‘The second sex’
Tamzin Reynolds explores the consequences of a world designed for the male body on women’s health outcomes.
If you are a woman, the chances are you’ve felt othered at some point in your life. I encountered it in the gym again the other week: whenever I go to a new gym, I’m faced with machines not built for me—a non-disabled cis woman of average height. The machine handles are often too thick for me to use comfortably (women’s grasp and wrist strength ranges from 50-60% of men’s). My arms aren’t long enough to use the bench press comfortably, and my feet don’t touch the floor on some machines. Yes, I can buy wrist straps and use alternative exercises to sort this out (as my male friend kindly reminded me), but why should I have to?
“Why do women have to change themselves?”
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My gym gripe may appear trivial, but other male-default designs have more serious impacts on health and wellbeing. Simple everyday examples include seat belts which don’t sit comfortably across women’s chests and other car design flaws resulting in women being 47% more likely to be seriously injured, and 71% more likely to be moderately injured than a man. Other examples include Personal Protective Equipment, which makes going to the bathroom a major operation, and police body armour, which doesn’t protect women because it isn’t made to fit their bodies.
In 1949, French feminist and philosopher Simone de Beauvoir wrote, “The lives of men have been taken to represent those of humans overall”. This famous quote from her essay The Second Sex still perfectly encapsulates this feeling of ‘otherness’. From small design flaws that make you feel like this world isn’t quite made for you, to the glaringly obvious discrimination all over the world, women suffer at the hands of bad design and the systematic ignorance of their experience.
But what does this mean for health? In a world designed for men, does women’s health suffer? The short answer is yes. From more obvious discrimination to daily microaggressions, the systemic otherness of women materialises in poorer health outcomes.
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“In a world designed for men, does women’s health suffer? The short answer is yes.”
In almost all parts of the world, women have a longer life expectancy than men; in the United Kingdom (UK), women’s life expectancy at birth was 83 years, while men’s was 79 years in the period 2018–20. Yet women also spend over a quarter of their lives in disability or ill health, while the figure is only one fifth for men. These figures translate to women in the UK living with ill health or disability for over five years more than men, and this gap is widening. The reasons behind this disparity are multifaceted and wide-ranging. Some, however, are remarkably simple and, therefore, surely simple to fix.
Until recent years, there has been a prevailing perspective that the only difference between men and women is size: that women are just ‘small men’. This perception has resulted in women being vastly underrepresented in research, which has serious impacts on health.
A 2008 analysis of textbooks from some of the most prestigious universities in Europe and North America found that male bodies were used three times more than female bodies to represent ‘neutral’ body parts. Caroline Criado Perez’s 2019 book Invisible Women: Data Bias in a World Designed for Men shone a spotlight on the degree in which the world is manufactured for a male prototype. This assumption of female bodies being ‘essentially the same’ as male bodies persists to this day, and it is dangerous. Although studies have found female representation increasing over time, the trends are modest and unlikely to resolve the wide gaps in research. For example, examining the 25 most-cited cardiology articles each year between 1996 and 2015, the percentage of women included only increased by 0.29% each year, and still only sat at 32.2% of female participants in 2015.
“This assumption of female bodies being ‘essentially the same’ as male bodies persists to this day, and it is dangerous.”
Similar stories are seen with HIV research. Women represent almost half of HIV-positive adults in the world, yet within research conducted in the United States, women were represented in only 38.1% in vaccination studies, 19.2% participants in antiretroviral studies, and 11.1% in studies to find a cure. With these gaps, how can clinicians hope to understand why men and women have different experiences of HIV? A stand-out distinction, for instance, is that women are less likely to start antiretroviral therapy, often due to family commitments making appointments difficult, fears about pregnancy, or socioeconomic circumstances. Without accurate research, these simple features of a woman’s HIV experience cannot be addressed.
While gender differences in health research have only more recently entered public consciousness, the gender pay gap has had a longer history in the headlines. Worldwide, for every £1 a man makes, a woman only makes 77 pence, and, while this pay gap is slowly narrowing, the impacts of COVID-19 saw the forecast time taken to close the global gender gap increase from 99.5 years to 135.6 years.
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Globally, women do 75% of unpaid work (this includes tasks like housework and caring for children, relatives, and spouse’s relatives), spending almost triple the amount of time carrying out this work, often alongside full-time jobs. Yet, the work women do is fundamental to keeping the world moving; it is estimated that unpaid domestic and care work contributes between 10–39% of a country’s Gross Domestic Product and can add more value to the economy than the commerce, manufacturing, or transportation sectors.
Unfair and frustrating? Certainly. But how does this affect health?
Low control over one’s job and an effort-reward imbalance are known to increase stress, resulting in poorer health outcomes like heart disease and stroke. For women, whose ‘primary’ jobs are often unpaid care and work, one can see how the high effort and low reward would fit this model. Perhaps predictably, given the underrepresentation in research, there are few studies which look at how this model plays out for different genders, but those that do find poorer health outcomes for women.
Beyond the psychosocial effect of women’s unpaid work and its repercussions on health, having a lower income than their male counterparts results in health inequalities. Worldwide, women can expect to earn between 31 and 75% less than men over their lifetimes due to their unpaid work and other factors like inadequate maternity leave, male bias in pensions, and biased employment procedures. Wealth helps protect against life stressors. As women live longer than men, and are less able to accumulate wealth, it’s no wonder women spend more years of their life in poor health.
“Women can expect to earn between 31 and 75% less than men over their lifetimes.”
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What happens when being a woman intersects with other marginalised communities? When we consider this, de Beauviour’s quote could read: “The lives of straight, cis, white, non-disabled, young men have been taken to represent those of humans overall.”
While women are underrepresented in research, this is even more true for women of colour, older women, women of child-bearing age, those with disabilities, LGBTQI+ women, and those of lower socioeconomic status. For example, in nail salons, where the workforce is almost exclusively female and often migrant (a population who often lack access to regulatory and health systems), workers are exposed to dangerous chemicals for long periods of time—the effects of which have not been researched by dose. This is not a problem women of higher socioeconomic status contend with.
In the UK, black women are five times more likely than white women to die in pregnancy or childbirth; an inequality which should not be tolerated, yet the dual evils of misogyny and racism (misogynoir) hinder change. Shockingly, a woman I know going through menopause told me how her general practitioner believed white women experience worse menopausal side effects. Do black women feel less pain, or are they given less attention and socialised to complain less, lest they be marked as an angry inconvenience? Evidently, more research on the menopause and female reproductive health is needed, and the inclusion of black women’s experiences is urgent.
A promising sign that change may be afoot came on International Women’s Day this year, when the UK government began a call for evidence for its Women’s Health Strategy. Submissions were invited from the public, clinicians, researchers, and groups interested in women’s health. The hope is that the government is finally addressing the historic difficulties women have had in accessing appropriate and adequate healthcare. The challenge will be to make sure positive change is effected across all groups of women.
“The challenge will be to make sure positive change is effected across all groups of women.”
More broadly, artificial intelligence (AI) may play a part in driving change. We’ve seen that when AI is trained on data which doesn’t consider the female experience, it only expands inequalities. But perhaps the rise in Femtech (female technology, a term applied to a category of software, diagnostics, products, and services that use technology to focus on women's health) will provide a partial solution to this—most likely in the areas of fertility and fitness for which apps and devices are commonly designed, providing women with the knowledge and control of their bodies that they deserve. There are, of course, concerns about data sharing, and care must be taken not to profit from an individual’s data without consent. Additionally, there must be a recognition that data harvested in this way is not concentrated on only women with more social privileges.
Ultimately though, we need more women in positions of power and influence, from a diverse range of socioeconomic backgrounds and cultures, more women engineers designing our world, and a general shift in the default men mindset. Women make up half the world; let’s have them shaping it accordingly.
The author recognises that statistics and discussion on women’s and men’s health represent a (cis)gender binary, and do not fully encapsulate the experiences of transgender, non-binary, and folks across the gender spectrum. Along with Tamzin’s own reflections on women’s health, more voices from marginalised genders are needed to deconstruct the white, cisgender, able-bodied, male norm in health research and care.
How the "menopause is natural” narrative is a damaging one
Aishwarya explains that discussing menopause as a natural phenomenon perpetuates social and health inequities, leaving women to push through their symptoms alone without practical and effective health advice.
If you Google menopause, a long list of symptoms appears. There may be a mention of how menopause symptoms are unique from person to person and advice not to take the list of symptoms at face value. But that part may be skipped over, leading straight into a paragraph on hysterectomies and hormone replacement therapy (HRT). This paints menopause as a well-structured process with simple solutions. It was only when I began to search for research papers on menopause in India that I uncovered a glaring problem: in conversations about menopause, authentic experiences had been left out completely.
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“In conversations about menopause, authentic experiences had been left out completely.”
Menopause is the one-year anniversary of a person’s last period. Since a person is born with a finite number of eggs in their ovaries, at a certain age, usually between 35 and 55, the number of eggs reaches below a threshold. Oestrogen—the hormone responsible for retaining and maintaining this constant—begins to fluctuate from its cyclical nature. As oestrogen governs more functions than just the menstrual cycle, decreasing hormone levels also result in a spectrum of symptoms throughout the body. For example, oestrogen plays a key role in controlling body temperature, and a low oestrogen level can cause a sudden spike in body temperature known as a ‘hot flash’ or ‘hot flush’—a common symptom of menopause.
I decided to conduct my postgraduate research on menopause experiences of cis-women in India through qualitative interviews. My research asked: if women were reporting difficulty during their perimenopause (the 5–15 years of physiological changes leading up to menopause), were their negative experiences a result of not making use of the available medical facilities? Since COVID-19 had limited my sample to middle-class women with access to Zoom, my participants were all literate and had easy access to hospitals and gynaecologists. But by the end of the first interview, it was clear that I had a lot to learn. My ignorance stemmed from a combination of my own privilege, and my education: studying science had distanced me from social issues and structures. By the end of my 30th interview, I had uncovered just how entwined social and health inequities are.
