Race & Health: Intersectionality

In our final episode of this collaboration between the Race & Health podcast and The Lancet Voice, intersectionality brings three researchers together to discuss how intersectionality can serve the health community and promote health equity. The episode explores where intersectionality comes from, why it was created, and how it can be used to address health inequities across the health community. 

Guests include Dr Brenda Hayanga, Presidential Fellow at the School of Health and Psychological Science, University of London; Dr Geordan Shannon, medical doctor and ex-academic, and founder of Stema, Unexia, Planet.Health, and Global Health Disrupted; and Dr Zara Trafford, Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Cape Town, South Africa.

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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 race and health podcast, partnering with Lancet voice. My name is Delan Devakumar. I'm a professor of global child health in UCL. And this is the last in the current series looking back at the academic work in the Lancet on racism, xenophobia, discrimination and health. This episode is on intersectionality, which has become increasingly popular recently.

It's a term coined by Kimberley Crenshaw in 1989. It's an analytic framework that can be applied to discrimination that treats multiple axes of oppression together. As usual, I've got three great guests to talk about this. The first is Dr. Brenda Hayanga, who is a Presidential Fellow at City, University of London.

Brenda's research examines ethnic inequalities in health, particularly in how individual level processes intersect with social, historical, and structural processes to shape the health outcomes of minoritized ethnic groups. Next is Dr. Zahra Trafford, who's based at the Department of Global Health in Stellenbosch University.

She has a background in social sciences. Her work is aimed at understanding the lived experiences of disabled people in low resource environments. As well as in diverse approaches to disability and ableism studies. Then we have Dr. Jordan Shannon who led the academic paper on intersectionality. Jordan is a medical doctor and ex academic who's founded several organizations that blend arts, technology, finance, health, and environmental flourishing.

Jordan is passionate about linked local actions, radical collaboration, and other forms of relationships that help us weave a better collective future. Thank you to all my guests. So can I start with what intersectionality means? Where did they come from and how is it used today? Brenda. 

Brenda: Thank you Delan.

You already mentioned that it was coined by Kimberly Crenshaw in 1989. And she used it to denote the ways in which black women were excluded from feminist theory as well as anti racist policy discourses. Being that if we consider that the feminist The theory tended to center on the experiences of white women, and then the anti racist policy discourse centered on the experiences of black men, thereby ignoring the fact that gender and race intersect, and then the black women's experiences almost like falling through the cracks.

But an important thing to note is that she put a name to a concept that was already being used by black activists and feminists, as well as, indigenous and queer and Latina scholars, often without naming it as intersectionality. This term's been used As I suppose some people refer to it as a theory, as a perspective, as a paradigm, or even a framework.

I like the way that Patricia Hill Collins and Selma Bilge put it as this tool in its basic forms to help us to understand the social world around us. It highlights the fact that people are simultaneously positioned within social categories, which can't be understood in isolation. For instance, we're thinking about age, we think about gender, we're thinking about ethnicity.

We can't look at those individually. We need to consider the fact that these social categories, they intersect within these connected systems of powers and the structures of power, for example, sexism, capitalism, racism. All the isms, that you can think of to privilege some individuals while disadvantaging others.

Originally, I think you can say that it came from race and gender studies, but it's something that's filtered through to other disciplines. I've used it myself in looking at researching ethnic inequalities in health to try and understand the root causes of inequalities. And using an intersectionality approach ensures that I don't just focus on, the individual causes of inequalities, but rather I use it in terms of to ensure that I don't focus on individual causes of inequalities, but to interrogate the roles of structural processes in how these inequalities develop and how they are maintained and how they are exacerbated.

Delan: Zara, maybe to you, so thinking about disability studies, because it started off thinking about racism, sexism, primarily, and I guess Kimberley Crenshaw added in class or wealth into that. How has it expanded to include other isms such as ableism? 

Zara: My honest answer to that is I'm not sure that it has sufficiently.

I think that it's an incredibly valuable tool to better understand, as Brenda was talking about, the way these different aspects of identity and also environment interact to affect lived experiences and to produce them. But also it's a useful tool to thinking about how to challenge them as well.

So it's two sides of that coin. I'm actually fairly new to disability about four years in now and how, despite having had a pure social science training at a time where we learned a lot about intersectionality it was really striking to me that having worked in public health and having had a social sciences background, the concept of disability was really unfamiliar to me.

