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:

๐Ÿฅ Racial disparities in maternal healthcare

๐Ÿ—ฃ๏ธ The importance of being heard in healthcare

๐ŸŒ The role of race in healthcare

๐Ÿšฎ The idea of environmental racism

๐ŸŽ“ The gap between healthcare education and systemic challenges

๐Ÿง  Racism as a public health issue in mental health

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๐Ÿ“„ Show notes:

[00:00] Introduction

[02:02] The impact of racism on maternal health

[04:19] Health inequalities among ethnic minorities

[05:48] The role of stress in maternity and health

[09:21] Racism is immeasurable

[11:33] Why is it important to be heard in healthcare

[14:23] Race and cognitive bias in NFL lawsuits

[16:52] The influence of race norming in medicine and sports

[19:20] The role of physician diversity in healthcare

[23:47] Healthcare pressures and social inequality

[26:43] How pollution affects student performance

[29:04] The effect of racism on environmental health

[32:10] Neighborhood factors and their influence on health and education

[35:56] Systemic barriers in healthcare education and access

[37:16] The impact of racial inequalities on mental health

๐Ÿ—ฃ Mentioned in the show:

FIVEXMORE | https://fivexmore.org/

Ella Kissi-Debrah | https://ellaroberta.org/about-ella

Racial bias in pain assessment and treatment | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/

Parkinson's disease | https://www.who.int/news-room/fact-sheets/detail/parkinson-disease

Serena Williams | http://serenawilliams.com/

Dementia | https://www.who.int/news-room/fact-sheets/detail/dementia

NFL | http://www.nfl.com/

NFL race-norming formula | https://www.newscientist.com/article/mg25133434-100-how-medical-tests-have-built-in-discrimination-against-black-people/

Chronic traumatic encephalopathy (CTE) | https://en.wikipedia.org/wiki/Chronic_traumatic_encephalopathy

Diversity, equity, and inclusion (DEI) | https://www.sca.org/wp-content/uploads/2020/01/DEIMissionVision.pdf

An Audit of UK Hospital Doctorsโ€™ Knowledge and Experience of Myalgic Encephalomyelitis | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8464998/

NHS | https://www.nhs.uk/

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

Urban heat island effect | https://en.wikipedia.org/wiki/Urban_heat_island

General Certificate of Secondary Education (GCSE) | https://en.wikipedia.org/wiki/GCSE

Malcolm Gladwell | https://www.gladwellbooks.com/

Full episode transcript below

๐Ÿ‘ค Connect with Layal:

Twitter: https://twitter.com/layallivs

Website: https://layalliverpool.com/

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

๐Ÿ‘จ๐Ÿพโ€๐Ÿ’ป 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.

๐Ÿฃ Twitter: @Delikwu / @itstheknowledge

๐ŸŒ Website: https://www.davidelikwu.com

๐Ÿ“ฝ๏ธ Youtube: https://www.youtube.com/davidelikwu

๐Ÿ“ธ Instagram: https://www.instagram.com/delikwu/

๐Ÿ•บ TikTok: https://www.tiktok.com/@delikwu

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๐Ÿ“– Free Book: https://pro.theknowledge.io/frames

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Decision Hacker will help you hack your default patterns and become an intentional architect of your life. Youโ€™ll learn everything you need to transform your decisions, your habits, and your outcomes.

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๐Ÿ“œ Full transcript:



Layal Liverpool: Tackling racism and recognizing it as a public health issue is really beneficial for everyone, even if you might think that you're far removed from this or you haven't experience racism or discrimination, this affects you too, because anything that kind of makes our healthcare systems unfair, but also, you know, racism makes our healthcare systems inefficient. It wastes time, money and resources.

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

Now Layal has worked as a biomedical researcher at UCL, the University College London, and also at the University of Oxford. Her writing has appeared in Nature, New Scientist, Wired, The Guardian and a bunch of other places. So she was a really interesting guest. This was an incredible conversation.

In this part, you're going to hear us talking about the impact of racism on maternal health. We talk about the role of race in healthcare and we talk about the impact of things that are systemic that might [00:01:00] not be intentional, but simply because of the way society is structured can result in certain externalities and negative health outcomes for people of different genders, people of different races, et cetera.

We also talk about this concept that I heard of, and you know, I was a bit wary of called environmental racism, but there is so much that actually makes a ton of sense when you dig into it. And so you're going to hear us talking about that and breaking that down. We also talk about the gaps that exist in healthcare outcomes, education outcomes, and other systemic challenges that are present within society.

And then finally also about how racism can affect mental health outcomes.

So Layal has a wealth of incredible information to share. You can get the full show notes, the transcript and read my newsletter at theknowledge.io. And you can find Layal online on Twitter @layallivs. We'll have the links to her website and book below.

