Advancing racial and ethnic equity in science, medicine, and global health

A special joint episode sees Prof. Delan Devakumar, host of the Race & Health podcast and Professor of Global Child Health at UCL, speak with Prof. Tendayi Achiume, Dr. Gideon Lasco, and Dr. Sujitha Selvarajah about what racism means to them,  how racism affects health, and what we can learn from The Lancet's new Series on racial and ethnic equity in science, medicine, and global health.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Delan: Hi everyone, welcome to a special edition of the podcast where the Lancet voice is joining forces with the race and health podcast. My name is Delan Devakumar and I'm a professor of global child health and a public health consultant in University College London. For those of you who don't know, The Lancet Voice is produced by The Lancet Journal and seeks to unravel stories behind the best global health policy and clinical research of the day and what it means for people around the world.

The Race and Health Podcast explores racism, xenophobia and discrimination and how they affect health, particularly focusing on power systems and how they shape unequal health outcomes. I'm the usual host of the Race and Health podcast, and today we're going to talk about the new Lancet series on racism, xenophobia, and discrimination, and health.

And this is a series that I'm leading, which is being published on the 8th of December 2022. within a special issue called Advancing Racial and Ethnic Equity in Science, Medicine, and Global Health. I'm joined today by three wonderful guests and co authors on the series, Professor Tendayi Achiume, who's the inaugural Alice Mignogna Professor of Law, and the former UN Special Rapporteur on Contemporary Forms of Racism, Racial Discrimination, Xenophobia, and Related Intolerance.

We've got Dr. Sajitha Selvarajah, one of the founders of Raisin Health and an obstetrics and gynecology registrar in the UK. And finally, Dr. Gideon Lasko, who's a physician and medical anthropologist and senior lecturer at the University of the Philippines. Nice to see you all. Can I start by asking you all what racism means to you on a more personal level?

What does it mean to you? 

Tendayi: Thanks so much, Dylan, and it's really a pleasure to be here with this group, and it's a pleasure to have collaborated with all of you on this project. You know, it's, in some ways, really hard to think of one snapshot that captures what racism means to me, but I suppose The thing I'm thinking the most about right now is that I have a toddler who will be racialized as black in the United States.

And I think one of the things racism means to me is fearing for his life in encounters with law enforcement and even encounters with private citizens on account of the color of the skin and feeling entirely powerless over that. 

Delan: Thank you. Sajitha. 

Sujitha: But I guess, in terms of what racism means to me, it gives, it gives me context.

You know, I'm sat here in my room in South London, but it kind of explains to me a lot about why and how I'm here. My family, before I was born, they, they fled a civil war where they were persecuted for their identity. Their identity, it can be categorized as race or ethnicity, but being Tamil meant that they weren't safe.

My mum has told me the stories of her holding my A young sister on her hip and trying to walk through across her road, but there are missiles coming, but she's just found out her, her dad has died and she's in the middle of war with a new child on her hip. And that's a reality that I can't quite imagine, but that's the reason why they left, right?

For a place of safety. And when they're leaving, they're thinking, right, well, it's going to give us safety and opportunity. And it's a, it's a country that has built its wealth through colonialism. through extraction. And so it kind of makes sense that that's why I'm here now. So I guess for me, Racism gives me a sense of context, but also a great sense of a feeling of injustice.

Delan: For 

Gideon: me personally racism is having to carry a burden of proof for once important as opposed to just enjoying a presumption of value and dignity that befits every human being. This burden of proofs can manifest in having to show your ID when you're doing a credit card purchase. It can be just an inconvenience like that, that overrides your ID as if.

I am more of a risk or fraud than the person in front of me who is different. I think it can be a burden of proof for some inconveniences in life, but it can also be a burden of proof for the right to live itself. And we've seen this many times in my own country, in the Philippines, where we have a large global diaspora.

And so people all over the world face different threats from the, from violence. in workplaces to anti Asian hate in, in the US. So it's many things in different situations, but what they have in common, I think, is this burden of proof that can be sometimes insurmountable. 

