David speaks with Layal Liverpool, an author and science journalist with expertise in biomedical science, particularly virology and immunology. She worked as a biomedical researcher at University College London and the University of Oxford in the UK. Her writing has appeared in Nature, New Scientist, WIRED, the Guardian, and elsewhere, and she has worked on staff as a reporter for both Nature and New Scientist.

They talked about:

🎭 The difference between perceived racism and actual racism

🚫 The ineffectiveness of racial categorization

πŸ—οΈ The idea of race as a social construct

🩺 The misconceptions of 'black' and 'white' diseases

πŸ“‰ Systemic racism in healthcare

🌍 Racism as a public health issue

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πŸ“„ Show notes:

[00:00] Introduction

[02:37] The origin of the surname 'Liverpool’

[04:06] Perceived Racism vs. Actual Racism

[05:57] The definition of 'race’

[09:07] The limitations of racial categorization

[11:16] Race is a social construct

[12:59] Racial disparities in disease

[16:55] How racial bias affects medical diagnosis and treatment

[19:13] Is the coronavirus racist?

[23:12] Bias and predisposition in health systems

[26:19] The impact of racism on maternity health

[28:33] The influence of history on contemporary beliefs

[34:03] Racial biases in healthcare practices

[36:06] Strategies for balancing race in healthcare

πŸ—£ Mentioned in the show:

Liverpool slave trade | https://en.wikipedia.org/wiki/Liverpool_slave_trade

International Slavery Museum | https://www.liverpoolmuseums.org.uk/international-slavery-museum

Systematic racism | https://theknowledge.io/issue13/

Islamophobia | https://en.wikipedia.org/wiki/Islamophobia

Antisemitism | https://en.wikipedia.org/wiki/Antisemitism

AAA Statement on Race | https://americananthro.org/about/policies/statement-on-race/

Garrett Jones | https://theknowledge.io/garettjones-1/

Sickle cell disease | https://en.wikipedia.org/wiki/Sickle_cell_disease

Lyme disease | https://en.wikipedia.org/wiki/Lyme_disease

Malaria | https://www.who.int/news-room/fact-sheets/detail/malaria

Anti-blackness | https://www.bu.edu/antiracism-center/files/2022/06/Anti-Black.pdf

Cystic fibrosis | https://en.wikipedia.org/wiki/Cystic_fibrosis

COVID-19 | https://theknowledge.io/issue7/

Influenza A (H1N1) | https://www.who.int/emergencies/situations/influenza-a-(h1n1)-outbreak

Samuel A. Cartwright | https://en.wikipedia.org/wiki/Samuel_A._Cartwright

American Thoracic Society | https://site.thoracic.org/

European Respiratory Society | https://www.ersnet.org/

FIVEXMORE | https://fivexmore.org/

Maternity Discrimination | https://maternalmentalhealthalliance.org/news/black-maternity-experiences-survey-five-x-more/

William Turner | https://en.wikipedia.org/wiki/William_Turner_(anatomist)

Long lunches in Paris | https://theknowledge.io/issue65/#:~:text=Long lunches in Paris

Clandestine Pad Thai | https://theknowledge.io/issue65/#:~:text=Clandestine Pad Thai

Murder of George Floyd | https://en.wikipedia.org/wiki/Murder_of_George_Floyd

Full episode transcript below

πŸ‘€ Connect with Layal:

Twitter: https://twitter.com/layallivs

Website: https://layalliverpool.com/

Book: SYSTEMIC: How Racism is Making Us Ill | https://amzn.to/4c9lnaW

πŸ‘¨πŸΎβ€πŸ’» About David Elikwu:

David Elikwu FRSA is a serial entrepreneur, strategist, and writer. David is the founder of The Knowledge, a platform helping people think deeper and work smarter.

🐣 Twitter: @Delikwu / @itstheknowledge

🌐 Website: https://www.davidelikwu.com

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πŸ“Έ Instagram: https://www.instagram.com/delikwu/

πŸ•Ί TikTok: https://www.tiktok.com/@delikwu

πŸŽ™οΈ Podcast: http://plnk.to/theknowledge

πŸ“– Free Book: https://pro.theknowledge.io/frames

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πŸ“œ Full transcript:



Layal Liverpool: I also wanted to kind of validate people in their experiences and show that there's nothing wrong with us or our bodies. There's nothing wrong with being black or belonging to another group that is discriminated against, that means that you're sort of destined to become ill. That's not how it works. It's very much that by living in an environment where there's racism and there are social inequalities, that's what leads to worse health outcomes. And I think by recognizing that it means we can start to tackle the problem because if it's just an inherent thing, if there's like, something about being black that means you're going to get ill. There's nothing we can do about that. You can't change your race, right?

