Intersectionality w Akua Gyamerah, DrPH, MPH

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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Transcript

Nada Fox: 0:05

Welcome back, public health enthusiasts I, Nada Fox, am here today with Akua Gyamerah, assistant professor here at University of Buffalo. Thank you so much for taking the time to meet with us today.

Dr. Akua Gyamerah: 0:20

You're very welcome. Thanks for inviting me.

Nada Fox: 0:23

Absolutely. So before we get into all your very interesting research, can you tell us a little bit about your background?

Dr. Akua Gyamerah: 0:32

Absolutely. So I, my background, let's start with being born in Ghana and growing up in New York City. Because it really shaped my experiences with public health, and just accessing health. So you know, growing up in an under resourced community, in Ghana, and then in under the stories community in New York City, in Queens, New York City, I saw the ways, you know, social factors impact health outcomes. And it really inspired me to pursue a profession in health, initially medicine, and then eventually public health. And so that's a little bit about my personal background, in terms of my professional background, you know, I trained in social Medical Sciences at Columbia University. That's where I got my masters and my doctorate. And then I did a postdoc at University of California, San Francisco, and HIV. And so it's from Oakland, California, San Francisco, California, that I then moved to Buffalo, to teach at the Community Health and Health Behavior department. So my research area is in global health, and I focus on HIV prevention and care, the intersection of gender and sexual rights. I'm also very much interested in the impact of social stressors like criminalization, violence, stigma, and factors like that, how those shape mental health and other physical health outcomes among sexual gender and racial minorities. So my research has primarily been in Ghana, Africa, West Africa, but I've also done research in the US with minoritized communities, particularly trans women, queer folks, and the topics of, of, of violence, mental health, substance use, and HIV. So I think I'll stop there. Or maybe I'll just add to that, that, you know, at the heart of this research is, is really to document people's experiences, particularly marginalized populations experiences, so that it can inform advocacy and social change. And so that's, that is what I'm passionate about. And that's what this work is driven by.

Nada Fox: 2:52

It's wonderful, and it's really important work.

Dr. Akua Gyamerah: 2:55

Thank you.

Nada Fox: 2:56

So your research focuses on how historical and socio structural factors such as racism, and our intersectional stigma, impact disease outcomes? How did these factors contribute to health disparities and these marginalized communities?

