This section goes in depth into some key questions: What is inequality? How widespread is it in the CM/ID sector? Why should it be addressed? What impacts it may have?

The following topics will be deepened.

A1 – Firstly, we will consider gender inequality, which is the most common form of inequality in the CM/ID sector, showing how it is widespread, what consequences it has and how women try to react to it.

A2 – Then, other forms of inequality will be considered, including those grounded on national origin, disability or sexual orientation.

A3 – Another topic is the marginalization of CM/ID specialists and researchers in the international community because of their belonging to countries or regional areas which are considered as backward in terms of scientific production or quality of medical education. This kind of inequality does not directly affect the working environment but may have significant consequences and impacts on the career and professional life of CM/ID professionals.

A4 – The main effects of inequality are then considered. All in all, inequality limits, hinders or impedes the access to a set of assets (time, money, professional recognition, etc.) which are important to advance in the career or to attain one’s own professional objectives.

A5 – The last topic is why fighting inequality. A reflection is proposed about the many motivations and benefits of equality.

Inequality is a multi-headed dragon, which assumes different aspects and shapes, often difficult to detect and therefore to cope with.

A1. Gender inequality: the mother of all inequalities

First of all, gender inequality. It is the most widespread form of inequality, systematically present everywhere in society. It can be considered as the mother of all inequalities, if only because it affects more than half of the World population. One could think that in the fields of clinical microbiology and infectious diseases, gender inequality is less diffused or sharp than elsewhere since women are, in these two specialties, often the majority, if not the large majority, of the staff.

This is not true!

The Survey promoted by the ESCMID Parity Commission in 2011 provides a detailed account of the gender inequality patterns present in the CM/ID sector in Europe. These patterns have tangible effects on the career of women (see Box 1) and produce serious consequences on the possibility of women to combine professional and personal life (see Box 2). Considering only academic positions, also in the CM/ID sector the different trajectories of women's and men's scientific careers are well represented by the
scissors diagram , showing how much women are disadvantaged in reaching middle and top positions. It is not surprising that, among CM/ID professionals, as many as 29.2% of women interviewees reported different kinds of discriminatory events on the ground of gender in their professional environment.

The results of the Survey are in line with data in the medical sector as a whole, not only in Europe, but also in the US, showing how women are systematically underrepresented in leadership positions.

Mechanisms producing and reproducing gender inequality are many and of different nature. The Research Study promoted by the ESCMID Parity Commission in 2015 allows to grasp many inequality patterns in place in the CM/ID sector. It also shows how female and male specialists perceive the presence and seriousness of gender discrimination to a different degree.

Beyond the negative impacts and distortions it produces on the life of the organization, gender inequality strongly affects women's life, sometimes having serious psychological impacts. Often women try to react by activating different coping strategies. However, in the majority of cases, these are poorly effective in redressing the situation.

A2. Other forms of inequality

Undoubtedly, gender-based inequality is the form of inequality which is overwhelmingly the most prevalent in the CM/ID sector. However, other forms of inequality have non-negligible impacts on the life of CM/ID professionals and on the quality of the environment they work in.

Inequality grounded on national origin is one of them. It is to notice that the presence of expatriates in European public hospitals is limited, while in European universities and research organizations it is undoubtedly higher. However, the mobility of health workers within Europe is reported as increasing, especially since the 2007 economic crisis (see Box 3.) This may trigger discriminatory dynamics, since foreign medical doctors who completed their training abroad (including other European countries) meet different kinds of obstacles in accessing medical positions in the hosting country.

Disability may be another factor activating discriminatory mechanisms within the organization. As in the case of the expatriates, such mechanisms are already at work limiting the access of disable people to medical professions. However, the number of disable people among CM/ID professionals is very small.

As for discrimination grounded on sexual orientation, this is perceived more in some national contexts than in others but, in general, explicit homophobic behaviors are reported as rare. This is sometimes attributed to the fact that homosexual patients are often significantly present in infectious diseases wards. Therefore, ID professionals would be more used to and open towards gays and lesbians than professionals in other specialties. On the other hand, self-declared homosexuals among ID professionals tend to be very few, suggesting the idea that perhaps the working environment is not so favorable towards homosexual doctors, precisely because of the association (largely based on cultural biases) between homosexuality and infectious diseases.

As for inequality based on religious belief, some problems can be detected as concerns expatriate Muslim professionals, particularly due to the present geo-political context which is feeding a sense of distrust in Muslims all over Europe. Problems increase in the cases of professional adhering to traditional expressions of Islam. In some contexts, wearing a scarf can be for women specialists extremely problematic.

