POSITION PAPER – CORONAVIRUS (COVID-19)
Prepared by the EUROPEAN INSTITUTE OF WOMEN’S HEALTH – April 2020
Authors: Peggy Maguire and Kristin Semancik, European Institute of Women’s Health
Version 1 17th April 2020
© 2020 – European Institute of Women’s Health, CLG, 33 Pearse Street, Dublin 2, Ireland
Telephone: +353-1-671-5691 Email: firstname.lastname@example.org
Coronavirus (COVID-19) Position Paper
Globally, the coronavirus (COVID-19) pandemic has shaken health and social systems as well as society as a whole. Much of the world’s population is in “lockdown” while health and social systems are being pushed to their limit in an effort to contain and combat the pandemic. As of mid-April 2020, more than two-million people have been infected, and currently, over one hundred and twenty-five thousand people have died. This number is expected to continue rising over the coming weeks.
Not since the Spanish Flu Pandemic of 1918, which infected a third of the global population and killed tens of millions of people, has the world seen a pandemic of this magnitude.
Society is at a critical juncture. As the EU and the world rebuilds from this crisis, we must take concerted efforts to eliminate health, social, economic and power inequities that have been worsened by and as a result of this crisis.
Europe must take steps for action in their review, to ensure that on any subsequent occasion, lessons learned can be quickly and more easily implemented for any future crisis that involves our communities at large.
A Global Crisis
On the 11th of March 2020, the World Health Organization (WHO) declared the new coronavirus, COVID-19 outbreak, a pandemic. As the number of cases and deaths continue to rise drastically, researchers and health experts are working quickly to better understand COVID-19 and take steps to effectively combat it. Concerted action must be taken in both the short and long-term to address not only the health issues, but also the broader societal implications, including its socio-economic effects, utilising current EU instruments and enacting new mechanisms as needed.
About the European Institute of Women’s Health
Founded in 1996, the European Institute of Women’s Health (EIWH) is a non-governmental organisation (NGO) that uses an evidence-based approach to advocate for an equitable, sex- and gender-sensitive approach in health policy, research, promotion, treatment and care. The Institute promotes biomedical and socio-economic research that addresses sex and gender-based differences to ensure access to quality treatment and care for women across their life span.
Importance of Women’s Equality, Health and Wellbeing
The promotion of sex and gender equity has been a long-standing theme in the philosophy and operation of the EU. In line with Articles 160 and 168 of the Treaty on the Functioning of the European Union and the UN Sustainable Development Goals (SDGs), the European Institute of Women’s Health (EIWH) calls on the EU to commit to the reduction of health inequalities and provide equitable health for all.
Biological and social influences (sex and gender) are critical to health. Women face higher rates of some diseases than do men. Other diseases affect men and women differently. Women do not present the same for conditions and respond differently to treatment than do men. Many factors outside of the health sector such as socioeconomic status, education, culture and ethnicity also affect behaviour and resource access.i,ii,iii,iv Lack of resources or decision-making power, unfair work divisions and violence against women all impact health. These social determinants have large repercussions for health and access to healthcare. Strategies must account for these differences.
In Europe, women outlive men by on average more than five years, but their healthy life expectancy advantage is less than nine months.v Sex and gender have important implications for healthcare (health service delivery) and health systems (policies and organisation). Due to women’s reproductive role, their health can affect the health of their unborn child and so that of future generations. Women also play a vital role as healthcare professionals, caregivers, patients, mothers, daughters and friends, particularly in an ageing Europe. Healthcare and health systems should be highly responsive to women, but too often fail them. The link between income and health is well known. Well-being and economic policies are closely intertwined and mutually reinforcing. Economic growth improves people’s well-being, and a healthy population enhance economic growth and stability.
A comprehensive, inclusive Europe must prioritise women’s health. The UN’s Fourth World Conference adopted the Beijing Declaration in September 1995, committing to gender equality, women’s empowerment and social justice. 2020 marks twenty-five years since the Beijing Declaration and five years of the UN’s Social Development Goals (SDGs), yet large sex and gender inequities continue to persist and are now in danger of being heightened as a result of the coronavirus pandemic.
