Race & Health: COVID-19 and racism

Host Delan Devakumar is joined by Kevin Fenton (Public Health Director for London, UK), Ayoade Alakija (Chair of the African Vaccine Delivery Alliance), and Kumanan Rasanathan (Executive Director, Alliance for Health Policy and Systems Research)  to explore COVID-19 and racism by unpacking key themes of power and influence. Drawing from their experiences in public health practice and global health policy, they discuss how racism stratifies power across the community and structural levels, and why communities of colour bore the brunt of the pandemic. How do policies informing preparedness and resource distribution reinforce these differences?

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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 the new series of the race and health podcast. We'll be partnering with the Lancet voice podcast to discuss issues raised in the series of papers published in the Lancet in December, 2022 on racism, xenophobia, discrimination and health. My name is Delan Devakumar. I'm a professor of global child health in University College London, and I was the lead on the academic series.

In this first episode, we're going to cover a range of issues about racism in relation to the COVID 19 pandemic. And we've got three fantastic guests to talk about. Go through this with me. First is Dr. Ayode Alakidja, who is the World Health Organization special envoy for access to COVID 19 tools accelerator, chair of the African Vaccine Delivery Alliance and chair of the FIND board.

She's been a leading voice in calling for the urgent re imagining of how The globe should respond more consciously to the inequities exposed by the COVID 19 pandemic. Second, we have Professor Kevin Fenton. Professor Fenton is the Regional Director for London in the Office for Health Improvement and Disparities within the Department of Health and Social Care.

Kevin is the President of the Faculty of Public Health and he's a Senior Public Health Expert and Infectious Disease Epidemiologist who's worked in a variety of public health leadership roles across government and academia. And finally, we have Dr. Kumaran Rasanathan. Dr. Rasanathan is a public health physician who is currently the executive director of the Alliance for Health Policy and Systems Research in the World Health Organization in Geneva.

He's worked as a policymaker, a program manager, a clinician, and a researcher over his career in a number of different countries, including serving as the WHO COVID 19 incident manager in Cambodia in 2020. Thank you to all of you for joining me. The COVID 19 pandemic has had Devastating health consequences for all populations around the world.

From the direct impact of COVID itself to the indirect impact with its effect on health systems and other illnesses. But there's then the broader impact on other sectors of this society as well. But this impact has not been equal. And minoritized populations, poorer populations, face far worse consequences.

We saw how racism played out at multiple levels throughout the pandemic, from interpersonal attacks on East Asian people, particularly early on, to structural issues that led to disparities in health outcomes by racial or ethnic group. Data UK showed a four times increased mortality for Bangladeshi women compared to white women, and similarly five times increase for Bangladeshi men.

And now we're still seeing vaccine inequity on a national level and within countries. So my first question to all of you is to delve into this a little more and describe in a bit more detail how racism and xenophobia has manifested within and since the outbreak of COVID 19. Kumunan, can I come to you first?

Kumanan: Thanks Dylan. And it's a pleasure to be with you, all of you today. You know me a little bit. And as I'm a big fan of Rudolf Virchow. And there's always a Rudolf Virchow for any occasion when we talk about these issues. And I think the one for COVID 19 is when he said that epidemics resemble big warning signs.

It's from which you can read that the development of the population has met a disturbance, which even carefree politics can no longer overlook. And I think that's really what we've seen with COVID is that in the first place, it's unmasked the racism and xenophobia in our societies. So those differential outcomes that you mentioned, which we've seen in all countries, differential outcomes in terms of infection, mortality, hospitalization, and the social and economic impacts of COVID.

see them according to race and ethnicity in every society and they were predictable. So in the first place what COVID has done is that it has really shone a light on how racism affects how we deliver health services. Racism affects people's vulnerability. To health threats. It affects the resources that people have to contend with health sets.

It's what we call a structural determinant. So that's what we've seen. I think early In the pandemic, we knew which groups and societies were going to suffer the most just by our previous experience of how racist manifests and the prevalence and incidence of other conditions. And so I think that unfortunately has come to pass sadly and entirely predictably.

