FRIDAY FILE - The latest World Health Organization's (WHO) Ebola situation report estimates the death toll in the current Ebola virus epidemic at nearly 9,400 with close to 23,300 people infected, AWID spoke to Liberian activists to learn more about the impact of the epidemic on women and girls in the region.
By Mégane Ghorbani
In the spotlight since March 2014, having already spread to Liberia and Guinea-Conakry, the Ebola epidemic-related crisis, and the international public health emergency situation that resulted, was not officially addressed by WHO until August 2014. While mainly concentrated in Liberia, Sierra Leone and Guinea, the number of cases of infection includes other countries in Africa, North America and Europe. This epidemic has disproportionately affected women, who constitute 75% of patients in Liberia, according to the Ministry of Health. Understanding the reasons for this disparity, and the impacts on the vulnerability of women and girls in this crisis is essential to ending it.
Failing public health systems
The Ebola virus, known for 40 years, has severely affected countries where health systems are weak or simply nonexistent. As Caroline Bowah Brown, Country Director of medica mondiale in Liberia, explains "After ten years of peace, we are always asking where are the benefits of peace for women. Ten years later, we still lack good roads or health services, and corruption still diverts resources needed for development. If things were working right, Ebola would not have hit us as hard. Understand that we had 3-5 ambulances operating nationwide right in the midst of the Ebola crisis." At the beginning of 2014, Liberia had only fifty doctors for a population of 4.3 million.
For researchers Kentikelenis Alexander, Lawrence King, Martin McKee and David Stuckler, the failure of health systems in Guinea, Sierra Leone and Liberia is largely due to the rigorous budgetary requirements of the International Monetary Fund (IMF) in implementing economic reform programs, in return for loan agreements; specifically: reducing public spending, lower wages in the public sector and decentralization of health systems. A World Bank survey also shows that Liberia and Sierra Leone are among the countries most dependent on external assistance to finance their social safety nets, up to 94% and 85% respectively.
The most recent report on the Millennium Development Goals in Africa reveals that in Guinea and Liberia, less than 50% of births are attended by skilled health personnel, while the rate was 62.5% in Sierra Leone. Despite some progress in recent years, Liberia and Sierra Leone have the highest maternal mortality rates in the world, having respectively recorded 770 cases and 890 cases of maternal death in 2010.
The Ebola outbreak - an unequal social process
According to anthropologist Brooke Grundfest Schoepf, "epidemics are social processes influenced by history, politics, economics, culture, social organization and dynamics." Like other social processes, the Ebola outbreak is then a vector of increasing gender inequalities existing in these countries. For Antoinette Sendolo, journalist and youth representative on the Board of Directors of the Young Women Christian Association of Liberia "In our recent history, the deadly Ebola virus has become Liberia’s number one enemy, putting women and girls at a very high risk of early death, loss of income, loss of family ties, loss of social mobility, delay in formal education and professional development."
Because of social norms that differentiate roles in society based on gender, women make up the majority of epidemic victims. Social expectations vis-à-vis the role of women in assisting the sick, whether in the home or in a professional health environment, as well as their traditional role in funeral rites exposes them to greater risks than men in contracting the virus. Bowah Brown explains, "women are the first to provide care at home and in the community. A sick family member is more likely to be treated by a female family member than a male one. Traditionally, this role falls to women. This exposed more women to the virus than men. It is the same for their roles as health care workers."
In addition, the Ebola epidemic affects more women than men because of their unequal access to care. According to a report by the Urgent Action Fund Africaadvocating for the integration of a gender perspective and women's rights in the response to the Ebola outbreak, it is especially because of their concentration in the informal sector and in economic activities that do not provide health insurance or precautionary measures against the Ebola virus that women are more infected.
Sendolo adds, “What is worse is that many women lack basic first aid skills and knowledge to handle such deadly virus disease as Ebola. High illiteracy rate is largely a contributing factor to this precarious situation for women amidst the Ebola pandemic in Liberia.”
