Journey of Women in Gastroenterology in South Asian Countries: From Training to Leadership

Deepika Kedia¹, Lubna Kamani², Most Rokshana Begum³, Aabha Nagral⁴, Mamun Al Mahtab⁵, Shivaram Prasad Singh⁶

¹Department of Gastroenterology, AMRI Dhakuria, Kolkata, West Bengal, India; South Asian Association for the Study of Liver (SAASL)

²Department of Gastroenterology, Liaquat National Hospital and Medical College, Karachi, Pakistan; South Asian Association for the Study of Liver (SAASL)

³Department of Hepatology, Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh; South Asian Association for the Study of Liver (SAASL)

⁴Department of Gastroenterology, Jaslok Hospital & Research Centre, Mumbai, Maharashtra, India; South Asian Association for the Study of Liver (SAASL)

⁵Interventional Hepatology Division, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh; South Asian Association for the Study of Liver (SAASL)

⁶Kalinga Gastroenterology Foundation, Cuttack, Odisha, India; South Asian Association for the Study of Liver (SAASL)

Corresponding Author: Deepika Kedia, Department of Gastroenterology, AMRI Dhakuria, Kolkata, West Bengal, India; South Asian Association for the Study of Liver (SAASL), Phone: +91 9831239520, e-mail: kedia.deepika@gmail.com

How to cite this article: Kedia D, Kamani L, Begum MR, et al. Journey of Women in Gastroenterology in South Asian Countries: From Training to Leadership. Euroasian J Hepato-Gastroenterol 2023;13(1):41–43.

Source of support: Nil

Conflict of interest: Dr Mamun Al Mahtab is associated as Co-Editor-in-Chief of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of the Co-Editor-in-Chief and his research group.

Received on: 07 June 2023; Accepted on: 10 July 2023; Published on: 03 August 2023

ABSTRACT

Women in gastroenterology are underrepresented all over the world and in South Asia, the numbers are even fewer. Women doctors in South Asia have their unique set of problems that they have to deal with. They are trained well and are keen to publish but are not considered good enough. They do not get the same opportunities as their male colleagues. There is more expectation from women doctors to look after their families and children. We can correct this discrepancy by giving more opportunities, arranging flexible training, deserving promotions, leadership roles, equal pay, and research mentors for women doctors in gastroenterology in South Asia, and educating our society to treat women doctors, at par with men.

Keywords: Gastroenterology training, Leadership, Women in gastroenterology, South Asia, South Asian Association for the Study of Liver.

Women all over the world are not fortunate enough to get the same opportunities as men in all spheres of work. Women may be more competent or better trained than their male counterparts but they are very rarely considered to be leaders or significant contributors to the workplace. This holds for medicine too. Women go to medical schools in big numbers, nearly the same as men, but as they go up the ladder, training in their specific fields, the numbers start reducing because they do not get the same opportunities as men. This holds for gastroenterology too; in South Asian countries, women have their unique set of problems which cause more delays in their training and getting research opportunities.

Many societies in South Asia do not let their daughters study or go to college or take up a profession such as medicine which involves many years of studying and training. They send their sons to a private school even if they cannot afford it, but the daughters are either not sent to school or if at all they attend school, it is a government-aided school which is usually not very good academically. Most of these girls help their mothers at home with household chores and look after younger siblings.

Two iron ladies in colonial India paved the path for female doctors in India and the Indian subcontinent. The first lady doctor of Western medicine in India was Dr. Anandi Gopal Joshi of Pune. She studied in the United States at the Woman’s Medical College of Pennsylvania, Philadelphia 1883. She was in Serampore near Kolkata, before going to the US and in her famous speech at Serampore College, said “In my humble opinion, there is a growing need for Hindu lady doctors in India and I volunteer to qualify myself for one”. She graduated in 1886 but sadly contracted tuberculosis and died in February 1887. The second one was Dr. Kadambini Ganguly of Kolkata. She joined Calcutta Medical College and Hospital (CMH & C) in 1883 and graduated in 1886. She pressurized CMC & H to allow women as students.

