May 22, 2024 • 57 mins
Dr. Akua Gyamerah and Nada Fox discuss the importance of considering intersectionality in understanding health disparities. Dr. Gyamerah emphasized the need to examine how different social determinants intersect to produce unique health outcomes, while Nada Fox inquired about the challenges of studying these complex issues. Both speakers highlighted the importance of measuring intersectionality to better understand these interconnected factors. Later, they discussed the intersections of gender-based violence, substance abuse, and HIV/AIDS, emphasizing the need for comprehensive approaches that address these interconnected issues.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Nada Fox (00:05):
Welcome back, public health enthusiasts I, Nada Fox,
am here today with AkuaGyamerah, assistant professor
here at University of Buffalo.
Thank you so much for taking thetime to meet with us today.
Dr. Akua Gyamerah (00:20):
You're very welcome. Thanks for inviting me.
Nada Fox (00:23):
Absolutely. So before we get into all your very
interesting research, can youtell us a little bit about your
background?
Dr. Akua Gyamerah (00:32):
Absolutely.
So I, my background, let's startwith being born in Ghana and
growing up in New York City.
Because it really shaped myexperiences with public health,
and just accessing health. Soyou know, growing up in an under
resourced community, in Ghana,and then in under the stories
(00:55):
community in New York City, inQueens, New York City, I saw the
ways, you know, social factorsimpact health outcomes. And it
really inspired me to pursue aprofession in health, initially
medicine, and then eventuallypublic health. And so that's a
little bit about my personalbackground, in terms of my
(01:16):
professional background, youknow, I trained in social
Medical Sciences at ColumbiaUniversity. That's where I got
my masters and my doctorate. Andthen I did a postdoc at
University of California, SanFrancisco, and HIV. And so it's
from Oakland, California, SanFrancisco, California, that I
then moved to Buffalo, to teachat the Community Health and
(01:37):
Health Behavior department. Somy research area is in global
health, and I focus on HIVprevention and care, the
intersection of gender andsexual rights. I'm also very
much interested in the impact ofsocial stressors like
criminalization, violence,stigma, and factors like that,
(01:57):
how those shape mental healthand other physical health
outcomes among sexual gender andracial minorities. So my
research has primarily been inGhana, Africa, West Africa, but
I've also done research in theUS with minoritized communities,
particularly trans women, queerfolks, and the topics of, of, of
(02:22):
violence, mental health,substance use, and HIV. So I
think I'll stop there. Or maybeI'll just add to that, that, you
know, at the heart of thisresearch is, is really to
document people's experiences,particularly marginalized
populations experiences, so thatit can inform advocacy and
(02:45):
social change. And so that's,that is what I'm passionate
about. And that's what this workis driven by.
Nada Fox (02:52):
It's wonderful, and it's really important work.
Dr. Akua Gyamerah (02:55):
Thank you.
Nada Fox (02:56):
So your research focuses on how historical and
socio structural factors such asracism, and our intersectional
stigma, impact disease outcomes?
How did these factors contributeto health disparities and these
marginalized communities?
Dr. Akua Gyamerah (03:13):
Yes, these factors are very, very
important. And I reallyappreciate this question. I
teach pub 420, socialdeterminants of health. It's an
undergraduate class. And ofcourse, as I said, I trained in
social medical sciences. Thesefactors are what I focus on in
my own research, I really,really think it's important in
public health that we train, youknow, generations of researchers
(03:37):
to understand how social factorsand historical factors impact
health and how they are thedeterminants of downstream
factors, right downstreamfactors being individual
behavior, within interpersonalyou know, factors like social
support, and, you know, personalrelationships. You know, those
(04:00):
are, are all important, but whatpeople are able to do for
themselves and with for eachother, is shaped by our
conditions, right? You know, areshaped by conditions, do I have
time to show up for someone? DoI have time to exercise for
myself? Do I have time to reallychange my health if things are
(04:24):
moving in a direction that isadverse to my my health
outcomes? So I'm just being liketime, for example, because many
working people are spending somuch time so much of their time
awake, working, and it cuts intoyour ability to actually care
for yourself, right? This is noteven to speak to the conditions
(04:46):
of one's work, or speak to youknow, whether someone has money
to even afford to make changesthat are being required of them.
So that's just given examplesfrom related to, you know, one's
class status. Well, I tend totalk about poverty. And in
(05:06):
sometimes we distort how orwhat's the word I'm looking for?
Characterize? Poverty, right?
Many people are living paycheckto paycheck, right? That's not
exactly a way to survive, right?
We don't talk about researchthat shows that, you know, how
(05:27):
stressful living paycheck topaycheck is on people's lives.
So, just to come back to yourquestion, just given examples
of, of structural determinants,historical determinants, I named
that because there is a, there'sa way our understanding of,
let's say, racism, for example,is watered down, and I talk
(05:51):
about this in my class, oftenbecause it's become racism has
become you know, about how wetalk to each other, or treat
each other, or personal biases,and less about actually the
historical legacy of racism. Andlet's say, in this country,
racism differs from country tocountry. But in this country,
which is the birthplace of, of,of racism, there's lots written
(06:16):
and I will go on tangents ondebates on that. But, you know,
the transatlantic slave trade,marked the beginning of, of the
construction of race to justifythe stealing and exploitation of
human beings to build thisnation, and that historical
legacy, just, you know, endedover to a little over 200 years
(06:40):
ago, right. And so, to thinkthat, while the slave slavery
did not racism, it then wasrestructured in, in different
ways, to then as a, as the ruleof law in this country. So, you
know, post reconstruction in theUS we had, sorry, Jim Crow,
(07:06):
right, which, you know, fordecades was the law that that,
you know, segregated blacks,blacks and whites in this
country, and eventually, withsocial movements that was
overruled, and we hadintegration, but that was then
replaced by what MichelleAlexander calls The New Jim
(07:26):
Crow. Michelle Alexander is alegal scholar, who has written
incredible things about how massincarceration has has, is the
new caste system that maintainsracism in this country. And she
says, After Jim Crow, it wasreplaced by the new Jim Crow,
(07:47):
and that is the disproportionatepolicing and incarceration of
black people in particular. And,and the the second class
citizenship, those who areincarcerated then are reduced to
right. So she talks aboutdisenfranchisement of formerly
(08:07):
incarcerated people, ways yourrecord follows you and
unemployment, loss of access topublic programs, because of your
background, right, and the roleof the war on drugs and, and
these policies, right history,historical policies, on on
(08:30):
incarceration records of, ofblack communities, right. So I'm
going on that time just to showyou that there's like historical
legacy of racism and how it's,it's transformed over
generations to consistentlyimpact the conditions of black
people, or Latin X folks orindigenous people, etc. And that
(08:50):
we can actually trace that andstudy how that has impacted
people's health outcomes. Soracism, poverty, social networks
have all been identified asfundamental causes of health
disparities, health outcomes andhealth disparities. Bruce
Lincoln and Joe Phelan havewritten about this, this
(09:13):
concept, and the argue that weneed to as public health
professionals, not just focuson, you know, you know, like
different factors, but actuallytarget the most fundamental
ones, because what they theorizeand documented or demonstrated
(09:34):
through literature reviews wasthat there are particular
determinants that arefundamental regardless of how
you change the pathway, right,how you intervene on this
particular factor. The outcomeis still adverse. And that is
because there's somethingfundamental about that issue,
and they named poverty, socialnetworks and racism among
(09:57):
others. Gender was another one.
I'm particularly men, which isinteresting as as all causes of
health, you know, healthdisparities, including, you
know, lower life outcome andmortality, different mortality,
morbidity, morbidity outcomes.
(10:19):
So, all of that is to say, Ihope I answered your question,
that these structural factorsare really important, the way
they framed it was like, whatare the determinants of the
determinants? Right? What arethe the factors that are driving
other factors downstream, thatthen shape our conditions and
(10:40):
health outcomes. And it allboils down to whether someone
can have access to resources tohelp them mitigate. Other risks?
Yeah. So, if your risk isgenetic, right, and you have a
lot of money, you are able toafford the best, best standard
health care. Right, but if youknow, you have the same genetic
(11:02):
risk, but you are poor, oryou're not in a network of
people who might have you know,might be medical doctors, or
might have more money to helpyou by this, you know, genetic
predisposition, you will havemore likely to have an adverse
outcome, right. That's just anexample of, you know, just
(11:26):
using, you know, class or socialnetworks or in class as examples
of fundamental causes. Outthere, but you can ask follow up
questions, if you want. Yeah,
Nada Fox (11:39):
Well, I just, I think it's really interesting the
determinants of thedeterminants, it's not like
something like I have thoughtabout before, but then that
makes like total sense, the wayyou like, kind of laid that all
out. So sorry, that's why I wassitting there like staring at
you, my mouth. Never heard this.
Dr. Akua Gyamerah (11:55):
And when I heard it to, and just like, you
know, it clicked, like, ofcourse, is the determining
factor determines the internetin a very flat weight, right? In
part of what social ecologicalmodel tries to do this, you
know, like, show the way thesedifferent levels of factors
shape each other. And, but Ithink what the fundamental
(12:18):
causes theory does is take anadditional step and says, yes,
you'll look at that model. Andthere's a lot of factors, but we
want you to focus in on the mostimpactful factors, the things
what they call the mostfundamental, if we give everyone
universal income in thiscountry, meaning enough to
survive and you know, take careof your needs. Their programs
(12:43):
are piloting that, right? Andthey're trying to highlight that
a universal income. Why couldn'twe do that? Right? Why can't we
redistribute wealth so thateveryone can live it like a
dignity and not be struggling?
