This year, the MWF Katherine Branson Essay Prize had an outstanding level of entries from medical students across the country. We have chosen to feature all entries on our website as they are all written to a very high standard.
Here are some entries on the essay title:
COVID-19 has thrown a stark light on inequalities in healthcare. What are the challenges that we face and how can we tackle these to move towards a more diverse and inclusive society, that’s fit for the future?
Entry 1 : Written by Saneaah Khan
Closing the gap in healthcare
Have you ever used a pulse oximeter on a patient? Ever looked up a dermatological manifestation of a disease? Ever wondered why people that were of Black or ethnic origin (BAME) were more likely to die during the COVID-19 pandemic? All these things are impacted by intrinsic inequalities in our healthcare system. In black individuals, hypoxaemia is under-detected by pulse oximetry; in black individuals, melanomas are underdiagnosed; and in members of the BAME community, more people died due to COVID-19 pandemic (1). In this essay, I will discuss challenges such as these, that are faced by ethnic minorities in healthcare, and discuss ways to tackle these.
At the point of care, there may be inequalities in communication. This includes micro-aggressions towards a patient or a colleague, assumptions made about a patient from their language or appearance, around their pain threshold in labour, and racist stereotypes that can ultimately impact the care of a BAME individual. Before this, there is inequality in the training received by those in charge of our care; How many dermatological features can you identify on a person of colour? Although there is now a push for inclusive imagery in medical school resources such as PowerPoint slides, there is still a lack of research that is inclusive of BAME populations; therefore, the inequality is found throughout the healthcare system.
It is evident that there are inequalities at every stage of healthcare, from initial research, to diagnosis, to treatment, to basic communication in a healthcare setting. However, there are ways to amend these. There are small acts that can reinforce the importance of reducing health inequalities such as standing up for colleagues or patients when they encounter a micro-aggression in front of you. Moreover, by creating inclusive learning opportunities during medical school to learn about individual experiences of fellow students or learning how clinical science looks different on bodies of different colours and funding the development of educational resources that are inclusive, the negative consequences of inequalities can be reduced. One such example is the ‘Mind the Gap’ (5) handbook of clinical signs in black and brown skin developed by a medical student and lecturers at St. George’s University of London. This handbook is freely available online, making it accessible for healthcare professionals to educate themselves and improve patient care. A statistic from the MBRRACE study (4) reinforced the importance of identifying biases, advocating for patients, and validating the experiences of black and Asian mothers during their vulnerable time of pregnancy and childbirth by listening; the study found that ‘Maternal mortality rates were found to be more than four times higher for Black women, two times higher for mixed ethnicity women and almost twice as high for Asian women.’ The Another way to tackle inequalities is through mentoring and events. The development of organisations aiming to empower black students and healthcare professionals such as ‘Melanin Medics’ (3), host events and workshops at universities to raise awareness of inequalities and provide a platform for black medical professionals to share experiences and achievements, as well as mentoring.
Within the NHS, creating roles that enable easier reporting of inequalities and dealing with these issues, can be useful. It will also make it easier to collect data on inequalities to drive and monitor changes. Evaluating wider determinants of health (2), such as the socio-economic factors like housing, employment, and accessibility to health information, can contribute to the disparities experienced by ethnic minorities. This includes improving access to resources by making it available in a range of languages as well as working with community and religious leaders within ethnic groups to raise awareness of healthcare services and improve access.
In conclusion, for a diverse and inclusive future, it is imperative that changes are made at each level; from research studies to provision of care, policy and who is involved in decision making, education and looking at wider societal factors. Improvements are already being made with increasing awareness and research demonstrating the need for change, however, there is still room for improvement to ensure an inclusive future.
References
https://www.bmj.com/content/376/bmj-2021-065574
https://www.nhsrho.org/wp-content/uploads/2021/06/Ethnic-Health-Inequalities-Kings-Fund-Report.pdf
https://www.melaninmedics.com/
https://www.birthrights.org.uk/2021/11/11/new-mbrrace-report-shows-black-women-still-four-times-more-likely-to-die-in-pregnancy-and-childbirth/
https://www.sgul.ac.uk/news/mind-the-gap-handbook-now-freely-available-online
Entry 2 : Written by Olivia James
When Spanish influenza struck in 1918, it was overshadowed by war and soon after became a forgotten pandemic by historians - it would truly be a tragedy to repeat history. When Aneurin Bevan founded the NHS, his philosophy was “no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means”. Fast forward to the 21st century and ‘lack of means’ has evolved to mean more than just class; it is learning disability, ethnicity, age, gender, mental health and socioeconomics. The handling of COVID-19 exposed health inequalities woven into our fabric, and I propose that there are more subtle changes outside of policies that we can enact to equalise these.
Spanish influenza disproportionately killed those aged 20-401. Had COVID-19 been Spanish influenza, would we have cared more about the negative outcomes of shielding, social distancing and isolation? This is a heart-breaking question, but it is true that until 15th April 2020, "negative [coronavirus] tests are not required prior to transfers/admissions into the care home"2. This meant the impossible clinical decision of sending COVID-19-positive patients back to a care home housing the most vulnerable in society, and highlighted just how under-resourced we were. Despite 36% of new cancer diagnoses occurring in people over 753 as well as multiple comorbidities, older people have many barriers to access: transport, utilisation of technology and elderly-specific information. Consider the remote way in which COVID-19 has pushed us, the likelihood of its future continuation and the future impact of this on the elderly population.