Delan: Thank you. And thank you to all of you for giving that sort of personal input, because we, we talk in very abstract, conceptual terms within the series.

Racism means something very personal. For me, it's, I mean, I guess it's very similar to your Sajitha in that it's broadly two things. It's growing up as a young South Asian boy in the UK. But also my family history from Sri Lanka, religious, ethnic conflicts and being a little bit older than you, I, I remember some of this and we had just left.

It shaped my family's history in a big way. So yeah, thank you for doing that. Can I ask, maybe Sajitha, this question to you is why is racism important as a topic for health? Why, why should we talk about this? 

Sujitha: Yeah, I think when we understand racism, I think lots of people have got different definitions of it, right?

But if we understand racism as a system, quite an all encompassing system that exists everywhere, that affords power and privilege to some and not to others, in accordance with a hierarchy. Those processes that are so pervasive affect the way that we live, affect everyone. The way that we live, how we live, our, will inform every institution, every system.

that governs our society. And so in doing that, there's so much of that that affects health. We know that so much of health is determined well before somebody goes to a hospital, well outside of healthcare systems. So to have something that is so pervasive, of course it's going to affect health. Of course it's going to contribute to ill health and inequities.

That feels like common sense almost. So the fact that it's been so ignored and kind of sidelined and never really been center place. in global health, in public health. I think that's kind of testament to kind of how racism and discrimination operates. 

Delan: Thank you. Thank you. And I think that's a very good segue into the series and why we're doing this.

So let's talk about the series. This has been a long time brewing. It started pre COVID and my aims before the series started were to really to raise the profile of racism, xenophobia, so that they are considered public health priorities because they are, as you say, relatively ignored. And, you know, Gideon Sajuthas, especially to you, you may be different, but when I used to take a clinical history, I didn't ask about the discrimination that someone faces.

I didn't, you know, think about that, whether it be interpersonal or structural. And that's something I want clinicians to think about when they are taking histories. Secondly, I think this is a global health issue, that this is something where similar processes happen in every society, everywhere. And that there are similar discriminatory ideologies, whether they're based on race or ethnicity, caste, indigenous status, migratory status, religion, skin color, there are very similar things going on in terms of causes and the health outcomes.

And finally, that this is a structural problem that we think about acts of violence. We think about verbal abuse, but. We usually don't think about what happens and what lies underneath the root causes of this. So what we did was to write four papers, and we'll go through each one in turn. The first one covering the history and politics.

Then the second one health outcomes. Third one looking case study take intersectional approach. And the fourth one focusing on interventions. So, Tindayi, can you tell us about the first paper just to describe what's in it and some of the important messages, please? 

Tendayi: Sure. So the first paper sets the tone for the rest of the series.

It provides a conceptual framework and provides historical, political, and legal background for how we should be thinking about racism and its relationship to public health. So very often, I think our tendencies to think of racism as being solely about prejudice and about explicitly expressed. Prejudice, but what we articulate in the paper is the ways in which race has operated as an organizing principle in many ways, a mechanism for creating global hierarchies, according to some, according to which some people in some places are designated inferior or superior.

And we say in the, in the paper that we're looking at race, but we're also looking at ethnicity, we're looking at indigeneity, looking at caste, and we're looking at all of these categories that are based on two moves, essentially, which is the separation of different people and power hierarchies that are then layered over those separations.

And so. Paper situates the present in the past and really outlined the way that historical legacies of racism and discrimination continue to shape the way that race and racism operates today, whether we're thinking about whether we're thinking about the caste system in the Indian subcontinent, whether we're thinking about the historical treatment of Jews.

Or whether we're thinking specifically about the relationship between race and colonialism and the way that race operated in the colonial area to designate life chances for different groups and how that continues. in the present. We highlight in the paper as well the way that contemporary politics, so the rise in ethno nationalism, right wing ethno nationalism xenophobic scapegoating of refugees and asylum seekers, and different sorts of political currents that actually exacerbate racism and xenophobia also end up manifesting, shaping the ways in which people experience health and health outcomes as well.