To survive to take care of theirfamilies or themselves? Right,
Mike, this is this, we don'thave to live the way that
(13:03):
society structured, right? It'snot necessary, we have more than
enough to meet everyone's needs.
And for me, that is really mybiggest frustration. As someone
who's very, you know, feels verypassionately about health
justice, and another socialjustice issues. But anyway, I'll
(13:25):
stop there.
Nada Fox (13:26):
I like I agree with you. I remember reading like
this that like, startlingstatistic that there are more
houses than people in thiscountry. I know, like, put them
why is there anybody that'shomeless? Like, everybody should
have a roof over their head islike a fundamental right. So
you're in like minded company,like, you know, there's some
facts you can't unhear, and thenyou can't be blind to anymore?
Dr. Akua Gyamerah (13:49):
Yeah, exactly. Yeah. I also wanted to
speak to I think, the otherfactors I study is
intersectionality. So we'vetalked about, you know, poverty
and, and race, you know, thereare different forms of, of
determining or differentcategories, categories that we
(14:13):
often talk about in publichealth, and often will study it
in a very shallow or symbolicways, right? If you feel a
survey, what's your race, what'syour income, what's your you
know, Job Status, what's your,you know, gender. And there are
(14:34):
folks in social determinants,because you can study social
determines from that angle,right. But there are other
scholars, you know, activistcommunity activists who say we
can't look at these thingsbecause they don't represent
what you think it they don'tmeasure what you think they're
measuring right race does notmeasure racism. Right. Race does
(14:57):
not measure racism racemeasures, race. How do we
measure the impact of racism onsomeone's race? Or a race of
people? Right? These are not thesame things. And so thankfully,
there's no, I'm going to say amovement but like a trend in
(15:21):
public health now, where peopleare trying to figure out ways to
measure racism, right? What arethe mechanisms that lead to
disparate racial outcomes,right, these health inequities
among minoritized, raciallyminoritized populations? And so,
you know, studying massincarceration, for example, how
(15:42):
does racism manifests in thiscountry? Racial segregation,
looking at the impact of racialsegregation, and people self
looking at the impact of, youknow, different carceral
policies, people can look atstate level policies, people can
look at disenfranchisement, andsee whether you know, their
health outcomes is impactingdifferent health outcomes in
(16:05):
terms of racial disparities,right. So that is one of the
things that I think is reallyimportant to talk about, like,
so we've made the factors, howare we actually studying and
measuring it. And that isanother thing, but it plays to
why it's important to have asocial analysis and social
framework, to then inform howyou're studying the issue,
(16:28):
right? Because how you definethe issue. And understanding
will shape how you measure it.
And so I just want to say thatall that is to say, one of the
other trends in public healthis, is bringing in the framework
of intersectionality. Trying tounderstand the relationship
(16:50):
between multiple forms ofoppression to each other, how do
how do racism, gender, sexualityclass interlock to produce a
different outcome than theindividual parts, if that makes
(17:14):
sense, right? So, you know, Idon't know how you identify
racially, or do you intensify?
Nada Fox (17:23):
I'm white.
Dr. Akua Gyamerah (17:25):
Okay, so, you know, let's say you identify as
a or someone who identifies as awhite woman will experience you
sexism as an example, right?
Sexism differently than someonewho's a black woman, right? This
is the intersectionalintersectional intersectionality
detection theory basically,emerges from this analysis,
(17:46):
right? It's a theory thatemerges from black, fig women
figures, activist, historicalfigures. The concept itself is
the term itself is relativelynew, but the concept is not.
Right. So during the truth inthe 1800s, as well, I'm speaking
to the women's convention says aNyoman right, because black
(18:09):
enslaved black women were wheretheir issues were not considered
in, in the first iteration ofthe women's rights movement,
right? They were in talkingabout racism and enslavement and
how that impacts black women.
And so she talks about thatconcept and talks about the
(18:31):
different oppression that blackwomen faced, right. Fast forward
to, you know, the next century,you have generations of black
feminists who talked about thisin different ways. The Combahee
River collective. You know, Billhooks talks about this, many of
Angela Davis talks about this.
And then Kimberly Crenshawcoined the term
(18:54):
intersectionality in her legalpaper. I think that that the
intersection is I don't want tobutcher the title look at look
her up, but it's a formativepaper. She's a legal scholar and
Critical Race theorists. And herwork was incredible because what
she did was look at laws and sawhow women of color were falling
(19:16):
in the cracks. Because theselaws were only focusing on one
dimension of the oppression theywere supposed to mitigate.
Right? She says here, you know,example, the carceral system is,
(19:37):
you know, judicial system issupposed to prosecute sexual
abusers. Well, let's look at thedata. You know, black men are
most likely to be incarcerated,especially if they have their
victims are white women. Blackwomen are the least likely to
receive justice, especially ifthey're, you know, their
perpetrators are white men. or,you know, other other men who
(20:00):
are not necessarily black,right. And she shows through
that data, she shows us a, youknow, an intervention made for
immigrant women that wassupposed to support abused
immigrant women from leavingyour abuser so that you're not
dependent on on documentation,like immigrant papers,
(20:21):
basically, legal documentation.
So a lot of women wereundocumented women were stuck in
abusive relationships, becausethey're afraid to leave and not
have a chance to get citizenshipor permanent residency. So this
law, you know, there's, youknow, a law passed to allow for
(20:42):
me to leave, but they didn'ttake into consideration all
kinds of factors related tolanguage barriers, income
barriers. And so, the point herewas, like, there's a policy
that's addressing a genderissue, but not looking at the
impact of class on on thesewomen, right? Or the impact of
(21:03):
gender in addressing racism, theimpact gender has an undermining
the progress that's made aroundracism, and she says, we need to
address these intersections, sothat multiple oppressed people
are not falling in these cracks.
So intersectionality is nowbeing used in public health
(21:23):
research increasingly used inpublic health research to
actually understand how multipleinterlocking oppressions shapes
people's health outcomes, and wecannot assume also that the
impact of this interlockinginterlocking oppressions is
cumulative, that if you areblack, and poor and gay, and you
(21:49):
know, you know, non binary and,you know, that means things are
worse for you. Sometimes youlook at actually multiple people
with multiple workersidentities, their outcomes
actually better than those whoare not, you know, so what she
(22:12):
points to is like to actuallyunderstand the, the, what
happens when these differentthings interlock and interact,
are there things that areactually protected? Are they,
you know, does it you know, theoutcomes worse, the point is to
understand because something ishappening here that we do not
catch, if we only look at itfrom one dimension. So I'll use
and I'll stop here, I'll useimmigrants as an example. I'm
(22:36):
sorry, Latino populations,including, there's a lot of
research done on immigrantcommunities on this, and there's
this has been this called theHispanic paradox. And this has
found that research documentingthe index communities actually
have better health outcomes,then compared to, you know,
(23:04):
white, white populations, andpeople were surprised by that,
because of the history of racismagainst black people in this
country. And so, research, tryto understand why that is,
(23:24):
right. The other there are othersocial determinants that you
know, show that they have, youknow, lower average income or
education, because ofmarginalization, they might have
higher disability, etc. However,in terms of, you know,
mortality, they have lower riskof mortality, like 24%, lower
(23:45):
risk of mortality, compared towhite people. And so the
question was, like, what'shappening here? And one of the
theories is that thosecommunities are more communal,
there's more networks, andnetworks, as I mentioned
earlier, can be a fundamentalcause, right? And you'll find
(24:06):
this in other immigrantcommunities, too. So this is
also why, you know, I'll justtake for example, when people
study black racial disparities,also say let's break it up by
communities because sometimesimmigrants, black immigrants are
doing better in terms of healthoutcomes, then, you know, black
(24:28):
communities that havehistorically been here and like
historically marginalized in away that, you know, recent
immigrants are not experiencingright. There's studies looking
at epigenetics and how one'senvironment right. Can shape
once genetics rate, people arestarting to study you know, how,
(24:51):
you know, slavery might havechanged, you know, are shaped,
you know, different I haddifferent biological impacts
that might be affecting health.
Now, I that is not to say thatrace can be biologically
measured. Let me not get intothat. That race signs nonsense.
(25:13):
That's not what I'm referringto. But really looking at once
and how a one's environment canactually interact with with the
body and adversely impacthealth. So anyway, I'll stop
there.
Nada Fox (25:30):
Thank you. And that was really interesting. So you
did a project that explored theimpact of gender based violence,
and the COVID 19 pandemic onalcohol use and treatment among
gender minorities in the SanFrancisco Bay Area? How do you
(25:50):
approach studying these complexand interconnected issues? You
just talked about all thesedifferent intersectionalities?
And how we need to look at this?
How do we design this research?
How do we go about studyingthat?
Dr. Akua Gyamerah (26:04):
That's a great question. Well, I
definitely don't have answers,because that's part of what the
number of us are studying.
There's actually anintersectionality training
institute that was formed a fewyears ago by a really wonderful
scholar, another one of theleading scholars in looking at
into intersectional, stigma, andhealth and health. Lisa bowlegs,
(26:25):
she's a psychologist, and peopleare trying to figure that out,
actually, there are methodsbeing developed on you know, how
to measure intersectionality,especially quantitatively,
qualitatively, also, how do weanalyze it? But especially, or
(26:45):
ask questions, I couldn't get tosome of these factors on the
complexity of these factories.
In terms of this study, in SanFrancisco, that was a very
difficult study, to do justbecause of the trauma that many
(27:08):
people being interviewed hadexperience. It was a mixed
method study. So we hadquantitative measures exploring
people's experience of aviolence, gender based violence,
and the impact of alcohol andother substance uses on on that.