David Elikwu: This week I'm sharing part of my conversation with Layal Liverpool. who is an author and science journalist specialising in virology and immunology.

Now Layal has worked as a biomedical researcher at UCL, University College London, and at the University of Oxford. Her writings appeared in Nature, New Scientist, Wired, The Guardian, and elsewhere.

And this episode we're gonna cover a topic that gets a lot of people's heckles [00:01:00] up. And so I ask for your patience and consideration because Layal has a lot of really interesting research to share about the impact of racism in healthcare.

So you're going to hear us in this part talking about the difference between perceived racism and actual racism. We're going to talk about what race actually is, how racial categorization works generally in practice, and also specifically within the healthcare context. We talk about the idea of race being a social construct and how misconceptions of what race is and how it works can lead to negative health outcomes for people from different racial backgrounds. We talk about the misconceptions of black diseases and white diseases. She helped to clarify a lot of misconceptions that I personally had, and I'm sure many of you might share. We also talk about racism in maternity health and the concept of racism being considered as a public health issue.

So, this was a really interesting episode specifically personally for me. And I know for lots of you out there.

You can get the full show notes, the transcript [00:02:00] and read my newsletter at theknowledge.io and you can find Layal on Twitter @layallivs, her website is layalliverpool.com. We'll have all the links in the description or show notes, and you can find her debut book, Systemic: How Racism Is Making Us Ill, in all good bookstores, and we'll have links again for that.

So if you love this episode, please do share it with a friend, and don't forget to leave a review wherever you listen to podcasts, because it helps us tremendously to find other listeners like you. And last thing, there's going to be follow-up parts to this, so please do subscribe so that you don't miss that.

The origin of the surname 'Liverpool’

David Elikwu: One question I did want to ask, actually, and maybe this is where we can start. I was, I was just interested to know where your, your name was from?

It seems like a really interesting turn of events that your, your surname is Liverpool and you studied in Oxford and you're based in Berlin and

Layal Liverpool: Yeah, it's very confusing. I think people often get confused by my name.

So yeah, my surname [00:03:00] Liverpool, I mean, we believe it's a kind of slave name. So my dad is half Ghanaian, half Dominican. So Dominica is a small island in the Caribbean, close to Guadalupe. Yeah, so we think that's one of the ancestors on my father's side was enslaved and passed through or was trafficked through the port of Liverpool in the UK.

So Liverpool was a major slave trading port. And I have actually had the pleasure to visit Liverpool. Few years ago, I went there for a, actually like an immunology conference, and I managed to find time to go to the international slavery museum there. And it was really interesting because I could learn a lot about the history and I think with slavery often that it feels like a gap in the story or history. You don't often hear the stories told by, you know, enslaved people.

Yeah, so it's kind of, I think I like my surname. I think it's sometimes people, when they ask about it and I mentioned slavery, they kind of feel awkward or uncomfortable, but I think it's kind of good. It's a good maybe conversation starter to think [00:04:00] about all of our histories, how we're all connected somehow. And so I found it kind of a learning, yeah, a good learning tool.

Perceived Racism vs. Actual Racism

David Elikwu: I actually think that's a perfect starting point because just like, what you were saying, I think that race can often be, in general, this kind of nebulous thing that people dance around and makes people a bit uncomfortable whenever it comes up.

And there's this idea that, there's a tension between the idea that people maybe racist or may say something racist or think something racist or they think something and it may come across as racist, but it does that make someone racist? And then you also have outcomes in society where, okay, the outcome may produce some racial disparities and what does that mean? Does that mean people are racist or does that mean this does that mean that? I mean, how do you think about that, or navigate that those ideas?

Layal Liverpool: Yeah, I think this is something that's also come up a lot, talking about and researching the book.

People often want to talk about, Oh, who is racist? And particularly thinking about racism and how that affects our health and in medicine, it's like, Oh, there's this particular doctor is [00:05:00] racist, or let's talk about that. But I think it's actually, maybe it's less catchy, but I think often it is the systems and structures, institutions that underpin our society, our lives that lead to a lot of racial disparities in health. And I think those systems are racist and it's good to name racism as a problem in society, also as a public health threat.

But yeah, I think of course the actions of individuals are important too. And that, and I also talk about that in the book, I look at interpersonal racism and how those interactions can also affect our health. But I think probably the larger contributor to inequalities in health comes from systems, it comes from, for example, medical guidelines that embed racist ideas from the past that are still affecting people's health today.

And yeah, I really want us to be less scared of the word racism. Unfortunately it's a, it's a word that often evokes, as you say, maybe defensiveness or fear talking about that.

But I think being able to talk about these things is really important to be able to then start to tackle the problem.

