Wednesday, July 15, 2020

Women Good, Men Bad - Or Bad Science?

The picture above shows the presidents of two countries with outstanding COVID-19 responses - but outstanding in very different ways.

Taiwan's president Tsai Ing-wen led what can be characterized as the most successful response of all countries, keeping the total number of deaths in Taiwan limited to seven.

In contrast, Donald Trump's efforts have led to world-wide "leadership" of the USA in infection measures: the highest number of confirmed cases (3.6 million); the highest number of COVID-19 deaths (close to 140,000); and the highest number of new daily cases. The COVID-19 death rate per million inhabitants is about 1,400 times higher than the death rate in the US; only six countries in the world with a population of at least one million have a higher death rate, but the US is rapidly catching up.

So - can we conclude that women are better at leading countries than men? That seems a bit hasty, looking at just two examples. But what if we add a few more pictures? Italy, Spain, and the UK had very high COVID-19 case numbers and deaths, and all were led by men. In contrast, New Zealand did very well, and it's led by a woman. Similar arguments can be made for Germany, Iceland, and a few other countries. And indeed, composite pictures showing the "good" female leaders and the "bad" male leaders have become popular on Facebook, and even made it into articles on relatively conservative journals.

These images are convincing. I am a German-American, and I desperately wish that the US would mount a COVID-19 response similar to Germany's. If a female scientist like Angela Merkel, rather than a misogynistic reality TV star, would be leading the US, that would make me insanely happy.

But I have also looked at how different countries have handled COVID-19 way too much to just "buy" a simple explanation that "women are better". While Germany has done reasonably well when compared to Italy and France, it has not done great. Neighboring Austria, which share the same language and a very similar culture, has done better: the COVID-19 death rate (normalized to population size) is about one fourth lower, even though Austria is closer to Italy, and home of at least on of the initial "hot spots" in Europe. Austria's chancellor is male.

But even Austria has done poorly compare to some other countries that are also led by men. Singapore, for example, did extremely well in the initial response to COVID-19, and still reports a 20-fold lower death rate than Germany (and an 80-fold lower death rate than the US). Australia's response was a bit delayed, but still timely and effective, with very similar results. Greece had an outstanding response in the European Union, with a death rate that is about 30-fold lower than Italy's. All these countries have male leaders.

A quick visit to Worldometers will also show that the country with the highest COVID-19 death rate in the world is Belgium, with 844 COVID-19 deaths per million (if we ignore San Marino, with a population of less than 34,000). The Prime Minister of Belgium is female. In all fairness, Belgium does a better job at reporting COVID-19 deaths in nursing homes than many neighboring countries, but even taking this into account, the COVID-19 death rate would still be similar to the rates of other heavily affected countries like France, Italy, Spain, and the UK.

Now we come to the "Bad Science" part of the post. I am referring to a preprint titled "Women in power: Female leadership and public health outcomes during the COVID-19 pandemic".  As a preprint, this paper has not yet gone through the rigorous "peer review" process, where experts in the field look critically at the science - and this shows. However, you need to look closely before the weaknesses become clear.

The first warning signs come from the author list. The 12 authors come from a variety of institutions in different countries. The affiliations listed include "Department of Political Science", "European Environment Agency", "Environmental Planning and Climate Protection Department", "Institutes of Earth Sciences and Sustainable Development Studies", "Crawford School of Public Policy", and "Natural Capitalism Solutions". But let's put that aside and look a bit at the science.

The authors looked at 35 countries with a mix of male and female leaders, and a number of COVID-19 related measures that appear reasonable. They defined a number of criteria for inclusion, like a democratic regime (except for China) and minimum income levels. But things get "interesting" when the authors classify the countries. They write:
"Of  the  35  countries  considered,  10  have  a  woman-led  government  (Belgium, Denmark, Estonia, Finland, Germany, Greece, Iceland, New Zealand, Norway and Taiwan)"
There are two mistakes in this list:
Both of these countries have done well, but the government leaders are male (Germany, which is correctly included in the "female led" list, has a male president, who is also "mainly ceremonial").

This is a significant error, since it puts two countries with very good COVID-19 responses into the wrong category.

Another red flag is raised by the following statement in the preprint:
"We excluded countries with no lockdown or with only sub-national lockdowns in place to ensure consistency across countries."
But the list of countries used includes the USA, where a number of states never issued "stay at home" orders, as well as Sweden, which chose a "herd immunity" strategy and never issued a country-wide lockdown, and Taiwan, where a lockdown was never necessary. These are two countries that increase the numbers in the "male leader" category, and one country that decreases the numbers in the "female leader" category. I am not arguing that these countries should (or should not) be included - but a basic requirement for a scientific publication is that it describes what has been done. This is clearly not the case here.

Things become even more questionable when we look at two countries that the authors have excluded: Thailand and Sri Lanka. Both countries have done extremely well in containing COVID-19, and both have male leaders. The authors gave as justification that these two countries were "without a distinct peak in daily deaths over the study period". But that seems to be a highly questionable justification, especially if we compare the death curves for Taiwan (which was included in the "female" category) and Thailand (which was excluded from the "male" category:

Thailand does show a cluster of 1-4 daily deaths from the end of March to the middle of April.
Taiwan had even fewer death, with one day of two deaths.

Including Taiwan, but excluding Thailand, Sri Lanka, and Singapore would seem like an arbitrary decision, if not for the effect on the results: the exclusions make the "female lead" results look better. This very much looks like intentional data massaging. That's not science, that's politics.

The intentional bias becomes even more obvious when we look at sentences like this one from the preprint:
"Female-led countries reported 1,983 (± 2,724; 95% CI) deaths, while men-led countries 13,276 (± 9,848; 95% CI), by considering average values"
The primary reason for the difference? The "men-led" countries have larger populations! When taking the differences in population size into account, the differences mostly disappear. The authors write:
"When we normalize the data per population, we find that countries led by women had 1.6-times fewer deaths per capita than their male-dominated counterparts"
That's only a factor of 1.6. But to get this low factor, the authors had to manipulate the countries in the lists, as explained above! If we correctly place Greece and Estonia in the "men-led" categories, and add countries that have done extremely well in fighting COVID-19, but were excluded by the authors, the differences become a lot smaller: a factor of 1.27. This drops to 1.23 if we omit the US because there never was a nation-wide lockdown.

For illustration, let's look at a graph that shows the death rates:
Countries led by women are shown as red bars. Note that the x-axis is logarithmic, which is better suited for the huge observed differences in death rates. Sri Lanka and Thailand, the countries the authors chose to omit, are high-lighted.

The differences between countries in the "women-led" category are more then 2,800-fold; in the "men-led" category, the differences are more than 1,200 fold.  The differences between the sexes, on average? Just 1.2-fold. Perhaps the sex of the leader does play a role - but if so, that's a thousand-fold less important than other differences in how countries responded to COVID-19.

It appears that the authors of the preprint distort and misrepresent data to fit their pre-conceived conclusion that "female leaders are better". This behavior is at least close to scientific misconduct. It may give the authors a few moments of fame when this is picked up by media, but the long-term effect on science can only be detrimental. A lot can be learned from countries that have kept COVID-19 transmissions low, like Taiwan, Sri Lanka, and New Zealand. Focusing on the sex of the country's leader only distracts from learning what really works - like face masks, which were very much at the center of Taiwan's efforts to minimize COVID-19 deaths.

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