Dr. Akua Gyamerah: 3:13

Yes, these factors are very, very important. And I really appreciate this question. I teach pub 420, social determinants of health. It's an undergraduate class. And of course, as I said, I trained in social medical sciences. These factors are what I focus on in my own research, I really, really think it's important in public health that we train, you know, generations of researchers to understand how social factors and historical factors impact health and how they are the determinants of downstream factors, right downstream factors being individual behavior, within interpersonal you know, factors like social support, and, you know, personal relationships. You know, those are, are all important, but what people are able to do for themselves and with for each other, is shaped by our conditions, right? You know, are shaped by conditions, do I have time to show up for someone? Do I have time to exercise for myself? Do I have time to really change my health if things are moving in a direction that is adverse to my my health outcomes? So I'm just being like time, for example, because many working people are spending so much time so much of their time awake, working, and it cuts into your ability to actually care for yourself, right? This is not even to speak to the conditions of one's work, or speak to you know, whether someone has money to even afford to make changes that are being required of them. So that's just given examples from related to, you know, one's class status. Well, I tend to talk about poverty. And in sometimes we distort how or what's the word I'm looking for? Characterize? Poverty, right? Many people are living paycheck to paycheck, right? That's not exactly a way to survive, right? We don't talk about research that shows that, you know, how stressful living paycheck to paycheck is on people's lives. So, just to come back to your question, just given examples of, of structural determinants, historical determinants, I named that because there is a, there's a way our understanding of, let's say, racism, for example, is watered down, and I talk about this in my class, often because it's become racism has become you know, about how we talk to each other, or treat each other, or personal biases, and less about actually the historical legacy of racism. And let's say, in this country, racism differs from country to country. But in this country, which is the birthplace of, of, of racism, there's lots written and I will go on tangents on debates on that. But, you know, the transatlantic slave trade, marked the beginning of, of the construction of race to justify the stealing and exploitation of human beings to build this nation, and that historical legacy, just, you know, ended over to a little over 200 years ago, right. And so, to think that, while the slave slavery did not racism, it then was restructured in, in different ways, to then as a, as the rule of law in this country. So, you know, post reconstruction in the US we had, sorry, Jim Crow, right, which, you know, for decades was the law that that, you know, segregated blacks, blacks and whites in this country, and eventually, with social movements that was overruled, and we had integration, but that was then replaced by what Michelle Alexander calls The New Jim Crow. Michelle Alexander is a legal scholar, who has written incredible things about how mass incarceration has has, is the new caste system that maintains racism in this country. And she says, After Jim Crow, it was replaced by the new Jim Crow, and that is the disproportionate policing and incarceration of black people in particular. And, and the the second class citizenship, those who are incarcerated then are reduced to right. So she talks about disenfranchisement of formerly incarcerated people, ways your record follows you and unemployment, loss of access to public programs, because of your background, right, and the role of the war on drugs and, and these policies, right history, historical policies, on on incarceration records of, of black communities, right. So I'm going on that time just to show you that there's like historical legacy of racism and how it's, it's transformed over generations to consistently impact the conditions of black people, or Latin X folks or indigenous people, etc. And that we can actually trace that and study how that has impacted people's health outcomes. So racism, poverty, social networks have all been identified as fundamental causes of health disparities, health outcomes and health disparities. Bruce Lincoln and Joe Phelan have written about this, this concept, and the argue that we need to as public health professionals, not just focus on, you know, you know, like different factors, but actually target the most fundamental ones, because what they theorize and documented or demonstrated through literature reviews was that there are particular determinants that are fundamental regardless of how you change the pathway, right, how you intervene on this particular factor. The outcome is still adverse. And that is because there's something fundamental about that issue, and they named poverty, social networks and racism among others. Gender was another one. I'm particularly men, which is interesting as as all causes of health, you know, health disparities, including, you know, lower life outcome and mortality, different mortality, morbidity, morbidity outcomes. So, all of that is to say, I hope I answered your question, that these structural factors are really important, the way they framed it was like, what are the determinants of the determinants? Right? What are the the factors that are driving other factors downstream, that then shape our conditions and health outcomes. And it all boils down to whether someone can have access to resources to help them mitigate. Other risks? Yeah. So, if your risk is genetic, right, and you have a lot of money, you are able to afford the best, best standard health care. Right, but if you know, you have the same genetic risk, but you are poor, or you're not in a network of people who might have you know, might be medical doctors, or might have more money to help you by this, you know, genetic predisposition, you will have more likely to have an adverse outcome, right. That's just an example of, you know, just using, you know, class or social networks or in class as examples of fundamental causes. Out there, 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 the determinants, it's not like something like I have thought about before, but then that makes like total sense, the way you like, kind of laid that all out. So sorry, that's why I was sitting 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, of course, is the determining factor determines the internet in a very flat weight, right? In part of what social ecological model tries to do this, you know, like, show the way these different levels of factors shape each other. And, but I think what the fundamental causes theory does is take an additional step and says, yes, you'll look at that model. And there's a lot of factors, but we want you to focus in on the most impactful factors, the things what they call the most fundamental, if we give everyone universal income in this country, meaning enough to survive and you know, take care of your needs. Their programs are piloting that, right? And they're trying to highlight that a universal income. Why couldn't we do that? Right? Why can't we redistribute wealth so that everyone can live it like a dignity and not be struggling? To survive to take care of their families or themselves? Right, Mike, this is this, we don't have to live the way that society structured, right? It's not necessary, we have more than enough to meet everyone's needs. And for me, that is really my biggest frustration. As someone who's very, you know, feels very passionately about health justice, and another social justice issues. But anyway, I'll stop there.

