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Join hosts Doctor Xand van Tulleken and Dr Rochelle Burgess for Season 3, Episode 5 of Public Health Disrupted with Dr Halima Begum Prof Delan Devakumar.
Xand Van Tulleken
Hello and welcome to season 3 of public health disrupted with me Xand van Tulleken
Rochelle Burgess
…and me Rochelle Burgess. Xand is a doctor, writer & TV presenter, and I’m a community health psychologist and Associate Professor at the UCL Institute for Global Health.
Xand Van Tulleken
This podcast is about public health, but more importantly, it’s about the systems that need disrupting to make public health better. Join us each month as we challenge the status quo of the public health field, asking what needs to change, why and how to get there.
Rochelle Burgess
In today's episode, we're going to be exploring race and health. How does racism impact people's health? And how big is this problem? We're three years on from George Floyd's murder, which launched a wave of global protests under the banner never again. This, of course, has not been the case. We're also three years since the COVID pandemic began, which really highlighted the long standing racial health inequalities in the UK and beyond. So in this episode, we'll be exploring the systemic challenges faced by people of colour and the complex relationship between racism, health equity, and efforts for social justice,
Xand Van Tulleken
Delan Devakumar is a Professor of Global Child Health and an honorary consultant in Public Health. He is co-Director of the UCL Centre for the Health of Women, Children and Adolescents and is chair of the International Child Health Group, which is a special interest group of the RCPCH (the Royal College of Paediatrics and Child Health). Delan was lead for the Lancet Series on ‘racism, xenophobia, discrimination and health’ (The Lancet for anyone who doesn’t know is a weekly peer-reviewed general medical journal). As if all that wasn’t enough to qualify Delan to help us unpack the implications of racial inequality, Delan also leads the Envisioning Environmental Equity project on climate and racial justice, AND produces much creative content of his own including podcasts and newsletters as founder and director of Race & Health - we’ll let you know where to find out more about all that in the show notes.
Rochelle Burgess
We’re delighted to have Dr Halima Begum joining us all the way from Kenya for today’s episode, also bringing bucketloads of insight and experience of her own to this vital conversation… Halima was recently appointed the new CEO of ActionAid UK, an international development charity working with women and girls living in poverty. Until she starts at ActionAid later in 2023, Halima remains CEO of the Runnymede Trust, the United Kingdom's leading race equality think tank. As many of our listeners will know, during her time at Runnymede, the Trust has produced an important body of research on public health in the race context, including its work late last year with Greenpeace examining the impact of the climate emergency on minoritised communities. Halima also played a significant role during the Covid pandemic, working with government to secure vaccination priority for minority ethnic communities across the UK. She sits on the Board of the NHS Race and Health Observatory, and she has also held senior positions in the UK Department for International Development, the British Council and LEGO Foundation. Welcome Delan and Halima thankyou both very much for being here.
Delan, I want to start with you, can you give us an idea of the scale of the problem and the ways in which racism affects people's health?
Delan Devakumar
Thank you for inviting me today. So I suppose we think about racism in many different ways. And there are different versions of racism. So in our conceptual model, we go from the individual person up to the kind of structural core causes of racism.
Delan Devakumar
So if we think about it at an individual level, and that's, I guess what most people think about sort of interpersonal racisms acts of physical violence, verbal violence that can directly affect people. And you mentioned George Floyd in the introduction. Famous in the UK, Stephen Lawrence murder, going back to my childhood was a very important part of growing up here in the UK, remembering what happened at that time. And that, I guess, those kinds of racism, you can see obviously, how it can affect someone's health. But there are other ways that are a little bit more complicated that beneath the surface, maybe so it's this idea of chronic stress or allostatic load weathering is another term. And this is where acts of racism can affect the person it can affect how the body functions. So we see this in chronic levels of stress hormones increase, you get these changes in the neuro endocrine system. So changes in hormonal levels, changes in brain function and structure even. And this can result in an increase in non communicable disease. is, and some of the reasons why people from minoritized groups die earlier than others.
