Category: The Structure of Health and Medicine

Anna Nunag

27 March 2023

Mission trips to South America. Independent student research. Leadership positions. Summer volunteering. These are the ways applicants try to demonstrate to medical schools that they are well informed individuals, with a commitment to research and serving the humanity of others.

One consistent theme throughout this module has been the need for a change in culture for both current physicians and medical students entering the workforce. Students are assessed at a high standard to get into medical school, but how is this same well-roundedness fostered once applicants are accepted into medical school?  

I looked into current stances of how these assets are addressed in medical schools, and while it varies from school to school, efforts are being made to put in place ways for medical schools to help their students foster research and awareness for rare diseases, public health concerns, and empathetic interactions with patients. 

Awareness for Rare Disease

One improvement in the medical field that this module has shown light on is the lack of research and awareness for Rare Diseases (RDs). 

According to the World Health Organization (WHO), 400 million individuals are living with rare diseases and from a study surveying preclinical medical students, 92% feel “ill-prepared  to provide rare disease care” (Ayyappan, et. al, 2022). 

…from a study surveying preclinical medical students, 92% feel ‘ill-prepared  to provide rare disease care’

For example, Chronic Fatigue Syndrome or CFS is one contested illness, defined as an “experience [of] incapacitating fatigue” and “symptoms [persisting] for at least six months and cannot be explained by any other diagnosis” (Walker: 2012).

CFS is “without clear biomedical indicators” and shares many variable symptoms with other diseases,  making it hard  to pinpoint and define, and difficult to conduct clinical research trials on, ultimately leading to stigma around this contested illness (Walker: 2012). 

An article in the Journal for Vascular Anomalies, tactics of how medical schools could incorporate rare disease into curriculum while acknowledging the difficulty in diagnosing these contested diseases with no explicit etiology or symptoms.

These tactics include teaching an adequate vocabulary surrounding RDs and keeping students informed on research efforts, and some schools and student groups are pioneering this effort

For example at the University of Pennsylvania, student leaders of the ‘Rare Disease Interest Group’ have created an elective course containing “rare disease-specific information”, incorporating current RD research into lectures, and “training students to recognize rare diseases and to be cognizant of the unique needs and experiences of rare disease patients” (Ayyappan,  et. al, 2022). 

Some medical schools are making progress by offering RD in the form of an elective, but it is not a mandatory requirement standardized over all medical schools. 

Many medical schools are also distinguished research institutions, and RDs can be one area of investigation that is incorporated into curriculum so that more medical students feel confident and informed enough to tend to this patient population.

Public Health discussions

Next, demonstrating that an applicant is well-informed or involved in their community is an important factor for applicants, but these values are not fostered to the same extent in the actual curriculum.

According to an article from the National Institutes of Health, curriculum is a reflection of how “most institutions are evaluated on the basis of molecular science curricula and student performance is assessed via standardized testing on molecular science” rather than ‘relevant disciplines’ of public health concerns such as socio-economic and socio-ecological influences on health in communities (Rao, et al, 2020).

As the United States population is living longer and becoming increasingly diverse, this creates an increasing  need for physicians to have an understanding of socio-economic factors and a “cultural competence” (Rao, et al, 2020) in order to treat the “complex root causes of illness” in this future patient population. 

“…the United States population is living longer and becoming increasingly diverse”

The Crawford article, “Health as a meaningful social practice,” addresses one public health theme by arguing for the way in which health in the United States has become a form of social control, reinforcing social norms rather than taking into account societal factors and disparities that exist between communities.  

The Crawford article argues that health is viewed as personal responsibility rather than a reflection of socio-economic situation. 

This is seen through how “white, middle class Americans [are] privileged in being able to adopt healthy lifestyles, “ (Crawford: 2006) because they have adequate resources to maintain their health. 

On the flip side, those from a poorer demographic and more likely to be in worse health and this is not a reflection of personal failure according to Crawford because of the role of societal factors in personal health. 

This understanding of health as a form of social control is just one public health point of discussion that can be analyzed in medical school. This would allow for future physicians to both understand a patient population through the context of societal factors, but also understand how a patient grapples with their health in a society that views it is the fault of the individual. 

Tools for patient-doctor interactions

Lastly, empathy is another character element that medical schools like to see evidence of, and ‘delivering patient centered care’ is often a key term used in  medical schools mission statements. 

