key: cord-0684960-mm2iwtf6
authors: Yarrow, Emily; Pagan, Victoria
title: ‘Reflections on frontline medical work during Covid‐19, and the embodiment of risk’
date: 2020-07-03
journal: Gend Work Organ
DOI: 10.1111/gwao.12505
sha: 1551052d571170078bac9618800721028d0d9fa3
doc_id: 684960
cord_uid: mm2iwtf6

Drawing on the voice of a woman NHS frontline Doctor during the current Covid‐19 pandemic, we explore her lived experience of the embodiment of risk in the crisis. We explore her struggles and difficulties, giving her voice, and mobilising our writing to listen to these experiences, reflecting on them as a way of living our own feminist lives. Her story illustrates that the current crisis is not only a crisis of health, but a crisis for feminism. Through telling her story, we cast light upon the embodied amplification of inequalities, paternalistic discourses around risk, and lived experience of exposure to risk of contracting a deadly virus. We explore her work on the NHS frontline, providing a conceptual framework of the multi‐level facets of the embodiment of risk, through lived experiences of risk, and observations of the inequality of risk in the context of the Covid‐19 pandemic in the UK.

albeit there is a clear vertical gender segregation, but the organization and its responses to risk, particularly in a time of crisis, are gendered masculine (Acker, 1990; Hearn, 2000; Williams et al, 2012) .

We draw on one, exploratory in-depth, semi-structured interview with an NHS doctor. The interview was conducted in line with all current government guidance and restrictions on direct social contact in order to limit the spread of the Covid-19, as at 02/06/2020. It was conducted in line with our institutions' ethical guidelines. It is important to stress that the views expressed are of the Doctor herself, and not the NHS or the NHS trust by which she is employed. It was recorded and transcribed in full, verbatim to aid analysis. The analysis of the interview has drawn on Alvesson and Sköldberg's (2000) approach to reflexive interpretation, specifically in that this piece seeks to point out elements of interest rather than intending to be a complete or comprehensive set of analyses. There are many possibilities in the interpretation of the material and we present themes that occurred to us both as we interacted with the interview material, though we adopt a subjective interpretivist philosophical position, framing gender as socially constructed (Butler, 1990) . As such, the piece that follows is structured to show a dialogue between the interview with the NHS doctor, us as researchers, and relevant extant literature. It moves between all of these elements in the creation of a narrative, framed further by the concept of inequality regimes (Acker, 2006) and further illustrated in the conceptual framework we present (please see figure one). direct contact with Covid-19 patients, in turn, contracting the virus herself. Excerpts from the interview explore lived experience, the emotional and physical toll not only of the virus but also of struggles, resilience and reflection. We explore her experience of both working during the pandemic, and her own experience of contracting Covid-19 and subsequently returning to work. Her voice is featured in italics throughout this piece.

This article is structured as follows: first, we briefly discuss Covid-19 in the UK 1 context, though the research has been conducted with a doctor in England and so references to guidance and personal protective equipment (PPE) policy refer to those from Public Health England. We then explore the main facets of the embodiment of risk identified in the research. In our conceptual model (please see figure one), we conceptualise and highlight the embodiment of risk, characterised by, and through, the reflections of the participant, focussing on core themes to enable a focus on the experiential account of the participant, Louise.

It is important to situate this paper in the context of the pandemic in the UK, which has been criticised globally not only for a laggard response to Covid-19, but also for the political communications and handling of the UK governments' response, which may be described as morally moribund. A report published, although denied by Number 10, "quoted one 1 Devolved decision making in Scotland, Northern Ireland, and Wales has been, and is, in place with different lockdown easing dates, through centralised policy making is still a significant and indeed contested factor, particularly where the notion of herd immunity, behavioural nudges and behavioural science which characterise the UK government's policy approach to are concerned. anonymous senior Conservative as saying [of another senior advisor]: "He's gone from 'herd immunity and let the old people die' to 'let's shut down the country and the economy'" (Walker, 2020) . We further discuss the notion of herd immunity later with reference to the UK governments policy approach to the Covid-19 pandemic.

In the four months of the crisis to date, there is already evidence of the further entrenching and amplification of gender roles in the home, gendered ways of working, and gendered caregiving roles during the pandemic (e.g. Hupkau and Petrongolo, 2020) and it is already clear that in the longer term, this is set to worsen. It is clear that the current health crisis is also a crisis for feminism (Mukhtar, 2020) in terms of the widening of previously narrowing inequalities in work-life practices. The following sections explore these, considering the intersection of policy and how this is then translated into organisational practices.

