The confinement of Eve: resolving Ebola, Zika and HIV with women’s bodies?
by Susana T. Fried and Alice Welbourn for International Women's Day (March 8)
The pattern is clear: as a new global health crisis erupts, women are placed at the centre of impact. In some cases, women are held responsible for preventing transmission. In other cases, women are expected to manage the crisis in the face of failed health systems. And if the crisis has anything to do with children, pregnancy or sex, women are held responsible for managing it.
There are parallels between three major newsworthy viruses – Ebola, HIV and Zika -- in relation to the global public health response and persistent and often toxic gender stereotypes. In each case, women have been, at worst, objectified as “vessels and vectors” of disease, whose agency and will must be contained. At best, women are seen as responsible for containing and preventing disease transmission, and for caring for the ill members of their families and communities. Yet as over 30 years of experience in relation to HIV have shown us, such responses repeatedly fail to hit the target and repeatedly miss the point.
"There are parallels between three major newsworthy viruses – Ebola, HIV and Zika -- in relation to the global public health response and persistent and often toxic gender stereotypes."
We have purposefully chosen the word ‘confinement’ in the title to reflect its traditional biblical reference to women’s labour and childbirth. In the dictionary, ‘to confine’ means to keep within boundaries, to restrict, to curb, to limit. Readers of the 50+ articles in this openDemocracy series over the past seven years will understand already how women’s rights have repeatedly been ignored, curbed or violated by global HIV policy guidelines, poverty, gender-based violence in many forms, including forced or coerced sterilization and lack of informed choice or privacy. So here we build on this wealth of analysis about the gender dimensions of HIV as a springboard for understanding the gender dynamics of Ebola and Zika.
Both the Ebola and Zika viruses were identified many decades ago, and both have their origins in East Africa (the DRC in the case of Ebola and HIV, and Uganda in the case of Zika). All three diseases (though we focus here primarily on Ebola and Zika) flourish in contexts of inequality. And in contexts of inequality, women and girls are often the most unequal.
Ebola has severely affected Guinea, Sierra Leone and Liberia. Most people who contracted Ebola in Liberia were living either in rural communities or urban poverty, according to Tooni Akanni, and 75% of those who acquired it were women. The UN Development Programme (UNDP), drawing on World Health Organisation data, reports that the situation in Sierra Leone and Guinea showed even greater gender disparity, “The number of EVD [Ebola virus disease] deaths is higher among women than men in the three epicentre countries. Of the total cases of EVD in West Africa, 50.8% have been women, as of 7 January 2015. The gender disparity is more pronounced in Guinea and Sierra Leone; it is relatively lower in Liberia.”
The predominance of Ebola in women stems from women’s role as carers: women tend the sick as family members and healthcare workers, women prepare bodies for burial, and women in this part of West Africa are also travelling traders. This is exacerbated when health systems are in disarray. Women can also be exposed to Ebola (and Zika and HIV) sexually, and the likelihood of contracting the virus multiplies (as we have seen in the case of HIV) when they or their partner has multiple concurrent relationships. The recent outbreak of Ebola reflects a pattern that is similar to earlier outbreaks in other African countries.
"Any effective response to Ebola needs to take a gendered approach to understanding and responding to the respective roles of women."
Toxic use of gender norms puts women additionally at risk. Tooni Akanni explains how in many communities across the globe, women are expected to “sacrifice for their families, even to the extent of putting their own lives at risk to prioritise care for ailing family members. Norms around women’s care work are not just commonly held but also strategically reinforced.
There is anecdotal evidence in the WHO study that men in Congo deliberately used the social expectation that women care for the sick to their favor, explaining that they avoided contacting Ebola, during the 2003 outbreak of the disease, by ‘making sure’ that women took care of the sick.” - Akanni concludes that Ebola produces inequitable morbidity, mortality and economic damage for women and that any effective response needs to take a gendered approach to understanding and responding to the respective roles of women – and of men – in societies where it strikes.
Moreover, policy makers, governments and funders should invest in listening to, and acting upon, women’s experiences and perspectives: and their key role as “agents of change and social mobilisers” should be wholeheartedly embraced and supported, in order to produce an effective response to this extreme crisis.