Europe must ensure health, well-being and gender equality are systematically and deliberately included in all policy areas as Europe works together in the short and longer term to rebuild, recover and restructure as a result of the COVID-19 pandemic.
Sex, Gender and the Coronavirus
The existing evidence indicates that sex, gender and age have implications for susceptibility to coronavirus as well as survival from it. Based on preliminary data, men appear to have a higher mortality rate from the coronavirus than do women, although there is cross-national variation.vi
One argument for the difference is that women’s immune response is stronger than men’s immune response; women have two X chromosomes, whereas men have only one, which could be important as a defence from the coronavirus at the cellular level.vii
Other behaviours that vary by sex and gender, like smoking, also appear to influence the risk of developing coronavirus.viii Pre-existing conditions—such as heart disease, chronic lung disease and cancer—which vary in men and women have a huge impact on the outcome from infections such as coronavirus.
Older adults and those with serious chronic medical conditions have increased vulnerability to the coronavirus.ix These susceptibilities are influenced by sex and gender.x Therefore, it is critical that COVID-19 responses incorporate sex and gender considerations from the outset.
The coronavirus also has implications for the treatment and care of women who are pregnant. According to European Centre for Disease Prevention and Control (ECDC), clinical manifestations in pregnant women can range from asymptomatic to mild; however, there have been reports of critical cases in countries like Sweden.xi At the moment, there is very little data and information on the role that COVID-19 plays in pregnancy. Pregnant women have changes in their bodies that may increase their risk of some infections. Studies of other diseases, such as SARS and influenza, have shown that pregnant women have higher rates of infection and have more severe outcomes when compared to women of the same age groups.xii
There are no conclusive findings on COVID-19 affecting the unborn baby, but the ECDC concludes that intrauterine transmission cannot be ruled out, citing emerging reports that suggest possible perinatal transmission. In previous non-COVID-19-specific studies, fever in the first trimester has been shown to have a possible teratogenic effect. In addition, neonates can be exposed to COVID-19 when passing through the birth canal or through postnatal exposure. xiii
As a result, caesarean delivery has been used as a precautionary measure in infected mothers. There is a paucity of evidence regarding transmission during breastfeeding. As pregnant women are considered a vulnerable and high-risk group for COVID-19, efforts must be also made to study the safety of immunising pregnant women against coronavirus during the vaccination development.
Impact on Women and their Families
School closures, quarantines, business closures and other responses to the pandemic will impact women and their families physically, financially and emotionally.xiv In addition, broader sex and gender considerations must be taken into account over the coming weeks and months as global efforts to contain the pandemic escalate. Women and their families are impacted disproportionately by the pandemic response measures and their long-term effects, which could compound existing inequities. Job losses are hitting women-dominated jobs severely. Public transport, a service on which women disproportionately rely, has been disrupted by the responses to the pandemic limiting their ability to access services, go shopping or work, as needed.xv
Many women in Europe have lower pay, often by having less secure and informal occupations. Women earn 16% less and receive pensions that are 40% lower than men.4 Recent studies show that women were a third more likely than men to be in a sector shut down by the pandemic closures, by working in sectors like retail and hospitality. Low income workers were seven times more likely to be affected by closures than high income workers.xvi Thus lower paid, younger people and women have been hit disproportionately harder by closures, exacerbating existing inequities.