It is possible to see inequalities in health care workplace practices that are particularly embodied (Kerfoot and Knights, 1993; Liu, 2017) , both evident by the viscerally embodied nature of the virus, and the embodied nature of the treatment of patients. The medical profession, indeed like many professions is blighted by deeply ingrained vertical gender segregation (Crompton and Le Feuvre, 2003) . Despite increases of women doctors since the 1970s, globally there is a fervent persistence of gender inequality in the medical profession (Riska, 2010) . The NHS is the UK's biggest employer and the fifth largest employer in the world (NHS Employers, 2016) and although being made up of around 80% women, women are disproportionately represented in nursing roles (the largest professional group), and vastly underrepresented for example as surgeons, and further still at consultant surgeon level (Aldrich, 2019) . Clearly, in the light of the current crisis, women's lived experiences of working during a pandemic and the embodiment of [gendered] inequality and risk are vital.

The inequalities embedded in the decision making processes regarding the management of the crisis are manifest. Ultimately, this has been driven by Westminster, Boris Johnson as prime minister, and SAGE (Scientific Advisory Group for Emergencies). It is notable that the SAGE team is made up primarily of [white] men (16 men and seven women) and only one BAME expert. It is an indictment, given that Covid-19 has been found to disproportionately affect and have a significantly higher mortality rate for BAME individuals (NHS England, 2020a) that there is only one BAME individual on this advisory group. These contextual factors set the scene for characteristic paternalistic discourse and paternalistic, discursive strategy making in crisis (Sibony, 2020) , as well as, in turn, the intensification of gender performativity in the context of Covid-19 (Hennekam and Shymko, 2020) . Louise comments on her discussions between colleagues as follows:

'And once it became more vague with this stay alert well then it just, it just became a bit of a, it just became a bit of a joke, there's a lot of silly messages going around and just stuff made up and um I think it just was, we just talked about it being a political thing not a science-based thing.'

In this respect, policy making in the UK context surrounding Covid-19 may be said to be based on epidemiology and behavioural sciences (Politico, 2020) as well as the notion of 'behavioural fatigue', whereby people would get bored of staying at home, thus rendering the lockdown ineffective (Sibony, 2020) ; indeed the [current Covid-19] 'epidemic does not shut down politics' (ibid., 2020, p.352) but, if anything, seems to have exacerbated political influence in decision making on scientific responses. Scenario planning for global health emergencies happens, with Louise reflecting on inadequacies in the planning process as follows:

'You know, you can look back to the planning exercise they did I think back in 2016 and all the recommendations they had for equipment and lo and behold we didn't have it when this pandemic came'

The National Health Service was front and centre in the Government communication regarding the earliest stages of the crisis, with instructions distilled to the 'stay home, protect the NHS, save lives' initial soundbite. This was supported by the 'clap for carers', an embodied display of (healthy) public support for those putting their lives at risk in the protection of us all. This however shifts the responsibility for 'protecting the NHS' to the public, for them (us) to reduce the risk and moving the discourse away from the deeply politicised nature of the funding and management of healthcare provision in the UK -that indeed, 'lo and behold', the requisite equipment had not been invested in. Louise reflects further:

'there was a lot of evidence of that, community support groups being put up, a lot of people you know doing a lot more with supporting their neighbours, supporting vulnerable in the community, um people looking out for each other. And I think initially that was very strong um, and that was something really, really nice to see, the community support towards the NHS, all the clapping and everything um was good, um. Too little too late' This article is protected by copyright. All rights reserved.

The structural decisions made at policy, [macro political] level are translated into lived experiences of home and work. Whilst Louise recognises the benefits of community cohesion generated through this crisis, she also comments that this is 'too little, too late'. We also saw evidence of our own communities keeping our bodies at home, offering support to one another and also to the NHS workers through making masks, mask extenders, donating millions of pounds to NHS charities, and other material contributions to reduce the risks to the frontline medical workers. The public has been filling gaps in structural investment. But then, as time has gone on and our own rule-makers became rule-breakers (e.g. Weaver, 2020), using our bodies to protect NHS bodies through the minimisation of the risk of spreading the virus has become less of a focus. Louise expresses her frustration as follows:

'And you know however, I think we we've talked a lot about the fact that the public seemed to be on board before um and we were working hard, the NHS, to keep, you know to keep the, to keep the curve under control and the public were working hard to keep the curve flat and so we weren't overwhelmed, and to get the numbers down, and we were creating more beds at all these new Nightingale hospitals and; that all felt good getting on top of it. Um but whether it's just the general public running out of steam, whether it was messages weren't clear anymore, it became really frustrating as healthcare professionals to be in the hospital working you know, seeing colleagues still getting ill, seeing patients still being ill, patients still dying, families still being impacted, and yet looking outside to see people flout, you know flouting the rules, not isolating, people you know meeting in groups etc., it became a bit insulting' Linked to this, it is also of note to reflect upon the aforementioned notion of herd immunity in the socio-political context of Covid-19, the herd being the group of public bodies. Herd immunity refers to the notion that: 'Vaccination ideally protects susceptible populations at high risk for complications of the infection. However, vaccines for these subgroups do not always provide sufficient effectiveness. The herd effect or herd immunity is an attractive way to extend vaccine benefits beyond the directly targeted population. It refers to the indirect protection of unvaccinated persons, whereby an increase in the prevalence of immunity by the vaccine prevents circulation of infectious agents in susceptible populations ' Kim, Johnstone and Loeb (2011, p.683 ).

However, we mobilise the notion of herd immunity, as not only contested, but also critically as an antecedent for the behavioural nudges and behavioural science which typify the UK government's policy approach to Covid-19. This leads us to discuss the embodiment of risk in practice of frontline medical workers, such as Louise.

In conceptualising the notion of the embodiment of risk in practice, the embodiment of risk through emotion, and the inequality of risk, we adopt the definition of risk management in healthcare from Cure et al., (2014) which shifts the discourse from financial risk to ' include risks related to patient care, medical staff, employees, and property' (ibid, p.89) in the context of risk-based regulation (Beaussier et al., 2016) .

As such, whilst healthcare workers should be able to reduce these risks by wearing PPE as part of the responsibilities of the workplace as well as the agency of individual workers (Manne, 2019) , this has been insufficient. During the crisis, there have been three main factors affecting the levels of risk associated with PPE: 1) overall lack/shortages; 2) insufficiency of fit; and 3) different policies in terms of risk assessment regarding its use. We hereby explore these three factors through the concepts of embodied absence, embodied insufficiency, and embodied emotions as responses to risk and PPE policies.

Firstly, lack and shortages. Throughout the Covid-19 pandemic, though particularly in the early weeks in March and April, there was a consistent, and de facto lack, of PPE available globally, though this was particularly pronounced in the UK (Foster and Neville, 2020) Whilst not all healthcare professionals engage in close contact and/or aerosol generating procedures 2 (AGPs), the risk of contracting Covid-19 on the frontline is elevated compared to that of the general public, particularly for those from a BAME background; 'those of Filipino birth and those who are older have been disproportionately affected by Covid-19, with specific underlying conditions increasing risk of severe illness. In addition, 'being male has also been associated with severe disease' (BMA, 2020), further exacerbated by PPE shortages. There was little to no choice for Louise to say 'no' to enforced ways of working, a way of working which ultimately put lives at risk. The embodiment of risk here is presented here not only as deeply personalised, but also as a defining characteristic of the Covid-19 pandemic in the UK context under a Conservative government which notably appears to have tailored its guidance to the availability of PPE (Foster and Neville, 2020) Louise also discussed how the rhetoric of scarcity shaped the embodiment of risk in practice, though there was a critical gap of around three weeks between the upsurge of the pandemic in March 2020 and the April 2020, critically, this is also the period where the daily death rates from Covid-19 were the highest (NHS England, 2020b). Louise highlights her lived experience of PPE scarcity:

'there was quite a lot of chat of this is very precious, we need to be um [sighs] er careful with our resource, um minimise our use, but they, they always claimed once This article is protected by copyright. All rights reserved.

we started using it, once they changed the policy to that we would use it, about three weeks after the government guidelines, that we had enough'

This shifts the burden of responsibility onto the individual health workers, to take care not to let their bodies overuse the materials, but then claim that there was always enough (perhaps because of the under-use and under-protection of these workers).

Secondly, even where there was access, the PPE is designed and manufactured to fit and, in turn, work most effectively, when worn on the male 'standard' body (Topping, 2020) , this was also a concern expressed by Louise: In this respect, bodies other than the 'standard' body 'are judged and identified as problematic for organizations' (Simpson and Lewis, 2005 p.1264 ). In some organizational This article is protected by copyright. All rights reserved.

contexts, women's bodies are perceived as threatening, for example, in the military (Steidl and Brookshire, 2018) and corporate leadership (Mavin and Grandy, 2018) , but in these healthcare contexts, the threat is borne by the women themselves, it is their bodies who are threatened by insufficient access to and suitability of the protective equipment that could help reduce the risk.