Discriminatory mechanisms at work are in general similar to those identified in the case of gender, such as joke, isolation, specific attitudes or the overlooking of the professional skills and capacities.

A3. Marginalized countries in the international context

There is finally another form of inequality which does not develop within the working environment but in the international context. Indeed, it is not rare the case of researchers marginalized in the international community precisely because they come from some specific countries or regional areas which are considered as backward in terms of scientific production or quality of medical education.

This kind of discrimination affects CM/ID specialists in few but very effective forms: their access to international publications is limited; rarely they are invited as speakers in international conferences; their scientific production is overlooked or ignored at all. Even though the actual relevance of this kind of discrimination is controversial, in many cases its presence is strongly perceived by researchers in some European countries. It is to add that such a phenomenon may also be connected to with how expatriate professionals are viewed and professionally integrated in the hosting countries.

A4. A cross-cutting issue: the access to the available assets

Regardless of the kind of inequality, one of the most systematic effects of discriminatory mechanisms is that of limiting, hindering or impeding the access to tangible or intangible assets which are considered important or indispensable in a given institution for pursuing one's own professional objectives and to advance in the career.

The most evident example is the access to money and, in particular, the presence of the so-called "pay gap", i.e., the fact that members of two different groups are paid differently for doing the same or comparable work.

However, other assets are equally important in the life of, e.g., an hospital or a research institution. We can include, for example, time (for research, for clinical work, etc.), physical assets (such as office space, medical equipments, laboratory equipments, computers and software or supplies of any kind), formal and informal networks (i.e., personal ties, prevalently of an informal nature, connecting specialists with each other, with their leaders and with external actors), economic assets (beyond salary, for example, research funds), and information about the life and mechanisms of the organization. Even professional recognition, that is, being recognized for one's own capacity, skills and professional work, is undoubtedly an important asset which can be affected by biased mechanisms.

Differently from the pay gap, calculating the weight of discriminatory mechanisms in accessing these assets is practically impossible. However, some personal accounts, drawn from the ESCMID Research Study, could be useful for grasping the nature of the problem.

A5. Why fighting inequality

The reasons why inequality at work should be addressed as a serious problem may be considered as taken for granted. However, fighting inequality, especially in a such crucial sector like health, may produce many different benefits which are useful to acknowledge. Such benefits may concern the protection of individuals' rights, the efficiency of health services, and the wellbeing of the staff. A reasoned list of motivations for combating inequality is given here. These multiple rationales for equality can be used when negotiating with leaders and to reach out to different groups of internal stakeholders.

In addition, the lack of appropriate measures and policies at institutional level (hospitals, universities, departments, etc.), documented in many European countries, is making the need of fighting inequality in the CM/ID sector even more pressing. Hence the need to do something now!

The "scissors diagram" in the CM/ID professional in academic careers

The ESCMID survey also accounted for the different career trajectories between CM/ID female and male professionals in academic career.

The distribution of women and men in the different academic career grades originates the CM/ID version of the famous "scissors diagram" representing the different trajectories of women's and men's scientific careers.

The diagram has the typical shape of the one representing European women and men in all academic disciplines jointly considered.

Data generating the scissors diagram above are reported in the following table.

CM/ID professionals/Proportion of men and women in different academic grades

However, differences can be found between clinical microbiologists and infectious diseases professionals, as shown in the two figures below.

As it is easy to observe, the presence of women among the infectious diseases professionals is lower than men's at all grades, with the highest gap among associates professors. The situation of women among clinical microbiologists is remarkably better, since men are more than women only among full professors.

Source: - Tacconelli, E., Poljak, M., Cacace, M. et al. (2012), Science without meritocracy. Discrimination among European specialists in infectious diseases and clinical microbiology: a questionnaire survey, BMJ Open, 2012:2

Women in medical careers

The problems that CM/ID women professionals are matching are similar, to different extent, to those faced with by all women in the medical sector.

A study made in the UK in 2014 on women in academic medicine comes to the following conclusions:

• Female doctors are about five times more likely than men to have worked part-time in general practice and almost seven times more likely in hospital practice
• Taking into account career breaks and part-time work in the 15 years after graduation, women on average provide 60% of a fulltime equivalent role, compared with 80% for men
• Female doctors are under-represented in senior positions: women represent 44% of medical doctors, but just 30% of consultants
• In academic medicine, access to leadership positions is even more difficult: the proportion of female 'grade A' researchers (i.e. the single highest grade/post at which research is normally conducted according to the definition used to aid international comparisons) is only 23%.