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 just like you.


The impact of racism on maternal health

David Elikwu: Maybe to crystallize that, I'd love if you could expand a bit more on the example of maternity, which you've given, and I know you've also just had a child yourself, you know, when people talk about this idea of, oh, you know, black women are potentially more likely to die during childbirth, they're more likely to have some of these negative outcomes during the maternity period. What exactly are they talking about? And where do some of those things come from?

Layal Liverpool: I think it's actually a good example because, in theory, you know, maternity, it's not an illness, you're not sick, you're pregnant, and that should be a state of health. And we should be helping and supporting, you know, women and birthing people to go through pregnancy in a healthy way.

But unfortunately, as you say, there are inequalities in the UK, but also in the U.S. and in other countries, we see that there are biases. Actually, I mentioned The Grassroots Organization FIVEXMORE here in the UK. They have been doing really amazing work in this area. For example, they've published guidelines to support black women and birthing people in like advocating for ourselves in the healthcare setting. And I think that's really [00:03:00] great, obviously, super if you can be informed and know your rights in a health care situation. But I also think that we shouldn't put all the onus on, you know, people who are discriminated against to solve these problems. There also needs to be work done, for example, within health care, within medicine, and FIVEXMORE has also been helping with training resources for people working in health care so that they can, you know, learn about these issues and make sure that they're helping all people who they see.

But I think also more widely a lot of the issues that affect our health generally are also affecting maternal health. So maybe an example is thinking about health as something that doesn't start from the moment that we just, you know, arrive in the doctor's office or we collapse maybe and, we're going to the emergency room. It's something that starts way before, you know, it's like you wake up in the morning, what do you eat for breakfast? Where do you live? What kind of air are you breathing? How does that affect your health?

And those things are often correlated with race because of racism. And so it's important also that we think about how those things are affecting our [00:04:00] access to healthy living to, for example, healthy food environments. We see also racial inequalities here in the UK, but in other countries as well, in terms of what kind of food you have access to, whether you have access to green space to exercise. So, in England, for example, there's evidence that I think minority groups are less likely to live close to green space.

Health inequalities among ethnic minorities

Layal Liverpool: They're more likely to live in environments where, unhealthy food options dominate over healthy ones, but also just something as simple as the air we breathe. We see inequalities, you know, people of color in England are more likely to live in a very highly polluted area.

In the book, I highlight the really sad story of Ella Kissi Debrah, a young black girl in London who died in 2013 at the age of just nine because of exposure to air pollution in the environment where she lived in London. She developed a really severe form of asthma and again, this is a single story, but it's reflected in statistics. We see that black children like Ella, black adults and people from Asian ethnic backgrounds are more likely to be [00:05:00] hospitalized with asthma in the UK. And so you see that sometimes these patterns of inequality that have been driven by legacy and history of racism continue to lead to inequalities in health today.

And I think that also affects maternal health, because if you're going through pregnancy, obviously you want to be leading the healthiest life that you can at that time and in general, and if your access is already reduced before you even become pregnant, you're already seeing inequalities.

Before pregnancy, we see disparities in miscarriage. There was a study that looked at several countries, including the UK, that found that black women are more likely, I think, 43% more likely to experience early pregnancy loss. There are also inequalities when it comes to accessing fertility treatments.

So even before pregnancy, we see these problems. And then I think during pregnancy, that's just kind of compounded because of all the health effects that we see there.

The role of stress in maternity and health

David Elikwu: Okay, sure. I want to come back to the point you mentioned about climate change or, you know, the environment and how that can have impacts on our health in a bit, but just to, to ask another question about [00:06:00] this, the maternity factor, I am interested to know your thoughts on, is there an extent to which this can also potentially end up being self reinforcing? And if so, is there an extent to which we can untangle that?

And I ask that because I can't tell you, and I'm sure you probably have experienced this yourself. How many black women that I know that have this, you know, premonition about being pregnant? And this almost a fear because they are aware of these statistics and because they have this awareness of the differences in health outcomes for black women, you know, being pregnant, which maybe other races might not have.

And there might be a potential that, actually, if you're already having this fear about going into this period, you're already thinking about it. I can't imagine, you know, the extent to which that might create additional stress. It might affect your heart, your heart pressure. It might affect you in a bunch of other ways. And it's not even, I mean, nothing has actually happened yet, but it's just because you're aware that this thing is out there and there's potential [00:07:00] that your health outcomes could be worse. And so, in a sense that could already start to affect you even before you go into that period.

