(Illustration courtesy of the Robert Wood Johnson Foundation)
In countries and communities around the world there are organizers, leaders, and experts who are working to remove the barriers to health that are rooted in racism and structural discrimination. They are creating anti-racist strategies to respond because today too many people are limited by racism and discrimination based on ethnicity, caste, tribe, gender identity, sexual orientation, ability, and religion. The evidence is clear that racism and discrimination baked into our societies causes sicker lives and earlier deaths.
Dr. Tlaleng Mofokeng has been working for years to support those who have been marginalized due to racism and discrimination by providing care directly in South Africa, and advocating, teaching, and organizing at a regional and global level as the United Nations Special Rapporteur on the right to health and co-chair of the O’Neill-Lancet Commission on Racism, Structural Discrimination and Global Health.
Dr. Karabi Acharya, senior director of the Global Ideas for US Solutions strategic portfolio at the Robert Wood Johnson Foundation, sat down over Zoom with Dr. Mofokeng to discuss how anti-racist policies and practices in communities and countries around the world can inform efforts in other places as we work to build a more equitable, healthy world. The conversation has been lightly edited for length and clarity.
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Karabi Acharya: You’re a doctor, policy expert, and advocate, but I’d love to start by understanding why you went into medicine.
Dr. Tlaleng Mofokeng: I’ve always wanted to be a doctor, but I don’t have a really clear memory of making that decision. I grew up in South Africa in a Bantustan, which was apartheid-made space for Black people. We witnessed a lot of riots and a lot of protests, and I think my empathy and passion to want to help just comes from being exposed to people who need medical help and just didn’t get it.
Dr. Karabi Acharya
Acharya: It sounds like where you grew up, and specifically the sociopolitical environment of apartheid, gave you almost an intuitive understanding of the social determinants of health and an early recognition that health care alone was not going to solve these problems.
Mofokeng: I remember being in primary school and having a helicopter drop toothbrushes and toothpaste in the yard of the primary school from the air. And I’m like, why does this make sense to anybody? If you want to give us toothbrushes and toothpaste, give it to us. Why are you dropping it from the sky? So life was already not making sense. But I didn't have the cognitive ability to make it make sense at the time. That feeling of confusion and disbelief has followed me throughout my whole life.
Dr. Tlaleng Mofokeng
In medical school, I knew that the medicine I was also being taught and the kind of doctor I was being groomed to be was not the doctor that I needed to be. I knew that I had to pass medical school, I had to nod and say yes and do what I needed to do. But I knew that I would have to relearn parts of medicine and reteach myself how to be a better doctor.
I also knew that just because I’m Black doesn’t mean that I am destined for disease or for incarceration or for drug use. And yet a lot of the public health messaging had that framing. There was no dignity there.
We also need to be honest in the fact that the difficulties many people face are not of their making. That’s why I started reading up about racial justice and race as a determinant of health, and segregation and how town planning happens where you have particular communities where you have asthma and eczema, and all these allergic and inflammatory conditions because of the water and air and land pollution.
Acharya: In the United States, I think many people sometimes believe we have this unique, very exceptional experience with racism. I would love if you could just talk a little bit about this more globally. What are some of the ways in which racism manifests globally and is similar across different country contexts? And what are some of the ways in which it’s different?
Mofokeng: Racism is not a phenomenon that’s just located in one geographical area or region in the world. Racism is a tool to advance imperialism. If you look at India and the caste-based discrimination and colorism, that’s all a function of racism. And the color of your skin in many areas around the world was—and even now is—something that was used to gauge proximity to whiteness. Even in spaces where the majority of the population are not white people, there is anti-Blackness.
There are ways racism and structural discrimination manifest in similar ways in different places. In the US, especially now when talking about health, we often talk about the maternal health outcomes between white women in the US versus Black women in the US. The same discussion is happening in the UK. The same discussion is still happening in South Africa where fertility control was part of the apartheid regime. Even in a democratic South Africa, some of those practices still exist where doctors were sterilizing, forcefully or coercively, HIV-positive women. Because they were HIV positive, they were not seen as fit to be mothers, and they were Black, and they were poor. And so they were seen as a burden to the system. It wasn’t policy, but it was still practice.
“There are people every single day who are fighting racism, who are struggling with racism, who are surviving. And there are things they can teach us as they continue to survive.”
The remnants of racism and coloniality and imperialism permeate every sector of our society—economic, political, civil, socioeconomic, cultural. It permeates everywhere. And that’s why we talk about structural discrimination. This is not an issue of individual people not liking other people. Racism is a structural matter that recognizes and humanizes certain people just by merely being white. And it systematically disenfranchises certain people because they’re not white.
Acharya: Do you think there’s any place in the world where racism does not exist or is very minimal?
Mofokeng: Racism is not a factory fault; it was designed to yield these very inequalities we are facing. People often think that we are here because something just in the machinery, just the screw got loose. No. It was designed this way. It’s so systemic and so deeply entrenched that you can’t make an individual choice to say, “I’m nice today, therefore, I can’t be racist.”
Acharya: That is such a critical point. Tell me a little bit about The O’Neill-Lancet Commission on Racism, Structural Discrimination and Global Health, and specifically why now? Do you see something about this moment in history where this work is particularly important?