In South Asia, the opportunities women doctors get are the same as their male counterparts till graduation, that is, MBBS level. As the lady doctor graduates, many are not allowed to practice and become “doctor brides” or “trophy wives” especially in Pakistan or take up less busy specialties for higher training so that they can look after their families.^1,2 Women’s careers are viewed as secondary to their spouses, even if they are both doctors.³

When it comes to taking up gastroenterology including hepatology, women shy away from it. There are nearly 50% of female medical students in India. By the time there are fellows in Gastroenterology (GI), there are much less numbers of lady doctors. Indian female Gastroenterologists are less than 10% of the country’s total number of practicing Gastroenterologists. The training in endoscopy especially advanced endoscopy is longer. After their post-graduate degree in Gastroenterology, lady gastroenterologists do not want to or sometimes cannot spend time doing bleeding on calls, as most of them get married or have young children to look after. Fortunately or unfortunately women’s biological and professional clocks tick at the same time. This is not only their prime reproductive years but also the most important time to train in advanced endoscopy or get involved in research. Some of the women fellows in Gastroenterology are uncomfortable learning advanced therapeutic endoscopy from male seniors and are averse to exposure to radiation. Some male doctors are also not comfortable teaching female GI doctors. Perceptions that women are less skilled or capable of doing advanced procedures and this field is more suited or reserved for their male counterparts exist in most countries. There is a false belief among people that women doctors are suitable for gynecology, obstetrics, and the basic subjects. So, many patients do not want to consult with or undergo procedures with a lady hepatologist or gastroenterologist despite having the same skills as men.

Women in Gastroenterology and Hepatology all over the world get fewer opportunities, less pay, and are less published than their male counterparts. Once women gastroenterologists in South Asian countries like India, Pakistan, Bangladesh, Sri Lanka, Myanmar, Nepal, and others get past this stage of training then they have to compete with their male counterparts for faculty positions, getting research opportunities and funding for it. Fewer numbers of women as compared to men are promoted to full-time professors despite equal numbers of hours worked and articles written.^4,5 They hardly ever have female GI leaders as a role model. Most GI or Liver units do not have female unit heads. There are few female professors in Gastroenterology in South Asian countries. If there is one, then it has been seen that all over the world, women fellows flock to take up more training in all aspects of gastroenterology and research. It has been published that if a woman is the head of a GI training program, it attracts more female trainees as they consider the unit head as their role model. In Pakistan in 2019, there were 60 GI supervisors and only four females.⁶ Now, in 2023, there are 84 male supervisors but still only five females.

Hepatology and liver transplant are very popular among women doctors all over the world. Dame Sheila Sherlock was the first woman hepatologist in the United Kingdom and the world. She started her career in 1942 and has published widely. She paved the way for a lot of women doctors to take up Hepatology as their chosen field. She was the founder member of European Association for the Study of the Liver (EASL). Nancy Ascher was the first woman to perform live adult-to-child liver transplant in 1993. Anna Lock was the first Asian American Woman President of American Association for the Study of Liver Diseases (AASLD) in 2017. But in South Asia, there are very few females in hepatology and fewer in liver transplant surgery as it takes more vigorous training, long hours to perform liver transplants and postoperative care. With women being the prime caregiver in families in South Asia, women doctors do not take up these specialties leading to a further gender gap in this male dominating specialty.⁶ Late Sarwar Jahan Zuberi from Pakistan did some groundbreaking research in this region.

Women fellows or junior levels consultants in South Asian countries have to deal with more expectations to look after their families when they get married. They have to usually look after both sets of parents, household work, and young children apart from concentrating on their training in gastroenterology or hepatology. The environment at work is hostile in some units against women GI doctors as they are so few of them. Also, women GI physicians are not good at networking which is considered more of a male prerogative.

Women have unique challenges and requirements both as a physician and as patients. Due to cultural, social, and religious norms, women prefer and feel comfortable with same-gender endoscopists for endoscopy particularly colonoscopy.

