Research from the Ebola and Zika epidemics clearly demonstrated that disease outbreaks affect women differently to men, while also differentially impacting non-binary genders and transgender persons. The impacts have been amplified now by a wealth of studies and experiences from covid-19 across the world. Importantly, these effects are not the result of the virus per se, but a result of the policies that are created and implemented to respond to emerging pathogens, which are gender-neutral. This exclusion of gender considerations masks an explicit bias against women. It is women that are then disproportionately impacted; through providing additional labour, whether paid as healthcare workers or unpaid within homes and communities; through higher risk of infection; through fear of financial hardship; through increased risk of gender-based or sexual violence; through distortion of health systems, disruptions to sexual and reproductive health provision; and through increasing rates of disproportionately high mental health issues among women. This is all in the context of women being marginalised in decision making and powerlessness within health systems, which is further exacerbated in health security. 

To tackle the downstream effects of disease outbreaks on women and other excluded genders, we must examine the policies that are created to prevent, detect, and respond to health emergencies, and assess potential revisions to these policies to mitigate against some of these avoidable harms. The Independent Panel for Pandemic Preparedness and Response (IPPPR) and the IHR Review Committee can be starting points for taking action on gender. We identify critical changes to the International Health Regulations (IHR) and the Health Emergencies Programme at the World Health Organization (WHO). As the key normative framework and international legally-binding mechanism for global health security, amendments to the IHR and as a result, WHO’s efforts in health emergencies, would set precedent for meaningful gender mainstreaming in global disease control efforts. This commitment would encourage the cascade of needed gender awareness and inclusion efforts by everyone in the global health landscape, especially member states.

We recommend that changes should be made to the entire life-cycle of the epidemic process. Firstly, the way we prevent and prepare for outbreaks of infectious disease should be more gender-aware. The efforts governments are making to build core capacities to prevent and detect outbreaks, as per legally binding obligations under Article 5 and Annex 1 of IHR, must tangibly consider how these policies may affect different genders. We know, for example, that women are more likely to follow risk communication efforts, so how do we ensure that public health guidance is more inclusive and appealing to all? We also know that women comprise 70% of the global health workforce, and thus responsibility to support surge capacity, as well as conducting active community-level surveillance, will likely fall disproportionately on the shoulders of women. These realities should be considered in preparedness phases, to ensure that there is recognition of women’s paid and unpaid/underpaid labour, and often the hazardous conditions in which they work, in preventing and preparing for epidemics. This could be further encouraged through explicit inclusion of gendered considerations in the Joint External Evaluations (JEE) and WHO’s IHR monitoring and evaluation processes.

Beyond building gender into core capacities, the IHR must also be more gender inclusive. Currently “women” or “gender” are only mentioned twice in the IHR: once to ensure that women are not discriminated against when crossing borders, and once to ensure gender representation in the IHR Review Committee. We believe that this gender mainstreaming must go further, to ensure that there is a legal requirement for governments to recognise the gendered effects of disease outbreaks and to mitigate against some of these downstream impacts and include women in every aspect of the response. This, we hope, could have important knock-on implications for National Health Security Action Plans, which in turn should bear greater consideration to gender needs within states.

When a crisis hits, the WHO as an institution also needs to be more cognisant of gender. Firstly, there needs to be a commitment to the collection and publication of sex-disaggregated data. As of October 2020, the UN Women-WHO collaboration on sex-disaggregated data collection only accounts for approximately 40% of cases globally. Data is the cornerstone of good public health decision making. Without clarity over who is infected and how health outcomes are affected, evidence-based decision making is hampered. We need a full understanding of the gaps in data and detailed information about which public health measures are truly effective for all. Sex-disaggregated data should extend beyond epidemiological cases and be central to modelling or analysing economic and social effects. Moreover, efforts should be made to encourage qualitative data collection, including obtaining the authentic voices of women most at risk of, or most affected by, epidemics.