Meanwhile, Amber Huff emphasizes how development processes have undermined social and healthcare systems: “recent growth has been largely inequitable, benefitting international investors but not resulting in equal improvements in public services and economic opportunities for everyday people.” She describes how these challenges are exacerbated by widespread international exploitation of the region’s natural resources and related conflict, which have, in turn, had a knock-on effect on wild animal populations, thereby opening up opportunities for spread of new diseases, including Ebola through bats.
As Alicia Ely Yamin argues, the ravages of war produced a devastated healthcare system in Liberia and Sierra Leone, where women and children especially experienced marginalisation and poverty.
And as Yanoh Kay Jalloh explains, while the immediate crisis is over, the effects of Ebola on girls continue, with any pregnant girls being banned from school in Sierra Leone. Whilst this ban was already in place, vulnerability of girls to unplanned pregnancy through rape or transactional sex to make ends meet increased because of Ebola. 33% of teenage girls already had unplanned pregnancies before Ebola and this figure has risen since.
What of Zika?
Pregnancy, especially pregnancy among girls and young women, is the lynchpin for Zika. While Zika has been identified in many countries around the world – from Uganda and Nigeria in Africa, to several countries in the South Pacific, to the current outbreak in Latin America and the Caribbean. It appears that Zika can be sexually transmitted (like Ebola and HIV), though most cases are directly transmitted by mosquito.
The disease trajectories are different across the three viruses (HIV, Ebola and Zika). However, the toxic gender norms that fuel the diseases and magnify their impact are common threads. And, like Ebola and HIV, Zika thrives in conditions of inequality and ruptured health systems, bringing additional burdens of care to women.
"And, like Ebola and HIV, Zika thrives in conditions of inequality and ruptured health systems, bringing additional burdens of care to women."
There is a distinct gender specificity in the case of Zika: the link between Zika and microcephaly. In Brazil, a growing number of pregnant women who have contracted Zika in Brazil are giving birth to babies with microcephaly, a condition that disrupts full brain formation. At the same time, an Argentine doctors’ group has raised the possibility that that the cause of microcephaly may not be the Zika virus but the larvicide used in Brazil to kill mosquitos.
Whatever the cause of Zika, be it through mosquitoes themselves or the larvicide in the water, the specific and disproportionate impact on women runs through HIV, Ebola and Zika. In such a context, it is imperative that we focus on the bigger picture of disease prevention, treatment, care and support – a lesson learned over and over from HIV.
Telling women not to get pregnant is not a viable answer. A comprehensive response to mosquito control is not straightforward, should involve and build on the expertise of all sections of a community, and necessitates a combination of locally appropriate and sustainable social and technical approaches. It should not just single out and target those who are already most vulnerable. This is all the more important in countries where contraception and abortion are both rigorously controlled by the State.
"Telling women not to get pregnant is not a viable answer."
Throughout these narratives we hear again and again, the refrain of poverty, inequity, marginalization, gender imbalances and top-down, kneejerk reactions designed to contain and control women and girls.
As environmental scientists such as the late Rachel Carson, and Wangari Maathai, advocates such as Arundathi Roy and Erin Brockovich, investigative journalists such as ‘This changes everything’ author Naomi Klein and economists such as Lourdes Beneria, Marilyn Waring and Thomas Picketty have told us repeatedly over the past 50 years, growth-driven economies, combined with simple, top-down bio-tech, business-driven solutions to complex multi-issue challenges do not lead to social, economic or gender justice.
All these huge global public health issues have their connections with the bigger picture: with climate change, environmental degradation, and a glaringly simplistic – and misogynist – response. As Graham Brown et al recently eloquently articulated in the context of HIV, a recognition of the need to shape an effective response to HIV in the framework of its place as part of a complex adaptive system is crucial.
This response is now 3 decades overdue in the HIV response.
Those seeking to mitigate the effects of Ebola and Zika would be wise to take note from our experiences.
Eve, like nature, cannot – and will not – be contained.
Susana T. Fried is a Fellow at Yale University, Global Health Justice Partnership. Alice Welbourne is Founding Director of the Salamander Trust and is on the steering group of the Athena Network. This article was first published on openDemocracy 50.50 - AIDS, Gender & Human Rights.