Since care services are considered an extension of domestic work and are often performed by women; women healthcare workers’ emotional labor intensifies. The sources of our emotions, including compassion, are not unlimited.
The COVID-19 pandemic is defined as a hybrid disaster formed by natural causes (SARS CoV-2 virus) and intensified by humans. Since the abstract “human” category here often represents heterosexual white males, we can venture to say that what complicates the pandemic is the patriarchal capitalist system’s -that was established by them- responses.
The pandemic is considered a common traumatic experience: we experienced it firsthand, witnessed it, found out that one of our loved ones has been infected and went through all these steps at once as the healthcare workers. The health care system didn’t have enough time to prepare. The impact, scope, intensity, and duration of the pandemic are still uncertain. We became familiar with social isolation and quarantine measures. Domestic violence against women and children has increased. We’re going through a period of economic loss and experiencing financial challenges. With the restraint of basic human rights, curfews, and travel restrictions, we no longer can live freely, and our ordinary lifestyles have changed. Our regular grief processes have been disrupted and we started to have complicated reactions to deaths, through the restrictions imposed on funeral services and farewells with loved ones at intensive care units. (Yüksel and Öyekçin, 2020).
Some writers argue that the COVID-19 pandemic can be defined as a syndemic. Syndemic is a concept outlining the synergistic interactions between two or more epidemics that create more damage than the sum of its parts. The term was coined by M. Singer in the 1990s in USA, with regard to HIV/AIDS. Following processes in which inequalities and discrimination were considered, a holistic approach was upheld, later other diseases such as tuberculosis, depression, obesity… etc. have also been considered under this term. It was obvious that COVID-19 outbreak is not an isolated medical case, that has nothing to do with the crisis of civilization (food crisis, ecological and climate crisis… etc.). The magnitude of possibilities and threats have been emphasized.
How natural are natural disasters?
Are women and men affected differently by disasters? If so, why? Which women and men are we talking about? In fact, individuals’ and group’ social positions prior to the disaster also determine their conditions in the aftermath. Gender inequality prevails as an underlying issue. According to World Economic Forum’s Gender Gap Report published in 2020, Turkey ranks 130th (in 2006 it ranked 105th) out of 153 countries. The veracity of this situation continues to determine women’s lives during the pandemic.
During and after disasters and collective traumas, women are subjected to losses, distress and heavy burdens are imposed on them. Experiencing acute and chronic stress while taking care of children, sick, disabled and elderly individuals; women end up having a lot more responsibilities during a pandemic (Enarson et al. 2006).
Risk groups during the pandemic
“Disadvantaged” groups during outbreaks are listed as (WHO 2014): Employees that have the risk of getting infected (mainly healthcare workers -%70 of the healthcare workers, and more than %90 of nurses and midwives in the world are women-), relatives of those who have lost their lives from the virus, people in need of care, immigrants, and other vulnerable groups. Whereas women risk groups during natural disasters and collective traumas are listed as (WHO 2013): women who have children under 30; pregnant women; girls and adolescents; disabled, immigrant, refugee and homeless women at all ages; women of all ages who are members of ethnic minorities and who are in prisons or other penal institutions; children, and elderly.
What do women health care workers go through during the crisis of care / social reproduction?
Care is defined as all kinds of activities carried out for welfare and life to flourish, protecting, minding, being attentive to. It can’t be solely done for profit; it requires a certain dedication. It contradicts with the market logic. Devaluation of women’s labor of care starts in the family: invisible labor forms the basis of patriarchal power.
In neoliberal systems, absence of care, apathy and indifference prevail. The pandemic also revealed the shortcomings of nursing homes, shelters as well as the healthcare system. Once “life found a way of fitting home”, domestic space gained more visibility. However, this visibility didn’t reduce the workload, on the contrary it has multiplied it. The growing and diversified needs and expectations have increased male violence (Acar-Savran, 2020).