Layal Liverpool: Yeah. And there is also research looking at this, that not just in maternity, but in general, even the perception, or let's say the anticipation of experiencing racism can be harmful to health. And I think that's another aspect that we should think about when it comes to, when you are living in a society where there is racism, how that can affect your health, even before you might experience, you know, an acute instance of that and I think that is a big problem.

When it comes to maternity, I can speak from my own experience that I was actually researching and editing the book while I was pregnant. And that was something that was really difficult for me. And at some point I really had to kind of step away from some of these statistics because it is really worrying. And of course you want to do the best to protect yourself and your, um, your child. So I completely understand that, I think people should take care of their mental health in dealing with these things. Unfortunately can't escape from the realities that there is racism around. And I think, that's why it's [00:08:00] important that all of us recognize this is an issue that we care about and that we can do something about because then you're helping those around you.

And in the book I also make the case that tackling racism and recognizing it as a public health issue is really beneficial for everyone, even if you might think that you're far removed from this or you haven't experience racism or discrimination, this affects you too, because anything that kind of makes our healthcare systems unfair, but also, you know, racism makes our healthcare systems inefficient. It wastes time, money and resources. Here in the UK, people have probably experienced, you know, waiting times with the NHS and these problems.

And I think if we can remove bias in that setting that will be beneficial for all patients and anyone who is, for example, pregnant or has other reasons that they are engaging with healthcare. But yeah, I do think we need to also be careful about these conversations.

And I think it's very important to gather data when it comes to documenting racial inequalities in health, because that of course enables us to take action to tackle the problem. But I think we should be careful that to make [00:09:00] sure that we're not just gathering data, we're not just documenting inequality. We are actually then translating that into policies that can tackle that. Because again, we don't want to treat this as something that's inevitable or permanent, this is something that we can change, that we can do something about.

So I do feel optimistic in terms of the future, that by recognizing these inequalities, it does mean that we're already on the way to changing them.

Racism is immeasurable

David Elikwu: Do you have any idea of how we can get around the inherent subjectivity of, I think one part of it is the question of racism itself and oh, you know, how do you know if I'm experiencing something and maybe this is coming from this kind of place or it's just coming from maybe some incompetence or, you know, how might people be able to navigate or separate those aspects, but then simultaneously you also have the subjectivity on the part of the, you know, the medical person where, as we've talked about, there's this idea of, some race based medicine where actually someone is thinking perhaps, oh, and they're not thinking, oh, I'm being racist. They're thinking this is just something I've heard or something I've been told. This black person, if [00:10:00] they are subjectively rating their experience of how much pain they are going through, how much medication should I give them? How many, how much painkillers should I give them? If they are telling me, oh, they're feeling this much pain, should I discount that? Because, oh, I think maybe they're exaggerating or something like that.

You know, how do I guess, cause that comes at it from both sides. How do we balance the inherent subjectivity of that? Compared to, there are some things where maybe it can be quite objective and it can be maybe a lot more obvious, but in this type of area, I think that's potentially what leads to some of these health outcomes or people dying or things like that, because it's one person saying, this is how I feel, or this is what I'm going through. And then someone else deciding how seriously to take that.

Layal Liverpool: Yeah. And I, I think racism is difficult to even to measure or to assess. So I think it is a difficult thing to study, but I think we shouldn't shy away from that. I think we should try to understand these problems because we know that this is affecting patients, this is leading to worse outcomes for people.

And I think you gave the example of pain. I mean, there is also [00:11:00] research that can document this to an extent. So there's, there was a study in the U.S. showing that black patients, for example, are 40% less likely than white patients to be given pain relief in emergency rooms in the U.S.

And then there are myths about pain that we've talked about, but they also affect people in other countries, you know, there was a study of people living with Parkinson's disease here in the U. K. which found that, black people receive less pain relief compared to white people, even when they're reporting similar levels of pain in a questionnaire. Again, pain, of course, it's difficult to measure, and we're relying on people sharing their experiences,

Why is it important to be heard in healthcare

Layal Liverpool: but I think that's something that came through to me in the book, is that beyond these statistics, a lot of people who I interviewed who shared their experiences of racism in a health setting felt that they just weren't listened to or that their experiences were dismissed. There's a particular theme for black women, women of color, who just felt that they weren't listened to. And I think it really struck me that this seemed to be happening at kind of all income levels, let's say.

So, I think a story that many people may have heard is about Serena Williams, who [00:12:00] also experienced discrimination in the context of her childbirth. And I think what really struck me about her story is that, you know, Serena Williams is very successful athlete. She's wealthy, she has access to good health care. And she has also spoken of her privilege in that situation and said that, you know, she's lucky that she survived and everything was okay because she was able to afford that kind of good care. But she said that, you know, when she tried to advocate for herself, she wasn't listened to, until eventually it turned out that she was experiencing, you know, a blood clot in her lungs that was very dangerous. And unfortunately, action was taken eventually and she was okay. But she said, you know, doctors aren't listening to us. And I think it's a, it's an important point about listening. There is also research, not just looking at racism, but in general, looking at how important listening is that when patients feel listened to as well, that leads to health benefits. And I think that also links to maybe how our expectations about our health can affect our outcomes.