(27:29):
And yeah, the stories were, youknow, very difficult to listen
to obviously. So just a thing tosay, you know, what, one of the
things we don't talk a lot aboutus, like the how the mental
health impact of actuallystudying traumatic experiences
(27:49):
and studying violence, and evenstating things that might be
personal to you also, whetheryou share an identity or an
experience of trauma, etc. Soit's definitely not easy. But in
terms of the study itself, theywere looking at different
factors, it was right at thestart of the epidemic. And the
study was nested under aclinical trial, that was testing
(28:12):
the efficacy of a natural planton reducing alcohol use among
adults. So it's a Japanese plantcalled kudzu, you and it's
extract was used to, you know,just to was tested to see if it
(28:34):
reduces people's cravings foralcohol, as well as frequency of
drinking. So I just did my studyunder that I wanted to look at
gender specific factors thatimpact alcohol use. And I focus
on gender based violencespecifically. So, you know, we
(28:54):
we asked questions aboutlifetime experiences of
violence, as well as violenceduring COVID. If COVID had just
started, and we were seeingstudies, one of the most
immediate things we started withyou remember, was just like, you
know, studies are showingincreased drinking and also
increase in domestic violence.
And so I wanted to look at that.
And I wanted to look at therelationship between the two as
(29:15):
well. So that's what that studylooked at. So we did cross
sectional in depth interviewsbetween April like 2021 and
2022. And these questionsexplored, as I said, lifetime
experiences of verbal physicalsexual violence and real
substance use played in that andthe impact on people's lives.
(29:38):
And they're just, you know,different stories. Some some of
the, the folks we interviewedwere sex workers, who
experienced just, you know,horrific violence, gendered
violence. Some experienced datejust you know, women Hearing on
(30:00):
dates and experience date rapeand other sexual violence. Folks
who are housing insecure, alsoreported experiencing verbal
abuse. So these are thedifferent factors impacting
folks, right? Sex work, putpeople at higher risk, alcohol
(30:21):
during you know, Gates causepeople to be at high risk of,
you know, perpetrators usedalcohol as a way to facilitate
abuse is what The finding wasbasically one of the findings,
then, as I mentioned, housinginsecurity, as you may know, the
Bay Area has one of the worsthousing prices in the country.
(30:45):
And it's kind of like a, like,occurring epidemic with also
substance use and mental health.
And so, yes, there's a lot ofhomelessness and a number of
participants also experiencedsexual violence. Due to housing
insecurity, a number of peoplealso talked about, you know,
(31:08):
violence during your youth. Sosexual violence they experienced
as children. And this wasparticularly like, consistently,
we have 20, assembled 20 to fivewomen were black, and all of
them had the same story. So I'mlooking at the the ratio of the
racial dimension of this,understanding some of the impact
(31:31):
of childhood trauma on substanceuse adult, you know, substance
addiction, and, you know,subsequently homelessness. We
knew, all these women who hadexperienced sexual violence from
adult men in their lives orolder men, they might have been
children as well, but justolder, would make up the boys.
And this led to early use ofsubstances to cope. On some of
(31:58):
them were just introduced tothese substances, as I said, to
facilitate abuse. But some alsostarted and then became
dependent because it was amiracle. And then you had also
folks who experienced adult IPvintimate partner violence. And
(32:21):
then, and then there were youthintimate partner violence as
well. So you know, key findingsfrom our studies, you know,
there are, yeah, experiences ofviolence being facilitated by
(32:42):
violence, or, you know, peopleusing sort of being facilitated
by alcohol use or thesubstances. And, and folks are
also coping with the trauma ofviolence through substance use.
And so just a few findings fromthat study, another being that
COVID Many people share theirCOVID did worse than violence,
(33:03):
get experiences of violence,many people are trapped in homes
with abusers and couldn't leaveabusers, some of them are
dependent on the women formaterial support. And so they
would use them to maintain thatcontrol and support. So yeah,
and you know, the most heavyalcohol use was about 91% of the
(33:28):
participants, there wassomewhere to use about 28% of
participants and crack use22%.of participants. And, yeah,
I don't know if there's anythingelse. But yeah, and
Nada Fox (33:52):
Thank you for sharing.
And it sounds like self care isvery important when you're doing
this type of research.
Dr. Akua Gyamerah (33:58):
I would, I would be lying if I didn't say I
was very impacted my mentalhealth, my mental health
suffered from this. And I canonly imagine what it's like
living with that trauma. So ifyou know.
Nada Fox (34:13):
So, all right. Well, given your experience, or excuse
me, given your expertise in HIVprevention and care, what are
some key findings or insightsfrom your research that could
inform public health strategiesfor addressing HIV disparities
among LGBTQ plus populations?
Dr. Akua Gyamerah (34:37):
Yeah, thank you for that question. There's
definitely you know, one of thethings we learned very quickly
in the AIDS epidemic, the firstthe beginning days of that
epidemic is just the role ofstigma and anti anti gay
discourses and beliefs indriving stigma against
(35:00):
populations impacted by HIV mostimpacted by HIV. Right? So the
beginning days, it was calledthe gay related group, it was
called Great. I'm trying toremember what the Id still stood
for I look it up right now. Yes,gay Related Immune Deficiency,
or the gay play gay syndromealready was very much conflating
(35:25):
one sexual identity with withthe disease. And there was a
moral panic, driven by, youknow, social actors, anti gay,
social actors, politicians,conservative politicians, in
response to the epidemic, right,so we knew from the very
beginning what role that playedbecause it actually impacted how
(35:46):
quickly the government respondedto the epidemic, which was not
very quickly. You know, manywere like, well, this is
punishment for gay people forquote, unquote, sinning. And so
you know, let them die. And, youknow, as the epidemic
progressed, and we learned moreabout it, we found out that, you
(36:06):
know, Haitian immigrants weredisproportionately impacted.
injection drug users will alsodisproportionately impacted, and
hemophiliacs were impacted. AndI think the term was the four H
club, Haitians, homosexuals,hemophilia eggs, and forgetting
(36:27):
what the fourth H was. All kindof to me, here when users sorry,
and so very stigmatizing, right.
And that led to thesepopulations being marginalized
in society. And with moreknowledge about how the virus
(36:47):
spread, with protests from thecommunities impacted,
particularly the gay community,and allies, there was a shift
and finally funding,unfortunately, give that history
only to say that unfortunately,this legacy still exists. In our
research, there's still a stigmaagainst gay people around HIV,
(37:09):
whether people will see it ornot, it's not the same level
right? of stigma doesn't lookthe same. But there's still
stigma, including internalizedstigma within the community
around HIV. And so I think, interms of what can be done to
address it, we need to continueto educate people about HIV and
how HIV spreads, and how peoplebecome at risk for HIV IV,
(37:33):
right? How we construct a riskis really important. That's
another thing I talked about.
And it was something that Ifocused on in my dissertation in
Ghana, because in Ghana, andmany sub Saharan African
countries, governments did notinclude queer men in HIV
policies, the epidemic wasconstructed as a homosexual
(37:56):
epidemic in the West. And so inWestern countries, the US,
Europe, Canada, etc, compared toa quote unquote, heterosexual
epidemic in the Global South,particularly in Sub Saharan
Africa, which was the mostimpacted. And that's led to, you
know, this downstream effectwhere funding then went to
(38:18):
address in heterosexualtransmission and mother to child
transmission, young women, whowere, you know, at risk, because
of, you know, gender inequality.
And gay men were ignored. So ittook almost 25 years in Ghana,
in particular, for HIV policiesto acknowledge male same sex
(38:39):
transmission. And what we'velearned about part of that is,
you know, criminalization of, ofgetting, you know, identity or
same sex sexual activities is akey driver of, of these of high
HIV risk, right? I'll give sinceGunnersbury. Do my research.
(39:03):
Gay, Bisexual, and other men whohave sex with men have an HIV
prevalence of 80%. The mostrecent surveillance study that
finally included trans women,shows that trans women have any
JV prevalence of 46% that isalmost wanting to trans women
(39:26):
are HIV positive. And one infive gay men are HIV positive.
Or negative men who have sexwith men excuse me, just because
identity and sexual behaviorshouldn't have completed but
yes. So, you know, this is ahuge disparity there. The
(39:51):
country's prevalence is onepoint at this point, I think
it's 1.4 1.5%. And so You know,one could look at this and say
This is punishment for thecommunity or we can actually
look at what's driving thisepidemic. And, you know, as
research has demonstratedstigma, people being afraid to
go into the clinics because of,of anti gay sentiments and
(40:15):
criminalization of melting sexactivities. You know, lack of
public education on just how HIVspreads it, HIV is more and more
not spoken about, on the radioor on TV as much just not as
much public health campaignseducating people about it,
(40:35):
because especially in contextwhere populations, key
populations like trans women andgay bisexual other men are
criminalized. It's important tohave public education because
then everyone can have access tothat, including those who are
too afraid to come to programsthat would teach you targeted
(40:56):
programs that teach you aboutrisk and protection, good
resources, etc. In Ghana, malesame sex sexualities are
criminalized. It's a colonialera law, that is common in
Commonwealth countries offormerly British colonized
countries. So you'll find thisin the Caribbean in many parts
of Africa and parts of Asia.