In French public hospitals, women represent only 19% of the highest positions and 38% of directors working in public hospitals. However, only 16% of hospitals are managed by women. Moreover, only 23% of Hospital Medical Commissions (the commission representing the doctors within any French hospital) are chaired by a woman, while women represent 45% of the medical staff (there is therefore a gap of 22 points between the percentage of women chairs and women doctors with respect to men).

Women are still disadvantaged in medical careers also in the US.

The Association of American Medical Colleges carried out in 2014 a large survey on the state of women in academic medicine. Among the results, the following deserve to be mentioned here.

• In the US medical schools surveyed (129), women represented 56% of the instructors, 44% of the assistant professors, 34% of the associate professors and 21% of full professors.
• Considering permanent leadership positions, women's presence is still low: they represent 24% of division chiefs, 15% of department chairs, 46% of assistant deans but only 33% of senior associate deans and vice-deans, and as many as 16% of deans.
• Men make up 62% of full-time faculty, while women make up 38%. Research indicates that many women who take part-time positions do so on account of dependent children, while most men take part-time positions due to holding other professional positions.

Inequality mechanisms: voices of women professionals

The ESCMID Research Study allowed to identify many different mechanisms favoring inequality in the CM/ID sector. Most of them are subtle, hidden and difficult to identify and properly manage. Some examples are provided below, using excerpts from the interviews with women doctors on which the study was based.

Attitudes toward women Gender inequality is connected to stereotyped attitudes and expectations towards women.

• "The nurses in the Emergency Room assume that a male doctor is someone who knows what he is doing and he is going to be quick and efficient and good in every way. They also assume that a female doctor has to prove herself before they trust her".
• "When you (as woman doctor) have an outpatient clinic, you might be asked to go and fetch your own patients whereas the nurse might do that for the male intern".
• "Sometimes you've been speaking with patients for a quarter of an hour and then: 'When is the doctor coming?' And you know, I've introduced myself".
• "It happens that when women doctors go to patients, they have a consultation and they think everything is fine; and then they go out and the nurse goes in and the patient asks: 'Well, do you know when I'm going to see the doctor?'".

Informal interaction patterns and language. Inequality is also reproduced in informal interaction patterns and in the language used.

• "So it may happen that, instead of saying 'doctors', they (the males or the bosses) call the women doctors 'young ladies' or 'girls', said in a witty manner. It is definitely inappropriate".
• "One of the professors I had during the specialization period tended to make trouble using a sexist language (...). He used a rough language, making jokes that could be annoying and create difficulties".
• "(Sometimes it happens that) If a woman goes to talk to a Congress, she is presented in this way: 'Finally here is a beautiful female doctor'".

Unfriendly environment. Attitudes, a sexist language and informal interaction patterns contribute in making the working environment unfriendly for women, discouraging them from pursuing their career objectives.

• "All surgeons look at you … 'Well, you are a woman, you will never be a good surgeon" (...). When I was a student, there were not a lot of female students specializing in surgical specialties. They stopped sometimes their education to become general practitioners, to work in a consultation bureau or something like this".
• "I wanted to have my specialization in cardiology; and that was very hard. I worked only with men. I thought they looked more carefully to women than to men. I didn't manage to get the specialization".
• "In surgery, in orthopedics, there were sure a lot of men; and it was not so easy for women perhaps, I don't know. In our hospital we had lots of male doctors. Not many women. And the women were often sharp-purposed, they knew what they wanted. They wanted to be there and this probably because it was not so easy for them to get in".

Overloading women with clinical work. In academic environments, women are sometimes diverted from research activities through an overload of clinical work or teaching activities.

• "Since I didn't have time, I couldn't write papers.... I didn't go to an upper position. I regret this. If I could have more time and more papers, I would have gone upper. I regret that; I had too many patients".

Unfair task distribution. Gender inequality may also manifest itself through an unfair distribution of tasks between males and females within the organization.

• "(Sometimes) you have the perception that there is something wrong: some opportunities that are not given (...). You are not told that this happens because you're a woman or because you are male. You see that sometimes the tasks are given to some people and you do not explain why it is given to him and not to you".
• "In selecting the people who could participate in a congress, I was not selected. There were several causes of that, but one was that I am a woman. It wasn't just being a woman. There are many factors, but one of them is that of being a woman".

Unfair access to research funds and research leaves. As widely documented by the literature, another factor hindering women's career is the unfair access to research funds and research leaves.