So I think this shouldn't be dismissed, even though racism can be difficult to study. I think we should persist and try to [00:13:00] understand these interactions. And there is also great work looking at how this leads to also physical outcomes. Like there's even efforts to look at the impact of racism on the brain, for example, linking experiences of racism and trauma in early life to dementia later in life.

And again, I think this is so important. Dementia is a condition that is increasingly affecting huge numbers of people around the world. The prevalence is only growing. And if we can understand how racism contributes to that, how it might be leading to more cases or worse outcomes for people, then it means we can help more people, I hope. And just tackle this, this problem in health and beyond.


Race and cognitive bias in NFL lawsuits

David Elikwu: There was another example that I wanted to unpack specifically because I think it's a brilliant microcosm of the duality that we're talking about here, and it's non medical, which I think is also And I think it's something that you wrote about a few years ago, which is about the NFL race norming formula.

And so essentially, you know, what had been the case is that when players in the NFL were bringing lawsuits against the league for brain trauma that they may have suffered, they're getting CTE, things like that. Part of the formula that the NFL is using to calculate, or at least was using to [00:15:00] calculate how much they might have to pay out in a lawsuit is they're adjusting it based on race. And there's something implicit in the formula that says, oh, If this is a black person, we are just going to assume that they already have, you know, some subpar cognitive functionality. And so because of that, then we can actually just discount how much that we're going to have to pay them out, which seems insane.

And on the surface, I'm pretty sure that if I just took that set of facts, if I just said that to a bunch of people on the street, well, if you just said that, you know, in those terms to someone that worked in the NFL, maybe a league owner or something like that. They might say, Oh, that sounds terrible. That sounds racist. Like the idea that, Oh, if this person is black, I'm just going to assume they have subpar function, cognitive function. And so if I'm calculating how much I'm going to pay them, I'm just going to pay them less because, you know, their brainpower was already impaired anyway. And if they sustain these injuries, you know, maybe it's not so much my fault. That seems insane, but [00:16:00] somehow, you know, for a very long time, people were just applying this, you know? The lawsuits were being brought, they are doing this race norming.

And another important thing, they're just eyeballing it, right? There's maybe a lot of mixed race people in the league or people that have different ethnic descents. And the idea that someone is just looking at you and saying, Hmm, do I think this person is black and if I think they're black, then the formula says, this is not a subjective, well, the formula is a subjective thing it's, Oh, if I think they're black, then we're just going to discount the amount that we're going to need to pay them. And that's just what it's going to be.

And that seems crazy to me that people that if you spoke to them on the street separately, in some other context, they might say, Oh, I'm not racist. I have nothing against by people that they might not have any of those beliefs whatsoever, but then simultaneously, they are also applying something that seems on the surface, just extremely racist.

The influence of race norming in medicine and sports

Layal Liverpool: Yeah, absolutely. And I think it's interesting that you said, Oh, this is a non medical example, but actually, I interviewed a [00:17:00] neuropsychologist based in California. I think in the days after the NFL kind of got in trouble over this and the NFL said, we're going to stop using race norming to adjust a player's test results. And this neuropsychologist told me that actually, this idea of race norming comes from medicine, so it comes from neuropsychology, and it was an effort to correct for observed differences in cognitive test performance between black and white Americans in the last century.

And again, the evidence shows that those differences in cognitive test performance are caused by again, racism, in fact, and inequalities in access to education, opportunities, even the test setting not being suited for people depending on their background. There's lots of evidence essentially that there are inequalities that lead to these differences in test performance, but somehow that had been kind of interpreted as, oh, okay, black people's brains are inferior or work differently.

And I think you touched on this earlier that there's a whole, you know, a lot of worrying pseudoscience trying to justify this idea of racial differences in intelligence, but having that [00:18:00] embedded into a medical calculator, which really affects people's outcomes, which the NFL then adopted, because in their case, it was, it was beneficial because that reduced the number of payouts that they had to give to a black former players.

It's really worrying because this could affect people beyond just, I think the NFL exposed the problem because there's a lot of attention on American football. But what struck me is that this doctor said, no, these are widely respected norms within the field of neuropsychology in the U.S. and so these are being applied to patients in general.