Delan Devakumar
. And that can affect people at different parts of their life as well. So they're really sensitive periods, particularly childhood, that can affect you a long time later, as well. And even, it can affect the next generation. So we see the studies of increased stress due to racism in pregnant women. And we see these changes happening in the children who are born, increased rates of preterm birth, increased low birth weight in the babies who are born. we can also think about it at a structural level, in terms of the institutions that people go to the health system, in particular, we see these barriers to access for minoritized groups, we see reduced quality of care issues, , sometimes even simple issues around language and not being able to understand the health system. and then environmental forms of racism, indigenous communities living in polluted parts of the world mining industries affecting the quality of the food water systems in those communities. And in London, we talk about air pollution, some of the poorest parts of London, minoritized people live in have worse air and breathing in different air than other groups in London. And then we have the more kind of core structural causes the political systems and legal systems that have perpetuated racism, most famously the apartheid system in South Africa, that divided people by racial groups.
Delan Devakumar
racism means different things and connected all those different levels and can affect individuals and populations in those different ways.
Xand Van Tulleken
even within the medical profession, once you're in the clinic, where you think that you're dealing with objective science and measurement, you're still dealing with medical textbooks that only have pictures of white skin,. And then the date on which treatments are based very often not in very diverse populations, drug development, even in places where you think you're dealing with objective science, race plays into the care you receive.
Delan Devakumar
there are ways in which the whole health system can be structured in a racist way. This can be built in into the kinds of algorithms that we have. So if we think about kidney disease, there are these race corrections for someone's kidney function, where black people has a different correction that's added, which leads to poorer outcomes for those people, we see black people having access to dialysis at different rates than than white people. And this happens in the UK in the US in particular. And part of this is based on this false idea of race as being different biologically, and having different physiology, that you need these race corrections when actually that's not true. And, and what this does is it leads to poor health for those communities. And this is a way in which it's just built into the way that clinical work functions. So it's not the individual person, it's not the individual doctor doing something. Sometimes it's just automated within the lab reports as well. Sometimes the labs apply that race correction automatically, it varies and how it works is sometimes that the raw results are given, but sometimes within the laboratory results. That's already incorporated into someone's kidney function.
Rochelle Burgess
Oh, wow. Yeah, that's huge. I wondered if I could bring Halima in on this point because it is so deeply entrenched and cyclical and intersectional between personally mediated acts through individuals, systems within which they operate and institutions within which those sort of wider structural systems operate, , like in colonial legacies Halima, you've been doing the action bit for a really really long time. So I just love to hear from you on this point of disentanglement, and knowing where to start.
Halima Begum
Great, thank you really lovely to be here with you. I think we have to start with this notion that when we're discussing racism, we're not actually talking about individual acts of racism, yes, individual actions can exacerbate make worse a situation. But on the whole, when we're looking at poor outcomes on the health levels at the population level, it is not a single individual that's responsible for black maternal health figures in this country. it is a system that's producing that outcome. So I think we need to start with the notion that is indirect racism, which then is replicated and reinforced and pass on to the system, so much that an individual that's experiencing health treatment and outcome as a user is then impacted. It's an indirect act of racism that is leading to poor outcomes for racialized groups.
Halima Begum
Now, of course, this is not a new notion. If we go back to Steven Lawrence's murder, and the subsequent McPherson inquiry, McPherson, focused our minds on institutional indirect racism and how it was so important in explaining actually not not just the direct act of racist murder, but the subsequent handling of the police investigation that was really institutionally badly handled right. And McPherson did set out the notion of indirect racism and how that then institutionally manifests itself to produce outcomes at a population level. One of the questions I get asked regularly and it is so so complex, but is there one thing that you you could see being done that might change things for racialized minorities in this country so that they are not suffering from poor outcomes from the health system that's publicly funded from their own tax, as well. And I always go back to the point around maternal health or crisis in the system that we're currently aware of black maternal health, for example, if we know that it's a crisis, start with what needs to be done to reverse that, and then the whole system can follow.