And. As a lawyer, I was really thrilled that the, not just the first paper, but the series in general, I think, takes seriously the way that law and policy can operate for good. They have a very important role to play in terms of combating racism and xenophobia and improving health outcomes. But law itself and policy itself can sometimes be on the wrong side, and law and policy, even laws and policies that seem facially neutral, can have the effect.

Of reinforcing racist or xenophobic outcomes and ways that impact public health. I was rereading the series and thinking in particular about, about the environment and environmental conditions because climate is really on people's minds right now. And when we think about the kinds of laws that designate where different groups live, where, you know, toxic industries that emit pollution are located, many of those are located in, in, in parts of the world and even in, in neighborhoods and cities where minoritized groups dominate.

And so we see how law and policy can shape. Health outcomes, even in ways that aren't necessarily anchored in the explicit racism that we think of front and center. So, To my mind, those are some of the important dynamics that are set up in the, in the first paper. 

Delan: Thank you. And I think on that particular point, the Race and Health podcast, we've had a series on environmental racism that gets into some of those issues.

I know Lancet Voice had an episode on strategic litigation. focusing on the environment as well. Before I come to you, Sajitha, someone asked me the question, why now? And of course it isn't why now, because this, this has been going on for years and centuries, but has there been anything that you think has changed in recent times?

Tendayi: So the why now question is a really important question to ask, and you're right, racism and xenophobia are not new and their impact on public health and health outcomes in general are also not new, but I think prior to 2020, in many parts of the world, the framing or understanding of all races and xenophobia was out of You know, marginality, these are marginal issues.

And I think that speaks to the marginalization of the groups that are most harmed by racism and xenophobia. But in 2020, I think the, the kind of confluence of the racial justice uprisings globally, which I think made it difficult to avoid conversations about systemic racism in all fields, you know, not just in law enforcement, even though that's where the conversations began, I think it was just an opening for a kind of openness to understanding exactly what racial subordination looks like now.

And then COVID, you know, the COVID 19 pandemic, and it's just very clear racial and ethnic impact, I think also, and, and that dynamic globally, I think also put on the table in very real ways conversations about race and xenophobia that previously had been marginalized. So I see 2020 as marking a moment across borders where we were forced to confront.

dynamics that are typically pushed to the side because of the way that power operates in society. And I think we're in a moment where while we have this attention, we have to think about how we change society and how we change systems and structures, lest we go back in the next two years again to a world where it's difficult to have conversations about racism and phobia, like the ones that we're having.

Delan: Thank you. Gideon, Sajid, anything to add on that? 

Gideon: I fully agree that the confluence of different factors, the pandemic, All of these events that we're seeing, the toxic confluence of politics, and also how even the climate crisis is being experienced along lines of discrimination and racism, and that is also inseparable with health and environment.

But at the same time, I also want to highlight that it's also thanks to the efforts of activists and advocates around the world that have really insisted that this will happen, that we need to have a reckoning of racism in hell, that we are talking about it now. So I would like to pay tribute also to all of these academics who have and also activists who have paved the way for, for this to moment to actually happen.

Delan: Absolutely. Yes. Sajitha, tell us about the conceptual model in, that comes into paper one, but it's frames the whole series because you're, you're the brains behind this model. 

Sujitha: When we're talking about things like structural discrimination or structural racism, I think sometimes it can feel like almost like an ephemeral concept.

You can't quite. grasp it. What does that mean? We woke up tomorrow and not a single person on this planet was, was no longer racist, the world would still be structurally racist, right? To kind of show that it's not necessarily reliant on individuals for it to persist and to exert its effects. In terms of kind of visualizing this, lots of times when people think about racism and discrimination they tend to think about things on a one to one level, they're trying to think about, you know, police brutality at an individual level, that face to face level, and that feels quite something that we can kind of comprehend.

But if we kind of think about the, the visualization of the earth, that's what the framework refers to. And we think about humanity and communities existing on the surface level, that kind of one to one interaction is, is exactly that. It's the superficial manifestation of so much more that's happening.