Still, there are no standardized efforts across medical schools that directly address appropriate tools to empathize and approach patients grappling with their chronic illnesses. 

The article “Illness Narratives”  describes the stigma that chronically ill people face and other stresses that patients and their families experience as a result of illness.  

The article describes the important role that practitioners have in controlling the fear or  anger, “[restoring] confidence in body and self” and, “[educating] sick persons to escape both excessive feelings of guilt over failures in life activities and jealousy towards others” (Kleinman: 1988).

For example, in the “Illness Narratives,” a  patient with severe eczema felt shamed standing in front of physicians and their medical students inspecting his body. He felt shamed and exposed as a result of the physicians being insensitive to his privacy and respect.

Empathy to address these interactions is not a ‘hard science’ that can be taught or tested, but may come through experience and being better informed on how the effects of illness are felt by a patient and their family and how they internalize the societal stigma placed on a patient. 

“…how the effects of illness are felt by a patient and their family and how they internalize the societal stigma placed on a patient”

A course that directly addresses the importance of empathy in patient-physician interactions is not standardized, but it is possible that some schools may offer electives, such as at Temple University (Ayyappan, et. al, 2022). At this medical school part of the curriculum is having students practice interacting with patients with disabilities such as volunteer patients with congenital muscular dystrophy, with the goal that “such initiatives would humanize rare disease, training students to consider in addition to biological and clinical data, the human that lies beneath” (Ayyappan, et. al, 2022).

While offering an elective is making progress, it does not allow for appropriate tools for all future physicians expected to deliver ‘patient centered care’ and approach a patient grappling with their disease.  

Across all medical schools, there is no standardized way that Rare Diseases, public health, and strategies to approach patients are addressed.  

Continuing Medical Education may not be realistic avenue to change the way physicians think and what they value, so this proposal might be most effective by targeting the future medical doctors at the lowest level: medical schools.

The medical school curriculum should show that they are committed to developing well rounded, future physicians to reflect how they are valued in medical school applications in an evolving patient population.

Works Cited 

Gawande, A. (2017). The Heroism of Incremental Care. The New Yorker. 

Ayyappan, V.,  et. al.(2022). Spotlighting Zebras: A Role for Medical Students in Shaping Rare 

Disease Care. Journal of Vascular Anomalies.  https://journals.lww.com/jova/Fulltext/2022/03000/Spotlighting_the_Zebras__A_Role_for_Medical.4.aspx.

Walker, J. (2012).  Researching Contested Illnesses: The Case of Chronic Fatigue Syndrome \(CFS). Boston University School of Medicine. 

Rao, R, et al. (2020). The Evolving Role of Public Health in Medical Education. National Institutes of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344251/.

Crawford, R. (2006). Health as a Meaningful Social Practice. An Interdisciplinary Journal for the Social Study of Health Illness and Medicine. 

Kleinman, A. (1988). Illness Narratives: Suffering, Healing, and the Human Condition. 

20 February 2023

This summer I worked my first job as a Certified Nursing Assistant at a state nursing home in a predominantly white suburb of Philadelphia. This would be my first patient contact experience in healthcare, but I learned more about society and the healthcare system from the people I worked with than the residents I took care of.

As an aide I would be responsible for bathing, transferring, toileting, and feeding my assigned residents on the dementia floor of this nursing home in my 7am-3pm shift. Everyday I worked alongside a team of nurses and aides, of which the majority were from the African country of Sierra Leone. Other than the activities director, I was the only non-black worker on the floor last summer.

One common occurrence last summer was the way coworkers rotating on the same floor as me would assume that I was the nurse. I wore a surgical mask, scrubs and dirty shoes like every other aide, no makeup, and no jewelry, so this was probably based on my phenotypic differences from the other workers. The difference in my appearance other than my size and age were my straight hair and my biracial tan skin tone.

…coworkers rotating on the same floor as me would assume that I was the nurse.

Still, at least twice a week, a coworker would begin asking me a medical question, and I would quickly cut them off and direct them to the nurse on the floor.

 This was a firsthand experience seeing how racial differences are associated with higher status even to people of color and in health care. While this assumption was not an insult to me, it was showing her internal bias that a black person such as herself would have a job that requires less education and a non-black person would have a job requiring a higher degree.