Rochelle Burgess
I mean, one of the things that always strikes me, when I think about acting on racism, one of the challenges for me always feels that we respond to the crisis, as if it's about an individual, when part of responding to that crisis needs to be about responding to sort of those structural inequities. health systems struggle, they struggle to see how those things fit together, if the crisis is around, let's say, four times more, and we had the young activists who sort of launched that campaign, around maternal deaths in the UK, on our first series of our podcast, and thinking about, responding to that crisis, one of the things I I'm always drawn to is the fact that, minoritized bodies, women live in, in conditions that are not conducive to good health, and how much of addressing that crisis is, is a part of what we're doing to respond to that.
Halima Begum
Yes. So obviously, the NHS is part of an ecosystem of a public health system that needs to be responding to that wider issue. So for example, at the beginning of COVID, I think there was a lot of soul searching around why particular groups of minorities were disproportionately impacted. And of course, those of us who were disproportionately impacted actually knew why we were living in the inner cities, breathing air quality that is dangerous and toxic, and also living in households that were multi generational, and also with wage earners in the households that were employed in the gig economy, for example. So these are environmental structural reasons for why racialized bodies are more precarious in any situation. But on top of that, if you look at the the first doctors that died in the NHS, these were not socio economically working class minoritized bodies, these were middle class racialized bodies within the NHS system. So we we talked a little bit about how racialized bodies were under protected in terms of PPE. And then rights in the workplace. it's about whether we have the confidence to actually say, perhaps today doesn't feel right for me to come in, because actually, I might end up sharing a room with my multi generational family, and therefore, I need to protect myself.
Xand Van Tulleken
you both alluded to the distinction between interpersonal racism between individual people who are racist, and the kind of horror and discomfort with that, and then a system and an intersectional system as well, when you try and change the system? Where do you encounter the resistance? Where are the vested interests that need to keep things the same? Is it just inertia? Or do you then encounter individual interpersonal racism where people are like, I don't like to see these changes occurring for these reasons. Delan can we start with you
It's easy to say most people don't like to be called racist. So that that's obvious but but also, institutions and systems don't like to be called racist as well. And and Halima mentioned the McPherson report that was very controversial at the time, the police system being institutionally racist, You know, with that there are similar things to climate change arguments to to many other industries, there are people who are advantaged by the current system, and there are people who are disadvantaged, if we look at indigenous populations who have come may live in very difficult conditions. And that's due to extractivism to mining companies through the polluted environments that they live in. People get advantage get profits from those industries, and certain people are facing the consequences. And there's a different people, obviously, who who benefits from air pollution in, in the UK or elsewhere, there are certain industries who benefit air pollution as a byproduct of the profits that people are making this resistance to change anyway. But there are people who are actively resisting and there are people around the world who are benefiting from racist structures.
Xand Van Tulleken
it's sort of requiring you almost to point a finger at certain certain places and things in a way that's, that's, that's very difficult. Halima
Halima Begum
what has climate change and racism got in common? And I think there's one apart from the harm of course, the other thing that it's got in common is guilt. So often people who deny climate change, are guilty because of their own actions whether systemically or individually over the years killed is incredibly inhibitive. It paralyses you so it's better to just deny that it's happening same as racism, right? Better to deny that we live in a society that still has prevalent racism than to confront it.
Halima Begum
I think there's a peace around raising public awareness of the issues that confront us and challenge us, because if you can't name it, recognise it, then how on earth can we teach our children that this is still a societal issue at large, but it is not just about direct acts of racism.
Halima Begum
I'll give you an example. when I took my 86 year old father, for two year process where he was receiving cancer treatment for his very terrible situation, he has now passed away, it took an entire family of siblings to make sure he just got the right treatment. To the point when he was actually signed off for end of life palliative care, the doctor at the particular hospital, who was terribly caring and actually very committed to her job had managed to sign a consent form for end of life for no resuscitation without the family's consent and didn't think there was anything wrong with it, because her experience of British Bangladeshi patients coming in who didn't speak English, was that it was probably the right thing for them and just assume that consent wasn't required. And when we then challenged it, she then actually pointed us to the Google guidance on what end of life no resuscitation rules were. And I was able to say very politely, oh, I know how to Google what I'm questioning is your medical ethics. How were you able to sign off the consent without the family's consent? It's an ethical question I'm raising. it's that assumption of treating minorities for years and years and years and actually not being self aware of your own actions and your own professionalism within a system that's already inaccessible for many minoritized individuals. So I think it starts with naming the problem recognising it, not denying it. And also making sure that when our government denies that there's a problem of racism in this country, that all of us are aware that what the implication is we're denying that racism still exists in this country, because that means all the work post Steven Lawrence's generation that has been done to raise awareness is then undone. When we hear slogans like we may be living in a post racial society. I'd love that. I'd love it if we were. But there's an epistemic justice and injustice done to those of us who are still suffering as racialized minorities when we deny racism, right?
