Dr. Aditi Hegde
Picture Courtesy: The Weather Channel
How sure are we when we say that Coronavirus is impartial? In the past few months, politicians, health experts and religious leaders have repeatedly said that the novel coronavirus does not distinguish between human beings based on class, caste, religion or race: it affects everyone. Demographic breakdowns of the outbreak, however, seem to indicate that men are more commonly affected and are also at higher risk of death in some countries. Globally, sex-disaggregated data on positive cases has been released by 33 countries. Of these, about one-third have more positive cases in men than women. Most conspicuous is Singapore where 79% of 3,248 confirmed cases on 15th April are men.[i] Meanwhile, according to the Health Ministry of India, as of April 6th 2020, 76% of COVID-19 positive patients are men, while 73% of deaths have occurred in males.[ii]
Are men more susceptible and why?
Several countries are showing stark differences in incidence and mortality rates of COVID-19 among men and women. However, at a global scale, there does not seem to be much difference with respect to incidence of COVID-19. According to data available through Global Health 50/50, of 664,013 confirmed cases, 49.4% are in men and 50.6% in women. The mortality data, however, is strikingly different. Available sex-differentiated mortality data shows that 62.2% of all COVID-19 deaths are among males (Figure 1).Similarly, India also has higher incidence and mortality among its male population, most likely owing to difference in exposures.
NB: Analysis based on data available from Global Health 50/50, accessed on 20th April 2020. Missing bars indicate unavailable data.
Are women really better off when outbreaks take place?
While it appears that the mortality from COVID-19 is lower among women, it is worth exploring whether women are better off during outbreaks of infectious diseases, in the past and in present. Two recent public health emergencies, the Zika and Ebola outbreaks, show that the impact of these diseases on the health and well being of women goes beyond just the disease itself. Women’s economic activity, education, and access to health services were disproportionately affected in the aftermath of these epidemics.[i] It is not unreasonable to expect that the COVID-19 pandemic, because of its intensity and scale, will have a similar but greater impact on women, LGBTQ individuals and people with disabilities, in the short term as well as in the long term. Women care for the ill in formal settings as well as at home.[ii] In India, women are still the main caregivers of the family and yet have the highest unmet need for care themselves. Health-seeking behaviour among Indian women is influenced by autonomy and access to care and is generally low,[iii] even though as care providers, they are at the greatest risk of encountering ill individuals within the household. Therefore, there is a high unmet need for care, particularly healthcare, among them.
What’s happening during this pandemic?
Unique challenges for nurses and frontline workers
In fact, considering that health and social workers globally are mostly women (70%), they perhaps have higher risk of exposure. In contrast, India’s health workforce mostly comprises men (62%) but varies considerably according to cadre. The male to female ratio was as high as 5.1 for doctors but as low as 0.2 for nurses indicating the predominantly female nursing cadre.[iv] But these calculations leave out the frontline health workers (FLWs) or community health workers who are presently at the forefront of the epidemic containment strategy. Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs) and Anganwadi Workers (AWWs), all exclusively women, have been given a range of roles, from creating awareness to contact tracing, house-to-house surveillance and implementing home quarantine.[v] Many health workers, including doctors and nurses, have raised the issue of lack of quality personal protective equipment (PPE). As it happens, news of health workers being found to be COVID positive has only increased in the past few weeks. The majority of these are women. These cases have occurred in non-COVID designated hospitals too.[vi] Furthermore, as more healthcare staff are delegated to COVID wards, the ones in non-COVID wards have to pull longer shifts and manage more patients under worsening employment conditions.
Increased burden of work within the household and loss of opportunities outside Being primary caretakers, women are used to spending almost eight hours in household chores and childcare, and a large chunk of the remaining time would be devoted to market work. Some estimates suggest that about 66% of the work done by Indian women is unpaid in comparison to 18% for men.[vii] The lockdown with its stay-at-home policy, closure of schools and workplaces, and curtailment of movement has naturally increased the burden of unpaid work for women at home.[viii] Even women working in sectors where working from home is a possibility continue to handle their household duties, thus overburdening themselves. Additionally, since most working Indian women are employed in the informal sector, that leaves them in further distress due to loss of opportunities during the lockdown. Migrant women, in particular, are likely to be severely impacted because of economic vulnerabilities and low negotiating power.[ix]
Higher risk of violence
According to the National Family Health Survey (NFHS) 4[x], one in three women in India had faced spousal violence including sexual violence in her lifetime. The number of complaints received by the National Commission of Women doubled in the week, the lockdown began as compared to the first week of March prompting the Commission to start receiving complaints on WhatsApp. However, with only 43% of women having access to phones, more than half of the country’s women are left out. [xi] Hence, we can assume that there are more cases being unreported. LGBTQ individuals and women with disabilities are also at higher risk of gender-based violence during this time.[xii]
“A rise in domestic violence (DV) literally increases the risk to women’s lives: as one curve gets flattened, the other one slopes upwards, perhaps not exponentially, but sharply, nevertheless.”
