2022 Wales and Africa Health Conference Opening Address
2022 Wales and Africa Health Conference Opening Address
Prof. Kelechi Nnoaham, Cwm Taf Morgannwg University Health Board’s Director of Public Health and Chair of the Wales and Africa Health Links Network, delivered the opening address to the Wales and Africa Health Conference at the Temple of Peace and Health, Cardiff, on 7th October 2022.
Below is a transcript of his speech.
Bore da bawb, a very good morning to you. I’m really excited to see such enthusiastic turnout for this conference. We have lined up some great presentations and conversations today and I look forward very much to leaving at the end of the day both challenged and inspired in equal measure.
We have themed this conference around the subject of Empathy – and I won’t be surprised if we heard lots equally about Compassion as they are quite closely-related, if not perfectly overlapping, concepts. So, please bear with me as I attempt to set the context with socialising our thinking behind this theme.
Although I am a storyteller by nature, I do joke that the art of storytelling was taught out of me when I went to medical school many years ago. So, I have somewhat since been on an endless quest to resurrect that storyteller. So, here goes.
I grew up in Nigerian the middle child of a family of ten. Resources were very hard to come by and there was a small but definite element of survival of the fittest when it came to access to the family’s commonwealth – by which I mean FOOD. Perhaps more accurately, there was food, but it was often without a key desirable component, which in our time was MEAT. I wasn’t the loudest, quickest, or most physically gifted – all attributes that increased your chances of getting a good share of the little meat that went around. So, I devised a strategy as a young child. I realised I could tell extemporaneous stories which my siblings and other children from the neighbourhood would sit around and listen to with rapt attention. So, I exacted a commitment from them – I would tell them my stories for a little piece of everyone’s meat at dinner time. I think that’s probably why my first bit of serious research was on bowel cancer screening which I see as my personal protection plan against the consequences of an early life-course of heavy meat consumption.
I carried my interest in storytelling into medical school, so an early encounter with a wise old professor of medicine became pivotal in my later career direction. He said more than a few times – “when you become medical doctors and you have a patient before you, always ask three questions of yourself – why this patient, why this disease and why this time”. When eventually understood what he meant, it led me to a career in epidemiology and global health. I understood that those questions, which fit neatly into epidemiology’s paradigm of the ‘determinants and distribution of health states in populations’ were really about EMPATHY. Those questions were really about understanding the whole story behind the patient’s presentation. In the words of Robert Centor of the University of Alabama, “To Be a Great Physician, You Must Understand the Whole Story”. Empathy, which we define as identifying, understanding, and sharing another’s feelings and perspectives while maintaining a ‘self-other’ distinction – is really about understanding the whole story. It’s no surprise therefore that my love of storytelling meant that I responded instinctively and positively to the advice from that professor.
If EMPATHY is about understanding the whole story by walking in the shoes of another, then it’s hard not to see a deficit of empathy at the root of much of the very challenging social disruptions we see in our world today. Take for example:
- Political turmoil (be it Brexit or the global outbreak of identity politics),
- Racism (and the race injustice that gave rise to the BLM movement),
- The COVID pandemic – we saw the lack of empathy that played out in the vaccine wars between UK and the EU, but we also saw attitudes to mask-wearing displaying how some people valued ‘personal freedoms’ over the burden of caring for the health of a fellow citizen,
- Global conflict (the latest and probably most potentially far-reaching in consequence of which is Russia’s war in Ukraine), and
- The cost-of-living crisis being faced by much of the world today.
The deficit of empathy does not just drive global social upheaval, but it also shows up as one key determinant of the challenges that healthcare systems are facing daily. As we speak, the NHS in Wales is unrelentingly challenged in respect of waiting lists, unscheduled care, and transitions of care from health to social care.
For the sake of time, and before I home in on empathy in health and healthcare, I will explore two of the social trends earlier mentioned – political turmoil only briefly and, in a little more detail, race and empathy.
