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Does COVID-19 impact women more than men?

Gender Equity during a pandemic



Introduction

The COVID-19 pandemic and state of lockdown has challenged humankind collectively in every facet of life. The novel Coronavirus (SARS-CoV-2) pathogen, that spreads rapidly via droplet nuclei, left us scrambling for solutions to halt infections and premature deaths [1]. Quite simply – we were not prepared. At this juncture in the pandemic, we are able to reflect on what we have accomplished and where we may have erred. We are able to shine the spotlight onto erroneous decisions taken by authorities in haste or amidst the “COVID hysteria”, perhaps under the guise of pandemic planning, that may harbor ulterior motives. A recurring theme that was noted in previous public health crises, such Ebola and Zika virus outbreaks, is the disproportionate impact on the lives of Women [2]. These parallels are noted in the COVID-19 pandemic too.


The reasons for this are multiple but stem from pre-existing pervasive gender inequality social norms[3]. It results in gender-disproportionate effects on access to basic human needs (i.e. food, water, sanitation), health and especially Sexual and Reproductive Health (SRH), economic security, education and Gender-Based violence [5-10]. There are also important questions raised about the lack of equitable gender representation in key COVID-19 crisis groups internationally and in South Africa [6,10].

Health Impact Our understanding of COVID-19 is evolving rapidly. Initially there were many more cases amongst men than women, globally and in South Africa [8,10]. However since the publication by the Gender and COVID-19 working group in March 2020, the ratio has inverted in South Africa10,11. As of week 5 of 2021, there are significantly more COVID-19 cases reported amongst women (57.2%) than men in South Africa11. The reasons for this could include that more frontline workers in healthcare and other essential services (i.e. those at greatest risk for viral exposure) are women [8,10].

There are significant impacts on Sexual and Reproductive Health (SRH) from the pandemic and lockdown that are mostly experienced by women. The most prominent is the increased maternal morbidity and mortality as a consequence of delayed or substandard maternal care and the rise in unwanted pregnancies due to decreased access to adequate contraception and termination of pregnancy (TOP) services [5,7,8,10]. During pandemic planning, many SRH services were deemed “non-essential” meaning they were shut down and/or resources reallocated away from them [5,7-10]. Women that tried to receive SRH services, such as contraception, from health centres were harassed and accused of breaking lockdown laws [5]. This stigmatization further restricted access to SRH services. Marta Schaaf et al argue that SRH policies that did not have widespread support preceding the pandemic, for moralistic or other reasons, were deliberately undermined under the guise of pandemic neccessity [5]. The longstanding battles with and small victories for conscientious objection, adolescent contraception, rights of sex workers and others were instantly under threat as a result of loosened SRH governance at the health facility level during lockdown5. A silver lining has been the innovative use of digital technology to meet SRH demands. An example of this is how termination of pregnancy and contraception services utilized telehealth and medication delivery networks to ensure people have access [7,12].


Gender-Based Violence (GBV)


Lockdown and mandatory quarantine were intentioned for people to be kept safe in their own spaces. However, there are unintended consequence of people forced into close proximity to each other. There is a rise in Gender-Based and Interpersonal Violence associated with the pandemic [5,6,8,9,13]. The perpetual close proximity to their abuser means that women are less able to report incidents to authorities8. Women were also less likely to leave their homes to seek help in fear of contracting the virus8. Additionally, the reprioritization of health services meant that many GBV organizations, shelters or other services had reduced capacity or were closed [5,8]. An additional barrier, especially to impoverished victims, was the need for a proven COVID-19 negative test result prior to the GBV shelter accepting the victim8. This disruption in accessing an essential SRH service exacerbated the rising incidence of GBV and its consequences. Some innovative ideas to assist women in other settings during this period are the use of coded messaging to signify that one is a victim and needs help, re-purposing non-essential facilities as GBV shelters and the establishment of direct access 24/7 GBV hotlines with the police [8].


