The Intersection of Gender, Health and COVID-19 Across the Continent

Across the world it is hard to find any aspect of life and industry that has not been affected by the devastating spread of the novel Coronavirus. Across the African continent, over 42 countries have issued varying degrees of lockdown measures thwarting movement and activities to prevent the spread of COVID-19. The healthcare sector is arguably taking the hardest hit in terms of resources and overwhelming need, with countries in all corners of the world finding themselves forced to reckon with long-ignored public health policy and health system failures. 

Even the strongest healthcare systems are struggling to keep up with the demands of COVID-19. Millions of health care professionals are on the frontlines of this battle across the African continent working with limited resources, low and often reduced pay and a lack of protective equipment they need to keep safe. Some are fighting COVID-19, others are helping their patients recover from other illness facing new hurdles and restrictions due to lockdown measures. 

Seven out of ten of these health care workers are women.

Dorish Okundinia, a nurse in Uganda quite literally went the extra mile when a critically ill patient needed to get to another hospital. When the ambulance didn’t come for her patient, and private cars had been prohibited during the lockdown, Dorish pushed her patient several miles in his wheelchair so he could get the life-saving treatment he needed.

Dr. Amarachukwu Alliso’s quick action in diagnosing the first case of COVID-19 in February in Africa’s most populated nation, Nigeria, allowed the country to get ahead of containment. This was long before the complexities of the disease were understood, and her timely response resulted in containment, leading the Nigerian government to praise her brilliance.

These are just a few of the women who are working on behalf of a fractured health care system in the face of a global pandemic. While COVID-19 presents certain new challenges, many sub-Saharan African countries have a long history with pandemics. From HIV/AIDS to Ebola, Africa’s history with infectious disease is complex, and the economics of it are even more so. Sub-Saharan Africa accounts for 17%  of the world population, less than 1% of global health expenditure and just 3%  of the global healthcare labour force. By 2050, the population across the continent is expected to double, and half of that population will be under 25 years. 

While billions of dollars in foreign aid is invested in solving Africa’s health care ‘problem’ by the Global North, sub-Saharan Africa isn’t on track to meet the Global Development Goals for health by 2030. This disparity has shown that while foreign aid has contributed to massive advancements in African health care and the fight against infectious disease, both private and public health sectors across the continent have not only a responsibility but an opportunity to collaborate to meet the increasing healthcare needs of their booming populations.

The Reality of Healthcare Across Africa

One thing is for certain, there is no shortage of health care challenges across the African continent. From HIV/AIDS, to Malaria, to Tuberculosis, to maternal health and family planning, to malnutrition – the list goes on, and each sector is faced with its own unique set of obstacles. With its limited health resources and workforce, prior to the current pandemic sub-Saharan Africa accounted for nearly a quarter of the world’s global disease burden.

The demand for healthcare services far outweighs the available human resource personnel. In 2017 South Africa had .905 physicians per 1,000 people. In 2018 Kenya had .157 physicians per 1,000 people. In Ethiopia, there are just .077 physicians per 1,000 people. Globally, more than 60% of countries facing extreme shortages of health care workers are African countries.

In Senegal there are 3 nurses and midwives for every 10,000 people. While there is a depletion of resources, Senegal also has one of the most equal gender representations in the world, split nearly 50/50 for male and female nurses. Comparatively, South Africa 90% of the nurse workforce is female. In Nigeria, it is 87%. While by 2030 the global shortage of nurses is expected to improve overall, they are set to worsen in Africa . The ‘brain drain’ cannot be ignored when it comes to this shortage, however it cannot account for the entire problem, and the lack of strong health systems and education access must be considered. 

It goes without saying that a lack of health professionals leads to a lack of services rendered. However, the health care workers whom are employed are often overworked, underpaid and not given the support they need – leading to a high level of fatigue and burn out.

But that is just the tip of the iceberg. Even though women comprise the majority of the health care sector, the majority of health decision makers remain mostly male – globally only 25% of senior health roles are held by women, and there is little data on women in health leadership roles across Africa specifically. While women are leading on the frontlines, their voices are left out of important leadership decisions which affect both their personal and professional lives. 