I was not well acquainted with it. So even in a space where you would really think that would be a. a key focus it really wasn't. So I would argue actually that it's it hasn't been properly adopted into an intersectional perspective. It's always really quite low down on the list when we have these kinds of conversations, unless somebody with a disability is in the room.

I think I also just wanted to add to what Brenda was saying there about how another aspect of this tool that can be so useful is it helps us to understand how our identities are not static and how they can shift in different circumstances, right? So while at home. There are certain things that that give me a huge amount of privilege.

Sometimes when I travel overseas, particularly when it comes to being a South African, trying to travel to Northern countries, particularly visa processes, for example, can be, really complicated. So at home I have a huge amount of privilege because of whiteness, because of my kind of social class, because of my education levels, things like that.

But. When you travel, those things shift. So it just helps us to understand that these things are not static. It's an interesting tool because it lends itself well to a more fluid, a more to my mind, realistic way of looking at the world and how people interact with each other. 

Geordan: Yeah. I'd love to pick up on a few threads.

Brenda mentioned something that is really critical to intersectionality, I think, which is that Kimberly Crenshaw did a huge service to the world by naming something. But that it was already there. And so looking at intersectionality is something that we inherently know and practice in our lives.

Particularly those in Indigenous and minorities communities who are used to holding pluralities and complexity in their day to day lives, but just your average person on the street. They don't think of themselves in terms of health, or education, or race, or gender or any types of isms that they're experiencing.

One's individual life we have the capacity to hold oceans of complexity within us, within ourselves as humans. And so actually being able to understand that, to understand these pluralities, these dualities, these aspects of our lives that we all inherently hold during our day to day worlds and trying to align the practices whether that's of social solidarity or whether that's, injustice movements, or whether that's just simply an academia of understanding and naming and then trying to address these issues.

Being able to really align, I think, is really key and intersectionality provides one window through which to view these complexity and to act on it. Zara, you then mentioned this idea of dynamism when it comes to intersectionality and I think this is also really critical because in one instance we might have privilege and one other instance we may not.

And so seeing there is, there's a neat term around the two sides of the coin of privilege and oppression and seeing seeing this as a spectrum that operates within a larger structure. So we know that Homophobia, sexism, racism, all of these are larger social processes that operate in either oppressive or privileging structures, but they operate to give some people privilege over others.

And so seeing that as a spectrum is really key as well. It's not just that in some instance that that there's a certain situation that's always static, that always will produce the same outcomes. Seeing it as something that is fluid and dynamic is really key. And once again, intersectionality allows us that lens, which is really refreshing compared to the more boxed in approaches or static approaches to to analysis that we might see operate.

Delan: Thank you. So Zara. Okay, can you talk a little bit about the role that intersectionality's had in particularly in movements against racism and social injustice? 

Zara: Sure. I think I think what Brenda mentioned earlier about how the whole, this whole idea actually emerged from a particular large population feeling excluded from a wave of social change happening around them.

And so obviously Crenshaw and her kind of peers working in this particular civil rights space influenced to a large extent the emergence of kind of third wave feminism, which is sometimes called intersectional feminism which kind of challenged and expanded on earlier iterations of feminism which tended to privilege initially only white women and then as it evolved also, I think there was like a really strange dynamic with second wave feminism where it was just Replicating the exact same systems of power and just making sure more women are at the top of those systems of power.

So I think what was so powerful about this third wave, this kind of more inclusive perspective, was that it really pushed back against these things and started to highlight how these different aspects of identity and circumstance needed to be looked at the same time. And also how far short these earlier iterations were falling really in describing the experiences of black American women, particularly, I would say since then, it's been used by lots of different movements and taken up by lots of different movements.

And that's not really a, it's not necessarily used in the same way in these different movements. But of course we've seen intersectionality coming through in movements for sexuality, right? For, from my perspective in South Africa, socioeconomic factors are some of the most. Defining in people's lives really.

And so even though we have this historical pattern of racialized oppression, which now maps onto socioeconomic class to a large extent. So yeah, I would say lots of different social movements have picked it up and used it over the years. 

Brenda: Yeah, I think I think what I wanted to add to what Sarah was indicating was with the social movements and the solutions that they come up with, they're all striving for social justice.

And that's one of the key tenants. And I'm going to take it from like a research perspective in order for us to come up with these solutions that will inform some of the strategies that the movements take, they would need to be based on information that is evidence based, right? Collecting and gathering evidence that is informed by intersectionality helps to generate knowledge that at least you know that it's evidence based, you know that it's going to understand what the root causes are, and those then can come up and help us to tailor to come up with tailored interventions or effective interventions that are not only going to be Based on the lived experiences of the population that you're looking at, but also preventing harm because there's no need coming up with interventions that might, that aren't based on anyone's experiences that might then go and perpetuate the inequalities further.