Basic Needs Women and children face greater inequity of decreasing access to basic services such as safe water supplies and sanitation during the pandemic [8,13]. Additionally in settings with a centralized water depot, women most often are the ones who have to walk the long distances to retrieve it8. All of this may result in increased exposure to the virus and higher risk of infection. Female sanitary products may not be readily available in lockdown, exposing women to infection and depriving them of dignity [8]. Economic Insecurity Work in the informal, hospitality and retail sectors are mostly comprised of women and are most affected by the pandemic [8,14,15]. The economic effects of the pandemic on livelihood and food security are therefore most harshly seen on women. Women-headed households may be disproportionately affected by the strain of the pandemic considering that they are less likely to receive paid sick or family responsibility leave [16]. This is exacerbated by the fact that women are more likely to play a caregiving role in their home or work unpaid for domestic work8,17. The natural transition many forms of employment made towards a more digital landscape has overlooked the “gender digital divide” [8,17]. Women are significantly less likely to have access to smartphones or the internet, especially in low and middle income countries [18]. This means that many of the digital solutions may bypass women in the exact sectors where they are needed the most. Women and children are also more prone to malnourishment due to power imbalances when dividing up meals in impoverished families [8].



Education


The pandemic has negatively affected education, with greater impact to girls and women [8,10]. With the closure of schools during the pandemic and lockdown, children are more vulnerable to multiple social determinants of health. Schools offer much more than an education. It is often a sanctuary from an abusive environment, protection from child labour and a provider of meals for impoverished children.


There are also a few gender-specific services that are offered at schools such as the provision of the HPV vaccine and menstrual hygiene products to young girls8. Prior infectious disease outbreaks have shown that girls are more readily kept at home to assist with domestic tasks8. Therefore, the loss of school protection from these and other social determinants of health are disproportionately seen in girls. Furthermore, school closures disproportionally place the burden of childcare on women, in turn lowering their economic stability as described above [10].


Equitable Representation


There is a global lack of women representation in pandemic decision-making [6,10]. Kim Robin van Daalen et al investigated 115 COVID-19 decision-making task forces from 87 countries around the world for the gender diversity6. The vast majority were male-majority (85,2%) and the minority were women-majority (11.,4%) or had gender parity (3,5%)6. In a South African context, the Ministerial advisory committee on COVD-19 has 55.6% women-majority, however, it is not women-lead [6].

The general lack of women representation is archaic and homage to a broken outlook that women are not needed in governance.

Clare Wenham et al suggest that including women’s voice in pandemic response could improve outcomes [10]. This is supported by Kim Robin van Daalen et al point that countries with women leaders have better COVID-19 responses and outcomes [6]. In the past few decades, the struggles for women empowerment in decision-making has taking great steps towards gender parity, not by tokenism, but by merit. Complex problems require multifaceted thinkers and disregarding representation of half of the population cannot be justified. Therefore, it is querysome that many pandemic crisis committees opted to utilize the “status quo” of male-majority and/or male-lead teams rather than embrace a contemporary understanding of gender in governance and decision-making.



RECOMMENDATIONS

#1 Telemedicine for SRH in public sector


COVID-19 is reinvigorating the digital health revolution. Increasingly, digital solutions are transitioning from being seen as niche services to the primary mode of treatment due to the ability to remain socially distant. The services are generally only available in the private sector currently. It may be reasonable for the National Department of Health (NDOH) to either partner with or replicate SRH service providers like Pillsquad or Marie Stopes in the public sector [12,19]. The e-SRH service would include access to contraception and TOP services and access to a teleconsultant with a suitably trained health professional if need be. If medication is required, this can be collected from the clinic or delivered to the woman’s door. If injectable long-acting reversible contraceptives (LARCs) are required, it must be encouraged that self-administration formulations be prescribed, aligned with a recent update to the South African National Essential Medicine List allowing for this [20]. This will allow greater access and control to LARCs in a pandemic and lockdown setting as the contraceptive can be administered at home.


#2 WhatsApp bot service for GBV


The national Corona Virus WhatsApp update platform provides millions of South Africans with vital information. Following on this, a similar platform can be created in a joint project between the South African Police Services (SAPS), GBV NGO’s and the NDOH. A dedicated GBV WhatsApp bot is to be used to provide information about services available, helpful links, signs of GBV and IPV etc. to anyone needing it, confidentially and discretely. The bot will also allow for victims of GBV needing emergency intervention to be connected directly with their nearest emergency services by tracing the victim’s geolocation and request dispatch of SAPS vehicles and/or ambulances, using the application. An emergency message of “HELP!” can be sent to the bot to expedite this process. If the victim requires medical attention and/or needs a medico-legal report completed, local clinics and hospitals will be alerted and the victim can be transferred there without delay.