Spending more time at home, increasing hygiene precautions, closing of schools and daycare centers, growing need for the care of children, the sick and elderly, and the shortage of paid help in the domestic sphere culminated in an exigency of unwaged domestic labor. Prior to the pandemic, women were spending three times more time on unwaged domestic labor compared to men, this turned into an ever-growing burden under the current circumstances. Statistics have shown that women academics were publishing less articles and participating in less research projects compared to their male colleagues, most people related that to the increasing domestic labor. Ultimately, women are faced with a multi-faceted strait that has economic, temporal and academic aspects; and in the long they are at the risk of burning out (Ünal and Gülseren, 2020).
Performance in healthcare = mobbing
With the commodification of health care services both the patients and healthcare workers have turned into objects of production, deemed insignificant. The work has become meaningless. Through the pressure put on health care workers to keep working, the work itself has turned into an outcome of violence. A work environment where violence is a persistent pattern, wears people out, makes them miserable. Alienation is an important factor in suicide cases among healthcare workers. Sometimes seeing more than 100 patients a day, asking their symptoms without even knowing their names, prescribing medication… The healthcare workers are forced to make quick decisions and implement them rapidly; they are reduced to operators through algorithms and consequently are unsatisfied with their jobs (SES, 2018). Violence against both women and healthcare workers have increased, and in such a climate, women health care workers have become the targets of both kinds of violence.
Women’s labor in healthcare: they said we can never repay you, and they never paid us!
“Feeling worthless has worn us out”,
“They pay respects to the doctors calling them ‘Sir’, whereas they call us nurses Hey girl”,
“I don’t even know how I sweat my guts out”,
“Our workload has increased with flexible working hours”,
“Performance based system has made us worthless”,
“There is a clash between people from different professions, now everyone hates each other”,
“Aside from the anxiety of catching the virus, they have overwhelmed us with all sorts of anxieties. We have turned into control freaks, become obsessed with hygiene”,
“The already growing workload has intensified with increasing domestic work”.
“We’re neither recognized at home nor at work. The minister has only thanked ‘the doctors and healthcare system’ anyway”,
“The healthcare system is where invisible labor turns into a profession”,
“They are still trying to compensate the shortcomings of the system with female labor” (from the article series “Rebel Nurses”, Kadın İşçi [Women Workers], 2021).
The Ministry of Health has not shared any information regarding the gender, profession, residence, or place of work…etc. of infected or dead healthcare workers. Statements made by the Ministry of Health and their reflections in the press constitute the only sources of data. (Kurt-Azap, 2020). Turkish Thoracic Society has declared that, in Turkey healthcare workers get infected with Covid-19 46 times more than the other members of the society (4 September 2020). According to the data available on the platform siyahkurdele.com by Turkish Medical Association, as on 7 March 2021, 385 healthcare workers have died of COVID-19: 41(%10,4) of them were women. There are a few reasons behind male healthcare workers’ mortality rates being higher: gender equality in the medicinal fields is only a recent development and the number of women’ medical specialists has only increased in the past two decades; most of the healthcare worker above the ages 50-60 are men and comorbid diseases are more common among men. The departments that are the more occupied with the pandemic are infectious diseases, chest diseases, anesthesiology and reanimation, microbiology, public health, and family practice. The ratio of women is higher in all these departments. The associations related to these fields are also populated with women (Güngör, 2020). The pandemic appears to weigh on women health care workers’ shoulders.
“I (a woman healthcare worker) had to go to the men’s bathroom in the coffee house.” (Risky behavior such as decreasing the food and liquid intake to avoid going to bathroom)
“When we ask for food, they say ‘why do you want to eat outside, you should bring your own food’.”
“I couldn’t call the patients from the mainline. The institution has three land lines. We have 26 teams. So, I called all the patients on my cell phone… But then they start calling me. They call me at home, video call. Sometimes they video call even at night when I’m sleeping.”
“Our pregnant friends and the ones who have diabetes were forced to work on site. They could assign them office work, but they didn’t. A friend with diabetes has quit.”
“We are tired of doctoring through WhatsApp messages. They tell us ‘You’re coming in tomorrow’. Then say ‘you get samples from everyone’. Then order us not to… We can’t even ask for the related documents, the reasoning behind these decisions.” (from the Contact Tracing During the Coronavirus Pandemic in Istanbul Report, 2021).
