The irony of excluding women’s voices when it all goes wrong is that it is exactly in these extreme contexts that old prejudices are least justified, because women are already disproportionately affected by conflict, pandemic and natural disaster. The data on the impact of conflict (mortality, morbidity, forcible displacement) on women is extremely limited and sex-disaggregated data is even rarer. But the data we do have suggests that women are disproportionately affected by armed conflict.1 In modern warfare it is civilians, rather than combatants, who are most likely to be killed.2 And while men and women suffer from the same trauma, forcible displacement, injury and death, women also suffer from female-specific injustices.
Domestic violence against women increases when conflict breaks out. In fact, it is more prevalent than conflict-related sexual violence.3 To put this in context, an estimated 60,000 women were raped in the three-month Bosnian conflict and up to 250,000 in the hundred-day Rwandan genocide. UN agencies estimate that more than 60,000 women were raped during the civil war in Sierra Leone (1991-2002); more than 40,000 in Liberia (1989-2003); and at least 200,000 in the Democratic Republic of the Congo since 1998.4 Because of data gaps (apart from anything else, there is often no one for women to report to), the real figures in all these conflicts are likely to have been much higher.
In the breakdown of social order that follows war, women are also more severely affected than men. Levels of rape and domestic violence remain extremely high in so-called post-conflict settings, ‘as demobilized fighters primed to use force confront transformed gender roles at home or the frustrations of unemployment’.5 Before the 1994 genocide in Rwanda, the average age for marriage for a girl was between twenty and twenty-five years; in the refugee camps during and after the genocide, the average age for marriage was fifteen years.6
Women are also more likely than men to die from the indirect effects of war. More than half of the world’s maternal deaths occur in conflict-affected and fragile states, and the ten worst-performing countries on maternal mortality are all either conflict or post-conflict countries. Here, maternal mortality is on average 2.5 times higher, and this is partly because post conflict and disaster relief efforts too often forget to account for women’s specific healthcare needs.
For over twenty years, the Inter-agency Working Group on Reproductive Health in Crises has called for women in war zones or disaster areas to be provided with birth kits, contraception, obstetrics care and counselling. But, reports the New York Times, ‘over the past two decades, that help has been delivered sporadically, if at all’.7 One report found that pregnant women are left without obstetrical care, ‘and may miscarry or deliver under extremely unsanitary conditions.’
This can also be an issue in post-disaster zones: following the Philippines’ 2013 typhoon in which 4 million people were left homeless, an estimated 1,000 women were giving birth every day, with almost 150 of them expected to experience life-threatening conditions.8 Birthing facilities and equipment had been destroyed by the typhoon, and women were dying.9 But when the United Nations Population Fund asked donor nations for funds to pay for hygiene kits, staff at temporary maternity wards and counselling for rape victims, the response was ‘lukewarm’, with only 10% of the amount needed being raised.10
Post-conflict and post-disaster zones are also particularly vulnerable to the spread of infectious diseases – and women die in greater numbers than men when pandemics hit.11 Take Sierra Leone, the country at the heart of the 2014 Ebola outbreak, and which has the highest maternal mortality rate in the world: 1,360 mothers die per every 100,00 live births (for comparison, the OECD average is fourteen per 100,00012), and one in seventeen mothers have a lifetime risk of death associated to childbirth.13 The government has recently released data revealing that at least 240 pregnant women die every month in Sierra Leone.14
Throw Ebola into the mix and women suddenly had two types of death to fear: from childbirth and from Ebola. In fact it was worse than that, because pregnant women were at increased risk of contracting Ebola due to their high levels of contact with health services and workers:15 the Washington Post reported that two of the three largest outbreaks of Ebola ‘involved transmission of the virus in maternity settings’.16 The fact that Ebola decimated healthcare workers (themselves mainly women) made the feminised risk even higher: the Lancet estimated that in the three countries affected by the virus, an extra 4,022 women would die every year as a result of the shortage.17
The reluctance to factor gender into relief efforts is partly due to the still-persistent attitude that since infectious diseases affect both men and women, it’s best to focus 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’.18 Academics are also at fault here: a recent analysis of 29 million papers in over 15,000 peer-reviewed titles published around the time of the Zika and Ebola epidemics found that less than 1% explored the gendered impact of the outbreaks.19 But, explains a WHO report, the belief that gender doesn’t matter is a dangerous position which can hinder preventative and containment efforts, as well as leaving important insights into how diseases spread undetected.20
Failing to account for gender during the 2009 H1N1 (swine flu virus) outbreaks meant that ‘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’.21 During the 2014 Ebola outbreak in Sierra Leone, ‘initial quarantine plans ensured that women received food supplies, but did not account for water or fuel’. In Sierra Leone and other developing countries, fetching fuel and water is the job of women (and of course fuel and water are necessities of life), so until the plans were adjusted, ‘women continued to leave their houses to fetch firewood, which drove a risk of spreading infection’.22
Women’s care-taking responsibilities also have more deadly consequences for women in pandemics. Women do the majority of care for the sick at home. They also make up the majority of ‘traditional birth attendants, nurses and the cleaners and laundry workers in hospitals, where there is risk of exposure’, particularly given these kinds of workers ‘do not get the same support and protection as doctors, who are predominantly men’.23 Women are also those who prepare a body for a funeral, and traditional funeral rites lead many to be infected.24 In Liberia, during the 2014 Ebola epidemic, women were estimated to make up 75% of those who died from the disease;25 in Sierra Leone, the ‘epicentre’ of the outbreak, UNICEF estimated that up to 60% of those who died were women.26
A 2016 paper27 also found that in the recent Ebola and Zika epidemics international health advice did not ‘take into account women’s limited capacity to protect themselves from infection’.28 In both cases, advice issued was based on the (inaccurate) premise that women have the economic, social or regulatory power ‘to exercise the autonomy contained in international advice’. The result was that already-existing gender inequalities were ‘further compounded’ by international health advice.