• "The clinic gives research leaves and sums of money every year which can be allotted to the doctors. (Two years ago) of 17 females and 6 males who applied, there were one female and three male doctors who received the leave. Of course, there were reasons for this. They gave them to the projects that were the best. That was the answer. (...) I was really upset".

Unequal distribution of family care. The unequal distribution of family care between females and males remains one of the main factors hindering women's career, especially when childcare facilities and other forms of support are lacking.

• "If you, as a woman, are burdened with a large part of the responsibility for the children and the family and the logistics of it all, you are not going to have the capacity to do research. After a long day doing the laundry, and caring for the children, and everything ... and then you are going to sit down with your paper?".
• "I have two children, I have to spend time with them, at home in the evening or in the weekends. So if I have to read some medical literature, I do not sleep in order to be able to read them, for the next day. I have no other choice but to do it".
• "Families have never been supported. And therefore logically women live with the guilt for any absence from work due to the illness (of their child). (...) The paradox is that you feel the guilt towards the employer and not towards the children when they are small and perhaps they are crying at the door when you leave them, or when they are sick and you have to entrust them to strangers".

Unequal use of parental leaves and part-time work. Quite paradoxically, also the measures aimed at combating gender inequality may reproduce forms of gender inequality, as they are differently used by women and men. Actually, long leaves and part-time work may significantly affect career perspectives.

• "I think that there are increasingly more men taking parental leaves than in the past. And my boss takes part-time. But I still think it's a problem because I think women take much more part-time than men do."
• "I think it (working part-time) is difficult. If you want to make a career, you have to be available a lot of time, also if you have your problems at home with children and you feel responsible for them. So that's conflicting, always conflicting".
• "I had a remark from an older woman colleague who said 'you will never become a good specialist if you don't work 100%'. That's difficult when you have a small child".
• "I think working part-time is a thing that hampers progression in your career, in general. (…) Apparently people think: 'Ok, part-time means no ambition'. Which is not true. At least, in many cases it is not true, in some cases it is true, but I think that's an issue which is addressed in a wrong way".

Social stigma on maternity. The presence of a social stigma about maternity can be also reported, depicting it as a risk to avoid or prevent, something incompatible with professional life.

• "There was a researcher who was forbidden to get pregnant during the research project".
• "When I had a short-term contract, I got pregnant for the second time. And I experienced situations that were a little bit nasty. I was almost accused for that. (The head of department said) 'What are you doing? You already have a son and now you want to make another baby? These things must be planned!'".
• "A colleague who was just hired was prevented to participate in a course on ultrasound because everybody knew that she was just married and she wanted to have a child. And so she was told: 'I cannot send you now to the course, spending a lot of money and then you go away on maternity leave!'".

Males' and females' perception of gender inequality

According to the results of the ESCMID Survey, male and female professionals perceive the presence and the seriousness of gender inequality in different ways. For example:

• 33.6% of women and 11.3% of men believe that their career would have been different if they were of the opposite sex
• 19.3% of women and 11.6% of men think that there are problems related to gender inequality in scientific international societies specialized in clinical microbiology and infectious diseases
• 12.3% of women and 4.0% of men think that speakers at ECCMID/ICAAC international conferences are not representative according to gender
• 45.6% of women and 23.6 of men are agree or strongly agree with the sentence: More women in leadership positions in the medical science – and a more diverse leadership in general – would improve the way medical research is produced, communicated and applied".

As shown by the examples above, the percentage of women perceiving inequality dynamics are from two to three times higher than that of men.

The experience of being discriminated

Being discriminated is a bad experience, which may have heavy psychological consequences. Many research studies described them in details.

Isolation. Women can be isolated in different ways, especially by being excluded from informal networks where often decisions are taken or opinions are shared. Sometimes, in order to suffer less, the victims tend not to perceive isolation or to make it more psychologically sustainable by seeing it as due to their own choice.

Role strain. Role strain is defined as the personal conflict experienced when managing and fulfilling competing but fluctuating role obligations. In this case, role strain emerges when women have to deal with stress and conflicts of being a professional at the same time as being a wife and mother.

Loss of self-esteem. Being exposed to discriminatory mechanisms sometimes leads to feelings of inadequacy and guilt, e.g., for not being up to the demands of the heads or for not being a good mother or a good specialist. Some forms of discriminatory behaviors against women (such as ignoring or devaluing their ideas, attributing their ideas to their male colleagues or eliminating them from consideration for key positions) foster this kind of processes leading the victims to lose their self-esteem.

