Medical Woman – Vol 39. Issue 2 – Spring/Summer 2021

W EDICAL W MAN

VOLUME 40: ISSUE 1

SPRING/SUMMER 2021

The Digital Issue www.medicalwomensfederation.org.uk

Editor’s Letter To starting again…

D

espite the cycles of uncertainty that have come with the pandemic, the lockdowns, halts in life, and everyday frustrations, we have found silver linings. There has been

time for reflection, allowing shedding of an old skin which has brought with it growth, as well as an optimism for the future.

Medical Woman magazine has metamorphosed over the years, the current edition launches the digital only version.

In this issue, we are looking to the future with the advances female entrepreneurs bring and the rise of health technology.

We feature a Career Planning article from a radiologist,

as well as articles on failure and loss. Global health is a recurrent theme through this issue and we hear from Clarissa Fabre about work-life balance in relation to the pandemic, as well as insights from Nigeria during this time.

The Digital Issue houses several articles on women’s health, including on domestic abuse, period poverty, and infertility - all student contributions. In this issue we also feature an up-date on the gender pay gap, as well as our Unwind article and Sarah Matthews’ reviews the book Light Perpetual.

I hope you enjoy this wonderful issue and look forward to seeing you - virtually - at our next conference.

Fizzah Ali @DrFizzah Fizzahali.editoratmwf@gmail.com

Contents Medical Woman, membership magazine of the Medical Women’s Federation Editor-in-Chief: Dr Fizzah Ali fizzahali.editoratmwf@gmail.com Editorial Assistants: Miss Katie Aldridge Miss Danielle Nwadinobi Design & Production: Toni Barrington The Magazine Production Company www.magazineproduction.com Cover illustration: Pexels Articles published in Medical Woman reflect the opinions of the authors and not necessarily those represented by the Medical Women’s Federation.

Medical Women’s Federation Tavistock House North, Tavistock Square, London WC1H 9HX Tel: 020 7387 7765 E-mail: admin@medicalwomensfederation.org.uk www.medicalwomensfederation.org.uk @medicalwomenuk www.facebook.com/MedWomen Registered charity: 261820 Patron: HRH The Duchess of Gloucester GCVO President: Professor Neena Modi

News and Events

2

Skills Toolkit: Learning to fail 8

Feature: Light in the Dark

10

19 The Journey to MobiHealth

12

A Digital Future

16

Women’s Health

18

Domestic Abuse

18

Period Poverty

20

Pre-menstrual Dysmorphic Disorder

22

Global Health: the Forgotten Side of Fertility

24

Pandemic: the Nigerian Perspective

28

Spotlight: Mend the Gap

30

Unwind: Therapeutic Writing

33

Blog: On Loss

34

Book Review

35

President-Elect: Professor Chloe Orkin Vice-President: Dr Nuthana Prathivadi Bhanyankaram Honorary Secretary: Dr Anthea Mowat Honorary Treasurer: Dr Heidi Mounsey

20

24

28

33

Medical Woman: © All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the prior written consent of the Publisher. A reprint service is available. Great care is taken to ensure accuracy in the preparation of this publication, but Medical Woman cannot be held responsible for its content. The views expressed are those of the contributors and not necessarily those of the Publisher.

Medical Woman | Spring/Summer 2021 1

MWF NEWS & EVENTS

Highlights from the International Women’s Day Webinar: Pearls of Wisdom from Medical Women On 8th March 2021, we hosted our IWD webinar, titled ‘Pearls of Wisdom from Medical Women’, with the speakers being current MWF President Professor Neena Modi, Immediate Past President Professor Henrietta Bowden-Jones OBE, previous MWF President Dr Fiona Cornish and the current MWF East of England Representative Dr Angharad Ruttley. Each speaker shared their experiences of how they became involved with the MWF as well as sharing top tips for becoming successful in the medical profession.

This was then followed by a Q&A session where the audience asked some interesting and thought-provoking questions, where we discussed themes such as career challenges, emotional vulnerability in the workplace as well as how COVID has changed the landscape of the NHS and what this means for women.

Professor Bowden-Jones OBE emphasised the significance of networking on an international level, belonging to international organisations, choosing and publishing in a niche of interest as well as not being afraid to speak out and take opportunities as they come.

Professor Modi highlighted that as the MWF, we should be speaking not about women’s issues but as women on issues important to all of society. She also discussed the importance of being true to yourself and deciding what you want to do, and not letting others make that decision for you.

Dr Cornish discussed the importance of a healthy worklife balance and ensuring that you maintain a well-rounded personality by having friends outside of the medical world as well as building a good rapport with your colleagues and patients in order to become a better doctor.

Dr Ruttley stressed the relevance of understanding your finances, particularly your pay scale, pension and gender pay gap. She also highlighted that you should choose your partner wisely and discuss how your family will work before you have children.

Overall, the event was a success with over 100 delegates signing up and attending the webinar. I would also like to provide my utmost thanks to the four fabulous speakers for their inspirational ‘Pearls of Wisdom’ as well as to Danielle and Katie for managing the technical and logistical aspect of the webinar. I hope this marks the beginning of an annual tradition of IWD webinars.

I look forward to seeing you all at the upcoming Spring Conference.

Kethaki Prathivadi Bhayankaram, MWF Medical Student Representative for Cambridge University and IWD Webinar Organiser 2 Medical Woman | Spring/Summer 2021

St George’s University report

This is my first year as student representative for St George’s University and it’s been a very exciting process engaging students with the MWF within my university as well as establishing an official MWF society. I was drawn to the MWF initially by a conference I attended in January 2020 where three sets of speakers as well as an MWF representative spoke. I immediately felt inspired being surrounded by a group of such diverse and successful women each with a different, yet equally important message to deliver about women in medicine. I left the event feeling sure that this organisation was something I aspired to be a part of. At the start of 2021, myself and five other women founded the MWF society within our university - a fantastic achievement for us. As part of this process, I had to gauge and present to our student union who would potentially be interested in the society, and it was evident that many students were keen to be involved and engaged in the work of the MWF. As part of this application, I had to really reflect on why I wanted to establish this group and present this. My overriding feeling is that is absolutely paramount to have women standing together and striving for equality within this system.

On the 22nd of March 2021, we hosted our first event with Dr Jenny Vaughan – regional MWF representative for London and consultant neurologist. This was a tremendous first event in which Jenny spoke passionately about “the art of the impossible”. She talked about her personal involvement as a lead campaigner against the high-profile conviction and persecution of Dr David Sellu, as well as her involvement in the renowned Dr Hadiza Bawa-Garba case, and how detrimental blame culture can be. She discussed how also within her extensive work as a campaigner, it was apparent race and racial issues seem to factor into these persecutions against doctors. Listening to a woman who has been so actively involved in such pivotal cases, raising many issues surrounding blame culture, conviction and pressures doctors face, was extremely inspiring. The talk generated many questions from the students and some extremely positive feedback. Overall, the event was a great success and was the perfect start in ensuring we made our mark.

Tay Rockett, MWF Medical Student Representative for St Georges, University of London

NEWS AND EVENTS: MWIA

Work Life Balance: in and out of Covid Clarissa Fabre is a past president of the Medical Women’s Federation (2010-2012) and of the Medical Women’s International Association (MWIA) in 2019. She was the MWIA representative to WHO (2012-2019) and has just been elected as one of the two health representatives on the UK Women’s Equality Party Policy Committee (2021).

This is part of a talk she gave in February 2021 at a MWIA webinar arranged by the Work-Life Balance Special Interest Group, led by Dr Helen Goodyear (UK), Dr Yoshiko Maeda (Japan) and Dr Dabota Buowari (Nigeria).

A recent UK Government ‘STAY HOME. SAVE LIVES.’ social media advertisement was scrapped after a public outcry. It showed four little houses depicting a man, woman and child sitting on a sofa; a woman ironing; a woman home-schooling; and a woman cleaning.

The impression was that the Government thought women should be time-travelled back to the 1950s. Boris Johnson disowned the advertisement, saying that it did not reflect the Government’s view on women. However, the irony is that it accurately reflected the

reality: the primary responsibility for domestic care and organisation, and in particular childcare, falls on women, both before lockdown and exacerbated by lockdown.

With the pandemic there has been much more pressure on women with home-schooling, housework and childcare. Women have been more likely to lose their jobs; alcohol and drug abuse have increased in both men and women; and there has been a rise in domestic and sexual violence. Many women are locked in with their abusers. Vulnerable children have become ‘invisible’, with no outside oversight from teachers, health workers, social workers etc. Data from the World Health Organisation (WHO) suggests that many women around the world have lost access to contraception, Medical Woman | Spring/Summer 2021 3

NEWS AND EVENTS: MWIA and consequently there are more unintended pregnancies and an increase in sexually transmitted diseases (STDs).

Looking at the impact of Covid on women physicians, an editorial in The Journal of the American Medical Association (JAMA) by Dr Linda Brubaker in 2020 made some interesting observations.1 There have been unprecedented changes in working hours (too much or too little) and in types of work, for example being moved to intensive care or the emergency room.

When faced with serious overwork, allowing doctors to reduce their hours or cut down leadership responsibilities may be seen as helpful, and it often is. However, when these adjustments disproportionately fall on women doctors, they stigmatise women and derail career progression.

Academic physicians have additional challenges and opportunities related to the pandemic. There may be restrictions on research activities as well as new research opportunities, including the availability of significant research funding. Disproportionate adjustments made in work hours by women academics may result in fewer women accessing the Covid-19 related research opportunities that can facilitate career progression.

Well-meaning individuals, both men and women, make decisions with the intention of ‘protecting’ a woman doctor. For example, consider a high-achieving, ambitious woman who has just added a third child to the family. Rather than asking whether she would like to take on an available leadership role, she may be passed over because of the perception that she has a ‘lot on her plate’. Would this consideration be expected to be raised equally with men and women? It seems unlikely.

Many women physicians have turned to a rather unusual form of support, the Physician Mother’s Facebook Group or PMG. This was established in 2014 and now comprises 71,000 physician mothers from around the world. It provides support and advice, and not only in relation to motherhood. PMGs have become even more important with the pressures of the pandemic and have proved a lifeline for many doctors.

A survey was conducted by a United States PMG in April/May 2020. 50% of mothers said their biggest personal concern during the pandemic was that they would expose their children to Covid19. 50% of the respondents worked in areas with a high density of Covid-19 cases, and 55% modified their work schedules to provide telehealth consultations. 38% worked from home. Just 25% of mothers did not change their work schedule. 12% of the respondents voluntarily increased their hours, while 6% were required to do so. Eight of the top ten concerns of women doctors were about their co-workers and staff (morale, mental health, disrupted medical student training, short and long-term consequences for those in academic medicine).2 It is clear that Covid has placed an additional burden on women, and has further restricted the time they can put into their careers.

As Boris Johnson has said, ‘Covid has given us an opportunity to stop, take stock and see if we can build back a better future for all of us, men and women’.3 Moving away from Covid, I am now going to discuss some important elements of work-life balance for women doctors, drawing international comparisons. The last decade has seen many changes for parents to celebrate in many countries in the world - an increase in maternity leave, parental leave, the right to request part-time working after maternity leave, and an expansion in subsidised childcare. There have been important cultural shifts in 4 Medical Woman | Spring/Summer 2021

some countries, with fathers increasing their share of the domestic burden, but only to a quite limited extent.

In 2017, MWIA conducted an online survey looking at priorities for medical women. The key issue for women doctors was work-life balance. The other important issues were men’s violence towards women and girls, leadership and mentoring, sexual harassment and bullying, and career progression.4 Looking first at maternity/parental leave, there are wide variations between countries, and this is not related to the country’s wealth.

There are only two countries in the world where there is no legal right to paid maternity leave - Papua New Guinea and the United States of America.

Comparing European and African countries, the vast majority of African doctors (80%) took less than three months maternity leave compared to 50% in Europe. Very few African doctors took parental leave compared to European doctors (3% versus 22%), and far fewer were able to work part-time after childbirth (20% versus 58%).

I would like now to concentrate on a few countries with contrasting arrangements - the United Kingdom (UK), the United States and Japan.

In the UK parents are entitled to 39 weeks paid and 13 weeks unpaid leave. The first two weeks are specific for the mother, the following 37 weeks of paid leave may be taken by the mother or the father, and the final 13 weeks of the year’s leave are unpaid, and again can be taken by either parent. A study by the Academy of Medical Royal Colleges in 2016 (http://aomrc.org.uk/wp-content/ uploads/2016/06/Maternity_paternity_survey_200416-1.pdf) showed that women doctors who graduated after 2010 are more likely to take longer maternity leave. 80% of the younger doctors took more than six months maternity leave compared to 50% of older doctors. Very few of the younger doctors took three months or less.5 There is no legal right in the UK to part-time working after maternity leave. However, the National Health Service (NHS) usually agrees a return to work at 60% of full-time. There is local, regional and specialty variation. From the 2020 Gender Pay Gap in Medicine in England Report, looking at different specialties, 30% of paediatricians had at any point trained/worked part-time, against 48% of general practitioners and 10% of surgeons.6 In the UK, maternity leave and part-time working have a high level of social acceptability and many women doctors nowadays take up the opportunities offered. But the level of maternity pay is low (the UK ranks 22 out of 24 among European countries).

