Nancy M. Valentine, PhD, MPH, RN, FAAN FNAP
President, Valentine Group Health, LLC
Leadership Council Member, the Carol Emmott Fellowship
Women comprise the largest number of warriors on the front lines of health care in every sector: hospitals, clinics, home care. And although this virus is an equal-opportunity killer, not everyone involved in health care is at equal risk. Those who are standing at patients’ bedsides for hours on end, staffing ER’s, working in intensive care units, EMTs bringing in fresh cases, and team members delivering meals and cleaning rooms; these are the people most at risk. We already know that women are vital to health care, but never have we had such a sharp lens as the nightly news reports and press updates to view the images of who is delivering care versus who is making decisions, especially in a crisis.
The COVID-19 crisis presents startling images of our current reality: nurses wearing garbage bags for protection (in a country that spends more on health care than any other!), physicians crying after their shifts for brief emotional release before facing a new day. These are depressing and chilling images, and a window into the physical and emotional trauma being borne by those who serve and care at this time. We’re seeing heartbreaking loss of vital talent with at least 9500 U.S. healthcare workers contracting the virus, some dying. Additionally, the longer-term consequences of PTSD-like reactions among staff are unknown at present. Collateral damage among our healthcare workforce cannot be underestimated.
As communities rally to applaud health care workers and refer to them as heroes, the images begin to blur in a dizzying array as the days go on. Who are these heroes and heroines? Why did it take something of this magnitude—being brought to our knees in fear of death! —for people to recognize the art of caring and self-sacrifice performed by healthcare workers every day?
Clinicians work in teams and everyone is important, and our male colleagues are our partners. But in a state of crisis, let’s look at who is predominantly providing frontline defense. When we look behind the images, many of which we don’t see in the media, the story is clear. Most care is being provided by women. In a recent article, the New York Times reported that 73% of healthcare workers contracting the virus are women. (1)
Given the magnitude of what we are experiencing in stress on the healthcare systems, stress of caregiving, lack of PPE, and overall unpreparedness given the Covid-19 pandemic, we must ask, what are the implications—and opportunities– for women in health care? Where do women factor into influential leadership roles?
Let’s look at the numbers.
Physicians. There are nearly 1.1 million physicians in the US, and approximately 900,000 are in practice. (2) Female physicians now account for approximately one third of the U.S. physician workforce and comprise half of all U.S. medical school graduates. (3) In looking at where most female physicians are practicing, the numbers vary greatly by location. In those states hardest hit by CV-19, female physicians have a larger presence than in many other states: California (37%), Colorado (37%), Connecticut (40%), District of Columbia (48%), Illinois (39%), Louisiana (32%), Massachusetts (42%), New Jersey (38%), New York (40%), Pennsylvania (37%). (4)
o Approximately 25% of all ED physicians, a third of all infectious disease doctors, and nearly half of all internal medicine physicians are female. These are generally the specialties directly involved with this crisis and are areas where women are represented in relatively higher numbers as compared with other areas such as neurological surgery or orthopedics, for example. (5)
o Physician Assistants number 88,604; 55,677 are female and 29,850 are male (3,077 are unspecified). Highest concentration in the affected states of California, Illinois, New York, and Pennsylvania. (6)
o Registered nurses. There are more than 3 million registered nurses in the US and they are employed in hospitals (1,713,120/30.69%). home healthcare (177,790/11.86%), nursing homes (151,300/9.43%), outpatient (147,550/ 15.47%). Approximately 250,000 work as Advanced Practice Nurses in roles such as nurse practitioners, nurse midwives, and nurse anesthetists. Much like physicians, there are higher concentration of numbers in the most affected states as noted. (7) The percentage of RN’s who are women is 90%. (8)
o Licensed practical nurses. There are 728,900 LPN’s/LVN’s in the US. (9) The percentage of LPN’s/LVN’s who are women is 93%. (10)
With a combined workforce of nearly 4 million, nurses are in every workplace affected by the pandemic. Nurses make up 59% of the global health care workforce and deliver up to 80% of all health care services, making nurses the largest single sector of the healthcare workforce affected.
EMT’s and Paramedics. There are 262,100 employed in US. (11) Of this number, approximately 35% are women. (12)
Essential Support Staff. Women dominate roles as housekeepers, nurses’ aides, dietary staff, etc., all vital jobs in the operation of any healthcare facility.
The point is, women are on the frontlines in the “9/11 of health care” –working in teams, leading teams, savings lives, compassionately looking at death in the eyes of patients, comforting families at a distance, maintaining dignity in the midst of chaos, all the while putting themselves and possibly even their families at risk. They show up for work, volunteer, and travel from other states to help where needed. In the midst of fear, they move forward with courage and commitment despite the unknown.
And this is where the predominant representation of women in health care ends. As women are “doing,” it is men who are leading, men who are deciding the critical policies and industry responses to this crisis.