When Britain voted for Brexit in 2016, parts of society scrambled to understand what had just happened. A Chatham House analysis by Matt Waldman gave a thought-provoking analysis which essentially drew parallels with the emergence of Donald Trump in US politics. The analysis blamed those incidents on the fact that empathy was at once lacking on one side of the divide and perversely exploited for political ends by the other side. In a rapidly polarising world, the skill of grasping what others think, feel, and perceive is becoming ever so critical. Closer home here in Wales, 62% of the Ebbw Vale population where significant EU investment had gone in voted to leave. The question for me is this: what about their fears, feelings, and perspectives (rational or not) had we failed to hear?
On empathy and racism, I’m drawn to the distinction between racial discrimination which plays out largely in interpersonal interactions – and the more powerful and influential racial stigma, which plays out in more unseen social and economic processes. Fundamentally, I am making a very practical distinction between the way a person from a visible minority ethnic (VME) group might be treated and the way society structures itself, advertently or otherwise, to systematically modulate access to its commonwealth for those people. I am interested in this difference because my sense is that racial discrimination, much like a lack of interpersonal empathy, can be tackled by imparting cognitive skills.
Racial stigma, on the other hand and much like a lack of social empathy, has incredible capacity to embed and persist within the fabric of society. For example, despite having above average household incomes, there are reports of VME healthcare workers who are occupied with how their children might access society’s commonwealth – including education, skills, capital, and self-esteem – as readily as any other children might do without influence from race, ethnicity, or other differentiating attributes. These are broadly not concerns in the domain of interpersonal relationships where discrimination might be enacted. Rather, they sit in that more abstract and insidious domain of powerful societal forces.
The idea of racial stigma derives from the concept of ‘race as stigma’, and naturally, Ervin Goffman’s seminal work in 1963 is the key reference here. In his book titled “Stigma: Notes on the Management of Spoiled Identity”, Goffman described stigma as the experience of moving through life with a ‘spoiled identity’ ‘a trait which is seen socially as deeply discrediting’. He made clear that stigmatisation is an interactive social process where the ‘stigmatiser’ must identify an attribute in the stigmatised person that is deemed as deviant and socially dishonourable. He identified three kinds of stigma – the third of which is ‘tribal stigmatisation’.
Goffman used the word ‘tribal’ in a very broad sense to refer to race, religion, and national origin. But the element of Goffman’s contribution to the understanding of stigma, that is most relevant to the subject of EMPATHY is in how he advanced understanding of the fact that stigma is embedded in the social processes of categorisation and signification. In other words, society classifies its members based on the presence or absence of a specific attribute and then attaches to those attributes social significance – which can be either discrediting or approving. Whilst the vast majority of human differences are ignored and are therefore socially irrelevant (i.e., not significant) – e.g., the colour of one’s car – others – such as one’s skin colour, IQ, sexual preferences, or gender – appear to be highly salient in society.
A desire to understand the more insidious social forces of racial stigma leads one naturally to the work of Graham Scambler who described two dimensions of stigma. The first, enacted stigma, is discrimination by others on grounds of ‘being different’. The second, felt stigma, is an internalised sense of shame and a paralysing anticipation of enacted stigma. There is evidence across many studies that felt stigma is as damaging to people’s lives as enacted stigma. I regard the term ‘felt stigma’ a bit more widely to capture those perceptions, expectations and anticipation of stigma, which despite not being enacted in interpersonal interactions, are nonetheless so significant as to influence the life chances and outcomes of those who are experiencing them.
Take, for example, the oppositional culture theory, first proposed by Fordham and Ogbu in 1986. It suggests that low expectations (quite similar to the forces of felt stigma) lead ethnic minority students to feel ambivalent about school and to disengage academically, in the belief that academic achievement is the sole purview of white people and that their own hard work would not deliver the expected rewards. In her work in 2003, Roxanna Harlow examined how racial stigma affected the ‘emotion work’ of black professors, specifically how students’ assumptions and perceptions about the competency of their minority ethnic professors can create the need for additional impression management work or, conversely, emotional labour to shield the professors’ self-concept from negative perceptions by students.
