Editor's note: In the past, Brief19 has covered the substantial differences in covid-19 outcomes by race, gender, and age. A new research paper explores these issues further. We invited the authors of the study to file the following guest briefing. 

Inequities in covid-19 outcomes in the United States have been clearly documented for sex and race: men are dying at higher rates than women, and Black people are dying at higher rates than White people. Unexplored, however, is how sex and race interact in covid-19 outcomes. 

Our new paper, published in the Journal of General Internal Medicine based on work at the GenderSci Lab at Harvard University shows that Black women are dying from covid-19 at significantly higher rates than White men, and that disparities in mortality rates among women of all races are greater than those between White women and White men. These findings complicate the simple narrative that men are dying of covid-19 at greater rates than women.

Our study is the first to our knowledge to quantify the imbalance in covid-19 mortality looking at both race and sex simultaneously. We used US Census Bureau data and publicly available data from Michigan and Georgia (the only two states that currently report the relevant statistics by age, race, and sex) to calculate and compare covid-19 mortality rates. Key findings of the study include:  

• Black women have covid-19 mortality rates that are nearly four times higher than White men, three times higher than Asian men, and higher than White and Asian women.
• Black men have far higher covid-19 mortality rates than any other sex and racial group, including over six times higher than the rate among White men. 
• The disparity in mortality rates between Black women and White women is over three times greater than the disparity between White men and White women. 
• The disparity between Black men and Black women is larger than the disparity between White men and White women.

While, overall, men have higher covid-19 mortality rates than women, our paper shows that this sex disparity does not hold across racial groups. These findings demonstrate the limitations of uni-dimensional reporting and analyses and highlight the ways that race and gender have intersected to shape covid-19 outcomes. 

It is well understood that racism and social inequities, rather than genetics, are responsible for racial disparities in covid-19 mortality. However, some researchers and other commentators continue to focus on differences in biology in an effort to explain the sex disparity in covid-19 mortality. Our paper's findings challenge a sole focus on biology as an explanation for sex differences in covid-19 mortality and argue that societal factors related to gender, combined with racism and socioeconomic stratification, are important explanatory factors. 

Last week Houston Methodist Hospital made headlines by becoming the first major hospital system to require its twenty six thousand employees to receive their first SARS-CoV-2 vaccination or obtain a waiver by mid-April. The announcement cited the need for a major healthcare center to lead by example, especially since some healthcare entities are waiting until the US Food and Drug Administration (FDA) grants its full approval to the vaccines (rather than Emergency Use Authorization, currently granted to the Moderna, Pfizer/BioNtech, and Johnson & Johnson options) before issuing such a mandate.

Eclipsing this in scope, and announced in the same week, Italy issued a national mandate on April 1^st, declaring that all healthcare workers must promptly begin the vaccination process, becoming the first European nation to do so. Unlike the surprisingly high percentage of healthcare workers in the United States who have not pursued a vaccine (though fortunately this number has been dropping over time), Italian authorities estimate that just one in ten thousand of their healthcare workers has refused coronavirus vaccination so far.

Such requirements raise interesting ethical questions. The National Bioethics Committee in Italy generally supports voluntary measures but also notes that accepting mandates under special circumstances may be necessary. In this case, it called vaccination "an ethical obligation for health professionals." 

In addition, the constitutionality of the vaccine mandate in Italy has been called into question and experts anticipate that there will be legal challenges. While there is precedent in the United States for vaccine mandates, court decisions abroad could provide a preview of the road ahead in the United States, once the FDA issues full approval for the vaccines. Various.