Looking at the United States, there is no legal right to paid maternity leave. Each parent is entitled to 12 weeks of unpaid leave after the birth, meaning the job is protected. However, small employers with fewer than 50 employees are exempt from providing even this basic level of parental leave and job protection. Some women go back to work in less than a week to preserve their family’s income and sometimes their job.7 A paper published in 2016 in The Journal of the American Medical Colleges (JAMA) looked at Parental Leave in graduate medical education. Mothers took a median five to eight weeks’ maternity leave. 40% of those on maternity leave continued career-related activities in that leave. Most institutions did not plan for a reduced workforce when colleagues took parental leave.8 The results of a survey done in 2019, looking at parental leave

NEWS AND EVENTS: MWIA

Medical Woman | Spring/Summer 2021 5

NEWS AND EVENTS: MWIA

experiences of women doctors in the US revealed that the biggest priority for these doctors was the need for more leave, ideally four to six months. More than two thirds were dissatisfied with the paternity leave available. Financial factors were the main influence on the duration of leave taken. Almost all respondents breast fed or pumped breast milk at work. However, there was a lack of suitable places for breast feeding, and lack of adequate time for pumping breast milk was a common problem.9 In Japan in 2016, women accounted for just 21% of practising doctors. This is the lowest of the Organisation for Economic Co-operation and Development (OECD) countries, although the number is rising. Women are entitled to 14 weeks paid maternity leave. Men and women are entitled to one year each of unpaid parental leave, but there is a high risk of refusal of leave requests and the possibility of demotion for taking leave.

A 2015 paper in the BMJ discussed ‘The difficulty of professional continuation among female doctors in Japan’. The authors noted that there was a low level of confidence among Japanese women 6 Medical Woman | Spring/Summer 2021

doctors, resulting in low career aspirations. A particular problem was that full-time practice is a requirement for specialist status in Japan.

If a woman doctor in Japan changes to part-time working after childbirth, her career development is severely compromised. These factors, as well as family influences and national culture, mean that many women in Japan stop working in their thirties, and return after they have finished raising their children. The authors concluded that there was a need in particular to cut back the long hours culture in medicine in Japan.10 Symptomatic of these critical factors was the finding in 2018 that officials at Tokyo Medical University had been systematically lowering test scores of women applicants for several years, so that far fewer women gained entry to medical school. This practice was not confined to Tokyo University. There were profuse apologies from those involved and changes have been made.11 I shall move on now to Shared Parental Leave, an area where some countries have made great strides. In the UK, the uptake of Shared Parental leave by fathers has been disappointing. Three years after

MWF NEWS AND EVENTS However, we should be optimistic. In Scandinavian countries fathers are embracing a larger role in childcare, and that is the path I believe we should all follow.

Here are my suggestions: • One year of paid parental leave (no mention of maternity leave), with a use-it-or-lose-it quota of say three months for each parent (e.g. Finnish model) • Adequate job cover while a doctor is on parental leave to avoid resentment and maintain positive relationships • The right to return to work at 60% until the youngest child is aged three years old Implementation of these proposals in all countries would reduce stress on women at a difficult time in their professional lives and would make a serious start to sharing primary care for children with fathers.

References 1

Brubaker, Linda. Women Physicians and the COVID-19 Pandemic. JAMA, vol. 324, no. 9, Sept. 2020, p. 835. DOI.org (Crossref), doi:10.1001/jama.2020.14797.

2 https://www.healio.com/news/primary-care

/20201013/survey-reveals-impact-of-

covid19-pandemic-on-physician-mothers 3 Build

Back Better? Boris Johnson’s Plan Must Start with Wrecked Public Services.

The Guardian, 2 Oct. 2020, http://www.theguardian.com/society/2020/oct/02/ build-back-better-boris-johnson-public-services

4

Medical Women’s International Association (MWIA) Survey on Women Doctors. https://www.surveymonkey.co.uk/r/9LTCJMB.

5 The

Academy of Medical Royal Colleges Maternity/Paternity Survey Results http://aomrc.org.uk/wp-content/uploads/2016/06/Maternity_paternity_ survey_200416-1.pdf

it was launched, only 1% of new fathers in the UK had used shared parental leave. Take-up remains poor, in part because the payment is low at £150 per week.

Today, in Sweden, each parent has a use-it-or-lose-it quota of three months. Finland has an excellent policy: all mothers and fathers are entitled to nearly seven months paid parental leave each, half of which is non-transferable. All references to maternity and paternity leave have been scrapped in Finland, and only the term ‘parental leave’ is used. In Norway, 90% fathers use their leave. Quotas have transformed family life. This model is something we could all aim for.

A cultural shift is occurring, but not quickly enough. Having a use-itor-lose it element of well-paid leave for each parent is essential.

In conclusion, what is the future?

We can see that that the burden of domestic responsibilities, in particular childcare, falls disproportionately on women. This inevitably has a negative effect on her career progression, often a major negative effect.

6 Independent

Review into Gender Pay Gaps in Medicine in England. GOV.UK, https://www.gov.uk/government/publications/independent-review-into-genderpay-gaps-in-medicine-in-england.

7 Parental

Leave. Wikipedia, 6 Apr. 2021. Wikipedia, https://en.wikipedia.org/w/ index.php?title=Parental_leave&oldid=1016380719.

8 Blair,

Janis E. MD; Mayer, Anita P. MD; Caubet, Suzanne L.; Norby, Suzanne M. MD; O’Connor, Mary I. MD; Hayes, Sharonne N. MD Pregnancy and Parental Leave During Graduate Medical Education, Academic Medicine: July 2016 Volume 91 - Issue 7 - p 972-978 doi:10.1097/ACM.0000000000001006 https:// journals.lww.com/academicmedicine/Fulltext/2016/07000/ Pregnancy_and_ Parental_Leave_During_Graduate.27.aspx

9 Juengst,

Shannon B., et al. Family Leave and Return-to-Work Experiences of Physician Mothers. JAMA Network Open, vol. 2, no. 10, Oct. 2019, p. e1913054.

DOI.org (Crossref), doi:10.1001/jamanetworkopen.2019.13054. https:// jamanetwork.com/journals/jamanetworkopen/fullarticle/2752815

10 Nomura,

Kyoko, et al. The Difficulty of Professional Continuation among Female Doctors in Japan: A Qualitative Study of Alumnae of 13 Medical Schools in Japan.

BMJ Open, vol. 5, no. 3, Mar. 2015, p. e005845. bmjopen.bmj.com, doi:10.1136/ bmjopen-2014-005845.https://bmjopen.bmj.com/content/5/3/e005845

11 Tokyo,

Associated Press in. Tokyo Medical School Changed Test Scores to Keep Women Out. The Guardian, 2 Aug. 2018, http://www.theguardian.com/world/2018/ aug/02/tokyo-medical-school-changed-test-scores-to-keep-women-out.

Medical Woman | Spring/Summer 2021 7

SKILLS TOOLKIT: LEARNING TO FAIL

Learning to fail: how to embrace and deconstruct a fear of failure in medical school and beyond Rebecca Murphy Lonergan is a final year medical student at the University of Edinburgh and a scholar at the Healthcare Leadership Academy. As part of the HLA’s Women in Healthcare Leadership group, she is committed to promoting gender equality for healthcare workers and their patients, and empowering all students to take on leadership roles, even as undergraduates.

You started university spinning three plates: your studies, your hobbies and your social life, balanced perfectly and evenly above your head, displayed with pride.

You had successfully navigated a calendar of extra-curricular activities, the University Clinical Aptitude Test (UCAT) prep, and medical school interviews. You emerged from high school with an exemplary set of A Levels and the confidence that you would excel on your chosen path to becoming a doctor.

8 Medical Woman | Spring/Summer 2021

Over the next few years, you blossom in your new environment, filled with endless opportunities for educational and personal development. You take on a society committee position and help organise fundraisers for the school musical. You get offered a part time job just off campus and pick up an extra shift to cover the costs of placement. Each opportunity seems too good to pass up on and you collate content for your CV, your portfolio and your own sense of satisfaction, each time

SKILLS TOOLKIT: LEARNING TO FAIL

adding another plate above your head and carefully repositioning the others. You enjoy the compliments from your peers that you must be exceeding with such an ability to take on other projects and how dedicated you must be.

You feel yourself being stretched in each direction but, with a little more effort each time, the plates remain spinning.

Until finally its breaking point - you look up above your head and see with horror the chaos shadowing over you.

When did the plates multiply so rapidly? Each time you fix your attention on one, you feel the others start to teeter and with each reshuffle you feel yourself become more and more unsteady. Something has to give - hesitate a second longer and the damage will be exponentially worse, but which plate can you afford to let fall, to preserve the others?

It seems unachievable to make up for lost time, but it must be, you convince yourself, when you see your peers taking on new challenges and celebrating new successes. You have never seen them fail and you grow increasingly ashamed of your inability to manage all your spinning plates.

As a medical student, failure can seem inadmissible, but as a human and as a doctor, it is unavoidable.

In an environment as selective and high pressured as medical school, it can be easy to forget that intermittent setbacks and struggles are the norm in a demanding and dynamic career, and are not indicative of weakness or unprofessionalism. In fact, experiencing and overcoming the fear of failure as an undergraduate is vital to develop the coping strategies necessary to navigate the uncertainties and unforeseen tribulations of clinical practice.

Failure can come in many shapes and sizes - from rejected applications, low scoring assignments, or bad ward rounds - and imposter syndrome is being increasingly recognised as a culprit behind many physicians’ feelings of inadequacy.

For women and those who find themselves in the minority at medical school and later in the workplace, there can be an internal pressure to excel to prove oneself capable in an environment where we already feel out of place.

For those who choose to manage their career as well as a family, the joys and fulfilment of motherhood can bring additional challenges and the prospect of further failure.

Career mothers attempting to fully embrace both may experience a sense that they are fully succeeding at neither and they can become targets for criticism from both sides.

The sacrifices made, in missed conferences and missed playdates, can be disproportionate to those made by their prospering male colleagues, who are granted the luxury of professional advancement and fatherhood.

These fears of falling short are most exacerbated at the height of success. A leader in any visible capacity, from a student mentor to British Medical Association (BMA) board member, accepts an obligation to role model for others, which comes in partnership with an imposition over what a leader must look like. This can create a temptation to mask

our insecurities and hide our past errors, which must be confronted by shielding our moment of failure and shying away from our shortcomings, we perpetuate the notion that only the infallible achieve success and alienate those who struggle with imposter syndrome from taking on new challenges.

Embracing failure in a position of power is an excellent by-product of a leader who is willing to take risks, to try new and alternative approaches and to accept mistakes and responsibility within their team. These are all not just desirable, but essential criteria for bold and innovative leaders. Demonstrating a healthy relationship with failure encourages pioneering work and reinforces the strongly held misnomer that leadership is reserved only for those who achieve, or at least appear to achieve, perfection.

Learning to fail, or rather learning to accept and embrace failure, should be a cathartic practice for students and a key component of their development. By honestly reflecting on a situation, you may either identify areas for self-improvement or, where there are none, rid yourself of negativisms surrounding an undesirable outcome.

Going through this process alone can be meditative, but equally, surrounding yourself with people who support your development without pressuring you can create a nurturing environment for growth - try to avoid comparing the success others are experiencing with your own, as your circumstances may be very different.

Occasionally, you may notice that the number of plates you are juggling have crept up in number, and you must reassess your priorities. While it is always flattering to acquire new offers and opportunities, it is always prudent to fulfil your current obligations to a high standard rather than reaching for others that you may not be able dedicate yourself to at the time - opportunities may come again if they are worthwhile and right for you, but it is more important at an early stage in your career to demonstrate your commitment and perseverance with a current project, rather than letting your colleagues or family down by taking on too much. Recognising and respecting your limits is a sign of great maturity and insight, never of failure.

With so many exciting prospects competing for your attention as an undergraduate, it can be easy to lose sight of your primary goal - to successfully complete your training to practice as a safe and diligent doctor. At times, where the workload can seem overwhelming, it can be grounding to remember that your studies must always come first.

Even at a senior level, it is not possible to lead others without first mastering your own responsibilities.

Managing an ensemble of spinning plates is a dynamic process. Some plates may be swapped in and out through your career, while others remain constant. It is important to recognise these consistencies, the pillars on which you can rely and fall back on. This is the foundation of a successful relationship with failure - a goal that we can all strive towards.

Medical Woman | Spring/Summer 2021 9

FEATURE: EVERYTHING IS CONNECTED

Light in the Dark: shining light on life as a radiology registrar Samantha Fossey is a Clinical Radiology Registrar based on the South East Coast. She is a passionate advocate for flexible working and is involved in imaging education at both undergraduate and postgraduate level. Outside of radiology she is an avid reader, baker and developing her ability to lino print.

Can you tell us a bit about yourself?

I am in my seventh year of training flexibly as a clinical radiology registrar. I have been based on the south coast since studying at Brighton Sussex Medical School.

Why did you decide to do Clinical Radiology?

As an undergraduate I was fortunate to have a number of passionate radiology consultants involved in teaching which sparked my interest in the speciality early. I really enjoy anatomy and surgical pathology so I was torn between surgery and radiology during foundation training. I subsequently completed my core surgical training then felt clinically equipped and secure in my decision to pursue a career in clinical radiology.

Describe a typical day as a Clinical Radiology Registrar The best thing about clinical radiology is there is no typical day!

Over the course of a week you will be involved in a variety of: • Patient facing lists such as: ultrasound, fluoroscopy and image guided procedures • Referrer facing activity such as troubleshooting where you are available to discuss cases and protocol imaging tailored to the clinical question • Multidisciplinary team meetings • Reporting plain film and cross-sectional modalities both emergency and elective What do you enjoy most about a career in Clinical Radiology?

I love being a detective pulling together the clinical details and imaging to come to a diagnosis. Being able to see a wide range of pathology and applying basic sciences to diagnose disease is intellectually stimulating and fulfilling. I personally really enjoy the patient facing aspect of radiology. Getting to show patients the cause of their symptoms or educate them regarding anatomy alongside being able to perform image guided biopsies and drains is really satisfying.

What are the challenges in your chosen career path?