Nada Fox: 13:26

I like I agree with you. I remember reading like this that like, startling statistic that there are more houses than people in this country. I know, like, put them why is there anybody that's homeless? Like, everybody should have a roof over their head is like a fundamental right. So you're in like minded company, like, you know, there's some facts you can't unhear, and then you can't be blind to anymore?

Dr. Akua Gyamerah: 13:49

Yeah, exactly. Yeah. I also wanted to speak to I think, the other factors I study is intersectionality. So we've talked about, you know, poverty and, and race, you know, there are different forms of, of determining or different categories, categories that we often talk about in public health, and often will study it in a very shallow or symbolic ways, right? If you feel a survey, what's your race, what's your income, what's your you know, Job Status, what's your, you know, gender. And there are folks in social determinants, because you can study social determines from that angle, right. But there are other scholars, you know, activist community activists who say we can't look at these things because they don't represent what you think it they don't measure what you think they're measuring right race does not measure racism. Right. Race does not measure racism race measures, race. How do we measure the impact of racism on someone's race? Or a race of people? Right? These are not the same things. And so thankfully, there's no, I'm going to say a movement but like a trend in public health now, where people are trying to figure out ways to measure racism, right? What are the mechanisms that lead to disparate racial outcomes, right, these health inequities among minoritized, racially minoritized populations? And so, you know, studying mass incarceration, for example, how does racism manifests in this country? Racial segregation, looking at the impact of racial segregation, and people self looking at the impact of, you know, different carceral policies, people can look at state level policies, people can look at disenfranchisement, and see whether you know, their health outcomes is impacting different health outcomes in terms of racial disparities, right. So that is one of the things that I think is really important to talk about, like, so we've made the factors, how are we actually studying and measuring it. And that is another thing, but it plays to why it's important to have a social analysis and social framework, to then inform how you're studying the issue, right? Because how you define the issue. And understanding will shape how you measure it. And so I just want to say that all that is to say, one of the other trends in public health is, is bringing in the framework of intersectionality. Trying to understand the relationship between multiple forms of oppression to each other, how do how do racism, gender, sexuality class interlock to produce a different outcome than the individual parts, if that makes sense, right? So, you know, I don'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 a white woman will experience you sexism as an example, right? Sexism differently than someone who's a black woman, right? This is the intersectional intersectional intersectionality detection theory basically, emerges from this analysis, right? It's a theory that emerges from black, fig women figures, activist, historical figures. The concept itself is the term itself is relatively new, but the concept is not. Right. So during the truth in the 1800s, as well, I'm speaking to the women's convention says a Nyoman right, because black enslaved black women were where their issues were not considered in, in the first iteration of the women's rights movement, right? They were in talking about racism and enslavement and how that impacts black women. And so she talks about that concept and talks about the different oppression that black women faced, right. Fast forward to, you know, the next century, you have generations of black feminists who talked about this in different ways. The Combahee River collective. You know, Bill hooks talks about this, many of Angela Davis talks about this. And then Kimberly Crenshaw coined the term intersectionality in her legal paper. I think that that the intersection is I don't want to butcher the title look at look her up, but it's a formative paper. She's a legal scholar and Critical Race theorists. And her work was incredible because what she did was look at laws and saw how women of color were falling in the cracks. Because these laws were only focusing on one dimension of the oppression they were