Women and girls are hardest hit by social and economic circumstances stemming from the SARS-CoV-2 virus that causes Covid-19, according to analyses by multiple international organizations. Pre-existing poverty and virus-control restrictions leave millions across sub Saharan Africa without sanitary wear, clean water or medical supplies for children. Closed schools mean larger numbers of girls are forced into early marriage. Yet most women and girls who want protection from unwanted pregnancy, or are too young to safely bear children, have no access to prevention. Legal systems, often dating from colonial rule, discriminate in ways that penalize women. AllAfrica managing editor Juanita Williams discussed these challenges by video with Dr. Senait Fisseha, an Ethiopian-born scholar, Clinical Professor of Obstetrics and Gynecology at the University of Michigan Medical School and founding executive director of its Center for International Reproductive Health Training. She holds a law degree and a certificate in International Human Rights and Comparative Law from the University of Oxford in the UK and oversees international programs at the Susan Thompson Buffett Foundation. She chaired the transition team of Dr Tedros Adhanom Ghebreyesus , the first African Director-General of the World Health Organization, and led recruitment for the WHO senior leadership team that for the first time is 60 percent women.
Very nice to meet you, Senait.
Juanita, very nice to meet you, too. Are you based in Cape Town? And did I recently read an interview you did with (Gates Foundation CEO) Mark Suzman?
Yes, that was me. And I am in Cape Town – and happy to have a chance to speak with you about women and girl’s health during Covid-19. We know they are vulnerable from more than the virus during situations of lockdown. What is the threat to women and girls – and all adolescents, for that matter?
We do have empirical evidence that epidemics and pandemics disproportionately affect women. If you look at the Ebola outbreaks, and now at some of the data on Covid, it shows us that women are disproportionately affected. [Editor’s note: An outbreak of Ebola in the eastern region of the Democratic Republic of Congo (DRC) was declared over on 25 June 2020. A current outbreak is occurring in western DRC, and the World Health Organization and other international partners are working with DRC scientists and the Ministry of Health to contain it.]
If you look at frontline health-care providers, 70 percent of the work force across the world are women – community health workers, nurses, educators, doctors. In Hubei province in China [where the city of Wuhan is located], 90 percent are women.
Women have the highest risk of contracting the virus, and they are dying at a disproportionate rate compared to the general population. So that needs to be addressed. That needs to be discussed. And that needs to be a priority. We're not seeing that. We are not seeing particular attention being paid. Half of the population are women. In subSaharan Africa, 70 percent of the population are young people
Women’s higher risk of dying from Covid-19 and from domestic violence during lockdowns needs to be addressed, discussed and made a priority.
We also have data both from this pandemic and past epidemics, such as Ebola, that women have an increased risk of domestic violence, especially when you have a lockdown.
During the 2014-2016 Ebola epidemic in Sierra Leone, for example, when they closed schools for about nine months, UNFPA (United Nations Population Fund) reported that there were 18,000 teen pregnancies – 18,000! Schools and places of work, frankly, are safe harbors for women. Now many of them girls and women locked up with their abusers. They cannot go away.
Countries with resources, like France, are putting women at risk of gender-based violence in hotels. But when it comes to Africa, those things are not an option. So I think responders, particularly governments, as well as non-government partners, have the responsibility to pay attention to what's happening to women.
Women are faced with sexual violence; women are faced with early marriage; women are faced with unplanned pregnancies. Their need for sexual and reproductive health services have not been more important. There are going to be unplanned pregnancies. [Kenya has announced that there will be no school this year, and already teen pregnancies are soaring.] There is a need for contraception and the need for safe abortion, in the context of the law, and need for emergency treatment for prevention of HIV and other sexually transmitted infections – and a need for mental health counseling.
So much needs to be done to protect women and girls, but gender-disaggregated data is lacking.
There is just so much we need to do to protect women and girls. Sadly, in many platforms, I am not seeing this taking place. Everyone is worried, appropriately so, about this pandemic. The crisis of this pandemic, the unimaginable human suffering and the scale is just so much. We're all so overwhelmed. But I think one of the things countries need to do to respond to this is getting gender disaggregated data. That’s missing. We need to look at the societal drivers that have an adverse outcome on women, and I think gender inequality will come at the forefront of why women are not doing very well.