(41:18):
These laws exist their Britishcolonial laws, it used to exist
in the US until 2005, I believe,or three anti sodomy laws were
just recently. Yes, we're justrecently overall didn't at least
regularly. So. Yeah, this is,you know, when we talk about
history, very recent history,and some of it still ongoing in
(41:42):
different parts of the world. Sowe need to decriminalize, but
not just decriminalize, we needto protect people,
decriminalizing is not the sameas you know, having rates
criminalized and then haverights protections for LGBTQ
populations. I think we need tochange social attitudes,
(42:02):
decriminalizing given rightsprotections will have a
downstream effect, right,including changing social
attitudes. There are many peoplein Ghana who have quick, you
know, cousins or family membersand are, you know, hang out with
them and are cool with them, butpublicly will save violent
things, right? Because theydon't feel they feel socially
(42:22):
pressured to. I think when wechange laws, that can help shape
and create space for people toreally just publicly, you know,
show empathy and and feel saferto be supportive. Are there
people who are just supportiveand they're free to say
something because you're free,you're free to social
(42:44):
marginalization andostracization? I think we need
to have influential communityand public figures speak out
against violence. And this isall very specific in to Ghana,
in contexts like Ghana, wherethings are very, that's where
we're at. People don't even wantto speak out against acts of
violence, brutal acts ofviolence against LGBTQ people.
(43:07):
Currently, there is a proposedactually a past Parliament
proposed bill that is still notlaw, though. But it's a bill
that was introduced in 2021. Tofurther criminalize LGBTQ people
to went from criminalizing youknow, unnatural, carnal
knowledge, which is basically,you know, any sex is considered
(43:28):
a normal non, you know, vaginalpenetration of penal penetration
of whatever this is verygraphic. But, you know, what, I
mean, you know, this sodomy oryou know, other forms of
sexualities that are considereddeviant and unnatural, right. So
this bill aims to criminalizeidentities, advocacy, and Ally
(43:52):
ship of LGBTQ people, so LGBTQpeople can face up to three
years in jail, advocates canface up to 10 years. Ilyas will
face years in prison if theydon't, you know, and and it also
encourages people to reportfamily members and people they
know who are gay. It ishorrendous, it would it would
make illegal you know, anygender affirming care or
(44:15):
surgeries, etc. And so, youknow, this is a backlash and my
research actually mydissertation was looking at how
Ghana shift to include policy toinclude queer men in HIV policy
was contributing to thispolarization and politicization
(44:35):
and backlash. So I was studyingthat in 2014 2015 2016. And now
we're seeing some of the some ofthis backlash culminated to a
law or a bill that might verymuch become law. So I'm just
highlighting this becausethere's not space. When people
(44:56):
are criminalized, it is very,very difficult. Um, for them to
access resources that they need,when the very thing especially
around HIV risk, STIs, etc, thevery thing that might will put
them at risk is a criminalizedidentity or activity. Right. And
so, you know, I think that's,that's my key thing is we need
(45:20):
to take away the structuraldeterminants, right. This is
oppression of LGBTQ people. Andthere's no ways about it,
there's no way to live in aplace, right. This is why I talk
about in light of social, socialmedical. Researcher, researchers
talk about the limitations ofindividual behavior change.
(45:43):
Disproportionately public healthinterventions focus on
individual behavior change. Andover and over again, research
has documented that these don'treally have short term impacts,
they don't have long term orpopulation level impacts, right
in my work for the small samplethat you worked with, it's not
going to work for to addresspopulation disparities, we need
structural interventions toaddress population disparities,
(46:05):
we need to decriminalize, weneed to protect people's rights,
we need to give people access tocare, we need to you know,
subsidize health care, we needto have insurance, universal
insurance. So everyone can getcare, regardless of their income
status, or your documentationstatus, or their race or
whatever else. Right. So I'lljust say that and of course,
(46:26):
studying these issues from adifferent intersections, right,
the risk of, of adverse healthoutcomes differ for for LGBTQ
people, which is where adisproportionate number of
people are poor, because of thestigma, and because in society,
most people are working class,most people are not wealthy.
Another fact that people don'ttalk about, right, we want to
(46:47):
people are sold this idea thatwe can all become wealthy and
successful. And that's not thereality in this country. So all
that is to say, these are someof the few things that can be
done. And to do that underdifferent intersections.
Nada Fox (47:04):
Well, I have one more question for you. What advice
would you give to youngresearchers or students
interested in pursuing similarwork in the field of public
health and health disparitiesresearch?
Dr. Akua Gyamerah (47:21):
Thank you.
That is another another greatquestion. I think, you know, it
will not come as a surprise toyou that we need to, you know,
just based on what I've beensharing that we need for engaged
research to be rooted in andinformed by populations most
(47:42):
impacted by the health issueswe're working on. I think
there's some public health workthat is rooted in community. But
it's a lot of the biggestresearch studies are research
centers and academicinstitutions that are not rooted
in or connected to communities.
(48:02):
And I think we do importantwork, but oftentimes, that work
is disconnected from the mostimpacted communities and the
people doing the work or notreflecting those populations,
right. You know, public healthresearch is disproportionately
conducted by middle class, youknow, white academics, or, you
(48:23):
know, and, you know, and evenfor the people of color, were
middle class, right? We facedifferent different barriers,
experiences. I grew up workingclass, and I, you know, I've
experienced it on both sides.
Now that I'm a middle classprofession, you know, I see the
difference, like, whatdifference it makes to have
resources and to be connected toother people with resources, do
my education, right. But it iseasy to forget, if you're not
(48:54):
connected to communities, andengaged in your research in that
way. And I or your your work,whether you're into research or
doing applied work. So I wouldsay that and look at what
communities are doing. One ofthe things I really like to talk
(49:15):
about in my classes is the roleof social movements, the impact
of social movements on health.
We don't talk a lot about thismany social movements with the
gains that we've won around.
Health care. We're led bycommunity members. I show the
documentary The takeover, NewYork Times documentary
(49:38):
documenting Puerto Rican andblack. Puerto Ricans, me black,
but you know what I mean? Latinxpoetry Rican and non Latin X
black folks in South Bronx, tookover a clinic Lincoln clinic in
the Bronx in the 70s because Asthis clinic was the place where
(50:00):
people went and died, theycalled it the butcher block or
something like, you know, peoplego there and come out with with
worse outcomes. Because youknow, South Bronx is a poor
community, mostly people ofcolor. And these hospitals do
not care about their health. Andthey took over the clinic
overnight and demanded listed abunch of demands to improve the
(50:23):
conditions. There was a standoffbetween the NYPD and these
activists, and they were able tobecause of the the impact of
that takeover, they were able toget the clinic to build a new
hospital that improved theseconditions. Now we could spend
years studying how Lincolnclinic was not meeting the needs
(50:45):
of these community members. Andwe want community which we're
going to take over and throughthat, they were able to bring
this into national news and andget Quicker, quicker
transformation, right, thataddressed their structural
issue. We don't have this clinicis not functioning in the way or
hospitals not functioning theway our community needs it to,
(51:06):
in order to save lives andimprove outcomes. They started
an acupuncture center in thatclinic, to address addiction
that was community led that wasby black activists, anti racist
activists who were, you know,part of this movement. So I'll
(51:28):
give another example the BlackPanthers did a lot of health
activism, Alondra Nelson, who'sa sociologist writes about this
research in her work, and howthey took, you know, developed
community clinics, like, youknow, vans worked with doctors
to, to come into blackcommunities and provide health
(51:52):
care, they held a healthconference to address racial
health disparities, they did thefree breakfast program for you
know, poor black kids who arenot getting adequate nutrition
that actually inspired andinfluenced food policy or school
food policy where it wasn't itshifted from just providing
(52:12):
lunch to providing breakfast andlunch. You know, this is a
national thing. Now, sickle cellanemia, which is a health issue
that disproportionately impactsblack folks who are not being
researched, given research fundsto understand and Black Panthers
organized and fought forfunding, federal funding that
(52:33):
led to a federal law to fundsickle cell anemia research. So
I give these examples to saythat we need to be plugged into
how communities are actuallytalking about social conditions
and asking for, you know, betterhealth, health outcomes. There
are many communities doing thiswork trans communities, trans
(52:55):
activists are organizing aroundthese issues, you know, other
queer communities are doingthis. So if we don't do that, we
are removed from the people whoare actually impacted by these
issues and removed from theiragency and how they actually
take this on, not just us, youknow, so I will say with that,
that we approach this work withhumility and conviction and, and
(53:18):
also reflect on our biases andgaps in knowledge and
experiences. And really alwayslook into like, I'm interested
in this health issue, and I wantto address it, let me see what
people are saying about thisactually, in the community, you
know, let me look and see whatwe know about the structural
determinants of these, let's notjust do the individual is
(53:38):
focused on what we can do, canwe mobilize and and you know, or
protest or find ways to advocatebeyond these interventions are
more focused on individualbehavior change? We can do that.
But what more can we also do?
And then I think, lastly, thereneeds to be a little dose of
(53:58):
skepticism, because I say Ihighlight all these structural
determinants, but I also knowthat I have no illusions,
unfortunately, in this in thesystem that we live under, which
puts profit over human needs,unfortunately, like we don't
need to NIH doesn't need to findany more research on a on racism
(54:19):
and how bad racism is, or how,you know, there's lots of, you
know, fundings, understandracism, or, you know, just
sectional stigma or thesethings, we have the data,
because things are bad, povertyis bad. Racism is bad.