supposed to mitigate. Right? She says here, you know, example, the carceral system is, you know, judicial system is supposed to prosecute sexual abusers. Well, let's look at the data. You know, black men are most likely to be incarcerated, especially if they have their victims are white women. Black women are the least likely to receive justice, especially if they're, you know, their perpetrators are white men. or, you know, other other men who are not necessarily black, right. And she shows through that data, she shows us a, you know, an intervention made for immigrant women that was supposed to support abused immigrant women from leaving your abuser so that you're not dependent on on documentation, like immigrant papers, basically, legal documentation. So a lot of women were undocumented women were stuck in abusive relationships, because they're afraid to leave and not have a chance to get citizenship or permanent residency. So this law, you know, there's, you know, a law passed to allow for me to leave, but they didn't take into consideration all kinds of factors related to language barriers, income barriers. And so, the point here was, like, there's a policy that's addressing a gender issue, but not looking at the impact of class on on these women, right? Or the impact of gender in addressing racism, the impact gender has an undermining the progress that's made around racism, and she says, we need to address these intersections, so that multiple oppressed people are not falling in these cracks. So intersectionality is now being used in public health research increasingly used in public health research to actually understand how multiple interlocking oppressions shapes people's health outcomes, and we cannot assume also that the impact of this interlocking interlocking oppressions is cumulative, that if you are black, and poor and gay, and you know, you know, non binary and, you know, that means things are worse for you. Sometimes you look at actually multiple people with multiple workers identities, their outcomes actually better than those who are not, you know, so what she points to is like to actually understand the, the, what happens when these different things interlock and interact, are there things that are actually protected? Are they, you know, does it you know, the outcomes worse, the point is to understand because something is happening here that we do not catch, if we only look at it from one dimension. So I'll use and I'll stop here, I'll use immigrants as an example. I'm sorry, Latino populations, including, there's a lot of research done on immigrant communities on this, and there's this has been this called the Hispanic paradox. And this has found that research documenting the index communities actually have better health outcomes, then compared to, you know, white, white populations, and people were surprised by that, because of the history of racism against black people in this country. And so, research, try to understand why that is, right. The other there are other social determinants that you know, show that they have, you know, lower average income or education, because of marginalization, they might have higher disability, etc. However, in terms of, you know, mortality, they have lower risk of mortality, like 24%, lower risk of mortality, compared to white people. And so the question was, like, what's happening here? And one of the theories is that those communities are more communal, there's more networks, and networks, as I mentioned earlier, can be a fundamental cause, right? And you'll find this in other immigrant communities, too. So this is also why, you know, I'll just take for example, when people study black racial disparities, also say let's break it up by communities because sometimes immigrants, black immigrants are doing better in terms of health outcomes, then, you know, black communities that have historically been here and like historically marginalized in a way that, you know, recent immigrants are not experiencing right. There's studies looking at epigenetics and how one's environment right. Can shape once genetics rate, people are starting to study you know, how, you know, slavery might have changed, you know, are shaped, you know, different I had different biological impacts that might be affecting health. Now, I that is not to say that race can be biologically measured. Let me not get into that. That race signs nonsense. That's not what I'm referring to. But really looking at once and how a one's environment can actually interact with with the body and adversely impact health. So anyway, I'll stop there.