And as you said, people might not even know that this is being applied to them. It might be based on the doctor's perception of their race, or them being racialized in a certain way. And that can lead to worse outcomes for people because it essentially assumes that, you know, black people start out at a lower level of cognition, and so they need to have reached an even lower level, relatively speaking, compared to a white person to qualify for a diagnosis of dementia or of, you know, of CTE or brain injury. And that's important because diagnosis is the key to get treatment, to get help, to get support and yeah, these [00:19:00] conditions affect more and more people.

So I think it's beyond the NFL, we should be looking at medicine, which is where a lot of these ideas come from. And again, question, where is it coming from? Does it still make sense to have such guidelines? Who is it benefiting? Who is it harming? because this is really problematic and it's an example that, yeah, it was very disturbing to me as well when I learned about it.

The role of physician diversity in healthcare

David Elikwu: In thinking about how some of that is resolved, you know, it actually pulls my mind back to the maternity example. I know that there are some people who might say, Oh, actually I want to have a black midwife if I am, you know, going into the ward or something like that. And I know that some people will then also have this fear. And now I'm not so much thinking about black people of, you know, It's been common in the news now, people talking about this DEI problem and actually, Oh, you know, as we are trying to correct some biases in representation in certain fields, there is a fear that, Oh, this also means that actually we're going to be introducing some subpar people and people that are underqualified may just get jobs simply for the fact that we need more representation and [00:20:00] there's a supposed idea that there needs to be more people from different races in certain fields, and that is kind of diluting the quality of people that are, you know, professionals.

How do you think about that factoring in?

Layal Liverpool: Yeah, I think it's, it's an area where there also has been some research up more in the U.S., but looking, for example, at physician patient race concordance. So what's the impact if the race of the physician matches that of the patient in terms of health outcomes? And there is evidence in the U.S. Where obviously there's a particular context of racism against black people that having a black physician, um, can lead to better health outcomes.

For example, there was a study looking at cardiovascular outcomes for black men in California, which found that those black men had better outcomes when they had a black physician compared to a non black physician.

We've talked about racial inequalities in maternal mortality, but there are also inequalities when it comes to infant mortality, in the U.S. but also in the U.K. And research in the U.S. has also shown that black infants had better outcomes when they were cared for by a black physician. And I think that work is, [00:21:00] it highlights, I think, an important issue that it is beneficial when we have physician workforce or healthcare workforce that reflects the population that they're caring for.

But I also think that, you know, all physicians should be able to take care of all patients. All doctors should be trained, for example, to recognize conditions on diverse skin tones. There is evidence that there are problems with that. So, for example, there was a survey of users of an international medical teaching platform, which found only 5% of the medical professionals surveyed said that they feel really confident diagnosing conditions across, you know, a diverse range of skin tones.

So I think things like that are really important to tackle because, we can't just say, okay, everyone should be matched to have a physician that is of the same race. I also think when we think about those outcomes, when it comes to physician patient race matching, let's say, I think a lot of that is more about trust and about being competent to care for people rather than about the race. So I think, what people want is to have a doctor who listens to them, who they can [00:22:00] trust, who they feel is treating them, you know, it equitably fairly, and I think that is more important than necessarily them needing to be the same race at the same time. I think that there's inequality and access to jobs and opportunities and there are a lot of very talented people who could be, you know, qualifying as doctors and taking care of people. And I think it's good to see increasing representation and opportunities for people at all levels in medicine.

Something I hear a lot from people here in the UK people will say, Oh, but the NHS is extremely diverse, which is true. You know, healthcare workers in the UK are from diverse backgrounds. There's really good ethnic minority representation in the NHS. But when you look into the data in more detail, you see that there are inequalities. So, for example, black people are underrepresented when it comes to being the most senior doctors in the NHS, so consultants. And there is an impact of seniority and hierarchy in these organizations that having representation at a lower level is of course important. But it's also important that we see that at the top, because I think that affects the [00:23:00] culture and the practices in that organization. So I think there's still a lot of work to do in terms of improving representation diversity in healthcare. And I do think that that will be helpful.

And I do not think that that means you're compromising on quality at all. I think that's a common misconception. In fact, there are many talented people, many smart people out there. It's more about just giving people the opportunity to pursue a career that I think is very admirable, you know, I really admire people who work in the healthcare profession. It's a caring profession. Most of the people who I've interviewed and talked to who work in this field really do care. They care also about racism, and how that affects their patients. So I think it's just amplifying that and increasing the work in this area to ensure that all patients can access that kind of care, where they feel listened to, where they can really trust the person who's looking after them in the healthcare setting.

