The popular belief is that women are far less likely to be affected by covid-19. But mounting evidence points to the hidden toll that covid-19 could be taking on women in India.When the results of the second round of Delhi’s SARS-CoV2 sero-prevalence survey were released last week, one finding stood out: the prevalence of infections was higher among women than among men. This is not the first sero-survey to have found this. The Mumbai and Ahmedabad sero-surveys had similar findings, the magnitude of the gap being higher in Mumbai. The Pune sero-survey did not find such a gap.The reason this finding is unusual is because in terms of officially counted cases - persons confirmed as covid-positive after an RT-PCR or antigen test - women trail men significantly.“I don’t think we expected this,” said Ullas Kolthur-Seetharam, one of the two scientists from the Tata Institute for Fundamental Research who led the Mumbai sero-survey. “This could be because of the gender differences in social interactions, with women typically going out for household needs, to buy stuff from the market, and intermingling more with others.” The other possible explanation was that there could be an underlying biological explanation, Kolthur-Seetharam said.The question then becomes - are we seeing fewer women in the official case counts because fewer women are being tested, or because fewer women develop serious enough symptoms to warrant testing? The evidence thus far suggests that both might be true.In May, the Indian Council for Medical Research published its analysis of over one million diagnostic tests for covid-19 conducted between January 22 and April 30. They found that while men made up the majority of positive cases, women were slightly more likely to test positive than they were to be tested.This is consistent with older evidence that women are less likely to access healthcare. Economist Mudit Kapoor, now associate professor of economics at the Indian Statistical Institute Delhi (ISI-D), and others looked at data on all out-patient department (OPD) visits in 2016, excluding those for gynaecology and obstetrics - over 2.3 million in all. They found a large difference in the likelihood of men and women coming to the OPD. For every visit by a woman, 1.7 men visited.It’s also possible that women are less likely to develop serious forms of the disease, particularly since men outnumber women in terms of total recorded cases in all large countries globally. This issue has not been well examined in India so far.The consensus that women are less likely to contract severe forms of the disease also stems from the fact that fewer women than men have died of covid in India and worldwide.However, there is some evidence now that the risk of dying might not actually be lower for women in India. While international evidence points to potential biological advantages for women, this could be blunted by gender disadvantages women in India face, resulting in a higher risk of mortality in India. In a paper published in June in the peer reviewed Journal of Global Health Science, a team of researchers led by S V Subramanian, Professor of Population Health and Geography at Harvard University, William Joe, Assistant Professor at the Population Research Centre, Institute of Economic Growth, Delhi and others found that the risk of dying - ratio of deaths to recorded cases - was higher among women than among men.“There can be various underlying factors for such patterns in India,” the researchers said in an email. “Men suffer from several lifestyle risk factors. But at the same time a large proportion of women in India have poor nutritional status. This includes both underweight and overweight prevalence as well as micronutrient deficiencies.”Additionally, access to healthcare may be different across genders, the researchers suggested. “Among other factors, the circumstances of health care access and affordability are also important issues which are shaped by contextual factors such as household socioeconomic status and gender roles. However, it will be important to obtain quality data to verify these concerns,” they said.Additionally, there is the concern that women are less likely to be accurately counted in death statistics in ‘normal’ times. As of 2018, women made up just 40% of total registered deaths and just 38% of medically certified deaths , data from the office of the Registrar General of India shows. Women made up 47% of all deaths in 2016, according to estimates from the Global Burden of Disease study, suggesting that the ratio of missing women in official death counts is significant. Even if the high focus on covid keeps accurate medical certification high during the pandemic, the risk of women getting left out remains elevated.Ultimately, this isn’t just a question of statistics. Recent research has pointed to the likelihood of even asymptomatic patients or those with mild forms of the disease contracting lung and heart conditions, Giridhar Babu, epidemiologist with the Public Health Foundation of India, pointed out.In one German study, whose findings have been echoed by several others, scans revealed that a majority of patients continued to show heart inflammation well after being declared recovered, even if they had been asymptomatic throughout. Other studies have shown how lung damage in asymptomatic patients continued well after they started to test negative.Getting left out of India’s covid count could have very real consequences for women’s health.Rukmini S. is a Chennai-based journalist.