From the beginning, I struggled at the physical demands of this job. I would need to ask for help, adding to my workload of my coworkers who would reluctantly assist me.  At the end of the first week they made it clear they did not think I would be able to do this job.  Little by little I gained the trust of my coworkers that I would be able to handle a full workload as they do, turning obese residents and working efficiently enough to care for thirteen plus residents at a time.

I remember one day a coworker, an African aide, asking me about my ethnicity. I told her my dad was born in the Philippines and my mother was white. I remember her saying, “Oh that is why you are so beautiful, your mother is white.”  Later in the conversation she confided to me how stressful this job is for her, and further how she believes this job is ‘meant for black people.’

“Oh that is why you are so beautiful, your mother is white.” 

I remember not knowing how to respond, but I later understood why my abilities were underestimated when I first started. I think my coworkers could not grapple with someone from a non-black race sharing their same workload.

Both of these occurrences remind me of the Desmond and Emirbayer article that describes this “internalized racism” in which “people of color often internalize prejudice at their own racial group, unintentionally contributing to the reproduction of racial domination” (Desmond and Emirbayer, 2009: 346). The racial based comments my coworkers made were never offensive, showing how society gives my half-whiteness a higher, respectable status.

As seen in the US Health Care System Profile, “There is no universal coverage for long term care services” for Medicare or private insurance users. Public spending in the United States for long term care facilities, such as the state nursing home where I worked, represents “approximately 70 percent of total spending on long-term care services, with Medicaid accounting for the majority” (Tikkanen et al., 2020). The lack of funding for workers at this nursing home would be one of its biggest problems.

Three to five aides would be on a floor and have to provide for fifty-five residents of which the majority needed total assistance, making this job nearly impossible to give each person the care and attention they deserved. The lack of funding to nursing homes like this shows in the lack of supplies available to our residents, hurting their quality of care. Lack of funding also contributes to the low wages for both aides and nurses that would often work doubles, 7am-11pm multiple times a week. While I enjoyed the sense of accomplishment I got from my job, I did not have the stamina to do what they did.

Three to five aides would be on a floor and have to provide for fifty-five residents of which the majority needed total assistance, making this job nearly impossible

The stress and burnout of this job that I noticed in my coworkers manifested itself in habits and physical appearances.  One thing I noticed about my coworkers was how common it was for the aides to use their fifteen minute break to smoke cigarettes, as well as how many of the aides and nurses I worked with were experiencing obesity.  As seen in the Remote Area Medical movie, smoking is a way to cope with stress, and the nature of the job and the long hours worked certainly contributed to the need for this coping mechanism.

I came to view these habits not as the culmination of ignorance to health risks, but rather a coping strategy to work related stresses. The Zola article described the over medicalization of conditions in society deemed pathological (Zola, 1976).  While I do not deny the biological basis for conditions such as obesity, the over medicalization of obesity puts the fault on the individual and overlooks the underlying societal factors in one’s environment that contribute to these health conditions.

I came to view these habits not as the culmination of ignorance to health risks, but rather a coping strategy to work related stresses.

In this work environment I saw how my coworkers experienced stress, a lack of sleep and a lack of time and ability to care for their physical needs due to their financial need to work overtime. Society would first question an obese person’s eating habits, rather than how lack of sleep (Beccuti et al., 2011) and stress (Van der Valk et al., 2018) can contribute to one’s experience of obesity. 

The summer I was able to experience firsthand how systemic factors contribute to people’s health and bolster the effects of internal racism and over medicalization. To me, improving long term care conditions for both providers and residents, and solving the cycle of internal racism is multifaceted. The combination of lack of funding and coverage from Medicaid and Medicare (respectively), the lack of enforced legal restrictions on how many residents an aide can provide for at a time, and the lack of coverage for a high proportion of black women working in healthcare (Dickman et al. 2017) are all systemic factors that contribute to the health of black women in healthcare.

Works Cited 

Beccuti, G. and Pannain, S. (2011). Sleep and Obesity. National Center for Biotechnology 

Information. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3632337/.

Desmond M. and Emirbayer M. (2009). What is Racial Domination? 

Dickman, S., Himmelstein, D., Woolhandler, S. (2017). Inequality and health-care systems in the USA.  The Lancet. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30398-7/fulltext

Reichert, J. and Zaman, F. (2013). Remote Area Medical. IMDb.

Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., Wharton, G. (2020). International Health Care System Profiles: United States. The Commonwealth Fund. 