Women across Europe have been on the front line of the coronavirus pandemic. Women are, in the main, providers of both informal and formal care. Women also comprise 70% of health and social care workers. The roles that women mainly play in society, particularly as health professionals and caregivers, puts them at increased risk for catching the coronavirus. Nurses and healthcare workers for example, have particularly high exposure to the virus during pandemics due to their intimate care with patients.xvii,xviii Women provide the majority of unpaid care giving, which will rise due to the pandemic as well as increase their exposure if they are caring for infected individuals.xix In addition, not all people, particularly women who provide essential care, are able to social distance. xx
School closures have particularly affected women as they are disproportionately responsible for childcare.xxi Single parent households, the majority of which are headed by women, poorer households and healthcare works have been under particular pressure to find suitable childcare.xxii School closures have had particularly large impacts on disadvantaged communities and vulnerable populations who may not have any or a reduced access to remote learning.xxiii
Responses to the pandemic, including isolation, have implications for mental health.xxiv The pandemic can effect other issues, such as, domestic violence and access to reproductive services.xxv,xxvi An estimated 9.8 million woman globally may encounter family planning access issues as a result of coronavirus disruptions.xxvii The United Nations has reported a surge in domestic violence, particularly affecting women and children, as a result of international lockdowns.xxviii
Equitably Structuring Pandemic Responses
The EU must increase funding for research and development.xxix Sex and gender analyses are important in understanding disease outbreaks and to structuring effective and equitable public health and policy responses. As such, sex, gender and age data must be collected on the disease as well as on the health and political system response to the pandemic. Rigorous and thorough data collection is essential for drawing accurate conclusions and thereby ensuring a health for all approach. Europe must ensure we sufficiently fund research and innovation for vaccines, treatment and care as well as protect not only the patients with coronavirus, but all of society.
It is essential that pandemic responses integrate sex, gender and age amongst other factors. Targeted efforts must be taken to protect the most vulnerable populations and reduce inequities. The coronavirus outbreak impacts on health systems and healthcare workers. The pandemic affects access to care for patients, particularly the most vulnerable. Concerted action must be taken to address wide-reaching issues stemming from the pandemic, including the development of effective and safe vaccines, shortages of essential medications and equipment as well as the rise of antimicrobial resistance.
Failure to address sex, gender, age and other diversity considerations in disease outbreaks can have large and lasting repercussions.xxx As a result, pandemic responses must incorporate sex and gender in their design from the onset in order to avoid exacerbating inequities and to promote health.
Disadvantaged women and other vulnerable groups must be explicitly targeted and health equality must be a priority in pandemic responses to ensure such gaps are not widened during a crisis.xxxi
During disease outbreaks, women can have less power and decision-making roles responsible for designing responses that can lead to their needs being insufficiently addressed.xxxii Power dynamics can exacerbate existing inequities during times of pandemics.xxxiii Experts have highlighted the importance of including women in disease outbreaks and the responses to these.xxxiv However women still remain under represented on many high level pandemic and simlar response groups.xxxv
Women, who are on the frontline of health as healthcare providers, caregivers and patients must be included in this current and indeed any future responses. Europe can and must do more to protect women, men and their families at this critical juncture for society. Women are essential leaders both during and after the coronavirus and similar critical health responses.xxxvi
Review, Revise, React
Steps for Action – Europe
This pandemic will have lasting short and long-term repercussions on health and social care systems as well as society as a whole. The incremental nature of policymaking processes and budgeting cycles are, by their very nature, out of sync with the rapid changes of healthcare and societal needs, especially as displayed during this current crisis.
We must employ a life-course approach to health that focuses on well-being and incorporates the impact of the social determinants of health. We all must work together now to get the long-term strategy right from the start, including the integration of sex and gender considerations. During the pandemic the public health community response efforts must employ a holistic approach that incorporates the engagement of communities at local level as well as women themselves.
COVID-19 has highlighted and exacerbated sex and gender inequities in societies across Europe and the world. The EU and all Member States must start now to take action to co-ordinate the building of the economic and social recovery by taking the following actions in light of the current COVID-19 pandemic:
Fostering Research and Innovation
Supporting Cross Border and Pandemic Preparedness
Promoting Health and Preventing Disease
Encouraging Gender Equity in Europe
Advancing Socio-Economic Equality through Targeted Policies
Championing Women’s Empowerment and Engagement
Fostering Research and Innovation
Data Collection: Analyse and factor biological, social, economic and environmental considerations into research and responses. Require the cross-national collection of data, disaggregated by sex, gender, and age. Ensure data is comprehensive and accurate as this is essential to understanding and combating health crises and their impact. Reexamine the Framework regulations on health statistics and other related activities in light of the results from the current epidemic.
