Why Are So Many Women Dying From Ebola?

Studies show that infectious disease often affects one gender more than another -- but that knowledge isn't being put into practice. 

When people started dying from Ebola in West Africa in March, Martha Anker, a former statistician in communicable disease surveillance and response at the World Health Organization (WHO), began watching the news to see whom primarily the terrible disease would strike. Sitting in her house in Massachusetts, Anker had a gut feeling: that Ebola, as it had in the past, would claim women as its primary victims.

As it turns out, Anker was right.

On Aug. 14, the Washington Post reported that across Guinea, Liberia, and Sierra Leone collectively, women have comprised 55 to 60 percent of the dead. In Liberia, the government has reported that 75 percent of victims are women. "I felt very sad when I read that thing from the Washington Post," Anker says. "I'm so sorry to be right."

Back in 2007, Anker wrote in a WHO report, "Differences in exposure between males and females have been shown to be important factors in transmission of EHF [Ebola hemorrhagic fever]. Therefore, it is important to understand the gender roles and responsibilities that affect exposure in the local area."

That entreaty clearly didn't find its way to West Africa when this current outbreak began. Ebola spreads through contact with blood and other bodily fluids, and in Liberia, as in neighboring countries, women are usually the primary caregivers for the sick. They continue to be during the current epidemic -- they stay in their homes and become infected by their children or husbands instead of seeking out doctors and nurses for their loved ones. Rarely are the roles reversed. "If a man is sick, the woman can easily bathe him but the man cannot do so," says Marpue Spear, the executive director of the Women's NGO Secretariat of Liberia (WONGOSOL). "Traditionally, women will take care of the men as compared to them taking care of the women."

It shouldn't take so many deaths -- more than 1,200 at the time of this writing -- to realize how attention to gender dynamics might help save lives (in this case through, among other things, targeted messaging to women about the importance of using protective measures at home or allowing loved ones to be cared for by trained professionals). Indeed, there shouldn't have to be Cassandras like Anker -- for Ebola and other diseases.

Data show that many infectious diseases affect one gender more than another. Sometimes it's men, as with dengue fever. Sometimes it's women generally, as with E. coli, HIV/AIDS (more than half the people living with the virus are female), and Ebola in some previous outbreaks. Sometimes it's pregnant women and mothers, as with H1N1 (an outbreak in Australia is currently infecting women over men by a 25 percent margin).

Yet when women are the primary victims of an epidemic, few are willing to recognize that this is the case, ask why, and build responses accordingly. Indeed, experts say that too little is being done to put even the small amount that is known about gender differences and infectious diseases into practice -- to determine in advance of outbreaks, for instance, how understanding gender roles might help in the development of a containment or prevention strategy. Not only that, but there is too little research being done to understand how infectious diseases affect the sexes differently on a biological level. It's like Groundhog Day each time a disease surges, and people are losing their lives because of it. "We can't get past the 'interesting observation' stage," says Johns Hopkins University professor Sabra Klein. Public health officials generally gather data on age and sex in a crisis, but "nobody goes somewhere with it."

Klein, who studies biology and immunology, explains that going "somewhere" would mean consciously evaluating what happens in an outbreak, or in any health crisis, through a gender lens. It would also mean tackling systemic problems, such as women's unequal access to adequate health care or the finances they might require for treatment. In short, it would mean challenging fundamental and dangerous disparities.

Looking at who dies in an outbreak "shows you who has power and who doesn't," says Columbia University epidemiology professor Wafaa El-Sadr. "In a way, it holds a mirror to society. And it shows societies how they treat each other."


As in many spheres, the funding, research, and thinking in public health has long been geared toward white men. As Claudia García-Moreno, lead specialist in gender, reproductive rights, sexual health, and adolescence at the WHO in Geneva, puts it, "When I was in medical school, everything" -- drug dosages, public health scenarios -- "was still defaulted for the '70-kilo white male.'" García-Moreno says that though this has changed somewhat, "it's still not what we would hope it would be."

García-Moreno points to a persistent lack of attention to the "biological components" of disease. There are often basic differences in how men and women respond to infection, Klein echoes, and those can -- and should -- affect medical responses in the short and long terms. Take influenza, for instance; according to Klein, "Inflammation caused by infection is often greater for women than for men." Similarly, Anker noted in a 2011 WHO report, "A frequent mistake is to undercount the relative importance of symptoms that can only occur in one sex, such as vaginal bleeding in dengue."*

"You get these really interesting observations about Ebola, too," Klein adds. "[Yet when] research funding is coming in for Ebola, they will not even consider the role sex might play."

As evidence of this sort of dismissal of gender's importance in public health matters, Klein describes an anonymous note once included in a review of a grant application she wrote. "I wish you'd stop with all this sex stuff and get back to science," it read. "I've been in this field for 20 years and this [biological difference] doesn't matter," another note once stated.

