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Gender & Development Overcoming the 'tyranny of the urgent': integrating gender into disease outbreak preparedness and response Overcoming the 'tyranny of the urgent': integrating gender into disease outbreak preparedness and response

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This article contributes to discussions on the gender dimensions of disease outbreaks, and preparedness policies and responses, by providing a multi-level analysis of gender-related gaps, particularly illustrating how the failure to challenge gender assumptions and incorporate gender as a priority at the global level has national and local impacts. The implications of neglecting gender dynamics, as well as the potential of equity-based approaches to disease outbreak responses, is illustrated through a case study of the Social Enterprise Network for Development (SEND) Sierra Leone, a non-government organisation (NGO) based in Kailahun, during the Ebola outbreak.
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Gender & Development
ISSN: 1355-2074 (Print) 1364-9221 (Online) Journal homepage: https://www.tandfonline.com/loi/cgde20
Overcoming the ‘tyranny of the urgent’: integrating
gender into disease outbreak preparedness and
response
Julia Smith
To cite this article: Julia Smith (2019) Overcoming the ‘tyranny of the urgent’: integrating gender
into disease outbreak preparedness and response, Gender & Development, 27:2, 355-369, DOI:
10.1080/13552074.2019.1615288
To link to this article: https://doi.org/10.1080/13552074.2019.1615288
Published online: 28 Jun 2019.
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Overcoming the tyranny of the urgent: integrating gender into
disease outbreak preparedness and response
Julia Smith
ABSTRACT
This article contributes to discussions on the gender dimensions of
disease outbreaks, and preparedness policies and responses, by
providing a multi-level analysis of gender-related gaps, particularly
illustrating how the failure to challenge gender assumptions and
incorporate gender as a priority at the global level has national and
local impacts. The implications of neglecting gender dynamics, as well
as the potential of equity-based approaches to disease outbreak
responses, is illustrated through a case study of the Social Enterprise
Network for Development (SEND) Sierra Leone, a non-government
organisation (NGO) based in Kailahun, during the Ebola outbreak.
Cet article contribue aux discussions sur les dimensions sexospéciques
des ambées de maladies et aux politiques et interventions en matière
de préparation en proposant une analyse multi-niveaux des lacunes
liées au genre, et en illustrant en particulier comment le fait de ne pas
mettre en question les suppositions en matière de genre et de ne pas
incorporer le genre parmi les priorités au niveau mondial a des impacts
àléchelle nationale et locale. Les répercussions du manque dattention
accordée à la dynamique de genre, ainsi que le potentiel dapproches
basées sur léquité des interventions dans les situations de ambées de
maladies, sont illustrés grâce à une étude de cas du Social Enterprise
Network for Development (SEND) Sierra Leone, une organisation non
gouvernementale (ONG) basée à Kailahun, durant la ambée de
maladie à virus Ebola.
Proporcionando un análisis de múltiples niveles sobre los vacíos
relacionados con el género, el presente artículo contribuye a la
discusión sobre las dimensiones de género durante los brotes de
enfermedad, las políticas y las respuestas de preparación. En
particular, ilustra cómo incide a nivel local e internacional el hecho
de no cuestionar los supuestos vinculados al género y no incluir el
género como una prioridad. Un estudio de caso de la Red de
Empresas Sociales para el Desarrollo (SEND) de Sierra Leona, una
organización no gubernamental (ONG) con sede en Kailahun, explica
las implicaciones que tuvo descuidar las dinámicas de género
durante el brote de ébola, y analiza las posibilidades de impulsar
enfoques basados en la equidad en las respuestas implementadas
frente a brotes de enfermedades.
KEYWORDS
Health; gender; disease
outbreak; Ebola; epidemic;
policy; crisis response; care
work
© 2019 Oxfam GB
CONTACT Julia Smith jhs6@sfu.ca
GENDER & DEVELOPMENT
2019, VOL. 27, NO. 2, 355369
https://doi.org/10.1080/13552074.2019.1615288
Introduction
Since 2000, there have been a series of outbreaks of new, acute, or re-emerging commu-
nicable diseases that pose a threat of global spread. They have included Middle East res-
piratory syndrome (MERS) in Saudi Arabia and South Korea, epidemics of H1N1 and
H5N1 strains of inuenza, and severe acute respiratory syndrome (SARS), and the mos-
quito-carried Zika virus in South and Central America, as well as Ebola in West and Cen-
tral Africa. The West African Ebola outbreak from 2013 to 2016 attracted particular
attention to the need to address gender issues relating to the spread and control of infec-
tious diseases. A 2015 report from the Reference Group for Gender in Humanitarian
Action noted, Vigilance against a repeat escalation or future outbreak of the disease
(or any other similarly highly infectious virus) must incorporate the lessons learned on the
signicance of gender in the spread and control(2015, 1).
