By Mimi Tarrant
When Disparity Becomes Deadly
Is COVID-19 only a biological threat, or also a distraction from the social inequalities in the US today?
By MIMI TARRANT
From the earliest stages of the COVID-19 pandemic, alarming figures have emerged on the relative prevalence of cases and deaths among males and females within communities. Initial analysis suggests that the rate of infections and fatalities are not evenly distributed among males and females. Females typically make up the higher proportion of cases in U.S. states, yet males tend to make up the majority of deaths from COVID-19. For example, in Michigan, 10.72% of males who contracted COVID-19 died, compared to 7.31% of infected females (as of April 27). Similarly, in Alabama, data from the same date range show that males made up only 41.27% of cases, yet suffered 58.7% of deaths in the state. Such disparities in COVID-19-related outcomes between the sexes has allowed this difference to become sensationalized by the media, with many early reports of state-level coronavirus cases and deaths latching on to this apparent sex difference. However, it is important to understand that the complexities surrounding sex-level vulnerability fall beyond a simple comparison of numbers, and a more nuanced understanding must be pursued to better understand what these sex disparities truly represent.
The accessibility of state-level demographic data has often been lacking, with the recording and dissemination of demographic and intersectional data surrounding COVID-19 severely inadequate in the initial stages of the pandemic. Indeed, states such as Delaware, Nebraska, and Hawaii still do not publish any data on the sex of their coronavirus cases or deaths, showing a lack of conformity among states in sex data collection. Such variability lends itself to the nature of the epidemiological reporting system; the CDC is reliant on each state reporting case and death data, so that reliable data can be collected for the US as a whole. Therefore, if one state in this chain fails to report a demographic variable, the U.S. cannot publish complete data on this variable through the CDC, and thus the failings of such a non-centralized reporting system is highlighted.
The responsibility of states to have been recording this sex dis-aggregated data from the outset is further highlighted by the possible existence of a sex-specific disparity in infection rates. China’s initial epidemiological study on the first populations experiencing the outbreak of the coronavirus held two key insights that went largely unheeded by the rest of the world. First, their initial survey suggested that key demographic characteristics existed among cases, such as a skewing of the sex ratio toward males, and older age demographics being greater affected than younger. The paper, published in the Lancet in February, went on to further encourage the compilation and dissemination of clear, concise epidemiological information as the disease spread, in order to ensure the world was in the best position to tackle COVID-19. Despite these warnings, U.S. states entered into the pandemic blinded to the need of such reporting mechanisms, failing to disseminate the crucial sex dis-aggregated case and death counts.
Despite initially failing to report data, some states did respond accordingly; between April 13 and April 27, 10 more states began to include data in their daily updates about the sex of deaths, taking the grand total to 29 states reporting sex dis-aggregated deaths. However, by this time, much of the damage inflicted by media sensationalization had been done. Headlines such as, “What do Testicles Have to do With COVID-19?”, now proliferate, and the undercurrent of coronavirus being a sex-linked disease holds strong in academic and non-academic circles alike. However, such conclusions cannot be made based on the scarce demographic data on sex that we have so far; there are multiple holes to be picked within this absolutist argument of the biological vulnerability of males versus females, and many risk for gender equality follow these proclomations of sex-related vulnerability.
The first point of contention involves the process of reporting itself; how is a coronavirus death to be defined? We have observed some level of confusion surrounding this issue, with some states choosing to only include deaths that have definitely tested positive with COVID-19, while others including a “probable” category to their death count. This was observed in New York on April 14, where the death count was increased by 3,700 in one day to account for the “probable” cases which were subsequently allocated to the coronavirus. The definition of coronavirus cases interacts with the sex prevalence issue at hand, as there may be an unequal distribution of males and females in this “probable” category. Until the sex dis-aggregated data is released on these undetermined cases, it is feasible that this category is simply masking and creating the sex difference in death rates that are being observed in the determined coronavirus cases.
