Leaving women out of COVID-19 decision-making is not just bad for women — it’s bad for everyone. Research shows that achieving gender parity correlates with better outcomes in the pandemic overall, yet a new analysis found that only 3.5% of COVID-19 decision-making bodies have an equitable number of men and women. What does this mean for healthcare? We spoke to a panel of experts to find out.

Past outbreaks of diseases such as Zika and Ebola have taught us the same lesson time and time again: In situations of crisis, women’s rights and needs are pushed aside because they are seen as a bonus or privilege rather than a necessity. 

The trajectory is always the same — women make up the vast majority of care workers and are also overwhelmed with informal care duties, yet their contribution to decision-making is lacking. According to recent research, only 3.5% of 115 COVID-19 decision-making groups across 87 countries contained an equitable number of men and women.

The consequences are a rise in domestic violence, women being pushed out of the paid workforce, the contesting of abortion rights, and discrimination and harassment of transgender people, to name only a few. 

Health inequities affect all of us differently. Visit our dedicated hub for an in-depth look at social disparities in health and what we can do to correct them.

It is important to remember that marginalization occurs intersectionally, across several layers of society at once — pushing one group aside usually means excluding several others along with them.

People of color have also been largely excluded from COVID-19 decision-making, despite evidence that the pandemic has hit Black and Latinx individuals, Indigenous people, and people from other marginalized racial and ethnic groups the hardest across the globe.

On the other hand, there is evidence to suggest that countries with more female leaders had a better response to the pandemic. While this observation quickly became an internet meme, one study — which has yet to be peer-reviewed — found a six-fold lower death rate in countries led by women, compared with those led by men.

So, in this context, we ask: What has the gender imbalance in decision-making meant for healthcare during the pandemic? Is it time for men to “lean out” of the decision-making process to make room for female leaders? 

To find out, we consulted four experts who co-authored a recent paper titled “Symptoms of a broken system: The gender gaps in COVID-19 decision-making.” The paper appears in the journal BMJ Global Health, and its first author is Kim van Daalen, a doctoral candidate at the University of Cambridge’s Department of Public Health and Primary Care, in the United Kingdom.

We spoke with Irene Torres, Ph.D., a health promotion researcher for Fundación Octaedro, in Ecuador, who now focuses on gender and public health in COVID-19. Another expert in the discussion was Laura Jung, a medical student and research coordinator with Women in Global Health (WGH), whose research focuses on climate, gender, and health.

The conversation also featured Arush Lal, a board vice-chair of WGH, a consultant with the Pan American Health Organization, and a doctoral candidate in health policy at the London School of Economics, in the U.K.

The final expert we spoke with was Sara Dada, the director of implementation research and education at the Vayu Global Health Foundation, in Boston, MA. 

We lightly edited the conversation for clarity. To listen to the full discussion with our panel of experts, tune in to our podcast.

MNT: What inspired you to carry out your analysis? 

Arush Lal: While current evidence has been showing that COVID-19 has been more severe for men, we do always know that historically women are disproportionately affected by health emergencies, and that was one of the big, big motivations for even doing this research — because we’ve seen statistically that women have this kind of triple burden in terms of economic and social impact, and yet they’re often [absent from] leadership.

Then [there are] these kind of gender-based quarantine lockdown rules that aren’t sensitive to the different kinds of experience of the different genders and that have a direct impact on the livelihoods and well-being of particularly vulnerable groups, such as women, who’ve experienced a disproportionately high level of gender-based violence and domestic violence within households.

And also, we’ve seen reports of LGBTQ populations who have also had this kind of similar rise in domestic violence or mental health issues that are being exacerbated by being in lockdown, and they can’t even have access to community or safety.

[W]e’ve also seen that these quarantines have overlooked or disregarded women’s higher levels of income loss. Many of them make up the majority of the unpaid workforce, including unpaid caring roles. And they’ve kind of lost that informal gig economy that was devastated during [the lockdowns], and women have been hit the hardest by that.

The last point to really focus on is the importance of marginalization of individuals and intersectional inequities that happen. For example, I touched on transgender and gender-queer individuals. There are certain areas where racial equity adds an extra layer of marginalization, and having a lack of diversity in the health workforce, particularly in COVID responses, made it really challenging for folks who are developing lockdown rules to think about what exactly this means for some of the most vulnerable groups and communities that don’t have enough access or voices to speak up for themselves.

