With more than 750,000 coronavirus cases worldwide, and tens of thousands of deaths, it has become increasingly apparent that the virus not only discriminates by age and underlying health conditions, but also by sex – with men more likely to test positive, and more likely to die from the disease. The gendered death gap was also seen in the SARS and MERS outbreaks.
Whilst the facts that men tend to smoke more, consume more alcohol, and are less likely to take account of public health advice can account for some of the increased risk for men, there are also biological differences between men and women that might account for the differences. Some studies of viruses have been conducted suggesting that women generally have stronger immune systems than men, and are able to fight infections better due to women having two X chromosomes – where many of the immune associated genes are contained.
Research from the University of Iowa on SARS, a similar virus to coronavirus which also emerged in China found female mice were less susceptible than male mice. However, when their ovaries were removed or the female hormone oestrogen was blocked, that difference disappeared. This study demonstrated that intrinsic hormonal differences were at play – and provided a highly compelling argument for sex disaggregated data studies in public health policy and medicinal development.
The WHO has requested the reporting of sex-disaggregated data on epidemics since 2007, but in the current crisis only 11 countries provide details on male and female fatality, with only six providing sex-specific data for both cases and deaths (China, France, Germany, Iran, Italy and South Korea). Without better data, from more countries, it is difficult to find the right cures quickly, and harder for government to implement public health policies that target groups of people who are more vulnerable than the rest of the population. For so long as this data is not made publicly available, it cannot be analysed by outside experts for clues on why more men seem to be dying from the virus.
Caroline Criado Perez brilliant recent book, Invisible Women, details the significant issues in public healthcare caused by a lack of sex disaggregated data, and the problems women face in a healthcare system designed for men. The book shows one study from the University of Leeds that found women were 50% more likely to be misdiagnosed when having a heart attack because research, and symptoms taught to medical students, centres around the symptoms men experience, not women.
Heart attacks are not the only issue where a lack of consideration for the differences between the sexes makes a difference in the development of medicine and of public health policy. As Invisible Women highlights, medicines are tested on male mice and then male subjects – and tend to be based on the average male weight and height, without taking into account that the average woman has significantly different hormones to men and so will react to medication in a different way.
This imbalance is visible almost across the board. A 2014 op-ed published in the journal the Scientific American stated that including both sexes in experiments was a waste of resources. It’s no surprise then that, according to research on phase one drug trials, women represent only 22% of participants. Yet the second most commonly observed reaction in women in later stages of trial are that the drugs simply do not work on them. If there are drugs that work on men but not on women, it is feasible that there are drugs that would work on women but not on men – but these go unexplored due to over 75% of the participants being male.
Where data exists, we can learn from it. Where it doesn’t, we can’t. I’d urge the Government to collate and release data disaggregated by sex so that researchers can study data gaps and start to learn from them. This would benefit men with regard to SARS, MERS and coronavirus, and would benefit women in most areas of public health policy development. Governments should also require a minimum number of women to be included in drug trials from phase one (unless the drug being designed is specifically for a male issue) and women could then benefit from drug research continuing that might be ineffective on men, but work for women.
In addition to requiring women to be included in trials, we should ensure that medical textbooks and medical courses teach the differences between genders. A 2008 Dutch study found that sex-specific information was absent from textbooks recommended by Dutch medical schools even for topics where sex differences have long been recognised. Based on conversations with former medical students in the UK, it appears that the same is true here. If we are not teaching the doctors, researchers and scientists of tomorrow about the importance of sex disaggregated data, learnings and research, how can we expect them to account for it in their work?
Finally, as per the World Health Organisation’s request, Governments should commit to releasing sex disaggregated data for coronavirus cases and fatalities – and all other public health related statistics – as soon as possible. Remedying the failure to account for the differences in gender responses to coronavirus could support the development of a vaccine and improve methods of treatment – saving lives now and in the future.
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