Why COVID-19 Is Hitting Men Harder Than Women
Note: This story was originally published on Healthline on April 26, 2020. All data and statistics are based on publicly available data at the time of publication.
By Bob Curley
More men are dying from COVID-19 worldwide than women, and the potential reasons run the gamut from biology to bad habits.
The World Health Organization (WHO) reports that 68 percent of deaths related to COVID-19 in Europe have been among men.
A study by the Higher Health Institute of Rome found that among Italians hospitalized for the novel coronavirus, 8 percent of men died compared to 5 percent of women.
In New York City, men have been dying of coronavirus at almost twice the rate of women. The city's health department reports 43 COVID-19 deaths for every 100,000 men, compared with 23 deaths for every 100,000 women.
The Centers for Disease Control and Prevention (CDC) currently isn't reporting COVID-19 deaths by gender, but experts see no reason the trend would differ elsewhere in the country.
"Some of the underlying reasons why COVID-19 may be more deadly for men than women may include the fact that heart disease is more common in elderly men than in elderly women," Dr. Stephen Berger, an infectious disease expert and co-founder of the Global Infectious Diseases and Epidemiology Network (GIDEON), told Healthline. "Studies also find that high blood pressure and liver disease are more prevalent in men and these all contribute to more negative outcomes with COVID-19."
"Genetics may also play a big role," Berger said. "Women, because of their extra X chromosome, have a stronger immune system and response to infections than men."
"You can't get away from biology and genetics," agreed Salvatore J. Giorgianni, PharmD, a pharmacist and senior science advisor for the Men's Health Network, which advocates for the health of men and boys.
The phenomenon has actually prompted the launch of two clinical trials in the United States.
In these trials, scientists are giving men with COVID-19 sex hormones such as estrogen to see if that will help them recover from the illness.
Men Are Actually the ‘Weaker Sex’
Males are culturally conditioned to think of themselves as strong, Giorgianni told Healthline, but "women are not the 'weaker sex' when it comes to immunity."
Moreover, he noted, men have higher rates in 9 out of 10 of the leading causes of death in the United States.
That means they're more likely to have preexisting conditions that can make COVID-19 more dangerous.
Behaviors that impact lung health, such as smoking, also may play a role in the disease's deadly impact on men.
"In China, for example, smoking is largely a male habit, resulting in many men suffering from chronic lung disease," Berger said. "This puts men at a much greater disadvantage should they get COVID-19."
The WHO estimates that air pollution kills more than 4 million people annually by contributing to illnesses such as asthma, bronchitis, emphysema, lung and heart diseases, and respiratory allergies.
A recent study from the Harvard T.H. Chan School of Public Health in Massachusetts reported that people who live in areas with high levels of air pollution are also more likely to die of COVID-19 than those in less polluted areas.
Pollution could also be playing a role in elevated COVID-19 mortality rates among men.
"In most cultures, men are more likely to be engaged in outdoor work, exposing them to conditions associated with extreme climate and pollution," Berger said. "This could directly impact their response to an infection like COVID-19."
High-risk occupations deemed "essential" under pandemic emergency orders — notably first responders — also may be "disproportionately jobs men traditionally do," Derek M. Griffith, PhD, director of the Institute for Research on Men's Health at Vanderbilt University in Tennessee, told Healthline.
Higher rates of death among men in pandemics is not new.
Research on the worldwide flu of 1918, for example, found that non-elderly adult males died at a much higher rate than women, possibly because more men had a history of lung-damaging tuberculosis.
Risk Taking May Play a Role
Male behavior during the pandemic also could be increasing their exposure to the novel coronavirus.
A Gallup poll taken between March 2 and 13 found that women were more concerned about COVID-19 than men were (by a 62 to 58 percent margin).
"It's possible that men are more at risk because they tend to expose themselves more to larger crowds and social exchanges, including things like handshaking and sporting events," Berger said.
"There are men with invincibility syndrome that underpins a lot of behaviors, and they tend to be less compliant" with pandemic-related restrictions such as physical distancing, Giorgianni said.
For other men, he said, the issue isn't so much a cavalier attitude as simply being conditioned "to think of health as 'not their job.'"
COVID-19 prevention messages aimed at men should focus on these traditional male roles, "not ignore millions of year of biology and natural selection," Giorgianni said.