There are no guidelines on pregnancy and maternity leave at least in India from National Medical Commission NMC (India) for female residents or fellows. On discontinuation of jobs, the revival of career options is unavailable. There are no options for flexible training or any academic training. During the rural placement of women doctors, there are issues of safety, traveling, and hygiene in South Asia.¹ Keeping this in mind institutional policies and government planning at the national level has to be more gender friendly for a more pluralistic approach.

In India, in public health institutions, women GI physicians get the same salary as their male counterparts. The disparity exists in the private setup in South Asia, where women GI physicians have to be more assertive in negotiating. Some diagnostic centers, clinics, and private hospitals do not like to appoint female GI doctors as they have the misconception that women doctors will give less time to the hospital than their male counterparts due to their family responsibilities. They also think that women are incapable of doing night duties.

The numbers are abysmal for South Asian countries women gastroenterologists and hepatologists. According to the Indian Society of Gastroenterology (ISG), there are 3,232 male gastroenterologists, 201 females (6.21%). Indian Society for the Study of Liver (INASL) has 950 members in total out of which only 61 are women Hepatologists, i.e., 6.42%. In Pakistan, there are approximately 150 male gastroenterologists and hepatologists with only 15 female doctors – (9.09%) as per Dr. Lubna Kamani. In Sri Lanka, there are 19 male gastroenterologists with five females (26.3%) courtesy Dr. Jayani Manchanayake. Bangladesh ASL has 110 males and six females (5.45%) (Dr. Rokshana Begum). In Nepal, male hepatologists are 14 in number with three females (21.4%). Male gastroenterologists in Nepal are 68 in total, out of which 6 are females (8.8%) (Dr. Niyanta Karki). In contrast, AASLD, 2 years ago had 2,534 female hepatologist members and 4,343 males. 23 did not mention sex, so females were 58.34% (AASLD office).

There are hardly any data available for South Asia for women GI faculty positions. In the US, there have been studies done, where, in one study done recently by Daniel S Jamorabo published in Annals of Gastroenterology in 2021, data were collected from about 3,655 faculty members and trainees in 163 academic programs in gastroenterology. Women were 28.7% (1,049/3,655) which included 713/2,657 faculty (26.8%) and 56/289 (19.4%) as fellowship program directors, Departmental Chairs, and Chiefs.⁴ There are very few gastroenterology or hepatology women unit heads in South Asia. At All India Institute of Medical Sciences (AIIMS), Delhi, women doctors are 25.6% faculty, 36% of senior faculty, and 8% of Departmental Chairs. Only 5% in surgical specialties excluding eye and obstetrics and gynecology.⁷

Women GI physicians have a greater ordeal to get published. There are lesser opportunities and supervision for research and funding in their units and added to that, there is disparity at the journal level too. Most medical journals do not have enough women as authors, reviewers, editors, or on the editorial board. To ensure their journals are fair, senior editors should be held accountable for proactively uncovering and tackling gender bias.⁸

Lancet’s editors have commented that gaps are not because of a lack of qualified women, rather the “supposed meritocracy is rigged against them, resulting in an unjustified and unacceptable masking of women’s contributions”.⁸

All journals have to take the initiative to make sure they have 50% women on the editorial board, invited and non-invited authors depending upon specialty.⁸

There are very few women speakers at any gastroenterology and hepatology conferences in South Asia. There are sometimes no females in the Governing Councils of Professional Organizations for GI or liver in most South Asian countries. But an exception to this is that one of the authors is the President of the Pak GI and Liver Disease Society. The other author is a Governing Council member of the Indian Association for the Study of Liver (INASL). On the other hand, all professional gastroenterology and liver bodies in the US this year have female Presidents.

