*Researchers: Institute of Tropical Medicine ‘Pedro Kouri’ (IPK)
This article is part of the series “La Letra de Temas 2020 – Postpandemia: where to now?”
As a result of COVID-19’s peak having been reached, Temas-Catalejo asked a group of researchers to study the current status and the outlook for the rest of the year in Cuba. They were asked for a detailed diagnostic, examining not only the pandemic itself and its clinical aspects but also public health, and its socioeconomic, political, international and subjective ramifications—as well as the probable future.
In contrast to the haze of figures, received truths, declarations and reports that inundate the media, of hopes and recommendations directed to the government and which—as is common in the media—pretend to be analysis, this series is directed towards figuring out the present and the future of the country in order to understand it better, like a road between politics and its circumstance.
As per the standard of Catalejo, La Letra de Temas 2020 is more receptive to other analyses than to other opinions.
Addressing the issues related to gender in the field of health entails delineating some key definitions to avoid underestimating its social and healthcare implications, and contextualizing it in the battle against the current pandemic. Among its implications it is recognized that it may worsen healthcare inequities, understood as “unnecessary, avoidable and, moreover, unjust differences, which have direct repercussions on the conditions of and access to health” (Whitehead, 1991, 2000). These differences can be a product of socio-economic status, age, ethnicity, incapacity—just to mention some, and an assumption that justifies the growing tendency towards the study of intersectionality, the category that designates the “meaning and the relation between sex, gender and other social determinants, as well as the factors that create healthcare inequities in the processes and systems at the individual, institutional and global level” (OMS [WHO], 2018). Moreover, it is an analytical tool to study, understand and respond to the ways in which gender intersects with other identities, and how these crosses contribute to unique experiences of oppression or privilege (AWID, 2004), with particular relevance to health.
Because the Social Determinants of Health (SDH) [Determinantes Sociales de la Salud] related to the social construction of gender are the “norms, expectations and social functions that increase the exposure rates and vulnerability to the health risks, as well as the protection from them” (OMS [WHO], 2018), gender perpetuates healthcare inequities just by itself. National and international efforts are aimed at correcting the imbalance between the position of women and of men in response to the economic, sociocultural and political resources (Zabala, 2018), searching for a development in which gender relations would be equitable. Gender equity is “a just distribution of the benefits, the power, the resources and the responsibilities between women and men” (OPS, 2005). Its application to the field of health implies drawing up strategies to correct those inequities that place one or the other sex at a disadvantage to the access and control of the necessary resources for their protection.
A study done in this century showed that the pattern of gender differences in the Cuban social context is characterized by the wide spectrum of life’s components, which go from those related to health problems, its risks and damages; reproductive, productive and community functions; to the sphere of subjectivity and macroeconomic spheres (Castañeda et al, 2010). Although challenges remain, a decade after this study there has been a qualitative leap in the development of social and health-related policies and programs directed towards decreasing gender differences, with direct and indirect impacts on society (Fariñas, 2019; Lezcano, 2020).
Risk-taking behaviors, stereotypes and stigmas associated with gender and health
In retrospect, it is evident that since the beginning of this century the progress of research, policies and programs that properly attend to gender differences in health and its determinant factors, and promote equality and equity between women and men, has been stimulated more purposefully (OPS, 2005). However, risk-taking behaviors, stereotypes and stigmas related to gender persist, acting as patterns at a global scale.
In general, these patterns are intangible standards that rule men and women’s behavior in a way coherent with their perceptions, beliefs and prejudices, shared and imposed in every socioeconomic, political and cultural context, as to the differential way of behaving depending on the sex. That is to say, to men are attributed leadership and decision-making capacities in the family and work environment, as well as being the principal source of income in the house (CARE, 2020; de Paz et al, 2020). On the other hand, to women falls the role of being the caregivers of the children, the elderly and the sick; the fundamental burden of the household tasks; and the finding of provisions for the home (WEF, 2020). It is usually suggested that women attend more the health services, and adhere more to the treatment programs which are health-protecting factors (OMS [WHO], 2019); this without indicating whether they do so in order to receive medical attention or in their role of caregivers. In Cuba, although not schematically, many of these patterns are also produced when risk-taking behaviors are associated with femininity or masculinity and, therefore, discussions arise about their negative effects on the health of the community (Castañeda et al, 2010; Rivero & Hernández, 2019).
The guidelines mentioned may constitute social standards of the evaluation of behavior associated to gender; mediate and, in turn, be mediated by social appraisal; and, therefore, empower, suppress or substitute certain behaviors, according to what is socially expected. Studying the gender variable, academics also take the risks of unconsciously providing readings that echo “prejudicial” social standards.
COVID-19 and its mark on gender equity
In the confrontation with COVID-19 there are great gaps in knowledge. Irrespective of the fact that gender-health inequities are established by science, the particular manifestation of this illness needs to be studied in greater depth. Various studies address the influence of immunological components, and the different behaviors in men and women in the risk, the presence and the evolution of the illness. Similarly, the question of comorbidities has been raised, which greatly justifies the importance of the study of the interrelation of the sex-age binomial (Ruiz, 2020). The gender differences as related to risk-taking behaviors—like smoking, the consumption of alcoholic beverages, the neglect of physical and mental health, sleep and alimentary impairments, which are more frequent and more commonly seen in men because of the code of masculinity–-have been signalled as contributing factors to the COVID-19 comorbidities. From the gender perspective, the invasion of this pandemic also entails reflecting on the implications of the illness on the dimension of social equity.
Among the health and socio-economic impacts of COVID-19, the worsening of the pre-existing social inequities is being recognized; these include, among others, those referring to the gender component (Alon et al, 2020; Kristal & Yaish, 2020; Wenham et al, 2020). The form in which these inequities are being expressed depends principally on the context and on the characteristics of each population group (De Paz et al, 2020).