One of the most common phrases I heard was “it’s natural”. While menopause is indeed a natural phenomenon—after all, periods do eventually stop—calling menopause ‘natural’ seems to be doing more harm than good. If women are not accessing health infrastructure, and if health infrastructure is barely covering (or over-medicalising) the menopause, a deep dive into the ‘natural’ narrative may uncover some truths about where these health gaps lie. In the words of the women themselves, here is why the concept of menopause as ‘natural’ is both born from social inequities, and why using it perpetuates health inequities.
Calling it natural is a coping mechanism caused by lack of support
“Natural actually sounds good but I wish it was not traumatic. Not painful. I wish it was like, once you decide you don’t want to have kids you switch it off and everything stops. That would be more natural for me.”
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A menopausal support system requires two systems, each depending on the other to be effective: the social system and the medical system. While good gynaecologists may be available, most menopause symptoms do not have quick fixes. Dr Shaibya Saldanha, a gynaecologist in Bangalore, India, stressed the fact that menopause does not need to be a medical phenomenon. At the same time, she made clear that a natural process does not mean one without dietary and lifestyle interventions. For example, during perimenopause, sleep should increase while the body adapts to hormonal changes. However, “Women normally run on six hours of sleep … .They close the house down in the kitchen and feed every single person who eats at different times. And then they go to sleep and normally they would get up at 5:30–6:00 and start the next day.”
Solutions may appear feasible—such as sleeping for longer or shifting household duties to another family member—but support is often lacking. In a culture where gender roles are so deeply ingrained, social inequities play a role in menopause experiences. For example, the COVID-19 pandemic added to the workload of urban women, and this stress alone could have increased hot flashes and emotional fluctuations. Further, stigma surrounding menstruation continues into menopause. In some interviews, the women were unable to explain their menopause symptoms to their husbands because they had been discouraged from talking about their reproductive health during puberty.
This combination of shame and the lack of support at home leads women to use the word “natural” as a way of sweeping their health under the rug. If their health is not taken seriously then it must be unimportant, and most bodily processes that aren’t given attention are natural ones. Thus, menopause and its accompanying symptoms, no matter how harrowing, must be natural too.
An ayurvedic doctor that I spoke to explained how she bridged this gap. When a menopausal woman enters her clinic, this doctor ensures that either the husband or another family member is present during the consultation.
“Everyone takes doctors seriously and our word weighs. That extra step in counselling makes a big difference in fighting stigma.”
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Natural processes are common, and therefore you will manage
“Once [women] speak to their family they are ridiculed. Women of our generation are convinced, and it is very unfortunate, by women themselves. By women of the previous generation. They themselves say, ‘Oh you take this all so seriously, it’s very natural. You make a big deal out of nothing.’ Mind you this is not said by men. This is said by previous generation women. They are the ones who find it ridiculous.”
Two generations ago, treatment for menopause did not exist, nor did women have access to healthcare facilities. Tasked with running a household, women put their own health last. Along with the stigma surrounding menstruation, women had no choice but to manage their menopause alone. One of the most important long-term effects of the change in oestrogen level is a decrease of calcium uptake in the body. People going through menopause are encouraged to increase or supplement their dietary calcium intake so that postmenopausal concerns such as osteoporosis and arthritis are prevented. Unfortunately, rather than appreciating the availability of medical advancements for their daughters, women often look down upon other women who seek medical assistance. Silently suffering is seen as a display of strength: “We never used to complain about our cramps,” becomes “We never went to hospitals”. The prevalence of osteoporosis and arthritis in this generation shows just how damaging social inequities can be for health outcomes.
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Women’s health doesn’t warrant relevant medical attention
“We have a doctor but we don’t go much to the gynaecologist because it [menopause] is a natural process.”
Both postmenopausal women whom I spoke with regretted not having a check-up at the gynaecologist’s office. Yes, menopause is not a disease and nor is it a disorder, but, at the very least, a blood test to ensure that calcium and vitamin levels are normal is a must.
But the narrative around women’s reproductive health has always been ‘to manage’. Menstrual cramps in the middle of a class? Keep your head down and power through. A miscarriage? You’re shooed out the hospital door and expected to deal with the trauma on your own. Polycystic Ovary Syndrome? Despite it becoming an increasingly common condition, there is little progress in medical care provision. You’re handed a set of birth control pills and told to manage the side effects. Similarly, self-managing your menopause transition is the expectation. In fact, a woman who did seek medical help was dismissed by her gynaecologist who said, "Menopause is a part of life that everyone manages through.”
When it comes to menopause, unless your symptoms can be treated by medical intervention, there’s no space for a person going through menopause to seek guidance or support. “You have to stop everyone from removing your uterus,” was a common sentiment heard during my interviews with women. Instead of broadening the kind of support a medical environment can offer, menopause is medicalised and the fear of having unnecessary tests or operations prevent women from going to hospitals. Dr Saldanha told me frankly that there are only a few gynaecologists that sit menopausal women down and explain the practical lifestyle changes they can make to ease their symptoms. She had completed a one-year counselling course specifically so that she was better equipped to help the menopausal women who walked into her clinic. However, this kind of menopause counselling does not commonly feature in medical school curriculums.
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The lack of menopause education in medical schools because it is a natural process
“And I think that’s the nuances of medicine that is not taught to any of us as doctors. Beyond health; the needs of people. What about preventive health, what about a step beyond that?”
Menopause counselling sounds like a tall order, considering how menopause itself is barely covered in the MBBS (Bachelor of Medicine and Bachelor of Surgery). Five women interviewed were medical professionals and they were all disappointed by the lack of menopause training. Public health tends to focus on the prevention of disorders, diseases, and ailments. Although menopause should not be looked at through any single lens, public health education and health promotion should encompass menopause. When discussed, menopause is also primarily and problematically grouped under ageing concerns. The average age of menopause in my study was 47, and women reported feeling disconnected with the concept of menopause being a sign of old age. Generations ago, menopause may have come towards the end of life, but lifespans are longer than they have ever been.
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“I don’t want to have one foot in the grave. I am working, I actually started a new academic program just this month. I don’t think of myself [as at] that age… It doesn’t have to be a natural part of the end in life. It’s going on while life is also going on.”
Rather than finding an answer to where and how menopause should be taught, it’s skipped over altogether, with medical colleges teaching a slide or two at most. This has led to many medical professionals not knowing what menopause symptoms are at all. Since the onset of perimenopause is unpredictable, women often visit a general practitioner first for their menopause symptoms. Unfortunately, many women in my study consulted multiple doctors before the word ‘menopause’ was even brought up.
How do we remove these systemic health and social inequities?
One of the most important things that I learned through these conversations is that ‘natural’ does not necessarily mean a ‘good’ thing. Although the menstrual cycle is a natural process, its stigmatisation turns it into something negative. On the other hand, the perception that everything “God-given” or “natural” has to be good prevents women from seeking help when a natural process doesn’t feel good.
Public health systems need to take the initiative to spread menopause awareness, and doing so should involve those who will not experience menopause too: de-stigmatisation begins with open conversations. It is thus imperative for menopause counselling to be a part of every gynaecologist’s training. Considering that menopause can intensify mood swings and lead to depression, “removing the uterus” should not be the only intervention that gynaecologists are equipped to provide. Validation is an important and missing component. All of the women who had negative menopause experiences thanked me for simply giving them a space to share what they had endured. Because of health inequities, doctors did not give them a safe space or the time of day to allow them to share their trauma; and because of social inequities, they were unable to openly discuss the negative aspects of menopause at home. A combination of more research and counselling would help to validate that what is natural is not always good. More often than not, women understand that they will have to push through their symptoms; they also want proof that what they’re going through is indeed natural, and that it is okay to not enjoy it.
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Menopause is something that cannot and should not be generalised for all. If the person makes the choice to seek medical support, infrastructure and solutions should be available. If the person decides to go through the menopause symptoms without any medical intervention, social systems should be available to support them. Most importantly, strengthening both social and health structures will allow people going through menopause to be able to rely on both. With neither system currently making space for menopause, the word ‘natural’ has become synonymous with ‘isolated’. Women deserve more.
“Menopause is something that cannot and should not be generalised for all.”
Tiles
Emily reflects on the experience of working as a healthcare professional serving rural communities. This poem draws on the inspiration from colour and its contrast to the surrounding setting.
During my undergraduate degree, I completed a semester abroad in South India, where I took Public Health courses through a local university. As part of the programme we went to field visits once a week in the local community. This poem is about one of our visits to a tile factory. I was struck by the state of the factory: a dilapidated building strewn about with broken tiles, bricks, and the like. Dimly lit and dusty, the air was loud with the cranking of machines and the slapping of clay against oiled metal. In the midst of this relative chaos, women decorated by brightly coloured kurtas were working to make bricks on the lower level of the building. I was struck immediately by the contrast between the bright fabric of their clothes, and the dust and dinge that whirled around them. The image of these women, appearing in such stark contrast to their surroundings has stayed with me and from it this poem materialised.
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A girl walks the line,
Skirt drawn
Hands caked with clay
A grey streak marks her a laborer.
Sweat glistens in the sunlight that has snuck through the thick air
Her arms carry what will one day be a home
While her body,
covered by the dust of another man's future,
Is already home to her own.
So close … yet so far
Snehal discusses the harsh realities of the COVID-19 pandemic that are often overlooked and underreported. Reflecting on the death of a family member, Snehal demonstrates the dire need for increased availability of vaccines and provision of healthcare services in low- and middle-income communities.
“Delivering vaccines to countries is only one obstacle; being able to administer these vaccines on the ground to communities with poorly resourced healthcare is another obstacle altogether.”