Xand Van Tulleken
Was it Matt Hancock during COVID said the UK is not a racist country.
Halima Begum
it's very dangerous because it means those of us who are working on the front line trying to resolve health inequities, then we have a harder job . And this was on the back of Black Lives Matter when we were all leaning in to actually make sure that something like that never happens, ever again, in Britain or anywhere else. So that's very dangerous. it's gaslighting isn't it? That was a very difficult moment, but quite reassuringly. I mean, even the most conservative of medical associations to the most radical of associations that are the trade unions actually came together to ally and align on this fact and pushed back on that central message that was coming from the very Top of our country
Delan Devakumar
we talk about some of these issues as being, you know, a byproduct or not deliberate actions, but there are deliberate actions as well. And an example from the UK is a hostile environment towards migrants, this government policy, to restrict access for migrants and to make it a difficult place to live. And this has consequences for the health system, there's, you know, the NHS is famously free at the point of care, but it isn't for everyone. And migrants are charged, and some and charged for secondary care that charge at a higher rate than nationals of the country, which has consequences that people don't go to see their doctor, people delay going to see their doctor, they go with worse conditions. And this is, you know, also for children. I work in child health. And we did some work on undocumented migrant children who have to pay to go to see your doctor in secondary care. the government paints migration is a big problem for the UK. They don't talk about the advantages of migration, the advantage is purely in an economic sense to the economy of the UK, the advantages of migrants coming in.
Delan Devakumar
But this has real consequences. It has consequences for those people, for other people from minoritized groups in the UK. I took my son to the doctor for some allergy testing. And afterwards I received a letter letters kind of asking, should I pay the migrant charge. And it's very odd thing. It wasn't my, I'm a British national, my son is born in this country, the British National we shouldn't have paid the charge. But I think it was purely based on my name, that we got this letter and it wasn't even telling me to pay it was sort of questioning should I be paying, the whole system is set up to target migrants, but it has this knock on effect on all minoritized communities in the UK.
Rochelle Burgess
I'm really glad you brought that up because it is I think one of the hardest things I moved, I moved to the UK in 2007. Or formally, I guess 2010 When I started my PhD, and just sort of watch like a very have watched the decline of the narrative around migration into like, a much more and more like openly blatant racist narrative.. I'm constantly going for interviews and biometric cards and and, and I know that my pathway is made easier by the by two things by class because I speak a certain way I've been educated in a certain way my application is linked to very fancy schools. And, and also by my name Delan, like Rochelle Burgess is basically English plus French equals, she must be white. So there's, there's no, nobody is harassing me or chasing me around in that same way until I'm visibly in front of them. And so you really see the sort of the, the ways in which those those deeply problematic racist assumptions which are very, very old, and the hostile environment is very, very old, sort of going back to the also the 1700s 1800s these policies around who is a foreign British national who is a British national and like that sort of a hierarchy and those passports that they issue in those kinds of things., we can't say the thing we want to say that some groups of migrants are okay, sort of the way processes, new processes, embracing processes are created for some types of migrant bodies, and not other types of migrant bodies.
Halima Begum
I was gonna say, I was going to say that Delan, if, for example, you if there was a white, South African migrant, or actually a white Australian, they are never really asked about whether they should be paying for NHS prescriptions, or whether they should be paying big, big. So it's not just the migrant status, it's the racialized migrant status. So that then plays into who is a good migrant worthy of actually coming to Britain and who isn't right. So even beyond the migrant status, we apply race shore tropes around who is acceptable and who isn't.