"Guys are very concerned for their families, so tell them don't do it for yourself, do it for those who love you," he said. "Even if they feel like they're in good shape and can fight it off, they can still be a carrier and can cause the death of their spouse or daughter or their dad."
Griffith cautioned, however, that much remains unknown about COVID-19, including its different impact on men and women.
"It's worth considering these factors, but it's a little premature," he said. "Most of these statements seem to assume we know more about this disease than we do."
Taking Symptoms Seriously
One thing that is well-proven, however, is that men tend to delay seeking healthcare and ignore or dismiss symptoms of illness.
"Many men see self-care as an admission of weakness," David Ezell, chief executive officer of Darien Wellness, a mental health group in Connecticut, told Healthline. "We are taught to be self-sufficient and there for everyone but ourselves. That results in ignoring telltale symptoms of not only COVID but any life-threatening condition."
Dr. Deborah Birx, the COVID-19 response coordinator for the Trump administration, noted at an April 9 briefing that 56 percent of people who have been tested for the illness are male compared to 44 percent female.
Of the men who were tested, 23 percent were positive for COVID-19, compared to 16 percent of women.
"It gives you an idea about how men often don't present in the healthcare delivery system until they have greater symptomatology," Birx said. "This is to all of our men out there, no matter what age group: If you have symptoms, you should make sure that you are tested."
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Kevin T. Smiley
When hurricanes and other extreme storms unleash downpours like Tropical Storm Beta has been doing in the South, the floodwater doesn't always stay within the government's flood risk zones.
New research suggests that nearly twice as many properties are at risk from a 100-year flood today than the Federal Emergency Management Agency's flood maps indicate.
Flooding Outside the Zones<p>About <a href="https://furmancenter.org/files/Floodplain_PopulationBrief_12DEC2017.pdf" target="_blank">15 million</a> Americans live in FEMA's current 100-year flood zones. The designation warns them that their properties face a 1% risk of flooding in any given year. They must obtain flood insurance if they want a federally ensured loan – insurance that helps them recover from flooding.</p><p>In Greater Houston, however, <a href="https://doi.org/10.1111/j.1539-6924.2012.01840.x" target="_blank">47% of claims</a> made to FEMA across three decades before Hurricane Harvey were outside of the 100-year flood zones. Harris County, recognizing that FEMA flood maps don't capture the full risk, now <a href="https://www.hcfcd.org/floodinsurance" target="_blank" rel="noopener noreferrer">recommends that every household</a> in Houston and the rest of the county have flood insurance.</p><p>New risk models point to a similar conclusion: Flood risk in these areas outstrips expectations in the current FEMA flood maps.</p><p>One of those models, from the <a href="https://firststreet.org/flood-lab/research/2020-national-flood-risk-assessment-highlights/" target="_blank">First Street Foundation</a>, estimates that the number of properties at risk in a 100-year storm is 1.7 times higher than the FEMA maps suggest. Other <a href="https://doi.org/10.1088/1748-9326/aaac65" target="_blank" rel="noopener noreferrer">researchers</a> find an even higher margin, with 2.6 to 3.1 times more people exposed to serious flooding in a 100-year storm than FEMA estimates.</p>
What FEMA’s Flood Maps Miss<p>Understanding why areas outside the 100-year flood zones are flooding more often than the FEMA maps suggest involves larger social and environmental issues. Three reasons stand out.</p><p>First, some places rely on relatively old FEMA maps that don't account for recent urbanization.</p><p>Urbanization matters because impervious surfaces – think pavement and buildings – are not effective sponges like natural landscapes can be. Moreover, the process for updating floodplain maps is locally variable and can take years to complete. Famously, New York City was updating its maps when Hurricane Sandy hit in 2012 but hadn't finished, meaning flood maps in effect <a href="https://projects.propublica.org/nyc-flood/" target="_blank">were from 1983</a>. FEMA is required to assess whether updates are needed every five years, but the <a href="https://www.fema.gov/cis/nation.html" target="_blank" rel="noopener noreferrer">majority of maps</a> <a href="https://www.oig.dhs.gov/sites/default/files/assets/2017/OIG-17-110-Sep17.pdf" target="_blank" rel="noopener noreferrer">are older</a>.