And so the core of how discrimination and how does racism and xenophobia operate. is structural discrimination, and at the heart of that are two things. One, this concept of separation, which came from an indigenous collective in Canada called Gesturing Towards Decolonial Futures, the Musqueam community.

And the idea that separation being humans thinking that we are different individuals separate from one another, separate from the environment in which we exist, and separate from kind of different communities. So there's, that's the first thing. And then the second thing is that of hierarchical power, hierarchical power structures that govern our society.

And so if we think of that as the core, there's lots of things. Institutions don't all of a sudden come up and become racist. There's, there's historical context that places that kind of explains why that is. These, these ladders that have been created, where those at the top are afforded power and privilege and health, and those at the bottom aren't.

Those have been created by, you know, colonialism, neoliberalism, racial capitalism, the existence of these caste hierarchies that have been created. And so that kind of explains why institutions and systems have been created and why they exist how they are. And so when you're thinking about that in relation to health, health systems are, of course.

affected by that. The way in which all these complex processes are going to affect an individual and affect their health. It's going to be determined by where they are, what are the policies, what, what the laws and where you're living, who are the communities that are nearby. And that kind of brings in this layer of spatial determination that where you are will determine how all those core processes, how all those institutions and systems affect your health.

And then that you're looking at individuals within communities, whether that's communities that are brought together by some sort of connectedness, right? Whether that's identity or location or shared interests that will affect an individual's health. And then finally, when we're looking at individuals, kind of breaking it down into three things, actually responses to all of these complex processes.

These things are behavioural responses. So behavioural responses to discrimination can relate to your physical activity, your sleep patterns. Then the second being psychological responses. So it might be internalising racism. It might be internalising these ladders that have told you you're not worthy of being at the top.

You're not worthy of that power. And then very important to health, the physiological responses to discrimination. So that is related to stress, the daily stress of discrimination and how that can affect your health. The last thing is to do with time. The way that discrimination affects health is also related to the life course and how there's a cumulative impact of discrimination and how there's intergenerational as well.

Delan: Thank you. And before we go into these health outcomes, which is largely the second paper can I get in any thoughts? 

Tendayi: I was just going to say that I think what's, what's helpful about the model is that the conceptual models. It does have a visualization that brings together ways of understanding what racism is and does in different disciplines, in different areas of life.

It kind of brings them together to kind of give us a synthetic account of how we should be thinking about racism in Zenesovia in relation to public health. So to me, I think the best thing about the model is also the best thing about the collaboration. You all, I think, are predominantly in the field of public health and in the field of law and in different fields and in different areas of life, people are thinking and talking about the impact of racism and phobia on their lives and health is a very central part of our lives, but we often are not using language that makes it easy to conceptualize across those boundaries, and I find the model to very helpfully bring together different ways and different levels, scales, you know, geographies, and even temporalities, how we're thinking about, about racism and its impact on our lives.

So that, I found that helpful. And maybe I'm an insider and I've drunk from the same fountain that you had Satipa, so it makes it less compelling, but it's one of the things I really appreciated about it and about the collaboration. 

Delan: Thank you. And the other thing I like about it is that it flips the usual structural determinants model that we have in health, public health, in that the person is very small on the outside of the model and the central kind of structural causes are what's driving ill health or good health.

Okay, so Sajitha, following on from the conceptual model, can you tell us a bit more about paper two, please? 

Sujitha: Sure. I mean, from an academic point of view, we did a scoping review. We're trying to map these pathways of discrimination that we've just explained onto health outcomes. So in terms of that, that third thing at an individual level, looking at physiology and behaviours and psychology, what are the health outcomes that are essentially manifestations at an individual level?

of racism and discrimination. And the results of our scoping review is overwhelming. It's both overwhelming and an underestimate, both at the same time. So, we have categorized these health outcomes in terms of mental health, sexual and reproductive health, non communicable diseases, looked at mortality, and we've also looked at, separated those across the life course, and what you find is that discrimination affects health outcomes across all ages, across all aspects, all areas of the world, and it continues to do so across the life course.