Coupled with lack of access, there is insufficient funding put into treatment of elderly conditions. For example, cataract surgery was rationed in 2017, presumably resulting in more subsequent home falls4. Mental health services and comprehensive care home attention are also historically unmet needs; during lockdowns, isolation exacerbated elderly mental health issues and loneliness leading to cognitive decline5. And so, a cycle began since older people with mental health disorders are less likely to achieve ‘active ageing’ compared to those without6.
“The Marmot Review 10 Years On”7 highlights an undeniable link between socioeconomics and ill health in the older population and its final conclusion, like most other reports, calls for policies8. For example, those included in the NHS long-term plan’s ‘Ageing Well Programme’9. Whilst I believe that these policies are the main and only way by which to exact true and sustainable change, I believe them to be reactive. Upon researching policies such as these, I found it difficult to find any up-to-date assessments of their ongoing efficacy which would inform future policy making, as well as specification as to what each would involve. Constant evaluation and transparency should be increased moving forwards.
Instead, I would like to suggest an adjunct proposal – cultural empowerment. We need to involve patients with their thoughts on problem priorities. Patient involvement projects suggest those to be feeling like a burden, cultural expectations of capabilities in old age and visibility in the community10. It is also perhaps assumed that old people’s illnesses do not impact on society as much as younger people. For example, there is no sick time taken from work to matter to a company employing you. A study of 6121 participants found that negative perceptions of ageing was associated with accelerated declines in physical and cognitive function at sufficient follow-up, even after adjustment for comorbidities11. Promoting a healthier stereotype of elderly people is key for future generations, and I believe that the media has a role to play. Until regulatory boards such as the ‘Independent Press Standards Organisation’ and ‘Ofcom’ adopt guidelines on portrayals of elderly people, I believe that these views will perpetuate. Visibility in the community would help to dash stereotypes also, and so I believe that this should be another aspect of widening social care responsibility to which many policies allude. Most of these projects tend to be small-scale, for example, the ‘TOY project’12 which brings old and young people together for intergenerational learning. Government working with charities in policies would be the easiest way to achieve this. By making older people feel like they are valuable members of society with self-worth, they claim back their belief of entitlement to healthcare. It is known that older people who have more positive self-perceptions are more likely to access healthcare for troublesome symptoms13.
Although these suggestions would not comprehensively solve the problem, I believe they address an unmet need. Attitudes ingrained in our culture need evaluation so that we can address them, in this case, to empower people to empower themselves. I believe that this discussion of perception changes can translate to other health inequalities not discussed here. COVID-19 should be documented, dramatized and authored so that its lessons live on in our minds and inclusivity is instead woven into our culture.
References
1. Gagnon, A. et al. Age-Specific Mortality During the 1918 Influenza Pandemic: Unravelling the Mystery of High Young Adult Mortality. PLoS ONE 8, e69586 (2013).
2. Covid: What happened to care homes early in the pandemic? BBC News (2021).
3. Cancer incidence by age. Cancer Research UK https://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/age (2015).
4. Iacobucci, G. Cataract surgery is cost effective and should not be rationed, says NICE. BMJ 358, j3588 (2017).
5. Bailey, L. et al. Physical and mental health of older people while cocooning during the COVID-19 pandemic. QJM Int. J. Med. 114, 648–653 (2021).
6. Kenbubpha, K., Higgins, I., Chan, S. W.-C. & Wilson, A. Promoting active ageing in older people with mental disorders living in the community: An integrative review. Int. J. Nurs. Pract. 24, e12624 (2018).
7. Health Equity in England: The Marmot Review 10 Years On - The Health Foundation. https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on.
8. MacGuire, F. A. S. Reducing Health Inequalities in Aging Through Policy Frameworks and Interventions. Front. Public Health 8, (2020).
9. Plan, N. L. T. Ageing well. NHS Long Term Plan https://www.longtermplan.nhs.uk/areas-of-work/ageing-well/.
10. Alsaeed, D. et al. Older people’s priorities in health and social care research and practice: a public engagement workshop. Res. Involv. Engagem. 2, 2 (2016).
11. McGarrigle, C. A., Ward, M. & Kenny, R. A. Negative aging perceptions and cognitive and functional decline: Are you as old as you feel? J. Am. Geriatr. Soc. n/a,.
12. TOY project - Together Old & Young: intergenerational learning. ToyProject.net http://www.toyproject.net/.
13. Sun, J. K. & Smith, J. Self-Perceptions of Aging and Perceived Barriers to Care: Reasons for Health Care Delay. The Gerontologist 57, S216–S226 (2017).
Entry 3 : Written by Vina Soran
Healthcare inequalities and healthcare advocacy.
