Introduction

First detected in China’s Hubei Province in late December 2019, novel coronavirus 2019 (COVID-19) has since spread to 141 countries or regions, and health actors had confirmed more than 156,000 cases as of March 14. 1 Numbers are expected to continue rising exponentially in the coming days, weeks, and months. Initial research indicates that older persons are most likely to suffer serious complications from COVID-19 and that men are more likely to experience high mortality rates than women, but this analysis may change as COVID-19 more data becomes available.2 Regardless, all vulnerable populations will experience COVID-19 outbreaks differently.

Until recently, the transmission of COVID-19 to developing countries or those experiencing ongoing humanitarian emergencies had been limited,3 but such transmission is now occurring. Development and humanitarian settings pose particular challenges for infectious disease prevention and control.4 Access constraints and poor health and sanitation infrastructure are obstacles to disease prevention and treatment under the best of circumstances; when coupled with gender inequality and, in some cases, insecurity, public health responses become immeasurably more complex.

Each context is different, and each population within a context is also different—their needs and capabilities will vary as a result of circumstance and their unique, intersectional5 identities. COVID-19 is not the world’s first public health emergency, nor the first to which development and humanitarian agencies have been called on to respond to. Despite this, there is a marked lack of research on the implications of public health emergencies on different groups, especially women and girls.6 Less than 1 percent of published research papers on the 2014–16 West Africa Ebola virus disease (EVD) outbreak and the 2016 Zika outbreak focused on the gender dimensions of the emergencies.7 Research on the gender implications of previous health emergencies is even more scarce.

For nearly 75 years, CARE has been working to address the root causes of suffering and to provide lifesaving humanitarian assistance to people in need. Operating in more than 100 countries, CARE’s work focuses on women and girls because evidence shows that addressing gender equalities is key to effectively responding to crises and their underlying factors. For these reasons, CARE is deeply concerned about the implications that the spread of COVID-19 might have on women and girls in development and humanitarian settings. Informed by lessons learned from past public health emergencies, CARE’s analysis shows that COVID-19 outbreaks in development or humanitarian contexts could disproportionately affect women and girls in a number of ways, including adverse effects on their education, food security and nutrition, health, livelihoods, and protection. Even after the outbreak has been contained, women and girls may continue to suffer from ill-effects for years to come.

Analysis

Health

Social norms—such as expectations that women and girls are responsible for doing domestic chores and nursing sick family members—can expose women and girls to greater health risks.8 The 2010 cholera epidemic in Haiti and 2014–16 EVD outbreak in West Africa demonstrate how this places a three-fold caregiver burden on women and girls: they are responsible for household-level disease prevention and response efforts; at greater risk of infection, and subject to emotional, physical, and socioeconomic harm.9 Although men, the elderly, and persons with compromised immune systems may at be greatest risk of fatality from COVID-19,10 the greater caregiving role that women and girls are expected to perform may expose them to other consequences.11 The expectation that women should act as caregivers follows them outside of the home. Women comprise more than 75 percent of the health care workforce in many countries,12 which increases the likelihood that they will be exposed to infectious diseases. Evidence suggests that during past public health emergencies, resources have been diverted from routine health care services toward containing and responding to the outbreak.13 These reallocations constrain already limited access to sexual and reproductive health (SRH) services, such as clean and safe deliveries, contraceptives, and pre- and post-natal health care.14 Adolescent girls, who have unique SRH needs, may be particularly affected.

In addition to the caregiving burden, social norms in some contexts dictate that women and girls are the last to receive medical attention when they become ill, which could hinder their ability to receive timely care for COVID-19. This could have serious implications for older women or those with chronic conditions or weakened immune systems—such as women infected with HIV, malaria, or tuberculosis—who appear to be at greater risk of contracting COVID-19,15 or for women and girls experiencing malnutrition.

During the 2014–16 West Africa EVD outbreak, fear of contracting the disease resulted in fewer women attending health clinics. 16 Coupled with resource diversion from primary health care services and prevailing social norms, this led to a decrease in vaccination coverage17 and a 75 percent increase in maternal mortality in three of the affected countries.18 A similar combination of factors during COVID-19 outbreaks could exacerbate women’s and girls’ other health conditions or delay treatment for undiagnosed COVID-19.