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The last two years have been the most challenging medically and socioeconomically in recent history, leaving an extensive impact on global healthcare systems. The outbreak of the COVID-19 pandemic has caused the death of over 5 million people so far—and this number continues to rise. The impact this disease has had on people directly and indirectly means the world can never be the same again. As a doctor and frontline healthcare worker myself, the pandemic was a momentous challenge to say the least. But my life turned upside down when my beloved father tested positive for the virus on 31 December 2020. After being admitted to the intensive care unit, he was put on a ventilator for 13 days, and sadly lost his life on 27 January 2021. Being only 63 and physically fit, with no underlying medical conditions, my understanding remains clouded as to how this disease affected my father so severely. Yet we are only at the tip of the iceberg, and still attempting to make sense of how this disease affects certain individuals more seriously than others.
My story is no different than the millions of other families who have lost their loved ones or who are caring for those left with debilitating health conditions, either from contracting COVID-19 or indirectly through its consequences. We have become ominously familiar with the daily COVID-19 death rate governments publish, but these statistics may not be entirely accurate and might be substantially higher than reported. This can happen for several reasons globally. Firstly, civil registries and hospitals aren’t promptly processing certificates, causing a delay in reporting COVID-19 death toll, and thus a lag in data publication. Secondly, official statistics in several countries exclude those who did not test positive for COVID-19 before dying, which in many situations can be the result of inadequate testing due to limited access or capacity. Thirdly, inaccessibility to healthcare can delay people coming to the hospital with COVID-19, which has also contributed to overall mortality. Unfortunately, much of the above reasons remain particularly true in many low- and middle-income countries (LMICs) with substantial underreporting of COVID-19 deaths.
Fortunately, vaccines for COVID-19 have been developed quickly, protecting against severe disease and hospitalisation. I still remember discussing this with my father before he contracted COVID-19 at the end of 2020, just when the announcements of new vaccines were being made, and just before he tested positive. Sadly, he didn’t receive the vaccine in time, and never a day goes by that I wish he could have received his vaccine earlier.
“We must do better in overcoming these hurdles and making vaccine availability equal to all. ”
The United Kingdom’s (UK) vaccination programme is considered very successful now. Like many high-income countries (HICs), we are fortunate to have an abundance of vaccines, administered in a timely manner. Without it, our hospitalisations and deaths would have been far worse. Not to mention, all the economic consequences of COVID-19 on the country, on families, and livelihoods. But I can’t help but wonder how many people feel like I do, that they were unable to save their loved ones? Despite vaccines being manufactured at a phenomenal scale, LMICs still can’t access them. By March 2021, high- and upper-middle-income countries had already secured 6 billion doses, compared to the 2.6 billion doses reserved for LMICs. This is particularly disproportionate with the fact that HICs and upper-middle-income countries constitute only one fifth of the global population.
Inequitable vaccine distribution is leaving millions, if not billions, of people vulnerable to COVID-19. This allows for the emergence of deadly variants, which can spread globally and cause critical socioeconomic impact. An alarming eight out of ten people pushed into poverty by the pandemic will be living in the poorest countries in 2030—the majority in Africa, according to the United Nations Development Programme (UNDP). Reports of “vaccine hoarding” by HICs also remains a fundamental issue; as of November 2021, only 6.5% of people have been vaccinated with their first dose in LMICs versus 65% in HICs.
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In addition, HICs only need to increase their average healthcare spending on vaccines by 0.8% compared to 56.6% for LMICs to cover 70% of their population—a stark difference. Without global financial support, many LMICs will be unable to vaccinate sufficient population numbers. Organisations like COVAX have been set up to deliver better COVID-19 testing, treatment, and vaccines in LMICs, but unfortunately these efforts only tackle a few of the challenges. Delivering vaccines to countries is only one obstacle; being able to administer these vaccines on the ground to communities with poorly resourced healthcare is another obstacle altogether. Needless to say, this remains a challenge that also affects certain underserved communities in HICs. We must do better in overcoming these hurdles and making vaccine availability equal to all.
As the United Nations quotes, “no matter how rich or how poor, an infectious disease like COVID-19 will remain a threat globally, as long as it exists anywhere in the world”. We must therefore tackle this pandemic with a united global effort—enabling good healthcare, provision of affordable essential medicines, and availability of vaccines for the protection of everyone.
Considering the WHO Global Tuberculosis Report 2021 in light of COVID-19
The new pandemic sheds light on an old foe. Page summarises the World Health Organisation's 2021 Global Tuberculosis Report and discusses disparities in vaccine advancement and equity.
In October of this year, the World Health Organisation (WHO) reported that deaths from tuberculosis (TB) have risen for the first time in a decade, a major blow to their End TB Strategy. Simultaneously, global spending on TB declined by 8.7%, falling far below targets. The report attributed the rise in deaths to the impact of COVID-19 on global healthcare capacity and access. This comes as no surprise—you would be hard-pressed to find a single area of healthcare that has not been negatively affected by the pandemic. However, I find that there is something particularly hard to swallow about the increase in TB deaths attributable to COVID-19.
In comparing the response to these two diseases, I do not intend to downplay the devastation that COVID-19 has wreaked upon our world. As of 1 November 2021, the WHO reports that approximately 5 million people have died of the virus since the start of the pandemic, and the effects of COVID-19 go far beyond the death toll, from economic devastation, to mass burnout of healthcare workers, to major disruption to education. The constant headlines, though tiresome, are certainly well-deserved. My question concerns why TB does not receive comparable media coverage—or more importantly, funding.
TB, one of the oldest infectious diseases to affect humanity, has been termed the “forgotten pandemic”. Prior to the COVID-19 pandemic, it was consistently the top single-agent cause of infectious disease death in the world, and it continues to kill approximately 1.5 million people per year. Along with this death toll come the other, less quantifiable effects many of us are much more familiar with now—missed school, financial ruin, and bereaved families. It is difficult to conceptualise the impact of this toll over the span of decades. And yet, because the brunt of the disease burden is borne by countries with lower incomes, TB rarely makes global headlines. TB is a disease of poverty, endemic in areas where many people do not have access to well-ventilated housing or where malnutrition is common. In endemic regions, TB perpetuates inequalities both within and between countries by acting as a constant financial drain on individuals and healthcare systems, stagnating economic development. Cases in most high-income countries are rare and tend to affect marginalised people such as those who are homeless. The dominant attitude towards TB is complacency. The world has decided that this death toll is not newsworthy.
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“In endemic regions, TB perpetuates inequalities both within and between countries by acting as a constant financial drain on individuals and healthcare systems, stagnating economic development.”
Consider the global vaccine response to COVID-19. Mobilisation to develop a vaccine for COVID-19 was swift, a remarkable and unprecedented success. Thanks to financial investment, researchers were able to develop multiple highly effective vaccines in mere months. The most recent data suggests that the Pfizer and Moderna vaccines are 88% and 93% effective at preventing hospitalisation respectively, both very impressive figures. For TB, by contrast, we have one vaccine, the 100-year-old Bacillus Calmette–Guérin (BCG) vaccine. This vaccine works well for preventing disseminated TB in children, but for pulmonary TB, the main contributor to TB deaths, it varies in efficacy from 0 to 80%. For unknown reasons, vaccine efficacy depends on latitude, decreasing closer to the equator—a cruel and peculiar parallel to the geographic gradient of global disease burden.
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We need a better vaccine for TB. In the long-term, this will save the most lives, and even moderate improvements in vaccine efficacy would be cost-effective. Through the hard work of those committed to the cause, there are currently 14 vaccine candidates in the pipeline. However, the funding needed to accelerate vaccine development and improve our understanding of TB is simply not there, despite the fact that investing in TB has high financial as well as population health returns. The unfortunate reality is that research for deadly diseases often does not receive sufficient support until those with the most financial and social capital are affected, as we have seen in the past with the HIV pandemic.
“The unfortunate reality is that research for deadly diseases often does not receive sufficient support until those with the most financial and social capital are affected.”
Most of us in non-endemic regions are lucky enough to not have to think about TB in our daily lives. However, COVID-19 has illustrated that in an increasingly globalised world, infectious disease is everyone’s problem. Although we are far from ending the COVID-19 pandemic, the rapid development of vaccines has shown us what we can accomplish when urgency demands investment. How much longer will the world wait for an effective TB vaccine? We are capable of better. Those affected by TB deserve better.
The WHO Global Tuberculosis Report 2021 can be found here: https://www.who.int/publications/i/item/9789240037021
Can the data speak for itself? Tackling inequalities and exclusions in statistical research
Teresa discusses Professor Rohini Mathur, Dr Mhairi Aitken, Dr Darshali Vyas, and Professor Sherri Rose’s works in using statistical research and data practice to address inequalities in current health systems and medical research.
For years, researchers have unequivocally emphasised the health and social inequalities underpinning many health systems and medical research. On November 17 2021, the Centre for Statistical Methodology at the London School of Hygiene and Tropical Medicine (LSHTM) invited four researchers to discuss efforts to identify and eliminate these. The symposium, Tackling Inequalities and Exclusions in Statistical Research, explored a myriad of ongoing research efforts, particularly those intended to mitigate hidden biases in data practices. In this article, Teresa reflects on the researchers’ work and the ideas presented during the event aimed at ensuring fair decision-making in healthcare.
“…health outcomes are determined by factors associated with ethnicity, not ethnicity itself.”
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Rohini Mathur emphasised that ethnicity data is collected within a wider social context, and is thus shaped by historical, political, and social factors—including racism and discrimination. The influence of the socio-cultural environment on data generation and collection causes problems for the accuracy of ethnicity data itself. For instance, the majority of ethnicity data used in health research is collected from primary care facilities. As such, the data is unlikely representative of the whole population, as it omits people who do not utilise or attend these health services. Moreover, common ethnic categories listed in demographic and diversity surveys are often unsuitable for people that belong to multiple ethnic groups, who may find that the rigid categories do not capture their identities fully. Mathur discusses a case where a patient selected 'White', 'South Asian', 'Black', and 'Other' when asked to report their ethnicity on different days. Due to a lack of appropriate and encompassing categories, current ethnicity statistics will not always accurately reflect the population under study.