#3 Gender equity oversight committee


A major concern raised is the lack of equitable gender representation in COVID-19 task forces and decision-making bodies. Had a committee been established during pandemic planning that had oversight of the structure of the task forces and policies produced, many of these concerns would have been averted. The committee would thus be able to hold the national government/NDOH accountable for gender representation as well as provide gender-based analyses (GBA) to policies produced prior to implementation. The recommendations from the committee would need to have backing from the NDOH and government to ensure that it has power to do this. Without diluting the importance of gender and health, the committee would likely be part of a larger transformation committee that considers other factors, such as race and persons with disabilities, during pandemic planning.

REFERENCES


1. Karia R, Gupta I. Khandait H. et al. COVID-19 and its Modes of Transmission. SN Compr. Clin. Med. 2020; 2, 1798–1801. 2. Wenham C, Smith J, Davies SE. Women are most affected by pandemics — lessons from past outbreaks. Nature. 2020. 3. United Nations. Gender Inequality and the COVID-19 Crisis: A Human Development Perspective. United Nations Development Programme. 2020. 4. Bandiera O, Buehren N, Goldstein M, Rasul I, Smurra A. The economic lives of young women in the time of Ebola - lessons from an empowerment programme. International Growth Centre. 2018. 5. Schaaf M, Boydell V, Van Belle S , Brinkerhoff DW, George A. Accountability for SRHR in the context of the COVID-19 pandemic. Reproductive Health Matters. 2020;28:1. 6. van Daalen KR, Bajnoczki C, Chowdhury M, et al. Symptoms of a broken system: the gender gaps in COVID-19 decision-making. BMJ Global Health. 2020;5:e003549. 7. Nanda K, Lebetkin E, Steiner MJ, Yacobson I, Dorflingera LJ. Contraception in the Era of COVID-19. Glob Health Sci Pract. 2020;8(2). 8. United Nations. Covid-19 and women’s human rights: guidance. United Nations Human Rights office of the High Commissioner. 2020. 9. Tang K, Gaoshan J, Ahonsi B. Sexual and reproductive health (SRH): a key issue in the emergency response to the coronavirus disease (COVID- 19) outbreak. Reproductive Health. 2020. 10. Wenham C, Smith J, Morgan R. COVID-19: the gendered impacts of the outbreak. Lancet. 2020;395 11. National Institute for Communicable Diseases. National COVID-19 Daily Report – 8th November 2020. Available from: https://www.nicd.ac.za/diseases-a-z-index/covid-19/surveillance-reports/national-covid-19-daily-report/ 12. Marie Stopes South Africa. Safe abortion pills: how to access medical services in South Africa during the COVID-19 pandemic. Available from: https://mariestopes.org.za/safe-abortion-pills-how-to-access-medical-services-during-the-covid19-pandemic/ 13. Rivera C. A Dashboard Overview: Gender inequality and the COVID-19 crisis. United Nations Development Programme. 2020. 14. Bonnet F, Vanek J, Chen M. Women and Men in the Informal Economy: A Statistical Brief. International Labour Office. 2019. 15. Roy K. Why women will be hardest hit by a Coronavirus-driven recession. 2020. Available from: https://www.fastcompany.com/90479204/why-women-will-be-hardest-hit-by-a-coronavirus-driven-recession 16. Davies SE, Harman S, True J, Wenham C. Why gender matters in the impact and recovery from Covid-19. 2020. Available from: https://www.lowyinstitute.org/the-interpreter/why-gender-matters-impact-and-recovery-covid-19 17. Liff S, Shephard A. An evolving gender digital divide? Oxford Internet Institute. 2004;2. 18. Addati L, Cattaneo U, Esquivel V, Valarino I. Care work and care jobs for the future of decent work. International Labour Organization. 2018. 19. Pillsquad landing page. Available from: https://www.pillsquad.co.za/ 20. Takuva S, Bera E, Leong TD. Low dose subcutaneous DMPA contraceptive for family planning – review. South African National Essential Medicine List. 2020. 21. Reisner S, Poteat SL, Keatley T, et al. Global health burden and needs of transgender populations: a review. The Lancet. 2016;388(10042), 412–436 22. Stroumsa D. The State of Transgender Health Care: Policy, Law, and Medical Frameworks. Am J Public Health. 2014; 104(3): e31–e38.

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