The definition of 'race’

David Elikwu: And I think in your work, in many of the articles that you've [00:06:00] written, and I'm sure in your book, you talk about how this comes up in different types of circumstances. And I thought maybe a good starting point might actually just be to define what we mean by race as well. Specifically because I think there is an interesting conundrum that comes up when, you know, on one hand, sometimes you hear people say, Oh, race is just a social construct. And actually, you know, people are people. It doesn't matter if you're, you know, red, black or yellow or, you know, whatever people say, but then simultaneously on the other hand.

Like you can see statistically that sometimes, either that there may be some real racial differences, or at least that you just have some racial disparities in whether it's medical outcomes or outcomes in other types of areas.

And so it's a strange balance of, okay, on one hand, people want to say, Oh, actually we're colourblind, everyone's the same, obviously we shouldn't treat people differently because perhaps people are no different.

But then in reality, simultaneously, it seems like maybe there are some differences.

Layal Liverpool: Yeah. I'm really glad you brought that up. I [00:07:00] think that, that's a really important thing when we, when we start to talk about racial inequality, I think it's really important to think about how racism contributes to that.

I interpret race and racism very broadly in the book. So, I'm looking at all forms of discrimination that are racialized. This includes, you know, Islamophobia, antisemitism, there's also discrimination against white ethnic groups. So I interpret that broadly, but I think it's also important to recognize that there's a lot of, what I would call anti-blackness that is very, very strong when it comes to, for example, the history of medicine. And that also stems from the fact that I think, racism was very much kind of perpetuated in an era of European colonization, transatlantic slavery and used to justify those things.

So, of course, it's easier to kind of justify the oppression of a group of people. If you can use sort of science or pseudoscience to paint those people as inferior or, deserving of, of worse treatment. And of course that's a historical, but we know that these things continue to affect us until today.

And I think the [00:08:00] way you've mentioned that race is a social construct and I completely agree with that. I should say the evidence, you know, is clear that there's no such thing as race in a biological sense. So, you know, 99.9% of our DNA is the same. There is research looking at, for example, genetic differences between geographic groups or so-called racial or ethnic groups. And that research shows that, you know, 95% of the variation that we see exists within so-called geographic or racial groups compared to between groups. So it's clear that there's no such thing as race in that biological sense. But I think race is still a very real thing, in the sense that, we do experience that as a social construct. It does affect our lives and our experiences. So I think, race is a social construct. It doesn't have a biological basis, but racism does affect our health, and there is evidence that it can have a biological impact. So I think we shouldn't dismiss the harm that racism can cause on our biology on our bodies.

And I think that distinction between are we talking about [00:09:00] differences in race or are we talking about differences due to racism is something that's very important to me and I try to make that clear in the book as well.

The limitations of racial categorization

David Elikwu: Okay, this is really interesting, and I want to try and repeat back what I'm, like, understanding or passing from what you said, and you can correct me where I'm making some mistakes.

I think what you said that really is interesting, or at least where it took my mind, is this idea that potentially, there are definitely, certainly differences in different cultures, and there are some genetic differences and, you know, people that grow up in different places, there are differences in gene pools, et cetera, et cetera. And so, that can manifest in lots of different ways. And so you might have, oh, there are some people in these different ethnic groups where they happen to also have, you know, melanated skin or say they look black and they might have these distinctions here.

But it may just be that, you know, race itself is a very poor container for categorizing those distinctions. And so you might have, okay, [00:10:00] between lots of different ethnic groups or between different people from different cultures, et cetera, there may be some of those differences, but actually using race as a container by which to categorize people is substandard. It doesn't really do an adequate job, perhaps because there is within those racial categories, so much difference.

And actually that brings to mind, a conversation that I was having with Garrett Jones, who has done a lot of work, talking or at least thinking about some of the potential IQ differences, let's say, between different races or different cultures, et cetera. And I know that that's always been an ongoing conversation about, Oh, you know, do some racial groups have higher IQ than others.

And one thing that I found interesting from some of the discussion that we had is that simultaneously there is more, you know, even if you were to accept that there are some differences between, Oh, okay, the IQ distribution of some races and of others, but actually the variety within each race is greater than the variety between different races. And so actually [00:11:00] it's almost not useful. It might only be useful when you're thinking like about averages on a grand scale, but actually on an individual scale is useless because there is so much variety within the race itself that actually it's not worth comparing between the races, as an example.

Race is a social construct

Layal Liverpool: No, exactly. I think you got that exactly right. And of course, genetics is a very useful science. I definitely don't dismiss genetics for, I think it's really helpful for understanding. For example, you can compare groups of people who have a disease and a group who doesn't and look for these small genetic differences to try and maybe pinpoint targets for future treatments.