Outbreaks could also result in disruptions to mental health and psychosocial support services (MHPSS), putting the individuals participating in them at risk. Psychosocial wellbeing is a major issue for adolescents exposed to conflict, displacement, or violence, which is not uncommon in humanitarian settings.19 Moreover, MHPSS caseloads will likely increase during COVID-19 outbreaks, as frontline health workers, women and girls with caregiving burdens, and community members fearful of becoming infected or infecting others may all experience stress and trauma relating to the outbreak.20

Protection

Crises exacerbate age, gender, and disability inequalities and place women, girls, and other vulnerable populations—such as LGBTQIA individuals—at increased risk of gender-based violence (GBV) and intimate partner violence (IPV). In fact, IPV may be the most common type of violence that women and girls experience during emergencies,21 resulting in profound physical and psychosocial harm. In the event of COVID-19 outbreaks in development and humanitarian settings, IPV incidents may surge if movement restrictions or quarantine measures are put in place. 22 However, at the time when many women and girls need GBV and IPV services more than ever, evidence suggests that those services are likely to decrease as resources are diverted to dealing with the health crisis.

Sexual exploitation and abuse (SEA) of vulnerable populations—particularly women and girls—by development and humanitarian personnel has begun to be better recognized and addressed but remains a serious concern. Statistics on the prevalence of SEA are often lacking and vary by context, but SEA can have serious emotional and physical health complications for those affected.24 Evidence from the 2014–16 West Africa EVD outbreak and 2018–2020 EVD outbreak in Democratic Republic of Congo suggests that SEA incidents increase during public health emergencies.

Children face additional protection risks. If schools are closed, girls in development or humanitarian settings may be less able to access health, hygiene, and protection messaging and their caregiving burdens may increase.26 The economic impact of public health emergencies may force families to take their children, particularly their daughters, out of school to work,27 potentially leading to transactional sex or child, early, or forced marriages.28

All children are at risk of becoming separated from their caregiver during public health crises, as their caregiver may die, be quarantined, or become unavailable for other reasons.29 These risks may be magnified in areas with a high prevalence of HIV—where orphaned children might be cared for by grandparents or older relatives—as older persons appear to be most susceptible to severe complications from COVID-19.30 Separations expose children to greater risk of exploitation and abuse, as well as psychosocial trauma.31

Economic Empowerment and Wellbeing

Women living in development or humanitarian settings may be employed in informal, low-wage activities that are highly prone to disruption during public health emergencies. During the 2014–16 West Africa EVD outbreak, restrictions on the movement of goods and people hampered women’s trading activities, both cross-border and between communities, as well as their ability to cultivate their land and engage in other agricultural activities.32 As a result, women were unable to pay back loans from village savings and loan associations, which reduced the capital of the associations and affected women’s longer-term economic prospects.33 Coupled with potential loss of income due to the mortality of other household income earners, the economic impact of COVID-19 outbreaks on women and girls could be long-term and widespread.

Female migrant workers, particularly those engaged in care and domestic work, are also likely to experience grave economic consequences. Travel restrictions associated with the outbreak may keep women from reaching or leaving their jobs, 34 while unequal power dynamics between workers and employers may expose female migrant workers to additional risks.35 Concerns over the spread of the virus, travel restrictions, and xenophobia may limit migrant women’s work opportunities, cutting off livelihood support for them and their families.36

Education

It is likely that schools in COVID-19 affected countries would close for an indefinite period to mitigate the spread of the outbreak, impeding access to education for children around the world, but especially in areas that cannot shift to remote-learning systems. Girls in development and humanitarian contexts may be particularly affected. During the 2014–16 EVD outbreak in West Africa, relief actors found that girls whose mothers were infected with EVD were forced to take over their caregiving responsibilities. Even when their schools were not closed, girls found it increasingly difficult to balance their caregiving burdens with education, which led to increased absenteeism or to them leaving school completely. This had long-term impacts on the girls’ educational, economic, and health outcomes.37

Temporary school closures can have acutely negative effects for displaced or refugee children for whom school can provide a safe space for interaction with peers, psychosocial support, and even a reliable source of food. When schools are closed, children’s mental health issues might be exacerbated by the lack of peer support and alternatives for mitigation of risks.

Furthermore, a substantial number of teachers around the world are older individuals. As this population appears to be more vulnerable to COVID-19,38 outbreaks could have negative, long-term implications for educational services, particularly in areas that are already underserved.