Halima Begum
I also think there's the inertia piece as well. So when you speak to my well meaning friends, who I now share a lot of time with, they will say, but the NHS is broken, it's so broken, everybody's suffering, my mother in the suburbs, or the Chilterns, cannot get a health appointment, she can't get a doctor's appointment. And it is true that the health health system is broken. But minorities are then experiencing worse outcomes, even in a broken system. So yes, the NHS systems is universal, but certain certain minoritized bodies are experiencing health treatment differentlyat least with COVID, one thing was quite clear that we didn't experience COVID, in the same way, and some of us were better protected, due to class, first and foremost, but also whether we were racialized or not.
Xand Van Tulleken
Yeah. It's very interesting that you both will all three of you have mentioned the very, very long historical context of this., in terms of the scale of the problem, that question that I sort of almost felt a bit embarrassed to ask at the beginning, like racism, how big a problem is it? It is, it is at the core of all of global health, inequality, all of health inequality or poverty, you could make the case that it's one of the biggest health problems in the world, and that health and health and racism are very, very deeply connected. So I wanted to ask, the extent to which health professionals and healthcare systems offer a part of a solution Is there a possibility that that changes in public health and in in clinical medicine could have implications for wider society? Should health care professionals be trying to lead in this area?
Delan Devakumar
Well, yeah, yeah. And I, I think I didn't answer your question at the start about how big the problem is. It's a difficult question to answer, because you can look at it in terms of individual interactions, you can look at it in terms of differences in life expectancy differences in mortality rate, we mentioned maternal mortality COVID-19 differences by ethnic group differences in life expectancy. indigenous populations in Australia, New Zealand have about a 10 year lower life expectancy than the white populations. But I think, you know, as we've been discussing racism goes much further and it goes back into the histories of countries, it goes to the colonial history is the slave trade. And it's implicated into some of the worst atrocities that we've seen throughout humanity, wars, conflicts, genocide. I think it is one of the biggest things that we need to address. And I always advocate within a health field for it to be up there with the other big determinants of health. If we look at socio economic causes climate change environment, I think we should consider racism amongst those other determinants.
Delan Devakumar
In terms of what the health professional should do, I think we have to be part of the conversation, this isn't something that we can just say it's for others to fix. health professionals have a role to advocate to, to. And I say this in, in the sense that I know that it's difficult, I know, systemic change in a society is, of course, a massive thing. And an individual person, it's difficult for that person to make that change. But there are many routes to make a change, you can work within an organisation. activist groups, NGOs, within your your unions, for example. And some of the kind of civil rights movements that have been successful throughout history have been collectives of people, and health professionals are powerful. And I think the individual person forgets that they have a certain authority, they have knowledge to have a standing society. And those people come together a very powerful, very powerful force for change.
Halima Begum
I think that medical practitioners are in a hugely influential role, because we trust you with our health, when we're at our most vulnerable, then the level of trust it takes to place what our support needs are in your hands is incredibly important. that's a good starting point. Because I think, fundamentally, if we can build that trust and confidence that actually health practitioners will ultimately, you know, take care of us when we at our worst and our most vulnerable. I think that is a healthy place to start. So what does that mean that the health system has to do even when the government at the highest level in this country doesn't have an anti racist strategy, for example, at the prime minister's office, So in this country, we don't have, an anti racist strategy that is about reducing disparities across the nation. So in the absence of that, I think there are certain institutions and certain sectors like health and criminal justice system that can do more in order to cushion the impact of racism on our racialized communities.
Halima Begum
I think health professionals can start with just looking at the numbers, right if there is a racial disparity, or disparity in health outcomes for racialized groups within that particular city, or the area that you are responsible for what is a clear commitment to reduce disparities, so simple as that. So if we only stayed with the idea that health systems in this country are universal, free at the point of delivery, I think we'll miss a trick because we do know, in order to drive better outcomes, we have to reach different groups differently. So it's not that minority groups are hard to reach, we have to see it as our responsibility to reach different groups different if this was a commercial broadcaster, we wouldn't be thinking, Oh, those those audiences are hard to reach we'll just forget about them. Instead, they will be thinking how do we reach each and sing each and every bit of our audience within our demographic,
Halima Begum
And ultimately, I think the leadership has to come from the very top because the health system is probably the NHS is our most proudest asset in In this country, And to then make sure that that system is responding in all its busyness to the diverse needs of our communities, is what leadership needs to commit to doing. And I believe that in the health system and the criminal justice system, and also with the Met Police in London, if those three sectors were to think about a political, political commitment to reducing disparities on racial grounds, we would make inroads right? Maybe the prime minister's office will then follow.