'I find it hard to watch the statistics of looking at you know every time they announced another GP had died, another hospital consultant had died, um you know and nurses, um I find it difficult to watch that but when you look at you know, when you think about proportion and you know who's going to get what, but then to find out that that you know the hugely high percentage of doctors who lost their lives who are part the BAME group…..….., I mean once that kind of trend was being more and more identified there were more safeguards put in place, the risk assessments, we're not treating all colleagues the same, we're not putting in more protective measures for people in that group but um that didn't happen for a while and so, yeah that was, yeah just hard to watch'

There are also strong linkages here not only between the lack of fit in the physical sense, but also in the attitudinal sense, related to silencing and the facets of control and compliance in inequality regimes (Acker, 2006) . We argue that the silencing of doctors and other healthcare professionals over PPE shortages which has been endemic (DAUK, 2020), serves as a direct expression of control and compliance over individuals (Acker, 2006) , characterised by the 'systematic differences in access to and control over resources for provisioning and survival' (ibid, 2006, p.444 It is now known that: 'Multiple doctors have approached DAUK having been discouraged from speaking up. In some cases doctors have been bullied into silence, disciplined, or told their careers are under threat' (DAUK, 2020) . In this respect, there is an embodiment of risk in speaking out (Simpson and Lewis, 2005) characterised by the fears of being associated with the reporting of PPE shortages, which are gradually coming to the fore, despite for example the recent PPE survey by DAUK finding that 47% of respondents were told explicitly not to mention PPE shortages on social media (DAUK, 2020).

Throughout the interview it was evident that Louise was in emotional flux in relation to her experiences of risk, mobilising formal risk assessment, the following of PPE guidelines (from Public Health England), experiencing tensions between the source of her emotion and how to This article is protected by copyright. All rights reserved. mitigate this in order to carry out her job on the frontline. In healthcare contexts, the risks of contracting Covid-19 are for many, greater than those risks in everyday life, and there has been sustained media coverage not only the deaths of professionals in the NHS, but also the risks to which they are exposed. Notably 'both caring for the sickest patients with Covid-19 and undertaking airway management (so-called aerosol generating procedures, AGP) are associated with high risk of viral exposure and transmission' (Cook, Kursomovic, Lennane, 2020) .

'a mixture of between acceptance and, and being pragmatic about that, to also feeling frustrated and I get at times some fear and just frustration and as, and that escalated as we saw more and more cases of doctors, nurses, health professionals um contracting it, be it my colleagues and of people dying, of healthcare professionals dying'

There is an extent to which the assessment of risk, and different approaches thereto mentioned above, have been a source of both negative and positive emotion for Louise. In this respect, the different interpretations of risk assessment have caused worry and concern in some contexts, and have provided a source of comfort in others. In the first example following, on raising the issue of lack of the appropriate PPE, she encountered much conflicting information and indeed also emotional conflict, as the following quote highlights: Even where PPE is available and fits, there were different policies regarding its use and whilst to a certain extent variation according to context could be expected, as well as changes in relation to new learning and information about the nature of the virus and its transmission, variations in interpretation do affect the nature of the risk and its experience. But for Louise, the variation in interpretation in this context has been a source of discomfort and distress in her lived experiences.

The embodiment of risk through emotion is deeply personalised, gendered, racialised and felt acutely by frontline NHS healthcare professionals, typified by the constant emotional and pragmatic tensions of caregiving, self-protection, service, and the balancing of risk in an extreme circumstance. So in some circumstances such as those above, assessing risk has been a source of tension. In other contexts, however, there is an extent to which the assessment of risk has actually helped Louise to mitigate her emotional responses as a coping mechanism and source of comfort: In this case, Louise has absorbed a trust in the processes of risk such that she could 'balance that out', she could cope with the level of risk because of the way that level of risk was presented. We argue here, that because of the UK Government's approach to risk, and drawing on the recent work of Sibony (2020) that risk taking by the government, as aforementioned, contributed to not only PPE shortages but in turn, also the embodiment of risk in practice. Furthermore, whilst deliberating prospect theory (Tversky and Kahneman, 1992) , whereby if we consider the [rightfully] negative framing of the pandemic and associated deaths, this has arguably led to more risk taking, particularly where behavioural science and behavioural nudges appear to be central to Government policy making (Sibony, 2020) . We have witnessed a deeply disturbing trickle-down effect of the government's approach to risk, contributing further to the [gendered and racialised] inequalities of risk, with diminishing sensitivity and assumed responsibility on the part of the state.