Mofokeng: I was an essential worker during COVID and experienced firsthand the very things that I knew already before going to medical school; what would happen if we ever had a disaster like COVID. We knew who would be disproportionately impacted. And with all that knowledge, with all of the resources, there were still no plans in place because the people most affected were not the rich people. So COVID didn’t teach us anything new. It affirmed what we knew; that there are people in this world who matter, and there are those who don't matter.
For us, it’s really racism and not race that’s the problem. It’s racism that creates and maintains unjust and often avoidable health inequities. We want to understand structural discrimination and what it looks like in the US, in the UK, in Southeast Asia, for Indigenous Peoples in Fiji, for example. What are the kinds of research and collaborations we can embark on collectively to ultimately lead to change? The commission is about diagnosing the problem, identifying best practices and what’s actionable.
Acharya: I know the work is still early, but where are you seeing bright spots?
Mofokeng: It is still very early stages, but we had a convening in Cape Town in May at the end of the International Newborn and Maternal Health Conference where we had a group of women from around the world. We had someone who is from the US, one of the richest countries on earth, but experiencing inequality and health outcomes as bad as a developing country. Then we had women here in South Africa at the intersection of motherhood and sex work talking about their children’s rights. We need to think about them as well because they experience discrimination because their mothers are sex workers. And then a woman from Ghana with her personal experience of multiple pregnancy losses and the lack of support for people with high-risk pregnancies.
One thing that we achieved is that the women knew that what they were experiencing is unjust. Because a lot of what happens in the medical system is that you get gaslighted. It’s like, “You were late. You did this. You didn’t do that…” There’s a lot of just not believing women in health systems but especially Black women seeking maternal health and health care.
And the other thing that we achieved is that we could see the common thread. Of course, racism will look different, and it’ll be perpetuated and maintained at different rates through different societal hierarchies in different countries, but the women were able to imagine what solidarity looks like outside of their own region, outside of their own country, and also outside of their own silo issue of “We are sex workers,” or “We are Black American women,” or “We are in Ghana.”
That’s what solidarity is about. It is about being affirmed in your experiences and knowing that indeed what has happened to us happens to us. And that is called epistemic injustice, where people are just not believed when they say things have happened to them because of the power dynamic or because of some stereotype that they may be experiencing.
Part of that convening was undoing epistemic injustice, listening to women and hearing from them what they want.
Acharya: I love this concept of epistemic injustice and just this notion that whose knowledge counts? Whose knowledge matters? And the inequity in that. And to the point that you’re making that so many people, their knowledge, their own lived experience doesn’t count because of the system that we are in, which only values expert knowledge, and medical knowledge, and scientific knowledge.
How is the commission addressing this? And how are you taking a less extractive approach to learning?
Mofokeng: The process of the commission for me is as important as its outcome, which is a Lancet Report. And what that means is that the commission is intentional about listening and actively seeking voices and experiences of people who are often not seen as experts, especially to contribute to such a report like the Lancet Report. And that, for me, is something that’s really different and in that spirit of undoing epistemic injustice. We know a lot of history, a lot of knowledge was withheld—books and libraries were burnt to the ground—to try to deny the intellect and the sophistication of Black people around the world. It’s important in doing the work of the commission to excavate that knowledge and to start to show how the process of the commission is rooted in equality and justice.
Another important theme baked into our approach is this idea of restoration of dignity. And that means that we are probably going to have to do a lot more work with people who are rooted and located within communities. Which is why our commissioners themselves are people with a track record of doing work in communities they reside in. We must be intentional about amplifying the voices of and solutions from people experiencing these issues in very real ways in their daily lives. There are people every single day who are fighting racism, who are struggling with racism, who are surviving. And there are things they can teach us as they continue to survive. And it’s that humility that’s required to be able to do this work with the intention to support and restore the dignity of people.
In all of the multilateral system, there isn’t a vision for addressing racism and discrimination in health that we are all united around. And this is why it’s timely. Why are we so scared to talk about racism in health? I’m hoping that the commission can do some of that work, both in a global space and holding those in positions of power and influence accountable. But also really being intentional about the voice and the lived experiences of people who every single day are surviving in spite of these difficulties.
Acharya: That was a mic drop. Thank you. Do you have any last thoughts about how people should approach the work of dismantling structural racism and discrimination?
Mofokeng: Just this: Feminism and this anti-racist work—and the way we understand and know what needs to happen—really does not lie in these so-called sophisticated spaces. The first feminist I knew was my mother. The first people I knew and witnessed standing up against patriarchy were my aunts who were laughing out loud and refusing to be silenced. And so, we need to also not overly complicate what resistance looks like.
My life is merely but a series of perfectly aligned miracles. I don’t celebrate being the first or the only one. It only reminds me of how unjust the world still is. And that’s what keeps me doing the work that I do, and often at a very high personal cost. For the next generation of Black people, Black women, Black non-binary people, their success in life cannot be left to a series of perfectly aligned miracles. We really need to change the systems and the structures.
The views expressed herein are personal and do not necessarily reflect the views of the United Nations.
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Read more stories by Tlaleng Mofokeng & Karabi Acharya.