A severe multidimensional crisis
In addition to its direct impact on women infected with the virus, the outbreak, and specifically the improvised crisis management, caused a loss of confidence vis-à-vis public health personnel. The fear of contagion, especially via medical teams, also led to the killing of eight people who were carrying out awareness-raising activities in Guinea in September 2014. Spreading to Liberia and Sierra Leone, this fear was stoked by border militarization measures and hospital closures, which led to part of the health workforce fleeing. This also boosted other diseases, due to lack of medical care. Specifically, it become the cause of new challenges related to maternal health as assistance to women during childbirth was reduced or became altogether non-existent in some areas. Bowah Brown says she saw women giving birth in the streets because health centers were closed and health workers afraid to treat patients for fear of contracting the virus. Some mothers died as a consequence. At the same time, pregnant women's fears of contracting the virus also lead them to opt for a birth without assistance. According to UNFPA estimates from late October 2014, over 800,000 women in Guinea, Sierra Leone and Liberia, will give birth in the next 12 months. Of these, more than 120,000 will die from complications if rescue interventions in emergency obstetric care are not provided.
At the socio-psychological level, the Ebola outbreak has also been a source of discrimination and psychological trauma. Even people cured from the virus are considered a threat, and are rejected from communities. In certain homes, husbands have rejected their wives and their children, despite having certificates confirming their healed status. According to Agnes F. Kortimai, Executive Director of the rural women's organization ZODWOC (Zorzor Women Care Inc.), "those who survived are rejected or discriminated against. Some must take care of their relatives’ children who are orphaned." Bowah Brown adds that, "the current health situation has worsened the situation of women and girls, from decreasing their incomes, to increasing their vulnerability to violence. The psychological impact is also visible. We lost family members, friends. It was a nightmare. Some women, almost without any source of income, suddenly found themselves heads of household, their husbands gone, they must now shoulder responsibility for the family. In one of our operational sites, for example, a young girl who survived the virus has become the main source of financial support since the death of her parents. She said ‘I'm not ready for this role, but what can I do? I have to look after my siblings’. She's just starting twelfth grade.” The psychological, social and economic reintegration of survivors constitutes a crucial challenge.
Consequently, the economies of Liberia, Guinea and Sierra Leone were devastated by the epidemic, especially by changes in behaviour induced by fear of contagion, and will likely continue to be affected in the long term. Border closures and farm abandonment have been a particular cause of rising food prices and food insecurity.According to a report from the World Bank, the economic impact of the crisis in the three countries could reach $209 million if epidemic containment continues to be delayed. Economic growth rates in Guinea and Sierra Leone will respectively reach 2.4% and 0% in 2015 while Liberia will probably experience negative growth. Due to a domino effect across West Africa, the entire region could lose up to 32.6 billion dollars in 2014 and 2015. And with such a high number of women in Liberia in the informal agricultural and commercial sectors, these economic consequences will also likely have a long-term effect on women's poverty and access to the formal labour market.
Despite the mobilization of civil society and the authorities at national, regional and international levels to curb the epidemic through information campaigns, the creation of Ebola treatment centers or financial support of international organizations, cemented by the January 30, 2015 launch of the African Union's Ebola Solidarity Fund, the responses to this crisis have not sufficiently taken into account the gendered implications. Bowah Brown says "This is what happens in humanitarian interventions: no deliberate consideration of gender, whereas we know that the effects on women are different and often enormous." Without taking gender into account, both in the short-, medium and long term for women and girls, crisis management against the Ebola virus will remain ineffective.
 According to experts, these figures are grossly underestimated.
 The Ebola virus, discovered in 1976, is transmitted to humans from already infected wild animals and spreads through human transmission. For more information, see http://www.who.int/mediacentre/factsheets/fs103/en/
 The civil war that affected Liberia since 1990 ended in 2004.