I am still consoling myself with chocolate after England's Lionesses tragically lost to Spain in the final match of the 2023 Women's World Cup Football on 20 August. I am definitely not a football expert, but as the favourites, the Lionesses should have won. In their last 39 matches, they have only lost two games (including the 2023 final) and they won the European championship in 2022. Nevertheless, Spain dominated the final right from the start and deserved to win. I should stress that writing that statement is deeply painful to me. I am English and like most people from my country, I feel our ongoing sporting losses acutely. It would actually be far simpler for me to support the irritatingly successful, national sporting teams of my adopted country of Australia, after all, I have lived here for 20 years and now have three children who speak Australian (not English). Nevertheless, national pride forbids jumping onto the band wagon for the sake of having a win, and besides their sporting uniforms of yellow and green do not align with my own sartorial taste.

In all seriousness though, the 2023 Women's World Cup Football championship has highlighted many important issues. Firstly, women sports professionals (no matter the sport they play) must be recognized for their immense physical and tactical skills, prowess and determination to win. As such they are no different to men, yet they earn considerably less, receive less financial banking and media support, and the language used to describe women competitors and/or their teams is often sexist. As an example, the Australian women's football team (the Matildas) who recently became the nation's most popular sporting team, was repeatedly described in the media as ‘enchanting’, ‘entrancing’ and ‘loveable’ (https://www.smh.com.au/sport/soccer/they-may-be-likeable-but-our-newest-sporting-superstars-are-more-than-sporty-cinderellas-20230818-p5dxl5.html). Strange words to apply to powerful, highly-skilled and elite athletes with a killer instinct to win.

The second issue is that unsurprisingly women's sports competitions are just as interesting and exciting as men's. It is estimated that globally over two billion people watched the Women's World Cup Football tournament on television and over 1.9 million fans attended stadiums to watch the games live, albeit the English Royal family did not make the long flight to Australia to watch the final in person (https://www.reuters.com/sports/soccer/womens-world-cup-final-draws-record-tv-figures-spain-england-2023-08-21/). These impressive viewing figures highlight that while major disparities exist, a profound cultural revolution is under way, as these days women's football is highly visible, with both men and women enjoying watching the matches.

The third important issue is the lack of ethnic diversity in women's football teams. Lack of opportunities for girls to participate in football at school, particularly in more deprived areas, together with lack of access to training facilities for people from diverse ethnic groups or from lower socioeconomic groups have been identified as some of the major barriers in England (https://www.npr.org/2023/01/12/1148634656/u-s-womens-soccer-tries-to-overcome-its-past-lack-of-diversity). Similar issues regarding inclusivity and the need for change have been described in the United States (https://www.npr.org/2023/01/12/1148634656/u-s-womens-soccer-tries-to-overcome-its-past-lack-of-diversity).

So, what does any of this have to do with respiratory medicine? Well, firstly being active and taking part in sport is great for both our mental and physical health. However, more importantly, there are many parallels regarding the recognition and treatment of respiratory illnesses in women and people from different ethnic backgrounds.

A growing body of research describes the differences in disease characteristics, as well as in access to treatment between men and women with respiratory illness. As Somayaji and Chalmers highlighted in 2022, much of our understanding of health and disease has arisen from studies of men only or male animals (https://err.ersjournals.com/content/31/163/210111). In their paper, they articulately describe how multiple factors (including true biological differences, exposures, occupations, societal roles and biases in healthcare) contribute to differences in disease phenotypes and outcomes between men and women. One example is chronic obstructive pulmonary disease (COPD), which was stereotypically seen as affecting older men. However, a better understanding of the epidemiological risk factors for COPD, as well as changing smoking patterns, mean that in some regions COPD is now equally common in men and women. Nevertheless, women are less likely to be diagnosed with chronic obstructive pulmonary disease, or referred for spirometry or specialist care, yet experience worse symptoms and quality of life, and have poorer outcomes compared with men with COPD. Similar differences in diagnosis and outcomes between men and women are also seen in other respiratory illnesses (https://err.ersjournals.com/content/31/163/210111).

Similarly, increasing numbers of research studies have demonstrated that ethnicity also impacts diagnosis, clinical outcomes and access to treatment (https://onlinelibrary.wiley.com/doi/full/10.1111/resp.14563), or clinical trials in people with interstitial lung disease (https://erj.ersjournals.com/content/59/3/2102969) and other respiratory illnesses. Whether ethnicity is truly a determinant of illness outcomes, or in fact mediated through other social determinants of health, such as socioeconomic disadvantage, remains unclear.

Irrespective of whether we are considering sex, ethnicity or other social determinants of health, it is clear that there is an inequity amongst patients with respiratory illnesses. These factors cannot be ignored and must be taken into account when we provide healthcare to people with respiratory disease. Specifically, we must recognize and then promptly reject our unconscious biases and stereotypes. While there are no simple solutions, highlighting these issues is a crucial first step in changing beliefs and practices in respiratory medicine. The 2023 Women's World Cup Football championship has shown us that while major disparities persist, a cultural revolution has started in sport. Isn't it about time that we did the same in respiratory medicine and started kicking goals in support of diversity, equity and inclusivity?