The gender dimensions of outbreaks are both physical and socially constructed. Some
diseases by their nature aect the sexes dierently: an example is the Zika virus, which may
result in a relatively mild infection but is particularly risky during pregnancy, as it is linked
to birth defects. Where gender roles and relations are concerned, the care roles fullled by
women are signicant as women frequently take on the majority of the burden and risk of
providing health care in the home, often with little external support. Availability of health
services, interactions with emergency responders, and health governance structures also all
have gender dimensions.
To respond to the threat of future epidemics, a High Level Panel on the Global
Response to Health Crises was set up by the United Nations (UN) Secretary-General in
April 2015 to draw together the lessons to be taken from the Ebola response, and propose
recommendations aiming to strengthen national and international systems to prevent and
respond eectively to future health crises (UN 2016). The High Level Panelsnal report,
published in 2017, included the recommendation, Focusing attention on the gender
dimensions of global health crises(Global Health Crises Task Force (GHCTF) 2017,
16). The High Level Panel noted the need to incorporate gender analysis into responses,
as well as recognise the critical role played by women in responding to health emergencies.
It further stated that policy-makers and outbreak responders need to pay attention to gen-
der-related roles and social and cultural practices(ibid., 17). Responding to recommen-
dations from the High Level Panels report, in May 2018, the World Health
Organization (WHO) and World Bank announced the creation of a Global Preparedness
Monitoring Board to:
Strengthen global health security through stringent independent monitoring and regular report-
ing of preparedness to tackle outbreaks, pandemics, and other emergencies with health conse-
quences. (WHO 2018,1)
If and how the board will integrate the recommendations related to gender remains to
be seen.
To date, as I will show in this article, gender analysis has been conspicuously absent
from policy debates, documents, and processes. Instead, it is argued, outbreak responses
356 J. SMITH
and policies are characterised by the tyranny of the urgent, which puts aside structural
issues in favour of addressing immediate biomedical needs (Davies and Bennett 2016,
1041). For example, Sophie Harman (2016) presents a damning critique, from the per-
spective of women and gender issues, of the international response to the Ebola crisis.
Lack of gender analysis also extends to research on outbreak responses. While health sys-
tems and policy research has begun to incorporate gender analysis, few publications have
addressed gender issues relating to disease outbreaks. Sara Davies and Belinda Bennett
note that, The vulnerabilities of women and girls during complex emergencies are equally
present during a public health emergency but are relatively underexamined in these cir-
cumstances compared to the study of gender, health and inequality during natural disas-
ters(2016, 1044). In a review of the research on both Ebola and Zika outbreaks, they
found that less than 1 per cent of published research discussed gender issues (ibid., 1054).
In this article, I aim to reect on the silences around gender and disease outbreaks. I do
this by sharing insights gained from a literature review of scholarly and policy documen-
tation on gender and infectious disease outbreaks conducted in 2018. The majority of my
analysis draws on examples from the Ebola and Zika responses, as most of the literature
focuses on these cases. However, examples from other outbreaks are also considered. In
order to illustrate the gendered impacts of disease outbreaks and responses on the lived
experiences of women and girls, a case study based on the work of the non-government
organisation (NGO) SEND Sierra Leone is included. The case study is drawn from the
reports SEND produced during and following the West African Ebola outbreak in
20142016.
It is important to note that, while I worked for SEND Sierra Leone as Technical Advisor
during 20102011, I was not in Sierra Leone during the Ebola outbreak and am writing
this as an academic researcher, based at a Canadian university, and from a position of pri-
vilege that means I am unlikely to be vulnerable to disease outbreaks. I recognise that there
is a need to hear from those directly aected by disease outbreaks and health inequities in
order to inform responses that promote equity. I hope the more academic- and policy-
focused analysis that is presented here will also contribute to achieving these goals.
Methodology and approaches
A literature review using targeted key word searches (gender OR women OR feminist* OR
masculinity OR intersectional* AND outbreak OR epidemic OR pandemic AND policy
OR response OR preparedness) was conducted in various databases.
1
Publications that
discussed or evaluated disease outbreak policies and responses were used, including
both 20 peer-reviewed articles and 18 publications by organisations engaged in global
or public health.
Publications were then organised by policy level (global, national, and local) and
reviewed by applying a critical gender lens informed by gender and development
(G&D), feminist economics, and intersectional approaches.
