The COVID-19 Effect: Advancing Women and Women’s Health Beyond the Pandemic

October 9, 2020
UPenn Perelman School of Medicine FOCUS Conference

As I was gathering my thoughts for today, U.S. Supreme Court Justice Ruth Bader Ginsburg passed away. This loss has hit me hard, and of course I am not alone. Along with a profound sense of loss, there is also deep worry. It’s impossible to overstate the dangers of this moment, and nowhere is this clearer than with women’s health. Decades of progress are on the line, with the ACA, coverage of family planning, and­­­ Roe v. Wade all at serious risk—and that’s just at the federal level. On the 25th anniversary of then-First Lady Hillary Clinton’s pronouncement that “women’s rights are human rights,” those rights feel more precarious than ever.

Which brings me to the topic of today’s talk, The Covid-19 Effect: Advancing Women and Women’s Health Beyond the Pandemic.

The pandemic has both magnified and accelerated gender inequities. Much like the virus itself, the challenges that women face have expanded exponentially.

In March, the Atlantic published a piece with this chilling headline: “The Coronavirus Is a Disaster for Feminism.” It took aim at a narrative then taking root—that the pandemic should spur us on to ever-greater productivity. Proponents cited William Shakespeare and Isaac Newton, who did some of their greatest work during England’s plague years. But, as author Helen Lewis observed, there’s a big missing piece here: Neither of these men had to handle child care, or elder care, for that matter.

As so many of you know firsthand, the pandemic has upended structures that gave women a fighting chance to integrate work and family. We never came close to getting it right—and now we are fast losing ground. While I can’t see who is here today, I suspect that some who would have hoped to attend had their plans derailed by family responsibilities.

A piece published last week by Bloomberg dubbed this moment “the first female recession.” It painted a dire picture, stating: “The pandemic has erased years of economic gains for women and is poised to leave lasting economic scars. … As the crisis drags on, some of the biggest pain points are among women of color and those with young children.”  

In September 2020 alone, some 865,000 women dropped out of the workforce compared to 216,000 men—that’s four times as many women as men. The challenges are especially great for single parents, many of whom already live on the economic margins. Once again, communities of color are hardest hit. A majority of Black mothers, 67.5 percent, and 41.4 percent of Latina mothers are the primary or sole breadwinners for their families, compared with 37 percent of white mothers, according to an analysis of 2018 data from the Current Population Survey, conducted by the Center for American Progress.

The pandemic’s burdens on women loom especially large in countries that, like the United States, lack guaranteed paid maternity leave and affordable child care. As the New York Times put it, there are “[h]ard choices for rich women. Impossible ones for the poor.”

Further compounding these hardships, women—and women of color in particular—are on the front lines of this crisis in disproportionate numbers. In the United States, women hold 76 percent of health care jobs and make up more than 85 percent of nurses. One in three jobs held by women have been designated essential, with nonwhite women doing more such jobs than anyone else. Yet, for all the added risk, many still struggle to get by. Almost 6 million people work in health care jobs that pay less than $30,000 a year.

A whopping 83 percent of them are women, and half are nonwhite. All of this at a time when communities of color are at the epicenter of the nation’s worst public health crisis in more than 100 years.

All of this is deeply troubling. Yet none of it should surprise us. We know from history that pandemics have profound effects on gender equality—effects that ripple out for years to come. We’ve seen this with Ebola, Zika, SARS, swine flu, and bird flu. But as the old maxim goes: Those who do not learn from history are doomed to repeat it.

This wonderful conference is now in its 23rd year—that’s almost a quarter of a century. Much has been accomplished, yet so very much remains to be done. The pandemic has only thrown this into sharper relief.

You may have heard the saying “Never let a crisis go to waste.” These are words we need to heed. How can we mine this moment for opportunity? How can we make it the wake-up call that is so urgently needed?

I’ve given this a lot of thought, and one thing that’s crystal clear is that all of you in this room have a special role to play. You are MDs, PhDs, faculty, instructors, lecturers, fellows, and residents—in some cases, more than one of these. You are at various stages in your careers and come from a diverse range of tracks and departments.

