Elle Lett, PhD, MA, MBiostat, a statistician-epidemiologist and physician-in-training, visited the University of Washington in January for a two-day lecture series on intersectional and anti-racist public health research.
Sponsored by the ARCH Center, School of Public Health, and the School of Nursing, the lecture series covered the impact of our biases on researchers’ work, how racism is inherent to the production of knowledge, and how the complexities of intersectional identities can often be erased by simplistic thinking and categorizations within research.
Lett shared several case studies and different approaches to research methods. Using the lens of the Public Health Critical Race Praxis (PHCRP), Lett shared several key concepts interwoven throughout her case studies.
The first and foremost, is “we are storytellers,” Lett said. This means, there is no such thing as pure objectivity. As individuals, we all carry biases based on our positionality, or our understanding of ourselves of who we are and what we bring to our work. This applies not only to those of us who use qualitative methods, but to quantitative methodologists, affecting the research questions we ask, the populations we study, and the measurements we use.
Second, Lett said, “racism is inherent to producing knowledge in America” because “racism is part of America; [it is] embedded into the social fabric of society.” This phenomenon is so ingrained within our society, it is impossible for us to extract it from our day-to-day life.
Finally, simple investigations that only look at single forms of discrimination, which are often used in research, contribute to inaccuracies, and erasure of the experience of people with intersectional identities, who are subject to multiple, interactive forms of discrimination.
Dr. Lett is a Black, transgender woman whose research focuses on intersectional approaches to transgender health, reproductive justice, health impacts of state-sanctioned violence and other forms of systemic racism, and diversity, equity, and inclusion in healthcare. Now, she is turning her focus to algorithmic fairness in clinical prediction models and mitigating systems of inequity in health services provision. She is engaging in this new arm of research through a postdoctoral fellowship at the Boston Children’s Hospital Computational Health Informatics Program (CHIP), before returning to finish her clinical medicine training.
Lett’s research varied in both the breadth and depth of her work, but she focused on three research areas: reproductive justice, transgender health and state-sanctioned violence. From there she discussed each of these topics in three case studies:
Case Study #1 (Sexual Behaviors Associated with HIV Transmission Among Transgender and Gender Diverse Young Adults: The Intersectional Role of Racism and Transphobia)
In Lett’s first case study, utilizing the PHCRP concept of intersectionality, she explored how power and power structures impact the interpersonal and structural discrimination of sexual behaviors associated with HIV transmission among trans youth. Using a nationwide cross-sectional survey as well as various data provided by community-based organizations, Lett was able to measure structural and interpersonal transphobia and racism as well as map out how these oppressive systems have direct effects and contribute to the disproportionate HIV burden on transgender people of color.
“Racism is composed of transphobia,” Lett said, and from an intersectional lens, transphobia and racism are experienced simultaneously. Lett emphasized that “these forms of oppression are not experienced independently,” meaning that these two are inextricably linked. This type of intersectional discrimination creates a noxious environment that may contribute to increased rates of HIV transmission, and ultimately harm trans youth of color. Moreover, to accurately represent the results of these studies we have to adopt an intersectional lens that Lett was able to use to present such poignant information.
Case Study #2 (Racial inequity in fatal US police shootings, 2015-2020)
In Lett’s next case study, she opens with the statement, “Police violence as a public health crisis” and continues in explaining that [this is] “not just about the index fatality”, “but about the scars on our communities they left behind.” Further, “there is something to be said through police shootings about what it means to be Black in America and to see your kind killed in such a painful way.” She cited research that demonstrated that being in a proximal location to the murder by police of a Black person negatively affects the health and well-being of other Black people. This occurs physiologically and is closely linked to where a Black person lives; usually in economically low-income areas with little resources and support.
Lett noted that there is a lack of available data given our complicated sociopolitical context. For example, the FBI funded “Use-of-Force” database has less than 60% participation of US law enforcement agencies, thereby creating an environment that was difficult to study the role of police in the use of force and violence committed in communities of color.
Using the PHCRP concept Disciplinary Self-Critique, Lett continued with [it is] “Important to critique how we think about racial groups and how we discuss and navigate these groups.” For example, Native and Indigenous populations are often excluded or grouped into an “Other” category, thereby erased from public health studies.
Case Study #3 Presence of a community support person (Health inequities for Black and AI/AN Birthing People in the US)
Lett’s final case study focused on obstetric racism experienced by Black birthing people. Citing work from Dr. Karen Scott and Dr. Dana Ain-Davis, Dr. Lett shared that obstetric racism lies at the intersection of obstetric violence and medical racism. Obstetric violence is the gender-based violence experienced by people giving birth who are subjected to acts of violence because they are giving birth. Medical racism is racism against people of color within the medical system, which ultimately makes Black people less healthy; contributes to racial inequities in healthcare access and underlies the biases held by healthcare workers against people of color in their care. In prior work, Lett’s collaborators developed three different scales for measurement: the Humanity Scale, Kinship Scale and Racism Scale. These three scales comprised the measurement of Obstetric Racism (PREM-OB Suite) which was used in this study.
The researchers found that the presence of a community support person was associated with less obstetric racism across all three scales; less rejection of humanity (autonomy, empathy, etc.), less disrupted kinship (disruption of the community connections that supported the birthing person), and less experiences of racist acts. Just having another person in the hospital room advocating for the rights and health of the patient significantly decreased risk of death within a hospital setting. In sum, Lett advocated for the need to radically democratize the birth space.
Question & Answer
During the Q&A portion of the lecture series, Lett was asked how to further disseminate the message shared within her presentation. She said how the validity of her work was constantly questioned. Previously, she felt it was necessary to translate the principles of her approach and findings into a language that is “more accessible” to traditional researchers. She also described her own move towards outwardly presenting her whole self, one that feels more meaningful, and this personal movement has translated into her work.
Through collaboration and dissemination of her work, Lett has been able to demonstrate that there is an audience for this type of research. Further, she mentions, it’s hard to reject something that has been credentialed and validated. “Do the work to publish and demonstrate its utility,” she said. When asked how to incorporate more Black epistemologies, Lett mentions there are multiple for anti-racist research and it’s important to “adjust and adapt the theoretical framework and epistemology for the context and question at hand.” She highlighted that the real learning occurs when we push against and question status quos. In sum, Lett drives home the importance that there are different ways to give an antiracist lens across multiple scenarios within public health, but in doing so it’s important to stay true to core principles of intersectionality and stay oriented to advancing health for historically and contemporarily oppressed and excluded populations.