Despite these problems, Mathur still believes that using and improving ethnicity data is essential to gain a better understanding of health disparities. Ethnicity data allows researchers to understand how health outcomes in ethnic minority groups may differ from trends observed in more well represented populations. For instance, she and her colleagues studied the differences in COVID-19 infection and related hospitalisation rates across ethnic groups in the United Kingdom (UK). During the first wave, ethnic minority groups had an excess risk of suffering from COVID-19. However, their elevated risk decreased in the subsequent wave. Similar trends have been observed in the United States (US). They further noted that ethnic minority groups may be at higher risk due to a variety of other determinants, such as occupation, household circumstances, and the influence of policies and practices on their health-related behaviours. Mathur concluded that, “… health outcomes are determined by factors associated with ethnicity, not ethnicity itself”. We need to address the wider socioeconomic risk factors that contribute to these disparities, and improved ethnicity data allows us to do so with evidence-based research.
“[Data] ethics is not just about avoiding negative impacts, but it is also about maximising the potential benefits.”
Mhairi Aitken stressed the need to build public trust in research studies. She explained that bias comes in different forms: bias can occur within the crude data, but also during the process of data collection and analysis. For example, unconscious biases can influence how survey questions are formulated and analyses are carried out by researchers. For this reason, it is important that individuals with different perspectives and experiences shape data practices and influence research designs. In order to ensure that researchers do not interpret their findings from a narrow perspective, public engagement and trust in research is needed to gain these diverse insights.
Aitken advised that public engagement can be achieved by raising awareness about the importance of a research problem, consulting with the study population through socially sensitive and appropriate approaches, and empowering the population in conducting socially meaningful and impactful research studies. One way to achieve this is for researchers to begin wide-scale conversations with the general public on the uses of data in health research. Including the public in these conversations can resolve potential concerns in data practice and build public trust. An alternative solution is for researchers and patients to work collaboratively to co-design policies and practices, thereby broadening the process of research analysis by including patient views and experiences.
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Aitken concluded that addressing data ethics through public engagement can both limit negative impacts of research on patients and participants, and also maximise the potential benefits of research for all members of society. Data collection and statistical analysis are useful tools to address inequalities in society, and ethical considerations are needed to support and monitor this process.
“In the conversation of race, the differences between associations and causation should be more explicit.”
Darshali Vyas expressed the view that clinical decision-making algorithms that include race as a risk factor are unlikely to be reflecting genetic differences in observed health outcomes; a more likely explanation is that observed differences in health are due to the effects of racism and social inequalities.
In one of her studies, she discovered that the vaginal birth after caesarean delivery (VBAC) calculator used in the US unfairly discriminates against African American and Hispanic women. The VBAC calculator is used to predict the chance of a successful vaginal delivery. In the US, race is regarded as a risk factor to an unsuccessful vaginal delivery in the predicted model, along with factors such as height, weight, and previous vaginal delivery. This means that, for women of the same age and body stature, African American women may have a lower chance of successful vaginal birth after caesarean when compared to White American women according to the VBAC calculator. As a consequence of this prediction, African American mothers are less likely to be offered vaginal birth than White American mothers. Vyas compared the VBAC calculator used in the US to those used in Canada and Sweden and discovered that the same tool can be useful without including race, implying that race has been erroneously identified as a predictive risk factor. Instead, it is likely that socio-cultural factors, and systemic racism, are more legitimate risk factors in unsuccessful vaginal deliveries for African American women in the US.
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Further, Vyas pointed out that many clinical decision-making tools use White American as the default value and include other races as risk factors. She emphasised that a correlation between race and health outcomes does not suggest that race is really the cause of the observed health disparities. In fact, Vyas explained that much scientific evidence suggests that there is more genetic variation within racial groups than between racial groups. She continued on from this, saying: "In the conversation of race, the differences between associations and causation should be more explicit.”
Vyas concluded that the idea of race should be clearly distinguished from genetic differences that can be traced back by ancestry. She also encouraged professional societies to review tools, create guidelines, and re-evaluate existing race-correction on a case-by-case basis to identify and rethink principles and assumptions that are based on racial discrimination. Many of these small changes will accumulate to create structural change towards greater health equity.
“[Patient] data is not toy data. They are individual people. We need to have respect for data.”
Sherri Rose believes justice and fairness are essential in health research. When tackling a public health or medical problem, researchers usually identify the specific research question, the population they want to study, the social contexts of their data, and the methods and algorithms they plan to use in their data analysis. According to Rose, ethical machine learning and data analysis in health research should involve taking steps to ensure an equitable distribution of health benefits, risks, costs, and resources.
Rose analysed statistical models that health insurance providers use in the US to distribute their funds across health programmes. She discovered that many of these models disadvantage older adults and people with mental illness, as their specific health conditions are not considered in the methods—what Rose termed an ‘algorithmic fairness problem’. To address this problem, she uses a measure called ‘group fairness’ to compare the fairness of an intervention between a group of people with similar characteristics, and between the group of people with similar characteristics and those with different ones. One of her main research aims is to improve equity in healthcare decision-making by including built-in fairness criteria in statistical methods.
When considering the implications of research findings, it is important to remember that “[patient] data is not toy data”. Rose emphasised that patients “are individual people. We need to have respect for data.” In other words, data is not simply a collection of abstract numbers; the numbers reflect individual circumstances and stories. When analysing data, Rose encouraged researchers to examine the human stories, society, and real-world situations behind the figures. In doing so, she hopes researchers will keep in mind that the purpose of statistical analysis is to understand and solve real-world problems—including those that relate to health and social inequalities.
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In closing the symposium, the chair credited the researchers for their contributions to the progress that has been made in resolving previously overlooked biases and unfair assumptions. However, social inequalities continue to translate into health disparities, and we must keep building on the advancements that have been made thus far. More research and policy plans that target these inequalities are needed to create a healthier and more equitable society.
The article represents the author’s understanding and reflection of the symposium event. It does not speak on behalf of the four researchers. Importantly, the KHR acknowledges that the researchers conscientiously used the terms 'race' and 'ethnicity' to convey their points. We recognise the overlap between both terms and appreciate that they can have different meanings and connotations for various readers. Further information on the symposium and the speakers’ research can be found on the LSHTM Centre for Statistical Methodology’s webpage.
Researcher Bios
Rohini Mathur is an epidemiologist specialising in health equity research at LSHTM. Her work involves investigating the quality and completeness of ethnicity data in the United Kingdom and how electronic health records and cohort data are used in health research.
Mhairi Aitken is an ethics fellow of the public policy programme at the Alan Turing Institute. She is a sociologist who researches the social and ethical dimension of digital innovation and has a particular interest in the role of public engagement in data practice.
Darshali Vyas is currently a resident physician in medicine at Massachusetts General Hospital. She has researched the flaws of race-based clinical decision calculators and explored how these race-based prediction algorithms may perpetuate race-based inequalities.
Sherri Rose is an associate professor of the Centre of Health Policy at Stanford University and Co-Director of the Health Policy Data Science Lab. She is interested in developing and integrating statistical machine learning approaches to improve human health.
The new red scare: how rhetoric shapes the US healthcare system
Page argues that the rhetoric surrounding universal health care often plays into fears and misconceptions about a lingering socialist threat in the US, preventing the implementation of a more equitable and effective healthcare system.
“The current system is both economically inefficient and inequitable, and there is no reason that universal healthcare could not be implemented for a reasonable price tag.”
It is old news at this point that the United States (US) is one of the richest countries on the planet, but consistently ranks low across multiple metrics of healthcare quality in comparison to other countries with a similar gross domestic product (GDP). While there are many factors that contribute to the difficulties of delivering healthcare consistently across the US (not least its sheer size), the fact remains that among its higher performing peer countries, the US is the only country that does not have some system of universal healthcare.
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Support for universal healthcare among the American public has risen in recent years. Despite this, the idea of actually implementing it remains highly controversial, ostensibly due to the concern that it would be exorbitantly expensive. However, in reality, the US spends vastly more on healthcare per person than its peer countries with universal healthcare systems. In 2019, the US spent an eye-watering 17.7% of its GDP on healthcare, with nearly half of that coming from federal, state, and local governments. By contrast, Japan spent 10.9% of its total GDP on healthcare in the same year, and Germany 11.2% in 2017. In 2019, 10.2% of the United Kingdom’s (UK) total GDP went to healthcare, 79% of which was government funding. In other words, the US government is spending nearly the same percentage of its funds on healthcare as the UK government, but US citizens are more than doubling the country’s expenditure through insurance payments and out of pocket costs. The current system is both economically inefficient and inequitable, and there is no reason that universal healthcare could not be implemented for a reasonable price tag.
Here, I am not interested in discussing in detail the breakdown of US healthcare spending. Rather, I ask you to consider why the fallacy that universal healthcare would be unfeasibly expensive has persisted, when universal coverage has been achieved many times in other countries at much lower per capita costs than those in the US currently incur.
Healthcare is a highly political issue in the US, and much of the rhetoric surrounding universal healthcare seems to be left over from the Cold War. During the lead-up to the 2020 presidential election, universal healthcare (under the title “Medicare for All”) was, for the first time, floated as a legitimate policy position by multiple candidates. During this time, Fox News talk show host Tucker Carlson said, “Medicare for All is actual socialism, ‘for real’ socialism … Why do you think we don’t have it already? Because we can’t afford it.” He then proceeded to paint a vivid image for his three million some viewers of then presidential candidate, Senator Elizabeth Warren, having “complete and unquestioned control of America” under Medicare for All. “She is the most powerful person in the world—you can almost hear her repeating the phrase to herself,” he lamented.