Van der Valk, E., Savas, M., van Rossum, E., (2018). Stress and Obesity: Are There More Susceptible Individuals? National Center for Biotechnology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5958156/#:~:text=The%20Interplay%20Between%20the%20Stress%20System%20and%20Obesity&text=High%20levels%20of%20cortisol%20can,to%20abdominal%20obesity%20%5B4%5D

Zola, I., (1976). Medicine as an Institution of Social Control.

Mae Czerwiec

I’ve heard the story of my birth hundreds of times. I think it’s a source of great pride for my mother. I was born a week after my due date in a large hospital close to home, but my mother certainly didn’t have the typical hospital experience. She still keeps in touch with her treasured midwife through Facebook, and cheerfully recalls the squats she did in her hospital room– she did not have an epidural, was never sedated or hooked up to any machines, and was allowed to walk around up until the time when she gave birth to me (without surgical intervention) at 9:03 pm on November 30, 2001. I was of average size and weight and healthy, spending no time in the NICU. Though I still have no desire to ever give birth myself, I’ve always thought of my mother’s story as charming, celebratory, and full of agency and support.

Childbirth

So it was jarring to come to find out that my mother’s story is not the typical one. Though one survey of mothers in California found that 74% of them were against interventions in childbirth unless medically necessary, only 5% of that same group reported giving birth with no major medical intervention (California Health Care Foundation 2018). Most of these women were immobilized (61%) or had an epidural (68%) (California Health Care Foundation 2018), which is a far cry from my mother’s robust lower-body workout. Furthermore, 31% of these women had a C-section (California Health Care Foundation 2018), despite the fact that the World Health Organization recommends that all of its member nations avoid Cesarean section rates in excess of 10-15% (WHO 2015). In the context of what we know of the many issues with US healthcare, I was surprised to find that high rates of C-section alone are not a uniquely American problem. In the past 20 years, C-section rates in Canada, Italy, and the United Kingdom have all been around 20%, Spain has seen a C-section rate of 26.4% in Catalonia alone, and in Brazil, the C-section rate has been nearly 36% (Johanson et al. 2002).

“…when caesarean section rates rise towards 10% across a population, the number of maternal and newborn deaths decreases. When the rate goes above 10%, there is no evidence that mortality rates improve.”

World Health Organization, 2015

Of course in countries with high infant mortality rates, it would be beneficial for more women to have access to obstetric care; however, the consensus of many recent studies seems to be that medical intervention in the case of low-risk pregnancies is unnecessary, and has the potential to do more harm than good. For example, C-sections have been shown to have a global impact on maternal mortality and morbidity (Phelan and O’Connell 2015). I can’t help but wonder how much of this problem is tied to our view of women’s bodies as factories for reproduction, in desperate need of oversight and regulation, and a still-widespread societal belief that women are somehow incapable of making their own choices. Even my mother, a staunch Catholic who opposes the pro-choice movement for abortion access, has to admit that she was privileged enough to enjoy more choice than most mothers in her birth experience.

Breastfeeding

And certainly the medicalization of motherhood doesn’t stop once a child has left the womb. I think of my mother’s best friend, a pediatric nurse practitioner in Chicago, who has recently begun a side business as a lactation consultant. This role allows her to extend her practice to the task of assisting mothers with their concerns related to breastfeeding. In the 20th century, when infant formula was introduced by drug companies, breastfeeding came to be seen (like other issues of female reproduction, such as menstruation) as an arena of female inadequacy: that mothers were incapable of producing enough breast milk to satisfy the nutritional needs of their growing children. Even today, writes author Jennifer Torres, “breastfeeding continues to be constructed as likely to fail, and therefore, in need of medical management” (Torres 2014). Breastfeeding is also a complex issue for reproductive healthcare and women’s bodily autonomy, since women have at different points in history faced both glorification and demonization for their choice to either breastfeed or not breastfeed.