Throughout her career, Anker has been beating back against similar faulty notions, though ones often rooted in social, as opposed to biological, issues. "The general belief has been that since infectious diseases affect both males and females, it is best to focus public health attention during an outbreak on control and treatment, and to leave it to others to address social problems that may exist in society such as gender inequalities after an outbreak has ended," she wrote in the 2011 WHO report. However, addressing these "problems" can be critical to understanding and stemming an epidemic's spread.*

Consider nurses. They are primarily female worldwide, and they are frequently at the forefront of dealing with infectious diseases. Yet very often, they are too low on the social -- and gender -- totem pole for their needs to be heard clearly. "Research has shown that poor nurse-physician relationships are common in hospital settings, pose a potential threat to patient safety -- including the risk of infections [--] and have a negative impact on nurse satisfaction and retention," the 2011 WHO report stated. Moreover, after the 2003 SARS outbreak, Canadian studies found, according to the WHO, that a "lack of power and influence of nurses was linked to infection control deficiencies."

Considering gender more broadly, in one previous Ebola outbreak, an anecdotal report claimed that men dominated informational meetings on the disease, despite the fact that women were already known to be primary caregivers. During H1N1 (avian flu) outbreaks, government officials tended to deal with men because they were thought to be the owners of farms, despite the fact that women often did the majority of work with animals on backyard farms. And some dengue-control programs in Southeast Asia in the early 1990s, according to one report, "met resistance" because health workers "called into question the woman's ability to preserve health by maintaining a household free of disease."

These problems are certainly entrenched. Yet with each new outbreak or uptick of an infectious disease comes a chance to do things differently. "Whether they be acute or chronic epidemics, they tend to show the schisms and the vulnerabilities that exist [in a society]," says Columbia's El-Sadr. "Maybe with Ebola it will bring to the fore the weaknesses in the health system; it will bring to the fore the plight of people who have been disenfranchised."

"Maybe the lessons learned can help prevent the next epidemic," she adds.

With so many dying in West Africa, there is an opportunity to go against the grain, to try to incorporate a much-needed gender lens into medical and social responses. Now is the time to do it -- just like it was in the last crisis.

Correction, Aug. 20, 2014: Two quotes in an earlier version of this article were incorrectly attributed to a 2007 report by the World Health Organization. The report was actually published in 2011.

Photo by John Moore/Getty Images


Is Barack Obama More of a Realist Than I Am?

This president isn't weak and waffling. He's calculating, coldhearted, and decisive when it counts.

I had a strange thought late last week, while chatting with a colleague about the various hot spots that are dominating the news and interfering with U.S. President Barack Obama's vacation. Is it possible, I wondered, that Obama is craftier and more ruthless than I've realized? I've been disappointed by a lot of his foreign-policy decisions, but have I underestimated him? Far from being indecisive or too easily swayed by hawkish advisors, might he be even more of a realist than I am?

An early hint came in the 2008 presidential campaign, when Obama was asked to identify his favorite movie. His answer was The Godfather. His second favorite? The Godfather, Part II. It was a revealing moment, borne out by subsequent events. He followed the Godfather's advice when he appointed Hillary Clinton secretary of state ("Keep your friends close, but your enemies closer"), and his style as president resembles Marlon Brando's Don Corleone and Al Pacino's Michael Corleone in many ways. They don't make many threats, they never bluster, and they rarely raise their voices. But when the time comes, they dispatch opponents with remorseless indifference and pay little attention to who might get hurt in the process. "It's not personal; it's strictly business."

At first glance, you might not see this approach in places like Ukraine, Syria, Iraq, Afghanistan, Gaza, or East Asia. For some commentators, the various upheavals and confrontations in these places are signs that a more restrained U.S. policy has opened the door to instability and even chaos. Pundits and policymakers from Roger Cohen to Frank Bruni to David Brooks to Robert Kagan to Michèle Flournoy and Richard Fontaine now bemoan American malaise and complain that the pendulum toward disengagement is swinging too far. What these critiques lack, of course, is a convincing explanation of how doing more in all these trouble spots would make Americans safer or more prosperous.

In fact, because the United States is already so powerful and so secure, there is relatively little the United States could gain in most of these situations, even if they were to turn out well. Furthermore, diving back into the quicksand might easily make them worse. As Eurasia Group's Ian Bremmer tweeted on Aug. 12, "If the US had provided more arms to the Syrian rebels, the most likely outcome would have been a stronger ISIS."

Equally important is that Obama's approach is causing more trouble for America's various adversaries (and for some of its less cooperative allies) than it is causing the United States, and at a rather low cost to the United States itself. That's not a bad definition of a successful foreign policy: If you can give opponents headaches without having to do very much, what's not to like? The only downside is that innocent third parties end up bearing most of the burden, which merely underscores the degree to which Obama's approach is based on coldhearted realpolitik.