The Fellow of the Royal College of Radiologists (FRCR) examinations are quite gruelling especially when juggling them alongside a young family. It is a lifelong challenge to maintain sufficient breadth in knowledge and skills to manage emergency imaging whilst developing sufficient specialist interest knowledge to be a respected opinion at multidisciplinary team meetings.

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What advice would you give to medical students and trainees deciding on their future career path?

If you find yourself torn between different specialities try and gain experience of them; nothing can beat experiencing the speciality to provide insight and secure your career decisions. Don’t be afraid to change paths, take a break and/or slow the pace of training.

Enjoying your career journey is just as important as reaching your end goal.

FEATURE: EVERYTHING IS CONNECTED

Medical Woman | Spring/Summer 2021 11

FEATURE: EVERYTHING IS CONNECTED

The Journey to MobiHealth Funmi Adewara is the Founder and Chief Executive Officer of Mobihealth International. She has experience in clinical medicine, drug safety, and as a bioscience entrepreneur. Her hobbies include cooking, reading, music and photography. She also loves to spend time with her twin children.

Background I am Nigerian-born, British by naturalisation. I grew up in the Northern part of Nigeria, Kaduna State to a working-class family.

The fourth child and last girl of a family of five. My mum singlehandedly raised the five of us. My mother inspired me to venture into medicine and entrepreneurship.

Like many of my colleagues back home, I migrated right after my National Youth Service Corps, a mandatory one-year national service after housemanship in Nigeria. It was and still is the dream of many doctors to leave as soon as they have finished medical school or during residency programs after they had saved enough money and passed the United States Medical Licensing Examination (USMLE), Membership of the Royal College of Physicians (MRCP), or equivalent exams.

As an undergraduate medical student and fresh medical graduate, I was at the forefront of driving healthcare initiatives to underserved 12 Medical Woman | Spring/Summer 2021

communities. I was the Vice Chairperson of the Action Group on Adolescent Health and we pioneered the first Reproductive Health Centre at the University of Ibadan, Nigeria amongst others.

Inspirations My decision to become a doctor was undoubtedly influenced by my mother who herself had a passion for caring for the sick and vulnerable. I watched her care for her parents and family members when they were ill and her dedication and passion towards sick patients in the hospital made a great impression on me. The exposure to doctors and nurses in the hospital made it easy to find role models and mentors. My Christian faith had a great influence on me as well, in my early years and it still has. It gave me compassion for those in need.

Visiting the hospital with my mom exposed me to the various difficulties experienced by people trying to get medical care. I

FEATURE: EVERYTHING IS CONNECTED

Medical Woman | Spring/Summer 2021 13

FEATURE: EVERYTHING IS CONNECTED

vividly remember the smell of disinfectant and drugs on the hospital corridors and the smell of surgical rooms. The sight of people seated in the outpatient department, some slumped on their chair waiting their turn to be called in to see the nurse or doctor. The sight of the overcrowded Accident and Emergencies was worse, patients in their most vulnerable states being attended to by overworked doctors and nurses all trying their best to give care under the most challenging circumstances.

Such scenarios, and worse, coupled with my experience with grave illness around the age of ten years old, fuelled my passion to pursue solutions that could counter such narratives. This was why I founded Mobihealth. I saw the explosion in mobile technology growth across the African continent as a great opportunity for meaningful change.

Journey into entrepreneurship Like most women in Nigeria, my mother had a side hustle aside her day job as a nurse and social worker. She was a hardworking entrepreneur and she sold leather goods, bags and shoes to the hospital community. I got my passion for entrepreneurship from a very young age because I used to go to the hospital with her especially when she just got her consignments and needed extra support getting them to work. With my books in one hand, I would run errands around the hospital delivering the shoes and bags to her colleagues, or managing her inventory, amongst other needs.

During my undergraduate training, I started my own small business selling gold jewellery to medical staff and bankers. This sustained me financially during my last three years of medical school, plus the savings required to embark on my postgraduate studies.

I have had a versatile work experience across medicine, 14 Medical Woman | Spring/Summer 2021

pharmaceuticals and energy sectors, this business development experiences, and skill sets proved invaluable in building Mobihealth.

I worked in the National Health Service (NHS) for over a decade across various specialties, including as a middle grade stroke physician and loved it. At the end of 2018, the job became so demanding, requiring much of my time, that I found it was quite challenging being both a single mother and managing a team across four continents.

I started Mobihealth during the most difficult period in my life when it seemed as if my life was over - but I resolved not to let those challenges break me. Today, after just three years, and once on the verge of becoming almost homeless with two young children, I emerged on the global stage, with Mobihealth winning several awards locally and internationally with innovative solutions.

My story is an example of perseverance in the face of adversity. My hope is to help inspire others, especially young female colleagues who sometimes feel like giving up in the face of challenges, made worse by cultural perceptions and societal bias, especially against career women.

Today, Mobihealth is a multi-award winning and pioneering integrated telehealth company on a mission to make affordable, accessible quality healthcare a reality for all, especially people in underserved communities in Africa.

Empowered I have a Master’s degree in Bioscience Enterprise from Cambridge University. It is a multifaceted course with modules that include drug discovery and development, medical diagnostics, intellectual property, agri-biotech, and Master of Business Administration (MBA)

FEATURE: EVERYTHING IS CONNECTED invariably lead to high mortality rates. Remittances from the Nigerians in the diaspora exceeds $25 billion annually of which 10-20% is spent paying for healthcare needs of their families back home. This represents another $2.5-5 billion unstructured funds that could be channelled towards funding healthcare through a transparent decentralised system.

Mobihealth represents an opportunity to mobilise and harness the global medical human capital to bridge the supply gap. We built a scalable, secure Health Insurance Portability and Accountability Act (HIPPA) compliant solution that now allows patients anywhere to consult with doctors and other medical professionals around the world conveniently, twenty-four hours a day and seven days a week, accessible through a mobile app, solar and internetpowered telehealth clinics and a toll-free number. Mobile and communications technology can now be strategically leveraged to enable Africa to maximise the opportunities that abound in the digital revolution to deliver continent-wide access to universal health care and coverage.

modules. The versatility of the course gave me a broad knowledge and a skill set that helped me to bring scientific hi-tech innovations to market. It spring boarded me into entrepreneurship.

Armed with my Master’s degree, a stint in the Pharmaceutical industry as a drug safety physician, and working as a locum specialty registrar doctor on stroke and ortho-geriatrics, I was able to save some money to help me take that leap of faith. It is humbling to see where we are today - winning various awards across the globe. It is good to dream, and to dream big. It opened doors to endless possibilities!

How Mobihealth is positioning itself as a game changer As a medical student, I learnt the realities of suffering in Nigeria and many African countries. Africa is now home to 1.3 billion people, with over 90% of whom lack access to health insurance and basic healthcare. The continent bears a quarter of the global disease burden but is served by only 2% of the world’s doctors, not least because of the massive exodus and ongoing haemorrhage of African talent to Western countries in search of greener pastures and postgraduate training opportunities.

I was one of them. I left Nigeria over 15 years ago, and this trend continues. The majority of people in rural areas where 70% of the population reside have few or no functional hospitals or clinics.

Many are forced to travel long distances just to reach a hospital, which are typically under-equipped. Counterfeit medicines and doctored laboratory tests abound. High costs of treatment in private hospitals have denied the masses access, which continue to have a huge impact on healthcare outcomes for millions of people. The consequences are devastating, as the people who need care the most end up having the least, leading to worsening morbidity and mortality statistics on the continent.

In this seemingly dire situation, there is light and much hope, made possible by communications technology and improved digital access.

The African continent is one of the fastest growing markets in mobile technology adoption with half a billion mobile users, with Nigerians spending billions on airtime and data.

Financing healthcare, however, remains a major challenge. Low salaries for health professionals and under-equipped facilities

What are the two most important factors in building a successful startup The entrepreneurial journey can be like a black box; you never know what you will get. It is filled with highs and lows, setbacks and successes, like a roller coaster of emotions, and sometimes a very lonely path, often plagued by self-doubt, not helped by echoes of the naysayers.

The two most challenging parts of the journey, I would say, are funding and building a solid team. They often go hand in hand.

I consider these two as the most critical factors for success. Building an excellent, committed team is another major challenge. Finding people who believe and are committed to the vision, who are willing to work and sacrifice is not easy, but essential.

Unfortunately, female entrepreneurs have a hard time raising funding - notwithstanding data showing women deliver more value to the global economy, better financial performance and return on investment. Women reinvest their profits into their family’s wellbeing, education and health1.

COVID-19: a catalyst for telemedicine adoption Amidst the global havoc and devastation, one silver lining is that the pandemic has catalysed the adoption of telemedicine globally.

Virtual medical consultation in the United States and in Nigeria have multiplied, with telemedicine now taking centre stage as the primary initial mode of consultation across medical specialties. The global telemedicine market is booming and estimated pre-Covid to reach $130bn growing at a compound annual growth rate (CAGR) of 20-25% by 2025.

In today’s age of global communications and connectivity, Mobihealth’s aim is to work in connection with other likeminded individuals, groups, and leaders across the Continent, the African Diaspora, and the world - pool our collective talents and resources - and embark on a collective vision and journey that will change the narrative and legacy of healthcare on the African continent and beyond.

References 1 Allyson Kapin. 10 Stats That Build The Case For Investing In Women-Led Startups.

Available at: https://www.forbes.com/sites/allysonkapin/2019/01/28/10-stats-thatbuild-the-case-for-investing-in-women-led-startups/

Medical Woman | Spring/Summer 2021 15

FEATURE: EVERYTHING IS CONNECTED

Digital world: tech meets medicine Mala Mawkin is a previous Student Representative for the MWF, Digital Health Podcast Host for the Royal Society of Medicine and sits on the Editorial Board for the International Journal of Digital Health.

She is Head of Market Development at Cellen. In this article, Mala talks about her decision to move from clinical medicine into digital health full-time.

In 2019 I handed in my resignation letter to my clinical supervisor.

Leaving clinical medicine as a Foundation Year 1 doctor was a really tough decision, and making it often came with judgement from my peers and colleagues. The decision was made because of shortterm and long-term factors. Short-term, I needed to be home for unforeseen family circumstances. Long-term, I was eager to move into the technology world full-time.

When I held the position of Student Representative at the Medical Women’s Federation (2016-2019), I had admired the most incredible women at council meetings and conferences. Each meeting, these women would share tales about how proud they were that 16 Medical Woman | Spring/Summer 2021

they made the career decisions that they wanted to make. They sometimes went against the status quo, but at all times stood up for women to have the right to make their own decision about their career - whether it be as a clinical researcher, GP, surgeon or maybe even to leave clinical practice entirely. I was inspired to follow my own path.

During medical school, I was fortunate enough to work at a few health-tech startups, conduct research in digital health and undertake electives at the European Space Agency in Germany, Innovation and Digital Health Accelerator in Boston and e-health research centre in Malawi. I was fascinated by the amount of

FEATURE: EVERYTHING IS CONNECTED innovative ways we were able to tackle healthcare challenges, and I found my own personal mission: to help address healthcare inequalities through using technology.

So, when I was looking for a company to join after leaving clinical practice, I was desperate to find a company that matched my mission. This is where I was introduced to Cellen. Cellen is a health tech company that is aiming to improve the health and wellbeing of people living with chronic pain. Approximately 15% of the adult population is thought to be living with some sort of chronic pain, and back pain is the single largest cause of disability in the UK, with an estimated 3 million people out of the labour force as a result.

When I joined in March 2020, I was working with a driven team. We were able to do two main things: 1) Ignite and accelerate research in the novel medicines space for pain, including cannabis-based medicines.

2) Launch Leva Clinic, the UK’s first online clinic for pain (CQC registered).

My work at Cellen has allowed me to try and address some of the huge healthcare inequalities faced by people living with pain. Pain is rarely funded by insurers, and large waiting lists on the National Health Service (NHS) has meant that patient experience has not been at its best!

Leva Clinic is one of the first fully online secondary care clinics, and this is exciting as it means you can create the entire patient journey for online purposes (instead of just a single online appointment). A patient will either be referred to or sign up to Leva Clinic, and will receive an eligibility call. If eligible for the clinic, they will be seen by a dedicated team of doctors, nurses, clinical psychologists and physiotherapists on a virtual video call. This dedicated team will co-create a care plan with the patient to help them to better manage their pain through online consultations. We are currently running a service evaluation with an NHS trust and look forward to sharing the results in due course! Alongside this, we have built a digital pain management programme, with a messaging feature which connects patients to the clinical team triage service. The aim is to make sure support is always there, and ensure that patients feel that it is not their fault if their pain does not go away. It is okay for pain to be chronic, but there are techniques to “live well with pain” that we can support patients with.

As we integrate technology tools into clinical practice, we must make sure that we are creating these with patients to ensure we are getting the best outcomes. Working in digital health is not all tech and gadgets - much of the work is trying to piece together the fragmented systems that patients encounter and try to make it more seamless! It is about talking with patients, managers, stakeholders and clinicians to understand how we can improve patient outcomes and then seeing if there might be tech to help. Digital health is not just building an app and hoping someone will use it! It is a wonderful marriage of public health, clinical care, technology and healthcare management. Working in an early stage startup too has given me the flexibility and freedom in my role to keep it dynamic across a broad range of areas in the business - meaning I get to do purpose driven work across branding, marketing, product, partnerships and so much more.

The Medical Women’s Federation (MWF) helped me to have the courage to pursue my own journey. The women in the organisation have inspired me to fulfil my own personal mission. I am grateful for the MWF and am so thrilled to see what the future of digital health (especially chronic pain) looks like.

