SDG5 “Gender Equality” and the COVID-19 pandemic: A rapid assessment of health system responses in selected upper-middle and high-income countries

Policies and public health efforts have not addressed the gendered impacts of disease outbreaks. 1 The response to coronavirus disease 2019 (COVID-19) appears no different. We are not aware of any gender analysis of the outbreak by global health institutions or governments in affected countries or in preparedness phases. Recognising the extent to which disease outbreaks affect women and men differently is a fundamental step to understanding the primary and secondary effects of a health emergency on different individuals and communities, and for creating effective, equitable policies and interventions. Although sex-disaggregated data for COVID-19 show equal numbers of cases between men and women so far, there seem to be sex differences in mortality and vulnerability to the disease. 2 Emerging evidence suggests that more men than women are dying, potentially due to sex-based immunological 3 or gendered differences, such as patterns and prevalence of smoking. 4 However, current sex-disaggregated data are incomplete, cautioning against early assumptions. Simultaneously, data from the State Council Information Office in China suggest that more than 90% of health-care workers in Hubei province are women, emphasising the gendered nature of the health workforce and the risk that predominantly female health workers incur. 5 The closure of schools to control COVID-19 transmission in China, Hong Kong, Italy, South Korea, and beyond might have a differential effect on women, who provide most of the informal care within families, with the consequence of limiting their work and economic opportunities. Travel restrictions cause financial challenges and uncertainty for mostly female foreign domestic workers, many of whom travel in southeast Asia between the Philippines, Indonesia, Hong Kong, and Singapore. 6 Consideration is further needed of the gendered implications of quarantine, such as whether women and men's different physical, cultural, security, and sanitary needs are recognised. Experience from past outbreaks shows the importance of incorporating a gender analysis into preparedness and response efforts to improve the effectiveness of health interventions and promote gender and health equity goals. During the 2014–16 west African outbreak of Ebola virus disease, gendered norms meant that women were more likely to be infected by the virus, given their predominant roles as caregivers within families and as front-line health-care workers. 7 Women were less likely than men to have power in decision making around the outbreak, and their needs were largely unmet. 8 For example, resources for reproductive and sexual health were diverted to the emergency response, contributing to a rise in maternal mortality in a region with one of the highest rates in the world. 9 During the Zika virus outbreak, differences in power between men and women meant that women did not have autonomy over their sexual and reproductive lives, 10 which was compounded by their inadequate access to health care and insufficient financial resources to travel to hospitals for check-ups for their children, despite women doing most of the community vector control activities. 11 Given their front-line interaction with communities, it is concerning that women have not been fully incorporated into global health security surveillance, detection, and prevention mechanisms. Women's socially prescribed care roles typically place them in a prime position to identify trends at the local level that might signal the start of an outbreak and thus improve global health security. Although women should not be further burdened, particularly considering much of their labour during health crises goes underpaid or unpaid, incorporating women's voices and knowledge could be empowering and improve outbreak preparedness and response. Despite the WHO Executive Board recognising the need to include women in decision making for outbreak preparedness and response, 12 there is inadequate women's representation in national and global COVID-19 policy spaces, such as in the White House Coronavirus Task Force. 13 © 2020 Miguel Medina/Contributor/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. If the response to disease outbreaks such as COVID-19 is to be effective and not reproduce or perpetuate gender and health inequities, it is important that gender norms, roles, and relations that influence women's and men's differential vulnerability to infection, exposure to pathogens, and treatment received, as well as how these may differ among different groups of women and men, are considered and addressed. We call on governments and global health institutions to consider the sex and gender effects of the COVID-19 outbreak, both direct and indirect, and conduct an analysis of the gendered impacts of the multiple outbreaks, incorporating the voices of women on the front line of the response to COVID-19 and of those most affected by the disease within preparedness and response policies or practices going forward.