Male violence as the shadow pandemic
Male violence which is referred to as the shadow pandemic by UN Women, has intensified with the COVID-19 outbreak: One out of every three women (prior to the pandemic 243 million women) is subjected to physical and sexual violence, usually by their partners. Studies conducted about male violence in Turkey also attest that domestic violence against women has increased during the pandemic. For example, the number of women victims of domestic violence that has checked into the Dokuz Eylül University Emergency Room in March and April 2020 was three times more than the same period in 2019 (Ergönen et al. 2020).
Violence and gender in healthcare
The Ministry of Health does(can) not share the White Code (violence against healthcare workers) data with the public and healthcare workers. Who are the perpetrators? This question is vital for feminists that politicize male violence, and the answer to this with regard to violence against healthcare workers during the pandemic is: 1. Patients and their close ones, 2. Toxic work environments constituted by the managers enacting symbolic violence (expecting them to keep silent) (Oğan, 2020).
According to SES (Equality, Justice, Women Platform) VaW (Violence against Women) Research Report (2021) women working in healthcare and social services (half of them are nurses) are subjected to primarily psychological (%81) and other forms of violence and mobbing (%80) in their workplaces. According to the Self-Health Work Union Research Report (2020) funded by the Ministry of Family and Social Services, %67 of healthcare workers -including emergency medical technicians, medical secretaries and nursing staff- (%48 is women) were subjected to some form of violence -primarily verbal and psychological (%81), also physical and sexual- violence. at least once during their shifts. The report also notes that %76 of the perpetrators were patients’ relatives and close ones, and %69 of healthcare workers stated that they considered violence in the workplace as a common occurrence.
We watch news clips of people attacking healthcare workers with stones and sickles during night shifts contact tracing and at outpatient clinics; raids in emergency and intensive care rooms; burning down of wards; barricades at hospitals… etc. Healthcare workers don’t report most of these incidents. One of the main reasons behind this lack of reporting, is the fact that they don’t want to spend time on it (Oğan, 2020). Women healthcare workers are often in the frontline at home, work, emergency rooms, intensive care units; however, they are excluded from managerial positions and decision-making processes. They have to struggle against not only the lack of economic and social rights, but also the fixed gender roles. Whether or not they are subjected to mobbing at their workplaces, women have the tendency to initially take the blame and assume responsibility. They only object, oppose and claim their rights later on and usually uneasily. They are the first ones to be fired for multiple reasons (Yüksel 2010).
Women’s and women+’s rights to healthcare during the pandemic
A study conducted prior to the pandemic by Turkish Medical Association’s Women Physician’s and Women’s Health Branch, shows that women’s access to primary contraceptives has decreased and there were problems regarding the logistics (lack of storage of monthly / three monthly contraceptives, condoms provided in some cities but not in others…etc.) in all the cities the study covered. According to the data provided by Turkey Demographic and Health Survey, unmet demand for family planning services (percentage of women unable to have any protection even though they didn’t want to have any other children) has doubled (%6 to %12) between 2013-2018. During 2018, one out of every ten women was not able to use any birth control methods even though they didn’t want to get pregnant.
Even though we constantly underscore the fact that women’s health can’t be reduced to their reproductive health, medical issues related to sexual and reproductive health continue to constitute one of the main causes for illness and mortality among fertile women. Pandemics overwhelm healthcare systems of all countries. Services geared towards sexual and reproductive health are often excluded from prioritized healthcare services. Not having access to contraceptives during stay-at-home orders and domestic violence can result in unintended pregnancies. Miscarriage at home through drugs such as mifepristone and misoprostol has become an alternative in many countries (England, Italy) during this period. Prior to the pandemic there were already a lot of problems in terms of accessing sexual and reproductive health services in Turkey, during the pandemic these services were almost completely suspended. Since most hospitals have been allocated to COVID-19 patients, access to prenatal care and childbirth services also became difficult. First step services regarding sexual and reproductive health have been reduced to medical exams for pregnant women and babies. In second and third step health institutions, services related to termination of pregnancy have been restricted (Günay, 2021). Nevertheless, according to Turkish Statistical Institute, during 2020 population growth rate has drastically declined from 13,9/1000 to 5,5/1000: Births have been postponed during the pandemic and this might be reflected in next year’s statistics.