So we have seen those outcomes manifest in a number of ways. I think one key one is in the trust that people have. If you are subject to racism in your everyday life, you have much less reason to trust health and social services. And we've seen that in terms of who seeks care, but that lack of trust as well.

merited, because in terms of the care that you experience, you have differential outcomes. Because of structural racism, certain racial and ethnic groups get poorer quality care. And we've seen that. So not just in who has access to vaccines or who has access to antiviral agents or even who has access to basic measures such as masks.

Also, in terms of where, even when you do receive treatment, how that is delivered and the quality of that treatment. So I think that's one sort of issue. I think on the second issue is on the social determinants, people's daily living conditions and their access to power, money, and resources, which we know determined so much for people's health and therefore health inequalities.

And there we saw that some groups, in terms of whether it's housing, whether the sort of employment you have, so therefore, were you able to be at home and work from home? Who was able to do that? Who is able to access the social protection measures that often were delivered? So I think overall that what COVID showed was the how racism affects health in our societies and racism made COVID worse, was a deep driver of the inequities, but also racism impacted on those social determinants, which meant that, Always with any disturbance, as Ferko might say, certain groups are going to do worse.

And we didn't compensate enough for those because they were predictable. And I think the last thing I would say is what COVID has shown is that in a crisis, it's very difficult. So addressing racism needs to be part of the way we prepare our health systems and the way we prepare our societies for future pandemics, not only in firstly reducing racism and stamping out racism in our health systems and in our societies, but also acknowledging that racism exists.

So thinking, how are we going to allocate resources? When a pandemic happens, how are we going to compensate for racism in the way we respond to pandemics? 

Delan: Thank you. Yod, if I can come to you. 

Ayoade: I would say that what we've seen is an unmasking of racism and xenophobia. And I think it was happening pre COVID 19, if one were to be perfectly honest, with the sort of the way geopolitics has gone and the sort of wave of nationalism and populism sweeping across the world.

What COVID did was shine. Magnifying glass on the already deepening cracks and fissures across our world. It it put it all into very sharp focus. We were all focused in for that period of time because we were turned inwards as a as a global community. We weren't, engaging in external activities.

And so there was time then to dwell on that was, which was within each and every, One of us. There's a saying in my language, which is Yoruba, which means that it is what is within you that comes out when you're drunk. And so it was for humanity that it was what was within us already that was exposed by consciousness.

by COVID. Racism came to the fore because there was fear. Racism came to the fore because there was a lack of trust. Racism came to the fore because people decided to hoard, not just toilet roll, but also decided to hoard vaccines and medical countermeasures. Racism became, and xenophobia became our go to because we forgot that the enemy was a virus.

The enemy was not. the other, the enemy was not the person who we perceived to not be of ourselves, not be of our color or of our race or the person who was coming to take that very scarce resource. And what it was we were placed into a resource constrained, global resource constrained moment, but it was a fear reaction.

And that I think is what I would say COVID. Did. And then it was further exacerbated by the fact that once we did have the countermeasures, the vaccines the diagnostics, the therapeutics, they were concentrated in those geographical areas where people tend to be more of a particular hue and or wealthier or.

or, have greater socioeconomic status or financial resources. And then we began again to separate one from another. We became almost, animalistic in not just tribalistic, but almost, we reset back to our more primal instincts as a people. And that is what I would say personally I observed.

On the front lines of the be it in Africa or now on the global scene, with my role as a special envoy and co chairing the Access to COVID Tools Accelerator, I, from Africa as the head of the Africa Vaccine Delivery Alliance, I had a front row seat as I was one of those who was trying to purchase, pooled purchase, procurements of vaccines.

vaccines and medical countermeasures and the world literally pushing us back, saying no, it is not your turn, you cannot have these, to then getting up to global level and seeing the where in language racism becomes structural inequality, because people are uncomfortable with the term racism.

Delan: Thank you. Kevin. 

Kevin: I agree with my colleagues and I've been reflecting a lot about definitions and language and I'm always taken back to the definition of racism from Kamara Jones because it helps us to focus not on the individual manifestation of racism but the structural, the organizational, the system.

