MELINDA GATES is Co-Chair of the Bill & Melinda Gates Foundation.
It began as a mysterious disease, a novel coronavirus soon designated SARS-CoV-2. As countries shut down their economies to slow its spread, it became a global recession as well. Then, in April, the United Nations warned of another dimension to the emergency—a “shadow pandemic” of violence against women raging behind closed doors.
History teaches that disease outbreaks—from AIDS to Zika to Ebola—play out with a certain grim predictability. As they infect societies, they expose and exploit existing forces of marginalization, seeking out fault lines of gender, race, caste, and class. It is no coincidence, for example, that in the United States, black Americans are dying at disproportionate rates. Or that although more men are dying of COVID-19, the disease caused by the new coronavirus, the broader impacts of this crisis threaten to disproportionately affect women’s lives and livelihoods.
Every day brings new examples of the ways in which women are being left behind by the world’s response to the pandemic. There are women in labor being turned away from overburdened hospitals; domestic workers whose lost income won’t be replaced by stimulus funding; adolescent girls who cannot continue their education online because their communities frown at the sight of a phone in the hands of a woman.
“Gender-blind is not gender-neutral” is a refrain among advocates for women and girls. In this crucial moment, it must also be a call to action. If policymakers ignore the ways that the disease and its impacts are affecting men and women differently, they risk prolonging the crisis and slowing economic recovery. But if they use this emergency as an opportunity to replace old systems with new and better ones, countries can build back more prosperous, more prepared, and more equal.
THE SILENT TOLL
By nearly every measure, there had never been a safer time to be pregnant in Sierra Leone than February 2014. The country’s health system had historically been one of the world’s worst, but the maternal death rate had dropped more than 50 percent since 1990, and some level of antenatal care was almost universal. Then in March, the World Health Organization declared an Ebola outbreak in the region, and progress started to unravel. By November, you could plot the story with two terrible and mirrored curves: one that showed an exponential rise in Ebola cases; another that showed a corresponding crash in the number of pregnant women receiving care.
When the crisis ended, the silent death toll of women and babies was even higher than its official one: 3,589 people in Sierra Leone had been killed by the Ebola virus itself. The number of additional newborns and mothers who died during childbirth was somewhere between 3,593 and 4,936.
That is what epidemics do: they not only overwhelm immune systems but also overwhelm health systems. And because the parts of those systems devoted to caring for women are often the most fragile and underfunded, they collapse first and fastest. Early data suggest that in low- and middle-income nations, the cutback in maternal care during COVID-19 could claim the lives of up to 113,000 women.
There is still time to avert such an outcome. In every country—and for every woman—sexual and reproductive health care must be classified as “essential” services. Even during a pandemic, someone suffering a heart attack would never be told that a trip to the emergency room was optional. Yet the message millions of pregnant women receive during a crisis is that it’s okay to deliver at home, alone. It isn’t. During the 2014 Ebola outbreak, by far the biggest driver of maternal mortality was the fact that women were increasingly giving birth without medical assistance. Health ministers need to find ways to provide safe maternal care even in pandemic conditions. In some countries, that might mean designating separate health facilities—some for those suffering from COVID-19, others for mothers and newborns who are COVID-free. In other places, it may be easier and safer to bring the expertise of the clinic to the mothers themselves.
Sexual and reproductive health care must be classified as “essential” services.
Protecting the contraceptive supply chain is crucial, too. Early estimates also suggest the pandemic will cause 49 million additional women to go without contraceptives, leading to 15 million additional unplanned pregnancies. Part of the responsibility for addressing this rests with the international community. A small group of countries manufactures most of the active primary ingredients for generic contraceptives, and since the pandemic hit, they’ve been stockpiling those ingredients, even though there’s no evidence they are running short on them. It’s a heartless trade policy—and a senseless one.
A health system isn’t just a network of supply chains or a bundle of essential services. It’s made of people. Health workers on the frontlines need tools to keep themselves safe. Eventually that will require giving them first priority to a COVID-19 vaccine. For now, it requires supplying them with personal protective equipment that fits. The PPE that’s delivered to hospitals and clinics is often designed for men, even though 70 percent of health workers worldwide are female. Manufacturers should ensure they’re making enough PPE that will fit the people who need to use it, and health systems should make sure they’re buying enough.
Leaders should also use the pandemic as a forcing mechanism to integrate women’s health care. In many low-income countries, a random calendar dictates how people receive care: Monday is for vaccinations, Tuesday for antenatal care, Wednesday for family planning. Instead of scheduling one appointment, a woman is expected to show up at the same time as everyone else who needs some service, spend all day awaiting her turn, and then come back again the next morning to do it all over. This block scheduling never made much sense, and it makes even less during a pandemic, when no one should be spending any more time in a crowded waiting area than necessary.
WOMEN AT WORK
If health policymakers had to choose a place that most clearly illustrates the 2014 Ebola outbreak’s disproportionate impact on women, they would probably point to a maternity ward. Economists, though, might answer the same question by looking somewhere very different: food stands.
A few months after the epidemic subsided, Oxfam International and UN Women examined the economic impact on the region where Ebola hit. The virus, they found, caused the Liberian unemployment rate to nearly triple for both men and women. But whereas men’s incomes tended to bounce back quickly, women’s took much longer to recover. The majority of women were self-employed—many of them as food sellers—and no one wanted to “eat in the street” when a deadly virus was circulating.
COVID-19, too, appears to be affecting women’s livelihoods more drastically than men’s. Early estimates suggest that around the world, women’s jobs are 1.8 times as likely to be cut in this recession than jobs held by men. What’s more, right as women’s paid work is evaporating, their unpaid work caring for children and family members is increasing dramatically. Before the pandemic began, unpaid work was already a major barrier to women’s economic equality. Now, with many schools closed and health systems overwhelmed, more women may be forced to leave the workforce altogether.
