Firstly, what was it about health law that encouraged you to apply for the fellowship in the Law School?

I didn't study law at university at all. My undergraduate, Masters and PhD were all in anthropology and medical anthropology. But because medical anthropology is about understanding how human health and wellbeing is shaped by society, politics, economics and by global and local relations, being part of a law school is completely in line with trying to fully understand how governance impacts human health. When I saw the call for the VC fellowships I thought it would be an ideal opportunity to  better understand the mechanisms of law  in relation to health. In particular understanding how self-protective religious minorities and the state negotiate each other’s positions around healthcare and health policy – which is really the core of what I’m interested in.

This is closely linked with medical anthropology and illustrates different ideas of health care where you've got, for example, interpretations of religious law, and then you've got state policy and how the two intersect and conflict around particular issues. So, it's really exciting to be in a law school to understand the legal mechanisms of health and policy and how that interacts with the social worlds of minority religions and with the religious laws that people live their life by, to varying interpretations and stringencies.

You particularly wanted to work within the Centre for Health, Law and Society, why was that?

I’d known of the Centre for a number of years, since its launch in 2017.  It's got a fantastic reputation for multi-disciplinary research, and it's great to situate what I'm doing as part of those conversations. Initially, I’d been interested in the area of work that Professor Sheila McGuinness (the Centre’s current Co-Director) was involved in around reproductive rights and the social context of law and abortion law and abortion policy. More recently I’d discovered the work of my now mentor, Dr Peter Dunne, who I’d met at a workshop on children's rights to health in 2017, where I was presenting my research on how self-protective religious minorities navigate vaccination services and issues of trust with state institutions. .

It was Peter and his enthusiasm for research around law and LGBTI rights that encouraged me to apply for the Fellowship. He supported me to develop my application on the issue of statutory changes to the teaching of relationships and sex education (RSE), and particularly the apparent tension between different kinds of rights, so rights to religious freedom and rights for civic equality and protection. Sexuality education is an area that UNICEF considers a cornerstone of promoting positive adolescent sexual health and wellbeing. Yet, sexuality education is a global health policy issue that takes shape differently in local settings, as we're seeing with in the UK at the minute with the statutory changes to the teaching of RSE and how LGBT content has been addressed and how minorities are navigating that.

Being part of the Centre is an incredibly creative and productive experience. The opportunity to work with people like Peter and Sheila was very much something I was gunning for when applying for the Fellowship.

You started the Fellowship one year into a pandemic – how did that present the opportunity to look at other areas of your research through a ‘law lens’?

I’ve been working on issues of vaccinations since about 2013. As part of my PhD, I was looking at why self- protective religious minorities have suboptimal levels of vaccination coverage and to understand the tensions between services, ethics and policy. And so, there's obviously overlap with the issues affecting different areas of health care and how state policy or state law really interacts with the social worlds of people. As we’ve discussed, law affects lots of different areas of health and wellbeing, from new statutory changes to RSE – to what we’ve been seeing with COVID-19 vaccination programmes and the frameworks within which people can make decisions around their health and their wellbeing. My interest in how these kinds of policy issues affect, and are inclusive of, ethnic and religious minorities.

After my PhD, I was at the Hebrew University of Jerusalem looking at the issues of vaccination decision making among religious minorities after the 2018 and 2019 measles outbreaks – the biggest outbreaks in a quarter of a century in the US and Israel. My particular interest, which I think is most poorly understood from a public health perspective, is the so-called issue of ‘religious opposition’ to vaccination. Obviously, religion intersects with law in different ways. If we look in the US there are religious exemptions to vaccination mandates, for example, but how and whether people perceive religion as being at odds with vaccination, and what happens when religious authorities advocate for vaccination, but people refuse, are different questions entirely. These questions have gained a kind of renewed relevance in the COVID era of how to maintain and sometimes enforce optimal levels of vaccination coverage. My research looks at what the ethical questions are around that and what are the ethical ways of approaching exemptions.

So, the COVID-19 vaccination programme has given me the opportunity to keep monitoring the ways that vaccine programmes and uptake in minority groups are being represented in the public domain, in social media and in the press sectors of different minority groups – and to contribute to policy and public debates around that. So, for example, the longstanding research I've been doing in this area has been cited in World Health Organization's implementation guidance, which has been really exciting.