This article is protected by copyright. All rights reserved.

The following conceptual framework captures the multi-level facets of the embodiment of risk which we have explored in this paper, through lived and expressed experiences of risk, and observations of the inequality of risk in the context of the Covid-19 pandemic documented in the recent extant, evolving literature, as well as Acker's inequality regimes framework (2006) as a sensitising framework.

The conceptualisation of the embodiment of risk during Covid-19 serves to cast light on the role of the Covid-19 pandemic on the embodiment of risk, the multi-faceted nature of emotions of risk, and the associated inequality of risk, which are framed as contemporary expressions of inequality regimes (Acker, 2006) . The inequality of risk, and its connection to the shortages in PPE, may be directly linked to Acker's defining of inequality as systemic disparities between individuals' 'access to and control over resources and outcomes ' (2006, p.443) , the organizing of work, and 'control over resources for provisioning and survival' (ibid p.444).

We assert that the embodiment of risk is personified in the crisis by the lack of PPE, in turn shaping emotions of risk and lived experience of the tensions between self-protection and exposure to the Covid-19 virus, within the parameters of policy and guidance. Vulnerability to contracting Covid-19 through work on the frontline, as was the case for Louise, brings together the embodiment of risk, the emotion of risk, and by definition also the inequality of risk experienced by front line workers, whom have no option but to be exposed to the operational and occupational risks of their work.

This conceptualisation of risk, and the typologies we propose, in the Covid-19 pandemic assists us in the interpretation of the linkages between paternalistic, discursive policy marking at the macro level and the effects on the [multiple] levels of risk experienced by frontline medical workers such as doctors like Louise, at the individual level.

This paper has explored Louise's lived experiences as an NHS doctor, casting light upon the embodied amplification of inequalities, paternalistic discourses around risk, equipment shortages and lived and experience of exposure to risk, and we draw linkages between PPE inadequacies, vertical gender segregation in the NHS, as expressions of inequality regimes in the context of Covid-19, thereby conceptualising risk in the context of a contemporary inequality regime. Even organisations such as the NHS which have 'explicit egalitarian goals, develop inequality regimes over time' (Acker 2006, p.443) ; the ultimate expression of this is the disproportionate number of BAME healthcare professionals dying (NHS England, 2020a), albeit we remain hopeful that the visibility of inequality is increasing, and in turn, decreasing its legitimacy, ultimately to positively contribute to the protection of those who are most acutely affected by the entrenched and systemic inequalities, and indeed Covid-19.

It is clear that there are many gendered elements of the Covid-19 pandemic emerging, and over time we anticipate that this will, unfortunately, contribute to the deepening of gender inequality, vertical gender segregation, and women's lived experiences of work and organising, albeit the potential for the pandemic to counter macho masculinity in organizations (Alcadipani, 2020) remains to be seen. It is also important to reflect upon the aforementioned paternalistic, discursive policy making of the UK Government in the [at the time of writing] Covid-19 pandemic and indeed critically deliberate why 'did "behavioural fatigue" have the honour of featuring as policy justification?' (Sibony, 2020, p.356) , thus arguably increasing the inequality of risk. This article is protected by copyright. All rights reserved.

Ultimately, there is an extremely worrying disconnect between the state, policy makers, policy enactment, and lived experiences of work on the frontline of work during  this is of course indeed not novel, but in the current VUCA 3 context, it is costing lives, further entrenching existing gender and race inequalities, thereby setting a stage for long term regression of equality. We argue here that PPE inadequacies notionally serve as embodied amplification of inequalities, and in turn, also a crisis for feminism, with 80% of NHS workforce being women (albeit vertical gender segregation is also a core organisational characteristic). The intertwining of the embodiment of inequality, the crisis for feminism and the long term implications of Covid-19 on women are not only complex and axiomatic, but also must serve as an opportunity for positive change in healthcare provision and, in turn, working conditions, thereby potentially contributing positively to inclusion and positive changes in lived experiences of work and the embodiment of risk.

We are immensely grateful to our participant for taking part in this research, and sharing her experiences of frontline work during the pandemic and speaking so candidly. In our writing, we would also like to thank all NHS staff and key workers, for their unwavering commitment and dedication, emotional labour, and service-Thank You.

The data for this research will not be made publicly available in a repository, in order to project the identity of the participant further.

The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article. 

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