So I think one key movement is that with intersectionality from a research perspective helps us generate this knowledge that can then inform the movements and their strife for social justice. 

Delan: There's been pushback against intersectionality and lots of critique from different places. Can you speak to some of that, Jordan?

Geordan: Yeah, absolutely. So I think one of the major critiques that I've seen operating in the space is that, and this is shaped by media and political discourse too, is that we tend to apply intersectionality and focus only on identities. We have this sort of reduction of. the richness of intersectional practice into just simply talking about identities and thinking of them as like little categories that we can pick up and put onto someone.

But the reality of intersectionality is that we know that our identities are shaped by a number of factors. And actually it's that sort of socioecological or onion shaped approach where there are layers and that our identity. Is shaped by and inter interacts with a number of different wider forces.

We might identify as a woman, we might have a disability, et cetera, et cetera. But that the way in which those inherent characteristics are either privileged or disadvantaged operates in a wider spectrum where sexism operates in a way that privileges that which is seen as masculine over that which is seen as feminine.

And what we have to really strive for in intersectional practice is to go beyond the reduction of identities into something that allows us to see the ways in which those aspects of our lives are either provided privilege or oppression. And that's where the real richness actually comes from.

It's the ability to interact between the individual level up to the structural level and back down again. So it's that relationality as Brenda was highlighting before. And I think the other thing when it comes to intersectional work in the health space at least is that I want to quote another luminary here in the field is that the master's tools will never dismantle the master's house.

But we're really good at using the master's tools in public health and global health practice. And the master's tools look like Categorization creating categories, creating linear models that, that explain our realities and act on them. But intersectionality is the antithesis of that.

It creates a much more fluid and dynamic way in which we can deal with that, which is much more aligned with, I think, the human condition and reality more generally. 

Zara: Absolutely, and that's, also reflected somewhat in the fact that a lot of programming in public health might, for example, have an emphasis on, say, young women that you've got two aspects of your intersectional identity but it may find it very difficult to specifically adjust it.

Thank you. Those programs so that they also cater to the needs of the subcategories that exist within that larger category of young woman. So a young Muslim woman, for example, as opposed to a young Christian woman or a disabled woman or a non disabled woman. And so the more layers of complexity that you add onto that programming, I think the more difficult it becomes to achieve the outcomes that The master is looking for, so to speak, or that the institution is seeking.

So it's either our our own institution or it's the funder or it's just the world around us and how these kinds of projects are often focused on addressing a particular. Quite narrow angle. I mean in South Africa, mobile testing systems for HIV to reach What do they always call them?

Hard to reach population, hard to find population, something like that. Trans sex workers, for example, was like a big population that were not being connected with through primary care services. And so one can see if you apply an intersectional lens and you think, okay, who's being represented in our prevalence data, but not being addressed by our interventions, okay there, there's a kind of very applicable way of using this tool to say, who are we missing?

I think it does get complicated though, because as much as intersectionality is a sort of social justice influenced idea, that's at its core, as Brenda mentioned. And so it's imbued with all of these ideas about equity and The world around us has its own political and ideological trends going on as well.

I'm going to come back to a bugbear of mine, which is my own mother's work, which has been in HIV for 20 years. And her work has been on the epidemiology of HIV in South Africa. And it has shown that on all Metrics of the sort of 1990 90 UNA goals. Men are experiencing worse outcomes and are less connected to services, less connected to treatment, less adherent on treatment.

And you can look at that from a kind of more narrow perspective, which is that men are perpetrators of gender based violence and they are vectors of disease. Or you can say men are 50 percent of the population and. If you ever want to reach 90 90 90, you're not going to get there unless you include that 50 percent as well.

And it's not a very helpful or welcoming approach to treat people as though they're the cause of this problem if you are actually hoping to bring them into the fold in terms of their treat. But that is not a sort of popular thing to say. in the HIV landscape. And so despite very strong scientific evidence to this effect huge cohort studies over many years that have shown that this is not an effective way of doing it.

The landscape around us and the very real issues around the dominance of the patriarchy and problems with gender based violence which we have serious issues within the country have made it very difficult to approach that without And and I'm not a fan of approaching things without emotion, pure social scientist.

I'm all into the emotions. 