Water, Sanitation, and Hygiene

The quality and extent of water, sanitation, and hygiene (WASH) services—such as providing clean drinking water or hygiene supplies or conducting solid waste management—varies greatly in development and humanitarian contexts. WASH infrastructure, which may be limited in rural settings and over-burdened in urban areas, is often insufficient to meet increased demand during public health emergencies. WASH staff may be reallocated to respond to the health emergency, reducing populations’ access to safe water for cleaning or drinking at a time when good hygiene and sanitation practices are most critical.39 Health emergencies might also cause development and relief actors to pause WASH projects, exacerbating already-scarce resources.

In such situations, women and girls often find that their access to hygiene and sanitary materials is reduced due to decreased household income or increased household competition for scarce hygiene resources, impeding their ability to conduct household-level disease prevention efforts or to attend to their own hygienic needs. Women and girls who are reliant on humanitarian agencies for their sanitary supplies—including menstrual hygiene goods, soap, and water treatment tabs—may find those services interrupted. Finally, as the prevalence of GBV increases during emergencies and resources become scarcer, women and girls will become more vulnerable when travelling to collect water for household use or to use latrines.

Shelter

Female-headed households are more likely to have inadequate shelter than male-headed households.40 Inadequate shelter increases the risk of illness and disease by 25 percent over the course of a person’s lifetime, while overcrowded shelter conditions can greatly increase the spread of infectious diseases.41 Past public health emergencies have also prompted populations to migrate from rural to urban areas that are perceived as having more or better services,42 in turn leading to overcrowding and a higher risk of communicable disease transmission. These factors mean that internally displaced persons (IDPs) and refugees, especially members of female-headed households, are at particular risk should a COVID-19 outbreak occur in these settings.

Food Security and Nutrition

The 2014–16 West Africa EVD outbreak demonstrated the tremendous impact that public health emergencies can have on food systems. Movement restrictions and quarantine measures resulted in less trade of and accessibility to food, sending prices higher at the same time that populations found themselves less able to engage in economic activities.43 Some households were forced to use negative coping mechanisms, such as reducing food consumption, engaging in transactional sex, or borrowing money or going into debt to pay for food.44 Surviving EVD and the declared end of the outbreak did not automatically ease food insecurity or malnutrition in affected communities. Stigmatization prevented some EVD survivors from finding or returning to work, while lingering fears prompted some communities to deny access to food or shelter to EVD victims and survivors.45

The risk of heightened food insecurity and malnourishment during public health emergencies is particularly grave for women and girls because social norms in some contexts dictate that they eat last and least.46 When food becomes scarce, women and girls—who are already more likely to be malnourished than men and boys47— could face additional health complications quickly,48 including increased susceptibility to COVID-19 infection.

Potential Heightened Effects in Humanitarian Settings

COVID-19 outbreaks are devastating in any context. However, the dangers of such outbreaks will be magnified for the nearly 168 million vulnerable people around the world who are in need of humanitarian assistance and protection.49 The UN identified the increased risk of preventable disease in humanitarian settings as one of its top challenges for 2020, noting that disease outbreaks are intensifying humanitarian need in some areas.50 This prediction, made before COVID-19 emerged, will only gain force as the disease spreads. At particular risk are the more than 70 million people—half of whom are women—who have been forced to flee their homes due to persecution, conflict, violence, and human rights violations. Many of the displaced are sheltering in countries with weak WASH infrastructure51 and lack access to health services.52 Refugee and IDP populations in camps and informal settlements are acutely vulnerable, as overcrowding or exposure can exacerbate infection rates.53 Restrictions on entry, travel, and freedom of movement can also have adverse effects on populations on the move, restricting their access to safety and protection.54 Those who remain in conflict-affected areas also face dire circumstances. Conflict often interrupts health services, results in damaged health infrastructure, and impedes the ability of health care workers to conduct disease surveillance.55 Systematic and targeted attacks on health infrastructure and aid workers by parties to conflicts, politicization of aid and service delivery, and restricted humanitarian access also exacerbate the spread and impact of infectious diseases. Despite improvements in humanitarian response effectiveness, needs are growing and far surpass resources. Only 54 percent of the required humanitarian resources were provided by the international community in 2019;56 and as of March, only 2 percent of the $28.8 billion required for 2020 had been committed.57 Preparing for and responding to the spread of COVID-19 will stretch—or in some cases, redirect—these resources, while the effects of the pandemic and related movement restrictions hamper humanitarian access and capacity. Unfortunately, vulnerable people in the midst of crises will continue to bear the brunt of the gaps.