EU Research: Ensure sex and gender considerations are prioritised from the design of the research protocols to the analysis of the results in all future European research funding, including the Horizon Europe and Horizon 2020 Research Programmes. Fund research that explores sex, gender, age and socioeconomic differences, including immunisation, and providing advice based on robust European data. Encourage research that explores the safety and effectiveness of vaccines during pregnancy and breastfeeding.
Clinical Trials Representation: Include women, children and older people in coronavirus responses, research, prevention and treatment. Implement the Clinical Trials Regulation (536/2014) to ensure that mistakes are not repeated with regard to the current and potential from future pandemics as historically women, older people and children have been systematically under represented in healthcare research.
Promote Diversity: Ensure diversity from the start in all research and innovation as health experts and scientists work towards understanding the current pandemic, combatting this as well as providing positive inputs to all potential future pandemics, with the development of health implementation strategies, treatments and vaccinations. Encourage a sex and gender balance across all national ethics committees. Ensure sex, gender and social considerations are fully factored into all future research policy.
Health Technology Assessment: Include sex and gender considerations into the proposed EU Health Technology Assessment Regulation. Promote and share different tests and methodologies available around COVID-19, including exploring anti-body testing, as part of the range of test strategies being considered.
Safe Pregnancy and Lactation: Study the safe use of medicines including vaccines during pregnancy and lactation in the development of new initiatives and health tools to combat infectious diseases.
Women Researchers and Entrepreneurs: Fund women led research and entrepreneurship. Close the gap in the under funding of female led businesses high-level researchers by promoting access to capital, mentoring resources, networking opportunities, educational supports and increased awareness.
Supporting Cross Border and Pandemic Preparedness
Cross Border Policy: Mobilise European health prevention policies, the Cross Border Healthcare Directive and the Joint Procurement Initiative. Strengthen collaboration and coordination amongst the Commission and EU Member States so that they have a solid base and common strategy for protecting all of Europe’s population from infectious diseases.
Pandemic Strategies: Develop comprehensive national and European strategies on trans national health issues. Revise national pandemic strategies to include sex, gender age and other related factors. Support community members, including but limited to emergency services but also include others such as food chain and shop workers, bin collectors and others who provide essential services.
Health Resources: Ensure there is an EU strategic stockpile of essential medical equipment through the Emergency Support Instrument, RescEU’s common stockpile and strategies for joint procurement during crises.
Personal Protective Equipment: Collaborate and coordinate with Member States to assess, obtain, and produce personal protective equipment, medications and other vital supplies across the EU. Create a system that tracks and anticipates needs in a timely fashion, as well as ensuring safety and common standards.
European Centre for Disease Control and Prevention: Improve the role of the ECDC in collecting and sharing consistent and comparable epidemiologic data, disaggregated by sex, gender and age. Make surveillance more visible and standardised.
Equality Reporting: Explicitly include analysis on the impact of the pandemic responses on gender equality in Europe in the EU Annual report on equality between women and men.
Communication and Engagement: Develop robust pro-active communication programmes to create a health- and vaccine-literate public that understands the benefit of vaccination, health promotion and disease prevention for protecting both individuals and society from infectious disease. Use the EU Council Recommendation on Strengthened co-operation against Vaccine Preventative Diseases to enhance coordination between Member States and the EU.
Promoting Health and Preventing Disease
Health Promotion: Continue and strengthen all efforts to promote health and well-being with a particular focus on health promotion, disease prevention across the lifespan, early intervention, vaccination and health literacy.
EU Instruments: Mobilise resources such as, the European Regional Development Fund, European Stability Mechanism, the European Social Fund and the Multi-Annual Financial Framework (MFF) to support health and social care systems to provide vital services as well as to promote health and well-being.
- Gender Mainstreaming: Prioritise sex and gender considerations in all European funding mechanisms, evaluations,assessments and support, including the 4th Public Health Programme 2021-2025. Ensure that the European Investment Fund expressly targets women adversely impacted by the pandemic.