“breastfeeding continues to be constructed as likely to fail, and therefore, in need of medical management”

Jennifer Torres, 2014

Parenting

Disturbingly, there doesn’t seem to be an end to the ways in which we medicalize motherhood. Societally, of course, we have a problem of parent-shaming, pitting the parenting style that works for one family against the perceived failure of another parent’s style, both in private and public spheres. I’m almost ashamed to admit that I’m currently watching the tv series “The Parent Test” on Hulu, where twelve sets of parents are presented as exemplars of their particular parenting “styles” and then put through “challenges” with their children and families to effectively determine which style does the best job of raising well-adjusted children. But aside from sensationalizing or merely judging other parents, we as a society have also medicalized parenthood. In one article, author Ara Francis writes that “Parenting, especially mothering, has become an anxious endeavor, characterized by pervasive self-doubt and guilt” (Francis 2012). Francis’s paper concludes that parents, especially mothers, are subject to increased negative labeling when their children have “invisible disabilities”, such as learning disabilities, developmental disabilities, mental health problems, drug addiction, or other medical problems, and she posits that this negative stigmatization is a direct result of the medicalization of childhood (Francis 2012). The particular burden on mothers is consistent with the theme present in the issues of both childbirth and breastfeeding: that women and their bodies are perceived in terms of deficiency.

“Parenting, especially mothering, has become an anxious endeavor, characterized by pervasive self-doubt and guilt”

Ara Francis, 2012

Solutions?

So where do we go for solutions? How can we ensure that more women’s experience of motherhood is autonomous and affirming? In terms of childbirth, authors Phelan and O’Connell present midwifery as a promising solution to combat medicalization, but still encourage collaboration between obstetric and midwife teams (Phelan and O’Connell 2015). In Torres’s article on breastfeeding, she emphasizes the role lactation consultants can play in the de-medicalization of breastfeeding, using these providers to examine the concept she describes as “medicalizing to demedicalize” (Torres 2014). And in Francis’s article on stigmatization and “anxious parenting”, she describes parental stigma as a “relational phenomenon” that thrives on the intersection of dominant cultural assumptions and institutions of medical authority (Francis 2012). Taken together, these three authors come to the conclusion that both incremental change and widespread cultural overhaul may be necessary to combat the medicalization of motherhood: we have a lot of work to do before my mother’s story seems mainstream.

In summary,

Solutions for the Medicalization of Motherhood

1. Interdisciplinary Teams of Providers

2. “Medicalizing to Demedicalize”

3. Challenging Cultural Assumptions

References

California Health Care Foundation. 2018. “Infographic: The Overmedicalization of Childbirth.” From Listening to Mothers in California survey. https://www.chcf.org/publication/infographic-overmedicalization-childbirth/#related-links-and-downloads

Francis, Ara. 2012. “Stigma in an era of medicalisation and anxious parenting: how proximity and culpability shape middle class parents’ experiences of disgrace.” Sociology of Health and Illness 34, no. 6 (July 2012): 927-942. https://onlinelibrary.wiley.com/doi/10.1111/j.1467-9566.2011.01445.x

Johanson, Richard, Mary Newburn, and Alison Macfarlane. “Has the medicalization of childbirth gone too far?” BMJ (Clinical Research ed.) 324, no. 7342 (April 2002): 892-895. https://doi.org/10.1136/bmj.324.7342.892

Phelan, Agnes and Rhona O’Connell. 2015. “Childbirth: Myths and Medicalization.” https://www.euro.who.int/__data/assets/pdf_file/0007/277738/Childbirth_myths-and-medicalization.pdf

Torres, Jennifer M.C. 2014. “Medicalizing to demedicalize: lactation consultants and the (de)medicalization of breastfeeding.” Social Science and Medicine 100 (January 2014): 159-166. https://www.sciencedirect.com/science/article/pii/S027795361300600X

World Health Organization. 2015. “WHO statement of cesarean section rates.” World Health Organization. April 14, 2015. https://www.who.int/publications/i/item/WHO-RHR-15.02

“As economic inequality in the USA has deepened, so too has inequality in health”

(Dickman 1431)

As someone who is a firm believer in capitalism, it naturally makes sense to me that the different sectors of our economy, like healthcare, should be able to function properly under a capitalistic model. However, when reflecting on our course, it is clear that our capitalist market has led to some gaps, particularly in regards to medical care. We can see these gaps in the inequalities across different races, wealth groups, and genders and while I still believe that capitalism is the best market structure, I think it struggles to work the way that it should in the case of medicine. Our society has likely overextended capitalism, and we may need to seriously reconsider if it is the best structure for medicine.