Laura Jung: [A]lso, from an academic perspective, it could really be seen that women are falling behind more in their academic careers due to this pandemic, because for them, it has been a lot more challenging to keep up with their care duties and their academic work, especially during the lockdown, when schools and childcare facilities were closed. So, what we could see, actually, was that women published much less during the pandemic than men did and just advanced less within their careers. 

Sara Dada: As part of COVID 50/50, a team of us [at WGH] has also been looking at the speeches made by government leaders. We looked at 20 across the world — 10 men and 10 women — and we found that women were more likely to call out a variety of specific welfare or social programs [and issues]. For example, only Nicola Sturgeon, First Minister of Scotland, described domestic violence.

Women were more likely to also call out labor unions, mental health challenges, or substance abuse, in terms of some of the programming that they were incorporating into their COVID response plans, and that was something that we did not see when it was only a man as the head of government.

MNT: What are the implications of this gender imbalance for vaccine research and clinical trials? 

Laura Jung: There is a lot of focus now on the vaccine as a solution, […] but it shows another important problem that we have had in medical science for a long time: That often in clinical trials, there is not an equal representation, which is an issue due to mostly biological factors — like women having different hormonal systems and different immune systems than men.

[And if women] are not represented, especially, for example, in vaccine trials, it could be that something is developed that has not the same effect on men and women, or it has more side effects for one or the other. And interestingly enough, this is a very well-researched problem, so it should be on the agenda of every researcher in the field, but it seems like it’s not.

And now we’re coming to this very specific situation where research is done in a very short time — the timeframe we have is not what it normally takes to develop a vaccine, so it’s really research on a speed line. And what we see is that we might make those mistakes.

Again, it’s not only about including women in clinical trials, it is also [about] then taking the data that comes out and analyzing it so that we see the effects are actually different for men and for women.

And we have already seen that some of the developers said that they don’t plan to do that. It is very unclear why, as it is not a very difficult thing to do. But it seems that it’s not seen as a priority at this point, which is, I think, a risky stance to take.

[Finally,] there is one risk group that is traditionally excluded from trials, which is pregnant women, and they are also, again, often excluded from COVID trials.

And [besides] gender, we also see that ethnic minorities are very underrepresented in the clinical trials, which might sound counterintuitive, since we know that in many countries, ethnic minorities are harder hit by COVID-19, so you would like to include those groups, but that’s not what’s happening.

MNT: In your paper, you quote research that has found a correlation between countries with more women leaders and better COVID response and outcomes. What might explain this correlation?

Arush Lal: It’s one of those cases where we’re not sure whether causation necessarily implies [correlation]. But what we have seen evidence show, and one could make an argument for, is that women tend to be more risk-averse — many studies have shown, in health specifically, that if you provide women with cash transfers, they’re more likely than men to invest in their families and invest in their communities. 

So, perhaps some of those lessons are coming out within this community response, where women who are at the head of countries have been able to be more proactive about investing in our communities, thinking about more long-term impacts, being a bit more risk-averse, and following the science and evidence.

[Meanwhile,] we’ve seen many men who also statistically have been shown to be a little bit more averse to seeking [help], following guidelines, and following evidence. So while we do see these things at community levels, it’s hard to say how they filter up to leadership.

Irene Torres: I would think that’s a generalization about women not being as risk-averse as men. I don’t think we have the data on that, and also, COVID required [leaders] to take some risks, and you have the example of New Zealand, in which the [female] prime minister took risks.

Arush Lal: That’s a really important point. But I will also say […] that a society that would elect a female is maybe more likely to follow guidelines, to follow science, to be more inclusive of other communities, and to think about the impacts on marginalized populations within their society.

And so perhaps […] the right question is not if women leaders are doing more, but if societies that elect women leaders are perhaps better primed, and what that says about […] our responsibility as populations to improve the way we work with each other and, hopefully from the ground up, improve gender equity at the highest levels.

MNT: What is the importance of gender quotas?

Arush Lal: I think at the end of the day, the very fact that you do need a quota does say something about the broader issue at hand. I think many people would ideally just want there to be women that were seen as equal experts, and there wouldn’t be a need for a quota. I think quotas are largely a kind of stepping stone to where we need to be.

