There’s a moment’s disappointment the first time you meet Prof. Zdravka Poljaković when you realize she isn’t wearing a red dress. She would be if it were the first Friday in February, the day designated “Red Dress Day” in Croatia to make people aware of women’s vulnerability to stroke.
Originating in the US, the concept took root in Croatia the day Prof. Poljaković’s colleague Prof. Arijana Lovrenčić-Huzjan turned to her and said, “Look, Zdravka, we have to do it.”
And so they did, centering their campaign around red dresses by well-known Croatian designers worn by women who had survived stroke.
Their aim was to catch the eye and target the heart with a message no-one really wanted to hear about gender differences in stroke risk factors and outcomes. “It was something we already knew,” Prof. Poljaković says. “We all knew it but it was buried somewhere. It’s normal not to pay attention to it, but we were all aware.”
What they knew was this: More women die of stroke than men, for reasons related to longevity, physiology and their social role.
Women live longer than men so it is logical that more will succumb to an ageing-associated disease. And because they are typically older and sicker than men when they experience a stroke, treatment outcomes for women are worse. Age and its attendant comorbidities are also part of the reason why women are under-represented in treatment trials; they are also often excluded for being pregnant or of childbearing age.
Risk factors are differently distributed in women and some are unique, such as the hormonal changes associated with menopause, hormonal therapy and childbirth. Atrial fibrillation is more likely to cause stroke in women, and women have twice the incidence of subarachnoid hemorrhage and are more likely to die as a result of it.
Women with stroke are more likely to be misdiagnosed in the ER. They have poorer functional recovery and higher rates of depression, and due to poorer care after their first stroke women are twice as likely to experience a secondary and typically more severe stroke.
Lastly, because women still “carry the three corners of the house”, they neglect their own health in order to take care of family or work. Prof. Poljaković says, “A woman may ignore a mild stroke and only go to the doctor once she has dropped the kids at school. She will arrive too late for recanalization therapy, which in mild and moderate strokes is practically a cure.”
The delay will be devastating to her health and to the wellbeing of her family.
The main goal of the Red Dress campaign is to encourage these pillars of the family and community to rearrange their priorities and put their health first. Now in its sixth year, and enjoying the patronage of the Croatian president Zoran Milanović, the campaign plays out in three phases – a public health activation with preventative examinations on the main square in Zagreb, a scientific conference, and the main event – a fashion show that pierces the heart.
The women who wear their red designer dresses down the catwalk and share their survivor stories are all their patients, Prof. Poljaković says. “We know them, we treated them, but hearing their stories from the inside brings us close to tears.”
The emotion is the point. “When you talk about health, people say yes, yes, but they soon forget. But if you reach then with emotion, it’s different. Everything else flows from that.”
We do have the time
Prof. Zdravka Poljaković is a specialist in intensive care neurology, professor in the faculty of medicine at Zagreb University, head of the department of intensive care and cerebrovascular diseases at University Hospital Zagreb, president of the Croatian Neurological Society, and among this year’s nominees for the ESO Spirit of Excellence Award.
It was never her intention to follow her father into neurology, although growing up with two doctors made it near inevitable that she would become one too. “It’s a family burden,” she quips. Her mom, a paediatrician, wanted her daughter to have an easier life. “But as a child, when I came home, the only thing they talked about was their work. I did sport, music, languages, but the thing I knew most about was medicine.”
Working with patients wasn’t always on the cards: she’d intended to specialize in health ecology. But in her third year at medical school she briefly considered surgery, and in her fourth year she became fascinated by the brain.
“It wasn’t my dad’s fault,” she says.
She gravitated towards stroke because she wanted to do something active, and advances in stroke care made that both possible and necessary. The first thrombolysis she observed was carried out in defiance of a head of department who had declared the procedure would only be done over his dead body. They did it anyway and their mutiny was rewarded by a good outcome for their patient.
Neurointensive care was still barely recognised as a neurological subspeciality when in 2005 Prof. Poljaković crossed swords with anesthesiologists over her determination to master procedures such as intubation and mechanical ventilation. “They thought it unimaginable that a neurologist would take care of an intensive care patient. But I believe if a patient has a brain disease he must be treated by a brain doctor.”
Undeterred by 24-hour shifts, she became a specialist in neurointensive care, and in 2018 led her team to their first (and Croatia’s third) ESO Angels Award. University Hospital Zagreb now has 11 diamond awards and counting, but ahead of their first encounter with Angels they were skeptical, Prof. Poljaković recalls. “We were so full of ourselves, we said what could they possibly tell us. Then we did a simulation and discovered there were three or four points where we could be faster.”
The team embraced quality monitoring with enthusiasm, agreeing to collect data not only during one month but for every stroke throughout the year. “We cannot say there is no time,” she says of the most commonly cited reason why hospitals shy away from data collection. “We receive the largest number of stroke patients in Croatia and putting their data into RES-Q takes just two hours a week. Perhaps there are hospitals that cannot spare two hours of a neurologist’s time, but we have someone who does it and enters every single patient in the registry. We do have the time.”
This work makes me happy
At 60, Prof. Poljaković no longer works 24-hour shifts. Having assembled a team of young neurologists who share her convictions, she is free to turn to more public than routine work – organising conferences and petitioning government bodies such as the ministry of health. A three-year battle has at last resulted in a national registry that is modeled on and designed to be compatible with RES-Q. Involving eight hospitals and 1,200 patients, it is still at pilot stage, but the next step is to persuade the health minister to make data collection mandatory.
“This work makes me very happy,” Prof. Poljaković. “I don’t consider it hard work. If you have done something in your life, this part of the work is your reward. You have a name, people respect your work, and you can do something with it.”
Shorter work days do mean more family time and giving free rein to her deep and abiding love for horses.
“After 100 percent work, there’s another 50 percent that is horses,” she says. “I was born with it. When my parents asked whether I wanted a brother or sister I asked for a horse.”
It’s no mere hobby. Zdravka is president of the Croatian Equestrian Federation, an international horse-jumping judge, and president of Hiperion Eos, an association that provides equine therapy to special needs children and people with disabilities including survivors of stroke.
“Horses have a special connection,” she says. “One of the biggest problems with rehabilitation is losing motivation; it becomes boring and frustrating. But with horses there is always something new.”
The work that makes Prof. Poljaković happy covers the entire gamut of stroke care, from policy and prevention to registry and recovery. But out of all her “political” work, she knows that for maximum impact you must make the heart your target.
The emotional storytelling of Red Dress Day has found its mark. Most cities in Croatia have now adopted the campaign, once a year turning schools and shops into a sea of red. Politicians whom it can be difficult to sway with numbers are succumbing to the survivors’ stories, and this year the first Friday of February was declared the national day for stroke awareness in women.
“The first year they sent their deputies,” she says. “Now the president comes, we have the mayor, the minister of health, and everyone is close to tears.”
People are good, Prof. Poljaković concludes. “And when they see something good they support it.”
Evidence of the campaign’s impact is largely anecdotal for now but there are signs that the message is landing with the people who stand to benefit most. “What we know is what we see in our daily practice. We see women who say, ‘I have changed my life, I have changed my priorities. I have realized my health is important, because if I am well, everyone is well’.”