So, We know that someone who's pregnant who experiences discrimination, there's evidence to suggest that if you check the blood level, the cortisol level, the stress hormone of their, their child at six weeks, that's going to be higher compared to someone who did not experience discrimination when they were pregnant.

We also know that there is associations between discrimination when someone's pregnant with they're less likely to breastfeed, which is then associated with that child more likely to be obese, that child more likely to develop type one and type two diabetes. There are, there's a higher risk of infectious diseases to the baby.

There's associations between discrimination and mortality. That one exists all across the life force that happens in childhood, in adulthood, in older adults. There's associations between discrimination and type 2 diabetes and high blood pressure. All these things that kind of understand it in the context of the framework make sense.

But there's evidence that we have looked at that supports this. And I guess the question is, you know, we're saying that it's overwhelming and also an underestimate is that there is enough evidence to act. That's the main thing to say, yes, we need to be conducting more research and we need to have a greater understanding, particularly a greater nuanced understanding of how and where this is happening.

There's definitely enough. So I think that's one of the key things that comes out of paper, a paper two, there's a specific focus on how on stress and the allostatic load. And. This is the day to day discrimination has epigenetic changes. So there's changes in how our body. So if we think of input, I think of this as inputs and outputs.

So outputs are health outcomes. Inputs are experiences of discrimination. And then our body is the machinery that kind of processes that input to that out. And in terms of how our body. responds to that is that it's in this fight or flight mechanism, right? Which is an adaptive process. Our bodies were designed to do that, to kind of protect ourselves.

But actually in the context of day to day discrimination, which could be, you know, uncertainty about your job being made redundant, all of these day to day stresses that is related to discrimination, Relates to this thing called allostatic load and weathering where actually you're aging a lot earlier than you would and you're also more likely to develop these chronic conditions such as raised blood pressure and type 2 diabetes.

And that's a kind of a key way in kind of understanding this input of discrimination and this output of poor health and health inequity. 

Delan: Thank you. So what we get is this sort of overload of the system, this hormonal imbalances and you mentioned epigenetics, so this idea that the environment can influence the expression of your DNA without changing the DNA itself.

Gideon, as a, as a doctor and physician they, these kinds of concepts, are they there in your normal practice or not? 

Gideon: Yeah, they're definitely discussed at all in medical school. At least when I was studying medicine in the Philippines. There's really a, looking back now from the lens that we have from the benefit of all the insights that we have now, we see how, how our medical education has been largely based on textbooks from, from the U.

S. Without much reflexivity on how, in fact, what we learn, this kind of knowledge that's taken for granted as fact, it's influenced by so many factors, including discrimination, and it's so surprising coming from a country like the Philippines, that there's a lack of reflexivity around these issues. And, and I think that Sujitha was already talking about one of the things that can be done and definitely it has to include how our curriculum, not just in medical schools, but in all kinds of health fields and also in social sciences has to, has to be reflected in terms of, of what these impacts are, because you're going to just look at a medical condition and think that this is something that, you know, universal.

The specificity, the diversity of human experience has to be reflected in the way we think about medicine. 

Delan: Thank you. And just to describe the third paper of the series. So this paper has a series of case studies from around the world. And what I really wanted to do with this one is to show how there are similar things happening in different parts of the world, all over the world.

We covered the legal prison system in Brazil, Islamophobia affecting people in Europe and North America, maternal and child health care in India in relation to the caste system indigeneity in Australia, and xenophobia on a background of apartheid in South Africa. And this, this paper in particular takes an intersectional approach that considers abilities and disabilities, gender, socioeconomic status, and many other factors and, and brings them together in, in this analysis.

And Tanai, maybe you can come in at that point, because I know you've traveled and worked to many different places, particularly your former role as UN rapporteur. Do you have any thoughts on that? 

Tendayi: Yeah. So, you know, in, in my work, especially up until one of the things that I did was conduct country visits.