But all of you share a single critical identity: All of you work in the realm of academic medicine, a field with unique and enduring power to shape the future of medicine—and the future of women’s health, and therefore the health of all. You are conducting the research that gives rise to more effective clinical treatments and ultimately paves the way for health care system innovations. You are teaching the next generation of leaders in health care and medicine. During your time with them, you’ll do far more than communicate knowledge, important though this is. You’ll shape the perspectives that they bring to everything they do. And in so doing, you’ll shape their sense of what is possible.

We are hosted today by FOCUS, a program with a dual mission. First, to support retention, promotion, and advancement of women faculty. Second, to promote research in women’s health and in women’s careers.  As you’ve likely noticed, these goals go hand in hand. You can’t make significant progress in one without progress on the other.

I have seen this again and again, throughout my own career.

One of my greatest strokes of luck was having an early mentor who instilled in me the confidence to follow in her footsteps. Her name was Ruth Hubbard, and she was the first female biology professor to be awarded tenure at Harvard University. A truly pathbreaking researcher, Ruth became a powerful feminist voice in and for science. She passed away four years ago, at the age of 92.

It was spring of freshman year when I enrolled in Ruth’s now-legendary Bio 109: Biology and Women’s Issues. In her teaching, she made explicit something that others had known but not articulated: that science had made men the norm, both their bodies and their ideas, and that much of what was deemed scientific truth was socially constructed.

Ruth didn’t set out to train disciples. Rather, she taught us to approach the world in the same spirit that she did, to explore the larger forces that shaped scientific work.

One especially memorable experience was an independent study with Ruth and the late Stephen Jay Gould. It took place my junior year. At the time, a new field known as sociobiology was fast becoming an orthodoxy of sorts, going virtually unquestioned in many quarters. Ruth and Stephen challenged this, and pushed me to challenge it. This lesson extended far beyond academic debate. Most importantly, it taught me that I had a duty to question accepted beliefs. That this was not only my right, but also my responsibility.

Four decades later, I can still trace a direct line from what went on in Ruth Hubbard’s classes to my life today.

Throughout, I have carried her voice with me, urging me to question established beliefs that feel wrong or incomplete, reminding me that assumptions often blind us to the truth.

It was this perspective that ultimately led me to found the Connors Center for Women’s Health and Gender Biology at Brigham & Women’s Hospital, where I also relaunched the Division of Women’s Health.

More recently, it brought me to the presidency of Wellesley College. I’ll get to that a bit later.

This is the power of role models, of teaching and mentorship. Which brings me to a critical point: Life experience matters. We bring our whole selves to our work. We can’t have excellence if women are not fairly represented.

This is evident throughout history, and nowhere more so than in the realm of women’s health. Let me take you on a trip down memory lane.

Back when I began my medical career, women were rarely included in clinical trials—or in most of medical research for that matter. Investigators operated on the assumption that what was true for men would hold true for women for most conditions. That male biology was typical and women’s was, well, not.

There was just one problem with this approach: It was 100 percent wrong, totally at odds with science. We now know that women and men are different down to the cellular and molecular levels. It is not just our sex organs, but our brains, hearts, lungs, and joints that are different.

Simply put, to quote the sentinel 2001 report from the Institute of Medicine, “Exploring the Biological Contributions to Human Health: Does Sex Matter:” “Every cell has a sex.”

The implications are enormous, all-encompassing. Men and women differ genetically, and these genetic differences are compounded by hormonal and reproductive changes across a woman’s lifespan.

We now know that the circumstances of women’s lives impact their health in unique ways—even changing their genetics and operating through micro RNA. We know that the same disease often looks quite different in a man than it does in a woman.

And, shockingly, we know that violence experienced by women in their early years is the single most powerful predictor of chronic disease as they age. When we fail to take such realities into account, we leave women’s health to chance. This is dangerous, unfair, and all too often deadly.         

So, here’s the question—the question that propelled my work, and that of so many others committed to women’s health: How could we ignore over 50 percent of the population? Why on earth would we assume that their symptoms are atypical—and make those of the other near 50 percent the universal norm?

It’s a simple and obvious question, right? And yet, for the most part, it went unasked until the 1990s.

This finally started to change after the elections of 1992, which led to an influx of women into the Senate in the wake of the Clarence Thomas/Anita Hill hearings. This was known as “The Year of the Woman” and was, in many ways, a time not unlike our own, a moment where women were waking up to injustices and demanding action.