And she argues that racism is a system. of structuring opportunity and assigning value based on the social interpretation of how one looks, which is what we call race. And that system of structuring opportunity unfairly disadvantages some individuals and communities, and it unfairly advantages others.

Other individuals and communities and taking together the impact of systemic racism saps the strength of society through the waste of human resources. And in a sense, what we saw playing out almost in real time was this definition of the impact of structural racism on decisions on policies on programs.

And of course, on the epidemiology and impact of covert and therefore the response to the pandemic. What struck us, I think, most of all in London is just how quickly the inequalities in who was at risk of developing COVID, who was hospitalised and who died with COVID, began to manifest itself so quickly as the pandemic emerged.

And very early on, we began to see differences, not just by race, ethnicity, but by age, by gender, by socioeconomic status, by geographic area. Of residents. So there were many emerging disparities, which I think clearly illustrated where we had vulnerable communities pre pandemic and how covid and its introduction began to both shine a light on and exacerbate those inequalities.

And very early on, we began to see that people who lived in overcrowded or multi generational households, people who worked in. Jobs with increased risk of coming into contact with members of the public, or people who may have been infected with COVID people who lived in poor parts of the city, people who had low trust and confidence in services, which had high risk fear and stigma for COVID 19 and people with lived experience and historic and current experience of racism and discrimination began to see the disproportionality of COVID manifesting itself in these communities.

And this not only played out with the epidemiology of COVID, it then influenced the uptake of testing the performance of our contact tracing program. And when. The vaccines became available, it also influenced vaccine hesitancy and the willingness to take up the vaccine, resulting ultimately in the communities that were at highest risk of death of COVID being some of the least trustful of the vaccine when it became available.

In summary, we saw clearly the structural and systemic nature of racism playing out. Clearly, we saw the impact of structural racism on communities. access to and barriers to health care in biases in clinical decision making in inequalities in patient outcomes in the disparities in workforce and workforces and who was affected.

And finally, and really importantly, the lack of diversity in clinical trials and how that had an impact on both trust in communities and the applicability of new technologies such as a vaccine. to communities. So along multiple pathways, we were able to see the impact of structural racism. 

Delan: Thank you. And anyone want to come back in on any of those points?

Kumanan: I think what we're all saying is that, racism exists in society. We do often hesitate to name it. in public health. There's a lot of pushback, as Yodi said. Can you use that word? And yet, what we clearly saw was that two way relationship, is that racism affects and stratifies who benefits from clinical interventions, from public health interventions, both from withholding care, but also as Kevin just said, in people's trust and faith in who's delivering care, who's delivering social services, who's delivering public health and social measures.

And so it's a cycle that we have to break. I think that first step and the real struggle is that we're such reluctant to name racism as driving these unequal outcomes. And we did not see in pandemic preparedness plans sections on how to deal with racism in our society. health sectors and in our societies.

And I would argue going forward, we really need to see that. 

Ayoade: If I may, I, to discuss racism, we have to look at this history in medicine and science. I must think, and we need to examine the sort of historical context to be able to fully understand the roots. So let's look at the, infamous Tuskegee syphilis study.

In the United States the exploitation of henrietta lax which led to a breakthrough in cervical cancer Which only recently has been recognized. Kumanan's just talked about pandemic preparedness plans I know the pandemic preparedness is all the buzz at the moment. But I mean What is pandemic preparedness?

How do we define pandemic preparedness? The very act of pandemic preparedness is what You know, your colleagues, for instance, at WHO, people like Mike Ryan and his teams do every day. One would argue that actually the people who are most prepared for pandemics are those of us, people from my continent, people from Africa and Asia that are dealing day to day with epidemics with outbreaks, with, potential pandemics, who are dealing with the pandemic.

worst and longest ongoing pandemics of tuberculosis, malaria and and HIV in the world at the moment. And so we are typically the ones who have the greatest experience, the greatest lived experience, as Kevin said, but what racism does, so that is preparedness. We are. In effect, prepared.

We are the most prepared because we're living through those threats on a daily basis, preparedness is not just a plan. It is not just a piece of paper. It is not a declaration. Preparedness is a verb. It's almost, I like to call it a dynamic state of readiness. And yet we're not allowed to be prepared when the risk actually comes.