Medical Woman | Spring/Summer 2021 17

WOMEN’S HEALTH: DOMESTIC ABUSE

Lockdown: domestic abuse at the time COVID-19 Rishika Gidwani is currently a third-year medical student at the University of Glasgow. Rishika is passionate about the ethical aspects of medicine and addressing the gender and racial gap of the current medical workplace. She is currently on the committee for the Glasgow Medical Women’s Federation student branch working in public relations. Her non-medical interests would be sports, making new friends and taking on new opportunities outside her comfort zone like writing this article!

Domestic abuse and COVID-19 Despite the progress society has made in beginning to acknowledge the objectification, inequalities and injustice faced by women, women remain a target of domestic abuse. This gives the sense that a male dominated culture is still embedded within society. The emergence of the pandemic has exacerbated the abuse, due to several reasons which we will explore in this article.

What counts as domestic abuse?

While domestic abuse is mostly assumed to be physical abuse, it takes many forms. Verbal abuse, sexual abuse, and emotional abuse - such as gaslighting and manipulation - can leave victims as traumatised. Any situation which leaves individuals feeling uncomfortable, hurt or violated at the hands of their partners can 18 Medical Woman | Spring/Summer 2021

be defined as domestic abuse. Anybody experiencing anything like this should please speak up regardless of whether it is physical abuse or not. I encourage readers and others not to excuse any behaviour of their partners that makes them uneasy as any abuse is abuse.

The rise of domestic abuse amongst COVID-19 Before discussing the impact of COVID-19 on domestic abuse, I believe it is important to highlight that this article is not shifting blame of domestic abuse onto the pandemic and validating the ones who are to blame. This article simply explores how COVID-19 may have denied women of routes they would have otherwise been able to have. One of the biggest reasons for the unfortunate rise in domestic abuse cases during the pandemic was

WOMEN’S HEALTH: DOMESTIC ABUSE lockdown, an outcome of COVID-19. The United Kingdom (UK) was in extreme levels of lockdown from March 2020 to the respective summer and even currently each part of the UK has some lockdown enforcement in place. It was recorded that during the peak months of lockdown “around 20% of all offences recorded by police were flagged as domestic abuse compared to less than 15% in previous years”1. Lockdown gives women less ability to leave the house and increased time with their abusers2. This may lead to a higher frequency of abuse and in turn more severe injuries to women. In addition to not being able to leave the house, COVID-19 meant some charities and support groups were closed in at least some form. This narrows down women’s routes as there are limited places to call for help.

Women’s Aid UK carried out a survey of COVID-19 during the peak of lockdown.

• 67.4% of survivors experiencing abuse informed Women’s Aid that the level of abuse faced worsened since COVID-192.

• 76.1% informed they were spending more time with their abuser as a result of COVID-192. Hence this data suggests that the severity of domestic abuse has heightened in COVID-19 times.

Furthermore 91% of women who were experiencing abuse at the time said that the pandemic worsened their experience as they felt an increased sense of fear and the limited contacts to turn to for assistance left frustration on their part2.

•C OVID-19 has led to many people losing their jobs and in turn led to financial struggles. We statistically observe that women often end up bearing the brunt of the economic impact COVID-19 has placed on households. Almost a third of respondents to the Women’s Aid Survey reported their abuser blamed them for the financial struggles COVID-192.

Availability of help during COVID-19 Due to the close proximity family members are placed in with the UK in lockdown, reporting cases of domestic abuse is proving more challenging. There is a system in place after calling 999, called “Silent Solution” to alert emergency services. Additionally, very early in the pandemic a “code word scheme” was introduced where saying the code word “ANI” in supermarkets and pharmacies was an indication that that person was a victim of domestic abuse. However, despite the introduction of such innovative services, around two thirds of those responding to a survivor survey in April 2020 with SafeLives UK 3, did not ask for help since lockdown. These individuals found it hard to find support as everything was closed as a result of restrictions.

How can healthcare help victims during COVID-19?

How can we, as doctors, ensure we do not miss signs of domestic abuse? The British Medical Association (BMA) states that the healthcare profession possesses two obstacles to successfully reporting cases of domestic abuse: “the doctor’s attitude” and “the healthcare setting within which they work”4. The former refers to the discomfort doctors may feel in asking or due to the lack of time doctors have in dealing with such issues. The healthcare setting can reduce the number of cases reported due to patients finding speaking up daunting and the healthcare staff’s unawareness of the lack of solutions/resources available. By possessing knowledge of the signs of domestic abuse and the help available, the number of cases can be reduced:

Signs of emotional abuse5 • Signs of the patient being belittled in their relationship • Is the patient very apologetic and blames themselves for the faults of their partner?

• Signs of the victim being in a controlling relationship where their partner tells them how to dress and monitors their location • Ask the patient if their partner controls them financially Signs of physical abuse5 • Signs of bruising • Does the patient flinch with any sudden movement as if they are in danger?

• Burns or red markings on the wrist from being grabbed • Ask the patient if they have ever felt threatened or in a situation where they feel they could be severely injured/killed It is paramount that healthcare workers do not miss signs of domestic abuse as during the highest level of lockdown, the hospital is one of the only available escape routes.

References 1

BBC News. 2020. Coronavirus: Domestic abuse offences increased during pandemic. [online] Available at: <https://www.bbc.co.uk/news/uk-55073229> [Accessed 21 March 2021].

2 Hub,

E. and publications, R., 2021. Impact of Covid-19 - Womens Aid. [online].

Available at: <https://www.womensaid.org.uk/evidence-hub/research-andpublications/evidence-briefings-the-impact-of-covid-19-on-survivors-andservices/#1585739910691-6b8d326b-5792> [Accessed 21 March 2021].

3 Safelives.org.uk. 2020. Domestic abuse and COVID-19 | Safelives. [online] Available at: <https://safelives.org.uk/news-views/domestic-abuse-and-covid-19> [Accessed 21 March 2021].

4 Detection

of Domestic Abuse in Healthcare Practise [Internet]. Bma.org.uk. 2014 [cited 29 April 2021]. Available from: https://www.bma.org.uk/media/1793/bmadomestic-abuse-report-2014.pdf

5 nhs.uk.

2019. Getting help for domestic violence and abuse. [online] Available at: <https://www.nhs.uk/live-well/healthy-body/getting-help-fordomestic-violence/> [Accessed 21 March 2021].

Medical Woman | Spring/Summer 2021 19

WOMEN’S HEALTH: PERIOD POVERTY

Period Poverty: past, present and future Yang Yang Cao is a second-year medical student at the University of Glasgow, and sits on the committee for the Glasgow Medical Women’s Federation student branch. She grew up in rural England, aspiring to many different careers – ballet, teaching, human rights law – before committing to medicine. Yang Yang is especially interested in how liberal feminism and faith champion our rights as women in healthcare today.

Introduction Every day, millions of women and girls across the world menstruate.

However, not all women and girls can access the sanitary products they need for good menstrual health – a normal part of life – due to limited finances. Commonly known as period poverty, this is happening worldwide, including in the United Kingdom (UK), a relatively higher-income nation.

Period poverty is a major indignity for many women and girls of childbearing age globally. It may hinder work, education, and interpersonal relationships, to name but a few. This has only intensified with the financial, social, and psychological reverberations of the Covid-19 pandemic. If left to continue, it could adversely affect public health.

As female doctors and medical students, we can uniquely help to effectively eradicate period poverty, making a key difference in our patients’ health and lives, in the UK during Covid-19, and beyond. We can do this by recognising its well-documented frequency, its causes and effects, and what is being done about this health inequality.

20 Medical Woman | Spring/Summer 2021

In dire straits: a pervasive problem According to a 2017 survey by the global charity Plan International UK, 15% of girls aged 14-21 have struggled to afford sanitary wear for their periods, and 10% of girls have been unable to afford them outright1. Over 137,000 British children miss one day of schooling per year, it is estimated, because of period-related difficulties2.

Losing even one day of educational and social experiences, can greatly limit a girl’s wellbeing and potential.

Food and shelter are higher priorities than menstrual hygiene for women struggling with homelessness, lower incomes or displacement from war, famine or natural disaster. Sanitary product value-added tax (VAT) can reach 27% in some countries 3. Substituting materials like grass, calling in sick to work, and not changing regularly to save resources, increase unhappiness and risk of bacterial infections. Period poverty is putting at least 500 million women and girls7 at an unjust disadvantage in life.

Whilst the UK government has begun tackling period poverty (discussed below), prolonged Covid-19 school closures have only

WOMEN’S HEALTH: PERIOD POVERTY amplified a pre-existing problem. Plan International UK estimates that almost 1 in 3 girls aged 14-21 years have had difficulties during lockdown, in accessing or affording period products4. More than half have improvised with toilet paper4. Meanwhile, many women are using tea towels, socks, and even newspaper.

Fearing infection outside the house; being unable to leave during lockdown; not knowing who to approach for help; and local shops not stocking pads and tampons, have all become new hurdles to period product access4. Many more families have been financially stretched during the Covid-19 pandemic and rising unemployment rates, similarly prioritising food over period essentials – greatly increasing the proportions of women and girls battling period poverty and worsened emotional health5.

In dire straits: menstrual stigma Worldwide norms stigmatise menstruation as taboo. Around 70% of Ugandan girls are fearful and embarrassed about their periods3 ; more than 10% of their British counterparts have been expressly told not to mention them in front of their parents1. Periods are often socially distasteful, rather than something natural for half the human population, to be acknowledged and managed well.

Menstruating girls and women are socially ostracised and considered impure and harmful in some patriarchal cultures3. If internalised, the ubiquitous stigma, marginalisation, and social narratives may substantially damage mental and physical health.

Access to sanitary necessities is repeatedly blocked or undervalued.

Having periods is often already humiliating and daunting for women; being seen menstruating especially so. Adjusting to menstruation takes time and is a different experience for each girl. Nevertheless, girls may not know who to seek for support when they have insufficient sanitary products to manage their new periods, not least from fearing being shamed in front of people1.

Besides missing sports, education, work, or other activities, period poverty is worsened by such frequent menstrual stigma: a real pressure for women and girls.

Braving the flow: solutions Following a 2018 freedom of information survey, the British Medical Association (BMA) concluded that National Health Service (NHS) inpatients were not provided with enough sanitary products during their hospital stays, in England, Northern Ireland, Wales, or Scotland6. Consequently, NHS England announced in 2019, that free period products would be supplied for all inpatients in need6.

Free Periods, a legal campaign against period poverty launched by activist Amika George, has been successful in causing the UK government to fund free sanitary provision schemes in secondary and primary schools, since 20194,7. £1 million from the Welsh government has been pledged to local councils for the regions in direst need7.

From November 2020, Scottish local authorities, schools, and universities have provided free tampons and sanitary pads to “anyone who needs them”12. As of the time of publication, VAT has been removed from all period products in numerous countries, such as Lebanon, Malaysia, Tanzania3 and recently the UK from January 2021 onwards8.

Charities like Bloody Good Period9 and Freedom4Girls10 supply disadvantaged menstruating women and girls in the UK with period products, and challenge stigma via menstrual health management

education programmes. Binti, Dignity Period, and other global charities have the same goals in other countries around the world, and also research period poverty’s socioeconomic and cultural causes3,11.

Be aware and share: how we can help • Have a sound understanding of period poverty – especially its frequency and hardship in the patients we see. We should be sensitive, approachable, and compassionate with patients encountering it, and direct them to the right support and charities.

• Make some noise about it – wherever and whenever possible.

The more conversations, the more help we can share in tackling this barrier to women’s health. Responsibly educate each other on period poverty, to break the taboo-laden attitudes initiating and aggravating it.

• Endorse current period poverty elimination efforts – ensure your health service is regularly providing enough sanitary products, perhaps via staff, patient, or charity donations.

Donate to UK and international charities, where possible.

Through these, we can ensure that people have equal opportunities for period product access, regardless of where they are in Britain or around the world. As the UK prepares to reopen, continue supporting responsibly: our platform matters, because period health matters.

References 1

Plan International UK. Plan International UK’s research on period poverty and stigma. Plan International UK [Internet]; 2017. Available from: https://plan-uk. org/media-centre/plan-international-uks-research-on-period-poverty-and-stigma [Accessed March 18th, 2021]

2

RCN Congress. Period poverty debate. Royal College of Nursing [Internet]; 2019.

Available from: https://www.rcn.org.uk/congress/what-happened-at-congress2019/11-period-poverty [Accessed March 8th, 2021]

3

Wang V., Randolph K., Philipp J., Boyce S., Singh S., Thelwell K.. Period Poverty.

The Borgen Project [Internet]: 2020. Available from: https://borgenproject.org/ tag/periodpoverty/

4

Plan International UK. 3 in 10 girls struggle to afford or access sanitary wear during lockdown. Plan International UK [Internet]; 2020. Available from: https:// plan-uk.org/period-poverty-in-lockdown [Accessed March 13th, 2021]

5

BBC News. Period poverty: Rise in free sanitary products needed in lockdown.

BBC News [Internet]: BBC; 2020. Available from: https://www.bbc.co.uk/news/ uk-england-53236870 [Accessed March 18th, 2021]

6 Mehlmann-Wicks

J.. Sanitary product provision for inpatients. British Medical Association [Internet]; 2020. Available from: https://www.bma.org.uk/what-wedo/population-health/womens-health/sanitary-product-provision-for-inpatients [Accessed March 5th, 2021]

7

BBC News. Period poverty: Free sanitary products for schools is “huge step”.

