Ngozi Kalu: ‘When research lacks representation, findings become biased and inequalities emerge’

With master’s degrees in pharmacy and international public health, a PhD in public health and a wealth of experience working to address healthcare inequalities, Ngozi Kalu is well placed as leader of the NHS Race and Health Observatory (RHO) research portfolio. 

Since its establishment in 2021 by Lord Victor Adebowale, the RHO has set its sights on the ethnic inequalities in UK healthcare, as experienced by both patients and healthcare professionals. With a mission to close the gap on these inequalities, it commissions research, gathers data and works to implement real change across the NHS system.

In 2021, a RHO report into racial bias in pulse oximetry ultimately led to a government report that advised how “immediate mitigation actions” should be taken to ensure that pulse oximeters can be used safely and equitably for all patient groups, across different skin tones.

The Pharmaceutical Journal caught up with Kalu to find out more about her role, the work of the RHO and how pharmacists can support the RHO’s mission to help end ethnic inequalities across the healthcare system.

What’s your professional background, and how did you come to be working with the NHS Race and Health Observatory?

I qualified as a pharmacist about 16 years ago and began my career as a clinical pharmacist. I worked in that role for several years, rotating across several specialties. Over time, I realised that while I enjoyed supporting patients directly, I wanted to take a broader public health perspective on patient outcomes. I’ve always been interested in health inequalities, both nationally and globally, and in how health outcomes are shaped by countries’ histories and policies. That led me to complete a master’s in public health at the Liverpool School of Tropical Medicine, followed by doctoral studies at the London School of Hygiene and Tropical Medicine, focusing on how discriminatory policies impact health outcomes.

During my doctoral studies, I also worked on inequalities at the Terrence Higgins Trust and, from there, the transition felt natural. When I saw the role at the NHS RHO it aligned perfectly with both my professional background and my personal commitment to addressing inequalities and closing gaps across all communities and protected characteristics.

Over the course of my career, I’ve worked across women’s health, children’s policy, the HIV sector and LGBTQI-related policy, and now around race and ethnicity.

Can you tell me a bit about your current role as assistant director for research and evidence?

I lead our research portfolio and work closely with our academic advisory group and other stakeholder groups to ensure that our outputs are evidence-based, academically robust, and informed by community insights.

Importantly, our work doesn’t just highlight issues — it provides practical, actionable recommendations. These can be taken forward by us or by organisations within the healthcare system to create real-world impact. Ultimately, our priority is to improve patients’ experiences and outcomes.

Could you give me a brief history of the NHS Race and Health Observatory: what are its objectives and current priorities?

It began with work that our founder, Lord Victor Adebowale, led on the Workforce Race Equity Standards, when he wrote to NHS England and all the arm’s-length bodies asking for the establishment of the RHO. These recommendations resurfaced when he co-edited a special BMJ edition on racism and medicine in February 2020. The recommendations were taken up, which led to the establishment of the RHO in 2021.  

We’re hosted by NHS Confederation, and supported by NHS England and the Department of Health and Social Care. We provide evidence-based recommendations and practical solutions around long-standing inequalities affecting ethnic minority patients, communities and the healthcare workforce.  

We are an independent organisation and set our own work programme but, at the same time, we are close enough to the healthcare system. This allows us to develop recommendations but also to support their implementation, ensuring they lead to real, tangible improvements for patients. 

Our work takes three strands. First, we produce evidence about racial and ethnic inequalities in health through the work that we commission. Where this evidence already exists, we synthesise that information and mobilise it. Second, after we put together this evidence, we use it to influence leaders, producing practical recommendations on policy and practice.

The third strand is implementation: on the basis of our recommendations and in response to the needs of the communities, we support the healthcare system in implementing changes at grassroots level. We don’t want to be known only for highlighting inequalities, many people are already aware they exist. We want to ensure that action follows.

The NHS Race and Health Observatory has highlighted the importance of demonstrating leadership by naming racism. Could you explain what that looks like in practice and why it is important?

To solve a problem, you first have to acknowledge it. This is the first step highlighted in the RHO’s ‘Seven anti-racism principles and briefings’, published in November 2024. One of the RHO’s earliest publications, a rapid review evidence report in 2021, gained significant attention, not only because it highlighted inequalities, but because it explicitly identified racism as a root cause within parts of the healthcare system.

These inequalities are not just unfortunate differences in outcomes, they are rooted in structural racism and in historical practices that disadvantage certain groups. When you look at data and outcomes, taking into account any other characteristics, you start to see that even when you account for factors such as deprivation or gender, in many cases, a consistent gap remains between outcomes for black, Asian and minority groups compared with white groups.

For example, in maternal mortality, data show that among women of white ethnicity, risk of mortality increased as deprivation increased, but women of black ethnicity are at greater risk, irrespective of deprivation. Ignoring the role of racism means any intervention you design will miss the root cause and act only as a temporary fix. The inequalities will persist.

Naming racism allows us to address the actual drivers of unequal outcomes and to use the right policy frameworks to reduce them. Our role is to help the system do exactly that.

The NHS Race and Health Observatory talks about ‘applying a race critical lens to healthcare’. Could you talk us through some examples of that and what that would look like?