We're not allowed to be prepared because we're shut out of the rooms where the decisions are being made. So it's not just from the scientific perspective, but it's also from a policy perspective. I'm sitting here today in India at a high level policy governmental meeting where it baffles me every day that I sit around these rooms and I've been, given access in recent times to these tables.

The most of the people who are there are talking about me as though I'm I am not in the room. They're talking about us, those of us who are from other parts of the world and talking about doing things onto us and creating policies that are basically inherently grounded and rooted in their obvious bias and othering of people who have more experience, more knowledge, more preparedness, to use that term, than any other person.

of those who have come from many of these high income countries. They're those who are still arguing today that Black people have a lesser IQ, than those from other races. And this is part of the issue. So we can't just look at it within a, defining racism or defining structural inequality.

What is the very basis of the policies that we all sit in? What is the very basis of the institutions that we all work with and in? What were those institutions created to do? Who controls the funding and the, who controls the very essence of those institutions? That is where, but if we want to, bring shift.

We want to shift the Overton window and truly begin to bring change and systemic change. We have to look at the root of where these, the outworkings is what we're seeing in the health systems and the disparities, both within inner city London or Washington DC, where the maternal mortality rates are higher than many parts of Africa.

Where is the power in the room? And Those are the difficult conversations. I agree with what Kumaran has just said that, the talking about it and the being able to confront it. 

Delan: Thank you. It's a very powerful phrase here. We're not allowed to prepare. It's not that we're not prepared.

Kevin, would you like to come back? 

Kevin: One of the challenges that we have is having gone through the collective and traumatic experience of the pandemic and seen structural racism and inequalities laid bare in the way it has, and policymakers, whether working at national, regional, local level, members of the public, being more attuned now to the drivers of these health inequalities, not just being access to care, but many other factors, including structural racism.

The question, I think, for us, collectively, is how do we continue to build on that? In other words, what legacy will arise from our experience of going through the pandemic? And I think Kumudan has said the importance of naming it and ensuring that we create discomfort if that needs to be created in order for us to have more authentic conversations about the issue of racism and how racism manifests itself both within health policy, but also in communities experiences of the health service.

And be clear about. What are the things that are within our gift collectively and individually to do to address this? And I think those are the conversations that we're now beginning to have, for example, in the London health and care system, where the collective experience of going through the pandemic has forced leaders.

both health and political leaders within the city to say we have to do things differently moving forward, to do this with our communities, both understanding what the evidence suggests are the things that we need to do to tackle this structural racism and its impacts, but to ensure we leave a lasting legacy within the city as well.

And that legacy is the ways in which leadership It creates a voice and space for talking about anti racism, structural racism, and health. It's about how we treat our people, our workforce, our staff, really thinking not just about equity, diversity, and inclusion, which is absolutely important, but bullying, and harassment, and microaggressions, and unsafe environments within the workspace.

It's about properly funding, Programs which are focused on tackling health inequalities. It's about leveraging the health and care system's assets to tackle the wider determinants of health. So providing employment opportunities, safe work environments, thinking about the real things that the health and care system can do to improve the lives of minoritized communities within the city.

And finally, ensuring that We have a new contract with members of the public of communities to rebuild trust and confidence within our services. And to really think about how do we have as a legacy of the pandemic. I think it's really important that we take true co production, true partnership with communities, which creates a more equal balance to address some of the historic imbalances which we have.

The question I think that we have to begin to say and explore is, yes, we must name this, and we must say what steps are we going to take to truly change and effect change resulting from this shared experience. 

Kumanan: I think You know, it's a real pleasure to be part of this conversation because as you already mentioned, firstly, it is a decision of power.

And Kevin and I are both privileged to serve with Kamara Jones on the Lancet Commission on Racism and Structural Discrimination and Global Health. And it's complimentary to the commission that you're leading, Delon. And I think it's that Recognition that racism is also a matter of power, right? It's Yodi's point that we're some communities that were not able to be paired.

And so back to Kamara Jones, this sort of framework that racism structures, that structures and stratifies opportunity and structures and stratifies power. And I think what we should be looking at is the the, the overarching pandemic or all our crises is one of inequality. And racism is a key driver of inequality.