Could you give a broad look at what the statistics are generally for women and adolescent girls? What is the cost of their not having access to reproductive health services?
The cost is an enormous setback, both at the level of the individual and society. We've worked so hard in the last two decades to advance women and girls – but also health. If you look at maternal mortality, Africa – countries like Ethiopia, Nigeria and DRC (Democratic Republic of Congo) – we are the largest contributors to maternal mortality. We know that as girls get older, their ability to complete higher education declines. They drop out because of lack of basic things that most of us take for granted, like access to menstrual hygiene products. There is female genital mutilation.
The odds just stack against them. It's one thing after the other. I always say to people, the ability to prevent an unplanned pregnancy is the difference between me and most of my colleagues and compatriots in Ethiopia and Africa. The ability for a girl to finish school, to pursue higher education, to get a job – all that depends on her ability to control her fertility, to delay marriage, to be able to say, “Now is not the time for me to do this”. That basic autonomy seems to be missing.
One of the very exciting things that happened at the African Union Summit in February, was President (Cyril) Ramaphosa (of South Africa) making the pledge that during his AU chairmanship, he's going to use the time to eliminate all laws that are discriminatory against women in the continent. It's a very ambitious goal. I know it's not something he could do on his own. But how do we help them get there? And how do we hold African leaders accountable?
We have laws on our books that hold women back. We have so many photo opportunities where we talk about “we're doing this for equality” and “we're launching a fund for girls and women”. Give us the basics, like dignity. Get rid of these harmful laws and create an equal setting. We are not asking for more. We are asking – give us the basic rights you've taken away.
Not doing these things – not availing sexual and reproductive health services as part of the Covid response – is enormously detrimental for the continent and for young people. Africa has been talking about the demographic dividend: how do we invest in our human capital? We absolutely have the talent pool. We have incredibly bright young people. But if we don't help them delay pregnancy, prevent unintended pregnancy, keep their health, get education and get jobs, they are not going to overnight turn into a productive workforce.
If you look at the ‘Asian tigers’ – countries like Singapore, Thailand, South Korea, that leaped out of poverty into middle-income countries – they did that when they put a national program on family planning that allows families and girls to control and be in charge of their reproduction. And, also, they put women and girls into the workforce, gave them opportunity to go get jobs. For society to think that we're going to succeed, while leaving half of the productive workforce behind, is just mind boggling. It does not make sense from a pure economic perspective, forget the human rights and reproductive rights angle. As basic common sense economically, it just doesn't make sense.
WHO has [called for countries] to think through domestic violence and the services that are needed as a result. Agencies that are advocating for women and girls, this is their opportunity to step up and hold governments and non-government partners accountable to ensure that sexual and reproductive health services become an integral part of the corporate response.
Yeah, the Covid response. I hate to sound like those people that give speeches about the opportunities when we face adversity! But there are opportunities in the global response. One of them is definitely how we deal with women and young girls getting contraceptives. Unfortunately South Africa is an example of the vulnerabilities of lockdown. The number of phone calls to a domestic violence hotline in the first week were enormous. We’ve never had a hotline before. So the fact that we have a hotline is a good thing. But the fact that there need to be so many phone calls is not, obviously. The police minister said that violent crimes dropped in lockdown. Which means he didn’t include domestic violence! I’m flabbergasted at the cycle that we are in. How do we get out of that cycle? Because what's happening in governments across the continent is that we have mechanisms that put older people in positions of power, and then we have the same cycle over and over again. Recently, Namibia appointed a 23-year-old woman, Emma Theofilus, as a deputy minister in the presidential cabinet. She has a completely different understanding of priorities. You mentioned UN and other international organizations, but in terms of the government level of decision making, how do we get through to presidents and other policymakers?
I couldn't agree more. Give young people the opportunity, and they will come up with the solution. The same for women. Women, for centuries, have managed and created non-egotistical and non-confrontational ways to solve problems and raise their families and play a critical role, never wanting to be in the front. The truth is, if you look, for example, at health data right now, if you look at global response to Covid, despite 70 percent of the frontline being women, you do not see enough women in decision making. You do not see them in the boardrooms, you don't even see them in media. The experts that are being pulled in to give opinions on what should be done and what the response should be are men.