If the pandemic stalls progress toward gender equality, the cost will be in the trillions: even a four-year wait in taking new action to improve parity—for example, by introducing interventions to advance women’s digital and financial inclusion—would erase $5 trillion in opportunity from global GDP in 2030. As policymakers work to protect and rebuild economies, their response must account for the disproportionate impact of COVID-19 on women—and the unique roles women will have to play in mitigating the pandemic’s harm.
Take food systems. This year, owing to a confluence of catastrophes—a warming planet, a plague of locusts, a global pandemic—over 100 million people may require emergency food assistance. (The central problem is not a shortage of food; it’s the ability of families to pay for it.) This particularly affects women for two reasons. First, many depend on the food system for their livelihoods. Second, cultural norms mean women are usually the last ones to eat in their families—and therefore, when food is short, the first to go without it. Social protection programs, then, should make sure that women can afford enough nutritious food to feed their entire families. Policymakers can also support women farmers by scaling up insurance, savings, and other financial tools to protect them from the worst impacts of this shock while insulating them against the inevitable next one.
Another way to ensure that families can meet basic needs is by designing emergency cash transfers with women’s realities in mind. While efforts to slow the spread of COVID-19 have interrupted the flow of goods and services around the world, the World Bank estimates that over one billion people have received a COVID-related cash transfer from their government since the crisis began to help them meet basic needs. Yet the most economically marginalized women are often invisible to their governments—they are less likely to appear in the tax rolls, have formal identification, or own a mobile phone—and thus at risk of missing out on these benefits. Research shows that social protection programs that ignore gender can exacerbate existing inequalities. Well-designed cash transfers, however, can yield significant benefits. A 2019 study in India found that when cash benefits were deposited into a woman’s account (rather than her husband’s) and the woman was shown how to use that account, female labor-force participation rose.
The most economically marginalized women are often invisible to their governments.
Policymakers can also target stimulus funds at women by steering funds toward the businesses they own. Sometimes, gender discrimination hides in the fine print. For example, because women’s businesses tend to be smaller and earn less revenue than men’s, they may be ineligible for government loans or procurement schemes that require companies to meet certain capitalization requirements. Governments can follow Canada’s lead and ensure that some benefits are set aside specifically for women’s enterprises. Other nations are wisely directing funds toward sectors where women are heavily represented: Argentina is procuring masks from home-based workers, and Burkina Faso has waived utility fees for fruit and vegetable sellers.
Reaching women with many kinds of benefits also depends on their having equal access to mobile phones. A mobile phone is increasingly where goods are bought and sold, information is supplied and demanded, vital issues are debated, and money is moved between mobile bank accounts. Yet across low- and middle-income countries, women are ten percent less likely to own a mobile phone than men, and 313 million fewer women than men use mobile Internet. The result is a vicious cycle: gender inequality leads to digital inequality, which further entrenches gender inequality. To break the cycle, governments should look to Kenya and Bangladesh, which have offered special phone and data packages priced and marketed with women’s needs in mind.
Finally, the burden of unpaid work must be recognized, reduced, and redistributed. There is a global expectation that a woman should spend hours every day doing cooking, cleaning, and caregiving that keeps her family going but generates no income. The unequal distribution of unpaid work disempowers individual women, hurts economies, and will slow down the post-COVID-19 recovery. Globally, a two-hour increase in women’s unpaid care work is correlated with a ten-percentage-point decrease in women’s labor-force participation. Governments can make sure this work is valued by enacting policies such as paid leave for working parents and prioritizing infrastructure investments, such as electricity and piped water, that make unpaid work less time-consuming. Employers can offer employees flexible schedules, the opportunity to work remotely where possible, and options such as onsite childcare for those whose jobs must be done in person. All of these policies should be extended to both men and women, so that they upend gender roles instead of reinforcing them.
LISTEN TO THE EXPERTS
“Listen to the experts”—it’s another refrain that the pandemic has made popular. The curves remain flattest where people have heeded the guidance of public health officials on everything from the wearing of masks to the closing of restaurants. Scientists, however, are not the only experts that need to be listened to right now. Consider the proposals in this article. Nearly all of them involve acknowledging blind spots and raising new questions: If we shift health workers to treating COVID-19 patients, what are we shifting them away from? Do the economic data driving our nation’s response reflect women’s experiences, too? Can domestic violence shelters stay open under our definition of “essential services”? Questions such as these are more likely to be asked when women are there to ask them.
Most heads of state are men, by a wide margin. Three-quarters of the world’s national lawmakers are, too. Some of these men are indeed gender champions (South African President Cyril Ramaphosa, for example, has been vocal about ending gender-based violence even during his country’s COVID-19 shutdown). All of these leaders now have a stake in ensuring that women are involved in decision-making about the COVID-19 response.
The virus has created an explosion of blue-ribbon commissions, kitchen cabinets, and other ad hoc bodies that are helping decide everything from when economies reopen to how a vaccine will be distributed. Women—and, importantly, women from diverse backgrounds—must be equally represented in all of these conversations. Governments should reach beyond the typical halls of power to partner with grassroots women’s organizations, whose deep understanding of marginalized populations can help ensure the official response leaves no woman behind. Some governments have already found these groups to be important allies in the fight against this virus. In India, thousands of members of grassroots women’s organizations had, by early May, manufactured more than 100 million masks, 200,000 PPE kits, and 300,000 liters of hand sanitizer.
This is how we can emerge from the pandemic in all of its dimensions: by recognizing that women are not just victims of a broken world; they can be architects of a better one.