Women are largely absent in leading and influencing health care in top strategic roles.
Here are some additional realities:
The gender gap in hospital CEO’s is profound at 14% women (2014) (13)
CEO jobs for women in health care has stagnated at 13% with about 30% occupying other management level positions. (2019) (14)
Not a single woman serves as CEO of a Fortune 500 health care company. Only 22.1% of their board members are women, about the same level as the Fortune 500 overall (20.2%). As evidence of the sluggish improvement, in 2015, 21.0% of Fortune 500 healthcare board members were women. At this rate, we are not projected to reach 50/50 gender parity on health care boards until 2049. (15) Pharmaceutical companies, hospital chains, and insurance companies need women at the top for all the same reasons they are effective on the frontlines. But most of us may well be at the end of our careers—or dead! —before we see the full power and potential of women brought to bear in industry-leading roles.
The White House Coronavirus Task Force team of 21 members, mercifully, has two women represented: Dr. Deborah Birx, US Global AIDS Coordinator, is tasked as the response coordinator and Ms. Seema Verma is administrator of the Centers for Medicare and Medicaid Services. Although few are privy to “insider” White House discussions, it appears that most of the decision-makers and influencers are men—some who have no expertise in health care. And social media is now focused on Dr. Birx’s scarves as her signature in press briefings.
During this pandemic, we are witnessing strong people–men and women– working within a fragile health care system that is characterized not only by insufficient PPE, but by a general lack of emergency medical preparedness across healthcare settings. It is women who lack a voice in the business, governance, and policies that impact everyone risking their lives. Top business players and healthcare companies are making decisions on manufacturing of healthcare products, supply chain distribution, and innovations in care delivery—for the most part without the vital input, experience, and wisdom of women.
This is the moment in time for women to stand up and assert stronger control and influence in order to advocate for what is needed to improve our health care world. Women in health care have the in-the-trenches view of opportunities for improvement and innovation. Let’s speak up more loudly, clearly, and even publicly with our ideas and solutions. Putting our ideas in writing might seem too time-consuming during a crisis–and sometimes it is–but it’s one way to attract and solidify not only the appreciation but also the recognition we deserve from executives, board members, and influencers. Women belong at the top of organizations; our voices and ideas are needed there more than ever. Part of making that happen is up to industry and organization leaders and part of it is up to us. We must use our knowledge and voice to make the gains we all need and deserve.
Chaos can be a game changer. The Crimean war was Florence Nightingale’s “Lady of the Lamp” emergence as a world changing figure. (16) Clara Barton, referred to as “the angel of the battlefield” for her work during the Civil War and many contributions thereafter, became a lifelong influencer beyond the founding of the Red Cross. (17) Leaders do emerge from despair and seemingly impossible circumstances. We need to find our emerging women leaders, promote them, and support their transformation. It may have taken a world-wide, invisible virus for us to realize that the time is now for women to assume more leadership roles in health care. We cannot wait for another crisis. Allow the women in the trenches who have been on the battlefield emerge from their chrysalis, spread their wings and fly.
Women in health care have learned from this crisis and can use this knowledge and experience to take action locally, regionally, and nationally. Everyone has a network. Let’s think strategically. How can we use our personal and professional contacts to start conversations with business leaders, politicians, health care leaders, and others who are supportive of achieving the equity needed to impact healthcare on a broader scale? The Carol Emmott Foundation (CEF) is an exemplar and has been out front with an agenda that provides a “best in class” incubator for leadership development and nurturance of top talent.
With the support of CEF over the past five years, Fellowship leaders and participants alike have identified and tapped many top industry leaders who are networked with other talented thought leaders. This blossoming network has helped to bring the agenda to advance women in health care to the forefront. Recognition of the CEF career-changing work is spreading as a pebble in a pond. This is a positive example of contagion, as evidenced by an increase in applications for fellowships, former fellows advancing in next step positions, and many experts willing to donate time to coaching and mentoring participants. (18)
CEF has recently added The Equity Collaborative, which comprises 13 health systems across the nation with the goals of developing and sharing best practices in establishing gender equity within their institutions and across the nation. (19) These contacts in business and health care can be tapped along with others in social policy, political action, and corporate equity roles to think of what specifically can be done to accelerate the process of advancing talented women in order to more rapidly shift this equation.
Let’s not wait until the middle of the century for society to make the changes we have earned. Women can and want to advance in the near term. COVID-19 has served as a wake-up call. Now more than ever, we need women leading from the top as well as being boots on the ground. Now more than ever we need women steering health care in a positive and more accountable direction, with patient and consumer advocacy at the forefront. Let’s harness the sadness, sorrow, and vital lessons of this life-changing, world-wide experience to make these changes now. Those who died in this disaster would want nothing less.