- Ashwini Deshpande writing for Quartz India[xiii]
Decreased access to healthcare
India’s health system focuses largely on the reproductive health of women with little thought given to other health needs of women. Nevertheless, in crises such as this, even reproductive healthcare takes a backseat as funds are diverted to responding to the immediate emergency, irrespective of it being mentioned as an essential service by the Ministry. As access to healthcare, especially reproductive and sexual health services reduces, the effect on women will be manifold. The situation is likely to be worse in areas with weak health systems such as in rural India. Rural health services are not just limited to health centres and hospitals. Anganwadi centres provide supplementary nutrition pregnant and lactating women, as well as adolescent girls. The nutrition of women and children is likely to suffer to a great extent owing to the disruption in the services of the Anganwadis during lockdown. Owing to the discrimination, violence and lack of availability in services and support from the government and society at large, mental well being of women is also at stake. Responses to COVID-19, thus, should consider this vulnerability and make provisions to ensure mental health and well being of women, persons from the LGBTQ community, and those with disabilities.
Some good news though...
For all the reasons mentioned above, women and non-cis gender individuals, especially those who are from stigmatized communities, are likely to bear the brunt of the COVID-19 pandemic in the long run. But while they are more vulnerable during this outbreak, women leaders are also our saving grace. In rural Maharashtra, for instance, women self-help groups (SHGs) are coming together to manufacture masks, providing dry rations, distribution of cooked meals, and reintroducing digital ATM services in hard-to-reach areas. Additionally, by donating Re. 1 from their own income, these SHG women have contributed approximately Rs. 11.35 lakh to the Chief Minister’s Relief Fund.[i] In Assam too, women’s groups are leading the fight against COVID-19.[ii] The World Bank estimates that over 20,000 women’s SHGs from 27 Indian states have come together to produce 1.9 crore masks, 1 lakh litres of sanitizer and 50,000 litres of hand wash.[iii]
What needs to be done?
Almost every international organization has come up with recommendations for incorporating a gender lens when planning responses to the COVID-19 outbreak. Although these recommendations have not all been adopted by nations, they do tell us what we must do.
“Despite the WHO recognizing that women must be included in decision-making, decision-making bodies established specifically for COVID-19 do not reflect a gender balance between women and men.”
- Global Rapid Gender Analysis for COVID-19
Some of the broad recommendations are given below:
1. The priority must be to make provisions for healthcare workers on the frontlines of this battle against COVID-19, many of whom are women. Jan Swasthya Abhiyan, All India People’s Science Network and Public Services International have put forward a position paper on health workers’ rights in this pandemic’s context.
2. Concurrently, the government must make gender disaggregated COVID-19 case data available in the public domain. It is in the interest of the entire world to do this because studying the incidence and modifying factors that reduce the risk of mortality in women might give important clues to design prevention and treatment regimens.
3. Furthermore, at the time of writing this, there is almost no research on the impact of COVID-19 on non-cis gender individuals. This must be addressed by academic and government institutions by investing into gender-conscious, gender-responsive research.
4. Simultaneously, policy makers must ensure that there is equitable and meaningful representation of all genders in designing interventions and policy making. It is worth keeping in mind that gender-neutral policies rarely lead to gender-equal outcomes, and interventions and policies should be conscious of this.
5. Reinstate community-based services including that for nutrition, reproductive and maternal health, childcare, etc.
6. Grievance redressal mechanisms that address rights violation should be created, and where existing already, strengthened. It is necessary that human and financial resources are not diverted from essential services.
7. The media should be sensitive to gender while reporting on the pandemic. The media should bring out stories related to domestic abuse and violence which will alert the authorities.
8. In the long-term, governments need to invest into community-based solutions, as well as core health and education systems. Capacity building of women, especially those from marginalized and stigmatized communities, must take precedence. An opportunity for bringing in gender-responsive legislation for equal wages across genders, enabling family-friendly workplaces, equitable economic policies, etc. exists. The State should capitalize on this opportunity. Civil society must be recognised as a valuable aide to the government to accomplish these tasks.
For the most part, there is consensus among researchers, public health experts and health workers that sex and gender are important parameters determining the outcome of infectious diseases. Yet, at this early stage of the pandemic, the extent of this influence is poorly understood. What is clear though is that a gender-responsive approach is required to respond to this and future crises in an effective manner.
Dr. Aditi Hegde is a public health researcher associated with the Public Health Resource Network, New Delhi. The views expressed in the article are personal
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