Capitalism in the Current Structure of Healthcare

Currently, the U.S. healthcare system is composed of a mixture of public and private insurers and health care providers, some of which operate for-profit and some nonprofit (Tikkanen). The U.S healthcare system also includes government sponsored programs, like Medicare and Medicaid, that help groups receive medical care. As of 2018, 92 percent of the U.S. population was estimated to have insurance coverage, which leaves “27.5 million people or 8.5 percent of the population uninsured” (Tikkanen). Part of this lack of insurance can be attributed to the rise in healthcare expenses as costs in the U.S. grow between 4.2 percent and 5.8 percent annually (Tikkanen). Because of the capitalist structure, medical care in the U.S. functions almost like a monopoly, instead of perfect competition, where costs can continually rise unopposed as medical providers and insurance companies control the market. 

Negative Effects of Capitalism

As mentioned, the evidence as to why a capitalist market does not work well in regards to medicine is seen when looking at the disparities across racial groups, wealth, and gender. Based on our current model, many people need to work to gain insurance and afford medical care. However, this pressures people to continue working even when they are sick. During the COVID-19 pandemic, certain essential workers were deemed so necessary to our economic function, that they could not stop working. In most of these instances, these essential workers were racial minorities. Our extreme focus on production and economic growth has led to “Latinx food and agriculture workers [experiencing] a nearly 60% increase in deaths compared to prior years” (Maxmen). Because we want to continuously grow, we have let the medical needs of workers shift to the background, which has disproportionately affected people of different races. Thus, the capitalist model has led to a large gap in medical care for certain groups.

The negative side effects of capitalism in healthcare can again be seen in wealth disparities. The large economic inequality in the U.S. has now bled into health disparities as wealthier Americans have a life expectancy that is now ten to fifteen years longer than poor Americans (Dickman 1431). Geography has played a large role in this as many health care providers work in cities or larger suburbs (Dickman 1434). This follows basic supply and demand functionality in capitalism. The increased demand for healthcare in more densely populated areas, coupled with the higher likelihood of patients being able to afford care or obtain their own private insurance, has led to the greater supply of doctors in these areas. Yet, there is still a large population of people who need medical care in more rural areas, which demonstrates that a capitalist market may not be the most efficient when it comes to healthcare. 

Capitalism in medicine has even extended into the creation of products and marketing campaigns to deal with natural body processes, especially for women. This is evident in the creation of hormone treatments and medications to help women during menopause. Many feminists view this as “a superfluous product designed to keep women sexually available and conventionally attractive” (Dominus). Because we have allowed a capitalist structure to take over medicine and medical treatments, large industries have developed with products claiming to solve all sorts of problems (Dominus). While some of the extension of capitalism has created medications that are truly helpful, like the F.D.A.-approved hormone therapy for women, it has also led to greater inequalities between genders. There are significantly larger pressures on women to maintain physical appearance and be healthy, and yet many female issues are still not well understood. Despite this, the market of medicine has created products and industries to “alleviate” these differences.

Concluding Thoughts

Clearly, by allowing a capitalist market structure to control the medical field, we have allowed gaps in care and inequalities to fester. When reflecting on these issues, it certainly brings a lot to mind for me. Prior to this course, I would firmly stand behind a capitalist structure as the best way for the healthcare system to function. However, now, I am not sure that is true. Nevertheless, changing the current operations of the system would likely take a major overhaul – possibly exacerbating the issues mentioned above. While it is likely best to move towards more universal medical care, it will be extremely difficult in our profit and opportunity seeking society. Even if we cannot make any direct changes to the market structure of medicine right now, at least drawing attention to the issues that the capitalist structure has created will help begin to possibly resolve them. 

Works Cited

Dickman, Samuel L., David U. Himmelstein, and Steffie Woolhandler. “Inequality and the health-care system in the USA.” The Lancet 389.10077 (2017): 1431-1441.

Dominus, Susan. “Women Have Been Misled about Menopause.” The New York Times, The New York Times, 1 Feb. 2023, https://www.nytimes.com/2023/02/01/magazine/menopause-hot-flashes-hormone-therapy.html. 

Maxmen, Amy. “Inequality’s Deadly Toll.” Nature News, Nature Publishing Group, 28 Apr. 2021, https://www.nature.com/immersive/d41586-021-00943-x/index.html. 

Tikkanen, Roosa, et al. “United States.” International Health Care System Profiles: United States, The Commonwealth Fund, 5 June 2020,