That’s amazing. What particular aspect of your research was the focus of the World Health Organisation’s citation in its vaccine implementation guidance?

A need to understand what policy says and the community engagement needed to deliver it. We need to understand how different communities navigate policy – and that we can’t assume suboptimal vaccination coverage is an issue of ‘religious opposition.’ No one issue stands in isolation and they've got to be understood in relation to everything else that's going on in the prevailing climate.

So, it's really about understanding how context shapes decisions around vaccination. How engagement with local health care services, for example, influence those decisions. Orthodox Jews tend to have suboptimal vaccination coverage in Europe, North America, and Israel, so it might be tempting to look for patterns, but their issues and their healthcare relations are always going to be shaped by local context in slightly different ways. So, the UK and NHS system is going to be very different to the USA, where vaccinations are required for school-entry in a range of states.

But I think in terms of the coronavirus, it's really understanding how people make decisions around a vaccine that has been developed and deployed at an unprecedented scale – the largest vaccination programme in British history. It’s really quite frustrating that there's this assumption that religious minorities have religious beliefs against vaccination, and that's very often not the case. Often, they make decisions in very much the same way as anybody else in terms of risk and responsibility. But what influences those ideas of risk might be different, and so I've been really interested in deconstructing this question of what constitutes religious opposition to vaccination, and whether that is an accurate term.

You mention that there is a narrative around religious beliefs hindering vaccination programmes and that this isn’t helpful. How does the term ‘vaccine hesitancy’ feed into that?

The use of the term vaccine hesitancy is becoming a universal phrase and I’m constantly surprised at how many people have latched onto it, often uncritically. In 2019 the World Health Organization ranked vaccine hesitancy as among the biggest threats to global health - alongside the dangers of antimicrobial resistance and climate change. But this focus on vaccine hesitancy almost obscures how we look at the question and how we look at the issue because we might also ask whether vaccination services are user-friendly, as flexible, as pragmatic, as inclusive as they could be? We need to go beyond it, and we need to understand the issues of access, equity, transparency, ethics and of an appropriate policy.

This goes back to the question of community engagement. We need to understand how different populations engage with health care services, what their expectations are and how to meet them. I think that is a question of equity. But because of this focus on vaccine hesitancy there's a danger of placing the problem on people rather than these bigger questions relating to suitable services and provision.

Different minorities with some different positionalities. Maybe they had historical experiences of discrimination and then that experience is directed towards the vaccine, to voice concerns of trust in the authorities' making decisions. Perhaps we’re seeing that in Black minorities if we think about some of the issues that have come up around the uptake of the coronavirus vaccination. Windrush and the issue of systemic racism, for instance. Have those long running issues been directed towards a vaccine that's being implemented by the state? A state that has been far from compassionate or not demonstrated interest in addressing systemic inequalities. We need to remember that this is the largest vaccination program in British history. And as a mass vaccination program, it's going to affect social worlds in different ways.

Finally, you’ve talked about the need for community engagement to improve service delivery – how have you explored this in your own research and what role do you believe localisation will play in the future?

So, I have been collaborating with the London School of Hygiene and Tropical Medicine, looking at how Orthodox Jewish minority groups have had a high prevalence of coronavirus during the pandemic. We’ve been looking at how they have been responding to the coronavirus vaccination program and how they have been collaborating with others to deliver services. So, we've been looking at, for example, how a Haredi Jewish paramedic service called Hatzola, a rapid response service, has collaborated with public health providers to deliver vaccinations to its community to understand what the division of responsibility could look like in these localised models of implementation. We explored what public health had responsibility for and what this partnering organisation had responsibility for. What's been quite exciting about this collaboration is understanding how we can go beyond community engagement to engaging with community leaders to encourage localisation of services and delivery and sharing responsibility around implementation.

We’ve now submitted that research for publication and I think it could be quite interesting to see how that model could be expanded as part of the coronavirus vaccination program. The greatest challenge is to fully understand what localisation might mean in the future for, say, influenza. What it might mean for childhood vaccinations, to understand how communities can share that responsibility, be brought in as partners in the delivery of vaccination programs. Really the challenge is to start to change the way we look at community health. For minorities where there are suboptimal levels of vaccination coverage, we need to understand how we can make vaccination delivery more conducive or more equitable or more accessible than this. Localisation might play a part in providing culturally specific services that will help us take a mass vaccination program and shape it in local context with the intended beneficiaries in mind.