And racism means that people are stripped of power. That this is not an accident. This is not something that just happened. This is something where power is hoarded. Power is sequestered. That has happened over centuries and power continues. Those processes continue. And I think the public health approach is that we look at societies, we look at populations, we look at distributions.

And I said before, without confronting those power asymmetries in our work, without confronting those histories, without confronting racism, We simply cannot do our job in terms of public health. And I think that's what COVID, if nothing else, has shown very clearly. And I do think, to Kevin's point, then there are people, public health workers, clinicians, who are thinking deeply about what to do about that and have thought before.

Because it's been so stark. So it's not just naming this for the sake of naming it, but it's naming this because we cannot do our jobs if we are not confronting racism in our health systems, in our social systems, in our societies. And I completely agree with Yodi. It's not about just having a section in our plans, although that may signal redistribution of resources, allocation of resources.

So it is important, but it's really thinking about where does knowledge lie? What knowledge do we prioritize? And we should really, as a public health community, as a global health community, be really reflecting on what has gone wrong. How many millions of lives we've lost unnecessarily. When you look at the decreases in global life expectancy, unprecedented in virtually everyone on the planet's lifetimes.

So if that's not going to motivate us, To confront this together and think what we can do. The other thing to say when, and to your question about what should we do, we shouldn't forget that there were also positive experiences in the pandemic. So to give you an example, where I was in, in Cambodia at the beginning of the out pandemic, there was an outbreak.

in the Muslim community, which is a very small community in Cambodia and relatively poorer, relatively isolated. And there was a lot of concern that this would lead to stigmatization. This would lead to scapegoating and this would be a real problem. And actually the government Was very responsible and ran a campaign, reached out to that community, worked with the community to stamp out that outbreak in a respectful way, and really went out with government leaders that this should not be a question of stigma, that this is not, people are not to blame, to increase trust.

I think in a number of jurisdictions, we've seen that indigenous peoples. Have really led the way to protect themselves. So even if they weren't always allowed to prepare, they demanded the right to prepare the right to respond. And we'd. In many of the cases, so really inspiring examples of bravery. And we see this as Yodi says, in every epidemic, we see people who are so brave, who serve their people, who put themselves on the line to protect.

And is that question, can we learn from these experiences, which happened that happened during COVID? I remember speaking with villages in Liberia, in the context of Ebola, we see it with HIV. We've seen it with every big. Epidemic where people know what's needed in their communities and they want to lead.

They need that to be supported, to lead and need resources. And then they need to be listened to not just during the crisis, but going forward. The question for us is we've had the stark demonstration of the problem and how important it is. We've had the stark demonstration about how we need to confront racism going forward, not just for pandemics, but much more seriously in terms of public health and health in general.

Will those of us who have power, who have decision making roles, will those of us who don't in our communities, can we really take those decisions forward? Can we change the way we do things? Because if not, we're not doing our jobs. 

Delan: Yotti, how do we make those changes? 

Ayoade: Those are great points Kumail Nanjiani's just raised about how do those of us who have decision making roles or how those of us have power and then the sort of juxtapose that with a comment about the community who chose to, to protect themselves.

I think throughout history I think we have found that people will stand up in times of crisis, people will stand up and speak out, but too often, those, examples that we give are too, they're too isolated, there isn't a critical mass and the transaction costs are too high.

And so it is not sustained because the rest of the waves are pushing for those who like water analogies, the force of the wave is pushing you back so strongly that eventually you just slip under. I take that to the personal because for me, as Qumran says, how do those of us who have power, People have said to me during this pandemic that oh you have influence and you have power, but let me take you back three years ago where the very first time that I'd ever been in a global health setup was at the World Health Assembly in Berlin in twenty, twenty immediately after the world opened up in the pandemic.

I'd never met any one of the global health leaders. I had never met anybody in be it Tedros or any of those people until that moment, but I had chosen to use my voice and I had chosen to push against that wave of water and I had entered into that room almost trembling with Fear and anticipation all at once because I knew that I was bringing a hard message And I didn't know how that was going to be received.