BBC News [Internet]: BBC; 2019. Available from: https://www.bbc.co.uk/news/ uk-47553449 [Accessed March 19th, 2021]

8

Russon M-A.. Activists cheer as “sexist” tampon tax is scrapped. BBC News [Internet]; 2021. Available from: https://www.bbc.co.uk/news/business-55502252 [Accessed March 19th, 2021]

9

Bloody Good Period. About Us. Bloody Good Period [Internet]; 2021. Available from: https://www.bloodygoodperiod.com/about [Accessed March 19th, 2021]

10

Freedom4Girls UK. What we do. Freedom4Girls UK [Internet]; 2020. Available from: https://www.freedom4girls.co.uk/what-we-do/ [Accessed March 19th, 2021]

11

Binti Period. About Binti. Binti Period [Internet]; 2021. Available from: https:// bintiperiod.org/about-binti [Accessed March 19th, 2021]

12

Diamond C.. Period poverty: Scotland first in world to make period products free.

BBC News [Internet]: BBC; 2020. Available from: https://www.bbc.co.uk/news/ uk-scotland-scotland-politics-51629880 [Accessed March 19th, 2021]

Medical Woman | Spring/Summer 2021 21

WOMEN’S HEALTH: PREMENSTRUAL DYSPHORIC DISORDER

Premenstrual Dysphoric Disorder: an update Elina Joy is currently a second-year medical student at the University of Glasgow. She has a keen interest in learning about woman’s mental health conditions. She is a member of the Medical Women’s Federation student branch committee at the university. In her spare time, she likes to read, do yoga and taekwondo.

Many women tend to experience mood swings and increased irritability in the lead up to menstruation, however this is greatly exaggerated in someone suffering from premenstrual dysphoric disorder (PMDD). PMDD is essentially similar to its sibling condition, premenstrual syndrome (PMS) but with increased severity and an urgent need for medical attention1. Pre-menstrual dysphoric disorder is a debilitating neuro-hormonal condition affecting women of reproductive age, it manifests with physical, cognitive and psychological disturbances and its onset is prior to a woman starting their menstrual cycle. The symptoms associated with PMDD have a cyclical nature and will pass after menstruation is complete.

It affects around 3-8% of all women who are of childbearing age2.

Experiences of Women living with PMDD Women living with PMDD can face many adversities in their dayto-day life particularly with regards to maintaining inter-personal 22 Medical Woman | Spring/Summer 2021

relationships. Women with PMDD often describe relationship struggles and parenting difficulties as well as struggling to balance work one or two weeks prior to menstruation3. It was also found that there is an increased rate of absenteeism and decreased productivity at work amongst women with this condition. Women also have an increased risk of developing post-natal depression which in turn decreases their quality-of-life4. Women have an average of 400-500 menstrual cycles in their lifetime so this illustrates the chronic nature of the condition and how it can severely impact someone’s quality of life3.

Aetiology of PMDD The exact pathophysiology of PMDD is unknown however there has been sufficient evidence on physiological disturbances present in women who suffer from it. It is associated with hormonal fluctuations and increased sensitivity of hormones. Women with

WOMEN’S HEALTH: PREMENSTRUAL DYSPHORIC DISORDER PMDD show an altered functioning of serotonin with it being deficient as a result of the hormonal fluctuations in the menstrual cycle5. Also, it is thought that the hormone processing genes present in the brain cells display abnormal expression which also contributes to PMDD4. This disorder is not experienced by women who have reached menopause or those who are premenarchial1.

The symptoms PMDD presents with1,2: - Irritability - Anger - Depressed mood - Sadness - Suicidal thoughts - Appetite changes - Bloating - Breast tenderness - Joint and muscle pain Risk factors for PMDD Some risk factors for PMDD include previous history of depression, post-natal depression in the family and other mood-altering disorders. A family history of PMDD is thought to increase the risk of its inheritance. Lower educational attainment and cigarette smoking may have a role in the development of the condition5.

Some research suggests that it is associated with traumatic events in the past however there is currently no data to explain why this could be the case1.

Diagnostic criteria for PMDD The diagnosis of PMDD is highly complex, it can often be misdiagnosed for other mental health conditions due its psychological presentation2. A doctor will take a thorough medical history of the patient and additionally conduct a physical examination, the physical exam will be normal. Diagnosis involves keeping a diary of all symptoms experienced in the weeks prior to menstruation for several cycles. Common diagnostic instruments include: Calendar of Premenstrual Experiences, the Premenstrual Syndrome Diary, and the Daily Record of Severity of Problems (DRSP) 5. In order to diagnose PMDD there needs to be the presence of five out of eleven PMDD symptoms. When diagnosing someone with this condition other psychiatric disorders must be ruled out5. Many women are often undiagnosed for many years or not diagnosed at all.

Challenges in the diagnosis In June 2019, PMDD was recognised by the World Health Organisation as a condition deserving of medical intervention and now it is recognised as a legitimate condition worldwide6. This disorder was only included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013, making it a relatively new condition. There is a lack of awareness surrounding the condition among clinicians increasing the likelihood of misdiagnosis2. Women report the periodicity of the somatic and psychiatric symptoms to clinicians, but their concerns are often dismissed.

Treatment The treatment of PMDD involves effective teamwork between different branches in medicine due to the psychological and physical symptoms this condition presents with. Serotonin reuptake inhibitors (SSRIs) are considered effective treatment for PMDD

as these increase the serotonin levels in the body; they improve psychological and somatic symptoms. SSRIs were found to have a positive impact in maintaining good inter-personal relationships and improved social functioning of women with the condition6.

Pain relievers are often used to relieve symptoms such as muscle or joint pains. Birth control pills are also used in its treatment8.

Gonadotrophin releasing hormone (GNRH) agonists are used to combat the hormonal fluctuations which has been linked to the clinical manifestations of the condition1. Lifestyle changes such as cutting back on sugary and salty foods could also potentially relieve symptoms8.

Solutions In recent years, there have been many advances in providing support and increasing awareness about PMDD. An innovative app has been developed to track PMDD symptoms. Also, many organisations have started to raise awareness about it, including the International Association for Premenstrual Disorders but more needs to be done9. First of all, there needs to be elimination of stigma surrounding menstruation to address conditions like PMDD and PMS. There is often a misconception that all women suffer from PMS due to mass entertainment media’s inaccurate portrayal of it. Various entertainment platforms tend to belittle and downplay the struggles women endure during or prior to their menstrual cycle9. Such depictions and ideologies are especially harmful when women voice their concerns about having PMDD as they are often dismissed by others, making women reluctant to seek help. The notion that menstruation can have varied physical and psychological impact on different women has to be recognised by the public. Lastly, campaigns regarding the condition would help to increase awareness about it to the public and medical professionals.

Hopefully, in the near future, with increased awareness and further research on the condition, those that suffer from PMDD will be better supported.

References 1

What is PMDD? [Internet]. Mind.org.uk. 2021 [cited 19 March 2021]. Available from: https://www.mind.org.uk/information-support/types-of-mental-healthproblems/premenstrual-dysphoric-disorder-pmdd/about-pmdd/

2 Osborn

E, Wittkowski A, Brooks J, Briggs P, O’Brien P. Women’s experiences of receiving a diagnosis of premenstrual dysphoric disorder: a qualitative investigation. BMC Women’s Health. 2020;20(1).

3 Rapkin

A, Lewis E. Treatment of Premenstrual Dysphoric Disorder. Women’s Health. 2013;9(6):537-556.

4 Pearlstein

T, Steiner M. Premenstrual dysphoric disorder: burden of illness and treatment update [Internet]. 2008 [cited 19 March 2021];. Available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2440788

5 6

Ferri F. Ferris’s Clinical Advisor. 5th ed. elsevier; 2021.

World Health Organization adds Premenstrual Dysphoric Disorder (PMDD) into the ICD-11 | IAPMD [Internet]. IAPMD. 2020 [cited 19 March 2021]. Available from: https://iapmd.org/position-statements-1/2019/6/11/world-healthorganization-adds-premenstrual-dysphoric-disorder-pmdd-into-the-icd-11

7 Premenstrual

Dysphoric Disorder (PMDD) [Internet]. [cited 19 March 2021].

Available from: https://www.hopkinsmedicine.org/health/conditions-anddiseases/premenstrual-dysphoric-disorder-pmdd

8

Premenstrual dysphoric disorder (PMDD) [Internet]. womenshealth.gov. [cited 19 March 2021]. Available from: https://www.womenshealth.gov/menstrual-cycle/ premenstrual-syndrome/premenstrual-dysphoric-disorder-pmdd

9 Ro

C. The overlooked condition that can trigger extreme behaviour [Internet]. Bbc. com. 2020 [cited 19 March 2021]. Available from: https://www.bbc.com/future/ article/20191213-pmdd-a-little-understood-and-often-misdiagnosed-condition

Medical Woman | Spring/Summer 2021 23

GLOBAL HEALTH: INFERTILITY

The forgotten side of fertility: infertility a global public health issue Rahel-Ochido Ibilola Odonde is a senior registrar in obstetrics and gynaecology. Her special interests include the safe practice of abortion care and global health, having completed a MSc in Global Health. She is committed to promoting sexual and reproductive health and rights. She is a guest blogger for the Swedish non-governmental organisation (NGO) ‘My Period is Awesome’, and the Medical Women’s Federation’s representative at the United Nation Association’s Women’s Advisory Council.

There are many aspects to infertility, be that medical, environmental or social. Whenever, something is extremely complex, it serves us well to ask the very important question, “Why should we care about it?”

At the 1994 International Conference for Population and Development (ICPD) a consensus was reached by the international community that health issues covered by Sexual and Reproductive Health, such as maternal mortality, must fall and contraception provision should rise by 20151. These goals were reinforced by the Millennium Development Goals1, now superseded by the Sustainable Development Goals2. With the backing of political will, progress has been observed in the areas of maternal mortality and family planning, with advocacy being loud and clear for abortion.

However, this cannot necessarily be said in terms of the spotlight shone on the neglected issue of infertility and the denial of millions of their reproductive right to have a family.

The World Health Organization (WHO) has recognised infertility as a global health issue3,4. The field of sexual and reproductive health was given an international platform which was cemented at the ICPD1. It was made clear that from then on, every individual has the right to make informed decisions regarding their fertility, which includes family planning, infertility services and accessing

safe, available and affordable healthcare services1. Sadly, infertility has occasionally been utilised as a justification for a natural solution to population control. Despite in vitro fertilisation (IVF) most likely only contributing a maximum of 2% to deliveries in developing nations and other factors, such as increasing life expectancy from birth, having more to answer for5. Few organisations prioritise infertility programmes and this is reflected at the highest stages of advocacy, namely the ‘ICPD beyond 2014’, wherein infertility is glaringly omitted from their agenda on sexual and reproductive health services6.

Infertility affects couples’ mental health, potentially leading to depression. For women compared to men infertility impacts them more negatively, with its many societal repercussion such as ostracization and discrimination in many cultures7,8. It is a medical, social and cultural problem that is also simultaneously hugely personal. However, by and large it remains the social burden of women, even though it is a condition that affects a couple9.

In many countries, traditionally thought of as ‘developing’, a woman’s status, self-worth and identity are inextricably linked to her ability to bear children. Research has sadly shown that infertility is a risk factor for intimate partner violence10. This is the case even when the cause for infertility is not due to the female partner.

Figure 1: “Prevalence of primary infertility among women who seek a child, in 2010.

Infertility prevalence is indexed on the female partner; age-standardized prevalence among women aged 20-44 y is shown here.”

Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys. PLoS Med. 2012;9(12).

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GLOBAL HEALTH: INFERTILITY

Figure 2: Prevalence of secondary infertility among women who have had a live birth and seek another, in 2010.

Infertility prevalence is indexed on the female partner; age-standardized prevalence among women aged 20-44 years is shown here.

Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys. PLoS Med. 2012;9(12).

Infertility is defined as the inability to conceive after twelve months of regular unprotected sexual intercourse11 and can affect both males and females. Primary infertility is when someone has never been pregnant before and secondary infertility is when they have been pregnant at least once before but are subsequently having problems conceiving. At least 10% of females suffer from infertility worldwide12. The figure for males is unknown12. The true figure is difficult to ascertain as different studies use different ways of estimating the numbers. Methods range from demographic surveys13 to epidemiological studies9. In addition, how infertility is defined and whether studies are solely looking at ‘women’, ‘couples’ or ‘individuals’ means it is impossible to truly compare study results9,14.

Despite the many scientific advances including artificial reproductive technologies, the hope to become parents is never achieved for many people and families.

One study investigating the global trends in infertility, estimated that approximately 50 million couples cannot have a child, with approximately 19 million and 29 million suffering from primary and secondary infertility respectively13. Another study predicted that 72.4 million women were infertile in 200715. The absolute number of infertile couples or individuals has increased due to an overall increase in the global population, whilst proportionally the rates of primary and secondary infertility remained relatively stable, between 1990 and 201013. Across different regions worldwide, the trends for primary and infertility were generally mirrored. However, exceptions were seen in the prevalence of primary infertility. In 1990, Sub-Saharan Africa and South Asia, had the highest prevalence and twenty years later these regions saw a decline. The prevalence was also varied within the regions. Countries in East Africa (such as Kenya and Zimbabwe) exhibited a lower prevalence (1.0% - 1.1%) compared to countries in Central Africa such as Mozambique and the Central African Republic of 2.5% or more. Within the European Union (EU) 25 million citizens have been estimated to suffer from infertility16.

Some of the highest prevalence of primary infertility can still be found in Eastern Europe, as well as the Middle East, Oceania and Sub-Saharan Africa, with percentages reaching 3.0% or more (Figure 1)13.

The rates of infertility in Sub-Saharan Africa can be attributed in part to untreated sexually transmitted infections (STIs), poor maternal healthcare leading to post-partum infections, and unsafe and illegal abortions. All of these can sometimes permanently damage the reproductive tract causing infertility. In some communities up to two-thirds of women of reproductive age suffer from infertility18-20. It is stipulated that the response to the HIV epidemic on the continent has had a widespread effect of reducing the overall incidence of STIs13. Despite the improvements seen, the truth still remains that an inordinate number of women in low-resource countries are suffering from infertility – to be specific secondary infertility. Worldwide, secondary infertility is the most common type of female infertility20. In Central/Eastern Europe and Central Asia the association of unsafe abortions might explain the high rates of secondary infertility found6.