A good example is our work on pulse oximetry. During the [COVID-19] pandemic, these devices were used extensively to measure oxygen saturation. We found that the darker your skin tone, the less accurate those readings are. This review didn’t just highlight an issue — it led to solutions, such as taking multiple readings that are considered alongside other clinical signs, to obtain a more accurate picture of the patient’s condition.

Another example involves medications currently used in practice. Research we published [in 2024] looked at DPYD; a gene variation that can cause a deficiency in the enzyme dihydropyrimidine dehydrogenase (DPD), which is responsible for breaking down particular cancer drugs. Currently, when patients experience side effects, they get gene testing which is based on four types of DPYD variations: mainly of European ancestry. Our systematic review, produced with the University of Liverpool, identified an African variant that isn’t currently included in testing. We are continuing to explore the clinical significance of this finding, and the full research will be published in 2026. 

Then there’s the Apgar score for assessing jaundice in newborn babies. The Apgar score was developed in the 1950s and it includes subjective assessments based on skin colour, such as whether a baby is pink, or blue or pale. This makes assessment inaccurate for babies with black and brown skin tones. On our website we outline our ‘Ten steps to spot jaundice in black and brown babies’, published in January 2025, to help address this gap.

These examples show what happens when research lacks representation: findings become biased toward certain populations, and inequalities emerge. We then have to work backwards to correct these oversights. Applying a race-critical lens ensures that diverse populations are considered from the outset, reducing the risk of inequitable care.

The NHS Race and Health Observatory has commissioned its own review into the NHS workforce ethnicity pay gap. What would you like to see as a consequence of this? 

This work is being led by my colleague, Owen Chinembiri, assistant director for workforce. It will focus on examining differences in pay, career progression and the potential impact on cumulative financial earnings among staff from different ethnicities. We aim to highlight where sticky floors or glass ceilings still exist and identify nuanced differences between various staff and ethnic groups. Where are people being held back, and what might be happening in those spaces that leads to this lack of progression?

I believe the work will involve interviewing about 200 NHS staff members to gain deeper qualitative insight into what is happening within professional services: 

• How is your day-to-day experience? 
• How are you encountering these limitations and work opportunities? 
• Are opportunities coming to you, or are they not? 
• How are these factors impacting you? 

Our goal is not only to highlight the problem but also to provide practical solutions and actionable recommendations. 

What are your personal objectives for the next 12 months? 

A big objective of mine is improving representation in research. We are working with the National Institute for Health and Care Research and the wider research sector to understand what needs to change so that research participants better reflect the diversity of the population in medical research. In June 2025, we held a workshop with sector colleagues to explore what actions are needed to strengthen ethnic representation in research across the UK. We looked specifically at how to ensure that researchers design studies with representation in mind from the outset, rather than focusing on only a small subsection of the population. That work is ongoing and will continue over the next 15 months. 

We are also working with Macmillan and Roche to increase representation of black and Asian participants in breast cancer clinical trials. If research isn’t representative at the point of drug development, medications may be approved without ever having been properly tested in certain populations. To help address this, we now have a clinical research nurse in post who will provide one-to-one support to patients at Barts Hospital in London, our intervention site. They will work directly with patients diagnosed with breast cancer, guiding them through the process of identifying relevant clinical trials and helping them understand what taking part in a trial involves.

My hope for the coming year is that this work will lead to increased participation of black, Asian and other ethnic minority patients in medical research.

What can pharmacists bring to this kind of research? 

As pharmacists we work in many settings, both in the private and the public sector. Whether we’re in community, hospital, GP or industry, we provide services that reduce health inequalities and offer the first point of call for patients who need some support. So I would say, first of all, pharmacists can start by finding out more about the work that we do, keeping an eye on our website, our social media platforms, and on our health action research platform, which is our data platform providing information on inequalities in a few healthcare areas. 

Pharmacists can also contribute by sharing or amplifying our resources within their own practice, or through their communications platforms. They can join and help shape the work that we do through the platforms where we advertise opportunities. Whenever we run a call for community engagement, we welcome input from a wide range of communities. We also have our advisory groups and we recently did a call out to expand our stakeholder engagement advisory group. 

We collaborate with other organisations, so if there are key community or pharmacy groups that feel it would be valuable for us to connect, we encourage them to reach out. If they’ve got ideas of work that we could develop together or projects they’d like to be involved in, we are always open to those conversations. 

What would your message be to someone who is reading this and wants to get more involved in addressing health inequalities? 

I would say the first point is having that zeal — that calling within yourself — that you want to make an impact. And you probably already are, in the work that you’re doing. But sometimes you may feel a bit like you are on your own. I know how it can be, as a pharmacist, working in your own space most of the time. It helps to be able to join groups and get involved with organisations such as the RHO, so that you can amplify your work, get that backing, be plugged in and signposted to other organisations who are doing the work that you’re interested in. 

Doing this work alone is heavy, but joining a community of people can provide not only the right level of access, but also the social support that is often needed for doing work that is this heavy. Don’t do it alone. You are making a difference, but where you can, join up with other people who are also doing this work so that it can be amplified, you can feel a sense of community, and you can see the changes being made.