Healthcare pressures and social inequality

David Elikwu: What do you think is the balance of the extent to which this is something needing to be solved? Let's say within the medical profession versus perhaps a policy level in general, because I mean, one, I think that [00:24:00] that's a, a distinct question in itself, but then I also can imagine how there are some knock on effects where, for example, when we think about the NHS in the UK, if the government has certain policies around that affect the number of doctors that you have and the number of new people being trained, how does that then trickle down into, okay, how much time do doctors actually have to evaluate different kinds of patients? And what shortcuts might they take? And how might they, you know, make certain choices differently because they are understaffed and, and things like that, that they might not make if there were more doctors or different types of doctors, et cetera.

Layal Liverpool: Yeah, I think there are a lot of pressures working in healthcare, it's a really difficult profession.

In the UK, for example, there we know that there are enormous pressures on the NHS, people are also underpaid and, so I think tackling those problems will be really important in terms of tackling racial health inequalities, and supporting, you know, healthcare workers with resources like education to diagnose conditions and diverse skin [00:25:00] tones, being aware of how racism affects patients health.

I think this is something that would be really helpful. And I think a lot of healthcare workers who I've spoken to would love this, that they're really in favor of getting access to more of that information and education.

Again, I think this is an issue that people really care about in the medical profession, but to come back to your point about, you know, are these more problems in medicine or in wider society?

I think definitely it's both, and I actually think wider society is the most important thing. As I mentioned before, our health doesn't start from the moment that we arrive in the doctor's office or in the clinic. It's something of, it's to do with how we live our lives and what opportunities we have to live the healthiest lives that we can.

And we know already that in society there are huge inequalities, economic, environmental, that make it more difficult for certain groups of people to access healthy living. And so I think those are problems that we definitely need to tackle.

I mean, we're coming to a general election. I'm not going to get into commenting on politics or things like that, but I do think we should just think keep these things in mind when we're thinking about [00:26:00] voting and, you know, how are we going to make sure that we're tackling inequality in society as a whole to then ensure that everyone has the opportunities to lead healthy lives.

And again, this is an issue that I think everyone should care about because if society is healthier, that's beneficial for all of us.

I think we saw that really demonstrated with COVID 19, you know, racism or other inequalities act as kind of fault lines in our society through which problems and infections, pandemics like COVID 19 can kind of creep in.

So no matter who you are, this is something that can affect you ultimately, you know, viruses don't discriminate. Eventually, if there are inequalities that result in the spread of infections or result in worse health or pressures on the healthcare system, that's going to affect everyone.

How pollution affects student performance

David Elikwu: One of the last things I wanted to come back to is something you touched on before, which is this idea of, you know, some people refer to it as environmental racism. And I can admit, even I, I think the first time I heard someone say that climate change is racist, even I was a bit like, okay, it sounds [00:27:00] like you're kind of overreacting something here, or, you know, what exactly are you talking about? And it sounded a bit silly at first. And then the more I thought about it, actually, intuitively, it does make a lot of sense and I can give a perfect analog that I think of, but I'd love for you to to unpack it, the idea properly, even for me, because I, I must admit I'm, I'm, not super familiar with exactly what that entails.

But the part that comes intuitively to me, I can think of one example, which was actually from China, this is now a number of years ago, but it was, it was just a very interesting study where I think, they were looking at this, I think it was like a village or a town or something like that, there's a river that goes through it, and so you can look at the population on one side of the town and, some the population on the other side of the town. And they had noticed at the time that there was this disparity in the grades, the attainment scores for students. And so on one side of the river, students seem to be doing a lot better than students on the other side of the river. And people came up with loads of different hypotheses about why that might be. Okay, maybe on this side, I don't know, things are just better. There are some better [00:28:00] schools here. People might want to move to this side of the river and things are a slightly better here. But it also turned out, and this is quite a small town. There was a factory on one side of the village that was putting out some pollutants, and at some point they just removed the factory. And then you can look directly at the before and after of attainment scores for children on both sides of, of this river where the factory was and where there was no factory.

And suddenly, as soon as you take away the factory, the air quality starts to improve, the number of pollutants starts to decrease. And suddenly children start doing a lot better and you didn't change anything else about the, you know, the, the education policy. You didn't change anything else about the level of schools, level of teaching, anything else. But suddenly, you know, you suddenly have much better outcomes for, for students simply by making this one change. And I think that's the part that comes intuitively to my mind when people talk about, okay, how might the environment also have some, some racialized outcomes where perhaps you might have different levels of investment in different areas, or you might have different levels of regeneration in [00:29:00] different areas.

Is that, accurate? How accurate is that based on what you know?

The effect of racism on environmental health

Layal Liverpool: Yeah. I think that it's clear that there are huge, you know, environmental inequalities and often this does fall on racial or ethnic lines that when there are groups in society that are marginalized, often, this means people are living in specific neighborhoods. And as you've given the example of poverty, pollutants in the environment, and that's a huge thing. You know, in the U.S. people of color are more likely to live in areas affected by environmental contamination.