So there's a lot of benefit of looking at genes and looking at human variation at a population level. But I think sometimes we make the mistake of trying to apply that at a very individual level. And to group people into these containers, as you said, and labels. Particularly when we bring race into that.

Another problem that I have with race in a sort of scientific context is that it is a social construct, and because of that, that means it varies a [00:12:00] lot in time and place. It's very poorly defined. So in the book, I kind of, light-heartedly, give the example that you know, when I travel to Ghana, which is where my parents are from, I might be called a brunette, which is like something that means someone who's foreign or white person. Whereas here in the UK or in Germany, where I live, I'm racialized as white, or if I travel to Brazil or South Africa, how I'm racialized might change. And I think that just shows you how fluid and exactly a social construct race is, which is fine when we're talking about our social experiences. But when it comes to science or medicine, where we want to be extremely precise and have useful categories that can help us, for example, to diagnose a patient or decide about treatment, I think that's where race really doesn't have a place.

And that's why I think it's important that we talk about racism and how racism affects health rather than race. And that might sound like semantic, but I think that, that's actually a really important distinction and can really affect people's health outcomes.

Racial disparities in disease

David Elikwu: [00:13:00] Yeah, and okay, so making a part of a transition into discussing some of your work, one of the things that I've been thinking about earlier this week as I was preparing was just, it might sound a bit random, but I was just thinking about, okay, there's got to be some balance of, where's the distinction between, oh, perhaps there are some, let's say genetic differences between different people or something like that. And, oh, there are medical outcome differences.

And one example that just came to my mind is just thinking anecdotally, I might not know the specifics about what causes some of these different diseases, but, oh, I don't really hear anyone white talking about sickle cell, for example And simultaneously, I don't really think I've heard any black people talking about having Lyme disease. And I just mentioned that because it came, came to my mind in passing of just thinking, oh, you know, these things seem different.

However, from what I do know about sickle cell, some of that might make sense because actually, to my understanding, sickle cell is some [00:14:00] evolutionary response to malaria and actually, okay, fine. Perhaps where malaria is prevalent happens to be in places where there are lots of black people and there are not many white people. And so you might notice in day-to-day life that actually halt, it seems to be that most of the people that I see that have sickle cell are black people. And maybe there's some connection there in terms of genetics.

And I was thinking, Oh, maybe there's something like that for Lyme disease as well, which I didn't know as much about and I did, you know, some, some basic searches.

It seemed to be almost the opposite. And I was so surprised that actually it turns out that the Lyme disease, perhaps there, there is some aspects of it that is similar, uh, because I think it's a tick-borne disease that comes from horses. So maybe part of that is just due to the geography.

But what I found really interesting is that there were new stories going back decades and I was looking at, oh, there's a study that came out in the year 2000, or at least article that came out in was referencing studies that finished in, let's say 1996 about Lyme disease. [00:15:00] And saying, oh, we've just noticed that there were these massive imbalances in the medical outcomes for black people versus white people that have this disease. And I was like, Oh, that's strange, that's interesting.

Then simultaneously in late as 2023, just a year or so ago, you also have a study that also just came out that I think was looking from the time period of 2008 to 2016 that had the exact same conclusion. And so you have this 25-year gap where actually people are just saying the exact same thing. Somehow there's this massive difference in outcomes. So even if it is the case that actually maybe a lot more white people are getting it, I think in the study that came out in 2023, were saying, actually, it looks like, black people are having to wait five times as long to get the antibiotic treatment for this disease and, and that just seems strange.

So what is happening there? Because it, it might not seem, you know, if people think, Oh, my local doctor, is this person racist? Or does this person have, you know, something against black people? You might say no, [00:16:00] but somehow in the reality of treatment and people going through this process, suddenly these differences manifest.

The misconceptions of 'black' and 'white' diseases

Layal Liverpool: Yeah. And I think you've just, in the examples you've given, you've just illustrated that it is complex, and [00:17:00] there are a lot of different factors that contribute to health inequalities, but I think that, perhaps we can talk about sickle cell as an example. I think the fact that sickle cell has been racialized as a black disease, you hear that a lot. And of course, you're right that the malaria is prevalent, we also see an association with the sickle cell trait because it confers protection against malaria. So it's true, but that part of the world is actually quite a large area where malaria has been prevalent historically. So that includes large parts of Africa, but also the Middle East, parts of India, Southern Europe. So that actually, it isn't quite right to say that this is a black disease, although it's true that many black people are affected by it. And I think the fact that it has been racialized in that way has actually been harmful to sickle cell as in terms of investment and interest because of the racism that exists in our societies and anti-blackness. I think perhaps there's been a lack of sufficient investment in sickle cell because of that perception that, oh, this only affects black people, which is obviously terrible.