</p><p>Second, binary thinking can lead people to an underaccounting of risk, and that can mean communities fail to take steps that could protect a neighborhood from flooding. The logic goes: if I'm not in the 100-year floodplain, then I'm not at risk. Risk perception <a href="https://doi.org/10.1088/1748-9326/ab195a" target="_blank" rel="noopener noreferrer">research</a> backs this up. FEMA-delineated flood zones are the major factor shaping flood mitigation behaviors.</p><p>Third, the era of climate change scuttles conventional assumptions.</p><p>As the planet warms, extreme storms are becoming <a href="https://nca2018.globalchange.gov/" target="_blank">more common and severe</a>. If greenhouse gas emissions continue to increase at a high rate, computer models suggest that the chances of a severe storm dropping 20 inches of rain on Texas in any given year will increase from about 1% at the end of the last century to 18% at the end of this one, a chance of <a href="https://doi.org/10.1073/pnas.1716222114" target="_blank" rel="noopener noreferrer">once every 5.5 years</a>. So far, <a href="https://www.rstreet.org/wp-content/uploads/2020/02/195.pdf" target="_blank" rel="noopener noreferrer">FEMA hasn't taken into account the impact climate change is having</a> on extreme weather and sea level rise.</p>
Racial Disparities in Flooding Outside the Zones<p>So, who is at risk?</p><p>Years of research and evidence from storms have highlighted social inequalities in areas with a high risk of flooding. But most local governments have less understanding of the social and demographic composition of communities that experience flood impacts outside of flood zones.</p><p>In analyzing the damage from Hurricane Harvey in the Houston area, I found that <a href="https://doi.org/10.1088/1748-9326/aba0fe" target="_blank">Black and Hispanic residents disproportionately experienced flooding</a> in areas beyond FEMA's 100-year flood zones.</p><p>With the majority of flooding from Hurricane Harvey occurring outside of 100-year flood zones, this meant that the overall impact of Harvey was racially unequal too.</p><p>Research into where flooding occurs in Baltimore, Chicago and Phoenix points to some of the potential causes. <a href="https://www.nap.edu/read/25381/chapter/4#16" target="_blank" rel="noopener noreferrer">In Baltimore and Chicago</a>, for example, aging storm and sewer infrastructure, poor construction and insufficient efforts to mitigate flooding are part of the flooding problem in some predominantly Black neighborhoods.</p>
What Can Be Done About It<p>Better accounting for those three reasons could substantively improve risk assessments and help cities prioritize infrastructure improvements and flood mitigation projects in these at-risk neighborhoods.</p><p>For example, First Street Foundation's risk maps account for <a href="https://firststreet.org/flood-lab/research/flood-model-methodology_overview/" target="_blank">climate change</a> and present <a href="https://floodfactor.com/" target="_blank" rel="noopener noreferrer">ratings</a> on a scale from 1 to 10. FEMA, which works with communities to update flood maps, is <a href="https://www.fema.gov/media-library-data/1521054297905-ca85d066dddb84c975b165db653c9049/TMAC_2017_Annual_Report_Final508(v8)_03-12-2018.pdf" target="_blank" rel="noopener noreferrer">exploring rating systems</a>. And the National Academies of Sciences, Engineering and Medicine recently <a href="https://www.nationalacademies.org/news/2019/03/new-report-calls-for-different-approaches-to-predict-and-understand-urban-flooding" target="_blank" rel="noopener noreferrer">called for a new generation of flood maps</a> that takes climate change into account.</p><p>Including recent urbanization in those assessments will matter too, especially in fast-growing cities like Houston, where <a href="https://authors.elsevier.com/a/1boBRyDvMFW6W" target="_blank" rel="noopener noreferrer">386 new square miles</a> of impervious surfaces were created in the last 20 years. That's greater than the land area of New York City. New construction in one area can also <a href="https://scalawagmagazine.org/2018/01/city-in-a-swamp-as-houston-booms-its-flood-problems-are-only-getting-worse/" target="_blank" rel="noopener noreferrer">impact older neighborhoods downhill</a> during a flood, as some Houston communities discovered in Hurricane Harvey.</p><p>Improving risk assessments is needed not just to better prepare communities for major flood events, but also to prevent racial inequalities – in housing and beyond – from <a href="https://www.npr.org/2019/03/05/688786177/how-federal-disaster-money-favors-the-rich" target="_blank" rel="noopener noreferrer">growing</a> after the unequal impacts of disasters.</p>
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