I am blown away by the innovation of young people in Africa. They know that nobody's coming to rescue them with personal protective equipment, right? We have seen horrendous behavior by western leaders who are diverting ventilators or masks to their own nation, when they know they have other options. In fact, they have the option to social distance – most people in our continent don't.
So the ethical and the morally right thing to do would be to say, “Let's avail masks for those who cannot socially distance. But, rather, we're seeing the flip where those with the resources are controlling the market and the procurement, paying exorbitant prices.
But what I have seen in the continent are young people innovating and coming up with no-touch water pumps for hand washing, coming up with incredible ways of creating masks. Give these young people resources instead of creating a barrier. We know that even a cloth mask has a protective effect for the general public. How do we use this opportunity for our young people to go out and problem solve, get jobs and contribute to the solution?
Your mention of leadership is absolutely on point. There are many countries, like Ethiopia and Rwanda, putting dynamic young people in leadership positions. You know, when it comes to our continent, particularly when it comes to women, we start second guessing them when they're young. If you want solutions, they're the ones dealing with these problems. If leaders have not come up with a solution, why do I think they’re going to solve my problem? They’ve had multiple decades to solve this, and they haven’t.
There is nothing as powerful as inclusive leadership – people feeling like their voices are heard, they matter, and they're part of the solution. We have best practices in the continent,and we can learn from them.
But what we don't want is women or young people to be appointed for the sake of appointment. We see that – window dressing – when young people or women are put in positions but are not given the power to make decisions that effect change. That's why it's not only from the top, but it's also from the bottom. How do we create citizens platforms? For me, that’s where media platforms like you come in, in creating awareness and mobilizing citizens, in turning our frustration and anger into productive conversations where we hold our governments accountable.
What do we do about it? I find it mind boggling that a police official in South Africa will say violence declined during the Covid response lockdown, when you had thousands of women calling a hotline saying they are being abused, they're being hurt. What happens? They call, and what is the response?
South Africa is one of the most remarkable countries in the continent, but women need more protection. You have a constitutional right to safe abortion, but when you go to public-sector health facilities, it is not available. You have to go to a designated facility with a designated health provider. So poor African women hop from facility to facility, where they are pushed to have a baby, when they have not finished their childhood themselves, when their young bodies are not ready for this.
Rich people know where to go. If you are in Sandton (a wealthy suburb of Johannesburg), you find the fanciest clinics, where you get first-class care. We know medication abortion is safe. The UK passed a law saying sexual and reproductive health service is a critical part of the Covid response. The law says women can get medication abortion pills, and do this home and come to facilities only when they need it.
Our health systems, our leaders, need to be serious about women and girls, to protect the dreams of young girls. But we turn around and sabotage health services they need to fulfill their dreams. For me, there is no excuse. If we say we care about young people, we care about women and girls, there is no way around it other than making sexual and reproductive health part of an equal response.
Africa is such a good example of where we have laws not being implemented the way they're supposed to be. It erodes trust with government. And then citizens start not listening. The lockdown in South Africa took such a long time to become effective. People needed to die before other people took notice, because governments so often say one thing and do another.
There are a lot of reasons people don’t think contraceptives and sexual and reproductive health services are a good idea. One of them is religion. It's quite a sensitive topic, because people can be quite fundamentalist in views – Christian, Muslim and whatever other religions are common in different countries. What would be the best approach to that? What I’ve found is that many people listen to everything that is being said by their religious leader and follow that. And then the best thing to do is get to the leader. But what if that's not possible?
Yeah, it's very complex. There's a lot written about the history of religious attitudes and Africa. Africans really did not have this baggage, and we have managed sexuality. In fact, if you look at various countries, elders have done a great job. As young women came of age, they guided them as to how to take care of their body, how to avoid pregnancy. The anti-women and ‘anti-choice’ sentiment was really imported from abroad. If you look at our laws, a lot of those laws are colonial. Africans did not have those laws. In fact, if you look at Africa, a lot of women were treated equally until the colonizers came and started making laws that held women and girls back.