But we also see that in conditions which have been kind of racialized as [00:18:00] white. So, for example, cystic fibrosis is often racialized as a white disease but in fact, it can affect, you know, people of all backgrounds. And there's also evidence that that racialization of a cystic fibrosis as a white disease has been harmful to black patients who've then had to wait longer for a diagnosis. And you also talked about this example with Lyme disease.

But yeah, we see this also in other conditions that might not be thought of as conditions affecting black people or people with darker skin like, skin cancer, for example, so melanoma and non-melanoma skin cancer. Of course having more melanin in your skin is protective against skin cancer, it protects you from damage from the sun. But again black people can also develop skin cancer. And in fact, there's evidence from the U.S. that black people die from skin cancer at higher rates than white people. So even though they may be less likely to develop the condition, it seems that there are delays in diagnosis and in receiving treatment for black people, which leads to worse outcomes.

So I think it's very important to be careful again with by racializing these conditions, we're not [00:19:00] really helping with those outcomes. And it's something that I thought about a lot also during the COVID-19 pandemic, because there was a lot of conversation about, okay, in the UK, for example, ethnic minority groups are being worse affected by COVID.

Is the coronavirus racist?

Layal Liverpool: I was even asked in a podcast interview that I did in 2020, is the coronavirus racist? You know, is this virus racist? And I think what I would say to that is that of course, viruses aren't racist, but our societies are, and there are extreme inequalities based on race. We see differences in economic outcomes, in our environmental inequality, on racial lines because of the history of racism, but also because of things that are happening today.

We also see biases within medicine and in healthcare that contribute to those inequalities. So all of those factors together, you know, definitely contribute to unequal outcomes when it comes to health. And we do see that not just during COVID, but in other infectious diseases like HIV, but also in cardiovascular disease, cancer, which I've mentioned, but also mental health [00:20:00] conditions across all of these different areas of health. We see this pattern that people belonging to marginalized groups are experiencing worse health. And that's not only true, you know, here in the UK, but also in other countries in the US, I've mentioned, but also, for example, in India, we see that there are inequalities based on caste, related also to skin shade or tone.

So these inequalities happen wherever we see that there's racism or some discrimination against particular groups of people, those people are experiencing worse health. And I think that is a pattern that is worth looking at and worth considering and prioritizing as a public health issue.

David Elikwu: Okay, sure. I'd love to go more into the COVID example, cause I think that was a big part of the inspiration for your book. And you've mentioned that we should potentially consider racism as a public health crisis.

So I'd love if you could unpack, you know, what, what was it that was interesting or special about COVID that made you pay more attention to that?

Layal Liverpool: Yeah, so actually, I think it wasn't maybe just me who kind of paid more attention. I think it was kind of the wider society and I [00:21:00] think that there was a lot of things maybe that happened in 2020 that brought attention to these issues beyond people who might have already been campaigning on this for a long time.

So I think the inequalities, but also anti-racism protests that happened in 2020 around the world, I think put a spotlight on inequalities in our society, but also how that affects our health. And as a journalist, I was reporting on ethnic inequalities in COVID and looking at the factors that contribute to this. And what I discovered is that a lot of these inequalities have existed for a long time before COVID. And, you know, doctors and academics who've been researching racial health disparities will have told you this, that, for example, during the H1N1 pandemic. So that's the swine flu pandemic that happened 10 years before COVID.

We also saw ethnic inequalities in terms of who was becoming ill, who is dying from that virus. But I think perhaps during COVID, there was something unique and I guess really global about that, got people's attention and got people to notice some of these inequalities that were already present.

During COVID, there was a lot of discussion [00:22:00] of when it came to ethnic inequalities that, Oh, the reasons for this is that, for example, Oh, black people are poor or there are many black people or people of South Asian ethnicity in the UK, for example, that we have pre-existing health conditions that make us more vulnerable to COVID.

And I kind of found that argument to be quite circular because we're not asking the question, why is it that, for example, Black people are disproportionately experiencing poor economic outcomes or poor health. And the reason for that is when we look at the history and we look at our society today, the evidence really points towards racism, both historically, but also today in the way we lead our lives. There's evidence that racism causes stress, which can increase the risk of various conditions, including cardiovascular disease, which has been associated with worse outcomes with COVID. We also see evidence that there's bias within medicine and medical practice that leads to worse outcomes for people of colour often.

So I think it's important that we consider all of those things when we look at health disparities and recognize that there's nothing inherent about, you know, [00:23:00] being black or belonging to a marginalized group that should make you more ill. But living in a racist society while belonging to a group that is discriminated against is harmful to your health.

And that seems to be what the evidence is increasingly showing.