Laura Jung: One very common argument against quotas is that if there were enough qualified women, they would be in leadership positions. It’s just that we know that is not true, because in health, and global health security, and academic research there are a lot of very qualified women, and they have been disregarded, especially in the beginning of this pandemic.

[WGH] actually made a list of female experts in global health security or infectious diseases, which can be found on their website, and a lot of the local chapters also did this and tried to have a list of their female experts, just to make it as easy as possible. But what we see is [that] there are a lot of highly qualified women out there who are still being disregarded.

MNT: What did your research reveal about the United States?

Sara Dada: Within the U.S., the two task forces, or decision-making groups, that we looked at were the CDC response, which is the chief public health agency in the U.S., and the White House Coronavirus Task Force. It was interesting to see the difference between these two, in that the White House task force consisted of only 9% women, so a very small amount, whereas the CDC response team was over 80% [women].

And it’s interesting because we know already that women compose the majority of the healthcare workforce, and this kind of mirrors that — we have the public health agency mirroring [the healthcare workforce], whereas the decision-making, or governing, group mirrors what the rest of politics in the U.S. tends to look like. 

And we see that this governance and these mechanisms have followed the usual modus operandi, [as] we call it in our paper, in that it was a very quick delegation of who was in charge, who people knew, and who the politicians were, despite making national or international commitments to be more gender responsive in governance.

MNT: In your paper, you note that “Women are not automatically gender-inclusive advocates, nor are men inevitably gender-exclusive.” Could you expand on that?

Irene Torres: Absolutely, women will not be any different, in a sense, than men. But we have the same right to be in task forces and panels. This transcends […] the task forces, [and extends to] academia and government.

And then the question is, who elects these women? Who chooses these women to be in task forces? Who chooses women to be deans, to be chancellors of universities, who decides this? So I think that we cannot only focus on the composition [of men and women], of whether women are better, whether women should be better than men. Instead, [we should focus on] who is making these decisions and why.

Arush Lal: [A] second point that we have seen many times is that these two genders are just kind of pitted against each other. As if women [make up] all the experts on anything to do with gender, and men don’t have a say and shouldn’t even participate in gender [discussions]. And this is something that’s not really fueled by men or women, it’s just kind of the way society has propagated this.

And I think that point is important because we do need to also focus on the issue of allyship and having men who are equally considering the needs of women; we will not reach gender equality in leadership without men who are also allies and willing to engage. And also this benefits men, too, because some of these issues about intersectional inequity affect men just as much, especially when you’re not just [part of an] LGBTQ population but also [concerned with] men’s health.

Some of the ideas that come from more feminist literature can have some really important gains for gender as a whole, and the issue of toxic masculinity, and the effect that it has on men’s health. So, having men be part of the conversation and being inclusive of women is a really important part of this question that sometimes gets left behind.

Sara Dada: And, of course, for men to know when to lean out. 

As Arush has alluded to, there are some great allies out there. And I think engaging more with them in the conversation and empowering them to step aside is what we want to strive toward. 

MNT: What was the response you received after publishing your research?

Arush Lal: We were actually very, very excited to see the response, we were rather overwhelmed. […] We were aware of some of the leading stakeholders that we really wanted to target with this, such as the World Health Organization [WHO], many national governments, some leading women’s health and rights organizations and civil society groups responded really positively. 

This was actually one of the most widely shared pieces of its time in the journal, which is saying something, at a time when academic scholarship has gone through the roof.

And I think that’s an important point because I think it’s a sign this was overdue and [that] there was a lot of evidence that was lacking. […] Folks have witnessed this, they’ve seen this, they’ve lived this, and they weren’t surprised by this, but they didn’t have the numbers to finally be able to speak up about what was happening. And this was really a landmark study that way, so we’re really excited about that. 

Irene Torres: [W]hat happened was that CNN had shared the story and reported on the story, and then there was a barrage of messages saying, “Why are people even worried about this?” And that’s very interesting, you know, “There’s the focus on the disease, it’s a global pandemic, we have to prevent it, we have to cure people, why are we focusing on whether women are more represented in task forces,” and I think that’s the question we haven’t answered yet. 

And I think this is essential, especially in a country such as the U.S., we have probably the worst case example [of COVID-19] in the world. So this is something that the U.S., this huge, gigantic country needs to talk about and discuss more.