Globally there is a huge demand and unmet need for artificial reproductive technologies (ART). This demand has seen an explosion in the number of IVF clinics. At the start of the millennium only 24% of WHO member states provided IVF services9. Forward ten years later and over 500 clinics can be found in India. Alongside Asia, the Middle East and Latin America have developed their Assisted Reproductive Technology (ART) beyond former recognition. This pales in comparison to Sub-Saharan Africa, where many countries can only boast of having one IVF clinic. Nigeria and South Africa are seen as relative successes with their number of clinics being in double figures, entering the third decade of the millennium21.

It is very easy to only focus on Sub-Saharan Africa and forget that other regions experience this same lack of infertility treatment development. International Federation of Fertility Societies’ surveillance reports highlight a shadow on the map situated over the majority of Central Asia – with an absence in IVF clinics22. It is a double tragedy that this region has the highest levels of secondary infertility but next to none in terms of treatment.

From generation to generation, there has been a shift in particularly women’s views in regards to their reproductive rights. It is important to remember the distinction between the inability to have children, actively seeking to have children, a change in the preferred desire Medical Woman | Spring/Summer 2021 25

GLOBAL HEALTH: INFERTILITY for children and the preference in the number of children sought.

In many instances there is an increasing willingness to delay when couples try for their first child. This has its own repercussions, such as the impact of age on fertility and the age at which couples present to fertility services. This could partly explain the trend in increasing secondary infertility. Many assumptions are made which impact the research design and outcomes and therefore how we approach the perceived concerns of people with infertility.

International organisations and governments of low- and middleincome countries (LIC and MICs) can potentially find it hard to justify prioritising the expense of investing in and then maintenance of dear IVF/ART clinics against a backdrop of a multitude of competing health needs. Prevention is definitely better than cure and should be strived for especially when the main reasons for infertility are STIs, post-partum infections due to poor maternal healthcare and unsafe abortions. However, despite initiatives to address these problems, there will still remain a significant proportion of a population that will suffer from infertility as is well documented in high income countries. I argue that, as it still remains largely the woman’s social burden, the willingness and political will is sorely lacking.

Consequently, in settings where provision for infertility treatment is not a part of the healthcare system; especially in regions where they have the paradigm of high fertility rates coupled with high infertility rates, usually the wealthy ones, pay out of pocket for treatment.

This can and often does push households into catastrophic financial hardship23-35. This then in turn causes a widening of economic inequity that we are all trying so hard to reverse. Fortunately, there is an advent of low cost, and ever-increasing quality of ARTs such as ovarian stimulation regimes that hopefully mean cost is no longer a major impediment to incorporating infertility services into healthcare systems of LIC and MICs5,26. Therefore, with this and the provision of fertility treatments to allow people to become parents, social inequities and mental health problems can be somewhat alleviated25,27.

Infertility deserves the same political will and attention to detail and public awareness as other sexual and reproductive health issues.

Like other public health concerns, the contributing factors to the problem(s) and solutions are many. Furthermore, the impact of the COVID-19 pandemic on fertility and access to services cannot be ignored. Many may postpone when they start a family due to the coming recession and current financial hardships many are facing. As we know the age of a female is a major dictating factor in fertility and so there is work to be done by already encumbered governments to reduce this burden of infertility that will undoubtedly be borne mainly by the women in our societies. It is essential that (in)fertility and the wider area of family planning are one of the priorities in striving for better female and by extension public health globally.

References 1 UNFPA. Programme of Action: Adopted at the International Conference on Population and Development, Cairo 5-13 September 1994 [Internet]. United Nations Population Fund; 2004. Available from: https://www.unfpa.org/sites/ default/files/event-pdf/PoA_en.pdf 2 Fact sheets on sustainable development goals: health targets Sexual and reproductive health (SDG 3.7 & 5.6) [Internet]. Copenhagen, Denmark.; 2017. Available from: http://www.euro.who.int/__data/assets/pdf_file/0005/348008/Fact-sheetSDG-SRH-FINAL-04-09-2017.pdf?ua=1 3 Editors, Vayena E, Rowe PJ, Griffin DP. Current practices and controversies in assisted reproduction: report of a WHO meeting. Geneva, Switzerland; 2001.

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Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of infertility preva-lence and treatment-seeking: potential need and demand for infertility medical care. Available from: www.census.gov/ipc/www/world.html 5 Ombelet W, Goossens J. Global reproductive health - Why do we persist in neglecting the undeniable problem of childlessness in resource-poor countries? Facts, views Vis ObGyn [Internet]. 2017 Mar [cited 2021 Feb 27];9(1):1–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28721178 6 ICPD Beyond 2014 High-Level Global Commitments | UNFPA - United Nations Popu-lation Fund [Internet]. [cited 2021 Mar 1]. Available from: https://www. unfpa.org/publications/icpd-beyond-2014-high-level-global-commitments 7 Cui W. Mother or nothing: the agony of infertility. [Internet]. Vol. 88, Bulletin of the World Health Organization. 2010 [cited 2021 Feb 28]. p. 881–2. Available from: https://www.who.int/bulletin/volumes/88/12/10.011210.pdf 8 Chachamovich JR, Chachamovich E, Ezer H, Fleck MP, Knauth D, Passos EP. Investigat-ing quality of life and health-related quality of life in infertility: A systematic review [Internet]. Vol. 31, Journal of Psychosomatic Obstetrics and Gynecology. Taylor & Francis; 2010 [cited 2021 Feb 28]. p. 101–10. Available from: https://www.tandfonline.com/doi/abs/10.3109/0167482X.2010.481337 9 Inhorn MC, Patrizio P. Infertility around the globe: new thinking on gender, reproduc-tive technologies and global movements in the 21st century. Hum Reprod Update [In-ternet]. 2015 Jul 1 [cited 2021 Feb 28];21(4):411–26. Available from: https://academic.oup.com/humupd/article-lookup/doi/10.1093/humupd/dmv016 10 Serour GI, Serour AG. Ethical issues in infertility. Vol. 43, Best Practice and Research: Clinical Obstetrics and Gynaecology. Bailliere Tindall Ltd; 2017. p. 21–31.

11 WHO | Multiple definitions of infertility [Internet]. WHO. World Health Organiza-tion; 2019 [cited 2019 Aug 7]. Available from: https://www.who.int/ reproductivehealth/topics/infertility/multiple-definitions/en/ 12 WHO | Infertility is a global public health issue [Internet]. WHO. World Health Or-ganization; 2019 [cited 2019 Aug 12]. Available from: https://www.who.int/ reproductivehealth/topics/infertility/perspective/en/ 13 Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, Re-gional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys. PLoS Med. 2012;9(12).

14 Gurunath S, Pandian Z, Anderson RA, Bhattacharya S. Defining infertility—a system-atic review of prevalence studies. Hum Reprod Update [Internet]. 2011 Sep 1 [cited 2021 Feb 28];17(5):575–88. Available from: http://academic.oup.com/ humupd/article/17/5/575/756688/Defining-infertilitya-systematic-review-of 15 Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of infertility preva-lence and treatment-seeking: Potential need and demand for infertility medical care. Hum Reprod [Internet]. 2007 [cited 2021 Feb 28];22(6):1506–12.

Available from: https://pubmed.ncbi.nlm.nih.gov/17376819/ 16 A Policy Audit on Fertility Analysis of 9 EU Countries [Internet]. Darmstadt, Germany; 2017 [cited 2019 Aug 7]. Available from: http://www.fertilityeurope.eu/ wp-content/uploads/2018/03/EPAF_FINAL.pdf 17 Eurostat. Eurostat Statistics Explained: Fertility statistics [Internet]. Statistics Ex-plained. 2019 [cited 2019 Sep 23]. p. 1–22. Available from: http://ec.europa.eu/ eurostat/statistics-explained/index.php/Category:Tourism_glossary 18 Lunenfeld B, Van Steirteghem A. Infertility in the third millenium: Implications for the individual, family and society: Condensed meeting report from the Bertarelli Foundation’s Second Global Conference [Internet]. Vol. 10, Human Reproduction Up-date. Hum Reprod Update; 2004 [cited 2021 Feb 28]. p. 317–26. Available from: https://pubmed.ncbi.nlm.nih.gov/15192057/ 19 Rutstein SO, Shah IH. Infecundity, infertility, and childlessness in developing countries. DHS Comparative Reports 9. DHS Comp Reports [Internet]. 2004 [cited 2021 Feb 28];9:pages 13-50. Available from: http://www.measuredhs.com 20 Nachtigall RD. International disparities in access to infertility services.

21 Jones HW, Cooke I, Kempers R, Brinsden P, Saunders D. SPECIAL CONTRIBUTION In-ternational Federation of Fertility Societies Surveillance 2010: preface. 2010 [cited 2021 Feb 28]; Available from: http://www.iffs-reproduction.org 22 Ory SJ, Banker M, Brinsden P, Buster J, Fiadjoe M, Horton M, et al. IFFS Surveillance 2013 Editor-in-Chief. 2013.

23 Dyer S, Sherwood K, … DM-H, 2013 undefined. Catastrophic payment for assisted reproduction techniques with conventional ovarian stimulation in the public health sector of South Africa: frequency and coping. academic.oup.com [Internet]. [cited 2021 Feb 28]; Available from: https://sci-hub.do/https://academic.oup.com/ humrep/article-abstract/28/10/2755/620126 24 Maheshwari A, Teoh PJ. Low-cost in vitro fertilization: current insights. Int J Womens Health [Internet]. 2014 Aug 21 [cited 2021 Feb 28];6(1):817. Available from: http://www.dovepress.com/low-cost-in-vitro-fertilization-current-insightspeer-reviewed-article-IJWH 25 Njagi P, Groot W, Arsenijevic J, Dyer S, Mburu G, Kiarie J. Economic costs of infertility care for patients in low-income and middle-income countries: A systematic review protocol [Internet]. Vol. 10, BMJ Open. BMJ Publishing Group; 2020 [cited 2021 Feb 28]. p. 42951. Available from: http://bmjopen.bmj.com/ 26 Ferraretti A, Gianaroli L, Magli M, sterility PD-F and, 2015 undefined. Mild ovarian stimulation with clomiphene citrate launch is a realistic option for in vitro fertilization. Elsevier [Internet]. [cited 2021 Feb 28]; Available from: https://sci-hub.do/ https://www.sciencedirect.com/science/article/pii/S0015028215003520 27 Makuch MY, Simônia De Padua K, Petta CA, Duarte Osis MJ, Bahamondes L. Inequita-ble access to assisted reproductive technology for the low-income Brazilian popula-tion: A qualitative study. Hum Reprod [Internet]. 2011 Aug 1 [cited 2021 Feb 28];26(8):2054–60. Available from: https://academic.oup.com/ humrep/article/26/8/2054/648027 4

GLOBAL HEALTH: NIGERIA AND COVID

Medical Woman | Spring/Summer 2021 27

GLOBAL HEALTH: NIGERIA AND COVID

Pandemic: the Nigerian perspective Dabota Yvonne Buowari Department of Accident and Emergency, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria

Vivian Ifeoma Ogbonna Department of Community Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria

Aminat Oluwabukola Jimoh Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria

Ogechukwu Mary-Anne Isokariari Department of Community Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria

Overview of events: the COVID-19 pandemic in Nigeria The coronavirus (COVID-19) pandemic is caused by the SARS-CoV-2 virus1, it has put the world in a public health crisis2. It has spread across the world affecting 216 countries and the number of cases are on the increase3 with the advent of the second wave of the pandemic. The first case of COVID-19 in Nigeria was announced on the 27th February 20204. The transmission started with the first case, which was imported and has cascaded into community transmission4,5. As published by the Nigeria Centre for Disease Control official website, as of 1st March 2021, the total number of confirmed cases are 155,657 while a total number of 1,907 cases have died6.

Nigerian’s President Muhammadu Buhari on March 9th 2020, inaugurated the Presidential Task Force (PTF) on COVID-19 to coordinate and oversee Nigeria’s multi-sectoral inter-governmental efforts to contain the spread of coronavirus7. The various states have since followed the footprints of the PTF in establishing their state COVID-19 task force. Coronavirus has led to disruptions in health services, markets and the economy of the nation of Nigeria.

These disruptions present a real threat from the lockdown and restrictions. The traumatic experiences of the pandemic will not be forgotten in a hurry. The losses we have incurred will be a constant reminder at the individual and community levels.

Impact on the Nigerian Healthcare Service The COVID-19 pandemic has positive and negative impacts on the Nigerian healthcare system. During the first wave of the pandemic, there were reduced hospital visits as people were scared of contracting the deadly virus within the hospital community.

Also, there was the fear of being diagnosed with COVID-19.

This was worst if the patient had respiratory symptoms such as cough, and difficulty in breathing. The government established isolation centres that were in charge of managing patients diagnosed with COVID-19. Patients who tested positive for severe Coronavirus were tested and treated free of charge. During the periods of curfew and lockdown in the different Nigerian states, hospitals provided means of transportation to transport healthcare workers who did not have their vehicles whilst on duty to and from the hospital.

28 Medical Woman | Spring/Summer 2021

GLOBAL HEALTH: NIGERIA AND COVID Impact on communities The COVID-19 pandemic has caused a lot of economic distress which is not particular to Nigeria. Some people lost their jobs - especially those employed by private individuals. This caused significant financial burden on the breadwinner of the family.