Homophobia is bad. transphobiais bad. What are we going to do
about it? We can do morestudies, but can we take some of
(54:41):
that money? Can we change someof these laws? Do we have to
have segregation in the way thatit's manifesting, right, where
people are segregated and getless resources? Because of where
they live, because it'sdisproportionately black? Or
disproportionate, you know, orit's moved or you know, it's
indigenous or whatever else? So,yeah, I think we need to start
(55:03):
asking critical questions,right? We know these things are
bad. Why do we continue toignore and not change the laws
that produce these outcomes? Sothat's what I will say.
Welcome back, public health enthusiasts I, Nada Fox,
am here today with AkuaGyamerah, assistant professor
here at University of Buffalo.
Thank you so much for taking thetime to meet with us today.
Dr. Akua Gyamerah (00:20):
You're very welcome. Thanks for inviting me.
Nada Fox (00:23):
Absolutely. So before we get into all your very
interesting research, can youtell us a little bit about your
background?
Dr. Akua Gyamerah (00:32):
Absolutely.
So I, my background, let's startwith being born in Ghana and
growing up in New York City.
Because it really shaped myexperiences with public health,
and just accessing health. Soyou know, growing up in an under
resourced community, in Ghana,and then in under the stories
(00:55):
community in New York City, inQueens, New York City, I saw the
ways, you know, social factorsimpact health outcomes. And it
really inspired me to pursue aprofession in health, initially
medicine, and then eventuallypublic health. And so that's a
little bit about my personalbackground, in terms of my
(01:16):
professional background, youknow, I trained in social
Medical Sciences at ColumbiaUniversity. That's where I got
my masters and my doctorate. Andthen I did a postdoc at
University of California, SanFrancisco, and HIV. And so it's
from Oakland, California, SanFrancisco, California, that I
then moved to Buffalo, to teachat the Community Health and
(01:37):
Health Behavior department. Somy research area is in global
health, and I focus on HIVprevention and care, the
intersection of gender andsexual rights. I'm also very
much interested in the impact ofsocial stressors like
criminalization, violence,stigma, and factors like that,
(01:57):
how those shape mental healthand other physical health
outcomes among sexual gender andracial minorities. So my
research has primarily been inGhana, Africa, West Africa, but
I've also done research in theUS with minoritized communities,
particularly trans women, queerfolks, and the topics of, of, of
(02:22):
violence, mental health,substance use, and HIV. So I
think I'll stop there. Or maybeI'll just add to that, that, you
know, at the heart of thisresearch is, is really to
document people's experiences,particularly marginalized
populations experiences, so thatit can inform advocacy and
(02:45):
social change. And so that's,that is what I'm passionate
about. And that's what this workis driven by.
Nada Fox (02:52):
It's wonderful, and it's really important work.
Dr. Akua Gyamerah (02:55):
Thank you.
Nada Fox (02:56):
So your research focuses on how historical and
socio structural factors such asracism, and our intersectional
stigma, impact disease outcomes?
How did these factors contributeto health disparities and these
marginalized communities?
Dr. Akua Gyamerah (03:13):
Yes, these factors are very, very
important. And I reallyappreciate this question. I
teach pub 420, socialdeterminants of health. It's an
undergraduate class. And ofcourse, as I said, I trained in
social medical sciences. Thesefactors are what I focus on in
my own research, I really,really think it's important in
public health that we train, youknow, generations of researchers
(03:37):
to understand how social factorsand historical factors impact
health and how they are thedeterminants of downstream
factors, right downstreamfactors being individual
behavior, within interpersonalyou know, factors like social
support, and, you know, personalrelationships. You know, those
(04:00):
are, are all important, but whatpeople are able to do for
themselves and with for eachother, is shaped by our
conditions, right? You know, areshaped by conditions, do I have
time to show up for someone? DoI have time to exercise for
myself? Do I have time to reallychange my health if things are
(04:24):
moving in a direction that isadverse to my my health
outcomes? So I'm just being liketime, for example, because many
working people are spending somuch time so much of their time
awake, working, and it cuts intoyour ability to actually care
for yourself, right? This is noteven to speak to the conditions
(04:46):
of one's work, or speak to youknow, whether someone has money
to even afford to make changesthat are being required of them.
So that's just given examplesfrom related to, you know, one's
class status. Well, I tend totalk about poverty. And in
(05:06):
sometimes we distort how orwhat's the word I'm looking for?
Characterize? Poverty, right?
Many people are living paycheckto paycheck, right? That's not
exactly a way to survive, right?
We don't talk about researchthat shows that, you know, how
(05:27):
stressful living paycheck topaycheck is on people's lives.
So, just to come back to yourquestion, just given examples
of, of structural determinants,historical determinants, I named
that because there is a, there'sa way our understanding of,
let's say, racism, for example,is watered down, and I talk
(05:51):
about this in my class, oftenbecause it's become racism has
become you know, about how wetalk to each other, or treat
each other, or personal biases,and less about actually the
historical legacy of racism. Andlet's say, in this country,
racism differs from country tocountry. But in this country,
which is the birthplace of, of,of racism, there's lots written
(06:16):
and I will go on tangents ondebates on that. But, you know,
the transatlantic slave trade,marked the beginning of, of the
construction of race to justifythe stealing and exploitation of
human beings to build thisnation, and that historical
legacy, just, you know, endedover to a little over 200 years
(06:40):
ago, right. And so, to thinkthat, while the slave slavery
did not racism, it then wasrestructured in, in different
ways, to then as a, as the ruleof law in this country. So, you
know, post reconstruction in theUS we had, sorry, Jim Crow,
(07:06):
right, which, you know, fordecades was the law that that,
you know, segregated blacks,blacks and whites in this
country, and eventually, withsocial movements that was
overruled, and we hadintegration, but that was then
replaced by what MichelleAlexander calls The New Jim
(07:26):
Crow. Michelle Alexander is alegal scholar, who has written
incredible things about how massincarceration has has, is the
new caste system that maintainsracism in this country. And she
says, After Jim Crow, it wasreplaced by the new Jim Crow,
(07:47):
and that is the disproportionatepolicing and incarceration of
black people in particular. And,and the the second class
citizenship, those who areincarcerated then are reduced to
right. So she talks aboutdisenfranchisement of formerly
(08:07):
incarcerated people, ways yourrecord follows you and
unemployment, loss of access topublic programs, because of your
background, right, and the roleof the war on drugs and, and
these policies, right history,historical policies, on on
(08:30):
incarceration records of, ofblack communities, right. So I'm
going on that time just to showyou that there's like historical
legacy of racism and how it's,it's transformed over
generations to consistentlyimpact the conditions of black
people, or Latin X folks orindigenous people, etc. And that
(08:50):
we can actually trace that andstudy how that has impacted
people's health outcomes. Soracism, poverty, social networks
have all been identified asfundamental causes of health
disparities, health outcomes andhealth disparities. Bruce
Lincoln and Joe Phelan havewritten about this, this
(09:13):
concept, and the argue that weneed to as public health
professionals, not just focuson, you know, you know, like
different factors, but actuallytarget the most fundamental
ones, because what they theorizeand documented or demonstrated
(09:34):
through literature reviews wasthat there are particular
determinants that arefundamental regardless of how
you change the pathway, right,how you intervene on this
particular factor. The outcomeis still adverse. And that is
because there's somethingfundamental about that issue,
and they named poverty, socialnetworks and racism among
(09:57):
others. Gender was another one.
I'm particularly men, which isinteresting as as all causes of
health, you know, healthdisparities, including, you
know, lower life outcome andmortality, different mortality,
morbidity, morbidity outcomes.
(10:19):
So, all of that is to say, Ihope I answered your question,
that these structural factorsare really important, the way
they framed it was like, whatare the determinants of the
determinants? Right? What arethe the factors that are driving
other factors downstream, thatthen shape our conditions and
(10:40):
health outcomes. And it allboils down to whether someone
can have access to resources tohelp them mitigate. Other risks?
Yeah. So, if your risk isgenetic, right, and you have a
lot of money, you are able toafford the best, best standard
health care. Right, but if youknow, you have the same genetic
(11:02):
risk, but you are poor, oryou're not in a network of
people who might have you know,might be medical doctors, or
might have more money to helpyou by this, you know, genetic
predisposition, you will havemore likely to have an adverse
outcome, right. That's just anexample of, you know, just
(11:26):
using, you know, class or socialnetworks or in class as examples
of fundamental causes. Outthere, but you can ask follow up
questions, if you want. Yeah,
Nada Fox (11:39):
Well, I just, I think it's really interesting the
determinants of thedeterminants, it's not like
something like I have thoughtabout before, but then that
makes like total sense, the wayyou like, kind of laid that all
out. So sorry, that's why I wassitting there like staring at
you, my mouth. Never heard this.
Dr. Akua Gyamerah (11:55):
And when I heard it to, and just like, you
know, it clicked, like, ofcourse, is the determining
factor determines the internetin a very flat weight, right? In
part of what social ecologicalmodel tries to do this, you
know, like, show the way thesedifferent levels of factors
shape each other. And, but Ithink what the fundamental
(12:18):
causes theory does is take anadditional step and says, yes,
you'll look at that model. Andthere's a lot of factors, but we
want you to focus in on the mostimpactful factors, the things
what they call the mostfundamental, if we give everyone
universal income in thiscountry, meaning enough to
survive and you know, take careof your needs. Their programs
(12:43):
are piloting that, right? Andthey're trying to highlight that
a universal income. Why couldn'twe do that? Right? Why can't we
redistribute wealth so thateveryone can live it like a
dignity and not be struggling?
To survive to take care of theirfamilies or themselves? Right,
Mike, this is this, we don'thave to live the way that
(13:03):
society structured, right? It'snot necessary, we have more than
enough to meet everyone's needs.
