As the novel coronavirus pandemic tears across the globe, sickening and killing more of the population worldwide, scientists are starting to get a better idea of who is at risk and why
Aside from the elderly and the chronically ill, early research out of heavily hit countries like China and Italy shows that about half the world's population is at significantly higher risk of dying from COVID-19 — that vulnerable group is men.
"It's been observed with some types of infections that men will have higher mortality rates — that is even observed in childhood," said Dr. Juan Dumois, pediatric infectious diseases physician at Johns Hopkins All Children's Hospital. "But in men there are certain social issues which can be as or even more important, such as not seeking out healthcare when they should or increased risk of other things that are just generally unhealthy lifestyles like overeating or smoking, lack of exercise."
Men tend to make up a higher percentage of those diagnosed with and dying from COVID-19 in countries that offer data based on sex, according to a report from CNN in partnership with Global Health 50/50. But even in those countries where women account for more confirmed COVID-19 cases, men still comprise the majority of those dying from the illness.
In South Korea and France, for example, men accounted for 39 and 47 percent of confirmed COVID-19 cases, respectively, but made up 54 percent and 58 percent of fatalities, according to the report. In China, men accounted for 51 percent of cases and 64 percent of mortalities. And in Italy, a country besieged by a high death rate, a shocking 71 percent of COVID-19-related deaths occur among Italian men, even though they only make up 58 percent of confirmed cases.
Although there are likely any number of reasons why men are more susceptible to COVID-19 than women, Dr. Jon Andrus, adjunct professor at George Washington University's Milken Institute School of Public Health and former deputy director of the Pan American Health Organization, said biology plays no small role
Women are dealt a better deck of cards when it comes to immunity and longevity, with an average life span about five years longer than men in the U.S., according to the Centers for Disease Control. And there is some evidence to suggest that estrogen, a primary female sex hormone, invigorates the immune system, whereas testosterone has immunosuppressive effects.
Diseases also tend to affect men differently than women. Measles and mosquito-borne viral infection dengue kills more female children than boys, according to a report from the World Health Organization, whereas there was a significantly higher incidence of male mortality during the 1918 flu pandemic and the SARS outbreak. The viruses that cause SARS and COVID-19 both come from the same large family of coronaviruses.
"There are a number of diseases that biologically affect one sex over another. In this case, it may have an actual viral determinant that prefers men," Andrus said.
But as data pours in, researchers increasingly think social and behavioral factors play a role in mortality rates for the novel coronavirus.
One habit that can raise the risk of death or serious illness from COVID-19 is smoking. In addition to irritating airways in the lungs and reducing the immune response in the short-term, long-term smoking exacerbates asthma and causes lung diseases like cancer and chronic obstructive pulmonary disease (COPD). These diseases increase the risk of death and serious illness from coronavirus.
"Deaths and serious illness from COVID-19 seem concentrated among those who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is, therefore, reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19," Nora Volkow, director of the National Institute on Drug Abuse (NIDA), wrote in a blog on coronavirus and substance use.
And smoking, as it turns out, is a habit overwhelmingly preferred by men
About 40 percent of men worldwide use tobacco products, whereas only about 9.5 percent of women do, according to data collected by the World Health Organization. Those numbers are even starker in some countries, like China, where about 50 percent of men smoke, but only about 2 percent of women do.
In Italy, however, women and men smoke at a similar rate, and mortality rates are still substantially higher among men.
"We don't have a clear scientific answer [why COVID-19 kills more men]," Andrus said. "But at the end of the day in most cases, it's not usually one factor. It's usually a combination of factors."
Although men seem to be at higher risk of death and serious illness from COVID-19, experts warn that authorities and health officials shouldn't ignore certain social and economic impacts outbreaks like the coronavirus pandemic can have on women.
"What the situation in which women are marginalized during disease outbreaks represents in my mind is an exacerbation of the underlying control that men have over women over certain societies more than others," Johns Hopkins' Dumois said.
From a purely practical standpoint, women account for about 70 percent of the health and social sector workforce worldwide, according to the World Health Organization (WHO). Policymakers interested in keeping health care workers healthy during a pandemic like the novel coronavirus need to consider women's unique needs when preparing response efforts, like when providing personal protective equipment.
But beyond the front lines of virus response, pandemics can take a toll on women in a number of less obvious ways. Incidences of domestic abuse, for example, tend to rise during crises, like the outbreak of disease. And the COVID-19 outbreak, in particular, breeds the right conditions for abuse.
"The very conditions you need to fight the disease — social isolation, restriction on freedom of movement, disassociation from social networks — these are the very things that abusers look for," said Anita Bhatia, deputy executive director and assistant secretary general of UN Women. "So the perverse unintended consequence of lockdown measures is that the state is inadvertently … creating more opportunity for domestic violence abusers."
And financially, outbreaks tend to wreak more havoc on women. Women oftentimes have lower-paying jobs to begin with — women made 79 cents for every dollar men did in 2019 — meaning lost or reduced income might hit them harder. And since women more frequently play the role of caretaker in a home, Bhatia said, it's more likely that women will be the ones to step away from a job to homeschool children or take care of a family member who falls ill.
And when it comes to health care, resources for care specific to women tend to get diverted toward fighting off the spread of disease. Reduced or altered access to things like pre- and post-natal care or family planning can contribute to negative health outcomes for women — and pregnant women are considered higher risk.
Mississippi, Ohio, Oklahoma, Alabama, and Texas, for example, have classified abortions as 'nonessential" during the outbreak, and some have threatened serious punishments for doctors and clinics who do not comply. Officials in Kentucky are calling for similar action, although they face pushback from abortion rights groups like Planned Parenthood and Center for Reproductive Rights, according to NPR. Federal judges have already blocked the orders in three of the states implementing bans.
Bhatia stressed that combating the spread of coronavirus infections should remain the top priority for public health officials during an outbreak of the scale and intensity of coronavirus, but she urged officials to also consider the needs of women and other vulnerable populations during the crisis. Recovery efforts will be much easier if these portions of the population aren't left out of public policy.
"The number one priority is solving for COVID. Nothing should take away from that," Bhatia said. "But I think good public policy means thinking through implications on all populations."