That was two years ago, and I challenged them This is what kumaran is saying. That's what we need to do I challenged them in that room as they all sat down having a conversation and it was the global pandemic preparedness board Launch and they said what you know We have to make recommendations for what the world is going to do and I stood up and I said aren't y'all the world?

Are you not the world of global health? I don't understand what you're saying. All of you are in this room. What are you going, what are you going to do? And I then laid down the gauntlet and said that I propose for starters, we shift this power base and let's have a, meeting in the Global South.

Let's have a, let's take all of these conversations to where the people are truly suffering because you don't understand what it's like. And after the meeting people turned around to me and said Oh that's wonderful, when are you going to convene? And I realised in that moment that I was it. And so I did convene.

There was no funding, there was no support. I invited all the global health leaders of the world and they came to Abuja, Nigeria for Ports to Arms. And subsequently, yes, out of all of that, that voice was recognized, but let me go to transaction costs and let me go to the pushback and the backlash that, that the world does because to fix it, we have to understand what the consequences are for those who speak out.

Because if there isn't a critical mass, you don't have somebody that you can turn to and laugh with in that moment that somebody literally tries to shut you down. And until we have a critical mass, do not allow ourselves to be weaponized one against the other, brown against black, because that is what the world is now choosing to do.

Then that world is now choosing to say, oh colorism is coming into it. If you're Asian, maybe you're preferable to us, to the African. And it is only when we stand together. If you look at Martin Luther King and look at all of those movements, it was a power of the masses of people standing together, not being divided.

Delan: Thank you very much. Thank you. This is very powerful. Kevin, final word to you. 

Kevin: I've been reflecting on this powerful conversation and sharing today, hearing from my colleagues and I think this comes back to how do we make a difference in what can seem like an unchangeable environment and systems in, in which we're working.

And I think there are key things that we keep coming back to. The importance of having these tough, authentic conversations. Naming racism, being able to allow and to create spaces where we're naming and saying it to foster different conversations to lead to different outcomes. The second is opening our eyes once we've named racism and seeing how it operates within our organizations, within our teams, within our systems, within our the networks that we're operating within, and ensuring that we are laying that bare.

In our conversations with our colleagues, with our partners, in saying this is what racism is doing, this is how it's sapping the strength and effectiveness of this organization, and here's how it's operating, and this is what we need to do. And then the third is really acting on it, and I've been reflecting on each of us understanding what is our sphere of influence, and how do we make that difference.

in what we're doing. So if we're leaders, what does it mean for the organizations and systems that we're leading? If we're team members, if we're in the community, what does it mean in terms of how we organize and strategize to act? How do we use our individual power to do things differently and to force and to encourage different conversations?

And how do we use our individual ability to create collective action, I think that's another key aspect of what we do, how do we work with others to help to address this issue. Bringing this all together, I think understanding how we say, how we understand how it operates, and how we act, I think is going to be key.

And that's exactly what we're going to do. The space that we're in now working again using the really tangible example of London and the health and care system in London, where we're taking leaders, we're taking members, staff, we're taking communities through this journey of having more authentic conversations about systemic racism, its impact on health and care systems, and what we all do working together to address it.

It won't address historic inequities overnight. But it is a commitment to doing things differently and building upon the lessons and learning from the pandemic and creating new legacies for city. And I'm keen to see that this is being done in every place that we have the ability to create that change.

Delan: Thank you very much. Thank you to all of you. This is a fascinating conversation. I think we could go on for another couple of hours on this. So thank you to all my guests, to Yodhi, to Kunun and Kevin. The COVID 19 pandemic made. obvious racial inequities that exist in society and exacerbated and several others We have to name racism and we have to act and all three of you have described so eloquently how We can do that and how essential it is to do that.

Thank you to my guests Ayodee Alakidja, Kumaran Rasanathan and Kevin Fenton. This episode was produced by Mitha Hawke, Sofia Lobanov Rostovsky and myself, editing by Gavin Cleaver and music by Mitha Hawke. Do visit the race and health website on www. raceandhealth. org for more information about our academic work and to sign up for our newsletter.