And for me, that is really mybiggest frustration. As someone
who's very, you know, feels verypassionately about health
justice, and another socialjustice issues. But anyway, I'll
(13:25):
stop there.
Nada Fox (13:26):
I like I agree with you. I remember reading like
this that like, startlingstatistic that there are more
houses than people in thiscountry. I know, like, put them
why is there anybody that'shomeless? Like, everybody should
have a roof over their head islike a fundamental right. So
you're in like minded company,like, you know, there's some
facts you can't unhear, and thenyou can't be blind to anymore?
Dr. Akua Gyamerah (13:49):
Yeah, exactly. Yeah. I also wanted to
speak to I think, the otherfactors I study is
intersectionality. So we'vetalked about, you know, poverty
and, and race, you know, thereare different forms of, of
determining or differentcategories, categories that we
(14:13):
often talk about in publichealth, and often will study it
in a very shallow or symbolicways, right? If you feel a
survey, what's your race, what'syour income, what's your you
know, Job Status, what's your,you know, gender. And there are
(14:34):
folks in social determinants,because you can study social
determines from that angle,right. But there are other
scholars, you know, activistcommunity activists who say we
can't look at these thingsbecause they don't represent
what you think it they don'tmeasure what you think they're
measuring right race does notmeasure racism. Right. Race does
(14:57):
not measure racism racemeasures, race. How do we
measure the impact of racism onsomeone's race? Or a race of
people? Right? These are not thesame things. And so thankfully,
there's no, I'm going to say amovement but like a trend in
(15:21):
public health now, where peopleare trying to figure out ways to
measure racism, right? What arethe mechanisms that lead to
disparate racial outcomes,right, these health inequities
among minoritized, raciallyminoritized populations? And so,
you know, studying massincarceration, for example, how
(15:42):
does racism manifests in thiscountry? Racial segregation,
looking at the impact of racialsegregation, and people self
looking at the impact of, youknow, different carceral
policies, people can look atstate level policies, people can
look at disenfranchisement, andsee whether you know, their
health outcomes is impactingdifferent health outcomes in
(16:05):
terms of racial disparities,right. So that is one of the
things that I think is reallyimportant to talk about, like,
so we've made the factors, howare we actually studying and
measuring it. And that isanother thing, but it plays to
why it's important to have asocial analysis and social
framework, to then inform howyou're studying the issue,
(16:28):
right? Because how you definethe issue. And understanding
will shape how you measure it.
And so I just want to say thatall that is to say, one of the
other trends in public healthis, is bringing in the framework
of intersectionality. Trying tounderstand the relationship
(16:50):
between multiple forms ofoppression to each other, how do
how do racism, gender, sexualityclass interlock to produce a
different outcome than theindividual parts, if that makes
(17:14):
sense, right? So, you know, Idon't know how you identify
racially, or do you intensify?
Nada Fox (17:23):
I'm white.
Dr. Akua Gyamerah (17:25):
Okay, so, you know, let's say you identify as
a or someone who identifies as awhite woman will experience you
sexism as an example, right?
Sexism differently than someonewho's a black woman, right? This
is the intersectionalintersectional intersectionality
detection theory basically,emerges from this analysis,
(17:46):
right? It's a theory thatemerges from black, fig women
figures, activist, historicalfigures. The concept itself is
the term itself is relativelynew, but the concept is not.
Right. So during the truth inthe 1800s, as well, I'm speaking
to the women's convention says aNyoman right, because black
(18:09):
enslaved black women were wheretheir issues were not considered
in, in the first iteration ofthe women's rights movement,
right? They were in talkingabout racism and enslavement and
how that impacts black women.
And so she talks about thatconcept and talks about the
(18:31):
different oppression that blackwomen faced, right. Fast forward
to, you know, the next century,you have generations of black
feminists who talked about thisin different ways. The Combahee
River collective. You know, Billhooks talks about this, many of
Angela Davis talks about this.
And then Kimberly Crenshawcoined the term
(18:54):
intersectionality in her legalpaper. I think that that the
intersection is I don't want tobutcher the title look at look
her up, but it's a formativepaper. She's a legal scholar and
Critical Race theorists. And herwork was incredible because what
she did was look at laws and sawhow women of color were falling
(19:16):
in the cracks. Because theselaws were only focusing on one
dimension of the oppression theywere supposed to mitigate.
Right? She says here, you know,example, the carceral system is,
(19:37):
you know, judicial system issupposed to prosecute sexual
abusers. Well, let's look at thedata. You know, black men are
most likely to be incarcerated,especially if they have their
victims are white women. Blackwomen are the least likely to
receive justice, especially ifthey're, you know, their
perpetrators are white men. or,you know, other other men who
(20:00):
are not necessarily black,right. And she shows through
that data, she shows us a, youknow, an intervention made for
immigrant women that wassupposed to support abused
immigrant women from leavingyour abuser so that you're not
dependent on on documentation,like immigrant papers,
(20:21):
basically, legal documentation.
So a lot of women wereundocumented women were stuck in
abusive relationships, becausethey're afraid to leave and not
have a chance to get citizenshipor permanent residency. So this
law, you know, there's, youknow, a law passed to allow for
(20:42):
me to leave, but they didn'ttake into consideration all
kinds of factors related tolanguage barriers, income
barriers. And so, the point herewas, like, there's a policy
that's addressing a genderissue, but not looking at the
impact of class on on thesewomen, right? Or the impact of
(21:03):
gender in addressing racism, theimpact gender has an undermining
the progress that's made aroundracism, and she says, we need to
address these intersections, sothat multiple oppressed people
are not falling in these cracks.
So intersectionality is nowbeing used in public health
(21:23):
research increasingly used inpublic health research to
actually understand how multipleinterlocking oppressions shapes
people's health outcomes, and wecannot assume also that the
impact of this interlockinginterlocking oppressions is
cumulative, that if you areblack, and poor and gay, and you
(21:49):
know, you know, non binary and,you know, that means things are
worse for you. Sometimes youlook at actually multiple people
with multiple workersidentities, their outcomes
actually better than those whoare not, you know, so what she
(22:12):
points to is like to actuallyunderstand the, the, what
happens when these differentthings interlock and interact,
are there things that areactually protected? Are they,
you know, does it you know, theoutcomes worse, the point is to
understand because something ishappening here that we do not
catch, if we only look at itfrom one dimension. So I'll use
and I'll stop here, I'll useimmigrants as an example. I'm
(22:36):
sorry, Latino populations,including, there's a lot of
research done on immigrantcommunities on this, and there's
this has been this called theHispanic paradox. And this has
found that research documentingthe index communities actually
have better health outcomes,then compared to, you know,
(23:04):
white, white populations, andpeople were surprised by that,
because of the history of racismagainst black people in this
country. And so, research, tryto understand why that is,
(23:24):
right. The other there are othersocial determinants that you
know, show that they have, youknow, lower average income or
education, because ofmarginalization, they might have
higher disability, etc. However,in terms of, you know,
mortality, they have lower riskof mortality, like 24%, lower
(23:45):
risk of mortality, compared towhite people. And so the
question was, like, what'shappening here? And one of the
theories is that thosecommunities are more communal,
there's more networks, andnetworks, as I mentioned
earlier, can be a fundamentalcause, right? And you'll find
(24:06):
this in other immigrantcommunities, too. So this is
also why, you know, I'll justtake for example, when people
study black racial disparities,also say let's break it up by
communities because sometimesimmigrants, black immigrants are
doing better in terms of healthoutcomes, then, you know, black
(24:28):
communities that havehistorically been here and like
historically marginalized in away that, you know, recent
immigrants are not experiencingright. There's studies looking
at epigenetics and how one'senvironment right. Can shape
once genetics rate, people arestarting to study you know, how,
(24:51):
you know, slavery might havechanged, you know, are shaped,
you know, different I haddifferent biological impacts
that might be affecting health.
Now, I that is not to say thatrace can be biologically
measured. Let me not get intothat. That race signs nonsense.
(25:13):
That's not what I'm referringto. But really looking at once
and how a one's environment canactually interact with with the
body and adversely impacthealth. So anyway, I'll stop
there.
Nada Fox (25:30):
Thank you. And that was really interesting. So you
did a project that explored theimpact of gender based violence,
and the COVID 19 pandemic onalcohol use and treatment among
gender minorities in the SanFrancisco Bay Area? How do you
(25:50):
approach studying these complexand interconnected issues? You
just talked about all thesedifferent intersectionalities?
And how we need to look at this?
How do we design this research?
How do we go about studyingthat?
Dr. Akua Gyamerah (26:04):
That's a great question. Well, I
definitely don't have answers,because that's part of what the
number of us are studying.
There's actually anintersectionality training
institute that was formed a fewyears ago by a really wonderful
scholar, another one of theleading scholars in looking at
into intersectional, stigma, andhealth and health. Lisa bowlegs,
(26:25):
she's a psychologist, and peopleare trying to figure that out,
actually, there are methodsbeing developed on you know, how
to measure intersectionality,especially quantitatively,
qualitatively, also, how do weanalyze it? But especially, or
(26:45):
ask questions, I couldn't get tosome of these factors on the
complexity of these factories.
In terms of this study, in SanFrancisco, that was a very
difficult study, to do justbecause of the trauma that many
(27:08):
people being interviewed hadexperience. It was a mixed
method study. So we hadquantitative measures exploring
people's experience of aviolence, gender based violence,
and the impact of alcohol andother substance uses on on that.