G&D literature and practice raises awareness about how gender relations and assump-
tions shape humanitarian and development policies. G&D recognises that male bias is
GENDER & DEVELOPMENT 357
more than just personal perception, but is also a blindness to the policies and structures
that operate in favour of men as a gender, and against women as a gender(Elson
1993, 238). This approach emphasises the need to identify and recognise conscious and
unconscious bias through gender-aware and gender-visible policies. Gender bias can be
exposed through questions such as: Do policies consider the diering roles and experi-
ences of men, women, and other social groups? Do they aim to maintain the status quo
or promote gender transformation?
Feminist economics has particularly documented how conventional approaches fail to
recognise womens unpaid labour and the economic, social, and opportunity costs
women incur while fullling care roles (Folbre 2006). Applying a feminist economics
lens, in this context, promotes questions such as: Do policies recognise how gender
norms impact the health-care roles men and women full during an outbreak? Do they
support or exploit unpaid care work?
Intersectionality recognises the multiple social and identity factors such as ethnicity,
race, religion, sexuality, and disability that shape individualsvulnerabilities to disease
outbreaks, as well as their capacity to cope during emergencies and engage with
responses (Hankivsky 2012). This research asks if and how policies and responses
address multiple vulnerabilities, the rights of marginalised groups, and structural inequi-
ties, while recognising that more in-depth analysis is needed to understand fully the
unique intersecting identity factors that are important in individualsexperiences of
dierent disease outbreaks.
Global gender gapsin policy documents on disease outbreaks
Analysis of global-level policy documents related to disease outbreaks reveals a notable
lack of gender analysis. There is no mention of gender inequality, womens particular
needs, or ensuring the health of marginalised groups, in most high-prole policy docu-
ments.
2
Outbreak-specic documents also lack gender analysis. WHOsEbola Response
Roadmap includes only one sentence about women (Harman 2016). The World Banks
(2014) report on The Economic Impact of the 2014 Ebola Epidemic did not discuss gen-
dered economic impacts of the epidemic. External assessments of the WHOs response,
which provide recommendations to prepare for future outbreaks, such as the report by
the Harvard-LSHTM Independent Panel on the Global Response to Ebola, also fail to
include any discussion of the gendered dimensions of the outbreak or response
(Moon et al.2015).
Documents from the Global Health Security Agenda (GHSA), a multi-sectoral and
multilateral eort, established under American leadership in 2014 to accelerate progress
towards disease outbreak preparedness, also do not include any degree of gender analy-
sis. The GHSA is currently developing a framework to guide its future direction. The
current draft of this framework (circulated in June 2018) does not mention gender or
other equity issues (GHSA 2018b). Other GHSA publications and policy documents,
such as country roadmaps (GHSA 2016) and progress reports (GHSA 2018b), also
do not include gender analysis.
358 J. SMITH
Gender and security during humanitarian crises an example of global policy failure
The failure of global policies to include gender reinforces a policy context that ignores how
women, men, and other groups experience outbreaks and responses dierently. For
example, the GHSA particularly promotes greater engagement of the security sector in dis-
ease outbreak preparedness and responses, oering a framework and umbrella under
which defense departments can collaborate on threat reduction(2018b, 1). Its policy sug-
gestions reveal the assumption, embedded in other disease outbreak preparedness policy
documents as well, that security-sector engagement will improve disease outbreak
responses for all concerned. Yet Fionnuala Ní Aoláin writes, one has to start any conver-
sation about security with an interrogation of the assumption that womens security and
mens security are identical(2010, 19). She notes that, womens security in times of
humanitarian crises requires a broad conception of security that encompasses physical,
social, economic, and sexual security(ibid., 21).
Yet the security sector including the police and the army is shaped by societal
norms, including gender norms, which often position women at a structural disadvantage
and potentially vulnerable to gender-based violence and abuse. Research indicates that the
deployment of security forces, on humanitarian as well as conict missions, corresponds
to an increase in gender-based violence (Tripp et al.2013). Hence the security sector is
rarely well-positioned to uphold and ensure that everyone in a community can realise
all of their securities.