Science and innovation benefit from diversity. However, as the global community fights COVID-19, the productivity and scientific output of female academics are disproportionately affected, leading to loss of women's scientific expertise from the public realm. Women comprise 70% of the global health workforce and more than 50% of medical graduates in many countries. Despite this, women and gender minorities remain underrepresented in medical leadership. Only 22% of full professors in American medical schools 1 and 23% in Europe 2 are women. Women of colour are particularly underrepresented; only 0·5% of full professors in American medical schools are Black women. 1 Academic publishing is essential to career advancement. Women's first authorship in major medical journals has increased from 27% to 37% (1994–2014). 3 Yet, COVID-19 is threatening progress by amplifying existing gender disparities. Early data show that COVID-19 significantly affects women's publishing. Andersen and colleagues 4 compared authorship of 1179 medical COVID-19 papers with 37 531 papers from the same journals in 2019. At 30%, 28%, and 22%, women's shares of overall, first, and last authorship in COVID-19 papers decreased by 16%, 23%, and 16%, respectively. In a Github analysis of arXiv and bioRxiv submissions, Frederickson 5 showed that, although preprint submissions are increasing overall, the number of male authors is growing faster than the number of female authors. Female authorship in other research fields shows similar trends. 6 Our analysis of COVID-19 papers in The Lancet (n=159), excluding Editorials, World Reports, and Perspectives, indicates that overall, first, last, and corresponding female authorship was 30·8%, 24·4%, 25·8%, and 22·9% respectively. Furthermore, most authorships (61·3%) were affiliated with institutions in high-income countries and with the European and central Asia region (40·2%; further methods and details are described in the appendix). Overall female authorship of COVID-19 research articles (32·9%) is similar to previously reported authorship (29%, 2016–17), but overall female authorship of COVID-19 comments (30·6%) is lower than previously reported (39%, 2018). 7 Increasing the prominence of women and minorities in academia is crucial to the fight against COVID-19. Furthermore, ensuring that women's academic output is not disproportionately affected by COVID-19 might safeguard women's career trajectories. Challenges women in academia face are well documented in non-pandemic times. These challenges include male-dominated institutional cultures, lack of female mentors, competing family responsibilities due to gendered domestic labour, and implicit and subconscious biases in recruitment, research allocation, outcome of peer review, and number of citations. 8 COVID-19 has led to unprecedented day care, school, and workplace closures exacerbating challenges. Recent data from the USA, the UK, and Germany suggest women spend more time on pandemic-era childcare and home schooling than men do. 9 This is particularly difficult for single-parent households, the majority of which are female-headed. The academic community, funders, and health professionals should support women in academia during this pandemic (and beyond). First, recognise that women are probably taking on more responsibilities than men are. Help families access safe childcare, and provide options for academics caring for family members, by considering the lockdown period as care leave so decreases in productivity do not hinder later career advancement. Second, recognise how gender bias influences selection and evaluation of scientific experts and leaders during times of crisis. Women make up just 24% of COVID-19 experts quoted in the media and 24·3% of national task forces analysed (n=24). 10 However, countries with female leaders have some of the best COVID-19 outcomes. 11 Amplify the voices of women with established records in infectious disease, pandemic response, global health, and health security. Third, collect and report institutional data on gender representation, including academic output and senior positions. Set clear, specific goals and guidelines and be proactive about identifying and addressing evidence on the impact of COVID-19. Give credit for ideas and ensure that first and last authorship is shared equitably and that contributions are acknowledged fairly among colleagues. Fourth, identify and address structural implicit and unconscious biases in research institutions (eg, hiring) and publication processes (eg, peer review outcome, number of citations). Consider offering training in bias or double-blinded peer review for scientific journals. Establish accountability mechanisms to ensure professionalism and report concerns. Finally, and most importantly, recognise that women from ethnic minority groups face additional challenges in academia, and take structural action to provide support and address these challenges. Scientific expertise and knowledge from all genders are essential to build diverse, inclusive research organisations and improve rigour of medical research to tackle COVID-19. We can do better.