(27:29):
And yeah, the stories were, youknow, very difficult to listen
to obviously. So just a thing tosay, you know, what, one of the
things we don't talk a lot aboutus, like the how the mental
health impact of actuallystudying traumatic experiences
(27:49):
and studying violence, and evenstating things that might be
personal to you also, whetheryou share an identity or an
experience of trauma, etc. Soit's definitely not easy. But in
terms of the study itself, theywere looking at different
factors, it was right at thestart of the epidemic. And the
study was nested under aclinical trial, that was testing
(28:12):
the efficacy of a natural planton reducing alcohol use among
adults. So it's a Japanese plantcalled kudzu, you and it's
extract was used to, you know,just to was tested to see if it
(28:34):
reduces people's cravings foralcohol, as well as frequency of
drinking. So I just did my studyunder that I wanted to look at
gender specific factors thatimpact alcohol use. And I focus
on gender based violencespecifically. So, you know, we
(28:54):
we asked questions aboutlifetime experiences of
violence, as well as violenceduring COVID. If COVID had just
started, and we were seeingstudies, one of the most
immediate things we started withyou remember, was just like, you
know, studies are showingincreased drinking and also
increase in domestic violence.
And so I wanted to look at that.
And I wanted to look at therelationship between the two as
(29:15):
well. So that's what that studylooked at. So we did cross
sectional in depth interviewsbetween April like 2021 and
2022. And these questionsexplored, as I said, lifetime
experiences of verbal physicalsexual violence and real
substance use played in that andthe impact on people's lives.
(29:38):
And they're just, you know,different stories. Some some of
the, the folks we interviewedwere sex workers, who
experienced just, you know,horrific violence, gendered
violence. Some experienced datejust you know, women Hearing on
(30:00):
dates and experience date rapeand other sexual violence. Folks
who are housing insecure, alsoreported experiencing verbal
abuse. So these are thedifferent factors impacting
folks, right? Sex work, putpeople at higher risk, alcohol
(30:21):
during you know, Gates causepeople to be at high risk of,
you know, perpetrators usedalcohol as a way to facilitate
abuse is what The finding wasbasically one of the findings,
then, as I mentioned, housinginsecurity, as you may know, the
Bay Area has one of the worsthousing prices in the country.
(30:45):
And it's kind of like a, like,occurring epidemic with also
substance use and mental health.
And so, yes, there's a lot ofhomelessness and a number of
participants also experiencedsexual violence. Due to housing
insecurity, a number of peoplealso talked about, you know,
(31:08):
violence during your youth. Sosexual violence they experienced
as children. And this wasparticularly like, consistently,
we have 20, assembled 20 to fivewomen were black, and all of
them had the same story. So I'mlooking at the the ratio of the
racial dimension of this,understanding some of the impact
(31:31):
of childhood trauma on substanceuse adult, you know, substance
addiction, and, you know,subsequently homelessness. We
knew, all these women who hadexperienced sexual violence from
adult men in their lives orolder men, they might have been
children as well, but justolder, would make up the boys.
And this led to early use ofsubstances to cope. On some of
(31:58):
them were just introduced tothese substances, as I said, to
facilitate abuse. But some alsostarted and then became
dependent because it was amiracle. And then you had also
folks who experienced adult IPvintimate partner violence. And
(32:21):
then, and then there were youthintimate partner violence as
well. So you know, key findingsfrom our studies, you know,
there are, yeah, experiences ofviolence being facilitated by
(32:42):
violence, or, you know, peopleusing sort of being facilitated
by alcohol use or thesubstances. And, and folks are
also coping with the trauma ofviolence through substance use.
And so just a few findings fromthat study, another being that
COVID Many people share theirCOVID did worse than violence,
(33:03):
get experiences of violence,many people are trapped in homes
with abusers and couldn't leaveabusers, some of them are
dependent on the women formaterial support. And so they
would use them to maintain thatcontrol and support. So yeah,
and you know, the most heavyalcohol use was about 91% of the
(33:28):
participants, there wassomewhere to use about 28% of
participants and crack use22%.of participants. And, yeah,
I don't know if there's anythingelse. But yeah, and
Nada Fox (33:52):
Thank you for sharing.
And it sounds like self care isvery important when you're doing
this type of research.
Dr. Akua Gyamerah (33:58):
I would, I would be lying if I didn't say I
was very impacted my mentalhealth, my mental health
suffered from this. And I canonly imagine what it's like
living with that trauma. So ifyou know.
Nada Fox (34:13):
So, all right. Well, given your experience, or excuse
me, given your expertise in HIVprevention and care, what are
some key findings or insightsfrom your research that could
inform public health strategiesfor addressing HIV disparities
among LGBTQ plus populations?
Dr. Akua Gyamerah (34:37):
Yeah, thank you for that question. There's
definitely you know, one of thethings we learned very quickly
in the AIDS epidemic, the firstthe beginning days of that
epidemic is just the role ofstigma and anti anti gay
discourses and beliefs indriving stigma against
(35:00):
populations impacted by HIV mostimpacted by HIV. Right? So the
beginning days, it was calledthe gay related group, it was
called Great. I'm trying toremember what the Id still stood
for I look it up right now. Yes,gay Related Immune Deficiency,
or the gay play gay syndromealready was very much conflating
(35:25):
one sexual identity with withthe disease. And there was a
moral panic, driven by, youknow, social actors, anti gay,
social actors, politicians,conservative politicians, in
response to the epidemic, right,so we knew from the very
beginning what role that playedbecause it actually impacted how
(35:46):
quickly the government respondedto the epidemic, which was not
very quickly. You know, manywere like, well, this is
punishment for gay people forquote, unquote, sinning. And so
you know, let them die. And, youknow, as the epidemic
progressed, and we learned moreabout it, we found out that, you
(36:06):
know, Haitian immigrants weredisproportionately impacted.
injection drug users will alsodisproportionately impacted, and
hemophiliacs were impacted. AndI think the term was the four H
club, Haitians, homosexuals,hemophilia eggs, and forgetting
(36:27):
what the fourth H was. All kindof to me, here when users sorry,
and so very stigmatizing, right.
And that led to thesepopulations being marginalized
in society. And with moreknowledge about how the virus
(36:47):
spread, with protests from thecommunities impacted,
particularly the gay community,and allies, there was a shift
and finally funding,unfortunately, give that history
only to say that unfortunately,this legacy still exists. In our
research, there's still a stigmaagainst gay people around HIV,
(37:09):
whether people will see it ornot, it's not the same level
right? of stigma doesn't lookthe same. But there's still
stigma, including internalizedstigma within the community
around HIV. And so I think, interms of what can be done to
address it, we need to continueto educate people about HIV and
how HIV spreads, and how peoplebecome at risk for HIV IV,
(37:33):
right? How we construct a riskis really important. That's
another thing I talked about.
And it was something that Ifocused on in my dissertation in
Ghana, because in Ghana, andmany sub Saharan African
countries, governments did notinclude queer men in HIV
policies, the epidemic wasconstructed as a homosexual
(37:56):
epidemic in the West. And so inWestern countries, the US,
Europe, Canada, etc, compared toa quote unquote, heterosexual
epidemic in the Global South,particularly in Sub Saharan
Africa, which was the mostimpacted. And that's led to, you
know, this downstream effectwhere funding then went to
(38:18):
address in heterosexualtransmission and mother to child
transmission, young women, whowere, you know, at risk, because
of, you know, gender inequality.
And gay men were ignored. So ittook almost 25 years in Ghana,
in particular, for HIV policiesto acknowledge male same sex
(38:39):
transmission. And what we'velearned about part of that is,
you know, criminalization of, ofgetting, you know, identity or
same sex sexual activities is akey driver of, of these of high
HIV risk, right? I'll give sinceGunnersbury. Do my research.
(39:03):
Gay, Bisexual, and other men whohave sex with men have an HIV
prevalence of 80%. The mostrecent surveillance study that
finally included trans women,shows that trans women have any
JV prevalence of 46% that isalmost wanting to trans women
(39:26):
are HIV positive. And one infive gay men are HIV positive.
Or negative men who have sexwith men excuse me, just because
identity and sexual behaviorshouldn't have completed but
yes. So, you know, this is ahuge disparity there. The
(39:51):
country's prevalence is onepoint at this point, I think
it's 1.4 1.5%. And so You know,one could look at this and say
This is punishment for thecommunity or we can actually
look at what's driving thisepidemic. And, you know, as
research has demonstratedstigma, people being afraid to
go into the clinics because of,of anti gay sentiments and
(40:15):
criminalization of melting sexactivities. You know, lack of
public education on just how HIVspreads it, HIV is more and more
not spoken about, on the radioor on TV as much just not as
much public health campaignseducating people about it,
(40:35):
because especially in contextwhere populations, key
populations like trans women andgay bisexual other men are
criminalized. It's important tohave public education because
then everyone can have access tothat, including those who are
too afraid to come to programsthat would teach you targeted
(40:56):
programs that teach you aboutrisk and protection, good
resources, etc. In Ghana, malesame sex sexualities are
criminalized. It's a colonialera law, that is common in
Commonwealth countries offormerly British colonized
countries. So you'll find thisin the Caribbean in many parts
of Africa and parts of Asia.