So actually visit different countries and speak to government officials, speak to different groups who are racially or ethnically marginalized in order to form a picture for how well racial equality and racial justice norms were being implemented. And before I took on the role, I imagined that. I'm not sure what kind of conception I had, but I was actually surprised by what I found.

So one thing I found, which I think really resonates with what you're describing, which is that the way that racism and xenophobia manifest in different contexts can vary very different, can vary greatly. The experiences of racism and xenophobia in Qatar, for example, which is one country that I visited versus in the United Kingdom, you know, it's the histories, the context of shaping the way that people are experiencing health or any other system varies.

But what was uniform was that irrespective of where I visited, there was some kind of hierarchy or some kind of system that placed certain groups. At the top and at the bottom on the basis of racialization involved using, you know, how they look, how they talk, how they sound. And so I think, I think the work that is done in the series, both to talk to try and tell a story that is, you know, universal in the sense of applicable in many different places.

But then it also pays attention to case studies that looks at specific context. I think it's really important both for giving us a diagnosis that emphasizes that this is a challenge irrespective of where we are. But then how we think about responding has to be very much tailored to the, to the unique and, and specific context.

I think to me that, that those, that double move is, is what comes out of the way that the papers in the series are, are arranged and I, and I think it's, it's really important. 

Delan: Yeah. And then the other side of this is that the health outcomes as public health or clinical doctors, we see similar health outcomes from these different groups who might be.

persecuted, marginalized in different ways. There are similar non communicable diseases, issues with someone's mental health issues in perinatal health, as you described, Sajitha. 

Tendayi: One quick thing I would, I would add is that You know, in those country visits and in the consultations with minoritized groups, with refugees, asylum seekers, you know, they all report experiences of racism and xenophobia and accessing healthcare.

So even though I like to think about explicit prejudice and all of these sorts of things, it's not doing all of the work. Many of the people I consulted with spoke very vividly and in some cases, they were actually told that they were being given lower quality treatment because of the way they looked and the way that they spoke.

But on the other hand, in speaking to government officials, there was deep levels of disbelief. That this kind of a thing was taking place and I think showing that there's differences in health outcomes and having that be in, you know, a scientific journal, I think goes a long way to validating what many people who experience racial discrimination know about the treatment.

That they're receiving. So Gideon, you mentioned earlier the role of advocates and activists in getting us to a point where we can have this conversation. I think that work is so important side by side with interventions that show, you know, from a scientific perspective, how outcomes are actually, how outcomes are being affected because many times the people know this to be their life experience.

don't have a way of making the case that that is their life experience when they're in contexts where decisions can be made that would actually result in different outcomes. 

Delan: Thank you. And you know, we, we see this here in the UK, the UK has a national health system, but it isn't there, there are different barriers to access for migrants in particular.

Gideon onto the fourth paper, and if you can talk a little bit about interventions and what we might do and things that work. 

Gideon: Yes, thank you. So building on the three papers, what the fourth paper set to do was to survey various levels of intervention, and we ended up coming Finding, I think, 89 papers that fit our search criteria in terms of papers broadly when it's true that, that actually try to deal with or, or to document interventions that have been done.

And we saw that there's a skew towards individual and community level intervention. Mostly one example, for example, is children being, being showed films, anti rageist films, and then trying to measure what they felt like afterwards. So there were many of these study, but we saw that there's much less in terms of interventions, looking at health systems, institutions, social movements, and legal and human rights frameworks, even though there's great potential in those interventions, for example.

We saw that human rights interventions have had various impacts on health outcomes ranging from tuberculosis in, in South Africa to health insurance in Colombia, as well as HIV related outcomes all over the world. The U. S. civil rights movement and affirmative action to support minoritized castes in India.

We also saw some studies that show how this broad movement, social movements have led to. reductions in infant or child mortality. So more broadly, if we take all of these words together and we point out We, we expressed frustration in the paper that there's limited, so limited literature around these topics, and that's the first thing that we highlight as a, as a conclusion is that there's very little, and we need more in depth research that explores specific discrimination based issues in healthcare, explicitly around health, and examines how these interventions operate at a different level.