Nigerians have a communal style of living and practicing the extended family system. People fell back to their extended family members for survival if there was no source of income due to the pandemic. People whose businesses depended on travel were adversely affected such as long-distance drivers, as there was a restriction of interstate movement by most Nigerian states during the first wave.

Fashionable face masks in Nigeria Several preventive measures have been put in place to help reduce the spread and curtail the infection. Because of this, to protect against the infection, most countries advocate the compulsory wearing of face masks in public places8,9. The World Health Organization also advocates this, as it will help to protect the populace from contracting the infection from asymptomatic people10. The Nigerian president Mohammadu Buhari signed a Coronavirus Disease Health Protection Bill 2021 which made wearing of face masks mandatory in public places11. There has been a scarcity of medical facemasks, therefore non-medical facemasks are worn by non-healthcare workers. Indigenous tailors in Nigeria have taken up the challenge of fabric facemasks production.9 The National Centre for Disease Control of Nigeria (NCDC) encourages Nigerians to wear facemasks in addition to maintaining physical distancing and gave guidelines on who should not wear a fabric facemask, the do’s, don’ts, how to care for and handle the cloth facemask12. The fabric facemask is now also made fashionable, it is made with beautiful colours to match the colour of an outfit, and sometimes the same fabric is used in sewing both a dress and a facemask. This is not surprising as Nigerians are well known for appearing in uniform during social events - what the Yoruba’s in western Nigeria call ‘aso ebi’. Face masks are also made by institutions and organisations with their logo, sometimes these facemasks are distributed as welfare support to the under reached. For instance, the Medical Women’s Association of Nigeria (MWAN) has also made its own customised facemask with the MWAN logo.

Myths and beliefs surrounding COVID-19 in Nigeria As with other countries, populations have mixed opinions about COVID-19. Nigeria has various religious organisations with contradictory views about COVID-19. Some believe it is a punishment sent by God which can reflect in the public opinion on the vaccine. Some Nigerians believe there is something sinister about the COVID-19 vaccine which will soon be deployed on a mass scale in Nigeria. There is also some degree of denial as some people believe that the COVID-19 pandemic is a scam and not true.

The government and various organisations including the Nigerian Medical Women’s Association of Nigeria (MWAN) have conducted health education and promotion in educating the public on the pandemic. People have several myths about the pandemic and some have resulted in the consumption of a concoction made of herbs believing that it prevents and cures COVID-19, some of the herbs consumed for this purpose are scent leaf, neem plant, the bark of the mango tree, bitter leaf and lemongrass.

Conclusion The first case of the COVID-19 was diagnosed in Nigeria in March 2020, and there has been community transmission. The governments have enforced mandatory wearing of the facemask in public places and Nigerians have made the facemask fashionable increasing its acceptance. The pandemic has impacted in different ways on the Nigerian healthcare system.

References 1

WHO. World Health Organization. Coronavirus Disease 2019 (COVID-19).

Situation Report. 32. 2020. 2019 (February)

2 Nanda

K, Lebetkin E, Steiner MJ, Yacobson I, Dorflinger J. Contraception in the era of COVID-19. Glob Heal Sci Pract. 2020. 8(2), 8-10

3

Gupta R. Case study of COVID-19 in India reported data at 15. In 2020

4 National

Centre for Disease Control. Nigeria Centre for Disease Control and Fleming Fund. 2019, 2021 Mar 1(June). Available from :http://ncdc.gov.ng/ news/227/first-case-of-corona-virus-disease-confirmed-in-nigeria

5 Ayowole

D, Ogbonna V, Amoo A, Babarinde T, Nwafor J, Enebeli U et al. COVID19 at the community level: what are the countermeasures? Niger J Med. 2020, 29(3), 362-368

6 Nigeria

Centre for Disease Control. NCDC Coronavirus COVID-19. Microsite [internet]. Frequently asked questions. 2020[cited 2021 MAR1]. Available from : https://covid19.ncdc.gov.ng

7 Office

of the Secretary to the Government of the Federation. Presidential Task Force on COVID-19, 2020, 19, 1-8. Available from https://statehouse.gov.ng/covid19/

8 Aloui-Zarrouk

Z, Youssfi LE, Badu K, Fagbamigbe AF, Matoke-Muhia S, Ngugi C et al. The wearing of facemasks in African countries under the COVID-19 crisis luxury or necessity? AAS Open Research. 2020. https://doi.org/10.12688/ aasopenres.13079.1

9 Okoro

RN. Universal use of facemask against Coronavirus Disease-2019 in Nigeria: a necessity or an overreaction. Int J Health Life Sci. 2021, 7(1), e105638.

Doi.10.5812/ijls.105638

10 Ogonia

S. Covid-19: the need for a rational use of face masks in Nigeria. Am J Trop Med Hyg. 2020, 103(1), 33-34.

11 Sahara

Reports. Buhari signs bill making use of face mask in public compulsory. www.saharareporters.com/2021/01/27

12 National

Centre for Disease Control (NCDC). Advisory on use of cloth facemask. www.ncdc.gov.ng

Medical Woman | Spring/Summer 2021 29

SPOTLIGHT: MEND THE GAP

Mend the Gap Rashmi Mathew (FRCOphth, SFHEA) is a Consultant Ophthalmologist with a special interest in glaucoma. She is the Deputy Director for Undergraduate Education for Moorfields and also the Lead for New Consultant and Resident Leadership Training. She was recently appointed as Programme Co-Director for UCL MSc in Advanced Clinical Optometry and Ophthalmology, as well as the apprenticeship programme and is the Clinical Leadership Module Lead for these programmes. She runs EyeThrive which is a leadership course for senior ophthalmic healthcare professionals.

Gender Pay Gap in Medicine is a powerful report that uncovers some of the structural entities that sustain gender inequality. It also calls for cultural and social frame-shifts to enable women to have equality, not just in pay but all aspects of medicine. In this article some of the key aspects are explained and highlighted.

I was delighted to see the final Mend the Gap: Gender Pay Gap in Medicine report published in December 2020.1 It makes for eye-opening reading (excuse the ophthalmic pun), but it’s also a welcome and positive catalyst for change. After all, we can only change, what we know. Pay gap analysis is a way of highlighting inequality and the review illuminates some of the structural, social and cultural barriers that unintentionally, but inevitably hold medical women back. What I particularly like, is that the researchers also undertook qualitative research to make sense of the data and share the lived experiences of women in medicine. It is a report that everyone in medicine should read; as we all have a part to play in changing the inequalities experienced by women in medicine. Of course, seismic structural and policy shifts are needed. On a more individual level, change can start small; from the language we use, to our attitudes towards flexible training; being more supportive on a personal level, to actively sponsoring women and giving them opportunities to put them in the spotlight. It is also knowing and understanding when women cannot take on additional roles. We all need to consciously evaluate our roles in ensuring that women in medicine are able to fulfil their potential and promote the diversity that is much needed in all aspects of medicine and its leadership.

15% of professors in medical schools are women.4 Women are also under-represented in senior leadership roles.

The Gender Pay Gap in Medicine report1 was commissioned by Jeremy Hunt in 2017 after coverage in the national press of a large gender pay gap in medicine and the potential negative impact of the new NHS contract due to loss of increments for those having breaks in training.

How it is calculated Gender Pay Gap (GPG) is defined as the difference in average pay rates for men and women, as a percentage of men’s earnings. The report is the first to use payroll data for almost all doctors working in the NHS over a 10-year period: • Electronic Staff Records for 86,000 hospital and community health doctors (HCHS).

• NHS workforce census and workforce Minimum Data Set, which is linked to self-assessment tax record for the HMRC for 16,000 General Practitioner’s (GP’s).

• Higher Education Statistics Agency records for 4,500 clinical academics.

Regression analysis was used to look at individual characteristics, such as grade, experience and specialty and their impact on pay.

Statistical decomposition approaches were utilised to identify what characteristics are driving the gap. Finally, a Gender Pay Gaps in Medicine (GPGiM) survey of 4,854 doctors and 30 in-depth interviews were conducted to ascertain qualitative data and illuminate some of the payroll data findings.

The Reasons and Recommendations

Background Although healthcare is a female predominated career, women were not allowed entry into British medical schools until the late nineteenth century. Since 1996/97, more women than men have entered medical school. In 2017, 59% of medical school entrants were women.2 Interestingly, the structure of medical careers has little changed since the inception of the National Health Service (NHS) to accommodate the needs of a predominantly female workforce and as a result, many end up dropping out of medicine, entering specialties perceived as ‘woman friendly’ – and don’t feel able to pursue their passions or fulfil their potential.

Two-thirds of doctors in training grades are women. However, there is a dramatic shift in the consultant grade, with nearly 32,000 male consultants to 18,000 female consultants (National Health Service (NHS), 2019). Surgical specialties, although making slow gains, fair the worst, with only 13.2% consultants being women.3 Less than 30 Medical Woman | Spring/Summer 2021

Hours worked The highest GPG based on gross annual basic salary is in primary care (33.5%) followed by NHS Hospital and Community Health Services (HCHS) doctors (24.4%) and clinical academics (21.4%).

The report also outlines full-time equivalent (FTE) corrected pay in order to standardise the difference in working hours, such that the unit of analysis is comparable units of work (see Table 1).

As you can see that hours worked drives a large part of the gender pay gap, but even with corrected FTE, there is still a significant gap.

Grade and Seniority After accounting for differences in hours worked, there is still a substantial GPG. There is a significant variation in grade and seniority of doctors. Men account for two-thirds of senior roles in hospitals (consultant and associate specialists) and the minority

SPOTLIGHT: MEND THE GAP Table 1 Taken from Mend the Gap Report

Men gross Women gross GPG% Men FTE- Women FTE- GPG%

annual annual corrected corrected

basic pay basic pay annual basic pay annual basic pay

Proportion of GPG explained by gender differences in contracted hours (%)

Hospital £90,184 £68,200 doctors

24.2 £93,379

£75,759

18.9 22.5

Hospital £119,564 £99,379 consultants

16.9 £123,945

£107,808

13.0 22.9

GP doctors

33.5

£113,939

15.3

£78,546

11.5 46.3

£113,747

£75,671

Clinical £71,617 £56,318 academics

£134,578

21.4 £88,765

54.3

in the two junior most grades (FY1 and FY2). Men also make up 57% of GP partners, but only 27% of salaried GP’s. “Equalising proportions of men and women across grades would reduce the FTE-corrected GPG by two-thirds among HCHS doctors and GPs”.

Almost all of the HCSC GPG can be explained by age, experience, grade, hours, location; however, in primary care 50% is still unaccounted for and so one cannot overlook the possibility of direct pay discrimination within individual practices.

has the highest basic GPG (24.4%) and this is explained by men being older, more experienced and occupying senior grades.

Women in surgery tend to be younger and in more junior grades.

It is also important to note that certain specialties are seen as more accommodating of Less-Than-Full-Time (LTFT) working. GPiGM survey showed 10% of surgeons had worked flexibly in their careers, compared to 48% of GP’s, 33% of psychiatrists, 30% of paediatricians, 29% of radiologists.

Age and the motherhood penalty Taking time out of work or working reduced hours creates a sizeable penalty for women. It is interesting to note that GPG increases steadily with age. Equal numbers of men and women complete foundation training on time, this starts to change in core training and by the end of specialty training, 84% of men compared to 59% of women finish on time. The report shows that the mean age of a first-time medical mother is 31.5 years. 20-25 years after this, the gender pay gap for healthcare women is still around 14%.

It takes a further 10 years (around retirement age), for this gap to close. This is a lot slower than other professional groups, where GPG closes 15 years after the birth of their first child. Notably, by the time a woman doctor’s first child is 16-years of age, they have had on average four years less time at work, than the average male doctor at the same stage. The pay penalty is out of proportion to what would be expected, most likely due to the disadvantage in reaching the highest grades. This needs to be addressed by moving towards competency rather than time-based training. The report also recommends reducing the number of spine-points in the payscale to shorten the time taken to reach the top of the pay-scale and utilising job evaluations, so pay-setting is fairer.

Workplace factors (structural factors - LTFT training) At present, career options and structures do not accommodate pregnancy, maternity leave and motherhood easily. LTFT working is most commonly undertaken by women in later stages of their career (specialty training and beyond). Choosing LTFT is often difficult, but requisite for women and I have personally witnessed demeaning treatment of women working LTFT. Qualitative data from the report also showed LTFT trainees experience cultural resistance, particularly around their professional commitment to the specialty.

In order to reduce the stigma, LTFT in fact should be promoted amongst women and men and the report recommends all jobs be advertised as LTFT and as mentioned above a refocusing of LTFT training to competency based, rather than time-based training is needed. The large geographic deanery areas following Modernising Medical Careers are also not conducive for women with caring responsibilities and do not easily facilitate co-location with their partners.

Specialty Women need to be supported to climb the ladder into the higher paid specialties where there is under-representation. I cannot imagine that women don’t want to be consultants in surgery or cardiology or GP partners, but the inflexibility of the career pathway does not support them through to the senior grades.

GPG differences across male and female dominated specialties are mostly explained by age, grade and hours differences. Surgery

Additional payments & Clinical Excellence Awards (CEA) One of the striking stats in the report was that only 20% of CEA’s are awarded to women. Women consultants with caring responsibilities can find it harder to build the necessary portfolio to apply for CEA’s. Interestingly, CEA awards are reduced pro-rata in value for consultants working LTFT, although no doubt these women have substantial evidence in their application, to even be considered. NHS Digital data from 2019 showed elements of nonbasic pay are worth an additional 33% (on average) on top of basic pay and adds a meaningful supplement. CEA’s account for 22% of additional payments; however, payments for “additional activity” Medical Woman | Spring/Summer 2021 31

SPOTLIGHT: MEND THE GAP

(widespread) and “local payments” (rarer) accounted for a larger proportion. If women are disadvantaged in accessing these, they run the risk of indirect pay discrimination. Men are also more likely to negotiate locum wages, starting consultant salaries and GP salaries for example and until there is more transparency around pay and additional payments, us women need to do what many of us find so difficult and negotiate.5 After all, unless you ask, you don’t get.