Stereotyping. Women suffer for the diffusion in the workplaces of gender stereotypes, i.e., the attribution to women of a set of qualities - such as being passive, unassertive, empathic and emotional – which are viewed as interfering with leadership roles and professional life. Not rarely, such stereotypes are shared by women themselves. In other cases, women react by assuming "masculine behaviors" precisely to balance the impacts of such stereotypes, often exposing themselves to other stereotypes equally damaging (e.g., being too bitchy or aggressive).

Discomfort, unease and anxiety. Women in male-dominated areas can suffer a sense of discomfort, unease or anxiety. They may perceive to be in the "wrong place" for them, to work in a unfriendly environment which leads them not to feel a strong sense of belonging to the institution. Often their reaction is that of working more in order to demonstrate to be fit for the role they play.

Harassment. Sexual harassment remains a serious problem in the workplace, including hospitals and research institutions. This kind of behaviors may include undesired sexual overtures, sexually oriented language, inappropriate touching by others, or sexists remarks. The so-called "hostile environment sexual harassment" occurs when unwelcome conduct of a sexual nature creates an intimidating, threatening or abusive working or learning environment. The "quid pro quod" sexual harassment occurs when an academic or employment decision about a student or employee depends upon whether the student or employee submits to conduct of a sexual nature. Psychological effects of sex harassment are usually many and of different kind, including fear, uncertainty about one's own conduct, loss of motivation and ambition and lack of self-confidence.

Women's coping strategies

Women cope with the discrimination they are exposed to by developing, more or less consciously, various coping strategies.

The ESCMID Research Study identified four main kinds of coping strategy, i.e., reactive behaviors, adaptive behaviors, withdrawal and surrender.

Reactive behaviors. Reactive behaviors occur when individuals try to contrast inequality dynamics in order to fully or partially restore or establish fair conditions in the way they are treated. Reactive behaviors may take the form of formal actions or collective actions, but more often individuals tend to straightforwardly react to discriminatory mechanisms by themselves, without the mediation or the involvement of other people, e.g., claiming the respect of their own rights or refusing to take the expected behaviors.

Two examples, drawn from the Research Study, are reported below.

• "I was called during the working hours and I had to stop doing what I was doing to do other things, such as going to the laboratory for fetching him a folder, calling a patient, going to get a prescription for a patient or preparing slides for a conference. At one point I said 'No!'".
• "Actually sometimes it happens that some male colleagues greet me saying 'Hello, little girl'. But I answer them back saying something like: 'Hello old man'".

Adaptive behaviors. Adaptive behaviors don't act on discriminatory mechanisms, but rather on the people who suffer them, with the aim of reducing their exposure to unfair treatments. Two main action patterns seems to be prevalent. The first is when people double the efforts in their working activity so as to compensate the effects of inequality by demonstrating to be as skilled and reliable as the other professionals. The second action pattern is mimesis, occurring when people adopt behaviors aimed to make them less "visible", thus limiting their own exposure to discrimination.

Two examples are reported below.

• "Men are favored. So, to be perceived by others, you have to prove to be able to do much more than the others. And then you feel to become more oriented to competition. This is not just because you want to be competitive, but because you want to prove that you are at least at the same level as them, if not better than them. To do that, you have to work hard".
• "In the past, when I was younger, I used to say: 'This is not fair'. I didn't expect such things (discriminatory behaviors). I was honest, I told them what I thought. But in time, I learned to be silent, not to talk about it. Although I faced the problems, I did not mention anything about them. Because if I talk about the problems, they dislike me more".

Withdrawal. Withdrawal occurs when people prefer to escape from the working environment they feel as unfair, even though this could entail a change in one's own professional plans.

Two examples are reported below.

• "I think it would be much harder in these specialties (such as cardiology or internal medicine) to be recognized for your merits. Because they are bigger (than infectious diseases), and some of them are much more male-dominated. Some are both. So I decided that I didn't want to work there (…). I didn't want to work there since I would not feel at ease or confident staying there".
• "We have had two cases of bullying here. I cannot say for what reasons they occurred. One concerned a woman who was never involved in any activity like conferences or specific tasks. In the end she went away since she could not stand that situation anymore".

Surrender. Differently from the other behavioral schemes, surrender cannot be considered as a real coping strategy. Rather it seems to be a state or condition characterized by the incapacity of the individuals to react to discriminatory mechanisms. This state or condition is psychologically painful since individuals become in this way fully exposed to unfair treatments.