Let's start with Russia and Ukraine. The United States and its European allies bear considerable (though not sole) responsibility for causing the crisis in the first place, but the United States has so far escaped any serious damage. Instead, the immediate costs are being borne primarily by the people of Ukraine. The escalating confrontation has also inflicted real pain on Russia and on the European Union, whose fragile recovery has been jeopardized by the punitive sanctions imposed by the West. Russian President Vladimir Putin's reputation abroad has suffered considerably (and with some justification), but the short-term costs to the United States and to Obama himself have been minimal.

To be clear: I still think everyone would be better off if the United States were pushing harder for a deal that guaranteed Ukraine's status as a neutral buffer state, and the standoff makes it harder to get Russian cooperation on other issues. But in the short term, Obama has succeeded in pinning almost all of the blame on Putin, and it is mostly the Russians, Ukrainians, and Europeans who are getting hurt in the process.

Next, consider how Obama is dealing with Israeli Prime Minister Benjamin Netanyahu. Obama took office in 2009 hoping to achieve that elusive two-state solution, which he believed was essential to ensuring Israel's long-term future. While pushing for an end to Israel's self-defeating settlements policy, he also reaffirmed U.S. support for Israel in myriad ways and bent over backward to be supportive. His reward for his efforts? He has been repeatedly humiliated by Netanyahu, and his aides have been publicly maligned by Israeli officials. And his diplomatic envoys (George Mitchell, John Kerry, etc.) have gotten exactly bupkis for their time-consuming efforts to advance the cause of peace.

So what is Obama doing now? He's letting Netanyahu do pretty much whatever he wants -- including pummeling Gaza to no real purpose -- even when these actions damage Israel's legitimacy and hasten the arrival of the one-state solution that most Israelis oppose. In other words, Obama seems increasingly willing to watch Israel drive itself off a cliff, even though this policy necessarily entails further suffering by the residents of Gaza. He has to pretend to be sympathetic to Israel's plight in order to placate its lobby back in the United States, but I wonder whether what's really going on is a devilishly subtle form of payback. If so, Don Corleone would probably approve.

Which brings us to the Islamic State (formerly known as ISIS). Unlike the reflexive threat-inflators who dominate the U.S. foreign-policy establishment, Obama didn't panic over the emergence of this lightly armed group of bloody-minded radicals whose new "caliphate" extends over a lot of mostly empty territory. He recognized that this group is brutal and that its recent advances need to be halted, but he also knew it wasn't the reincarnation of the Soviet empire, Nazi Germany, or even Baathist Iraq. In particular, Obama understood that the threat to the United States itself was neither large nor imminent and that a permanent solution to the problem would require local actors to step up. Instead of doing "the full McCain" and plunging back into the quicksand, Obama has done just enough to give the Kurds and the Iraqi government the opportunity to contain the problem themselves.

Not only has he kept the United States off the slippery slope -- at least so far -- but this policy convinced Iraqis to rid themselves of divisive Prime Minister Nouri al-Maliki and pick someone who might govern more effectively. As he has done before, Obama, in short, was essentially buck-passing, a time-honored realist tactic. His measured response took advantage of the Islamic State's brutality and overweening ambition, which convinced local actors with far more skin in the game to get serious about dealing with the problem.

One can even see elements of this approach in Obama's handling of China. He has repeatedly emphasized Asia's importance to the United States, and the much-publicized "rebalancing" was obviously intended to signal to America's Asian partners that it wasn't abandoning the region. Obama reinforced these themes during his visit to Asia in April, but the administration has implemented this policy at a measured pace, content to let China's growing assertiveness do the work for us. Overreacting would alarm the local powers and let them continue to free-ride, while speaking softly makes present and future allies more eager for help and more willing to do what America wants to get it.

The common thread to these various responses is an appreciation not just of the limits of U.S. power, but also of the limited need to exercise it. "Limited" does not mean zero, which is why sensible people oppose a return to 19th-century-style isolationism. But this approach recognizes that the overwhelming majority of problems in the world do not threaten the United States directly and therefore do not require an immediate, forceful, and potentially costly U.S. response.

As Andrew Sullivan likes to say, Obama's greatest political genius has been his Road Runner-like ability to let enemies beat themselves. It would be even easier to do this if the Republican Party, the punditocracy, and some members of his own administration weren't constantly pressuring him to venture abroad in search of monsters to destroy. But I'm beginning to suspect that Obama understands America's privileged international position better than they do and that he also has a better grasp of where the public is on these issues as well. He's not running an especially noble foreign policy, but from a purely selfish U.S. perspective, it may be more effective than I used to think.