant was not ensured. They had limited access to contraceptives and sexual and reproductive health services, while abortion was illegal across many Latin American countries.
Secondly, women are not a homogenous group. Gender intersects with race, disability, geography and class, and governments failed to consider the differential impact of interventions on the lives of women. For example, the white and relatively better-off women from the Global North could not go on exotic holidays during the outbreak. In contrast, those affected the most but, in a way, invisible to policymakers – like the black, poor women living in rural Northeast Brazil – were advised to not get pregnant, to stay at home, and avoid storing water. This advice failed to consider the daily realities of women in those communities. They did not have access to sexual and reproductive health services or had limited control over their sexual lives, had to maintain a stable family income, often being a single parent, and did not have running water so some needed to be stored for household needs. Unlike their more affluent counterparts who were able to afford contraception and move from areas of high risk, the panellists discussed that these marginalised groups were more concerned with providing for their children and having access to clean water and sanitation than contracting Zika.
Government interventions failed to alleviate the burden on women. Women had to pay for transport to clinics, risked criminality to get an abortion through unsafe means and subsequently bore the financial and psychological costs for raising children suffering from microcephaly without appropriate support from the state, as highlighted in Feminist Global Health and other studies. Furthermore, men too could pass on the Zika virus through sexual intercourse. But men were not asked to take precautions and protect themselves and their partners against mosquitoes. Panellists concluded that the burden was put on women, reinforcing the various axes of inequality between men and women’s autonomy and power over their sexual and reproductive lives. This further underlies the gender inequalities of the response.
Learning from the past, or not?
The global health security response to Zika is not the only example of the failure to implement gender-mainstream policies and to appropriately protect women, who are also often at a greater risk of contracting infections in their roles as primary health workers and formal and informal carers. For example, during the global health response to Ebola in West Africa, women were not informed about the risk of vertical transmission through breastfeeding. The response relied on the “conspicuous free labour of women” in formal and informal care roles. As a result, 70% of Ebola cases in the Democratic Republic of Congo were amongst women and children. Today, despite the abundant literature and strong advocacy, government interventions have failed to account for their disproportionate impact on women. For example, the closure of schools limits women’s work and economic opportunities as they provide most of the informal care within families. Women are also more likely to lose their jobs – 80% of domestic workers left unemployed due to COVID-19 are women. COVID-19 has limited access to sexual and reproductive health services and information across Ghana, Indonesia, Kenya, Nepal, Uganda and Zimbabwe, where one third of young people reported not being able to access the needed family planning services . Others such as France and the UK have removed barriers to accessing contraception by making it available in pharmacies and supermarkets, offering some hope for the future according to Dr Wenham.
What does feminist knowledge bring to global health security?
The panel discussion and analysis of the Zika response in Feminist Global Health bring important learnings for global health security as a whole but also the COVID-19 response. Public COVID-19 vaccination campaigns should address concerns about the impact of vaccines on fertility which inevitably has fuelled vaccine hesitancy and reduced vaccine uptake among young women. Healthcare systems need to ensure the availability of pregnancy and postpartum services given the increase in maternal mortality, and its temporal relationship with the incidence of COVID-19, as observed in Brazil. The state should provide the much needed mental health and financial support to women in formal and informal caregiving roles. Overall, policymakers need to more carefully and explicitly consider what is needed to reduce the risk and vulnerability of women given their social and economic position. Furthermore, policies and interventions need to be grounded in the everyday reality of women and not assume that women absorb the costs (e.g. of caregiving or home-schooling).
The views expressed in this post are those of the author(s) and in no way reflect those of the Global Health Initiative blog or the London School of Economics and Political Science.
