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.
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