What do women healthcare workers go through?
With their heavy workload, nurses are women professionals that are overshadowed and rendered invisible. In surgical specialties, women still have to put in a lot more effort compared to men in order to keep a low profile and hold down a steady job. Chores are assigned to women more easily. They are also expected to perform more emotional labor. Some of the issues that have intensified for women -during the pandemic- are sexist language, jokes insulting women and women+ community, control over women’s bodies, interventions on pregnant women’s choices to give birth or not, arbitrary decisions on legal maternity leaves, personal protective equipment being produced with male body in mind. Throughout the pandemic these have been accompanied by lack of medical information and experience; deaths; being isolated, alone, away from your loved ones; working in high-risk settings; colleagues that have passed away; witnessing untimely deaths on a daily basis and the “guilt of surviving through”.
Women’s mental health during the pandemic
Fear of becoming infected refrained people from going to hospitals, thus access to diagnostics and treatment of psychiatric conditions caused by violence also decreased, and most cases weren’t recorded. New forms of violence emerged such as perpetrators threatening women with infecting them with COVID-19. Violence cases that are reported digitally started to constitute %11 of the reported cases. According to Europol, online child abuse cases increased. Economic losses and challenges made it even more difficult for women to leave their abusive partners and escape violence.
In every opportunity we get, we reiterate that violence and poverty are the two main factors affecting women’s mental health and both increase with gender inequality. Women health care workers are under multiple stress factors, and they are in high-risk groups both for COVID-19 and violence. In a study focusing on the increasing anxiety and burnout among nurses working in COVID-19 wards who are also mothers -1809 women healthcare workers have participated in the study-, results showed that %41 of them have mild/severe Common Anxiety Disorders. It was only %19 prior to the pandemic (Linos et al, 2021).
Another condition that is commonly experienced through secondary traumas is compassion fatigue. Since care services are considered an extension of domestic work and are often performed by women; women healthcare workers’ emotional labor intensifies. The sources of our emotions, including compassion, are not unlimited.
Moral injury is defined as an injury to an individual’s moral conscience and values resulting from an act of perceived moral transgression, which produces emotional discomfort.
Burnout: A syndrome resulting from chronic WORK RELATED stress in mismanaged work environments. While it is often emphasized that burnout as a medical term shouldn’t be applied to daily challenges, the fact that domestic space is also a working environment for women is overlooked. However, it is obvious that women need their double shifts not to be medicalized but politicized.
In Turkey women health care workers’ suicide rate is 4-5 times the national average. As it was described in a suicide note the pressure, humiliation, feelings of worthlessness and mobbing at “fucking hospitals” increase anxiety and fear (SES, 2018). Heavy workload, not being able to go home to avoid infecting loved ones, absence of 7/24 daycare services, refusal to perform screening tests that could reduce the anxiety of being infected, increasing emotional labor make it difficult for them to deal with stress. There are a lot of risks involved, and the only award on the table is the public acknowledgement of the work as a “sacred duty”-akin to mothering.
Solidarity and rights-based approach instead of ‘help’
So, what can we as women do? We can try to reach women who don’t even have access to phones and internet, social security, water, shelter, unable to speak Turkish, during the vaccination process. Paying attention to women and women+ individuals with chronic and severe mental health conditions and their access to monitoring and treatment. Demanding all healthcare workers to be trained to provide basic psychosocial support for male violence survivors. Trying to circulate the curriculum proposed by WHO and Word Psychiatric Association that aims to provide first-line support for survivors of violence through LIVES (Listen, Inquire, Validate, Enhance safety and support) approach. Supporting feminist strikes against the paid-unpaid labor gap. Spreading resistance, solidarity, and hope; soothing fear, hopelessness, and anxiety… perhaps. Starting from our own work environments, we can build attentive relationships in line with ethics of care, carry on the struggle for equality with respect to all the women we inherited it from.
*This text is adapted from the presentation in the panel titled “Discussing Gender in the First Year of the COVID-19 Pandemic” organized by SU-Gender (Sabancı University, Gender and Women’s Studies Center for Excellence) on 20 February 2021.
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Translator: Gülşah Mursaloğlu
Proof-reader: Müge Karahan