Nada Fox: 25:30

Thank you. And that was really interesting. So you did a project that explored the impact of gender based violence, and the COVID 19 pandemic on alcohol use and treatment among gender minorities in the San Francisco Bay Area? How do you approach studying these complex and interconnected issues? You just talked about all these different intersectionalities? And how we need to look at this? How do we design this research? How do we go about studying that?

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 an intersectionality training institute that was formed a few years ago by a really wonderful scholar, another one of the leading scholars in looking at into intersectional, stigma, and health and health. Lisa bowlegs, she's a psychologist, and people are trying to figure that out, actually, there are methods being developed on you know, how to measure intersectionality, especially quantitatively, qualitatively, also, how do we analyze it? But especially, or ask questions, I couldn't get to some of these factors on the complexity of these factories. In terms of this study, in San Francisco, that was a very difficult study, to do just because of the trauma that many people being interviewed had experience. It was a mixed method study. So we had quantitative measures exploring people's experience of a violence, gender based violence, and the impact of alcohol and other substance uses on on that. And yeah, the stories were, you know, very difficult to listen to obviously. So just a thing to say, you know, what, one of the things we don't talk a lot about us, like the how the mental health impact of actually studying traumatic experiences and studying violence, and even stating things that might be personal to you also, whether you share an identity or an experience of trauma, etc. So it's definitely not easy. But in terms of the study itself, they were looking at different factors, it was right at the start of the epidemic. And the study was nested under a clinical trial, that was testing the efficacy of a natural plant on reducing alcohol use among adults. So it's a Japanese plant called kudzu, you and it's extract was used to, you know, just to was tested to see if it reduces people's cravings for alcohol, as well as frequency of drinking. So I just did my study under that I wanted to look at gender specific factors that impact alcohol use. And I focus on gender based violence specifically. So, you know, we we asked questions about lifetime experiences of violence, as well as violence during COVID. If COVID had just started, and we were seeing studies, one of the most immediate things we started with you remember, was just like, you know, studies are showing increased drinking and also increase in domestic violence. And so I wanted to look at that. And I wanted to look at the relationship between the two as well. So that's what that study looked at. So we did cross sectional in depth interviews between April like 2021 and 2022. And these questions explored, as I said, lifetime experiences of verbal physical sexual violence and real substance use played in that and the impact on people's lives. And they're just, you know, different stories. Some some of the, the folks we interviewed were sex workers, who experienced just, you know, horrific violence, gendered violence. Some experienced date just you know, women Hearing on dates and experience date rape and other sexual violence. Folks who are housing insecure, also reported experiencing verbal abuse. So these are the different factors impacting folks, right? Sex work, put people at higher risk, alcohol during you know, Gates cause people to be at high risk of, you know, perpetrators used alcohol as a way to facilitate abuse is what The finding was basically one of the findings, then, as I mentioned, housing insecurity, as you may know, the Bay Area has one of the worst housing prices in the country. And it's kind of like a, like, occurring epidemic with also substance use and mental health. And so, yes, there's a lot of homelessness and a number of participants also experienced sexual violence. Due to housing insecurity, a number of people also talked about, you know, violence during your youth. So sexual violence they experienced as children. And this was particularly like, consistently, we have 20, assembled 20 to five women were black, and all of them had the same story. So I'm looking at the the ratio of the racial dimension of this, understanding some of the impact of childhood trauma on substance use adult, you know, substance addiction, and, you know, subsequently homelessness. We knew, all these women who had experienced sexual violence from adult men in their lives or older men, they might have been children as well, but just older, would make up the boys. And this led to early use of substances to cope. On some of them were just introduced to these substances, as I said, to facilitate abuse. But some also started and then became dependent because it was a miracle. And then you had also folks who experienced adult IPv intimate partner violence. And then, and then there were youth intimate partner violence as well. So you know, key findings from our studies, you know, there are, yeah, experiences of violence being facilitated by violence, or, you know, people using sort of being facilitated by alcohol use or the substances. And, and folks are also coping with the trauma of violence through substance use. And so just a few findings from that study, another being that COVID Many people share their COVID did worse than violence, get experiences of violence, many people are trapped in homes with abusers and couldn't leave abusers, some of them are dependent on the women for material support. And so they would use them to maintain that control and support. So yeah, and you know, the most heavy alcohol use was about 91% of the participants, there was somewhere to use about 28% of participants and crack use 22%.of participants. And, yeah, I don't know if there's anything else. But yeah, and

Nada Fox: 33:52

Thank you for sharing. And it sounds like self care is very 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 mental health, my mental health suffered from this. And I can only imagine what it's like living with that trauma. So if you know.

