Do diseases know gender?

This article is part of a series on women, peace and security that The Strategist is publishing in recognition of International Women’s Day.

Diseases don’t know borders. That maxim is often invoked to remind countries of their responsibility to deal with infectious disease outbreaks—to prevent, respond and contain. Sovereignty won’t protect an economy or a health system from a novel infectious outbreak. The language and the scenarios that are commonly used—the 1918 Spanish flu outbreak is a popular one—seek to play, as Stefan Elbe says, the ‘security card’. Scare politicians, scare their constituents, and hopefully they’ll listen.

The idea that infectious diseases are a security problem hasn’t escaped controversy—the HIV/AIDS awareness campaign is a good example. In 2000, the spread of the disease via peacekeepers secured the attention of the strongest security institution in the world and led to the first UN Security Council resolution on an infectious disease (resolution 1308). The entry point was maintaining international peace and security, and protecting the resources of troop-contributing countries—their soldiers—seemed the least controversial approach.

The resolution certainly gained high-level political attention and, arguably, financing unrivalled by any other infectious disease. But the language also cemented some damaging stereotypes about infection and sexual behaviour, and it did not direct the gaze to where it needed to be: the social and economic conditions that have led to young women (not just peacekeepers) facing the highest risk of infection from HIV.

Can claiming a ‘non-traditional’ threat like illness as a security threat be an act of emancipation or is security too embedded in a system that will not fight for the most vulnerable and powerless? Can we articulate a response to global health insecurity that doesn’t create new marginalised groups, or further marginalise existing groups, because they carry the ‘stigma’ of infectious diseases that may be unjustly associated with their poverty, ethnicity, statelessness and/or gender?

In an article in The Lancet’s recent special edition on women in science, medicine and global health, I argued with my co-authors, Sophie Harman, Rashida Manjoo, Maria Tanyag and Clare Wenham, that global health governance is struggling in its institutions, studies and leadership to embrace feminist research. Global health governance is the institutional response to public health issues that span international borders. Its success requires interstate regulation and cooperation, but it lacks a feminist framework of engagement.

The absence of feminist reflection on the policy and practice of the global health governance sector is evident in its representation: 70% of all global health positions are filled by women, but only 25% of women hold senior positions related to global health governance. Feminist research seeks to not only identify but suggest how to transform the unjust and unequal social order.

In the article, we suggested four areas of engagement where the global health governance system could heed the lessons of feminist research and advocacy in international relations, especially the security sector: institutional reform, attention to intersectional representation and inclusivity, attention to political economy of participation, and knowledge production.

What does it mean to argue for a feminist research approach to global health governance? Quotas, reports and conferences build vital momentum to promote discussions about and changes in gender representation in global health governance. Global health security, whether we like it or not, provides that platform of awareness-raising and engagement.

When the women, peace and security agenda was adopted by the UN Security Council in 2000, the focus was on women’s experience in war and conflict. Do women experience conflict and war differently? The past 20 years of research has been dedicated to exploring that question; networks have been assembled at the local, regional and international levels to answer it consistently and comprehensively. The process is ongoing, but it is building momentum and informing practice in peacekeeping, peace processes and conflict prevention. Have we asked a similar question consistently about infectious disease outbreaks?

To illustrate the cost of overlooking feminist methodologies and insights in this area, let’s turn to the case of tuberculosis. It’s a disease that kills nearly two million people a year and infects the poorest, most marginalised and most vulnerable populations every year—one person can infect 15 people by a cough or sneeze. Given that these people are more likely to live in overcrowded places with poor sanitation, it’s not hard to see why the disease still kills so many and why so many still receive no treatment.

The debate has always been over why men appear to have higher rates of TB infection than women, and why women appear to continue their drug treatment longer than men. The risk of HIV/TB co-morbidity is now changing this data—women’s numbers are catching up. Are the numbers catching up or were they always there but hidden?

If TB mostly infects prisoners, drug users, sex workers, migrants and refugees, indigenous populations and impoverished communities, can we be sure that the patterns of infection—and the reasons why some people present themselves for treatment but others don’t—are not gendered? As the Global Fund suggests, we don’t yet know for sure the reliability of data on women’s infection and treatment versus men’s because stigma, discrimination, time constraints and economic impoverishment are huge impediments to women seeking treatment, which is vital to first detect TB cases. Incorporating feminist research into the global health system demands that we re-examine the data available and search for the social and economic barriers to data collection, and to healthcare access.

Do women experience infectious disease outbreaks differently? The health field needs to lift its gaze to see how this question can be used to not just enforce existing power structures but emancipate actors and technical approaches. What comes next is promoting social justice in technical and economic programs in global health governance to answer this question.

The achievements of the WPS agenda provide an unparalleled example of how this can be done. The risk of co-option by security structures and state hierarchy was as much of a risk in that arena as it is in global health.

Advocates for the WPS agenda at the international, regional and subnational levels have experience in creating local, national and regional networks that promote equitable changes to hierarchical security structures. They have also, through experience, learned the pitfalls and advantages of using security language and structures to empower and engage marginalised communities. The global health governance sector has much to gain from tapping into that knowledge, particularly in the areas of infectious disease prevention and response.