Bias and predisposition in health systems

David Elikwu: Okay, I want to try and put myself in the mind of someone that might be disinclined to believe what you're saying, and I think

Layal Liverpool: Yeah, please do.

David Elikwu: There might plenty of people that, you know, they hear about, Oh, you know, this is happening because it's racist. And, know, people don't like that idea people say, Oh, pulling the black card or, you know, why are you happens like this? How might you assign the probabilities of let's say, okay, we can accept that whether it's deaths or negative health outcomes during the COVID period that there might be black people may have been disproportionately affected by that. How might you assign the probabilities of, okay, here are some potential different outcomes. And okay, this I think is the largest part of the blame, and I think actually this proportion comes from here. You know, how much weighting do we give to, Oh, just inherent [00:24:00] within the medical system, there may be some biases that led to some negative health outcomes, or is there some proportion that is, Oh, actually some people may be predisposed for, for such and such reasons, etc.

Layal Liverpool: Yeah. So I'm, I won't give numbers because I don't really have, it's difficult to put numbers on, on discrimination in that way, but I will give like my sense of the problem from, you know, researching this, interviewing doctors, scientists, and also people who've experienced racism in the context of health and also just from my own experiences.

So I think that the largest contributor to racial disparities in health is systemic racism. The reason is that, when something happens in a systemic level that affects obviously a lot more people compared to individual instances of discrimination, although I think those are also harmful and we should tackle them too. To give an example, I spend a lot of time researching, what's called race-based medicine. So this is where race is embedded into medical practices and guidelines in a way that is inappropriate and also increasingly the evidence shows that it doesn't make sense. It's [00:25:00] not based in good evidence.

So maybe to give an example, there have been guidelines for a long time to adjust lung function tests based on a patient's race, particularly for black patients that were based on this idea that can be traced back to a U.S. physician and slaveholder in the 1800s. His name was Samuel Cartwright, and he had this idea that black people's lungs are essentially weaker, and therefore that Black people benefit from being enslaved.

And you can of course see in that historical context, there was very much this need to justify the enslavement and oppression of Black people. And so coming up with this science to kind of justify that, in that context made sense but unfortunately, some of these sorts of ideas, including this, this example that I've given have made their way into medical guidelines that persist, you know, to this day, and it was only last year that the American thoracic society, and also here in Europe, the European respiratory society changed their kind of joint recommendations when it comes to lung function testing, and they eventually acknowledged that, you know, race is a social [00:26:00] construct, exactly what we've been talking about today, and that it doesn't have a basis in biology, and so they no longer recommend adjusting those lung function tests based on race, but those sorts of ideas and practices are very pervasive in medicine, and I can give many more examples. There's, you know, assumptions about black people's pain tolerance being different that have been widespread.

The impact of racism on maternity health

Layal Liverpool: I recently became a mom and, you know, going through pregnancy. It's clear that there are also racial disparities and outcomes, particularly in the UK, for example, black women are four times more likely to die during pregnancy or childbirth compared with white women. And you also see patterns of racism and bias, for example, in the care that women receive. There's been really amazing work by this grassroots organization called FIVEXMORE here in the UK. They've done research showing that 43% of black and black mixed women report experiencing discrimination in their maternity care. And in the survey that they did of black women, they also asked for kind of anecdotal experiences that people had and there've been experiences of people where their doctor, for example, has promoted this idea that black [00:27:00] women's pelvises are shaped differently than white women's, which again is, can be traced back to really problematic ideas, in this case from a British anatomist called William Turner, who had ideas about, you know, black women's pelvises are inferior and less suited for childbirth. They're more close to animals and all kinds of really problematic and racist ideas. But I think some of those things make their way into science and we sort of lose that, that racist history, and then they just sound reasonable that, oh, black people's lungs work differently. So let's just go along with that.

But thankfully, a lot of medical students, doctors, so people working in the medical profession have been recently questioning a lot of these guidelines. And I think, yeah, perhaps the inequalities we saw with COVID in 2020, and then also the anti-racism protests that happened to occur in the same year. I think maybe that also forced an accelerated reckoning with these issues. So I hope that that will continue because it's been great to see a lot of these guidelines recently being overturned. So I think this is something that is changing. I think we're increasingly recognizing that.

But I think that is an example of [00:28:00] how systemic biases have a greater impact on people's outcomes because of course, if you have, you're unlucky and your individual doctor is racist, that will be harmful. But if your doctor is following guidelines that tell him or her to adjust your, you know, test results based on your race, and that's going to have a huge impact because all patients are kind of affected by those guidelines.

So I think systemic, biases have a huge impact within medicine, but also within wider society. So I'll pause there, but I can talk more about, you know, how our living environment affects our health and, and all of these things that are also kind of systemic problems.