Security sectors in many contexts are characterised by the dominance of hypermascu-
linity; a masculinity in which the strictures against femininity and homosexuality are
especially intense and in which physical strength and aggressiveness are paramount(Ní
Aoláin 2010, 15). Research on peacekeeping and humanitarian responses has documented
how hypermasculinity dominates other masculinities in times of crisis, where responders
are largely men and those suering the eects of crisis are feminised due to their disem-
powered position and reliance on security personal for access to necessities such as food
and health care (Tripp et al.2013). While there is no apparent research on hypermascu-
linity and disease outbreak responses, communities that have experienced the use of secur-
ity forces to conduct disease outbreak surveillance note these roles are dominated by men
and report feeling fearful of excessive use of force and of violence (Abramowitz et al.2015).
Global responses promoting security-sector engagement also fail to recognise that as
security sectors across the world remain male dominated, and that those in the higher
ranks often represent dominant social groups (such as those who identify as heterosexual
white males in Western contexts), decision-making rarely includes the perspectives of
women and marginalised groups (Ní Aoláin 2010). Sophie Harman (2016) argues that
the military actors involved in the Ebola response in Sierra Leone had the tendency not
only to overlook issues of gender dierence in how men and women experience disease,
but also to reproduce gender norms in masculinised spaces of decision-making and
implementation. The uncritical promotion of security-sector engagement in disease out-
break responses at the global level reinforces a specic type of masculine dominance in
decision-making and may exacerbate insecurity for women and marginalised groups.
GENDER & DEVELOPMENT 359
Limiting national policies
The International Health Regulations (IHR) provide legally binding regulations on how
WHO member states prepare for, report on, and respond to health emergencies. Within
the IHR, gender only appears in terms of accounting for the concerns of travellers with
regard to their gender, ethnicity, religion, and sociocultural factors. In addition, only for-
mal health-care work is considered, neglecting any recognition of how the bulk of care
work during an emergency is conducted by women (discussed further below).
Under the IHR, state parties are required to meet core capacity standards, which are
measured according to the Joint External Evaluation of Core Capacity Framework (JEE),
a standardised tool used to assess country preparedness across 19 technical areas (WHO
2016a). While there is much debate about JEE components, processes, and eectiveness
(Wilson et al.2010), a feminist reading highlights the lack of gendered targets and indi-
cators. No targets refer to gender or other inequities, and none of the technical questions
which guide assessment of progress towards the targets request gender-disaggregated
data. For example, the target related to Workforce Development does not ask about the gen-
der composition of the health workforce or about supports for informal care work. There is
only one target that mentions marginalised groups; the immunisation target is for a func-
tioning national vaccine delivery system with nationwide reach, eective distributions,
access for marginalised populations, adequate cold chain, and ongoing quality control
that is able to respond to new disease threats(WHO 2016a, 29). Yet none of the technical
questions follow up on how delivery systems might reach marginalised populations.
Under the target related to preparedness for zoonotic diseases (diseases that can be
transmitted from animals to people), a technical question asks, Is there a plan in place
to address factors which might prevent farmers/owners from reporting animal disease
(may include lack of familiarity with reporting process, lack of indemnity, social stigma)?
(WHO 2016a, 17). While this question recognises that stigma can impact surveillance
eectiveness, the JEE does not include questions regarding if there are policies in place
to protect individuals, particularly those already at risk, from stigma (e.g. legislation
that prohibits evicting tenants or ring workers based on health status). While the JEE
could be a tool to encourage state policies to consider the gendered dynamics of outbreak
preparedness, it instead maintains androcentric, or male-centred, assumptions that purely
technocratic responses are adequate.
There is widespread consensus that a primary gap in disease outbreak preparedness, by
both recipient and donor states, is inadequate investment in health system strengthening
(HSS) (Regmi et al.2015). However, HSS not only requires resources, it also must include
specic policies to address gender and other inequities. Sarah Payne writes:
Health systems that are gender blind’–that is, where gender dierentials in health services are not
recognised may maintain and/or reinforce gender inequalities and gender inequity in wider
society, both in their day-to-day operation and in their development of health policies. (2009,4)
As there is substantial research on the need to, and how to, integrate gender and
other equity issues into HSS, it will not be repeated here (Morgan et al.2016). What
360 J. SMITH
is particularly relevant is that HSS eorts related to disease outbreak preparedness have
largely failed to address equity issues. For example, the Vaccine Alliances (GAVI) HSS
programme does not incorporate specic goals, targets, or supports related to gender
(GAVI 2016).
Where gender is mentioned in HSS policies related to disease outbreak preparedness,
it is most often conated with maternal and child health, reecting assumptions that
women are solely responsible for reproductive and family health (Witter et al.2017).