There is sad data about older men taking sexual advantage of young girls due to lack of safety nets.
What is fascinating is the colonizers go back to their countries after we dismantle colonialism, and they have gotten rid of these bad laws. So if you look at the UK and France, which are the two biggest colonizers of Africa, and the Netherlands, Portugal and Germany, all those countries, particularly the Dutch, the UK and France, have progressive laws in their own countries. But they have left us with their remnant colonial laws that have misused the Bible and the Quran, as well as our legal system, to hold women hostage.
As a legacy of colonialism, this has become highly politicized. I think communities have to deal with this – and it is going to be different for each community.
If we look at it from a public health perspective, there's a simple argument right now. We don't debate whether somebody gets HIV care or not. Of course, it was debated. In South Africa, three decades ago, HIV treatment was denied, and it took public awareness, engagement and education to change this.
If we ask young people for solutions, they will come up with them. Find a 14-year-old boy or girl and ask whether they are ready to be a mom or dad. We have to get over the assumption that young people are not going to have sex. We know that is not true.
But even when it's not their choice, we marry our young people off. If you take a 12 or 13, or 14-year-old and ask them, “Is this your choice?”, I think they will tell you that's not their choice.
There is really sad data on how early young girls are starting sex for money, commercial sex, because of socio-economics, because of lack of safety nets, because of lack of schools. And it is a tragedy that the men that take advantage of young girls are not boys their age. These are older men – the same men who will say to us, it's against their religion, the same men who will use politics to say [contraception and reproductive health services] are wrong, who say, “The right to control your fertility is against religion”.
When you have a young girl who’s being raped, don’t say to her, “You must have a baby”. When you have a mother who already has four children and is struggling to feed them and struggling to send them to school, struggling to avoid stunting (under-nutrition which reduces both physical and brain development), don't say to her, “You don’t have a choice, now you have to have a fifth and sixth baby. Frankly, these are crimes against humanity.
To condemn women and girls to death from too early or too closely spaced pregnancies is a crime against humanity.
For me, any religious or political leader who tries to politicize or use religion as an excuse is not having a grip on reality, not seeing what's happening to young girls in the continent.
If you look at the world, about half of abortions are unsafe – about 25 million. Of that, 90 percent occur in developing countries. For us to just sit there and go to funerals and suck our lips and feel sorry when women drop like flies is no longer acceptable.
From a pure public health perspective, women need the right to decide when to have a baby, when not to have a baby, when to go to school, when to get married. It should not be a communal decision.
I do recognize that many of us come from cultures where there is collective decision making. So how do we bring those that are in the collective decision making to see the same opportunities that are available for them should be available for girls From the lens of a parent, I seriously doubt you would have a father who looked at you in the eye and said, “Yeah, I want my daughters to be left behind”.
So how do we use the experiences of countries that are making progress? You know, Ethiopia is one of the most religious countries. Twenty years ago, one in three women in Ethiopia were dying from unsafe abortion – thirty percent of maternal mortality, until the government said, “This is a public health emergency. We have to take steps to prevent this.”
So for me, the Covid crisis is creating an enormous opportunity, if we can have our politicians and leaders and public health experts willing to bring women’s health into the conversation. What's the African Union doing? They're getting together and making responses around Covid and preparedness and taking a continental approach to fight the pandemic.
How about taking a continental approach to ensure that our frontline health workers that are mostly women are protected? How about taking an aggressive approach to ensure that women who are facing sexual violence have the services they need – that young girls who are out of school and don't have safety nets have access to contraception, have access to counseling, have access to mental health?
I think the kind of work you're doing as media allows all of us in the continent to deal with these issues that we have left too long as stigmatizing and polarizing. This is an opportunity for us to deal with this. Even one death is too many to ignore.
This has been wonderful. I think we have come to the limit of the time we booked with you. We could talk much longer, and I hope we can talk again.
I hope so too. Well, thank you for all you do. It’s powerful!
Media is the most powerful tool we have, especially trusted media.
Thank you, too.