The rise in coronavirus cases presented vast challenges in the UK, with fears that healthcare services could become overwhelmed. Instead of deterring students, a unified response was seen across the country, where many felt encouraged to get involved in the UK’s response to the pandemic. Almost two-years on from the start of the Covid-19 pandemic, systemic health inequalities remain in-situ. Namely, gender and socioeconomic disparities were shown to exacerbate health inequalities, highlighting the integral role of social, political and economic variables underlying public health 1.
Advocacy as a core principle
The coronavirus pandemic led to the early cancellation of medical school lectures, clinical placement and summative exams. In response to these unprecedented events, many medical students opted to take on a variety of roles in the effort to join the Covid-19 workforce. Nevertheless, examples of physician and student advocacy during the pandemic and the significant contributions made by many individuals, highlighted prevalent disparities.
Uncertainty in the early months of the pandemic required universities to readily adapt in response to social distancing policies. A reformed curriculum with integrated advocacy teaching, whereby students are taught about current health disparities and the efforts to erase these would be hugely beneficial. Moreover, this would improve confidence in the ability to recognise issues some people may face, for example those with learning difficulties, a language barrier, or vision impairments. Greater understanding and early exposure to the challenges some patients experience when accessing healthcare, can ensure that students are able to improve their advocacy skills and gain practical knowledge of how to address health related disparities.
Importantly, fostering an environment whereby medical professionals feel able to voice their concerns is key. In the pivotal stages of the pandemic, a significant proportion of healthcare workers reported inadequate supplies of Personal Protective Equipment 2. This underestimation in risk assessment may have led to countless avoidable deaths amongst medical professionals, whereby individuals should have been able to continue working on the frontline without sacrificing their safety. Therefore, in future instances, medical professionals should healthcare workers should be given jurisdiction to advocate for working conditions deemed safe to their health and well-being. Similarly, there is a need to integrate formal advocacy training into the medical school curriculum to provide all students with the knowledge to become successful future healthcare advocates.
Government reform & social inequality
Addressing these inequalities is two-fold. The Covid-19 pandemic highlighted a stark disparity in health outcomes between White and Non-White patients 3. Dismantling pre-disposing risk factors involves addressing socioeconomic, housing and education inequalities4. Directly addressing the underlying components is complex and requires national government funding. Nevertheless, efforts to combat the widening inequality gap, with particular regard to housing and employment opportunities may help to address avoidable inequalities. Likewise, improving healthcare literacy amongst demographics may improve baseline health status, by adjusting modifiable risk factors for disease.
Representation in clinical practice
Healthcare inequalities also present as an under-representation of the varied disease characteristics in people of colour. A second-year medical student from St George’s University London, Malone Mukwende, recently published an online book ‘Mind The Gap’ which detailed clinical presentations of various conditions on black and brown skin5. Mukwende’s work exposed a lack of representation in medicine and a need to decolonise the curriculum, whilst illustrating the role of student advocacy in improving the delivery of healthcare. With the pandemic exposing pre-existing inequalities in our healthcare system, we believe that it is our responsibility to ensure moving forward we aim to eliminate these. A medical school curriculum not inclusive of all patient demographics significantly compromises the quality of healthcare and the speed at which patients receive this. Consequently, it is integral that medical education is representative of all members of our population.
Conclusion
The pivotal impact of proactive responses demonstrated during the pandemic through student experience highlights the need for advocacy in medical education to properly equip tomorrow’s doctors with the means to address the disparities present in society. In addressing and tackling health disparities, we can advocate for improved healthcare services void of bias present in medical education. Integrated advocacy training in the medical curriculum can facilitate students with the correct skillset to identify inequalities within medical training to ensure good medical practice in the future. Since health outcomes are not solely based upon our understanding of anatomy and biochemistry, it is imperative to understand the social implications relating to access and provision of healthcare.
References
(1) Sardar S, Abdul-Khaliq I, Ingar A, Amaidia H, Mansour N. ‘COVID-19 lockdown: A protective measure or exacerbator of health inequalities? A comparison between the United Kingdom and India.’ a commentary on “the socio-economic implications of the coronavirus and COVID-19 pandemic: A review”. International Journal of Surgery (London, England). 2020; 83 189-191. 10.1016/j.ijsu.2020.09.044.
(2) Thomas JP, Srinivasan A, Wickramarachchi CS, Dhesi PK, Hung YM, Kamath AV. Evaluating the national PPE guidance for NHS healthcare workers during the COVID-19 pandemic. Clinical medicine (London, England). 2020; 20 (3): 242-247. 10.7861/clinmed.2020-0143.
(3) Phiri P, Delanerolle G, Al-Sudani A, Rathod S. COVID-19 and Black, Asian, and Minority Ethnic Communities: A Complex Relationship Without Just Cause. JMIR public health and surveillance. 2021; 7 (2): e22581. 10.2196/22581.
(4) Wheatle M. COVID-19 highlights health inequalities in individuals from black and minority ethnic backgrounds within the United Kingdom. Health promotion perspectives. 2021; 11 (2): 115-116. 10.34172/hpp.2021.15.
(5) Rimmer A. Presenting clinical features on darker skin: five minutes with . . . Malone Mukwende. BMJ (Clinical research ed.). 2020; 369 m2578. 10.1136/bmj.m2578.