Conclusion One of the things the report doesn’t address is the intersectionality of protected characteristics, such as ethnicity and disability. It touches on, but doesn’t go deeply enough into the long-term career consequences of bullying and harassment in the NHS and this needs to be addressed alongside the issues raised if we are to genuinely value diversity in the NHS. The pandemic has also brought gender inequality to the fore, with women shouldering much of the caring responsibilities, which in turn has set women back even further in terms of reaching pay parity. Conversely much innovation particularly around telemedicine has been scaled at pace, allowing many healthcare workers to work flexibly and from home, something that was unthinkable a year ago 32 Medical Woman | Spring/Summer 2021

and this needs to integrated in a coherent way to enable healthcare workers to work flexibly long-term.

The Department of Health and Social Care are in the process of setting up an implementation group for the recommendations outlined in the review. But change also needs to start on an individual level with both women and men lifting others as they climb in order to make the NHS a truly inclusive place for all to flourish. The time for change is now.

References 1 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/ attachment_data/file/944246/Gender_pay_gap_in_medicine_review.pdf (accessed April 2021) 2

Moberley T. Number of women entering medical school rises after decade of decline. BMJ 2018;360:k254.

3

https://www.rcseng.ac.uk/careers-in-surgery/women-in-surgery/statistics/ (accessed April 2021)

4

Penny M, Jeffries R, Grant R and Davies SC. Women and academic medicine: a review of the evidence on female representation. J R Soc Med 2014; 107: 259–263.

5

Bowles H.R. & Babcock L. How can women escape the compensation negotiation dilemma? Relational accounts are one answer. Psychology of Women. 2013;37: 80-96.

UNWIND

Writing: taming an active mind Born and raised overseas, Cathy Wield attended UK boarding schools before St George’s, London. She qualified with a baby but without recourse to part time training, so postponed house-jobs to complete her family.

Cathy became unwell just before starting flexible training in Emergency Medicine. Her memoir Life After Darkness describes recovery from a seven-year nightmare of severe mental illness culminating in brain surgery.

Cathy lives in Dorset and works as a SAS doctor in Emergency Medicine.

I have to be truthful that all this talk about wellbeing is getting on my nerves. I am fed up with ‘latest’ apps and the wonders of every healthy activity under the sun, all competing to turn me into a good, resilient doctor. Let’s face it, I’ve survived enough to know, that despite the need to have a cry every couple of weeks, I’m a pretty tough cookie. My life may be a bed of roses; I am well aware of the thorns.

I should know by now how to look after myself, especially since I have had prolonged absences from medicine with what was diagnosed as mental illness. But I realise how flawed the premise was that led to my diagnosis and the treatments described in my original published memoir (Life After Darkness; a doctor’s journey through severe depression). My understanding of the situation has evolved and developed over the years and so I am currently writing another book to put this right.

I lived in Denver, Colorado from 2016-19 and it was here that I learned so much more about myself as a writer. As a young child I excelled in story writing and was admonished for having a particularly vivid imagination. Yet as an adult, I had never made any attempt to write anything that could be classed as creative or in a genre related to fiction. I took a course in ‘free writing’ taught by Alex M Fourzan - she has since won the best first novel award in Mexico. I found intense pleasure in the discovery that my ability to tell a story didn’t die when I started medical school. I joined Alex in running these free writing workshops in Denver and have continued to do this occasionally since my return to the UK. I wrote for our local amateur theatre in Denver and found the primary writing relatively easy. What took time was the fine tuning and inevitable edits which the director kept suggesting. But since I am back working in Emergency Medicine, serious fiction writing has to be left for times when I get a more prolonged spell of time off.

I need ‘bandwidth’ for this, whereas I can quite easily get up in the middle of the night with an idea and write it into a skit within half an hour.

I am aware of the need for down time, but I can’t seem to believe I was made for rest; not that I particularly desire physical activity such as sport. I am happy to take a walk but my few years of disciplined swimming were not particularly enjoyable and I gave it up once I discovered dance. Being in a class suits my extrovert personality and I have really missed this during lockdown. But the real challenge for me is taming my active mind; it swings into gear as soon as my eyes open and will attempt to dominate even when I should be getting my precious eight hours sleep a night.

I tried to practice mindfulness and my guru husband kept reminding me that this is not a success or failure venture; but despite completely agreeing with the premise, I found that I was pressurising

myself to accomplish my obligatory twenty minutes a day, which more often than not left me feeling either frustrated or asleep.

I have let go of my attempts to discipline myself into doing things that don’t work for me. Instead, I have found the easiest way to settle my mind down is to read. I love a good book and when I need to lighten up, then a good comedy on TV does it for me.

But my real go to, is to write. I am not especially bothered which form this takes and I realise that I can be a little obsessional when it comes to crafting emails; it almost replaces writing a journal and feels very satisfying to me.

With writing comes vulnerability; while it may be driven by a deep desire to communicate, the act of writing is solitary and it takes courage for me to allow my considerable efforts to be subject to the whim of others’ opinions. I have learnt the hard way to seek feedback only from those I trust. I have suffered from a phenomenon common to many published authors, that whereas we may receive numerous good reviews, we can be unseated by the one ill-thought-out comment made by a stranger. Having said that, I am not out to produce a best seller or gain fame - life is too short. Even though writing can be painful at times and it can also be arduous, I believe I have grown as a person through my writing experience and it continues to be something I enjoy and simply feel compelled to do.

Medical Woman | Spring/Summer 2021 33

BLOG

Becoming an expert in loss Emily Plummer is a paediatric trainee doctor currently working in London. She is passionate about women empowerment from a grass roots level; having planned Women into Leadership events for healthcare professionals and setting up girls’ youth groups. In her spare time, she is trying her hand at being a school governor, loves reading and coaxing herself out on a run.

COVID-19 sadly was not the worst thing to happen in 2020, not for me and perhaps not for others. It played the pathetic fallacy of my year.

In January 2020, I lost a best friend to suicide; a friend in his twenties who had everything in front of him, or so it seemed. I cannot say enough how valuable and loved he was by many. There were no warning signs, or none that were picked up, and often this is the case with suicide. A phone call at the end of a busy night shift is what sent me into disbelief.

Over time, after the initial shock, the mind thaws and analyses preceding events until mine rested upon the conclusion that there was nothing that could have been done. There was no room for “what ifs”. This can be uniquely agonising when experiencing a bereavement from suicide. You become an expert in loss when grieving; I thought about what his family has lost, what his girlfriend has lost, what the future has lost and what I have lost. Loss has played a large part in our lives during the pandemic, from losing loved ones to losing routines and certainty, we have become familiar with its pain.

During medical school, I experienced waxing and waning mild depression accompanied with improving levels of insight when eventually I sought student counselling. With this positive experience, I went to grief support, counselling and had cognitive behavioural therapy (CBT) sessions through the Practitioner Health Programme*. These were all helpful, however, the grieving process is personal and most of the mental work is done individually. What I did not expect was the amount of energy that the grief would burn; this being on top of the drain of lockdown. I had enough to go to work and to provide support to friends where I could. A year on, the loss still burns away but it now feels controllable. I have sat my first postgraduate paediatric exams (I passed, thank goodness). I can turn my head to career enrichment, upping the Joe Wicks sessions and social plans (that being helped by the slow release of lockdown).

Throughout the year, I tried not to give too much space for COVID19 and its implications because I did not have the capacity. It would have meant thinking about different sorts of losses, personal and widespread. I actively avoided reading or hearing related news to preserve myself. That did not stop me needing to keep up with the (what felt like) ever changing protocol or worrying about my family and friends. I do harbour an element of “survivor’s guilt” because this avoidance has been possible; I was not redeployed and resided in a neonatal bubble over most of the pandemic. Certainly, I would 34 Medical Woman | Spring/Summer 2021

not have managed so well if I had been redeployed. For those who were, I respect their ability to rapidly adapt, their resilience on the frontline and for some, all whilst pausing their training.

I think about my friend every day and he will remain in my thoughts, his family’s, and his friends’. We are all on different paths and at different points of the healing process and we look out for one another. Writing letters to him, making a photobook of memories, and recording all the times we spent together during university and beyond were also helpful for me. This may mirror how health care workers feel about surviving lockdown; we are recovering in our own ways and have found value in being part of a unified team.

People have shown strength in coming together as a community, be it, supporting food banks, volunteering, or checking in on colleagues. As I am, we can begin to take stock of what the last year has meant for us.

This pandemic has been tough and exhausting for everyone and many would have lost loved ones so know I will not be alone in grief. Mind, a mental health charity, conducted research to measure the impact and reported an alarming rise in depression, substance misuse and self-harming behaviours1. They also noted this decline in mental health has disproportionally affected women, people with disabilities and frontline workers. The mental health burden was significant before COVID-19 so seeing it worsen, Mind is hoping to shake the powers that be to act and treat it with the appropriate gravitas.

If there is anyone going through a similar situation, please know that it is normal, and that there is no correct way to cope or indeed not to cope. There is no schedule you need to be keeping to, you will get there. Do look after yourself. It will be hard in a myriad of ways but there is a time when the grief or weight of emotion can become manageable.

I share this partly for catharsis and partly to raise the issue of another creeping pandemic. I know the mental health service desperately needs funding, resources, and improvement. But if possible, look for support from someone close or an appropriate service or take time to check up on your friends and colleagues, because this year has not been easy, and it can be dangerous to struggle alone. *The Practitioner Health Programme is a confidential service that provides a wide range of support for doctors and dentists; you are able to self-refer for mental health support here if needed: https://london.hee.nhs.uk/professional-development/traineedoctors-dentist-support-service-tddss 1

The Mental Health Emergency report by Mind https://www.mind.org.uk/

media-a/5929/the-mental-health-emergency_a4_final.pdf

BOOK REVIEW

Light Perpetual

by Francis Spufford

Sarah Matthews is a mid-50’s GP who works in Coventry. Her practice is urban and provides services to Coventry University students. She is the Coventry Local Medical Committee (LMC) secretary and has recently been elected to General Practitioners Committee (GPC). She is married to a histopathologist and they have two sons, Tom and Theo. She has a longstanding interest in medical humanities; particularly in the patient narrative.

Although the cover reminds us that this is the author of Golden Hill, Spufford’s new book is a move both in terms of setting and time, bringing us closer to home in both dimensions here, moving to the London of the post-war years.

There is, of course, ongoing interest in World War Two as a topic for the history programmes, with Lucy Worsley presenting the most recent on the Blitz. We were reminded that there was significant loss of life and health: about 40 thousand died with as many seriously injured. In addition, the London Blitz saw enormous damage to property with about 1 million London houses, predominantly in the East, either destroyed or damaged. Other cities such as my own adopted city of Coventry were also seriously affected and this lives on in the memories of older patients. A patient of mine has vivid memories of the night of the Coventry Blitz; of being sent away to relatives in the outlying village of Baginton, but looking across to the city and seeing it in flames.

Our context at the current time, and why this book has hit such a nerve is that the focus is on the loss of loved ones. The opening scene contains the following blunt statement: ‘Jo and Valerie and Alec and Ben and Vernon are gone. Gone so fast they cannot possibly have known what was happening which some of those who mourn them will take for a comfort and some won’t’. The premise is to project imagined futures for these children, lost in a specific bombing raid as to what might have been had they lived.

Currently we are seeing and looking after people who have lost loved ones; often unexpectedly and suddenly. They may have last seen their relative getting into an ambulance but looking not too bad. They may not have been able to speak to them during their hospital stay or to visit, and their death may have come as a sudden shock after a period when things were stable or recovering. Some of these relatives have been younger, although few children have died with Covid-19. But the focus on grief and mourning, and our response to it is timely. The world has spent a year thinking of little else.

We first come back to each of the children’s lives in 1949 to see where they are and what they are doing and then Spufford projects them forward to further years. Our last clear sight of them is in

2009 when they are 65, and then a short ‘infinity’ section.

I did wonder if the manner of looking away and back at intervals had something to do with the television programme ‘7-Up’ which took much of the same approach to the lives of real children and very effectively, and surprisingly at times, glanced at them with interviews every seven years. In its twists and turns, as the children develop new careers and relationships, or leave old ones, it feels much like the programme.

But the viewing of these imaginary lives is not careless in its intent.

It allows an exploration of what might have been. I do think this is part of the grieving process which is expressed by many, especially after the loss of children. Spufford recognises that each future might not only have contained happiness, but be varied and normal. He also uses the setting of London to look at some of the social history of the post-war years, for example the printers of Fleet Street and strike at the time of the move to Wapping in 1986.

This response, of looking back and looking forward, seemed very credible to me. The reflection at significant moments such as birthdays or family events, the acknowledgement of a family member who is missing and the sense of feeling their absence is an important one in families where a younger member has died as a child or a young adult.

Explicitly in the title, Spufford makes a Christian reference, to the Prayer for the Dead used in Catholic and Anglican churches. This is spoken ‘Eternal rest grant unto them, O Lord’ with the congregation replying ‘And may light perpetual shine upon them.’ This novel may be seen as a reflection on our response to death, and our ability to positively engage in grief and mourning. For those of us of many faiths, and of none, we need our own credible response to this world event which has blighted our last 12 months. Our calling to support not only the sick but the grieving needs consideration particularly now in a way which has not been needed, probably, since those mass deaths in the bombings of World War Two. Truly, that makes it a novel for our time.

Medical Woman | Spring/Summer 2021 35

Much progress has beenwomen made, The voice of medical but much remains to be done! onmore medical issues