MONROVIA, Liberia—When the Ebola epidemic reached its peak in Liberia in September 2014, Tina Williams was 14 years old, five months pregnant, and feverish. She had been raped and abandoned by her boyfriend. Now she lay in bed shivering and praying that she was sick with malaria, not Ebola.
Williams and her baby girl later tested negative for Ebola, but they were Ebola survivors of a different kind. As the virus swept across West Africa infecting nearly 30,000 people, so did another contagion: outbreaks of rape, sexual assault, and violence against women and girls.
While public health workers tallied the number of Ebola-infected patients, girls like Williams who were victims of gender-based violence went uncounted. Only now are we learning that Liberia, Guinea, and Sierra Leone saw a surge in teenage pregnancy likely caused by an increase in the incidence of rape during the epidemic.
In parts of Sierra Leone, the teenage pregnancy rate increased 65 percent during the Ebola epidemic, according to a study by the United Nations Development Program. Data on rape and teenage pregnancy in the region is hard to obtain because of under-reporting. But studies by Plan International and Save the Children documented increases in teenage pregnancy ranging from 10 to 65 percent in Ebola-affected countries.
The surge is no coincidence. Outbreaks of infectious diseases often leave girls and women vulnerable to violence and rape—a result of the civil unrest and instability that epidemics leave in their wake. “This wouldn’t come as a surprise if we thought of epidemics like any other disaster,” said Monica Onyango, a clinical assistant professor of global health at Boston University. “Epidemics are just like a conflict situation. You have a loss of governance; you have chaos and instability; and all of that leaves women vulnerable to gender-based violence.”
But the correlation between disease epidemics and violence against women hasn’t been well documented. “We know that sexual violence against girls and women goes up during times of war. It was documented during the civil war in Sierra Leone and Liberia and after the genocide in Rwanda and the war in former Yugoslavia,” said Onyango. “We need to do a better job of documenting rape and sexual assault in the wake of disease epidemics, because it happens. Women are very vulnerable.”
The Ebola outbreak in West Africa is a case in point. Quarantines, curfews, and school closures—the kinds of public health measures aimed at slowing the spread of disease—put girls and women at higher risk of violence and rape, said Marie Harding, a health care worker at the Star of the Sea Health Center in West Point, one of Liberia’s largest slums and the site of a disastrous 21-day quarantine during the outbreak.
At the height of the Ebola epidemic, football games were canceled, and bars were closed. Men who usually socialized outdoors were forced into close quarters with women and children in their homes. This led to outbreaks of violence and rape in Ebola-quarantined homes. In a study conducted by Save the Children in Sierra Leone, most of the 617 girls interviewed spoke of violent attacks and sexual assaults against girls in homes that were under quarantine.
In West Point, Harding said she witnessed the same. “It was so much stress. There was tension about what to do, where to get food to eat,” she said. “When a girl is not in school, when she’s at home all day, everyone is at home all day; that makes girls unsafe,” she said.
It’s not just physical containment during epidemics that makes women and girls more vulnerable. In Plan International’s study of Liberia, mothers said they feared for the safety of girls who were not in school and who had to serve as breadwinners for their families.
Hunger led some to trade sex for food. That was especially true for children who lost parents to Ebola and were forced to survive on their own: 10 percent of the children interviewed in the Save the Children study — many of whom lost at least one parent to Ebola—said that girls whose relatives died from Ebola were forced into sex work to buy food and pay for housing.
Walking between wooden benches in the waiting room of the Star of the Sea Health Center, Harding said she saw that happen in West Point. “These are children, but they have to look for their daily bread,” she said, waving toward the young women waiting for their names to be called. “Ebola killed their ma and pa, and they have to do things to make ends meet.”
Days earlier, Harding had tended to an 18-year-old girl who died of malaria. She had lost both parents to Ebola and was living with a man who was 65 years old. “That was her boyfriend,” said Harding. “A [65-year-old] man. Young girls with no family will be with old men because they cannot afford to eat. They be with them for security and money.”
Those who didn’t lose immediate family members still felt the economic effects of Ebola. Trade halted, markets closed, and many were pushed deeper into poverty. Even before the Liberian government shuttered schools because of the epidemic, some families pulled their girls out of class so they could help earn a living. Outside the relative safety of the classroom, they faced heightened risks of sexual violence.
Now, as the threat of Ebola recedes and aid agencies pack up and leave, the victims of this second epidemic are being left to fend for themselves. “It was bad before, but it’s worse since Ebola,” said Harding. "Sometimes we receive girls here who are 13, and they are pregnant. Ebola made things very, very tough for girls.”
West Africa will be dealing with the long-term effects of its teenage pregnancy epidemic for years, if not generations. For instance, Liberian law prohibits pregnant teenagers from attending class during the daytime, a policy that widens the gender education gap and forces women into lower-paying occupations. In Sierra Leone, pregnant girls are forbidden from attending school altogether.
One of the few schools in Liberia that allows pregnant girls to attend is the More Than Me academy in Liberia’s capital city, Monrovia. The green and white school building sits on a busy street, its entrance wedged between women selling flip-flops and sunglasses. During the Christmas holiday, it is empty of its 150 students; only teachers and administrators walk the corridors.
“We’re the only school that caters to girls from West Point who wouldn’t get an education otherwise,” said Iris Martor, the school’s program manager. But even here, where administrators have made a conscious effort to serve girls who would otherwise be shut out of the educational system, teenagers must drop out once they become visibly pregnant. “We don’t want to get shut down because we’re going against national policies,” said Martor.
The long-term effects of teenage pregnancy extend beyond the loss of education. Teenage mothers are more likely to suffer health complications such as prolonged labor and vaginal fistula or to die during childbirth. Children born to teenage mothers are also more likely to die in infancy. Neither of these problems was adequately addressed by the international response to Ebola, which gave little thought to the epidemic’s potential downstream effects.
In Sierra Leone, workers at so-called “Rainbo Centres”—facilities that provide medical care and legal support to rape survivors—told the United Nations Development Program that they saw a rise in gender-based violence and rape during the epidemic. But they emphasized that there was inadequate care for rape victims and that existing services for victims of sexual violence were hampered by the outbreak and the response to it.
That’s partly because public health responders are typically trained to go in, stop the spread of disease, and get out as quickly as possible. “We just didn’t have the capacity to think beyond the epidemic,” said Kaci Hickox, a nurse who worked in a Médecins Sans Frontières (MSF) Ebola treatment unit in Sierra Leone in 2014. “We definitely did not have training about rape or sexual assault, mainly because of the magnitude of this outbreak. All of the aid organizations going in felt like they were chasing their tails.”
Onyango, who is also an expert on humanitarian emergencies, said that aid agencies such as MSF aren’t solely to blame. “They’re going in to do a complicated thing,” she said. “They have one focus at that time. The problem comes in with donors. They are only giving you money during the emergency, and once the emergency finishes they are moving on to another emergency.”
That approach neglects investment in two critical needs in countries facing infectious disease outbreaks: local public health capacity and infrastructure. Without those, countries are at higher risk of future epidemics—and the subsequent gender-based violence directed against girls and women.
For now, health care workers such as Harding are left to deal with the lingering impacts of the Ebola crisis. She stands at the front of the waiting room in the Star of the Sea Health Center in West Point and calls Williams’s name. With her baby in her arms, Williams walks past a half-dozen teenagers, several of whom said they were victims of sexual assault during the epidemic.
“People came here to help with Ebola,” said Harding. “Then they said Ebola [has] gone, so they left. But what about these girls who got hurt, had babies? Who will help them now?”