• "I was in analysis for three years. I made my own personal path. (…) I thought I needed for an external support for understanding what was happening to me, what I was experiencing. (…) I keep on feeling today a sense of discomfort (…). It is becoming a struggle for survival".
• "I was terribly discriminated. I even went to psychiatrists because I was felt I was like a paranoid. But later I really learnt that it was real, that it was discrimination. (...)So I don't fight now. I don't even argue because it is not useful for me. It puts more strain to my job".

In their turn, Linda Pololi and Sandra Jones identifies other four coping strategies usually developed by women to deal with marginality, partially overlapped with those identified in the ESCMID Research Study.

Self-silencing. This consists in not expressing one's own opinions or points of view especially when leaders do not tolerate dissent, in order to gain acceptance and eventually a position of power from which to make institutional change.

Microenvironments. This stance consist in creating a supportive work microenvironment, a sort of an adaptive niche, so as to manage the impact of discriminatory mechanisms.

Balancing life and work. One of the coping strategies for women is balancing professional work with personal life so as to avoid to be too much exposed to the negative impact of inequality dynamics at the workplace.

Outsiders within: dual identity. Finally, some women tend to hold two different identities. The first is aimed at being successful in the organization, expressing ambivalence about the prevailing system. The second identity is that of an outsider using their success and power to help other women, although adopting a careful approach to change the status quo.

Perception of the different forms of inequality

The ESCMID Survey provided useful information on the diffusion of the different forms of inequality among clinical microbiologists and infectious diseases specialists.

In the following table, data is provided on persons declaring to have personally experienced or directly witnessed – in their working environment – discriminatory events, by type of discrimination. Data are given per gender.

As it is easy to see, discrimination based on gender has been suffered or directly observed by almost 18% of CM/ID professionals (30% of women and 6.1% of men). The second more frequent form of discrimination experienced or observed is that based on nationality (7.9%). The other kinds of discrimination involve less than 5% of people. It is interesting to notice that women declaring to have experienced or witnessed discrimination (all types included) are almost 38%, i.e. more than double of men (18%).

Also scientific international societies in the CM/ID sector are not perceived as fully fair. According to 11.1% of women and 4.4% of men, the composition of speakers at ECCMID/ICAAC international conferences is not representative according to gender, while, according to 9.6% of women and 11.0% of men, they are not representative according to geographical origin.

Forms of inequality

Inequality can be grounded on many features and qualities of people. However, the forms of inequality usually considered by institutions and anti-discriminatory policies are relatively few.

For example, in the case of the UK National Health Service, the forms of inequality taken into consideration are those based on:

• Gender
• Race
• Disability (including people with a learning disability, people who experience mental health conditions and people with sensory or physical impairments)
• Sexual orientation
• Sex reassignment (transgender women and men)
• Age
• Ethnicity (including expatriates, refugees and asylum-seekers, gypsies and travelers and migrant workers)
• Religion and belief (including those who are not believers)
• Marriage and civil partnership
• Pregnancy and maternity.

Some grounds of inequality may of course overlap with each other (for example, pregnancy and gender).

In some cases (for example, the French Association of Hospital Directors), other personal conditions are considered as a possible ground for inequality, including:

• Physical appearance
• Political opinions
• Health status
• National origin
• Family condition
• Residence place
• Social origin
• Cultural habits
• Genetic features.

Beyond gender: Inequality mechanisms in the voice of specialists

Different forms of inequality dynamics may affects specialists working in the CM/ID sector beyond those grounded on gender. Some examples are provided below, using excerpts from the interviews carried out in the ESCMID Research Study.

Discrimination grounded on the national origin

• "One of the teachers made some kind of joke about the fact that I was coming from a Middle Eastern country. He expressed like fears only because I was from there. However, this only happened once. It was not structural".
• "Everything was ok until I remained within certain limits. But if I was not as they wanted ... then 'No, you have to be quiet because you're even lucky to be here'. (…) Because for them a non-EU foreigner at that level of specialization was a privileged person".
• "When I was in France, yes, I felt big forms of discrimination there, where I worked. The boss was a man, he was very nationalist, let's say, (...). Really he didn't care about me. He only wanted me to do the job, but he was like … kidding me as a person! That was the feeling".
• "I felt a kind of discrimination in different environments, and in the medical environment as well. (…) I often felt that there are people that consider people from my country really badly. This is a bad feeling, the feeling of not being proud to come from your country".
• "My first year was very difficult. (...) It was really hard for me to communicate. There were teachers that would discriminate me. I could feel that they treated the other local students better than me. In the second year I began to open because my language became better, a little bit better. I began to make some friends. It was better in general. At the end of the year I was good. However, there still were the teachers that discriminated me, not directly, but indirectly".

