The world is divided between those who are vaccinated and those who are not. For those who are vaccinated, COVID-19 is something to be attentive to but thought of in the past tense. Those who are not vaccinated may similarly be keen to put the pandemic in the past, but without access to the greatest protection against the virus there is a huge inequality in who gets to move on. ⁵

An understandable focus on how to integrate a gender lens into future pandemic preparedness and post-pandemic recovery must be balanced against sustained interventions to ensure the world is vaccinated. Vaccines are a feminist issue. ⁶ Access to vaccines draw on transnational feminist solidarity and ideas of equality across the world. Moreover, vaccine delivery and uptake rests on the army of labour of female health care workers across the world. Our first concern for the future of women’s health is therefore to ensure all women around the world are vaccinated against the world, and that the women doing the vaccination are free from violence at work. ⁷

With every advance on women’s rights comes backlash. ⁸ A growing prominence of women’s health needs and the gendered impacts of health emergencies and pandemics will similarly be met with backlash. ⁹ This backlash may be insidious questions such as ‘what about men?’ or ‘why does everything have to be about women?’ or ‘what about race or class?’ These questions are rarely intended to focus on these important points and sources of inequality: they are always about silencing women and/or asking questions about gender.

Insidious questions mark a deeper unease, and in some cases resistance to anything to do with gender. This can be because the term gender confuses people, and often people can be resistant to what they don’t understand. Understanding takes effort and in some cases makes you confront how you see things and live your life. This can also be a deliberate form of ‘strategic ignorance’ ¹⁰ in not wanting to understand for a political purpose.

A more serious concern is a deliberate backlash against gender and so-called ‘gender ideology.’ ¹¹ This has little to do with a misunderstanding or an unwillingness to engage. It is a direct attempt by politicians to seize the gender equality agenda to their own ends, while completely disregarding the power systems that make the lives of men, women, and non-binary people unequal. Critics of ‘gender ideology’ tend to sit on the populist right. ¹² They hold firm that gender is an affront to family values and traditional ways of life. This is a clear political tactic – it is used to appeal to the past and ‘tradition’ as a means of gaining votes in periods of uncertainty. However it has serious ramifications for women’s health. Where anti-gender ideology comes, repression against women’s sexual and reproductive health rights is sure to follow. We saw this in Poland, we saw this in Brazil, and we have now seen this in America with the overturning of Roe vs Wade.

If you have worked in women’s health in the last two years you may think everyone was on board with the pursuit of gender equality as a means of better health for all. You would be very wrong. The opposite is true: if anything, women’s right to health is under greater attack that it has been in the last 50 years.

There is a high risk that when an issue gets attention because of its connection to a health emergency, everything about that issue becomes about the emergency. This is what we call emergency exceptionalism in global health security: when an issue attains specialised status precisely because it is linked to an emergency. ¹³ Exceptional status leads to additional funding and political will which in turn ensures it becomes one of the biggest health priorities in the world. This process is then circular: the more in which something is a priority, the more funding and political status afforded to it, and the more exceptional it becomes.

The risk with women and health is that the seismic impact and attention towards COVID-19 means that there is only attention, money, and concern for the impact of health emergencies on women, rather than women’s health more broadly. This is a problem. Making an issue exceptional within women’s health – women and health emergencies – leads to distortion of funds and attention away from other issues such as the leading causes of death of women in the world ¹⁴ . Health emergencies cause a huge short and long term burden on women around the world, but they are not the leading cause of death of women. These are: 1. ischaemic heart disease; 2. stroke; 3. chronic obstructive pulmonary disease; 4. lower respiratory infections; and 5. Alzheimer’s disease and other dementias. ¹⁵ Alzheimer’s disease and other dementias is the biggest growth in cause of death, and kills more women than men. ¹⁶

A day to day concern for women around the world is malnutrition. One of the biggest health concerns for women is they are overweight or underweight. And this is getting worse. 2020 saw a severe food shortage and an increase in hunger, particularly in low and middle income countries. These changes were undoubtedly linked to the pandemic. However the future outlook remains bleak with climate change and global consumption habits continuing to impact on hunger around the world, and new challenges such as the war in Ukraine and sanctions against Russia heavily impacting on global food supply. More women go hungry than men. According to the UN’s The State of Food Security and Nutrition in the World Report, ‘for every 10 food-insecure men, there were 11 food-insecure women in 2020.’ ¹⁷ Hunger is a fundamental problem for the future of women’s health.

A focus on the gendered impacts of health emergencies on women should not detract but be in addition to work on fighting these five leading causes of death of women. There is a risk that should a focus on the gendered impacts of health emergencies attain exceptional status, this will follow the path of other ‘exceptional’ health issues and cause huge distortions in women’s health away from other health programs. Advocates of women’s health need to be mindful of this trap and not repeat the past mistakes of global health security.

One way of making governments, international organisations, and private companies take women’s issues more seriously is to include women at every level of governance, including the top table. The logic being more women leads to greater diversity of thought and experience as to what it is live as a woman. Leading researchers such as Global Health 50/50 and campaigners such as Women in Global Health have done pioneering work in this area: identifying the extent of under-representation of women, and the absurdity of it. As Women in Global Health argue, health is ‘Delivered by women, led by men.’ ¹⁸ Health is different to other areas of international development in that women are ‘conspicuously invisible’ ¹⁹ – they are conspicuous across the health sector and make up the majority of healthcare workers in the world, but are invisible in policies, strategies, and across leadership.

Increased representation of women is a good in itself. However, it is not the end point of achieving gender equality in global health. There is a risk that institutions will point to their women quotas as evidence that they ‘do’ gender equality and therefore don’t have to do much else. This is a problem for four reasons. First, it puts a lot of onus and responsibility on women to effect change. This increases their workload and burden. Second, it assumes that these women want to do this work or have an inherent commitment to gender equality by virtue of being women. It fundamentally overlooks the diversity of women’s experiences in the world. Third, it shifts attention away from the gaps in the institution’s wider work. It is a classic deflection tactic. Finally, it puts all the emphasis on the individual without a wider commitment to structural change within a sector or institution. Greater representation of women and women in leadership is great. It is not an end point.

Getting institutions to sign on to commitments towards gender equality is one thing. But the formal and informal ways in which this plays out is another. For example, institutions may be happy to talk about gender with regard to HIV/AIDS or COVID-19 but not road traffic accidents. Commitment to gender equality can also often rest with key individuals with the power and leverage to support these initiatives. This creates a set of problems: a lack of critical mass to galvanise and build institutional support and change, and an absence of progress should an individual leave the institution. Finally, there is institutional fatigue. People like to sign up to equality and justice initiatives when the world is looking at them, but then rapidly shift to the next issue or lose interest. Think about how quickly the narrative around #metoo and Black Lives Matter moved on. When this happens the gender equality advocate who was so desperately engaged by leadership, and most probably put on the front of their website for a month, becomes side-lined, and worse, a nuisance.

External partners and friendly critics need to hold institutions to account on their promises. More than that, we need to push them to do more. For example, sex disaggregated data across the policies and programmes of the World Health Organisation (WHO) would be amazing. But data alone is not enough in the same way representation is not enough. We need to keep pushing for more. If we think we’re pushing too hard, we’re just getting through.