A turning point came the following year, when Congress passed the NIH Revitalization Act. This historic measure mandated the inclusion of women and minorities in phase 3 clinical trials conducted by the NIH. The motivating force was a Government Accountability Office report that was called for by the Congressional Women’s Caucus, which showed that NIH was violating its own policy on inclusion of women in research.

The passing of the law marked the culmination a remarkable bipartisan effort whose champions included Democrat Patricia Schroeder and Maine Republican Olympia Snowe, who detailed the accomplishment in her memoir Fighting for Common Ground. Imagine, there was such a thing in the ’90s, and women led the way!

Slowly, the medical research community began to shift. Some 30 years later, women are routinely included in clinical trials and overall in clinical research.

And as a result, we have learned much more about the differences in how women and men experience disease. From heart disease to lung cancer, from depression to Alzheimer’s, we have a growing body of evidence on the many ways women and men express diseases differently.

It’s taken far longer than it should, and for predictable reasons.

U.S. Rep. Pat Schroeder put it like this: “I’ve had a theory that you fund what you fear. When you have a male-dominated group of researchers, they are more worried about prostate cancer than breast cancer.”

This is very much in line with my own perception. It’s no coincidence that groundbreaking work on women’s medicine and health tends to be spearheaded by women. Diversity is not a PC add-on—trendy window dressing. Rather, it goes to the core of where our commitments lie. Who we are shapes the questions that we ask and how we move forward.

An article published in the Lancet offers further compelling evidence on this. Vincent Larivière and colleagues analyzed some 115 million scientific publications covering public health, clinical medicine, and biological research by the authors’ gender over 30 years. They found that studies with a female first or last author were more likely to report research findings by sex. The effect was strongest when both first and last authors were women.

In sum, advancing women through the ranks of health care and medicine is not simply a matter of fairness and equity—though it is certainly that. It’s also a matter of ensuring that research takes into account the fundamental biological differences between women and men, and that the related findings are widely accessible.

For all our progress, we still have a long way to go.

A study by Stacie Geller and Molly Carnes looked at 782 randomized trials in 14 leading U.S. medical journals in 2015. Of the 107 that were the primary report of an NIH-funded RCT conducted in the U.S. and included both sexes:

  • We have made progress with 81 percent enrolled ³30 percent women.
  • But, only 26 percent reported at least one outcome by sex or included sex as a covariate in statistical analysis.
  • Seventy-four percent didn’t include sex in the analysis.
  • Seventy-two percent did not mention whether sex was included in their analysis, didn’t report any sex-specific outcomes, and didn’t provide explanation.
  • Two percent explained why they didn’t include sex in their analyses.

Tellingly, the authors noted that there had been no statistical improvement compared with a similar study performed in 2009.

Think about the implications: When you give an average as a result, that’s not really good for women or men. It doesn’t give the right answer for either of them. I’m reminded of this quip from the 4-foot-11-inch former Labor Secretary Robert Reich: “Shaquille O’Neal and I have average height of 6 feet, 2 inches.”

Or as someone else remarked: When Jeff Bezos walks into a room, everyone—on average—becomes a billionaire.

There’s an irony here: Even though we are on the cusp of the precision medicine revolution, there is astonishingly little awareness of the impact of sex, the most basic genetic difference that we know of.

Sadly, we are seeing this once again with COVID-19.

As you may know, there is a growing body of evidence that men and women respond to COVID-19 differently. Notably, mortality rates appear higher for men than for women. We have seen this in data from China, where the virus originated, as well as from Italy, another virus epicenter. It is also true in South Korea, a nation that moved far more rapidly to flatten the curve. Where sex-disaggregated data are available, mortality rates for men compared with women from COVID-19 mainly range from an increase of 1.5-fold to near a 2.0-times fold across the world. [Global Health COVID-19 Sex-Disaggregated Data Tracker: Country data April 2020].

The differential is especially notable given women’s risk levels. As I described earlier, women—especially women of color—make up a disproportionate share of frontline health care providers, caregivers, less-skilled hospital personnel on the front lines, as well as family caregivers.