Great initiatives have been made, but we need to do more. South Asian Association for the Study of Liver has had a women’s wing for the last 2 years which has all the women hepatologists from South Asia under one umbrella which was the brainchild of President Dr. SP Singh from India and Secretary General Dr. Mamum Al Mahtab from Bangladesh. The recently organized first-ever female gastroenterology live advance endoscopy workshop by Asian Institute of Gastroenterology in Hyderabad was attended by 500 lady gastroenterologists from all over South Asia and the Middle East. All the advanced endoscopy was performed by women doctors from India and all over the world. Another step has been the formation of Special Interest Group Women in Gastroenterology by the Indian Society of Gastroenterology (ISG) to find out how we can encourage more and more women to take up Gastroenterology and Hepatology. One of the authors is the Co-Chair of this SIG.

Socially, we all need to sensitize sons at home to respect women, to role play for engender work like cooking, cleaning, outside chores, looking after children and looking after both sets of parents after marriage. Social media can play a good role here. We need to encourage our daughters to break the glass ceiling. On the medical front, we have to encourage more and more women to take up Gastroenterology and Hepatology and provide them a conducive environment in the form of flexible training opportunities even in advanced endoscopy and transplant hepatology and provide mentorship in all aspects for professional growth, research, publishing, and leadership roles. The details of the number of female trainees, fellows, faculty, professors, and unit chiefs in Gastroenterology and Hepatology should be studied for each country in South Asia to improve as there is no data available. Training programs should be made transparent where the leadership is evaluated based on handling juniors and women doctors. This can be implemented by SAASL or local GI or liver bodies in each country in South Asia. There can be institutional rewards for gender equality.

We have to ensure that capable women in all fields of Medicine including Gastroenterology and Hepatology are elected to head professional societies in the South Asian countries. More women should be invited to deliver talks at medical conferences whereas present-day medical conferences have very few female doctors as speakers.

We have already seen that during the pandemic, women heads of state have shown exemplary leadership qualities and have kept their countries much more safe compared to other countries by taking tough, timely decisions. So as a society, particularly in South Asia, we have to ensure that women are given a fair chance in all fields of work including Gastroenterology and Hepatology. They will possibly outperform their male colleagues in similar posts.

AUTHORS’ CONTRIBUTIONS

Deepika Kedia – Conceptualization, literature search, drafting of the first manuscript, critical reading and revision, final Editing

Lubna Kamani – editor and revision

Abha Nagral, Mamun Al Mahtab, Most Rokshana Begum, Shivaram Prasad Singh – reviewer.

REFERENCES

1. Nadeem A, Yasmeen R. The kaleidoscope of the glass ceiling: Experiences of Pakistani female doctors - A qualitative narrative inquiry. J Pak Med Assoc 2023;73(3):539–546. DOI: 10.47391/JPMA.6436.

2. Moazam F, Shekhani S. Why women go to medical college but fail to practice medicine: Perspectives from the Islamic Republic of Pakistan. Med Educ 2018;52(7):705–715. DOI: 10.1111/medu.13545.

3. Raj A, Kumra T, Darmstadt GL, et al. Achieving gender and social equality: More than gender parity is needed. Acad Med 2019;94(11):1658–1664. DOI: 10.1097/ACM.0000000000002877.

4. Jamorabo DS, Chen R, Gurm H, et al. Women remain underrepresented in leadership positions in academic gastroenterology throughout the United States. Ann Gastroenterol 2021;34(3):316–322. DOI: 10.20524/aog.2021.0597.

5. Hamel MB, Ingelfinger JR, Phimister E, et al. Women in academic medicine-progress and challenges. N Engl J Med 2006;355(3):310–312. DOI: 10.1056/NEJMe068143.

6. Kamani L, Hooft JEV. Rising trend of women in Gastroenterology: A Paradigm Shift. J Coll Physicians Surg Pak 2021;31(2):121–122. DOI: 10.29271/jcpsp.2021.02.121.

7. Sood M, Chadda R K. Women in medicine: A perspective. Indian Journal of Gender Studies 2010;17(2):277–285. DOI: 10.1177/097152151001700204.

8. Silver JK. Medical journals must tackle gender bias. BMJ 2019;367:l5888. DOI: 10.1136/bmj.l5888.

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