For example, Canadas Feminist International Assistance Policy commits to strengthen-
ing health systems and ghting infectious diseases primarily by funding maternal, new-
born, and child health initiatives (GAC 2018). While maternal health must be a priority
during outbreaks (as is discussed further below), the nearly exclusive focus on reproduc-
tion perpetuates gender norms that conne women to maternal roles, while failing to
address womens marginalisation in society or the health eects of inequality (Yamin
and Boulanger 2013). The focus on maternal health also obscures the roles and respon-
sibilities of men related to reproductive health, the health needs of women unrelated to
reproduction, and of the right to sexual health for people of all genders who cannot or
chose not to have children.
This is not to say that comprehensive sexual and reproductive health (SRH) is a not an
important priority within disease outbreak preparedness and response. Disease outbreaks
can be exacerbated by and exacerbate lack of access to SRH services, which are already
restricted by prohibitive laws and customs in many contexts. The South American Zika
outbreak illustrates the importance of SRH services to eective disease outbreak response.
In most cases Zika causes only mild infections. However, it can have severe reproductive
health impacts and cause congenital syndromes in infants born to mothers infected by
Zika. Consequently, family planning to ensure protective measures are taken prior to
and during pregnancy is the best way to prevent this health concern (Guttmacher Institute
2018). The WHO recommends countries aected by Zika
provide equitable access to quality sexual and reproductive healthcare and services for all women
and adolescent girls of reproductive age in Zika-aected areas, including access to family planning,
counselling, contraceptive services, including emergency contraception, and supplies, quality pre-
natal care, quality obstetric care, safe abortion services (where legal), and post-abortion care.
(WHO 2016b,1)
Central and South American states aected by Zika, however, have done little to change
prohibitive laws or improve access to SRH services, instead simply arguing women should
avoid pregnancy. In 2017, 24 million women of reproductive age in Latin American and
the Caribbean had an unmet need for modern contraception, and more than 97 per cent
lived in countries with restrictive abortion laws (Guttmacher Institute 2018, 1). A recent
assessment in Brazil found no increase in contraception use since the Zika outbreak, con-
cluding this is due to continued poor access (Bahamondes et al.2016). As analysis from
the Guttmacher Institute notes, Blanket recommendations that women avoid pregnancy
in several Latin American and Caribbean countries [aected by Zika] unacceptably shift
the burden of responding to the crisis to individual women(2016, 1).
GENDER & DEVELOPMENT 361
Such recommendations also exacerbate existing inequities. While Zika is a threat to all
pregnant women, wealthier women can often protect themselves by accessing contracep-
tion and travelling to either seek abortion services or avoid exposure to Zika while preg-
nant, and impoverished women cannot (Harris et al.2016). Consequently, children with
Zika infection-related disabilities are disproportionately born to women of low socioeco-
nomic status (Lowe et al.2018). The burden of care for children born with congenital syn-
dromes due to Zika also falls largely on women from lower socioeconomic groups living in
remote areas. Most of these women give up their jobs or studies to care for their children,
and anecdotal reports suggest many become single parents (Diniz 2017).
Poor access to SRH services and restrictive laws combine with weak health systems to
create a context of poor maternal health care, which is exacerbated when scarce resources
are diverted to outbreak responses. During the West African Ebola outbreak, Médecins
Sans Frontières (MSF) closed its obstetric and paediatric care facilities in aected areas,
depriving the local population of essential services(Stockhold Evaluation Unit 2016,
12). Across the region, the closure of NGOs and non-Ebola health services resulted in
reduced access to family planning services, increasing the risk of unplanned pregnancies.
Quarantine policies prevented pregnant women from accessing care and women suspected
of being infected were denied care (Erland and Dahl 2017). Midwives struggled with a lack
of clinic guidelines and little information on how to care for pregnant women in the con-
text of Ebola. Maternity care was only provided in clinics after Ebola results were obtained,
causing delays in care which contributed to increased foetal and maternal deaths.
Across the Ebola-infected region, the number of women giving birth in hospitals and
health clinics dropped by 30 per cent and the maternal mortality rate increased 75 per
cent (Davies and Bennett 2016, 1043). A midwife who cared for pregnant women with
Ebola noted,
We have some kind of moral imperative, but as a global community, I dont think we have the
moral voice to be able to say: yes, we did the best we could for pregnant women in Sierra
Leonebecause we didnt. (quoted in Erland and Dahl 2017, 26)
Implications for local realities
The impact of outbreaks on care work
Lack of investment in health systems at the national level has particular gendered impacts
at the local level, resulting in a downloading of care responsibilities on to women, a situ-
ation which is exacerbated during outbreaks. Sophie Harman explains that the feminised
unpaid reproductive care economy acts as a shock absorberin periods of crisis
Women absorb the burden of care through self-exploitation (leading to direct and indirect
health impacts on women as a gender), reliance on family, or outsourcing care roles to
poorer women(2016, 525).