We've talked earlier a bit about air pollution. I mentioned in England, for example, people of color are more exposed to air pollution, in the U.S. as well, you know, there's research showing that black and hispanic people actually contribute less to the production of air pollution, but they're still more exposed to it. And we know that air pollution is harmful to health, affects the lungs, increases risk of asthma and other things. But we also see this with other things, like for example, I mean, climate change on a global scale, it's very clear that there are massive inequities in terms of who's affected by that.

Often black and brown people in the global south are disproportionately [00:30:00] impacted, but even within, you know, wealthy countries like here in the UK or in the U.S., there are inequalities. So, in the U.S., you know, people of color are more affected by what's called the urban heat island effect. So living in neighborhoods that have less trees to create shadow and, you know, release moisture that makes it much, much more difficult to keep cool in hot weather. And I think heat is something maybe, it isn't perceived as a health threat, but you know, it's really can be really deadly. There's research showing that, you know, rapidly rising temperatures have exposed vulnerable populations to 3.7 billion more heat wave days in 2021, for example, compared to every year between 1986 and 2005. So we already see that change in quite a short time scale.

I think we need to be thinking about those sorts of inequalities, how we're making it harder for people to lead healthy lives just in the environments they live before they might develop an illness where they then need treatment and care. And then when it comes to accessing healthcare, we also see inequalities in terms of where people live. In [00:31:00] the U.S. for example, there's issues with access to, for example, maternity care, just simply where people live means they might not live close to a maternity ward because there have been a lot of closures of maternity wards in black neighborhoods.

So there are just examples like that where our living environment affects, you know, the air we breathe, water we drink. I was actually, as you were talking, I was just looking up, in the book, I mentioned, the issue of lead poisoning. So young children are particularly vulnerable to lead poisoning and it can really cause permanent damage to the brain, to the central nervous system. And there was a study in the U.S. showing that, you know, poor black children are especially at risk. So there was a study showing that black children living below the poverty line were four times as likely to have elevated levels of lead in their blood, compared to white children living in poverty.

So even there, where you're looking at a situation of already economic inequality, which definitely is something we need to be tackling. On top of that, you have racism and the history of racism that affects, you know, where people live and what they're exposed to.

So I think we really need to be thinking about [00:32:00] that. I think that's arguably the biggest, you know, factor that is contributing to inequalities is just where we live and what we're exposed to, which unfortunately is very much correlated with our race because of racism.

Neighborhood factors and their influence on health and education

David Elikwu: I think this is actually, I mean, everything we've talked about is extremely interesting. But this is actually extremely interesting and so pernicious in a sense, because it really is something that can so easily fly under people's radars.

And you often hear people talking about, Oh, pull yourself up by your bootstraps and oh, if these people can work, then these people can work. And it's just incredible that even if you take away all the individual experience, just the fact that you live in a certain type of area will have so much of a dramatic impact on your life outcomes in a lot of different ways. You know, like you mentioned the example of, okay, literally when you imagine the difference between perhaps the inner city and the suburbs, just the fact that you have more or less trees in a particular area can impact the amount of heat that you feel, the number of hot days that you have, and how that can affect you.

And [00:33:00] also I know there's been studies on, I think the UK in general, and also specifically in London, where, and this is just generally on the impact of air quality on children's exam results and on the days that in London, there just happens to be lower air quality. Children perform worse on exams. And I know that that's not necessarily something that test takers take into account and they say, Oh, actually air quality is pretty bad today. Maybe we should move everyone's GCSEs up by a day, but just the idea that that has an impact, then you can also think about, okay, for people that live in areas that have lower air quality. How might that impact their homework, their studying, their day to day lives, even outside of school and everything else that happens before the exam day. Like that is already something that's affecting them.

And funnily enough, something that you were saying also brought to my mind, this example, slightly, I mean, kind of health related in a sense, but you'll, you'll understand where I say it.

One example that relates to what you're saying is also like food deserts, right? So in certain areas, there's not many [00:34:00] resources. There's not enough stores, things like that. But one study I found really interesting, I think it was Malcolm Gladwell that was looking at this was, people very often referenced this idea that in certain black neighborhoods, there are a lot more, you know, the homicide rate is higher. There were a lot more people that die from certain kinds of things, blah, blah, blah. And what was so interesting is they did the study and they looked at it twice, where actually, there is a distinct difference between the homicide rate and the gunfire rate. And so what that means is, okay, if you look at how many like, shootings were there versus how many people died, there is a drastic difference. And then you can take that map of places where shootings happen or someone got shot then you can overlay that map against where are the hospitals and where are the ICUs?