(41:18):
These laws exist their Britishcolonial laws, it used to exist
in the US until 2005, I believe,or three anti sodomy laws were
just recently. Yes, we're justrecently overall didn't at least
regularly. So. Yeah, this is,you know, when we talk about
history, very recent history,and some of it still ongoing in
(41:42):
different parts of the world. Sowe need to decriminalize, but
not just decriminalize, we needto protect people,
decriminalizing is not the sameas you know, having rates
criminalized and then haverights protections for LGBTQ
populations. I think we need tochange social attitudes,
(42:02):
decriminalizing given rightsprotections will have a
downstream effect, right,including changing social
attitudes. There are many peoplein Ghana who have quick, you
know, cousins or family membersand are, you know, hang out with
them and are cool with them, butpublicly will save violent
things, right? Because theydon't feel they feel socially
(42:22):
pressured to. I think when wechange laws, that can help shape
and create space for people toreally just publicly, you know,
show empathy and and feel saferto be supportive. Are there
people who are just supportiveand they're free to say
something because you're free,you're free to social
(42:44):
marginalization andostracization? I think we need
to have influential communityand public figures speak out
against violence. And this isall very specific in to Ghana,
in contexts like Ghana, wherethings are very, that's where
we're at. People don't even wantto speak out against acts of
violence, brutal acts ofviolence against LGBTQ people.
(43:07):
Currently, there is a proposedactually a past Parliament
proposed bill that is still notlaw, though. But it's a bill
that was introduced in 2021. Tofurther criminalize LGBTQ people
to went from criminalizing youknow, unnatural, carnal
knowledge, which is basically,you know, any sex is considered
(43:28):
a normal non, you know, vaginalpenetration of penal penetration
of whatever this is verygraphic. But, you know, what, I
mean, you know, this sodomy oryou know, other forms of
sexualities that are considereddeviant and unnatural, right. So
this bill aims to criminalizeidentities, advocacy, and Ally
(43:52):
ship of LGBTQ people, so LGBTQpeople can face up to three
years in jail, advocates canface up to 10 years. Ilyas will
face years in prison if theydon't, you know, and and it also
encourages people to reportfamily members and people they
know who are gay. It ishorrendous, it would it would
make illegal you know, anygender affirming care or
(44:15):
surgeries, etc. And so, youknow, this is a backlash and my
research actually mydissertation was looking at how
Ghana shift to include policy toinclude queer men in HIV policy
was contributing to thispolarization and politicization
(44:35):
and backlash. So I was studyingthat in 2014 2015 2016. And now
we're seeing some of the some ofthis backlash culminated to a
law or a bill that might verymuch become law. So I'm just
highlighting this becausethere's not space. When people
(44:56):
are criminalized, it is very,very difficult. Um, for them to
access resources that they need,when the very thing especially
around HIV risk, STIs, etc, thevery thing that might will put
them at risk is a criminalizedidentity or activity. Right. And
so, you know, I think that's,that's my key thing is we need
(45:20):
to take away the structuraldeterminants, right. This is
oppression of LGBTQ people. Andthere's no ways about it,
there's no way to live in aplace, right. This is why I talk
about in light of social, socialmedical. Researcher, researchers
talk about the limitations ofindividual behavior change.
(45:43):
Disproportionately public healthinterventions focus on
individual behavior change. Andover and over again, research
has documented that these don'treally have short term impacts,
they don't have long term orpopulation level impacts, right
in my work for the small samplethat you worked with, it's not
going to work for to addresspopulation disparities, we need
structural interventions toaddress population disparities,
(46:05):
we need to decriminalize, weneed to protect people's rights,
we need to give people access tocare, we need to you know,
subsidize health care, we needto have insurance, universal
insurance. So everyone can getcare, regardless of their income
status, or your documentationstatus, or their race or
whatever else. Right. So I'lljust say that and of course,
(46:26):
studying these issues from adifferent intersections, right,
the risk of, of adverse healthoutcomes differ for for LGBTQ
people, which is where adisproportionate number of
people are poor, because of thestigma, and because in society,
most people are working class,most people are not wealthy.
Another fact that people don'ttalk about, right, we want to
(46:47):
people are sold this idea thatwe can all become wealthy and
successful. And that's not thereality in this country. So all
that is to say, these are someof the few things that can be
done. And to do that underdifferent intersections.
Nada Fox (47:04):
Well, I have one more question for you. What advice
would you give to youngresearchers or students
interested in pursuing similarwork in the field of public
health and health disparitiesresearch?
Dr. Akua Gyamerah (47:21):
Thank you.
That is another another greatquestion. I think, you know, it
will not come as a surprise toyou that we need to, you know,
just based on what I've beensharing that we need for engaged
research to be rooted in andinformed by populations most
(47:42):
impacted by the health issueswe're working on. I think
there's some public health workthat is rooted in community. But
it's a lot of the biggestresearch studies are research
centers and academicinstitutions that are not rooted
in or connected to communities.
(48:02):
And I think we do importantwork, but oftentimes, that work
is disconnected from the mostimpacted communities and the
people doing the work or notreflecting those populations,
right. You know, public healthresearch is disproportionately
conducted by middle class, youknow, white academics, or, you
(48:23):
know, and, you know, and evenfor the people of color, were
middle class, right? We facedifferent different barriers,
experiences. I grew up workingclass, and I, you know, I've
experienced it on both sides.
Now that I'm a middle classprofession, you know, I see the
difference, like, whatdifference it makes to have
resources and to be connected toother people with resources, do
my education, right. But it iseasy to forget, if you're not
(48:54):
connected to communities, andengaged in your research in that
way. And I or your your work,whether you're into research or
doing applied work. So I wouldsay that and look at what
communities are doing. One ofthe things I really like to talk
(49:15):
about in my classes is the roleof social movements, the impact
of social movements on health.
We don't talk a lot about thismany social movements with the
gains that we've won around.
Health care. We're led bycommunity members. I show the
documentary The takeover, NewYork Times documentary
(49:38):
documenting Puerto Rican andblack. Puerto Ricans, me black,
but you know what I mean? Latinxpoetry Rican and non Latin X
black folks in South Bronx, tookover a clinic Lincoln clinic in
the Bronx in the 70s because Asthis clinic was the place where
(50:00):
people went and died, theycalled it the butcher block or
something like, you know, peoplego there and come out with with
worse outcomes. Because youknow, South Bronx is a poor
community, mostly people ofcolor. And these hospitals do
not care about their health. Andthey took over the clinic
overnight and demanded listed abunch of demands to improve the
(50:23):
conditions. There was a standoffbetween the NYPD and these
activists, and they were able tobecause of the the impact of
that takeover, they were able toget the clinic to build a new
hospital that improved theseconditions. Now we could spend
years studying how Lincolnclinic was not meeting the needs
(50:45):
of these community members. Andwe want community which we're
going to take over and throughthat, they were able to bring
this into national news and andget Quicker, quicker
transformation, right, thataddressed their structural
issue. We don't have this clinicis not functioning in the way or
hospitals not functioning theway our community needs it to,
(51:06):
in order to save lives andimprove outcomes. They started
an acupuncture center in thatclinic, to address addiction
that was community led that wasby black activists, anti racist
activists who were, you know,part of this movement. So I'll
(51:28):
give another example the BlackPanthers did a lot of health
activism, Alondra Nelson, who'sa sociologist writes about this
research in her work, and howthey took, you know, developed
community clinics, like, youknow, vans worked with doctors
to, to come into blackcommunities and provide health
(51:52):
care, they held a healthconference to address racial
health disparities, they did thefree breakfast program for you
know, poor black kids who arenot getting adequate nutrition
that actually inspired andinfluenced food policy or school
food policy where it wasn't itshifted from just providing
(52:12):
lunch to providing breakfast andlunch. You know, this is a
national thing. Now, sickle cellanemia, which is a health issue
that disproportionately impactsblack folks who are not being
researched, given research fundsto understand and Black Panthers
organized and fought forfunding, federal funding that
(52:33):
led to a federal law to fundsickle cell anemia research. So
I give these examples to saythat we need to be plugged into
how communities are actuallytalking about social conditions
and asking for, you know, betterhealth, health outcomes. There
are many communities doing thiswork trans communities, trans
(52:55):
activists are organizing aroundthese issues, you know, other
queer communities are doingthis. So if we don't do that, we
are removed from the people whoare actually impacted by these
issues and removed from theiragency and how they actually
take this on, not just us, youknow, so I will say with that,
that we approach this work withhumility and conviction and, and
(53:18):
also reflect on our biases andgaps in knowledge and
experiences. And really alwayslook into like, I'm interested
in this health issue, and I wantto address it, let me see what
people are saying about thisactually, in the community, you
know, let me look and see whatwe know about the structural
determinants of these, let's notjust do the individual is
(53:38):
focused on what we can do, canwe mobilize and and you know, or
protest or find ways to advocatebeyond these interventions are
more focused on individualbehavior change? We can do that.
But what more can we also do?
And then I think, lastly, thereneeds to be a little dose of
(53:58):
skepticism, because I say Ihighlight all these structural
determinants, but I also knowthat I have no illusions,
unfortunately, in this in thesystem that we live under, which
puts profit over human needs,unfortunately, like we don't
need to NIH doesn't need to findany more research on a on racism
(54:19):
and how bad racism is, or how,you know, there's lots of, you
know, fundings, understandracism, or, you know, just
sectional stigma or thesethings, we have the data,
because things are bad, povertyis bad. Racism is bad.
Homophobia is bad. transphobiais bad. What are we going to do
about it? We can do morestudies, but can we take some of
(54:41):
that money? Can we change someof these laws? Do we have to
have segregation in the way thatit's manifesting, right, where
people are segregated and getless resources? Because of where
they live, because it'sdisproportionately black? Or
disproportionate, you know, orit's moved or you know, it's
indigenous or whatever else? So,yeah, I think we need to start
(55:03):
asking critical questions,right? We know these things are
bad. Why do we continue toignore and not change the laws
that produce these outcomes? Sothat's what I will say.
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