Education: Support and protect essential health and social care professionals, who are disproportionately women, now and in future. Invest in the inclusion of sex and gender in training and education for health and social care professionals. Include essential service providers (e.g. shop workers and all emergency and essential services) in health education and training.
Addressing Challenges: Address current and future issues—such as drug resistance, medication shortages and socioeconomic inequities that may increase as a result of a pandemic. Use digital health to reduce inequities and empower patients to take control of their health and treatments.
EU-Wide Collaboration: Strengthen the use of EU Mandates on and co-ordination of health promotion, disease prevention and social solidarity. Increase investment in critical public health infrastructures to better manage pandemics and many other health threats. Implement the Sustainable Development Goals (SDGs) to ensure healthy lives, promote well-being and guarantee equity for all regardless of age.
Improving Access: Foster supports for all patients in both the short and long-term across Europe. Employ a holistic approach to health, incorporating mental health, moving forward as part of the common European response to the coronavirus outbreak. Make patient rights a central focus of European policy and programming. Enact Europe’s Beating Cancer Plan in order to reduce the cancer burden for patients, carers and their families. Reduce delays in care, access issues and shortages of treatment due to pandemics, so preventing the widening of any inequality gap.
Encouraging Gender Equity in Europe
Equitable Systems: Invest in equitable health and social care systems across Europe to better manage health outcomes and social stability in times of crises, taking steps to make sure that changes do not heighten inequities.
Gender Pay Gap: Economic recovery will be a vital aspect of the pandemic response. Enforce policies, including the Equal Treatment Directive (2006/54/EC), the Equal Pay Recommendation (2014/124/EU) and the European Pact for Gender Equality. Propose binding pay transparency measures by the end of 2020 In line with the Gender Equality Strategy 2020-2025 as gender policies have been shown to have a stronger impact on GDP growth than labour market and education policies.
Economic Support: Fund national supports that compensate for the lack of economic activity in certain sectors, including retail and specific food sectors, where female workers are dominant. Review and frame social policy through the European Semester.
Income Certainty: Ensure fair wages for all workers as set out in the European Pillar of Social Rights and guarantee all workers in Europe will have a minimum income during times of uncertainty.
Caregiving: Pass policies to support those providing essential care giving work, the majority of which is unpaid in Europe. Take steps to formalise the role and status of unpaid and low paid informal carers in line with the European Pillar of Social Rights, which has a strong focus on care, equal opportunities and labour market access.
Work Life Balance: Enact the Work Life Balance Directive for Parents and Carers (2019) in order to address women’s underrepresentation in the labour market as well as to support women as patients, employees and vital caregivers.
Health and Social Care Education: Actively involve all stakeholders in the process of development and implementation of new, cutting-edge curricula on women’s health, gender and diversity in order to connect the contemporary education to the future needs of women, minorities and all disadvantaged populations.
Advancing Socio-Economic Equality through Targeted Policies
Social Priorities: Support policies and programming addressing issues including domestic violence, mental health and family planning that may have been impacted as a consequence of the pandemic. Target the disproportionately affected populations to ensure that limited resources are used effectively. Promote the EU guidelines on violence against women and girls and the combating of all forms of discrimination.
Vulnerable Groups: Safeguard the vulnerable and marginalised groups who may have limited access to health and social care, including temporary and seasonal labour migrants, refugees, the homeless,disabled and those exposed to domestic violence who have been disproportionately affected by the crisis. Target pregnant women, older people, persons with pre-existing conditions and minors. Protect older people, accounting for older people’s needs during isolation, including maintaining social interaction, good mental health and access to medicines, in policy planning and responses.
Childcare: Aid Member States enacting the Council Recommendation on high-quality early childhood education and care systems (2019). The Pandemic has highlighted the need for proper childcare policies to be in place to support essential health and social care workers on the frontline against the pandemic. Propose the European Child Guarantee in 2020 in order to ensure that children have access to basic services.