This issue pertains to the crux of the argument against absolutist biological views on the vulnerability between males and females, as it highlights the implications of social factors that may instead contribute to vulnerability. That is to say, it may not in fact be a male or female’s biology that makes them more susceptible to COVID-19, but instead the social setting which they find themselves in as a result of their biology. This implicates gender as the driving force of such disparities, and mounting evidence suggests that COVID-19 may lend itself to being sex-biased, as opposed to sex-specific as the media portrays. For example, women may be experiencing higher rates of infection. They make up a higher proportion of the healthcare workforce; therefore, they are exposed to the virus more persistently and readily. In 2019, the U.S. Bureau of Statistics predicted that nearly 80% of healthcare workers in the U.S. were women, supporting this claim that livelihood may be one of the many social factors contributing to the higher infection rates in females.
A nuanced analysis of social factors may allude to the higher death rates in males, with a clear example coming from initial findings on comorbidities and lifestyle habits such as smoking. From the few states that are currently releasing data, hypertension, cardiovascular disease, and diabetes appear to be the most prevalent co-existing diseases among fatalities. These comorbidities appear to have some importance in the rate of deaths, as shown by data from Massachusetts: of the 1,491 deaths in the state as of April 29, 98.2% had some form of an underlying condition. Gender and social factors play into comorbidities through the acknowledgement that men and women suffer from these comorbidities at different rates. A heavily gendered social behavior that is linked to the top comorbidities of diabetes, cardiovascular disease, and hypertension is smoking, and this remains an area of interest in coronavirus analysis. Data from WHO suggests that global sex disparity in smoking rates is as high as 40% in males compared to 9% in females; while this gender disparity is smaller in the U.S., men are still more likely to smoke than women, with smoking rates of 15.6% versus 12%. Therefore, differences in death rates between males and females may be a result of an interaction between socially imposed gendered behaviors and biology, rather than an explicit dependence on the different biology of males and females. More data collection and analysis must go toward distinguishing COVID-19 as either a sex-linked, or gender-linked, disease.
The importance of this distinction is two-fold. First, alarming reports of medical trials related to estrogen administration to men are filtering into mainstream media, only acting to hype and lay undue emphasis on this disputed sex theory surrounding coronavirus. Not only is this science unfounded, but it provides a slippery slope into a world where social and gendered factors are swept at the wayside to make room for ‘pioneering’ science, underpinned by the idea that males and females are essentially different as a result of hormones alone. Such views, blinded to gender as they are, may not actually address the core root of the issues at hand with coronavirus, and thus potentially will do more harm than good.
Covering COVID-19 as a sex-linked disease in the media is problematic because it hides other demographic trends that may in fact be more pressing for analysis. Following the sex disparity hype created by the media, reports began to emerge of racial and ethnic disparities in case and death numbers, with black and minority ethnic (BAME) individuals reportedly dying in disproportionately higher numbers. Yet, this disparity has had little of the coverage that sex differences in rates have had in commonplace media, and one can’t help but question whether this is because sex differences are an easier (and potentially less controversial) topic to grapple with than that of race. In addition, race and ethnicity reporting in case and death data is even more lacking among U.S. states than that of gender, exacerbating the worry that academics and journalists may in fact be focusing on the wrong kind of demographic variable, either through conscious or unconscious decisions. In addition, the disparities among race and ethnicity rates could also be attributed to social factors, and thus show the importance of a dissociation from sex essentialism for understanding the epidemiological trends of COVID-19.
Ultimately, for a country that regards itself as a world leader in gender equality, the U.S.’s response to the coronavirus epidemic has given anything but this sense of leadership. Not only has the analysis of COVID-19 rates failed to adequately assess the nuanced gendered causes of infection and fatality, but as we begin to emerge into the ‘new normal,’ gender equality will be hampered by the disproportionate effects that the economic downturn have on women versus men. Women make up the majority of the service industry which has been destroyed by global lockdowns, with states such as Minnesota and New Jersey reporting that women made up nearly two-thirds of those filing for unemployment in March. With so much uncertainty surrounding the future of gender equality in the US workforce, it is essential that sex differences are not misconstrued in present-day epidemiological analysis, so that previously existing inequalities are not exacerbated by ill-judged sex essentialism.
Mimi Tarrant ‘21 (firstname.lastname@example.org) hopes that you are staying safe and healthy in lockdown.