DAVID GREENE, HOST:
Around the world, COVID-19 seems to be killing more men than women. Global Health 50/50 is keeping track of the data in dozens of countries. It's an independent initiative at University College London. Sarah Hawkes is one of its co-directors. She has worked in public health for some 25 years.
SARAH HAWKES: It's been seen from the beginning. If you look at those initial clinical reports, they stated that it seemed to be affecting men more, and the risk of death was higher amongst people with what are called comorbidities - in other words, other underlying diseases. And that, to be really honest with you, should not have come as too much of a surprise because that's pretty similar to the picture that we saw in both SARS and MERS, which were the other two corona-related epidemics.
GREENE: Well, so if we're seeing a gender difference emerge, as you said, in previous viruses and then this one as well, let's talk about what might be at play here because I know some point to women perhaps as having stronger immune systems. Is that one theory that might explain this?
HAWKES: There's quite a lot of good evidence that shows that across a number of aspects, that female immune systems are essentially a lot stronger. That might explain why women seem to have less severe infections and less risk of death. But from the work that we do, we would argue that whilst recognizing that there are these important biological differences between the immune systems of men and women, that that doesn't go the whole way to explaining it because if it (inaudible) all down to biology, you might expect to see really quite similar differences between death rates in men and women in every country. And we don't actually see that. And so we think that there's something else happening there, as well.
GREENE: What else do you think might be at play here?
HAWKES: Yeah, so for that, we think that this is probably down to what I talked about earlier, which is these other underlying diseases, the diseases particularly that affect the heart and the lung. And we know from global data that those diseases are more common in men. And from the work that we do, our hypothesis is that those diseases are more common in men because of the gendered behaviors of men.
So a large part of the burden of heart and lung disease globally is driven by exposure to factors such as tobacco smoke and drinking alcohol and even things like air pollution. And a lot of that is very gendered behaviors. In many societies, it's men who are more likely to smoke; it's men who are more likely to drink alcohol, and it's men who are frequently exposed to high levels of outdoor air pollution because they are frequently the people who are driving cars, taxis, buses, trucks, whatever.
GREENE: What about behavior right now? I mean, is there anything that the men are doing differently, you're finding? I mean, I don't know about if it's washing your hands less, if it's being not as careful to avoid contact with other people. Could anything happening in this moment be playing a role?
HAWKES: That doesn't seem to be playing as much of a role. What could be playing a role and where we've seen this in other diseases, including previous viral epidemics, is that men have tended to seek care later in the course of a disease than women do. So if you look at what happened in the Ebola epidemic, for example, there was a delay in health care seeking amongst men compared to women, and there was also a higher death rate from Ebola amongst men compared to women.
If we look at the HIV data in southern Africa, we see quite clear data showing that men tend to seek care later in the course of an HIV infection compared to women. They've got much higher viral loads. Their immune systems are much worse. And hence their survival rate is actually much lower compared to women's survival rates. So in terms of the immediate here and now, it might be that men are seeking care later in the course of their COVID infection.
GREENE: What is the response? I mean, is there some kind of public messaging for men that should be taking place right now?
HAWKES: Yeah. I mean, I think that there's probably public messaging for men, and there's public messaging for people making health policy. So for men, if our hypothesis turns out to be right - that men are being stoical or are more afraid to seek health care or are more reluctant to seek health care - then the obvious intervention, the obvious message there is to say, you need to seek health care as soon as possible.
In terms of the messaging for health policy, we would like to be sure that there isn't a need, for example, for different clinical care pathways for men and women. So you know, do we want to intervene earlier in the stage of a disease amongst men in older age groups with these other coexisting conditions? Is there a case for that? That would clearly require clinicians to start thinking about sex differences and gender differences in their treatment pathways.
But we know from lots of previous work that we've done that the profession of health researchers is actually remarkably bad at taking sex and gender into consideration in their health care provision. And we're seeing that reflected now by the sheer paucity of sex-disaggregated data coming out from many major countries, for example.
GREENE: You think this could be a wake-up call.
HAWKES: It would be a terrible thing if it takes a global pandemic for people to wake up to that piece of knowledge. But hopefully, this'll be a starting point for people to do better as far as recognizing and acting on sex and gender differences in health and medicine in the future.
GREENE: We've been speaking on Skype to Sarah Hawkes. She's professor of global public health at University College London and also co-director of Global Health 50/50. Professor, thank you so much.
HAWKES: It was a pleasure. Thank you very much.
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