Nada Fox: 34:13

So, all right. Well, given your experience, or excuse me, given your expertise in HIV prevention and care, what are some key findings or insights from your research that could inform public health strategies for 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 the things we learned very quickly in the AIDS epidemic, the first the beginning days of that epidemic is just the role of stigma and anti anti gay discourses and beliefs in driving stigma against populations impacted by HIV most impacted by HIV. Right? So the beginning days, it was called the gay related group, it was called Great. I'm trying to remember what the Id still stood for I look it up right now. Yes, gay Related Immune Deficiency, or the gay play gay syndrome already was very much conflating one sexual identity with with the disease. And there was a moral panic, driven by, you know, 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 played because it actually impacted how quickly the government responded to the epidemic, which was not very quickly. You know, many were like, well, this is punishment for gay people for quote, unquote, sinning. And so you know, let them die. And, you know, as the epidemic progressed, and we learned more about it, we found out that, you know, Haitian immigrants were disproportionately impacted. injection drug users will also disproportionately impacted, and hemophiliacs were impacted. And I think the term was the four H club, Haitians, homosexuals, hemophilia eggs, and forgetting what the fourth H was. All kind of to me, here when users sorry, and so very stigmatizing, right. And that led to these populations being marginalized in society. And with more knowledge about how the virus spread, with protests from the communities 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 stigma against gay people around HIV, whether people will see it or not, it's not the same level right? of stigma doesn't look the same. But there's still stigma, including internalized stigma within the community around HIV. And so I think, in terms of what can be done to address it, we need to continue to educate people about HIV and how HIV spreads, and how people become at risk for HIV IV, right? How we construct a risk is really important. That's another thing I talked about. And it was something that I focused on in my dissertation in Ghana, because in Ghana, and many sub Saharan African countries, governments did not include queer men in HIV policies, the epidemic was constructed as a homosexual epidemic in the West. And so in Western countries, the US, Europe, Canada, etc, compared to a quote unquote, heterosexual epidemic in the Global South, particularly in Sub Saharan Africa, which was the most impacted. And that's led to, you know, this downstream effect where funding then went to address in heterosexual transmission and mother to child transmission, young women, who were, you know, at risk, because of, you know, gender inequality. And gay men were ignored. So it took almost 25 years in Ghana, in particular, for HIV policies to acknowledge male same sex transmission. And what we've learned about part of that is, you know, criminalization of, of getting, you know, identity or same sex sexual activities is a key driver of, of these of high HIV risk, right? I'll give since Gunnersbury. Do my research. Gay, Bisexual, and other men who have sex with men have an HIV prevalence of 80%. The most recent surveillance study that finally included trans women, shows that trans women have any JV prevalence of 46% that is almost wanting to trans women are HIV positive. And one in five gay men are HIV positive. Or negative men who have sex with men excuse me, just because identity and sexual behavior shouldn't have completed but yes. So, you know, this is a huge disparity there. The country's prevalence is one point 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 the community or we can actually look at what's driving this epidemic. And, you know, as research has demonstrated stigma, people being afraid to go into the clinics because of, of anti gay sentiments and criminalization of melting sex activities. You know, lack of public education on just how HIV spreads it, HIV is more and more not spoken about, on the radio or on TV as much just not as much public health campaigns educating people about it, because especially in context where populations, key populations like trans women and gay bisexual other men are criminalized. It's important to have public education because then everyone can have access to that, including those who are too afraid to come to programs that would teach you targeted programs that teach you about risk and protection, good resources, etc. In Ghana, male same sex sexualities are criminalized. It's a colonial era law, that is common in Commonwealth countries of formerly British colonized countries. So