We look at the individual, the community. the, the social movements, institution, and of course, even frameworks like, like legal frameworks. And we also know that, that the overwhelming number of these studies tend to be in countries like the U S and even within the U S there's been little work on racism and xenophobia as concerned particular communities, like the East and Southeast Asian communities, for example.

So we need more country focused papers and also building on the conclusions of the In the earlier three papers, the most important thing, one of the most important things in the paper is that it really creates a case for more transformative action to address the structural drivers of racial injustice.

Delan: Thank you. And maybe Tendai, if I can come back to you, because those kind of legal interventions seem to be, at least from my perspective, some of the ones that are the most effective. I mean, you wrote a lot of that section. 

Tendayi: Yes, yes. So, you know, I think what was exciting about doing the research on this section was actually seeing that there were contexts where shifts in law and policy had actually made a concrete difference on the ground.

And Gideon kind of spoke to this. You know, in international human rights, for example, we have a framework that is about promoting racial equality, and I'm doing so also in the context of of health and part of that framework is about affirmative action. So, you know, specific steps that are taken by governments to address racial inequality by providing resources on and kind of legislative interventions that seek to lift groups that have been racially discriminated against to kind of, you know, Ensure that they also access a quantity.

And so it was it was really reassuring from from somebody who studies the law to see that these interventions make a difference. I think what was really disheartening and this is echoed and what Gideon was saying is that there isn't, and. Every place where we have these legal interventions, we don't necessarily have studies that are showing us what the impacts are.

So in parts of the world like South Africa and parts of the world like the United States where resources are being, you know, devoted to these sorts of studies, we have a lot of information, but in other parts of the world, we do not. And even though, as we've mentioned on this podcast. We can think of racism and xenophobia as affecting many parts of the world.

Context matters, and local context matters, even in the way that laws and policies have their effect. And so I think one of the takeaways from the series and from doing the research is that we need more research, not because we don't think law can have an impact, but the nature of that impact is going to be contingent on factors that depend on the on the context that you are in.

It was also remarkable to me in doing the research for this, that in many of the spaces where policymaking is taking place and where human rights are being translated and being implementable at the local level, those conversations are dominated by lawyers, you know, and other types who don't necessarily have the public health background that say you all have, and that has to be essential, I think, to thinking about how you make human rights real and very local context.

So just In terms of thinking about takeaways and, and, and key directions we want to go going forward, one of them is thinking about how we disrupt the disciplinary side silos that mean that law and policymaking is taking place in one, in one area. And then those people who are working on actually measuring or delivering health outcomes are sort of taking place in a, in a, in a different area.

One, one other thing. And thinking about the final paper in the series and the recommendations that we make, one thing that is especially valuable is I, is I think that the series is oriented towards actionable items that are sort of digestible, but I think is also ambitious and in situating the entire project where we start by saying, if what we're interested in is different kinds of health comes more equitable kinds of outcomes, we have to be thinking about decolonization, for example, and what the project of decolonization is.

In the context of public health, you know, and for many people's decolonization can feel like a call to something either that's already happened or something that's very amorphous. But I think the paper, the final paper really attempts to concretize that and say, and say part of what we're trying to do is shift the way we understand the way that race operates in society.

And that is a decolonial project in the parts of the world where that has been shaped by. Decolonization. So just the ambition of some of the recommendations I think matches nicely with some of the concrete proposals. That are provided and we haven't spoken as much in our conversation about intersectionality, even though intersectionality very deeply informed the entire drafting, you know, paper one, paper two, paper three, paper four.

But that's one of the recommendations in the, in the, in the final paper as well to say we have to take intersectionality seriously and then intersectionality that moves beyond thinking that that just means. Thinking about women and thinking about cis women and cis white women to be specific, really thinking about intersectionality is bringing together complicated ways of thinking about race, ethnicity, gender, disability status, and how all of these things shape the kinds of health outcomes that we're thinking about as well.