And then I think they were looking at Southside, Chicago as a specific example, where actually, if you can only take someone with a gunshot wound to these three ICUs, and all of them happen to be in wealthier areas because you have to pay, [00:35:00] those wealthy areas are also whiter areas. And so actually if someone gets shot over here in an area that is, you know, that has less resources, that has disproportionately more ethnic minorities or black people specifically, it's going to take them longer to get to the hospital and to get treatment. And simply because it's going to take longer to get someone that's been shot to a hospital, they are more likely to die, and so the homicide rate is almost guaranteed to be higher.

And so it's just this idea that, simply because of how we design our neighborhoods and how we design our cities, and simply because of the way different people live in different areas, that in so many implicit ways affects their health outcomes that, we don't even realize on the surface. And it's so easy to point to the easy excuse and say, Oh, these people must just be killing themselves more. Well, actually, no. Like if you put some hospitals in this specific area, so ICUs, how much might that change people's health outcomes?

Systemic barriers in healthcare education and access

Layal Liverpool: Yeah. I think that that's, I didn't even, I wasn't aware of that [00:36:00] example in that detail, but I think it's such a good point that it's access to healthcare is really important and having just the resources that we need to live healthy lives.

You often hear discussions about, Oh, we need to educate people, we need to teach people how to be healthier, which can feel a little bit patronizing as if it's like, Oh, people don't know how to be healthy. I think people know, but as you point out, some of these things are just so pernicious, they're in our environment. It's almost like you're already being set up to fail when it comes to your health. And I think that's really unfair to kind of put that onto people.

Talking about COVID and there was a lot of discussion, for example, about vaccine hesitancy among black communities, Asian communities in, in the UK. And again, I felt that this discussion was kind of missing the context of, you know, people may have been harmed by this healthcare system. There may be historical reasons for that mistrust and dismissing it as, Oh, these people just don't understand how vaccines work is really, it's really incorrect, but also it's, yeah, it's dismissing people's real experiences. [00:37:00]

People have experienced racism and it's important that we approach that from a point of how are we going to build trust with people and make sure that people do have access to vaccines rather than treating that as something, you know, dismissing people and thinking that they just don't understand how these things work, because I think that's just not true.

The impact of racial inequalities in mental health

David Elikwu: Is there anything else that either you cover in your book or that you're aware of that you think would be worth discussing that we haven't covered?

Layal Liverpool: We haven't talked about, as much, but, that I think is also important. We've talked a lot about physical health because I think, maybe that's an area where there's, there's a lot of research, but I think also mental health, is an area where we see racial inequalities.

And I think it's important, you know, it's as important as our physical health and, I think there, there are different ways that, that affects health. So I think, there's the issue where racism itself, we kind of touched on this, that just knowing about these inequalities and experiencing racism affects our health and maybe our expectations about our health.

But I think also, there can be racism when it comes to prevention. So, you know, in mental health care, it's [00:38:00] something that I also experienced in the past, just trying to access, you know, therapy, just to process things happening in my life, that when I tried to broach topics related to racism or experiences of racism that I was facing in my life, one of the white therapists that I saw was really struggling with that. And I could feel that she was uncomfortable with me talking about racism. And I think that's a big issue that, you know, practitioners need to be trained to be able to, to tackle these issues because racism is something that can affect people's mental health.

I am based in Germany usually and, in Germany there's research showing that, you know, many people, particularly black people, have felt that their experiences of racism aren't acknowledged or are kind of dismissed in the context of psychotherapy. So there was a survey showing that I think 62% of black people felt that their experiences of racism were not taken seriously in psychotherapy. But there is also similar research in the UK and in the U.S., so I think that's important because it can put people off seeking care and that then can contribute to inequalities that we see when it comes to mental health conditions. So, you [00:39:00] know, I think minority groups are often undertreated for common mental health conditions like depression and anxiety.

But we also see, for example, that for black people, black people are underdiagnosed with depression, but then overdiagnosed with schizophrenia in a kind of stigmatizing and racialized way. So I think there's a lot of dynamics there. In the U.S. as well, we see that, there are inequalities in terms of, black people experiencing a mental health problem, particularly black men are more likely to be dealt with by police and maybe shot by police compared to white men experiencing a mental health problem in the UK and in the U.S we see that black people are more likely to be detained involuntarily for psychiatric care. This is obviously really traumatizing and is a huge problem that can also affect people's experience seeking mental health care.

Yeah, that's my long way to say that. I think we should also think about how racism affects mental health, because we also, we know that mental health and physical health are connected. And yeah, these things are all important when it comes to, to recognizing racism as a public health issue and then thinking about what we can do [00:40:00] to address it.

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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