We are all in the same storm, but we are not all in the same boat

In memory of Dr Lorna Breen, Emergency Physician and ER Medical Director, 

New York Presbyterian Allen Hospital

Gender-based considerations apply in the current COVID-19 pandemic just as they do in other times.  Despite the worldwide support for healthcare workers, the burden of inequity remains. 

Data from past global outbreaks highlights the importance of incorporating gender analysis into preparedness and response efforts, in order to improve the effectiveness of future health interventions and to promote gender and health equity goals. For example, during the West African Ebola outbreak of Ebola, gendered norms meant that more women were infected by the virus due to their predominant roles as caregivers within families and as front-line health-care workers. 

Many female emergency doctors suffer the “double jeopardy” of having more than one factor for potential discrimination in addition to their gender, be it race, sexuality or family status. These considerations will affect other individuals and groups who are not female but belong to minority groups, have health considerations or have caring responsibilities or home situations which lead to disadvantage.   

There are many ways in which COVID-19 has the potential to disadvantage women and halt, or potentially reverse, the progression of gender equality. The four listed below are particularly relevant to women in the Emergency Medicine workforce.

PPE

PPE should be designed to fit a variety of body shapes, but it doesn’t. When putting it on, the ideal shape would appear to be that of a front row rugby player - 190cm high, 100+kg in weight. There are few females who can match that description!  Recognising gender-based differences in PPE fit (as noted with face shields and masks) and acquiring a range of sizes is of paramount importance. In addition, women who are breastfeeding or menstruating will need additional breaks and may use more PPE.

Training Delays

Many trainees will be impacted by delays in training progression due to COVID-19. This has resulted in anxiety, frustration and additional stress to trainees and their support networks. The impact on external rotations, 4-10 regulation requirements, primary and fellowship exams, as well as the subsequent training delay for women in the context of pregnancy, planning pregnancy and fertility treatment, requires particular attention. Care is required to protect their well-being and the professional progression of those affected. Pregnant trainees should be reallocated to lower-risk duties without adversely affecting their training. Disruption and distress for all trainees should be kept to a minimum.

Leadership Opportunities

During COVID-19, leadership opportunities are arising and being filled at a greater rate than usual.  However this can lead to positions not being filled in an equitable and transparent manner, despite research demonstrating a positive relationship between leadership diversity and improved performance. Women are susceptible to the “Leaky Pipeline”and “Glass Cliff” phenomena. The ‘“leaky pipeline” occurs when some women progress through to lower level leadership positions, yet suffer a disproportionate drop-out rate along the way due to various obstacles. The "glass cliff" applies to female leaders who are more likely to be promoted into positions of power during crises, when failure is more likely. Reasons cited for both of these phenomena include reduced access to mentoring opportunities and role models, isolation, a lack of managerial support, lack of recognition, and decreased access to resources such as personnel and space.  High levels of transparency in appointment processes, as well as maintenance of diversity in appointments, must not be compromised by a requirement for efficiency. Let’s relegate the shoulder tap to the garbage bin of the past, where it belongs.

Overload at home and at work

School closures, daycare closures and home isolation move the household work away from the paid economy.  Traditional caring roles and domestic duties may disproportionately fall to women based on historical norms within the home. These can be both time-consuming and physically arduous, and detract from the ability to perform paid work. Whilst the number of hours performing unpaid household work at home has increased for both men and women during the pandemic, it is estimated that ⅔ of that increase is shouldered by women.  Likewise, the cognitive load of managing a family mainly falls to women, and continues to do so during the pandemic. There is great need for continued workplace flexibility during the COVID-19 pandemic, for all genders.

It seems inevitable that the only way many households will be able to manage their caring responsibilities is by reducing their paid work. This will be a financial hit not only for them but for the wider economy. The closure of child-care centres will be especially tough on working mothers.

Whilst many of these unpaid child-care roles have been traditionally overlooked by our governments, the pandemic has placed a spotlight on the number of females in “essential services”, for example, medicine, nursing, allied health, teaching and childcare. This position at the front line places them at risk, and to date in Australia the virus has been most commonly diagnosed amongst females aged between 20  – 29. It has been noted that male-dominated professions have received additional federal governmental support whereas female dominated professions such as childcare have not.  In New Zealand's June quarter, of the 11 000 people who lost jobs, 10 000 were female. 

The heightened anxiety and stress of the varied pressures to which this pandemic has contributed can cause an increase in both mental health issues and domestic and family violence for health care workers, their family members and the wider community.  Females are more likely to experience domestic and family violence. Women are also more vulnerable to the moral injury associated with caring for families and patients. There is a known increased risk of suicide in female doctors and medical students that requires recognition, attention, support and resources.

Let’s acknowledge this now - we are not all in the same boat as the COVID storm continues. This is an opportunity to listen, review and mindfully act. To use the privilege we have to challenge and to create change, so next time the storm hits the boats are robust and equitable. 

References

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10. Templeton, K., et al. (2019). Gender-based differences in burnout: issues faced by women physicians. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington DC.https://doi.org/10.31478/201905a

11. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020). COVID-19 Statements and Guidelines: information for pregnant women. [online] Available athttps://ranzcog.edu.au/statements-guidelines/covid-19-statement/information-for-pregnant-women[accessed 13 May 2020].

12. Wood, D., Griffiths, K., and Emslie, O., (2020) Victoria’s child-care shutdown is a hard blow for working mothers. The Conversation. [online] Available at https://theconversation.com/victorias-child-care-shutdown-is-a-hard-blow-for-working-mothers-143837

13. Savage, M. (2020) How Covid-19 is changing women’s lives. BBC Worklife. [online] Available at https://www.bbc.com/worklife/article/20200630-how-covid-19-is-changing-womens-lives

14. Vergara, M. (2020) 11,000 New Zealanders have lost their jobs – and 10,000 of them were women. The Spinoff. [online] Available at https://thespinoff.co.nz/business/05-08-2020/11000-new-zealanders-have-lost-their-jobs-and-10000-of-them-were-women/