Not only are women left out of leadership, they are likely to be paid less. In Africa’s strongest economic state, South Africa, the average income a CEO makes in 5 days is more than a South African nurse will make in a year . Without nurses, a healthcare system would cease to exist. Yet when South African nurses began protesting the poor working conditions at their hospitals after being exposed to COVID-19 due to lack of personal protective equipment, they were met with rubber bullets from police. Nurses across South Africa have raised their voices against injustices, in particular the lack of personal protective equipment to keep them safe while working with COVID-19 patients. The South African government had not paid them hazard pay, or given tax incentives for their work – nor provided them the necessary tools to keep themselves safe. 

The African response to Coronavirus has had its challenges, but it has been far more effective at controlling the spread than the Global North predicted. The hard reality is that we don’t know how COVID-19 will play out across the continent, with many experts warning the worst is yet to come. At the time of writing this, Africa constitutes for the least amount of cases across all continents right now. In some countries, lockdown measures to prevent the spread of COVID-19 have killed more people than the disease itself – within the first two weeks of Nigeria’s lockdown that started on March 30, the police had killed 18 people. COVID-19 had taken 12 lives at that time.

While the health care systems scramble to meet the new demands of COVID-19, women cannot be left out of the solutions. The underlying structures of a broken system need to be examined and improved on – with women included in leadership. Women’s access to health care across the continent is troublesome and layered. The complexity of health issues African women face demands a holistic, multi-sectoral approach to address the root issues. Lack of access to education, poverty alleviation, empowerment and female-focused health care policies all intricately factor into why African women bear a greater disease burden than African men. 

General view during the official opening and hand over of the quarantine centre for Covid-19 to the provincial health department on June 14, 2020 in Pietermaritzburg, South Africa. The 500-bed site is one of the health facilities in the province designed as a quarantine or isolation centre for Covid-19 patients. Photo by Darren Stewart/Gallo Images via Getty Images

What Africa Can Learn from Past Pandemics and Community Solutions

Ebola virus disease was first discovered in East Africa when two outbreaks occurred simultaneously in 1976. The disease spreads rapidly, and kills in equal force – boasting a staggering average of 50% mortality rate for those that contract it, with some strains as lethal as 90%. In the 44 years since Ebola first emerged there have been over 20 significant outbreaks across the African continent, the majority taken place in East Africa. However, the world’s worst seen Ebola outbreak played out across West Africa starting in 2014. The outbreak lasted for 2 long years, leaving a wake of devastation in its path. Over 11,000 people lost their lives – but it could have been much, much worse without the dedication of the formal and informal health care sector.

For many across the continent, especially those in remote and hard to reach areas, the first touch-point with the health care system is through a community health worker. Where the professional health care system lacks the capacity, reach, and accessibility – community health workers are trained to help fill in the glaring gaps. Some of these individuals are employed, others are volunteers – data on these individuals is largely understudied, and they are often recruited and trained by NGOs or civil society organizations. There is very little research and data on the gender makeup of community health workers across African countries, however we can make an educated guess that the gender gap of professional health workers is reflected in that of the informal sector of community health workers. 

With the Ebola pandemic raging on in West Africa, community health workers were supported to do the crucial work of contact tracing and educating communities on the dangers of Ebola and how it spreads. Two of the hardest hit countries were Liberia and Sierra Leone – both had never seen Ebola previously, while its neighbouring East African countries had decades of experience in fighting and containing the virus. 

A few years before the Ebola outbreak, three counties in Liberia invested in and established community health worker initiatives. Once Ebola hit, it catapulted the Liberian healthcare system into crisis, services were disrupted at all levels and Liberia was left completely dependent on foreign aid to handle the Ebola pandemic. The exception to this was the community health workers across these three counties who were able to continue with their work, providing lifesaving maternal and child health services while the nation was in a state of emergency.

Another benefit of community health workers which was illuminated during the Ebola outbreak in West Africa was the implicit trust they had within their own communities. When outsiders came to warn of Ebola, some in hazmat suits, telling communities about a virus they had never experienced first-hand, in a language many did not know, people were understandably wary. Community health workers were able to lead to the end of the pandemic by using their positions of respect and providing education on the virus, creating change from within their own communities. 