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It may be unclear to the viewer what Mr Carlson’s definition of “socialism” is, but whatever it is, it’s bad. One imagines Senator Warren lording over the American populace with an iron fist as they are forced to give up their dental coverage to pad her coffers in the era of “socialised medicine”. This Red Scare-esque use of language is nothing new—The Affordable Care Act (ACA), colloquially known as Obamacare, was subject to similar rhetorical treatment by conservative political commentator Bill O’Reilly in 2014, and by Fox News: “Obamacare is much more than providing medical assets to the poor—it's about capitalism versus socialism.” Further examples abound; the ACA has been variously referred to as “the crown jewel of socialism” and a “centralised health dictatorship”. Former presidential candidate and MD Ben Carson once proclaimed, also on Fox News, that Vladimir Lenin had called socialised medicine “the keystone of the arch of the Socialist State”. This quote has not actually been linked to Lenin, and was likely fabricated during the 1940s when the American Medical Association launched a propaganda campaign against one of the first universal healthcare bills. This rhetoric, especially in spoken language, is successful because it plays off American distrust of big government, values of self-sufficiency, and belief in free-market capitalism; it is designed to induce a response of fear.
But let’s look at the facts—compared to peer countries, the US has low life expectancy; high infant and maternal mortality; high rates of teen pregnancy and sexually transmitted infections; high disability prevalence; and high rates of diabetes, heart disease, chronic lung disease, and obesity. A recent analysis also found that in addition to health outcomes, the US ranked last among 11 other high-income countries in terms of access to care, administrative efficiency, and equity.
“The first step to developing a system that works for everyone is to end fearmongering and combat misinformation.”
The issue, clearly, is multifaceted, and there are no easy answers. Some of the issues with the system overlap with larger inequalities within the country; for instance, the US has much wider disparities in access to care by income than its peer countries, and black mothers have higher rates of maternal mortality regardless of socioeconomic status or education. However, costs are high across the board compared to peer countries. In a recent analysis, 22% of US patients recorded serious problems paying medical bills, over twice as high as the next highest country, France. 34% of US patients reported their insurance denying or underpaying for care, again double the next highest country’s rate. It is worth noting here that increasing insurance coverage only does so much when insurance fails to cover costs. In 2017, over half of those experiencing catastrophic healthcare costs in the US were insured. Even for those who can afford coverage, medical bills can be devastating when a sudden illness or injury occurs.
The misconceptions surrounding universal healthcare in the US must be addressed. Many Americans worry that universal healthcare would increase their wait times or restrict their choice of provider. In reality, other countries with universal coverage have achieved comparable or even lower wait times, and even in the UK’s single payer system you are perfectly at liberty to choose which practice you attend. In fact, in some countries with universal coverage, such as Germany, many citizens opt for private insurance. Others are concerned that adopting a universal system would increase administrative costs; however, the US already devotes a larger proportion of its health spending to admin than its peer countries with universal healthcare.
I am certainly not equipped to offer an easy solution here. The American healthcare system is a vast and complex entity, and what works well in any other given country may not be the best solution in the US. However, I can say that no one should be left with the double burden of a dead loved one and a six figure hospital bill, or die from rationing insulin after aging out of their parents’ insurance plan. The first step to developing a system that works for everyone is to end fearmongering and combat misinformation. No, universal healthcare will not send us hurtling back through time and space to the USSR. But it just might save a few bucks—and a few lives.
Why don’t our doctors look like us?
Dhruv illustrates why doctors often do not reflect the populations they serve through the stories of two medical students.
“Privilege is when you think something is not a problem because it is not a problem to you personally”
I’ve spent the past five years mentoring and guiding students who are underrepresented in medicine (URiM) through medical school admissions in the United States (US). With their permission, I will share two stories to highlight some of the systemic causes for why doctors often do not reflect the populations they serve.
Andre identifies as African American and was born and raised in northern California. Although he faced many challenges growing up, he persevered and graduated from the University of California, San Diego (UCSD). Andre’s educational background was astounding: not only had he graduated from UCSD with a 3.95 grade point average, but along the way he had published four papers in the field of molecular biology and was working as a medical scribe in a primary care clinic in Sacramento. However, when Andre sat for the US Medical College Admissions Test (MCAT), he scored in the 48th percentile—a score completely incongruent with his intelligence. After learning more about how he had prepared for the exam, it became quite clear why he scored lower than he was capable of. Andre was whip-smart and great at taking exams, but he didn’t know which resources to utilise and how to effectively prepare for a standardised test. No one had told him which question banks to buy, what books were the best, or how to develop a long-term study plan. The MCAT isn’t just any college exam; it often requires strategic knowledge and information privy to those with rich networks and resources. Once Andre had that information, he scored in the 97th percentile and is now a medical student in California pursuing primary care. Andre’s story shows how standardised tests are about more than a student’s intrinsic ability and will to achieve; they reflect the privilege and inaccessibility of higher education. There are also the temporal and monetary costs of taking the exam. Taking the MCAT once costs about $300 and students study for 30–40 hours per week for about three months. Both present additional obstacles for an exam that is touted as an equaliser in the field of medicine.
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“Standardised tests are about more than a student’s intrinsic ability and will to achieve; they reflect the privilege and inaccessibility of higher education.”
Tiffany lives in San Francisco and attended school on the East Coast of the United States. She aspired to go to medical school so she could be a physician in the community she grew up in. She speaks Vietnamese and understands the culture and background of her neighborhood. Previously, Tiffany was a stellar student and earned excellent grades and test scores, but her obstacles lay beyond her report card. Her extracurricular list was much shorter than her colleagues. Coming from a lower income household, she worked two jobs during her undergraduate to make ends meet. This meant she couldn’t pursue the same opportunities in research, community service, and unpaid clinical work as her classmates. I could feel her concern, worry, and lack of confidence. Despite her hard work, Tiffany did not see herself as an equal and valuable participant in the application process. She felt behind her classmates, and imposter syndrome settled into her psyche. Tiffany recently scored in the 90th percentile on her MCAT, and is now working as a medical technician at an ophthalmology clinic with plans to apply to medical school next year. Situations like Tiffany’s are sadly common, where bright students who would excel in medicine simply don’t have the money, either from their own pockets or from their family, to finance a diverse and impressive list of extracurricular activities. These students have no choice but to take a gap year (or more) to slowly build up an extracurricular list that can compete in the admissions battleground. Many students become consumed by these gap years and lose interest in a career in medicine. A truly equitable system should create opportunities for students, regardless of their financial situation.
Today, medical education includes a renewed focus on understanding and accommodating our patients’ backgrounds, and there has been much research into the benefits of a diverse physician workforce. These studies largely revolve around the idea that concordance between physicians and patients promotes greater understanding of the socioeconomic and cultural determinants that play a role during a given patient’s healthcare. To achieve such goals, the medical education system must create pathways to success for students who will represent and contribute to a diverse physician workforce so that one day our doctors look like our patients.
“The medical education system must create pathways to success for students who will represent and contribute to a diverse physician workforce.”
Through photographs Franca shares her own day-to-day experiences working as a non-local Research Assistant in The Gambia.
Potential health benefits of companion animals
Akshay shares his love of companion animals with us and enumerates the (evidence-backed) benefits of having pets.
The feeling of coming home to an excited furry friend wagging its tail is unparalleled. Ask anyone with pets how their lives have been enriched and every single one will come up with a long and compelling list of benefits. It is perhaps due to the pandemic lockdowns and ensuing isolation that millions of people across the world have adopted pets over the last year. In the United Kingdom alone, nearly 3.2 million households welcomed pets into their homes. Given this current trend, it seems like a relevant time to explore the science behind the health benefits of companion animals.
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Mental health benefits
Pets can be cuddly, loving, and a great source of companionship. Dr. Gregory Fricchione observes, "We do best medically and emotionally when we feel securely attached to another, because we're mammals and that's the way we've evolved.” According to Fricchione, we are particularly comfortable with cats and dogs because they convey a feeling of unconditional love.
“Having a pet during childhood and adolescence has a wide array of mental health benefits.”
A number of scientific studies provide evidence for the benefits of such human-animal companionship. Having a pet during childhood and adolescence has a wide array of mental health benefits ranging from improved self-esteem, reduced feelings of loneliness, increased social competence, and even an improvement in intellectual and cognitive abilities. Among the elderly, companion animals can improve quality of life and reduce symptoms of depression, anxiety, and behavioural and psychiatric symptoms of dementia. Having a pet, however, can also have negative effects on our mental health. While people living with mental health problems do experience the benefits outlined above, they are also exposed to additional risks, such as the psychological distress of losing a pet.
Physical health benefits
Pets can also help with our physical health. Having a pet can encourage people to go outside and exercise; people with dogs, for example, walk more and engage in more physical activity than those without. In the case of certain diseases, there is some evidence to show that having a pet is associated with reduced severity and lower mortality: studies indicate, for example, that people with pets have a lower prevalence of systemic hypertension and lower adjusted cardiovascular mortality.
When should you perhaps think twice about getting a pet?
While there are health benefits to having a pet, there are specific situations in which having one may not be advised. For people with mental health conditions, the distress of losing a pet can be significant; in times of crisis, this grief can exacerbate a mental health condition that they may already be struggling to manage. As for risks to physical health, people with weakened immune systems, and those undergoing cancer chemotherapy, ought to take precautions to avoid contracting zoonotic diseases—those transmissible between animals and humans. For pregnant women, the Centres for Disease Control advises against handling new or stray cats so as to avoid the risk of contracting toxoplasmosis, a parasite-borne illness that can lead to birth defects.
For those not subject to such concerns, however, the benefits of a companion animal are compelling. If you are contemplating getting a cuddly, furry-tailed friend, and cannot resist those puppy dog eyes at the shelter, then do not worry, for science is on your side.
Minding the grocery gap
Maria discusses the impact the climate crisis has on our global ability to attain the most fundamental human need: access to proper food.