you'll find this in the Caribbean in many parts of Africa and parts of Asia. These laws exist their British colonial laws, it used to exist in the US until 2005, I believe, or three anti sodomy laws were just recently. Yes, we're just recently 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 different parts of the world. So we need to decriminalize, but not just decriminalize, we need to protect people, decriminalizing is not the same as you know, having rates criminalized and then have rights protections for LGBTQ populations. I think we need to change social attitudes, decriminalizing given rights protections will have a downstream effect, right, including changing social attitudes. There are many people in Ghana who have quick, you know, cousins or family members and are, you know, hang out with them and are cool with them, but publicly will save violent things, right? Because they don't feel they feel socially pressured to. I think when we change laws, that can help shape and create space for people to really just publicly, you know, show empathy and and feel safer to be supportive. Are there people who are just supportive and they're free to say something because you're free, you're free to social marginalization and ostracization? I think we need to have influential community and public figures speak out against violence. And this is all very specific in to Ghana, in contexts like Ghana, where things are very, that's where we're at. People don't even want to speak out against acts of violence, brutal acts of violence against LGBTQ people. Currently, there is a proposed actually a past Parliament proposed bill that is still not law, though. But it's a bill that was introduced in 2021. To further criminalize LGBTQ people to went from criminalizing you know, unnatural, carnal knowledge, which is basically, you know, any sex is considered a normal non, you know, vaginal penetration of penal penetration of whatever this is very graphic. But, you know, what, I mean, you know, this sodomy or you know, other forms of sexualities that are considered deviant and unnatural, right. So this bill aims to criminalize identities, advocacy, and Ally ship of LGBTQ people, so LGBTQ people can face up to three years in jail, advocates can face up to 10 years. Ilyas will face years in prison if they don't, you know, and and it also encourages people to report family members and people they know who are gay. It is horrendous, it would it would make illegal you know, any gender affirming care or surgeries, etc. And so, you know, this is a backlash and my research actually my dissertation was looking at how Ghana shift to include policy to include queer men in HIV policy was contributing to this polarization and politicization and backlash. So I was studying that in 2014 2015 2016. And now we're seeing some of the some of this backlash culminated to a law or a bill that might very much become law. So I'm just highlighting this because there's not space. When people 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, the very thing that might will put them at risk is a criminalized identity or activity. Right. And so, you know, I think that's, that's my key thing is we need to take away the structural determinants, right. This is oppression of LGBTQ people. And there's no ways about it, there's no way to live in a place, right. This is why I talk about in light of social, social medical. Researcher, researchers talk about the limitations of individual behavior change. Disproportionately public health interventions focus on individual behavior change. And over and over again, research has documented that these don't really have short term impacts, they don't have long term or population level impacts, right in my work for the small sample that you worked with, it's not going to work for to address population disparities, we need structural interventions to address population disparities, we need to decriminalize, we need to protect people's rights, we need to give people access to care, we need to you know, subsidize health care, we need to have insurance, universal insurance. So everyone can get care, regardless of their income status, or your documentation status, or their race or whatever else. Right. So I'll just say that and of course, studying these issues from a different intersections, right, the risk of, of adverse health outcomes differ for for LGBTQ people, which is where a disproportionate number of people are poor, because of the stigma, and because in society, most people are working class, most people are not wealthy. Another fact that people don't talk about, right, we want to people are sold this idea that we can all become wealthy and successful. And that's not the reality in this country. So all that is to say, these are some of the few things that can be done. And to do that under different intersections.

