Interview with Lu Gram, Research Fellow at UCL and Commissioner on the Lancet Commission

Sonora: It’s a pleasure to have you here today, Lu. By way of introduction, you are a research fellow at the UCL Institute for Global Health, where your work spans a variety of large scale, public health trials ranging from topics on newborn and infant health to communities’ and women's empowerment.

You are also a co-author on the Lancet Series, on racism, discrimination and health and a member of the Steering Committee for the Lancet Commission on Racism and Child Health.  Your main research interest is in the promotion of grassroots, collective action for women's empowerment. To start off with, can you tell me more about your work and how you came to researching racism and health?

Lu: As you’ve said, I work across many different topic areas. The unifying theme across all of them is that I work with communities to study how communities come together to try to solve problems that affect them.

When communities need to come together to solve problems that affect them, there are various theoretical perspectives that you can take on it. In the community participation literature, the general perspective is that there is an ethical and moral right of communities to participate in decision making and to take action on their own. That is a perfectly valid perspective, but I also focus on the practical question of when communities actually come together to take action to deal with common problems that affect them.

So, a lot of my research is on collective action problems, where a group of people are all facing the same issue that affects them but there are certain barriers to them working together to solve the problem.

Racism and health is an intersection where collective action is a very salient issue.  Social movements such as Black Lives Matter and the Civil Rights Movement in the USA, are examples of political movements that require a large group of people with a common interest to come together to advocate for that common interest.

Problems that could potentially be solved if minoritised people came together agitated for them to be solved don't get solved because of collective action problems such as divisions and other issues that prevent them from coming together to cooperate.

Sonora: Considering the role of collective action in progress on racial justice, how do we arrive at the point where collective action generates change?

Lu: Collective action is only part of the puzzle. You cannot rely exclusively on people bottom-up solving the problem on their own, and that would also be putting the onus of dealing with the issue of racism on the people who are affected by racism themselves by saying that it is their responsibility. There are many examples of political systems that essentially require people to take collective action again and again to solve common problems rather than having institutions and structures that solve these issues for people. For example, in the United States, where many issues are very open to being influenced through lobbying and through pressure groups and through interest groups, you do see that people with more resources are the ones who are able to mobilise those groups and take action rather than the people who are actually the most affected. That’s an example of where the onus is put on people to make change, and it creates an inequality in that sense.

So, collective action can't ever be the only solution, but it does have to be part of the solution. There must be ways in which we can diminish inequalities in access to collective action and access to collective power between the people who do and don't have resources. But there must be structures and institutions and laws and policies that remove the necessity for people to do this again and again.

Sonora: That is a very relevant point to the final paper of the Lancet Series on racism, xenophobia, discrimination and health which focused on interventions to combat racism and its health effects, including at the structural and institutional level. Can you tell us more about what that paper found about interventions that can be used to combat racism and its health impacts?

Lu: So, we did a review of health literature, predominantly in relation to addressing the health impacts of racism, xenophobia, and discrimination. What we found was that there was surprisingly little evidence in the health literature on this topic, particularly from a wider structural point of view. There were some small-scale trials and studies that looked at small populations of people. For example, studies that ran workshops with 20 people, trained some health providers, testing short-term interventions on a small scale to address racism and its health effects. But there were relatively few large-scale studies looking at big structural changes, and how those mitigated the health impacts of racism.

We did find a few larger studies from the US. For example, there is a whole series of studies from a program called Moving to Opportunity. It's not exactly a programme that provides you with a policy response, but it tells you about the impact of structural racism on health at a spatial level. The programme assigned people living in racialised low-income neighborhoods in the US a random chance of being picked through a lottery system for relocation. Families that were chosen through this lottery were supported by the state to move to high-income neighbourhoods. The state pays all relocation costs, including for a new house. The study demonstrated that simply moving people from low-income to high-income neighbourhoods dramatically improved health status. So that shows you how much the environment in which you're living in affects health, with implications for policy.

Another study focused on big structural policies that have really made an impact, including desegregation. In the US, under the Jim Crow laws, public spaces were racially segregated. This applied to hospitals as well, so Black children couldn't be treated in wards where White children were being treated, leading to racism and discrimination in terms of treatment, availability of medical supplies, etc. In the wake of the Civil Rights movement and Civil Rights Act of 1964, there was mandated desegregation across the US, including in hospitals. This led to a rapid decline in neonatal mortality among Black children once desegregation began. That study showed the high impact of something very structural, such as the removal of segregation between races on a very tangible health outcome - child mortality.

Sonora: So, there is a lot missing from the current evidence base. However, based on what we do know, what are the key things that you think people should keep in mind when considering interventions and combatting this issue?

Lu: In the paper we call for six key principles: decolonisation, understanding intersections between multiple axes of discrimination, increasing diversity and inclusion, reparative and transformative justice, active promotion of racial equity by opposing racism, and human rights-based approaches.

One of these principles that really strikes me and that relates to the collective action research that I do is that genuine diversity and inclusion. We don't want tokenism, and that is one thing that has been treated in the collective action literature. Tokenism is a very convenient political tool for demobilising collective action because if everybody in a society doesn't have access to power, then they will feel frustrated, and they'll feel like they have a reason to band together and take action to change the status quo.

However, if everybody has a 0.001% chance, for example, of getting to power - even though they still don't really have much of a chance to get into power - they will feel that they may have a chance to get to power, and so they feel like they don't really need to band together with other people to take collective action.

There are many psychological studies looking at this dynamic showing that you can manipulate people's willingness to change the status quo by offering them these token positions that then make it seem like everybody has a chance. But in reality, even if one person gets a chance at wielding power, that still means that the remaining 999,999 people are left behind.

That’s why we are calling for genuine diversity and inclusion and for non-tokenism in approaches to racial equality that aim for structural change rather than focusing on individuals.

Sonora: That’s so interesting, Lu! As a final question, what do you see as the path forward towards health equity?

Lu: That’s a big question, so I will give you a small answer. In the Lancet Commission on racism and child health, we are trying to take into account all the different complexities that are involved in racialised health inequity without reducing those complexities. Racism is an issue where it's very easy to go wrong by reducing some of those complexities down to something very simple and binary when it isn't a simple or binary issue. So, as a start, look at the Commission!