Abraham Maslow’s ‘hierarchy of needs’ positions the lowest rung to be that of physiologic needs: the need for food is the base of any living being’s existence before all other needs. Recent times have proven this to be a challenge, with more and more people across the globe having less access to sufficient and nutritious food. In their latest report on the State of Food Security, the Food and Agriculture Organization (FAO) noted that globally there is a lack of resources to end world hunger and malnutrition by 2030. A 1.5% increase was seen last year alone due to the pandemic, causing the prevalence of undernourishment (PoU) to reach 9.9%, or about 720 million people in 2020. Generally, high-income countries are those that are most food secure with Ireland, Austria, and the United Kingdom holding the highest ranks. Contingently, countries holding the lowest spots are those with low incomes, with African nations having the least food security. One in five people are facing hunger in Africa according to the FAO, which is double that of other regions in the world. Child malnutrition is also, accordingly, most prevalent in regions with little food security. Worldwide, 149.2 million children under the age of five years suffer from stunting, with the majority living in sub-Saharan Africa, Central Asia, and Southern Asia. In the year 2020, almost all countries with low and middle incomes recorded an increase in the PoU five times greater than the highest increase in the past 20 years.
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The burden of food insecurity is not only pressed upon the shoulders of countries with low and middle incomes. In fact, low food security is also pervasive in countries with high incomes, such as the United States (US). The United States Department of Agriculture (USDA) revealed that 8.6 million Americans currently live with low food security, and one out of four households experienced some form of food insecurity in 2020. With the onset of the pandemic, more homes have experienced food shortage as a result of jobs being terminated. One of the most affected populations are children: close to 14 million households in the US with low food security are homes with children.
An issue that gravely affects food security is the climate crisis. According to the Intergovernmental Panel on Climate Change (IPCC), the rising temperatures, increasing episodes of extreme events, and changes in precipitation have already affected yields for certain crops. Moreover, an increase in cases of heat stress has been observed for some fruits and vegetables as higher temperature speeds up their development cycles leading to yield losses, decreased quality, and in the long run, higher food wastage. The rise in greenhouse gas (GHG) emissions is also attributable to current food systems, which adds up to 21–37% of total emissions. Among these, crop and lifestyle activities account for 9–14%, and land use, land-use changes, and deforestation contribute to 5–14%. The IPCC found that supply-side practices can opt for alternative activities such as reductions in use of certain fertilizers, soil carbon sequestration, better grazing land management, and using higher quality feeds to mitigate their contribution to the climate crisis. Moreover, a reduction in food loss and waste could also lower GHG emissions and, in turn, improve food security since food loss and waste account for 25–30% of total food produced, generating 8–10% of total anthropogenic GHG emissions. As such, a means to address food insecurity from the demand-side could involve mindful purchasing of food to lessen food loss and wastage.
Having access to proper food ensures that a person is getting good nutrition to live a healthy life, in turn lessening their chances of going to the hospital or falling ill. As such, any effort to improve food security by mitigating the climate crisis will inherently create a more healthy population. The provision of sufficient access to food is a means to bridge the gaps in social inequities, allowing people to move up Maslow’s hierarchy of needs towards the pinnacle: self-actualisation.
“Any effort to improve food security by mitigating the climate crisis will inherently create a more healthy population.”
Unregulated prescriptions
Clive and Anandita discuss how healthcare inequities across India provide fertile ground for unregulated medical practice, contributing to growing antimicrobial resistance in rural populations.
How the perilous state of India’s healthcare system is contributing to antimicrobial resistance
Universal health coverage (UHC) champions easy access to health services, whenever needed, and at an affordable cost. Alas! In reality, UHC is a privilege for marginalised communities all over the world, such as those inhabiting the wilderness of Chhattisgarh in central India.
Health inequity prevalent throughout India is magnified in this region for many reasons. One being the perennial conflict between the Indian government and the Maoists—a conflict fueled by a myriad of factors, such as the government’s exploitation of the mineral-dense region. These ongoing clashes have hindered development in the region, including the urgent development of formal health services. As a result, the nearest and only hospital is often tens of miles away. Moreover, due to a history of colonialism and exploitation of these indigenous lands, there is widespread distrust in government facilities—like hospitals—that further dissuade locals from seeking healthcare. Lastly, access is often limited as roads tend to be poorly constructed and transport services are sparse. With the implementation of COVID-19 lockdown measures, these villages have been severed from links to high-quality biomedical healthcare. Working within these communities during the COVID-19 pandemic, we witnessed how the villagers’ wariness in seeking healthcare services was reinforced as misinformation regarding COVID-19 swirled. Such misinformation further deterred them from accessing hospital services and added to the burden of morbidity and mortality in the population.
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Although the issues around health inequity in this region are complex and there is no quick fix, a notable and rectifiable cause of inadequate healthcare is the shortage of formally trained medical professionals. Inequitable distribution of biomedically trained doctors between urban and rural areas means that patients lack formal consultation and advice when they do seek out healthcare. This scenario can be summed up as the inverse care law: the “availability of good medical care tends to vary inversely with the needs of the population served”. In turn, the lack of good medical care creates fertile ground for the growth of informal healthcare services.
“Lack of good medical care creates fertile ground for the growth of informal healthcare services.”
In India, the shortage of doctors has led to the emergence of “self-taught” doctors known as rural medical practitioners (RMPs). Despite their lack of formal qualifications and training, their services are availed by 67% of the people in India requiring healthcare attention. As per reports, 57.3% of those practising allopathic medicine did not have a medical qualification in 2019. RMPs thrive due to the strong relationships cultivated with the population they serve, providing them with emergency care and consultations at home for low fees. These gaps in the formal public healthcare system have even forced the Ministry of Health (MoH) to recognise these practitioners in certain states, deploying them to primary healthcare centres and sub-centres, and training, certifying, and advocating for their involvement. Additionally, and alarmingly, the patronage and incentives of nascent pharmaceutical companies motivate the RMPs to prescribe expensive and unnecessary medications—including antibiotics—to patients. Erroneous prescription of antibiotics raises the risks of antimicrobial resistance (AMR), which is the process in which bacteria become resistant to treatment after repeated misuse of antibiotics, meaning the drug is no longer an effective cure. Although some might argue that unqualified healthcare providers have been saving people’s lives in rural regions, allowing them to distribute medicine without adequate training is arguably a shoddy attempt to seal the cracks in a dysfunctional healthcare system.
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The misuse of antibiotics and subsequent rising levels of AMR demonstrate the harmful side effects of this patchwork system. Antibiotics are included in the Drugs and Cosmetic Rules (1945) in India and are required to be sold by retail only under the prescription of a Registered Medical Practitioner. However, given the hapless state of the healthcare system and the absence of adequate legal regulations, antimicrobials are being sold to consumers whether or not they have a prescription. Members of the general population tend to approach pharmacies and RMPs due to their ease of accessibility, yet they are usually unaware of the drugs being given to them, let alone their side effects. Most often, these drugs are provided in high doses exceeding the therapeutic limit or sometimes in subtherapeutic doses. Additionally, many misconceptions circulate amongst the population celebrating antibiotics as powerful drugs that can bring about quick relief to their ailments. Smaller drug shops are also driven by larger pharmaceutical companies to promote their brands to maximise profits, despite generic drugs being significantly cheaper. Thus, considering the financial component, the cost of superfluous antimicrobial medications dispensed by pharmacies in India is estimated to be between 1.1 and 1.7 billion dollars.
“Given the hapless state of the healthcare system and the absence of adequate legal regulations, antimicrobials are being sold to consumers whether or not they have a prescription.”
The situation in India forms just the tip of the iceberg. AMR is a global threat: it is projected to cause around 10 million deaths globally by the year 2050. However, its burden is disproportionately higher in countries with lower incomes. Weak infrastructure and inadequate preventive measures, widespread corruption, and mismanagement in lower-income countries have led to a high burden of infectious diseases. The provision of clean water, sanitation, and hygiene could break the chain of transmission of infections and would reduce the need for treatment and curb the chance of developing AMR. For instance, reports from four middle-income countries (including India) have shown that with universal access to safe water and sanitation, the use of antibiotics for the treatment of diarrheal diseases would reduce by 60% from the current 500 million courses.
Interventions in the form of global public awareness to educate the general population about antibiotic resistance is vital. India launched the ‘Red Line Campaign’ to restrict the misuse of antibiotics by discouraging self-medication, learning to identify prescription drugs (through a red line printed on the packet), the importance of completing the full course of antibiotics, and so on. This novel initiative needs to be commended. However, the results so far have not been very promising, and the application needs to be further strengthened.
India spent only 3.8% of its GDP on healthcare in 2018. This has led to the vast healthcare inequities and disproportionate allocation of resources, especially in rural areas. In an ideal world, a well populated country like India would be free of RMPs and other forms of quackery. However, the current scenario suggests attempts to eliminate such practices have been futile so far. Instead, the government must make the best use of the RMPs as human resources through formal training and guidelines—such as those for community health workers in India. Detailed guidelines and protocols would outline the roles and responsibilities of RMPs, including diagnosing and treating basic illnesses while stressing the avoidance of handing out antibiotics. Emphasising the immediate referral of complicated cases would decrease the hesitancy of RMPs to refer to higher centres, and official integration of RMPs at the grassroot levels of the healthcare system would abolish their unregulated practices.
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Along with better training of RMPs, expansion, reinvigoration, and implementation of stringent laws aimed to curb imprudent dispensing of over-the-counter antibiotics and other drugs along with strict vigilance is requisite. Pharmacists need to be repeatedly trained, via continuing medical education and workshops, for proper dispensing of antibiotics and how it impacts AMR. Lastly, regulatory bodies should aim at instilling a sense of responsibility within the pharmacists themselves.
AMR is a global issue and is not restricted by international boundaries: we are all so well connected that microbes constantly cross borders with us! Global action is therefore essential to make meaningful progress over the long term.
It is time we do more than just ponder: antibiotic resistance anywhere is a risk everywhere!