The measures for combating the pandemic, as recommended by WHO, encouraged changes in the behaviors of society in general. Physical distancing, working remotely, reduction of population mobility, as well as the closing of socio-cultural and educational institutions confined men and women to the home (WHO, 2020a). This may suggest that those who have labor stability are in better financial conditions and, supported by labor policies and social security, may do work adaptable to the measures imposed by political and health authorities in order to maintain their income (OIT [International Labor Organization], 2020). However, the real shape of this situation is not far from the gender-labor statistics, and it is mediated by socio-economic, political and cultural elements that, within every country, determine the access, variety and legality of jobs, as well as the salary and social politics—in which inequities persist that favor men.
In Cuba thirty-six measures were implemented related to labor matters, salary, security and social assistance. Among the principal guarantees are salary protection to workers who remain out of their establishments because of illness; seniors, or other vulnerable workers; people who have to work remotely, mothers taking care of their children; as well as confirmed cases or contacts who remain in isolation centers or hospitals (Silva, 2020). A critical view of these measures from the perspective of gender, shows that in spite of the progress made, traditional patterns of gender inequity are still being maintained. One example is the risk of reproducing the pattern, attributing the role of care-givers fundamentally to women; this has individual and labor implications, because women represent 49% of the state labor force, and 80% of them are at middle or higher education levels (Lezcano, 2020). In addition, the salary gaps in the self-employment sector—in which men form the majority, and in which many activities were disrupted—were not addressed as much (Colina, 2020).
Some studies suggest that there will be a disproportionately negative effect in the world on women and on their employment opportunities and income, in the short, medium and long term (Alon, 2019; CARE, 2020; Gumber A. & Gumber L., 2020; Kristal & Yaish, 2020). In the health sector, although women represent 70% of the workers, there are fewer probabilities that they will have full-time jobs; their salaries are less and they are seen as being at a lower status, receiving less recognition and leadership than men (WHO, 2020b).
In Cuba, at the close of 2019, women represented the greater proportion of health workers (71.2%), and in nursing (87.8%), figures similar to those in other latitudes. Women also constitute a high percentage of specialized doctors (63.8%), which is higher than the global tendency and which would favor them regarding professional development and opportunities to assume executive positions (MINSAP, 2019)—although men are principally those who manage.
In the times of COVID-19, women could be more exposed to contract the illness because of their higher presence and responsibilities in the health sector and the family sphere (CARE, 2020; Wenham et al, 2020). However, the proportion of men and women that are infected in the world and in Cuba occurs in similar ways, giving rise to a large number of questions relating to gender and its interrelation with sex, as well as to other dimensions of social equity. Even if the illness does not discriminate according to sex, in certain circumstances the gender models could favor a more inequitable outcome of the effects of the pandemic.
On the other hand, during confinement, men have more frequently assumed the role of caregivers and the domestic chores, whether shared or as the person most responsible. This last factor has taken on a particular form in the Cuban context due to the combination of men’s isolation at home and to the changes in the collective imaginary because of the demystification of the sexual division of labor and the advances made in gender equity (Fariñas, 2019; Lezcano, 2020).
To stay at home reduces the risk of being exposed to the illness, but in addition to working remotely and fulfilling the usual errands, it also means struggling with the scarcity of resources because of the economic crisis generated by the health emergency in the world. In Cuba this scenario is influenced by the consequences of the blockade and the socio-economic situation of the country. In order to satisfy the people’s demands and fulfill the physical distancing measures, the State adopted the equitable distribution of some essential products by means of the basic food basket; the participation of public officials in commercial centers; providing special attention to vulnerable persons and groups; and the use of e-commerce. These measures have been presented and analyzed in the mass communication media, mostly with encouraging results, but it is also necessary to consolidate the gender approach in its implementation and evaluation, and to recognize that its articulation may be different in men and in women.
In summary, we can point out that those who combine different responsibilities are more subjected to the negative emotional states that the illness generates: the confinement, the sudden rupture of everyday life, the deferral of plans, and the crisis in its widest sense (Li et al, 2020). At the same time, there may be an increase in gender violence, which fundamentally affects women (UN Women and WHO, 2020; UN Women et al, 2020). The outcome of these circumstances will depend on the interrelation of various factors: the conditions of life, the functionality and family resilience; the appropriateness of the socially assigned roles to the current situation; the efficacy of and the confidence in the measures adopted; timely, truthful and contextualized information; the identification and handling of social inequities; and a relative labor flexibility that would allow income to be maintained. These factors, relating to the individual, to the family and to governance are also mainstreamed by the dimension of gender and its intersectionality with other social determinants of health (SDH) that increase health inequities (OPS, 2005; OMS, 2018).
The conjugation of the biological characteristics and the gender patterns of men and women, intertwined with the specific features of COVID-19 and its method of transmission, and with the historical, social, political and economic elements of the various contexts have different implications. Although many of the ideas sketched in this article act like global-scale tendencies, in contexts in which male chauvinist and patriarchal cultures dominate or where gender inequities in labor, health and social security policies are stronger, it will be more complex to reverse the negative consequences in the short, medium and long term of the pandemic, and gender breaches will continue to deepen. In the meantime, countries like Cuba, which shows progress in the development of equitable labor policies, in the suppression of stereotypes and stigmas relating to the sexual division of labor and the psychological assistance to vulnerable people and the population in general, are in a better position to minimize the gender breaches that worsened during the pandemic.
Seen at the national and global level, a critical and reflexive view by researchers, decision-makers and society—in its widest sense— of their own conceptions of gender is required, to redirect them and diminish the impacts of COVID-19 on health in general, and on gender equity in particular.
Translation: Catherina Vallejo
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