Discrimination grounded on disability

• "I had problems when I went to interviews with people that didn't know me, when they met me for the first time. They liked the way I presented myself in the letter, then they liked the way I presented myself personally, and then I got the reaction back. Most of the times the reaction was: 'You have the best interview. We like the way you look to the work and probably how you work. But we chose someone else'".
• "I came here for my internship and I also had interviews then. But, maybe because you come for an internship for five months, they likely thought: 'She comes for an internship and in four, five months she will go. Why don't take her?".

Discrimination grounded on sexual orientation

• "We have some colleagues with another orientation but I do not feel that they are discriminated. (…) Sometimes I heard someone that makes jokes, but nothing very offending".
• "There was a situation that particularly struck me, that of a senior colleague of clearly homosexual orientation. Despite being very prepared, he was marginalized by the group leader. (…) I always was impressed by how he was treated. He was placed in the ward, kept out of any possibility to publish and teach. He remained a researcher for many years and never became associate professor, though he was very prepared and would have had many career opportunities in the academia".

Discrimination grounded on religion

• "We may speak about the jokes. That's happened all the time of course. I don't think it was really clear discrimination or inequality but … you know, Al Qaeda, and the bombings and … there are jokes about Islamic people, etcetera. If you are one of those people, sometimes you think: 'Oh, it is not really nice'".
• "I had been discriminated for my Islamic belief there. Mainly because I worn the scarf. Not during the lessons, but after the lessons I took my scarf. I am wearing a scarf since when I was 12 years old. This is linked to my belief. I have been discriminated by professors, but also by my friends. (...) Among the friends, I felt to be isolated. In practice, there were some attitudes and forms of mobbing against me".

Multiple discrimination

• "I was doing well, no one ever complained about me. But I had to work and be quiet. It is so. I felt I had to do twice in order to be considered like the others. Yes I had to prove twice because, first and foremost, I was considered too young. But anyone who saw me could say: '1) Ah! You are young; 2) you are a foreigner; 3) you are a woman".

Marginalized countries: the voice of researchers

It is evidently impossible to provide reliable information about the dimensions and actual features of the process of marginalization of researchers coming from some specific countries in the scientific international context.

It is however interesting to notice that, according to the ESCMID Survey carried out in 2011, 28.4% of professionals think that there are problems of country misbalance in scientific international societies specialized in clinical microbiology and infectious diseases. Moreover, according to 9.6% of women and 11.0% of men, the composition of speakers at ECCMID/ICAAC international conferences is not representative according to geographical origin.

Some examples are provided of how these researchers perceive this process through excerpts from the interviews conducted in the framework of the ESCMID Research Study conducted in 2015.

• "For example, it is very difficult for us to have our manuscripts accepted and published in medical journals. Because, although we do a good work and we write it down in an appropriate manner, just because of our country they say: 'This is not so good to be published in our journal'. It is very difficult for my citizens to have publications in high quality journals, I mean journals with a good index".
• "Articles, publications, from northern European countries are more … I don't know how to explain … If you have a research question, and you go to internet, most people are maybe more eager to read the Scandinavian or American studies than Turkish or Bulgarian".
• "I feel they reject papers coming from our country. Why do I think it? Because I saw very similar papers (written by people from other countries) published, but my paper rejected. But there have been many improvements in the last years".
• "Gradually the situation is improving. In the past it was worse. For the publication, in the journals from continental Europe, Scandinavia and even USA, there is a discrimination. This is based on my experience".
• "I think it (the double-blind method) will make a big change, because today the names within the list of authors are very important when you get published. (…) And it (the publication system in the academic world) is clearly biased. The quality of the work is not the most important thing in some cases".

How large is the pay gap?

There are many studies about the pay gap between different social groups within various organizations. However, data are difficult to produce and the dimension of the pay gap changes according to many variables, including national context, type and size of organization and hierarchical level.

As for the medical sector, particularly interesting is the report delivered in 2016 by the NHS Foundation Trust of the Great Ormond Street Hospital for Children, based in London, which provides a comparable picture of the size of the pay gap suffered by various groups working in the hospital. According to the Report, the pay gap between white and black and minority ethnic staff was calculated at 13% while that between male and female staff was calculated at 10%.

A research carried in out in France in 2015 speaks about a pay gap between male and female hospital leaders calculated at 20-22%.