Why, then, do men appear to be dying at higher rates? As of now, we don’t know—and the hard truth is we will never know unless we look at data by sex.

So far, we appear to be squandering this opportunity. When a reporting team sought sex-disaggregated data from the 20 countries with the highest number of COVID-19 cases, only six provided data broken down by sex for both confirmed cases and deaths. These were China, France, Germany, Iran, Italy, and South Korea. Notably missing was the United States—as of early April 2020, the U.S. Centers for Disease Control and other popular disease trackers had no data reported by sex due to the lack of consistency of the available data. We owe a debt to the researchers seeking to fill the void—I think especially of Clare Wenham and her co-authors at the London School of Economics.

Let’s be clear: This is not a women’s issue. It is an everyone issue. Looking ahead, if women—and men—are to receive appropriate care, we must understand how and why they may respond to the virus and potential treatments differently. This can only happen if we include adequate numbers of women and racial and ethnic minorities in clinical trials of potential treatments and vaccines. In today’s political climate, this is especially fraught.

We also need to adopt an intersectional lens. We know that the virus has exacted a disproportionate toll on communities of color, though few seem to appreciate its full magnitude. At the first presidential debate, Democratic candidate Joe Biden asserted that 1 in 1,000 Black Americans have died in the COVID-19 pandemic.

The statement induced a flurry of fact checking, as many questioned the claim. In fact, it is all too true. Now, we need to drill down further, to clarify the impact on Black women, as well as women of other races and ethnic groups.

Among the many dangers, a lack of sex-specific data in the United States and the lack of analysis of data worldwide leaves us without information on the susceptibility of pregnant women to the disease and its impact on expectant mothers. We are left with preliminary findings and anecdotal data. Last month, the New York Times reported on studies suggesting that pregnant women could be at increased risk of both severe illness and pregnancy loss.

This is especially concerning given our nation’s dismaying track record on maternal mortality, at the low end of developed countries, with Black women dying at three to four times the rate of their white counterparts.

So here we are at a moment like no other, a moment with no road maps. What is the way forward? What does it look like to lead at a moment like this? What role should each of us play?

My favorite definition of leadership comes from a piece I read some years back in the Harvard Business Review: “Leadership is about making others better as a result of your presence and making sure that impact lasts in your absence.”

In my experience, this starts by getting very clear on core values and commitments, and being open and flexible on pretty much everything else. Leadership in service to what? That is the question from which all else flows.

For me that core commitment is improving women’s health and improving women’s lives. This has been the critical through line of my career. When I left the Connors Center for Women’s Health—the organization that I’d founded and to which I’d dedicated more than 15 years—some were quite surprised. They saw my move to Wellesley College as an abrupt shift. But for me, the move to women’s education could not have been more natural. Throughout my career, I’d been spurred on by a number of powerful questions. Yet, ultimately, all were facets of a single inquiry: How do we create the conditions for women to flourish and reach their full potential, both in service to them and in service to the world?

None of this is easy. Right now, those of us in academia have our own unique challenges related to research and publication. There are a number of reports to suggest that women’s outputs are falling in a range of fields, including academic medicine. One such study looked at 1,893 articles related to COVID-19 published between January and June 2020, compared to 85,373 papers published in the same journals in 2019. The analysis showed that the share of women first authors dropped 14 percent. Looking only at March and April, the drop was a stunning 23 percent!

We have also taken on a new campus-wide public health mission: doing all we can to keep our campuses COVID-free. Now, I am not complaining. Indeed, rarely have I felt such a sense of purpose—that I am exactly where I need to be. That being said, it is a lot—for faculty, researchers, staff, students, for each one of us.

On days when I am feeling besieged, I find it helpful to reconnect with my core values. Inclusive excellence. Gender equity. Empowerment and social change. These are few of the most prominent. They are powerful drivers. They remind me of all that is at stake.

Now is a moment for all of us to double down and recommit to such fundamental values. When enough of us do this, that’s when culture shifts.

To be sure, there are not enough of us yet, not nearly enough. Here are a few data points from the Association of American Medical Colleges’ 2018–2019 report on the state of women in academic medicine:

In 2019, women accounted for 48 percent of medical school graduates, yet only 29 percent of division chiefs, 25 percent of full professors, 34 percent of senior associate deans, 18 percent of department chairs, and 18 percent of deans.