Arush Lal: [I] think that’s a really challenging thing about addressing inequity during emergencies, because people often like to separate that — “Oh, this is an emergency time, we don’t need to be thinking about this fluffy stuff.” This isn’t fluffy stuff, there are lives that are lost because of this gross negligence. And it starts with leadership. […] [People who don’t] understand the need for this, they’re not seeing the bigger picture of how that does translate into lives lost.

Laura Jung: Yeah, [this reaction] is a bit connected to this idea that a crisis is not interlinked with other challenges or other threats to health because we know that if we disregard women in decision-making, it is a threat to mostly female health.

Obviously, COVID-19 is getting a lot of attention these days, but we have to see it within the bigger picture. It’s actually worsening all the other health threats that we were facing before, and it’s not standing by itself. And I think that’s how we have to see it. And that’s why we have to look at COVID-19 from the perspective of those other threats as well, and we can’t just all be doing COVID-19 vaccine research, I don’t think that would be very valuable for society either.

MNT: What are the next steps emerging from your research?

Irene Torres: As I finished [my] contribution […] to the article, I was looking for the data on Spanish- and Portuguese-speaking countries. I work mostly on my own country, Ecuador, and that’s an interesting story — people say, “Why do you focus on such a small country that is not interesting for the global conversation?”

One of the things we did was extract all the codes of response in COVID, in the norms and the instructions from the government, and we realized that it’s not just women — it’s Indigenous populations, it’s ethnic minorities, it’s senior citizens, it may be people [with disabilities], everybody is excluded from the response, if you think of it, from making the decisions. 

And in Ecuador, we have a law that forces the government to have this conversation — it’s called the Community Participation Article for Risk Management, and there was no community participation, and this is a fact. We looked through all the agreements, meetings, and instructions that we’re giving. 

And I think that’s the next step — it’s not just women, it’s everybody who’s disenfranchised, vulnerable, and intentionally excluded. 

I belong to a COVID researchers email group, and I’ve been colonial-splained, mansplained, Global North-splained, everything — the whole mix. So I think that’s the next step, [including everyone who has been excluded].

Arush Lal: [In terms of] where we should move forward, there are three main things that I look at. 

The first [is that] it’s really necessary to open up this dialogue — make this space for dialogue about gender equality, especially within our moments of crisis. This is exactly what we need to do, it’s critical to build a more inclusive path forward.

The second thing is, I think we should support new, concrete recommendations. There is a new policy brief that drew on research like [our study] and others to outline three major areas of work to improve gender mainstreaming in the WHO’s health emergencies program and its related mechanisms.

Hopefully, that will guide member states to also follow suit, if the WHO is committing to these things in a more concrete, robust way.

And then the last thing is, I think we really need to remember that health security doesn’t occur in a vacuum. This inequity of leadership in COVID-19 task forces, it really is a symptom of a broken system, and we must draw from and link to lessons in other related fields, including peacemaking and justice, climate change, [and] economic well-being.

[T]his isn’t just a health issue. It’s not just a women’s issue. It is a global issue. And what we learned from here can impact so many other fields. This is just one part of the puzzle.

Laura Jung: To add to this, countries in the global North [are] experiencing a second wave […] and what we see is that the response has already changed from the first response that we saw in March–April, and it seems that many countries have chosen different priorities — for example, now there is a focus on keeping schools and keeping childcare facilities open, which was not the case in the first wave that we saw.

This is something that has definitely changed in many countries, and I think that also shows how the understanding on a political level has been changing over the [course] of this pandemic.

Irene Torres: I think that if we want to account for differences in gender, we also need to account for differences in cultures. […] What does including women mean in Arab countries or in some Asian countries? So we cannot prescribe a recipe or prescription to solve this.

And I think that’s the whole point of diversity in the response, of having women, men, ethnic minorities, Indigenous populations, vulnerable populations, disenfranchised, excluded populations [included, but also acknowledging] that countries in diverse regions of the world are diverse. And we need to account for that and figure out: [Given] this diversity in these cultural landscapes — what is possible to do, and how?

Sara Dada: I just want to reiterate that the context matters and that our job isn’t done when there’re more women sitting at the table. There’s so much more that we need to do for a really holistic transformation of the way we govern, and [there’s] more than just two types of people out there, and we won’t really have a fair and equitable response until we are truly considering differences in age, race, religion, ability — everything across the board.

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