According to a study conducted in 2006 on women in academic medicine in UK, in turn, women doctors earn 18% less than male doctors. In particular, for university employees, average salaries are 5% lower compared with those whose primary contract is with the National Health Service. In academia, women earn 17% less than men whereas women in the National Health Service earn 21% less than men. Factors that influence and may explain the pay gap include grade, hours worked, experience, administrative roles and specialty.

Inequality and access to professional assets: personal accounts by CM/ID specialists

The interviews made in the framework of the ESCMID Research Study in 2015 provide vivid accounts on how inequality may interfere in the access to important assets available in the organizations. Some examples are provided below.

Time

• "It's just that women are home longer with their kids. So they get behind. If you have these five years, as resident, it takes longer, almost always. We had a woman resident here in infectious diseases (…) and she had two children during her residency. She started almost the same time as me, four years ago, but she's far behind me because she's been home so much more. I've just been home with one kid, six months".
• "I gave myself about a year to do all the clinical work, to get experience, to do that very smoothly and then to look around and to try to do some research activities, (…) but working in the clinics for less time was not possible".

Physical assets

• "In my clinic there are two men and they have two separate rooms. The other four female doctors are in one room".

Networks

• "Sometimes you are rejected, sometimes not. But you don't know when it happens, why you are rejected and suddenly you are accepted. You have a mobbing period and a non-mobbing period and you don't know why".
• "We are always talking about the men who were in charge for very long time in this hospital. They are famous, they know each other from their student time, they have a very good network. They are still here and they can decide a lot".

Professional recognition

• "I think there is some inequality in general. I see for example the media. When there is an influence, whatever epidemic or pandemic influence, media like to interview the heads of the departments and the decision makers. And then, in our country and here in my institute as well, the chances are highest that it would be a man".
• "About the leaders, I think that in this hospital a woman can be chosen to be a leader in the department, but only if there is not a man there. If there is a man, I think that, if he is a little capable, the one who will be chosen will be the man".

Why inequality needs to be challenged: a reasoned list of motivations

Many institutions and scholars had tried to identify the motivations to fight inequality in general and in the medical sector in particular. Combining different sources, an attempt is made here to develop a reasoned list of motivations.

Because it is right. Combating inequality at work meets an ethical obligation or standard which is widely shared and socially supported in European contemporary societies.

Because the law prohibits discrimination. Beyond the ethical principle, anti-discriminatory measures match the need of complying with domestic and EU regulations on human and civil rights. Institutions which do not ensure equality at work are de facto out of law.

Because it enhances the working environment. Inequality produces conflicts, decreases the quality of professional relations and creates dissatisfaction. Adopting measures against inequality makes the work environment better for the benefit of everyone and of the organization as a whole.

Because it allows to better match the users' needs. Increasing the diversity of the staff allows to better dealing with the increasing diversity of contemporary societies. This is especially true when health services are concerned. Inequality dynamics systematically hinder this process.

Because it allows to shape a better leadership. Inequality makes it more difficult to reward the most skilled specialists and to select the best leaders. Contrasting inequality enhances CM/ID leaderships.

Because it allows to shape a better staff. Inequality hinders the possibility to build up a motivated and skilled staff. Therefore combating inequality favors the establishment of an organizational environment where the competences of all employees are valued and fostered.

Because it allows to attract and retain talents. People do not like to work in an environment which discriminates them. Those who have not many alternatives may accept this situation. Those who have more opportunities will likely prefer to go where their rights are better protected.

Because it increases the reputation of the institution or the department. Addressing inequality makes the institution or department more visible and credible, thus increasing its reputation. This may be a competitive advantage for, e.g., accessing research funds and sponsorships or negotiating with the management or with local and national counterparts.

Because it improves the overall quality of research and the service provided. All the factors mentioned above have the final effect to improve the overall quality of the research carried out by the institution or the service provided by the hospital.

The lack of an institutional engagement on inequality

Research institutions and hospitals are usually scarcely engaged with inequality at work.

In the framework of the ESCMID Survey, some data emerged in this regard. The vast majority of CM/ID professionals interviewed (62.4%) report that discrimination is not an issue of discussion at all in their own institution, while 25.7% of respondent said that it is an issue of discussion only at the informal level. Only 11.9% of CM/ID professionals mentioned discrimination as an issue of discussion in their own work environment at a formal level, with an engagement of the institution leaders and structures.

We can therefore conclude that, at least in principle, only slightly above one in ten institutions puts in place specific equality measures or policies aimed at contrasting inequality.

Information coming from other sources depicts a similar picture.

For example, in the framework of a survey organized by the French association of hospital directors, 72.4% of the hospital managers said that in their health institution no specific action has been done for addressing equality-related issues.