All in all, women account for 41 percent of full-time faculty, up from 36 percent in 2009. Of these, white women make up 61 percent and women from under-represented [in-medicine] race or ethnicity groups account for just 13 percent, up a scant one percentage point over the previous decade. [AMA Fig 12, p. 19]

What is to account for this state of affairs?

These are many possible answers and much excellent work on the topic from researchers such as Molly Carnes—I mentioned her earlier—who has shown the bias that exists against women investigators as they apply for grant funding, and Phyllis Carr, long a leader in research on gender differences in academic medicine.

But today, I want to spotlight a single issue: sexual harassment.

In 2016 I co-chaired the first evidence-based study that looked at the impact of sexual harassment on women in academic STEM fields, a joint effort of the National Academies of Sciences, Engineering, and Medicine. What we found was alarming: Academic workplaces are second only to the military in the rate of sexual harassment.

Based on our commissioned data, a staggering 50 percent of women faculty and staff in academic medicine have experienced sexual harassment. That’s one of the highest rates of sexual harassment of the three areas studied—science, engineering, and medicine. Women students, trainees, and faculty experience sexual harassment by patients and their families in addition to the harassment they experience from colleagues and others in leadership positions. As a result, women fall back, change fields, and drop out.

It was also troubling that the data collected in academic medical settings tended to be absent or of poorer quality than in other academic settings.

Our report offered 15 detailed recommendations aimed at preventing sexual harassment, which includes gender harassment: “put downs” rather than the “come ons,” sexual coercion, and unwanted sexual attention, which includes sexual assault.

We made clear the scope of change needed—nothing less than, and I quote: “systemwide change to the culture and climate in academic STEM.”

This reality is further underscored by AAMC data showing that in 2019, 17.4 percent of women faculty felt disrespected in the academic medicine workplace due to their gender. This is compared with 1.2 percent of men who felt disrespected due to their gender.

Predictably, the toll is greatest on women of color. White women account for 61 percent of all women faculty, yet only 18.9 percent of women who feel disrespected. By contrast, while under-represented women account for just 13 percent of all women faculty, Black/African Americans account for almost 20 percent [19.6 percent] of those who feel disrespected while Hispanic/Latinas account for another 14.6 percent.

On a more positive note, there are some signs of progress. The NSF and the NIH have led by example on this. Following the release of the report, the National Academy of Science, National Academy of Engineering, and National Academy of Medicine (NAS, NAE, and NAM) began reviewing their policies and procedures, with the NAS adopting a code of conduct for its members and approving an amendment to bylaws that permits the NAS Council to rescind the membership for egregious violations to the code of conduct, including proven cases of sexual harassment.

NSF, NIH, and NASA require reporting to the agencies regarding any PI or co-PI being put on leave relating to a sexual harassment investigation or if they are found to have committed sexual harassment or assault. They are also taking special care to prevent trainees and postdocs’ careers from being derailed because of these consequences.

More broadly, we have also seen some promising developments on the research front.

Prominent among these is a 2016 NIH policy on including sex as a biologic variable, which requires investigators to factor sex into the design, collection and analysis of data, and reporting of vertebrate animal and human studies in order to strengthen science.

The policy also requires the inclusion of adequate numbers of women in all phases of clinical trials to achieve meaningful results.

This marks a major milestone. For all these reasons, this policy could be a game changer if implemented rigorously. Even just asking the question could be transformative in both pre-clinical and clinical research. The policy will only be as good as the NIH’s willingness to monitor and enforce it vigorously. Time will tell.

So much hangs in the balance right now. As I said at the start of this talk, COVID-19 has both magnified and accelerated the challenges to women, and to women’s health.

Now, we must work to magnify and accelerate solutions. We do this by committing to consider sex and gender in research and the clinical care it fuels and by speaking out when we see this go missing. We do this by mentoring and supporting other women, by building a culture—and a world—where all women have a chance to live into their full potential. We do this by holding fast to our core values, to the things that matter most.  

The long-term COVID-19 effect is not preordained. To a large extent, it will depend on all of us.

I leave you with these words from the Indian writer Arundhati Roy:

Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it.

That is where I am today.

I hope you will join me.