While women often view care work as their duty and take pride in it, they also report
hardships related to lack of resources, and the desire to be able to access professional ser-
vices when necessary. Assessments of the care work associated with the HIV epidemic in
362 J. SMITH
sub-Saharan Africa demonstrate that women providing care often sacrice their own
health, safety, and resources (Ogden et al.2006).
During the West African Ebola outbreak, the majority of care was provided by
women, many of whom continue to suer from the psychological trauma of being solely
responsible for the ill and from the fear of contracting and passing on the virus, par-
ticularly to their children (Abramowitz et al.2015). Noting the sensitive nature of
care work, Fionnuala Ní Aoláin writes that humanitarian assistance and other forms
of crisis intervention should not increase womens vulnerability, neither by undermining
their coping strategies nor by reinforcing damaging coping strategies(2010, 13). In
other words, the care work provided by women should be supported, while providing
alternatives that empower women.
While there are numerous examples of programmes run by states and NGOs providing
supports to home-based care providers in non-emergency contexts, these remain reliant
on the unpaid care work of women, are usually poorly resourced, and are ill-equipped
to deal with outbreaks. For example, during the 2008 cholera epidemic in Zimbabwe,
home-based care providers lacked access to basic essentials such as oral rehydration
salts (Mason 2009). Reports from Zimbabwes 2018 cholera outbreak suggest the situation
remains much the same if not worse (Burke 2018). During emergencies, inadequate sup-
port for home-based care is exacerbated. Existing programmes are often cancelled as
organisations suspend operations out of fear of infection, and outbreak responses rarely
include support for home-based care providers.
Emergency response organisations also frequently fail to consider gender roles, such
as those relate to care work, when designing communications materials. MSF notes the
eectiveness of its health promotional materials during the West African Ebola outbreak
was limited by lack of understanding of local gender norms (Stockhold Evaluation Unit
2016). Public health materials, such as posters and radio advertisements, advised against
touching and cleaning up after those who appeared sick. Such isolation messages
were irrelevant to women responsible for caring for family members at home. As
Sharon Abramowitz et al.reected, Dont touch messages do not recognise that
women have to touch to give care(2015, 11). Isolation messages can also indirectly
stigmatise those required to provide care by highlighting their potential role in
transmission. Instead, gender-sensitive communications would answer questions
like, How do I manage a family of children, including infants and toddlers, in
quarantine?(ibid., 11).
A case study: SEND Sierra Leone
Sierra Leone, bordering Liberia and Guinea, ranks 184 (out of 189) on the Human Devel-
opment Index, and Kailahun District is one of the poorest regions of the country (UNDP
2017). Only 32 per cent of the adult population is literate in Sierra Leone, and less than 20
per cent of women in Kailahun can read and write (SEND Sierra Leone 2018). The
maternal mortality rate 83.3 per every 1,000 live births (UNDP 2017,1)is among
the worst in the world.
GENDER & DEVELOPMENT 363
The Social Enterprise Network for Development (SEND), a West African-based NGO,
began operations in Kailahun in 2008. SEND Sierra Leones mission is to work to promote
good governance and equality for women and men in Sierra Leone(SEND Sierran Leone
2018, 1). It implements Livelihood Security, Women in Governance, and Accountability in
the Health Sector projects. In addition to mainstreaming gender within its activities,
SEND facilitates, as part of the Women in Governance project, the Kailahun Women in
Governance Network (KWiGN). The network includes over a hundred womens groups
across the district which engage in district-level policy processes, conduct gender audits
of political parties, support female candidates during elections, co-ordinate micronance
savings groups, and host weekly radio shows.
Kailahun was the region most aected by the West African Ebola outbreak. Health sys-
tems collapsed, and markets and schools closed. Trade and travel disruptions resulted in
food shortages and rising prices of essential items. Those in aected households destroyed
their possessions out of fear of contagion, and in some cases houses were burnt to the
ground. By July 2014, the district was recording an average of 30 conrmed Ebola cases
per day (Ayamga 2014, 2). In one community where the KWiGN co-ordinates a micro-
nance project, six out of 35 women from a savings group died; in another, nine out of 35
died within a few days of each other (Kamara 2015, 1).