Nada Fox: 47:04

Well, I have one more question for you. What advice would you give to young researchers or students interested in pursuing similar work in the field of public health and health disparities research?

Dr. Akua Gyamerah: 47:21

Thank you. That is another another great question. I think, you know, it will not come as a surprise to you that we need to, you know, just based on what I've been sharing that we need for engaged research to be rooted in and informed by populations most impacted by the health issues we're working on. I think there's some public health work that is rooted in community. But it's a lot of the biggest research studies are research centers and academic institutions that are not rooted in or connected to communities. And I think we do important work, but oftentimes, that work is disconnected from the most impacted communities and the people doing the work or not reflecting those populations, right. You know, public health research is disproportionately conducted by middle class, you know, white academics, or, you know, and, you know, and even for the people of color, were middle class, right? We face different different barriers, experiences. I grew up working class, and I, you know, I've experienced it on both sides. Now that I'm a middle class profession, you know, I see the difference, like, what difference it makes to have resources and to be connected to other people with resources, do my education, right. But it is easy to forget, if you're not connected to communities, and engaged in your research in that way. And I or your your work, whether you're into research or doing applied work. So I would say that and look at what communities are doing. One of the things I really like to talk about in my classes is the role of social movements, the impact of social movements on health. We don't talk a lot about this many social movements with the gains that we've won around. Health care. We're led by community members. I show the documentary The takeover, New York Times documentary documenting Puerto Rican and black. Puerto Ricans, me black, but you know what I mean? Latinx poetry Rican and non Latin X black folks in South Bronx, took over a clinic Lincoln clinic in the Bronx in the 70s because As this clinic was the place where people went and died, they called it the butcher block or something like, you know, people go there and come out with with worse outcomes. Because you know, South Bronx is a poor community, mostly people of color. And these hospitals do not care about their health. And they took over the clinic overnight and demanded listed a bunch of demands to improve the conditions. There was a standoff between the NYPD and these activists, and they were able to because of the the impact of that takeover, they were able to get the clinic to build a new hospital that improved these conditions. Now we could spend years studying how Lincoln clinic was not meeting the needs of these community members. And we want community which we're going to take over and through that, they were able to bring this into national news and and get Quicker, quicker transformation, right, that addressed their structural issue. We don't have this clinic is not functioning in the way or hospitals not functioning the way our community needs it to, in order to save lives and improve outcomes. They started an acupuncture center in that clinic, to address addiction that was community led that was by black activists, anti racist activists who were, you know, part of this movement. So I'll give another example the Black Panthers did a lot of health activism, Alondra Nelson, who's a sociologist writes about this research in her work, and how they took, you know, developed community clinics, like, you know, vans worked with doctors to, to come into black communities and provide health care, they held a health conference to address racial health disparities, they did the free breakfast program for you know, poor black kids who are not getting adequate nutrition that actually inspired and influenced food policy or school food policy where it wasn't it shifted from just providing lunch to providing breakfast and lunch. You know, this is a national thing. Now, sickle cell anemia, which is a health issue that disproportionately impacts black folks who are not being researched, given research funds to understand and Black Panthers organized and fought for funding, federal funding that led to a federal law to fund sickle cell anemia research. So I give these examples to say that we need to be plugged into how communities are actually talking about social conditions and asking for, you know, better health, health outcomes. There are many communities doing this work trans communities, trans activists are organizing around these issues, you know, other queer communities are doing this. So if we don't do that, we are removed from the people who are actually impacted by these issues and removed from their agency and how they actually take this on, not just us, you know, so I will say with that, that we approach this work with humility and conviction and, and also reflect on our biases and gaps in knowledge and experiences. And really always look into like, I'm interested in this health issue, and I want to address it, let me see what people are saying about this actually, in the community, you know, let me look and see what we know about the structural determinants of these, let's not just do the individual is focused on what we can do, can we mobilize and and you know, or protest or find ways to advocate beyond these interventions are more focused on individual behavior change? We can do that. But what more can we also do? And then I think, lastly, there needs to be a little dose of skepticism, because I say I highlight all these structural determinants, but I also know that I have no illusions, unfortunately, in this in the system that we live under, which puts profit over human needs, unfortunately, like we don't need to NIH doesn't need to find any more research on a on racism and how bad racism is, or how, you know, there's lots of, you know, fundings, understand racism, or, you know, just sectional stigma or these things, we have the data, because things are bad, poverty is bad. Racism is bad. Homophobia is bad. transphobia is bad. What are we going to do about it? We can do more studies, but can we take some of that money? Can we change some of these laws? Do we have to have segregation in the way that it's manifesting, right, where people are segregated and get less resources? Because of where they live, because it's disproportionately black? Or disproportionate, you know, or it's moved or you know, it's indigenous or whatever else? So, yeah, I think we need to start asking critical questions, right? We know these things are bad. Why do we continue to ignore and not change the laws that produce these outcomes? So that's what I will say.