Delan: Thank you. And thank you to all of you for describing this massive amount of work in such a short time. My final question to you is just what is your take home message for the listener to the podcast? 

Gideon: Well, despite all the heavy challenges that lie ahead, I think that series actually give me hope.

Because some interventions have actually worked and there are people who are working to document these. There are people who have not given up and in fact are trying in different levels from the individual to the institutional to the structural to address this. And we can take strength from that and we can build on those.

Knowing, for example, that As Tendai said, that legal frameworks actually matter. These are not just pieces of paper that politicians sign and we can actually use them to demand, to make certain demands for, for minoritized people. These are important sources of encouragement. And I think that it should inspire us to continue this work in all.

different places with an intersectional mindset, but also with some encouragement that we can actually try to make a world that a less, less dangerous place for people who are experiencing xenophobia and discrimination on a daily basis. 

Delan: Thank you, Sajitha. 

Sujitha: I think. I think mapping racism and discrimination to health outcomes is quite powerful because there's something so palpable, so real about health outcomes.

There's something about health and ill health that everyone can relate to and that feels like a measurable outcome, something very tangible. And more specifically for those within health, when, for so long, we have been taught all these health outcomes, various cancers, cardiovascular disease, lung disease, diabetes, blood pressure, for so long we have been taught, you will see on one side is your modifiable risk factors and your non modifiable risk factors.

And we have been taught that race. and minoritized ethnicities and indigeneities are your non modifiable risk factors for all of these health outcomes. But what this series does is it rejects this genetic basis of it and instead proposes a framework for showing actually fine, if it's not genetics, what is it?

And this is a, you know, a vast model. There are so many pathways and also everyone is implicated. So everyone can do something about it. And I think actually, if we believe instead that this relationship between ill health and race and ethnicity and minoritized people. It's not, it's not that it's non modifiable, it's in fact modifiable and actually the onus is on every single one of us to modify that risk, that actually should feel quite empowering.

There's something we've been told that's inevitable that we're now thinking actually we can do something about it. I think actually embodying that belief, whether that's on a one to one basis, whether that's with every patient that you see, that's from a minoritized background, or whether that's you organizing.

and changing guidelines at your local practice, or working across disciplines, seeing how you can change things in law, in culture. I think all of that contributes towards making a difference. 

Delan: Wonderful. Thank you. Tendayi, last word to you. 

Tendayi: So it's hard to think about what the last word is, but I think I, I agree a lot with, with what both Satitha and Gideon have said, and in some ways it makes it easy.

I can just say what they said is exactly what I think should be the last word, but, you know, I think about my own education and Gideon, you were referencing your own education. And this is a podcast of kind of elite educated individuals, which is worth marking because I think. The spaces that we move in often are the spaces that are shaping law and policy, you know, and decisions that are being made in many of the spaces that we care about.

In many of these spaces, education around racism and xenophobia and the way that it shapes society just doesn't exist at all. And that feels unconscionable. And I think what's exciting about this series and even the Lantert Commission on Race and Health, which I, I know. Is, is scheduled is that it gives everybody who is in a role of educating a a resource to be able to start having those conversations around the ways in which race and xenophobia, racism and xenophobia shape help outcomes.

I would say one thing I would hope, which is very concrete is for those of you who are listening, who are educators, that you really deploy the series as a resource to really shift the way that we are. Shaping how people's come in to understanding their own role in this field's relationship to racism and xenophobia and in society.

So this is the educator and me saying. The series just offers, I think, a very helpful and neat way to start conversations otherwise can be really difficult to have in, especially in spaces where conversations about race are taboo, which quite frankly remains many, many, many spaces. 

Delan: So thank you very much to all of you for joining me and to the Lancet Voice podcast for hosting this.

If you like this, do check out and follow the Race and Health and the Lancet Voice podcasts. And if you want something a little different, also check out my other podcast, Global Health Lives, where I talk to people in global health about themselves and their work. Thank you very much and see you next time.