SENDs reports during the epidemic share the stories of those aected: a single mother
died, leaving three children to be cared for by their disabled grandmother; another grand-
mother lost seven members of her family and was left caring for the remaining two chil-
dren; a 22-year-old woman lost both parents, becoming responsible for six younger
siblings (Kamara 2015). A SEND evaluation found that women were providing the vast
majority of care to orphans and faced the additional hardship of stigma. The report
notes, In situations where the husband and wife were infected, and the wife survived,
the in-laws would accuse her to have bewitched the deceased husband. She will be rejected
in the community, as well as evicted from her marital home(Kohteh 2015, 5).
SEND staobserved that the majority of the national and international response eorts
were primarily directed at health service delivery and failed to address the contextual and
cultural factors causing the disease to spread (Kohteh 2015). While these included denial
and traditional practices, they were also related to a lack of access to water, low literacy
rates and the need to travel to nd food as local markets were closed. Remote communities
in the district were not receiving any services or supports. Because sensitisation activities
did not specically reach out to women, women were not participating to the same degree
as men.
To respond to the immediate needs of those aected, SEND developed a relief pro-
gramme with support from partners such as CORDAID Netherlands and Christian Aid
UK. Funds provided 250 families aected by the outbreak with household goods, food,
and a monthly stipend to meet basic needs. The KWiGN co-ordinated a community foster
parent programme for Ebola orphans, and used its radio show to speak out against stigma,
providing education about how Ebola spread and how to care for those who were ill while
avoiding infection. The radio show was particularly crucial in reaching remote commu-
nities where no other information services were being provided (Kohteh 2015).
364 J. SMITH
While SEND did not have the capacity to contribute to the emergency health response,
it set a goal of improving health systems to respond to those concerns that were being neg-
lected and to protect against future outbreaks. Along with international partners, SEND
helped connect the district hospital to the municipal water supply, renovated peripheral
health units, provided supplies such as blood pressure machines of health units bought
motorbikes for health sta, and trained staon how to use mobile technology.
SEND also co-ordinated Village Ebola Watch Committees to provide sensitisation and
support to those communities not reached by other programmes. The committees
included KWiGN members and Christian and Muslim leaders. SEND found that includ-
ing religious leaders resulted in local acceptance of the committeesmessages, and that
including KWiGN members increased womens participation in sensitisation workshops.
The committees also worked with security personnel, deployed by the government to con-
duct surveillance and monitor travel, acting as a liaison between security forces and com-
munity members.
KWiGN members continue to participate in surveillance activities at the 53 border
checkpoints between the district and neighbouring Guinea and Liberia. At some of
the more remote locations they are the only health monitors presents; in others, they
work alongside security personnel (SEND Sierra Leone 2018). An evaluation of
SENDs Ebola responses programmes nds, The organization employed a commu-
nity-based approach that puts local community members (particularly women) and
local authorities at the heart of their programming and this has made their projects
very successful over the years(Kohteh 2015, 4). It further notes, The collaboration
between SEND and KWiGN contributed to the projects high acceptance rates among
the local populations(ibid.).
This case study demonstrates both the gendered impacts of the Ebola outbreak and the
potential of responses that aim to promote gender equity. Importantly, SEND established
equity goals at the onset of its programmes, building capacity through its development
initiatives that it was then able to capitalise on when the Ebola outbreak occurred.
While the KWiGN was initiated to advance womens leadership, it responded to the crisis
by transforming into an outbreak response team that provided gender-sensitive care, sen-
sitisation, and surveillance. KWiGNs leadership capabilities and networks enable SEND
to build partnerships with other actors, such as religious leaders. While SEND provided
supplies and stipends to those providing care, KWiGN members also took on roles in
addition to care-giving, such as within Village Ebola Watch Committees. Through these
activities, womens needs were prioritised and the position of women leaders was
reinforced, putting them at the centre of the response. SENDs response did not choose
between addressing immediate practical needs or structural inequities it did both.
Lessons learned
There seems to be an unspoken agreement demonstrated by the lack of gender analysis
in global-level policy documents that gender is not relevant to global-level processes. Yet
global policies inuence local health outcomes (indeed, if they did not, we would have to
GENDER & DEVELOPMENT 365
ask what the point is of all those very expensive meetings at global institutions!). The
securitisation of outbreak responses puts military personnel in local communities, poten-
tially leading to increased rates of gender-based violence. The failure of the IHR to con-
sider gender allows assumptions that all people benet equally from one set of policies
to trickle down to state outbreak preparedness planning. The lack of investment in HSS
at the global and national level contributes to failures to provide comprehensive SRH ser-
vices, and continued reliance on, but lack of recognition of, the care work conducted by
women during outbreaks. Lack of consideration of gender roles by health organisations
translates into public health messages that are irrelevant and potentially stigmatising.