Gender Reporting: Commission an EU Parliament cross-committee own initiative report to explore the short and long-term health and social issues of the coronavirus pandemic from a sex and gender perspective. Promote equitable outcomes in responses through multisectoral and interdisciplinary collaboration instead of through silo responses.
Comprehensive Programming: Encourage diversity and collaboration in the development of all policy and programming responses. Bring together European researchers, policymakers, patients, caregivers, healthcare professionals and other relevant stakeholders in order to develop equitable, effective, efficient and creative responses to the coronavirus pandemic. Account not only for health issues but also broader socio economic considerations. Target education, housing, technology, violence, social and other policies that are vital in long term responses to the coronavirus.
Universal Coverage: Strengthen health systems for universal health coverage that provides access regardless of age, sex, socio-economic background, culture and ethnicity. Tackle the inequalities highlighted and heightened by the pandemic in disadvantaged populations Implement Goal 3, Target 3.8 of the Sustainable Development Goals on universal health coverage, which stresses the importance of all people and communities having access to quality health services based on health need and not the ability to pay.
Women’s Health Prioritisation: Establish and support an EU Parliament Interest Group on Women’s Health. Guarantee that equity underpins health and healthcare. Tailor for better outcomes for both women and men rather than the “one-size fits all” approach. Invest in women’s health and wellbeing today in order to not only combat inequities, but also to lay a strong foundation as the health and equity of women affects that of future generations. Ensure a comprehensive strategy to support women’s health by working across policy areas, including social factors.
Championing Women’s Empowerment and Engagement
Equality Prioritisation: Enact the Gender Equality Strategy 2020-2025 and explicitly target equality in decision making in policy and programming, as economic recovery will be a vital outcome of the pandemic response.
Women on Boards: Pass the Women on Company Boards Directive to ensure that women are represented in key decision-making positions.
Women in Policymaking: Engage and involve women throughout policymaking processes and foster gender balance in decision making.
Female Leadership: Include women in high level decision making positions for pandemic responses and innovations. Foster diversity in order to effectively, efficiently and equitably address the pandemic in the short and long-term.
Women in STEM: Close the gender gap in STEM (Science, Technology, Engineering, and Mathematics) in order to increase female labour participation, improve health through diversity and raise the European GDP. Tailor programming to encourage and support women’s participation in STEM.
Women and Sustainability: Promote gender equality as its essential for our society to ensure sustainable development. Support NGOs and women’s organisations that foster the empowerment of women across their lifespan and whose aim is to eliminate inequalities and discrimination.
Community Involvement: Employ a community lens to coronavirus responses and recovery activities. Engage key stakeholders such as government officials, regulatory agencies, academic institutions, NGOs, industry professionals, healthcare providers and women themselves in policy and programmes. Enlist social scientists, epidemiologists, experts in logistics, psychologists, and social workers to promote local engagement.
Additional Resource Inputs
- World Health Organization (WHO) Situation Reports: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports
- European Centre for Disease Prevention and Control (ECDC) Situation
- ECDC micro-learning course on COVID-19: https://www.ecdc.europa.eu/en/news-events/online-micro-learning-activities-on-COVID-19
- European Commission Coronavirus Response: https://ec.europa.eu/info/live-work-travel-eu/health/coronavirus-response_en
- European Medicines Agency (EMA) guidance to stakeholders on adaptations to the regulatory framework to address challenges arising from the pandemic: https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/coronavirus-disease-covid-19
- EMA COVID-19 EMA Pandemic Task Force (COVID-ETF): https://www.ema.europa.eu/en/news/ema-establishes-task-force-take-quick-coordinated-regulatory-action-related-covid-19-medicines
- The European Commission, European Medicines Agency (EMA) and the European Medicines Regulatory Network: https://www.ema.europa.eu/en/glossary/european-medicines-regulatory-network
- Johns Hopkins University COVID-19 Global Dashboard: https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
- Health System Response Monitor (HSRM): https://www.covid19healthsystem.org/mainpage.aspx
All references were tested as correct at time of completion.
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