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Editor's Note: Retired Rear Admiral Susan Blumenthal, MD, MPA, is the senior medical and policy advisor to amfAR, the AIDS Research Foundation and clinical professor at Tufts Medical Schools and Georgetown University. She served as a medical officer in the administrations of four US presidents, serving as assistant to the director-general for Health, first deputy assistant secretary for women's health, chief of the Behavioral Medicine and Basic Prevention Research Branch of the NIMH and as a White House health adviser. The opinions expressed in this comment are specific to the author. See more opinions at CNNe.com/opinion.
(CNN) - As the covid-19 pandemic overwhelms communities in the United States, many of us in the medical and scientific fields cannot help but remember the early days of the AIDS epidemic. In the 1980s, HIV was a mysterious and deadly new virus that was rapidly spreading throughout our country. Fear and misinformation fueled outbreaks. Critical points emerged in New York City and California.
I remember the devastating impact of the epidemic at its inception: once people who were otherwise healthy began to die quickly, the stigma surrounding the disease increased and the government was slow to respond. Without medications to treat the disease, the only tools to help prevent it were individual behavior changes. My job at the National Institute of Mental Health was to stimulate a scientific research agenda on behavior change strategies, to convene the first conference of the National Institutes of Health (NIH) on women and AIDS, and to contribute to the first report from the director general of healthcare that warns all Americans about this new infectious disease
Around this time, Dr. Anthony Fauci was at another NIH institute, the National Institute of Allergy and Infectious Diseases, working to discover medications to treat and prevent HIV / AIDS.
Initially, the research community did not recognize women as an important group to study. As a consequence, clinical trials of HIV / AIDS drugs and preventive interventions excluded them. We continue to pay the price for this public health oversight: women now account for nearly 52% of people living with HIV globally. The disease disproportionately affects women of color: In 2018, 79% of new HIV diagnoses among women in the United States were racial and ethnic minorities.
Now, we are seeing similar events with the covid-19 pandemic. Once again, the government is responding slowly. Once again, vulnerable populations, particularly the poor and people of color, are dying at higher rates. Once again, we find ourselves in need of modernizing our healthcare systems and mobilizing the research community to develop effective testing, treatment and prevention strategies. And once again, the answer hasn't taken into account the important differences based on sex when it comes to the impact of covid-19 in the United States.
My work at the NIH, and my time as the country's first deputy assistant secretary for women's health, helped me bring women to the forefront of our nation's health care agenda. A new field emerged to study sexual differences from the cellular level to the social and environmental factors that influence health and disease. We now understand how critical these differences are to how a disease progresses and to the effectiveness of treatment and preventive interventions.
When it comes to covid-19, biological sex differences in the immune and endocrine systems can help explain the most severe cases and the highest death rates in men. Sex chromosomes and hormones influence the immune response to microbes, and women generally have stronger immune responses to infections and vaccines.
Studies in mice infected with the Severe Acute Respiratory Syndrome (SARS) coronavirus suggest that estrogen may have protective effects. For example, the female sex hormone decreased lung damage during a cytokine storm, a fatal overreaction of the body's immune system in response to infection, by decreasing this immune response. In the same study, females died at almost the same rate as male mice when their ovaries were removed or estrogen receptors were inhibited. Although it is a long way from a mouse to a woman or a man to determine the mechanisms of a disease, animal studies can help us understand the role that sexual differences in hormones and the immune system play in the presentation of symptoms, disease severity and mortality rates.
Women may also have increased immunity after infection. A comparison of 331 patients in Wuhan, China found that in the most severe cases, higher levels of antibodies were found in women, compared to men, after recovering from covid-19. The research hasn't had a peer review yet, and we need more studies looking at this correlation, which could have a profound effect as scientists struggle to find effective treatments.
While biology may be protective for women as a result of immune or hormonal factors, they experience the devastating social and economic consequences of covid-19 more acutely. A recent report indicates that women are 16% more likely than men to say that the pandemic has had a negative impact on their mental health. Reports of domestic violence are also on the rise, disproportionately affecting women as victims, with some local media reporting a 46% increase in calls to the police in the US During the Hubei, China lockdown, Jianli County Police reported three times as many cases of domestic violence in February compared to the same period last year.
Additionally, there are more women than men in the first line of healthcare response to covid-19. According to the US Census Bureau, Women make up 76% of all health workers and 85% of all registered nurses and home and mental health assistants. In some states, healthcare workers comprise 20% of coronavirus cases, and many of them are dying from this disease.
Women have also been hit hard by unemployment resulting from covid-19. In the United States, women accounted for almost 60% of the 700,000 jobs lost in March alone, according to estimates by the Women's Policy Research Institute.
Furthermore, the economic repercussions of the pandemic could have a lasting impact on women in the workforce and as caregivers. Our government must mobilize to respond to those most economically affected and focus efforts on getting women back to work safely with equal pay and risk pay for essential workers.
Women's reproductive health services, including access to contraception, are also at risk. In Texas, abortion was listed as a nonessential procedure that could be postponed until the governor reviewed the order after a legal battle. Iowa, Ohio, Arkansas, and Alaska have also imposed restrictions on the medical procedure during the pandemic.
We have also seen emerging data indicating that the coronavirus disproportionately affects black people as well as older people. Unfortunately, in the midst of the covid-19 pandemic, most countries, including the U.S., still don't report data disaggregated by age, sex, race, or ethnicity, with the breakdowns listed side by side so they can compare.
In response to Congressional oversight, the Centers for Disease Control and Prevention has now added racial / ethnic data by age in the states where this information is available. However, it should be noted that these important racial data are missing in 64% of reported cases. The CDC does not yet include parallel data on these three key demographic factors for comparison. Additionally, there is an alarming omission of biological sex in the key demographic picture, making it very difficult to analyze the differences in covid-19 rates among white, black, and Latina women by age group.
While HIV and the new coronavirus differ in many ways, we can apply the lessons we learned from HIV to this deadly new pandemic. As we search for effective treatments and a vaccine, the inclusion of women and minorities in clinical trials is critical.
More research should be done to analyze the potential impact of sex, along with other demographic factors, on patients with covid-19. It is also imperative to study these demographic factors together to better understand the mechanisms of coronavirus infection, its clinical course, and the safety and effectiveness of interventions. Meanwhile, the collected research data on biological, social and environmental risk and protective factors around the world must be disaggregated and analyzed in these demographic categories.
In the fight against covid-19, women must participate in the design and implementation of coronavirus response plans. And scientists and doctors must address gender, age, and race / ethnicity differences when conducting research and providing health care services. These are the pillars to help curb the devastating impact of this disease on the health and economic well-being of women and men in our country.