Xand Van Tulleken
It does feel like you're making a very good case that whether you're in public health, or whether you're in healthcare in general, you have a disproportionate responsibility to push against the racist structures and individuals.
Halima Begum
And a positive duty of care as health professionals to do good that other professions possibly don't have
Rochelle Burgess
I really want to also hold what Delan's saying about the importance of sort of, like, community work. I mean, you're saying it and not saying it, but I always associate NGOs, with community work and activism and professionalisation of activism, because that is an outgrowth of citizens visions of their being a problem that needs addressing. And, you know, trade unions and these historical movements against institutional racism have always simultaneously been driven by that bottom up movement. And so they're both they sort of are needed in dialogue, aren't they?
Rochelle Burgess
Anyway, our final question that I want to ask is about this idea of disruption. I think both of you are very active disruptors. And we're really interested in in understanding disruption, how it happens and, and thinking alongside it, so not just in public health, but everywhere. And so we always ask our guests about a piece of art or music or poetry or experience that they've had in their life that has disrupted their perspective. And it would be great if we could hear from each of you about that. Delan, we could start with you.
Delan Devakumar
So I was thinking about this, and I think it I get disrupted quite often by things. You mentioned at the start a product envisioning environmental equity. And within that project, we had young people produce, films produce comics, and around climate change and racial injustice is people in Brazil, Uganda, the Philippines, we've had children, we've had young people, we've had people creating films or artwork talking about the issues that they face, and they're all disruptive they all challenge things in different ways. There was the international Child Health Group just now is produced something where asylum seeking children have drawn pictures about their journeys and sort of narrated over to this animation. And it's it's very challenging for us people part of this work, but hopefully, it challenges others to people who make decisions as well to presenting their stories and just the power of the narrative is so important.
Rochelle Burgess
Yeah. Thank you for sharing that Halima over to you.
Halima Begum
Recently, I attended an exhibition at the Wellcome Trust, I think it's still on called milk. And when they invited me to take a look at the exhibition and speak, I thought Milk Milk, have they asked me to speak about it, because milk is white. And so I will talk to the concept of milk being white. So I went in, not quite sure what to expect, was an amazing exhibition, because it was looking at the process of extraction of milk from a cow, literally a cow. And the whole process of mechanisation and scaling up and what implications that has on obviously, the the cow to begin with, but the way in which we extract from, you know, other animals in our lives and our planet, and how that process then is linked to consumption, and links to colonialism and trade in the past that has been very extractive. So I thought I was seeing what was an exhibition on milk. But it actually caused me to think a lot around the disruptive nature of how we've been led to believe that scaled up processes of production in the past is beneficial, when in fact, this might be the process that will lead our planet to implode. So it was very, it was very disruptive in very quiet ways.
Xand Van Tulleken
Oh, that's so good. Thank you that was really insightful and inspiring and optimistic and sort of terrifying all at the same time. So thank you both. You did a beautiful job on that. Thanks for Thank you.
Rochelle Burgess
You've been listening to Public Health Disrupted. This episode was presented by me, Rochelle Burgess and Xand Van Tulleken, produced by UCL Health of the Public, and edited by Annabelle Buckland at Decibelle Creative. Our thanks again to today’s guests, Delan Devakumar and Halima Begum.
Xand Van Tulleken
If you'd like to know more about Delan's work, you can go to djdevakumar.com. And that web address is in our show notes. And if you want to hear more of these fascinating discussions from UCL health of the public, make sure you're subscribed to this podcast so you don't miss future episodes. Come and discover more online and keep up with the school's latest news events and research just Google UCL health of the public. This podcast is brought to you by UCL minds bringing together UCL knowledge, insights and expertise through events, digital content and activities that are open to ever