Recommendations

All Actors Should:

Commit to proactive, early information sharing and coordination to ensure a robust global response that utilizes intersectional analyses to account for the needs of all individuals, irrespective of ethnicity, gender, nationality, or sexual orientation. These efforts should take place with the full participation of at-risk populations, particularly women and girls.

Health Service Delivery Actors Should:

• Short Term:

o Engage with local communities to provide access to information for all populations, avoiding convening

large groups where this may increase the risk of transmission. Account for age, disability, education,

gender, migration status, sexual orientation, and the existence of pre-existing health conditions in this

engagement, and be cognizant of the fact that no group is homogenous, so programming cannot be

either;

o Train health care workers to properly identify GBV and IPV risks and cases; to handle disclosures in a

compassionate, non-judgmental way; and know to whom they can referral patients for additional care;

o Involve existing female health care workers and local women leaders in decision making to ensure that

responses to COVID-19 outbreaks adequately address the needs of women and girls in each community;

o Consider the disparate effects of quarantine or social distancing measures on different populations;

o Work with humanitarian organizations to plan for and mitigate the risk that outbreak response

measures might result in unaccompanied or separated minors;

o Ensure that menstrual hygiene, obstetric, reproductive, and other primary health care commodities are

well-stocked and available at health care facilities;

o Disaggregate outbreak-related data by sex, age, and disability so that health experts can understand

differences in exposure and treatment and tailor preventive measures.

• Long Term:

o Devote more resources toward researching the gendered implications of public health emergencies,

especially disease outbreaks, so that public health preparedness and response plans can mitigate harm

to women, girls, and other vulnerable groups;

o Involve more women of all ages in global health leadership. Although women make up the majority of

the health workforce in many countries, they are underrepresented at senior levels, particularly within

global bodies. Organizations that do not include women in their decision-making processes cannot make

the best decisions for women.

Development and Humanitarian Organizations Should:

• Short Term:

o Prepare for possible surges in GBV, IPV, and SEA incidents among women, girls, the LGBTQIA

community, and other vulnerable populations. Support mobile hotlines to mitigate and respond to these

risks where it can be done safely, understanding that not all women and girls will have access to phones;

o Continue development and humanitarian service provision as much and as safely as possible, accounting

for the potential imposition of movement restrictions and social distancing measures. Where possible,

continue GBV, psychosocial support, and WASH services along with the provision of food, nutrition, and

hygiene commodities and shelter support.

• Long Term:

o Develop targeted economic empowerment strategies and/or explore cash transfer programming to

mitigate the impact of COVID-19 outbreaks, including support for populations who were employed

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during the public health emergency and who lose their revenue stream once the outbreak is contained,

and for communities to recover and build resilience against future shocks;

o Continue or commence work to find durable solutions for IDPs and refugees that include adequate

shelter and livelihood opportunities and that account for particular vulnerabilities related to age,

disability, and gender;

o Work with local communities, particularly women’s groups, before, during, and after public health

emergencies to ensure continued trust, access, and to provide the best possible services.

National Governments Should:

• Short Term:

o Ensure that aid and health care workers have access to all populations in need, including across borders,

to accommodate surges in health personnel and allow the transport of humanitarian and medical

commodities as needed for preparedness and response activities;

o Prepare and put in place, when necessary, plans to ensure the continuity of education, including via

remote learning or radio broadcast;

o Ensure that asylum seekers, IDPs, and refugees are included in national surveillance, preparedness, and

response plans and activities;

o Ensure that any movement restrictions relating to COVID-19 account for the needs of different

vulnerable groups;

o Maintain compliance with international legal obligations, including the right to seek asylum

• Long Term:

o Ensure that emergency preparedness and response plans are grounded in sound gender analyses,

considering gendered roles, risks, responsibilities, and social norms, and accounting for the unique

capabilities and needs of other vulnerable populations. This includes ensuring that mitigation and

response measures address women’s and girls’ caregiving burdens and heightened GBV risks.

International Donors Should:

• Provide immediate flexibility and additional funding to ensure that existing development and humanitarian

operations can rapidly scale up and adapt to the risks posed by COVID-19;

• Require that all funding proposals contain comprehensive gender analyses and protection mainstreaming

provisions.