Brenda: I wanted to add one other criticism in terms of the implementation of intersectionality in research, and there is a lot of guidance on how you can do intersectionality research In terms of like qualitative work and Leslie McCall's got her approaches that she has written out for people who are look seeking to understand people's perspective through qualitative research methodologies.

However, it's more challenging to do research. In terms of quantitative approaches, just because the ways that some of the data sets are set up might not necessarily be set up to allow for this, so even as much as you want to do it, you might be limited in such a way that if the data is not collected correctly, if you know they collect variables on age, gender, ethnicity, but then they don't collect any variables on other aspects, then you're limited in what you can actually look at.

The method is another thing in terms of, some of the methods the statistical approaches can take like these additive stances towards an understanding phenomena. However, first of all, there is the issue of just getting the right data, sometimes even getting the right questions. They might not ask the right questions that will allow you to look at these wider Processes.

I know we focus on like multi level analysis, if you've only collected data on individual factors, and we're striving to look at, wider processes and this multi level aspect, then if you don't have that particular data, then it's tends to be quite difficult. So I guess it's a request for people who do collect data to be able to allow us to be able to do this analysis by correcting the right type right questions.

To create the right variables for us to be able to do the right analysis. 

Delan: Thank you. Can we focus a little more on health now? And Jordan, if I can ask you what's the role of intersectionality within the health community and actions towards improving health? 

Geordan: After thinking through the aspects of intersectionality from a more theoretical perspective, I think it's really important to highlight now the role that intersectionality has as a practice.

It is a way of being and doing, whether that's in creating health. Doing health research, making health policy and beyond. So thinking about intersectionality as being something that is in motion, it's a doing as much as, and a being as much as a thinking process. In the health field, I think intersectional work can be really good at illuminating.

areas of attention that are either overlooked or under undervalued. And as an example, I think in the COVID pandemic what intersectional activists and scholars were really effective at doing was to draw attention to the ways in which COVID disproportionately impacted certain groups.

So whether that was the disproportionate Mortality in certain subpopulations in the UK and beyond, or the way that covid operated trans nationally and the global disparities in either covid mortality or access to, to, to resources to address covid. So that, that, that can be like a really useful tool to draw attention to and to describe, but I think intersectionality.

Allows us to then move beyond that descriptive analysis, which is really key, but then to start to shape solutions. And so to think about intersectional work, I might provide an example from my own world of work as a doctor in the bush in Australia. So I have done quite a bit of work in a small bush hospital called.

Catherine Hospital. It's in the Northern Territory on Darwin Country. And it services a small population that's spread out over a huge geography. Catherine's in the middle and it takes about 10 hours to get to the farther reaches. And it has a it serves a mixed population but has a high proportion of indigenous people who come to the hospital and seek care.

And many years ago, I worked with Dr. Simon Quilty and other really wonderful people from Menzies and from Worley Jangen and others, where we started to think about the drivers of people who are coming into the hospital through the emergency department, who were delivering, arguably like incredibly socially vulnerable, but had a lot of really complex conditions that were operating in their lives, which meant that they were seeking healthcare really frequently.

And so we did some research on that. And then we use that research to, to build a program, which is still in existence called the Katherine Individual Support Pathway KISP. And what that does is that it allows us to receive people who we know have incredibly complex. social lives and to use the hospital and healthcare system as a bit of a hub to coordinate their care around the town.

So bringing in legal services, housing services, food security and addressing that to be able to wrap someone in the care that they need, which addresses multiple facets of their lives and their vulnerabilities. So it's not really about saying You, you are this category of this category.

You're actually just saying, look you're a really vulnerable person and there's lots of reasons why that's happening historically, structurally, etc. Let's do what we can and let's work our services around you rather than you having to fit into our system. Because I guess. If I was to name one of my bugbears building on Zara's term, what I see happening again and again is the potential for health services to perpetuate violence in a way which is completely the opposite of the purpose of health care.

So health care is, our purpose is to heal and to create flourishing in humans. And what the health system may do would be something more structurally violent where we don't really embrace the culture and the needs of the individual. So what a program like this does is to operate in with intersectional principles to, to, to not only achieve dignity for the person, but to wrap that sort of person in complex care in a way that attends to a lot of their needs.

Zara: How lovely. What a nice thing. Yeah, I think that's very much the kind of attempt at many of our public sector hospitals. A bigger issue for us and maybe this highlights another aspect of intersectionality that isn't always as, I think it's growing. But, the dynamic between the North and the South, by and large, the South is dealing with.