The influence of history on contemporary beliefs

David Elikwu: Yeah, you've touched on so many things that I'd to come back to and, and double click on.

But one thing I just wanted to double down on is a really important point that you mentioned that I think is really important people to understand is that, again, I know a lot of people will instantly just baulk at the idea of, Oh, you're telling me I have some beliefs that happen to come from some, some racist place or from something like this. And it's [00:29:00] so interesting how, you know, even as you say it, a lot of it makes sense intuitively to me that someone at some point in history could have just made something up or, you know, they had some incentive to say something and that can just spread throughout history.

And it can become quite innocuous where suddenly we hold this belief that doesn't really have a real medical basis. And there might be people that hear that and think, Oh, you know, I can't believe that's true. How can you just say that, you know, some of this science is made up? But it's so easy to believe and understand that it's true when you realize how many other areas of our lives we have these implicit things that come from.

And I remember I wrote a post about this a while ago, just talking about how many of aspects of people's daily lives are actually just psyops from, from the past. And so, you know, there's a bunch of great examples. For example, you might ask, Oh, you know, why do people have long lunches in France? And people say, Oh, it's just part of the culture. And, you know, French people culturally this and that, blah, blah, blah. Actually, this came from the [00:30:00] industrial revolution as a way to stop airborne tuberculosis, like people were dying in the factories because they all had to come into Paris and they were working all day in the factories. And at some point, so many people were dying that they were like, okay, we need to get everyone out. Let's clear out the factory for, for, for little while in the middle of the day so that we can, we can air it out and then people can come back. And that's where the long lunches started.

And actually the women's rights movement in France started because at this point that everyone had to come out and leave the factories, there were, you know, people were harassing the women and actually they were arguing that they want to be able to go back inside and have their lunch in peace indoors inside the factory and not have to be, you know, facing all the lewd men outside.

And so it's funny how, okay, that started as some tiny little thing, some small little policy in the 1800s to stop airborne tuberculosis. And now French people think, Oh, it's part of je ne sais quoi and you know, is just our cultural artefacts. actually, you know, it just comes from this random thing.

The same thing with, let's say home ownership in the UK, the same thing with breakfast, [00:31:00] you know, someone just made up the food triangle, which now we know doesn't really mean anything factually, but suddenly, Oh, breakfast is the most important meal of the day.

And again, this idea that so much of, the way we think about food and the way that we think about what we eat just comes from adverts and lobbyists. And actually some of these things are not even that old. And I think that's the key fact as well, you know, with some of the things you're talking about, they actually go back hundreds of years, which should only amplify their power, but there's some things that we live with day to day right now, that actually are only a few decades old and a few decades ago, someone decided that they believe this thing and they put that idea out into the world.

You know, I was talking about Pad Thai as an example. Thai, I mean, you know, it's going to sound bad, but it doesn't really exist. You know, when, when Indonesia was changing from Siam, they went through a period of nationalism, right? You know, national pride. And so they just started calling a lot of things, Thai things, because, you know, that's the new name, like Thailand, Thailand, [00:32:00] Thailand. And so they just took this recipe, It was an old Chinese recipe. They printed it in the newspaper and they said, okay, this is Pad Thai. And literally that just happened one day and suddenly this is now the new national dish, and everyone's like, oh my gosh, I love this thing, blah, blah, blah.

So again, just this idea that someone at some point in history could just completely make things up and it can shape so much of our lives, so much of our culture without us realizing it happens in many of, many areas of our lives. And I don't even think people realize that to start with, but I think once you do realize that, then it's also very easy to realize that actually some of these things were done by racist people and there could have been someone that happened to be racist or happened to have racial beliefs at some point in history, and simply because they said something, it has now proliferated through time, and now lots of people have these beliefs.

And maybe to connect this to something that you've talked about is this idea that within the medical system, there are people that have certain beliefs. There was a really interesting study that I looked at, I'm not sure if it [00:33:00] was you that showed it, actually. It was interesting to note that I think they looked at particularly just white doctors and the beliefs that they hold. And you can see that almost there's a correlation to the number of years of training that they have, where when they start, they have all these crazy beliefs about, Oh, white people are like this, black people are like this, you know, white people have larger brains, black people don't have, you know, strong pain receptors, and obviously by the time they become resident after many years of training, once they actually have some facts and better knowledge, they actually don't have as many of those beliefs that they once had, but that tells you that those beliefs come from somewhere and it might not necessarily be that, oh, they themselves are racist, because you see their beliefs change over time or at least based on the number of years of training that they have. But if they are coming into the medical system with those beliefs, that tells you that those beliefs are already percolating in society.

And so actually just as a person that had started medical training, they are coming into the system, believing a bunch of these things. And [00:34:00] it takes a certain number of years to kind of weed through those beliefs.