Note that none of these examples involves direct acts of racial discrimination enacted in interpersonal interactions, yet they show that racial stigma can become embedded, systemic, and persistent, producing effects without the need to enact racial discrimination in those interactions.
There are similarities in the underlying mechanisms of racial stigma and a lack of social empathy but more striking is the fact that they mutually amplify one another. It takes genuine empathy to identify, understand and share the internal social processes associated with the sense of racial stigma sometimes borne by people from VME groups.
VME groups make up about 13% of the UK population and about 20% of the NHS workforce so the subject of EMPATHY is relevant in health and healthcare. We know that empathy is associated with positive outcomes in healthcare, such as improved patient satisfaction, better adherence to treatment and better pain control. But there has also been a notable decline of empathy among healthcare staff in recent years. Reports following clinical malpractices have highlighted a deficit of empathy in current medical practice. As Kerasidou and colleagues showed in their research, where this deficit of empathy has been seen, it’s less about any innate callousness than it is factors such as long working hours, understaffing, inability to spend sufficient time with patients, increased pressure to meet operational targets and increased workload.
Similar to the comparisons I made earlier between interpersonal racial discrimination and more structurally determined racial stigma, there’s a tendency to direct interventions to enhance empathy towards individuals, trading off a focus on the role that systems play in facilitating or impeding interpersonal empathy. A system that rewards healthcare personnel for focussing on the illness rather than treating the whole patient would reinforce the belief that skills such as empathetic engagement are not valuable or important and therefore should not be prioritised.
So, our healthcare systems need to become systems and institutions that are structured and organised in such way as to create conditions that facilitate empathetic interactions in care delivery. They need to be governed by empathy-promoting political goals and decision-making frameworks that facilitate empathetic interpersonal interactions. Specifically, it would make for more empathetic global healthcare systems if, instead of considering healthcare as a commodity to be subjected to market forces and rules, health was treated as a human right, healthcare as a basic good, and access to healthcare based on need rather than ability to pay.
Coming back to the wider social upheavals that a deficit of societal empathy partly explains, there are useful lessons to be drawn from the idea of “restorative justice”, in which offenders are brought face to face with the victims of their crimes, to hear how they have suffered because of them. The victim goes beyond their rage with some understanding and forgiveness towards the offender, and the offender empathises with the victim, becoming aware of the real meaning of their crimes. When people are brought together in a neutral context, with an open, trusting attitude, empathy naturally establishes itself.
In a dynamic post-COVID world where we are restoring social mixing and re-growing collaborations, it is my hope that we restore the foundations for empathy. This commitment to empathy means we will also need to respond to the current climate emergency by innovating new ways of empathy-building social mixing that does not take a toll on the environment. In my time as Chair of WaAHLN, I will be prioritising working with the Charity’s Trustees and our partners to nurture empathetic global partnerships built on active listening, trust, and racial justice.
In closing, I draw from two paradigms of epidemiology and leadership in pressing home my view that we need to look beyond the individual to the wider systems that support racial stigma, addressing the institutional norms and practices that reinforce it. The first is found in more recent discourse in epidemiology and public health, where there’s a shift away from a focus on the health-related behaviours of individuals towards understanding the causes of the causes – i.e., the wider determinants that influence those behaviours. The second is in healthcare leadership, where there’s a similar shift away from looking at leadership purely from the individual perspective to thinking more about how systems are primed to be well-led. The work of William Tate at the Centre for Progressive Leadership is a great reference in this respect.
For too long, racism has been seen as an individual bias rather than a structural and institutional problem and we desperately need to reframe this debate. So again, in my time as Chair of WaAHLN, I want to think systems and institutions. Engagement with governments and institutional systems will be key to how WaAHLNs evolve from this point, and we look forward to nurturing the re-emergence of empathy onto the centre-stage of society and global health.