We welcome the recent explicit recognition of the gendered effects of covid-19 response policies by the IHR Emergency Committee. These policies have been expanded to include the risks of gender-based violence and the need to ensure continuity of sexual and reproductive care during health emergencies. But this is not enough. The IHR Emergency Committee itself needs greater commitment to gender parity and inclusion. Since the H1N1 outbreak in 2009, there has been increasing participation of women on the IHR Emergency Committee, but there should be a requirement for equal representation of men and women in all committees, and more women chairing these meetings. To date, only one IHR Emergency Committee has been formally chaired by a woman. Moreover, 85% of national covid-19 task teams and advisory groups are majority men. Representation is not enough—just because women experts are in the room, it doesn’t necessarily make them experts in analysing gendered effects of outbreaks. For this, we call for the inclusion of gender advisors in IHR Emergency Committee meetings. Just as gender advisors sit on decision making bodies for other emergencies, such as the climate emergency and humanitarian crises, the same requirement should apply to epidemics. They would be able to pre-empt potential impacts of policy decisions for women, develop policy that is more inclusive, and in doing so mitigate against gendered impacts. 

In responding to an outbreak, governments should be required to include gender in a risk assessment to ascertain where potential policy failures may occur. This should be championed by the WHO, as part of IHR obligations with appropriate guidance. This would encourage states to identify downstream effects of their policies and re-consider efforts to manage potential challenges. For example, this could include ringfencing sexual health and maternity care provision from disruptions in health services provision during health emergencies, or ensuring financial stimulus for childcare. Gendered impacts of policy decisions should also be included in After Action Reviews undertaken by WHO and its Member States.

Implementing these improvements to the central policy tools developed to respond to health emergencies would notably reduce the potential impacts of health emergencies on women and marginalized genders. Importantly, such efforts would not only make significant improvements for women’s lives and livelihoods during health crises, but the same methods could be utilised to protect against all vulnerable groups. We know that health emergencies do not affect societies equally, and thus feminist knowledge and practice can provide useful tools to recognise and reduce unintended inequalities.

Health security does not occur in a vacuum. Similar commitments to mainstreaming gender to strengthen global initiatives can be reworked from the United Nations Security Council Resolution 1325 for Women, Peace and Security, the UN Political Declaration for Universal Health Coverage, the CEDAW Committee General Recommendations, and the UN Sustainable Development Goals. Critically, gender responsive health security policy is not costly, nor does it necessitate wildly innovative solutions. It simply requires us to reconceptualise who we are actually serving with policies created to effectively respond to outbreaks, and how we can ensure that the beneficiary is not only the default white male. A simple place to start is for the IHR, the Health Emergencies Programme, WHO, and Member States more broadly to answer the question: where are the women? 

Clare Wenham is assistant professor of Global Health Policy at London School of Economics (LSE).Twitter: @clarewenham

Sumegha Asthana is an independent health consultant and Chair & Co-founder Women in Global Health India (WGHI). Twitter: @sumeghaasthana

Arush Lal is an MPhil/PhD candidate in the Department of Health Policy at the London School of Economics and Political Science (LSE) and also serves as Vice Chair of the Board of Directors at Women in Global Health. Twitter: @Arush_Lal

Roopa Dhatt is co-founder and executive director of Women in Global Health. She is a passionate advocate for gender equality in global health and a leading voice in the movement to correct the gender imbalance in global health leadership. She is also a practicing internal medicine physician in Washington DC. Twitter @roopadhatt

Maike Voss leads the Global Health Governance Research Team at the German Institute for International and Security Affairs (SWP) in Berlin. Twitter @maike_voss

Alexandra Phelan is Assistant Professor at the Center for Global Health Science & Security, Georgetown University. I declare no competing interests. Twitter: @alexandraphelan 

Sara E Davies, PhD is a Professor of International Relations at the School of Government and International Relations, Griffith University, Australia. I declare no competing interests. My twitter handle is @DaviesSaraE  

Competing interests: None declared by all authors.