A. Why Inequality Matters

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.


Box 1

Did you know that, in the CM/ID sector...

It is more difficult for women to access leadership positions: 

  • Less women than men are heads of divisions in the CM/ID specialties (37.1% vs. 62.9%), even though the imbalance is much higher in ID, where only 29.2% of women are division heads, as compared to 42.7% in CM
  • Women are remarkably less than men both as associate professors (35% vs. 65%) and in full professor positions (36.3% vs. 63.7%), even though more women than men are assistant professors (52.7% vs. 47.3%) 
  • The presence of women in committees and boards is systematically lower than men's for a percentage varying from 20 to 30 points.

It is more difficult for them to start an academic career: 

  • Less women than man (45.3% vs. 56.7%) pursue it.

It is more difficult for them to get research funds: 

  • While the percentage of women and men getting European research funds is similar (around 3%), those related to national research funds are remarkably different (16.7% vs. 26.2%).

It is more difficult for women to publish scientific works:

  • The percentage of female microbiologists who published more than 50 works in peer-reviewed journals is systematically lower than that of their male colleagues (14.6% vs. 28.8%); the same trends is observed in the case of infectious diseases professionals (12.6% vs. 26.8%).

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


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.


Box 2

Did you know that, in the CM/ID sector...

It is more difficult for women to have a smooth career path: 

  • Women are more likely than men to suffer discontinuities and to lose career opportunities because of caring responsibilities (39.3% vs. 25.0%).

It is more difficult for them to have children: 

  • Less women have 2 or more children than men (35.4% vs. 55.6%)
  • More women (around the double) than men declare to have fewer children than desired because of their career (30.7% vs. 15.7%).

It is more difficult to find women satisfied of how they combine work and personal life: 

  • More women than men, all ages considered, are dissatisfied with their work-life balance arrangements (27.2% vs. 15.0%); women in the age class 39-45 (when child and elder care overlap) were found to be the more dissatisfied (59%), while no significant differences from the average value are recorded for men (15.0%).

CM/ID professionals accomplish household duties much more than their male colleagues: 

  • More women than men declare to accomplish more than 75% of household duties (55.3% vs.16.7%)

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

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.


Box 3

Mobility of health workers within Europe

Mobility of health workers has been increasing in the last years in Europe.

Overall, in the period 2001-2006, 12,963 European doctors asked the recognition of their professional qualifications for the purpose of permanent establishment within the EU Member States, EEA countries and Switzerland. In the period 2010-2015, this number increased by almost 5 times, from 12,963 to 75,886 units, even though from 2013 to 2015 a slight decrease is reported.

Source: European Commission Regulated professions database (http://ec.europa.eu/growth/tools-databases/regprof/)


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!