Large populations and very under resourced environments, and the North is dealing with smaller populations and well resourced environments, broadly speaking. Sorry, I was just gonna comment on the fact that although we have a most of our public hospitals and our primary care facilities attempt to do the same thing that Jordan mentioned about referring people to local social support sector services and, people will, social workers will pay out of their own pocket for people to eat that day, for example, they will really bend over backwards to make sure that people do have some kind of additional support beyond the health system, but it is the existing formal support services are so poorly integrated with one another and so sporadically distributed across the country or even within provinces or within cities that it makes it very difficult to do that in a kind of holistic and sustainable way.

And it tends to happen in a much more ad hoc kind of way that then obviously. at a population level doesn't reflect. So 

Brenda: can I just I'll add something. I'm not a clinician, but I do research health services and health systems, especially let's say how people from minoritized ethnic groups who are living in the UK access, utilize and experience healthcare systems.

And I like what you both indicated, you've highlighted this issue of the resources that's. And using an intersectional lens has actually made me appreciate that, the same way that we've got individuals being influenced by all these, societal processes, even if we look at the definition of health from what I can remember in health studies in undergrad, it's like the, it's not merely the absence of disease or infirmity, but, complete social, mental, emotional well being.

So it only makes sense that we have a tool that would be able to. Speak to those particular aspects of health those wider processes as well. But I wanted to stress the point that it's this intersectionality has given me an appreciation that the same way that individuals are influenced by these wider processes.

So our health systems and health care providers, right? So here I am, perhaps maybe I am advocating for, the solution would be primary care for them to do more and help the patients, but then they're restricted in what they can actually be. Implement, right? They've got processes in place and this funding issues that have to be taken into consideration.

There's the geographical differences. There's even the makeup of a pop, of a, of an area, right? You can have an area that is serving more deprived populations as opposed to an area which has got like more affluent population. So it's given me this understanding that in the same way that individuals are influenced.

Delan: Thank you to all of you. And just to round off, could you all give me one way that we can incorporate intersectionality into our practice? 

Geordan: The words that come to mind are imagination and empathy. I didn't mention this earlier, but I think there's a really useful concept I've been digesting on imagination asymmetry when it comes to power differentials, where those who are more privileged don't really need to employ the same amount of imagination and empathy for the other as those who are less privileged.

And this was a term and a concept that was introduced by David Graeber, and I've really found this useful because those who are less privileged or more oppressed tend to really need to work hard to understand the system from the perspective of those who have the privilege. And so what I, my call is not to do or to do anything specifically, but to actually employ imagination and empathy, because I think that will be key.

And that's a lens through which we operate, we work, we research, and we be in life together. That would be my suggestion. 

Delan: Thank you. I haven't heard that one. I love David Graeber. I'm very sad that he died recently Zara 

Zara: Yeah I echo Jordan's point there. I'm currently trying to figure out how to encourage our frontline welfare services to incorporate empathy into their training.

And it's a big job to figure out how to frame that in the way that they want to hear it. I guess I would add vulnerability and they sit in the same category. I think that for me is a really valuable tool in my own practice as a researcher. I try to without being Hopefully overly performative or demonstrative about it, but I hope I always try when I'm working with people in a kind of co researcher space to be vulnerable with people and to show them myself in a way that's less guarded than it might otherwise be in a professional setting or less tailored.

So I think that for me is something that I find very valuable in my own practice. 

Brenda: For me, it incorporates both the imagination and the empathy and vulnerability. And I suppose I see the way to do this would be to include the voices and the experiences of marginalized people.

In trying to understand the issues involving them from the outset of if like from a research perspective from the very beginning of developing your research questions, not just at the end when it comes to disseminating, I think, by involving them at the very beginning, then you're able to. Understand what their needs, what they, how they want to be seen and how they, what their, what they believe their needs are.

And then that will be able to allow us to come up with solutions that are going to be suitable and appropriate for them. 

Zara: Just to say that I agree completely with Brenda about as early as possible co production. And for me, working in disability a big part of that is also about making sure there's enough budget to compensate people adequately so that we're not replicating exploitation but also time a bit more time and energy than we are traditionally able to give in research projects.

If one really wants to commit to it, it requires a little bit of shifting the way that we do things. 

Delan: Thank you to all my guests, Brenda Heunger, Zara Trafford and Jordan Shannon. This episode was produced by Mitha Hawke and myself. Editing by Gavin Cleaver and music by Mitha Hawke. Do visit the Race and Health website on www.

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