Racial biases in healthcare practices

Layal Liverpool: Yeah. And I think you're so right about sometimes these ideas are very sticky and I think racism is an idea, right? It's an idea of superiority and inferiority and it has been persistent, but also these more specific examples of beliefs in science, but also in medicine have also been persistent sometimes and continue to affect people's health.

There was a study in the U.S. of, I think mainly white medical students and residents found that about half of the students endorsed beliefs such as, you know, black people's skin is thicker than white people's or that black people's nerve endings are less sensitive. And so these ideas do seem to sort of persist.

But I think, by discussing this and highlighting racism as a public health issue, it also helps to frame those discussions within medicine and within science. And it's been great to see a lot of different fields of medicine reviewing some of the guidelines that have been based on race. I think a lot of that reckoning started in 2020, actually, like following George Floyd's [00:35:00] murder by police in the U.S. I think there was a wider discussion about racism and that as you've pointed out, there's racism in society, but, you know, medicine exists within society. Doctors are going home and watching the same TV shows that we all watch, and they're influenced by all these stereotypes and ideas. And so I think it's been good to see that reckoning happening in medicine.

What I would love to see more is, I think there's been a lot of reflection within specific subfields of medicine. I've done a lot of work, for example, with nephrologists and eventually that led to changes to kidney function test guidelines that were also racialized.

There are many other fields which I think we still see these racist ideas, and I think it would be great to have a wider review of the use of race within medicine in general, and just to interrogate these assumptions one by one and ask, you know, is this coming from some context, some historical racist context that isn't relevant today, or can we just double check all of these things and make sure that is this based in evidence or is this just one of these sticky ideas that's kind of hanging around? [00:36:00] Because I think in medicine, it's so important that we're evidence based and that we're up to date as well.

So that's something that I would love to see more of.

Strategies for balancing race in healthcare

David Elikwu: Okay, so one question that I wanted to ask as a follow-up to that, that I think quite intuitive there is, so how do we find this balance then? Because on one hand, we can acknowledge that it seems to be the case that there are some disparities. Does that mean that maybe we should pay more attention to race in some circumstances and actually think about it? But then simultaneously, part of the problem is that there's already, you know, quote-unquote race-based medicine where people are factoring in race when making certain diagnoses, and that's part of the problem.

So how do we balance those two ideas?

Layal Liverpool: I think that's, that's such a great question. That's something that I've been thinking about so much and especially researching and writing the book. I think, it's the question of how should doctors consider race? How should race be considered in medicine? And I think what I'd love to see more of in medicine is that doctors will be thinking about, how racism affects their patients rather than race.

So I think, there are many instances where we talk [00:37:00] about race, where I think we could actually instead be talking about racism. So we hear a lot of these statistics, you hear it all the time. Black people are more likely to die with COVID or during childbirth or from cardiovascular disease. And the way we frame that, it makes it sound almost permanent or inevitable as if there's something inherent about being black that is bad for your health.

And I think this is also something with the book. I also wanted to kind of validate people in their experiences and show that there's nothing wrong with us or our bodies. There's nothing wrong with being black or belonging to another group that is discriminated against, that means that you're sort of destined to become ill. That's not how it works. It's very much that by living in an environment where there's racism and there are social inequalities, that's what leads to worse health outcomes. And I think by recognizing that it means we can start to tackle the problem because if it's just an inherent thing, if there's like, something about being black that means you're going to get ill. There's nothing we can do about that. You can't change your race, right?

But racism is something that we can do something about. So by naming that and [00:38:00] recognizing all the harms that racism causes, it means we're saying, Hey, this is a problem that we can fix. And I think there's a lot of things that we can do to tackle the problem. You know, there are just even basic things like we can teach doctors to recognize health conditions and diverse skin tones. I haven't talked much about this yet, but there are a lot of disparities in terms of skin, health, but also recognizing conditions that might manifest on the skin, but might be more serious in the body.

And yeah, there are issues with recognizing these things on diverse skin tones. You know, doctors might not have confidence to diagnose people, can talk also about research in that area. But also just removing bias and racial bias from medical algorithms, as we've talked about, for example, with lung function testing or kidney function testing.

So there's a lot of things that I think we can do to tackle this and also in our wider society, just tackling inequality in general. I think tackling economic inequality, environmental inequality, these things are very much related and correlate with racial inequalities also for historical reasons.

So I think by tackling those issues, we're also going to [00:39:00] help people to live healthier lives.

David Elikwu: Thank you so much for tuning in. Please do stay tuned for more. Don't forget to rate, review and subscribe. It really helps the podcast and follow me on Twitter feel free to shoot me any thoughts. See you next time.

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