Artist spotlight: David
Gwen features the works and journey of artist, photographer, and entrepreneur, David. David advocates for physical and mental wellbeing to support the health of communities.
Content warning: this article contains mentions of racism and mental illness.
Back in 2019, David Lee turned his camera towards me. I felt self-conscious and suddenly didn’t know how to be natural in my own skin. But his approach to photography centred on connection and introspection, which made the experience more like a cathartic release than a purely aesthetic pursuit. He gave me the opportunity to talk about the things that were on my mind and reminded me how to be myself again. David and I met as community advocates who were still exploring the ways that we fit into supporting the social, environmental, economic, and health needs of our microcosm of community. Most of our conversations were about how we work in relationship to the community and how we take care of ourselves. That night in my flat we had the same conversation but somehow it felt more vulnerable to have a camera there and to have it be documented: at the same time, it was therapeutic to have those moments preserved. David has taken that intimacy of documentation and turned it into his full-time pursuit as a photographer and artist.
Photography by David Lee
Creativity has always had a place in David’s life, but his emergence as a creative was tangled with his identity and wrangling with others’ perceptions of him. He recalls that different learning environments impacted the reception of his art by his teachers. Early on he was not encouraged to pursue art, which raised larger questions on how stereotyped identities, specifically expectations of black people, can hinder and limit growth. “I think sometimes black people are expected to perform in certain ways … looking back I didn’t get the encouragement like my peers did, and I won’t say why, but I noticed that, and it got to me.”
Photography by David Lee
Initially, this kept David from identifying as a creative. It wasn’t until middle school that his poetry was recognised and won a competition. “I remember winning that and the first time feeling like I was a creative. Like my school actually did think it was a big deal. The school was majority black and that was the first time I went to a predominantly black school.” This recognition and ability to self-identify as someone who is creative gave David license to continue exploring his art, which soon led him to photography.
His exploration of photography began as an ode to memories and an outlet for his own depression. Looking through old family photos in what his family called their “library”, David became interested in photos and memory. “These memories are important. I realised how important they were to me. So, I went and bought a bunch of disposable cameras and went around taking pictures of middle school.” Reflecting back on this period of time, David recounts some of his own struggles with depression and finding photography and poetry as a means of dealing with his own internal world.
“I can see that’s when my childhood depression started to manifest the most and so I needed these outlets. Friendships were starting to look weird … my art usually centres around mental health and trying to create these outlets of expression so people can process and see themselves reflected back. I think that’s when it started for me.”
Photography by David Lee
Memories of middle school years are ones he has shared with me a couple times, and it brings together so many aspects of David that I’ve come to know. He has an incredible ability to capture vulnerable, authentic moments. Part of his art is tapping into the undercurrent of a moment and pulling out the right words and images that describe some of those unspoken emotions. Photography is his way of slowing things down in an age of hyper-stimulation. “It’s a chance to press pause and allow people to go back to that moment and think about what they were feeling and see the subtleties of who they are”. Oftentimes, David shares his photos with poems and prose about that moment, the interaction, or what the experience brought him. Whenever I see David’s work, photography and poetry paired together, there is no doubt it’s his voice and vision that come through.
Photography by David Lee
“Photography is his way of slowing things down in an age of hyper-stimulation. “It’s a chance to press pause and allow people to go back to that moment and think about what they were feeling and see the subtleties of who they are.””
During the summer of 2020, George Floyd was murdered. Black Lives Matter protests spread across the United States and around the world. David was there—documenting through his lens the rawness of the people, the protests, the events, and the emotions.
The pandemic was ongoing in the backdrop, which brought into sharp focus health inequities, particularly in black communities. The broader social conversation around racism, critiques of the carceral system, and health inequities shifted—it was suddenly more critical, urgent, and mainstream. “During those protests I realised this wasn’t my space anymore. I started to see allies showing up and screaming at the top of their lungs, with signs and linking arms on the frontlines. Like ‘Huh, cool it’s been done’ and it felt like the energy shifted. So where do I need to go if this isn’t the space, because the work needs to continue. I chose physical health, community, and mental health. Getting outdoors was the way to do it.” The protests in 2020 felt different to him and having allies show up in those spaces offered David the flexibility to do the work he really wanted to do. This was when he transitioned to being a full-time co-founder and photographer.
Photography by David Lee
Choosing the name of his organisation was an act of radical self-naming and claiming an identity. David reflects: “How is that going to come off to people, is that marketable? But in my community it’s important to say this is who we are and not allow other people to dictate what our expression should be. … So, I started the organisation Negus in Nature (NIN) with my business partner Langston”.
Within NIN, David is in his element—sharing the joys of the back country while documenting a community becoming connected with their mental and physical wellbeing outdoors. He’ll be starting his artist residency at the Kala Institute, which will give him access to an array of mixed media materials. He’s really excited to be sharing some of his new works coming up as he says, “A lot of the protest photos I have not shared yet because it’s like ‘aight this is raw and I don’t know what this is for just yet … and so now everything is coming together and it’s this collective idea of ‘this is where I was in the pandemic and this is where I was before and this is the processing.’” He wouldn’t share much more about his upcoming project, but he’s dreaming up something with paper mâché, dabbling into the world of mixed media.
Stay up to date with David’s projects on Instagram: @d.xoti
You can follow NIN’s adventures on Instagram: @negusinnature
If you want to sign up for an excursion you can visit NIN’s website
Medicine man: the Stan Brock story
In advance of its international premiere at the Global Health Film Festival (25 Nov–5 Dec), Rosalie Hayes reviews Medicine Man: The Stan Brock Story which recounts the remarkable life of Stan Brock and his founding of the charity Remote Area Medical.
Film review
Image credit: Medicine Man: The Stan Brock Story
Year: 2020
Director: Paul Michael Angell
Language: English
Rating: Entertaining 4/5 | Informative 4/5 | Inspiring 5/5
“Part cowboy, part naturalist, part lots of other things—he is in many ways a baffling man.” So begins Medicine Man: The Stan Brock Story, a documentary focused on the remarkable life of Stan Brock and his founding of the charity Remote Area Medical (RAM).
The film charts Stan Brock’s life from humble beginnings in Preston, Lancashire to living as a vaquero, a barefoot cowboy, amongst the Wapishana people in what was then British Guiana. A chance meeting with a TV producer from Chicago eventually led to Brock presenting a hit wildlife TV show and starring in Hollywood films. But by 1985, he decided to take a different path, founding RAM with the intention of providing basic healthcare to people living in the most remote areas of the world.
Brock’s unusual early career may be what draws the viewer in, and understandably constitutes a significant chunk of the documentary, but he is the first to point out that it’s “not important really”. Indeed, any admiration one has for his resilience as a young man is tainted by his complicity in a colonial administration and his former disregard for the Wapishana people (which he later regrets). Instead, it is what he and the 135,000 volunteer clinicians have achieved through RAM that is truly extraordinary.
Despite its original intention to serve remote regions of the world, RAM soon turned its focus to the 50 million people without access to healthcare in the world’s richest country: the United States (US). Although RAM operates on a shoestring budget and Brock takes no salary, it has delivered free healthcare to nearly one million Americans since its inception. Scenes from RAM’s pop-up field hospitals in some of the most impoverished areas of the US, including the gratitude with which RAM patients receive their care, are moving to witness.
While the issues raised in Medicine Man: The Stan Brock Story won’t be news to anyone even vaguely familiar with the US healthcare crisis, it’s hard not to be shocked by the image of hundreds of people camping for days on the pavement so that they can receive basic medical care. The film powerfully showcases the human impact of the politicisation of healthcare and serves as an urgent reminder of the fragility and inadequacy of US healthcare reform. RAM patient Dee Bailey puts it best when she exclaims:
“In the land of the free and the home of the brave, it’s hard. In America it shouldn’t be this hard.”
Medicine Man: The Stan Brock Story is being screened live at the Global Health Film Festival on Wednesday 1 December, followed by a panel discussion including the director, Paul Michael Angell. Global Health Film Festival is the annual flagship event of Global Health Film, a UK charity promoting the power of storytelling in global health. More information and tickets can be found on their website.
Two birds with one stone
Clare discusses the impact of low wages on the care sector in the UK and how a pay increase will not only help the social care staffing crisis, but also local economies.
Levelling up through social care sector pay rises
Image credit: Unsplash
The need for reform within the United Kingdom’s (UK) adult social care sector is indisputable. A national conversation is essential to determine how the nation funds and structures the social care sector. Regardless of what is ultimately decided, the sector requires a labour force that is sufficient to meet the UK’s growing need for social care.
Any restructuring of the social care sector will need to address its existing staffing deficit, which in 2019–2020 stood at over 100,000 unfilled vacancies, or 6–7% of the entire workforce. Unless something is done, this staffing crisis is set to increase: it is estimated that the sector will require an additional 490,000 staff by 2035 to meet the demands of increasing morbidity within an aging population.
“The sector will require an additional 490,000 staff by 2035 to meet the demands of increasing morbidity within an aging population.”
What accounts for the social care staffing crisis? Simply put, other sectors of the economy—such as retail—provide better wages, working conditions, and more opportunity for career progression in roles that require far less responsibility. Although social care can be incredibly rewarding, it involves long hours of physically and emotionally demanding work, placing the responsibility of administering medication, providing personal care, and managing the welfare of some of the most vulnerable members of society onto overstretched staff. The median value assigned to this work is £9.01 per hour*, and 72% of care workers are paid less than the ‘real living wage’—pay that is commensurable with the cost of living.
Increasing wages is not only a moral obligation but also a practical necessity. The ongoing Heavy Goods Vehicle driver shortage in the UK demonstrated that increasing wages can surmount recruitment challenges for roles that were previously viewed as less desirable. However, while the private sector was able to swiftly raise wages to make these roles more appealing, the care sector cannot do the same.
Image credit: Unsplash
“Increasing wages is not only a moral obligation but also a practical necessity.”