Global policy responses can learn from examples such as SEND Sierra Leone. SEND did
not include a gendered approach in its response as an afterthought; it was at the heart of
the response because SEND had an established gender strategy. The emergency context of
disease outbreaks makes it essential to include gender in preparedness policies, as addres-
sing structural issues, such as gender inequality, require foresight and planning. At the glo-
bal level this could be achieved through greater recognition of the gendered and other
social dimensions of the IHR, which could then inuence national policies through the
development of JEE indicators and targets reective of an intersectional approach.
These could be developed through consultation with feminist activist and social move-
ments, an approach that has proven successful within Global AIDS Response Progress
(GARP) reporting processes, where civil society organisations have worked with the
UNAIDS Monitoring and Reference Group to develop indicators on gender-based vio-
lence, stigma, and the rights of marginalised groups (Smith et al.2017).
Another key lesson from the Ebola case study is that the leadership role of the
KWiGN was essential in reaching out to other women, communicating eectively,
and building partnerships with other actors, such as security personal. Evidence from
other sectors demonstrates that gender and related rights issues will be neglected if
there is not a designated responsibility for inclusion. There needs to be concerted
eorts to engage women and members of marginalised groups in all levels of disease
outbreak policymaking and response. For example, the Disease Outbreak Preparedness
Monitoring Board could include a gender focal point to solicit input from those most
aected by disease outbreaks. Davies and Bennett (2016) advocate a greater role for the
Special Rapporteur on the Right to Health within disease outbreak policymaking.
National and local-level policy processes need to innovate to create spaces for greater
engagement with women and marginalised populations.
All levels of response need specic policies in place to ensure compressive sexual and
reproductive health at all times. One option would be to adoption of the Minimum Initial
Service Package (MISP) for Reproductive Health, a co-ordinated set of priority activities for
decreasing SRH-related morbidity and mortality during an emergency, to infectious disease
outbreaks. Programming and policy responses similarly need to rst recognise the care
work conducted largely by women in such situations, and then nd ways to support such
work without relying on it. This includes strengthening health systems to provide health-
care options and providing opportunities for women in all aspects of the response, whether
it be through formalised work in the health sector, decision-making, or security.
366 J. SMITH
While it may not be clear when and where the next major outbreak will occur, we
unfortunately do know that it will occur. In order to overcome the tyranny of the urgent,
there is an immediate need to incorporate gender-based analysis, the voices of women and
marginalised groups, and feminist perspectives in disease outbreak preparedness and
responses.
Notes
1. These databases consisted of Google, Google Scholar, PubMed, and Eldis.
2. These include the Global Monitoring of Disease Outbreak Preparedness: Preventing the Next Pan-
demic published by the Harvard Global Health Institute (2018) and The Neglected Dimension of
Global Security: A Framework to Counter Infectious Disease Crises published by the National
Academy of Medicine (2016).
Acknowledgements
Research for this article was supported by Global Aairs Canada, and the Social Sciences and
Humanities Research Council of Canadas International Policy Ideas Challenge
Notes on contributor
Julia Smith is a Research Associate in the Faculty of Health Sciences at Simon Fraser University, Canada.
She has worked for health and development organisations in Africa, Europe, and North America. Postal
address: c/o The Editor, Gender & Development. Email: jhs6@sfu.ca
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The nature of human security is changing globally: Interstate conflict and even intrastate conflict may be diminishing worldwide, yet threats to individuals and communities persist. Large-scale violence by formal and informal armed forces intersects with interpersonal and domestic forms of violence in mutually reinforcing ways. Gender, Violence, and Human Security takes a critical look at notions of human security and violence through a feminist lens, drawing on both theoretical perspectives and empirical examinations through case studies from a variety of contexts around the globe. This fascinating volume goes beyond existing feminist international relations engagements with security studies to identify not only limitations of the human security approach, but also possible synergies between feminist and human security approaches. Noted scholars Aili Mari Tripp, Myra Marx Ferree, and Christina Ewig, along with their distinguished group of contributors, analyze specific case studies from around the globe, ranging from post-conflict security in Croatia to the relationship between state policy and gender-based crime in the United States. Shifting the focus of the term “human security” from its defensive emphasis to a more proactive notion of peace, the book ultimately calls for addressing the structural issues that give rise to violence. A hard-hitting critique of the ways in which global inequalities are often overlooked by human security theorists, Gender, Violence, and Human Security presents a much-needed intervention into the study of power relations throughout the world.