Women on the Frontline

If you followed the progress of the 2013 Ebola pandemic, you may recognize the name Salome Karwah. If you don’t, you will definitely recognize the photo of her donning protective gear, arms crossed, a sober look across her face. This image graced the cover of Times Magazine when Salome was named their co-person of the year in 2014, among other ‘Ebola Fighters’. While Times person of the year is a globally renowned honour, it came at great cost. Salome lost most of her family and almost her own life to Ebola.

Salome and her family were some of the first in Liberia to contract Ebola. They were cared for by a unit set up by Doctors Without Borders. Her partner, James Harris, was fighting for his life alongside of her, when both of her parents succumbed to the disease. During this time, Salome was ill yet devoted to keeping her sister alive providing day and night care. The staff at the Ebola unit took note of both Salome and James’s compassionate service. When they both had recovered and were discharged, yet they were asked to stay on at the unit – as mental health counsellors.

This is the exact community response that exemplifies the power of community health volunteers. As survivors, both Salome and James were immune to the specific-strain of Ebola ravaging their country. While they did not have formal education in the sector, they had compassion, on the job training and lived experience. 

Salome was, by all means deserving of the prestigious Times title. She had devoted her life to the very thing that nearly took it from her. While in life she was a hailed a hero, in her death she was a victim of the very health care system that she fought to uphold. Three years after being named Time’s Person of the Year, Salome went through a difficult pregnancy and caesarean section. Days after giving birth to a beautiful son and being released from the hospital despite complications, Salome collapsed at home with convulsions. James rushed her back to the hospital, only to be met with nurses and doctors who knew she was an Ebola survivor – not one of them would treat her. Due to the small size of Ebola outbreaks, and even smaller numbers of survivors due to the diseases rampage on human life, little is known about long-lasting health effects on Ebola survivors. Despite Ebola long being conquered by Salome, there are questions around the understanding on how the virus continues to live in some survivors’ bodies. Despite this, it would have been a very small chance she would have infected someone, almost nil with the necessary precautions. The virus she fought with her life to overcome, led to her death through stigma and misunderstanding. After several hours James was able to find an epidemiologist that was willing to treat Salome, but it was too late.

The word tragedy does not come close to giving Salome justice. Women, across the African continent, cannot continue to be expected to bear the burden of health when the system fails to support them in their own times of need. COVID-19 is surrounded by uncertainty at the moment, especially in how it will play out across Africa in the coming months and years. We must do everything we can to make sure that the Salome’s of today have a bright, and healthy, future.

The Health Care System is Set up to Fail Women

Across the continent, women are fighting the social hierarchy gender imposes on them. Women will likely be more exposed to COVID-19 more than men, as they were with Ebola in the West Africa outbreak, due to gender norms placing them as the main caregivers of their families and the fact that they compromise the majority of frontline health care workers. 

However, we cannot talk about furthering women’s rights, without talking about men. Traditional patriarchal structures often shame men for taking part in caregiving. More often than not young boys are told to grow up to be doctors, not nurses. Men are conditioned from a young age that care giving is the lesser role – the woman’s role. While COVID-19 may carry a higher exposure risk to women due to their roles as caregivers, studies have been exploring how men have been more likely to die from the disease. Research is still being done, but this isn’t because of biological differences alone. Societal differences are at play here as well. Men are more likely to ignore social distancing and not go to the doctor when sick. To fully address gender equality, both male and females need to restructure their world views and how they fit in a better world, where gender does not restrict neither males or females. 

The fact still remains that if women are not involved in policy decisions regarding their health during this pandemic and after, for themselves or their families, their needs will go unmet. Women need autonomy for any health care sector to thrive. In India, a study showed that having women in local council leadership positions decreased the neonatal mortality rate steadily, while also increasing access to immunization and pre and post-natal care. 

Studies show men and women prioritize different polices. When it comes to gender diversity in leadership in health, closing the gender gap has an opportunity to strengthen struggling health care systems. With a never-ending list of problems that need to be fixed in global health care, gender equity seems like a quick-win with immeasurable benefits across the entire sector.

Coronavirus will one day be better understood and hopefully eliminated, and in its wake we must do better for the Salomes who have put their lives on the line for us – so the lives they fought for, including their own, are not in vain.

Cover photo by TONY KARUMBA/AFP via Getty Images

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