Profit margins are narrow in the social care sector, and with staffing costs being the greatest expenditure, there is little leeway for providers to increase wages. Similarly, it is difficult for the sector to increase its revenue as care providers are typically commissioned by local authorities. Moreover, austerity and funding cuts have further stretched local authority budgets, meaning that the maximum threshold councils are able to pay for social care is insufficient to raise staff wages. The sector is thus unable to adjust for the disparity between the demand and supply of the social care labour force itself, and requires government intervention and financing to offer higher wages and encourage recruitment.
In-work poverty in the UK is rising with dire consequences. In the social care sector, low wages meant that many care staff could not afford to isolate during the early stages of the pandemic. It doesn’t take much to consider the broader consequences of these poverty wages on the health and wellbeing of social care staff. Government intervention to ensure that social care staff receive at least (but preferably above) the real living wage would reduce poverty, and improve the living conditions of employees—particularly those who live and work in cities with high living costs.
Higher wages for social care workers in more deprived areas would have additional benefits for local economies. The demand for social care is likely greater in these areas as a result of higher morbidity rates. Therefore, paying social care staff enough to provide them with a moderate amount of disposable income could inject much-needed capital into more deprived communities. Increased expenditure by social care staff would stimulate the local economy, providing opportunities for local businesses to grow and to hire new staff. Thus, increased spending by social care staff will lead to greater economic growth and rejuvenation of local communities.
“Increased spending by social care staff will lead to greater economic growth and rejuvenation of local communities.”
Opponents of this proposal are likely to argue that increasing wages of care staff would require wage increases for all other staff in the health sector and point to the considerable amount of government spending required to do so. However, as health sector employees have experienced significant real-term pay cuts since 2010, a public sector pay rise is arguably long overdue. To which the question remains: how do we pay for a large public sector pay rise?
An increase in health and social care sector wages need not trigger immediate tax hikes. Instead, increasing wages should be viewed as an investment in local economies which currently experience high levels of unemployment and deprivation—local economies which previously thrived owing to the well-paid jobs provided by large-scale manufacturing plants. However, the opportunity to exploit cheap labour elsewhere has made it financially unappealing to continue to manufacture goods in the UK and many of these jobs have been lost as a result. Governments frequently offer tax breaks and incentives to entice large scale employers to establish themselves somewhere, with expectation that the employment provided by these firms would provide the surrounding area with economic stimulus.
Image credit: Unsplash
Some communities—like those in the South Wales Valleys—have experienced successive waves of employment and unemployment arising from the repeated opening and closing of such factories. Instead of unpredictable cycles of employment and redundancy, local communities need a sustainable source of large scale, well-paid employment that requires few formal qualifications. Given that the care sector can provide this, costs to the taxpayer of increasing their wages would be offset in the long-term by the increase in local prosperity. If there are few qualms in providing private tax breaks and financial incentives to large companies to set up shop in the UK, why should there be any resistance to increasing care sector employee wages through similar means?
“If there are few qualms in providing private tax breaks and financial incentives to large companies to set up shop in the UK, why should there be any resistance to increasing care sector employee wages through similar means?”
Boris Johnson’s government has been vocal about their desire to “Build Back Better” and “level-up” the nation—slogans intended to affirm the government’s commitment to “reduce inequality between places while improving outcomes across all places” in the UK. The use of this rhetoric has even resulted in the government renaming the ‘Ministry of Housing, Communities, and Local Government’ the ‘Department for Levelling-Up, Housing, and Communities’. However, the contents of the Autumn 2021 Budget along with the recent decision to increase employee’s National Insurance tax does not demonstrate a real commitment to tangibly reducing inequalities. Much like the lack of substantive plan to fix the social care crisis, the verbal commitment to addressing health inequalities may also be bluster. However, if the government were serious about addressing both issues, they could kill two birds with one stone by increasing funding for local authorities to earmark for social care sector wages: increasing health and care sector wages would improve living conditions, while also levelling up local economies in deprived communities.
* The government’s national minimum wage for anyone over the age of 23 is currently £8.91; however the real living wage (the amount someone needs to live on) is set as £9.90 across the UK and £11.05 in London.
Covid by numbers: making sense of the pandemic with data
Joanna Hindley reviews Covid by Numbers, in which statisticians David Spiegelhalter and Anthony Masters distill how we might “data” our way out of the pandemic.
Book review
Year: 2021
Authors: David Spiegelhalter and Anthony Masters
Rating: Entertaining 4/5 | Informative 5/5 | Inspiring 4/5
Image credit: Penguin Books
The COVID-19 pandemic saw conversations about data thrust into the mainstream as never before. Reproduction numbers (‘R’ numbers) and the relative efficacies of different brands of vaccine were not only discussed in academic journals and at conferences, but in newspaper headlines and ministers’ speeches. During this time, individuals such as Professor David Spiegelhalter and Anthony Masters became familiar voices to many, clearly communicating mathematical concepts and scrutinising the claims made by politicians and in the media. Following from their successful column in The Observer, Covid by Numbers aims to distill some of the key metrics that informed the debate, and the pitfalls that arose when they were misused and misunderstood.
Each short chapter explores a different question relating to the pandemic, mostly contextualised in the United Kingdom. These cover an impressive range—from the nature of the virus and the utility of epidemiologic modelling, to the wider consequences of successive lockdowns. Attention is given to debates that dominated the headlines, such as (incorrect) comparisons between COVID-19 and the flu, as well as issues less frequently discussed, such as the outcomes for patients being discharged after hospitalisation with the virus.
All of this is written in an uncomplicated style with clear and relevant figures. Excessive detail on statistical concepts is avoided, however there is much to be learned here for both the expert and general reader. Crucially, the authors emphasise the imperfect processes inherent in collecting and analysing data. They explain, for example, why it is challenging to measure levels of hospital-acquired coronavirus and how this led to wildly different estimates being quoted in the media. In doing so, they make clear that while statistical science is a powerful tool for understanding the world around us, it has limitations and claims of certainty should always be approached with a healthy degree of scepticism.
Masters and Spiegelhalter also carefully ensure that the data are never separated from the human suffering that each figure represents. “Counts and measurements are stories writ large” they say in their introduction, and this contextualisation is a continuing thread throughout each chapter. Such sensitivity is important: the reader is likely all too aware of the tragedy brought about by this virus. Furthermore, it strengthens their case for greater consideration of data in handling the present and future pandemics. It is easy to view statistics as a subject for dry academic debate. However, emphasising the human journeys that lie behind such numbers makes it hard to dispute their relevance in all our lives.
Photography feature: glimpses of the Gambia
Through photographs Franca shares her own day-to-day experiences working as a non-local Research Assistant in The Gambia.
For the last two months I was volunteering at The Gambia Medical Research Council (MRC) as a research physician. During this time, I gained some insights into the communities and the ways of living and learnt a little bit more about the health seeking behaviours.
These photos reflect scenes I encountered in the ordinary course of my day working as a non-local medical professional. This experience provided me with a perspective that is not all encompassing of life in The Gambia, but rather a glimpse into my own perceptions.
Photography by Franca Conradis-Jansen
9.00am: Every day before work, my colleagues would stop for a sandwich with onions fried in palm oil and bean fritters, which costs about 15 Dalasi (roughly 20 pence). A piece of fruit is often more expensive. An apple, which can be found in every fruit stand, costs twice as much as they are imported—like much of the food consumed in The Gambia. My colleagues told me that many Gambians’ diet is low in fresh fruits and vegetables, not only due to lifestyle habits, but also because of costs. One survey showed that only 22% of the Gambian population eat 5 portions of fruit and vegetables daily.
Photography by Franca Conradis-Jansen
10.00am: We bounce up and down in the car as we drive along the bumpy roads of a peri-urban zone. Most of the roads and properties are unpaved. During the rainy season, the unpaved roads become waterlogged. Goats, donkeys, and dogs romp around, and children play in the puddles.
Photography by Franca Conradis-Jansen
11.00am: As part of my duties as a research physician on an observational trial, I visited households in urban and rural areas. I saw a high prevalence of skin diseases—particularly in children—including bacterial, fungal, or parasitic infections. Affected individuals or their parents had often not sought or found adequate medical attention yet, in some cases for long-lasting manifestations or deep abscesses. The prevalence of children in this area with skin infections after the rainy season can increase to 16%, and those with pyoderma to 23%.
12.00pm: We would often smell and see smoke in the courtyards we visited, as lunch was prepared. Commonly, tea or food is cooked on smoking coals in the courtyard or in a hut of the compound. According to the latest Demographic and Health Survey, 80% of households in The Gambia use charcoal or wood for cooking.
Photography by Franca Conradis-Jansen
5.00pm: In the evenings, I would sometimes go for a stroll in the market. On one occasion, I met a shopkeeper who told me that he considers the health system in the urban areas to work well, and only a small flat fee is charged for visiting health centres and hospitals. However, the field team I worked with said that there is varying quality in healthcare services and often shortages in medicines. In many cases, people have to pay for medicines out of their own pockets in pharmacies, which can be a relatively big expenditure, especially when it comes to chronic diseases. It is estimated that 20% of people spend more than 10% of their household consumption or income on out-of-pocket healthcare expenditure.
Photography by Franca Conradis-Jansen
6.00pm: On the beach front, many women sold fruit at stalls like these. Two years ago, these would have been bustling during the high tourist season, but COVID-19 has halted tourism in the country. The tourism industry is a major contributor to Gross Domestic Product in The Gambia and many are reliant on its revenue for their livelihoods. I spoke to a 20-year-old fruit seller who told me that her income from these stands assisted with her family’s expenses.
Photography by Franca Conradis-Jansen
7.00pm: In the evenings and on Sundays, the beach becomes a hub for exercise, including football, rugby, jogging, or gymnastics. The beaches are open to all social groups, but I observed very few women exercising. Lack of physical activity may be one of the factors contributing to the fact that women are twice as likely as men to be affected by obesity in The Gambia.