EVERYTHING I THOUGHT WAS WRONG

Although the United States has the most advanced medical technology in the world—and spends more on health care than anywhere else—we lag behind all other wealthy nations in key measures of health that serve as a proxy for our overall well-being. It starts at birth and ends with death. The United States has the highest rate of infant mortality and the lowest life expectancy in comparison with other wealthy countries. An American woman is more likely to die as a result of pregnancy and childbirth than women in other countries of comparable wealth. That rate is higher now than it was in the 1990s, even though most of these deaths of mothers are avoidable.

The poor health outcomes of the world’s wealthiest nation are often presented as a mystery, yet their root causes are hiding in plain sight: these disparities are driven by inequality and discrimination, which lead to poor health in people of color in the United States, particularly African Americans. The health outcomes of Black Americans are by several measures on par with people living in far poorer nations. At every stage of life, Blacks have poorer health outcomes than whites and, in most cases, than other ethnic groups. Black babies are more than twice as likely as white babies to die at birth or in the first year of life—a racial gap that adds up to thousands of lost lives every year. Blacks in every age-group under sixty-five have significantly higher death rates than whites. Black life expectancy at birth is several years lower than that of whites. African Americans have elevated death rates from conditions such as diabetes, stroke, and heart disease that among whites are found more commonly at older ages. In a phrase, African Americans “live sicker and die quicker,” which, if you estimate years of life lost because of deaths that could’ve been prevented, adds up to tens of thousands of lost years.

Too often this story of inequity and disadvantage in health gets dismissed as “only” affecting the poor, or being one of class, not race. It is indisputable that poverty creates emotional disruption, inequality, and fear. Health-care facilities in lower-income communities are often underfunded and left to waste away. The poorest communities lack access to healthy food, clean water and air, and outdoor space—as well as jobs, safe living conditions, and quality education. This in itself is unfair and tragic and affects people of all races and ethnicities who live in pockets of rural, urban, and suburban poverty across the country. Too frequently, rather than taking into account these structural inequities, we blame the individuals, by insisting they wouldn’t be poor if they worked harder and wouldn’t be sick if they were educated and simply took better care of themselves.

However, poverty is not the sole factor in who gets sick and who doesn’t, in who survives and who passes away; it just makes the situation that much worse. Even when income, education, and access to health care are matched, African Americans remain disadvantaged and racial disparities in health cut lives short. College-educated Black mothers, for example, are more likely to die, almost die, or lose their babies than white mothers who haven’t finished high school.

I am a Black American and have been a journalist and author in both ethnic and mainstream media for several decades. Most of my work has looked at the health of African Americans, particularly Black women, and at racial health disparities. Of course, I have long understood that something about being Black has led to the documented poor health of Black Americans. But in recent years I have come to understand that much of what I believed about health disparities and inequality in the United States was wrong. The something that is making Black Americans sicker is not race per se, or the lack of money, education, information, and access to health services that can be tied to being Black in America. It is also not genes or something inherently wrong or inferior about the Black body. The something is racism. Income, education, determination, and self-empowerment can help individual Black Americans but cannot entirely erase the negative effects of centuries of discrimination, and ongoing bias, on the health of African Americans. To put it in the plainest terms, from birth to death the impact on the bodies of Black Americans of living in communities that have been harmed by long-standing racial discrimination, of a deeply rooted and dangerous racial bias in our health-care system, and of the insidious consequences of present-day racism affects who lives and who dies. These factors create physical vulnerability and systemic disadvantages that education, income, and access to health care cannot erase. This inequality, born more than four hundred years ago and embedded in every structure and institution of American society, including the health-care system, is driving our country’s poor national health outcomes relative to the rest of the developed world. It has taken me three decades of reporting on the health of African Americans and several disturbing personal medical crises to understand the ways discrimination and bias contribute to poor health outcomes primarily in African Americans, but in reality in all oppressed people.

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In the mid-1980s, I became a contributing nutrition and fitness writer for Essence magazine, and eventually the publication’s health editor. Like so many other Black women before and after me, I remember seeing Essence at my grandmother’s bedside and on my mother’s coffee table when I was growing up. It was first published in 1970, during the intersection of the Black Power and women’s liberation movements and served as a bible for Black women. The mission, instilled in everyone on the staff by our editor in chief, Susan L. Taylor, was clear: in a world full of negative representation and damaging mythology, give Black women positive images of themselves and empower what would eventually grow from fifty thousand to more than one million readers and a reach of more than eight million subscribers with information about relationships, finances, careers, travel, family, spirituality, food, health, and, most important, self-love and acceptance, to make their lives better.

At Essence, my personal mission was unambiguous: fix the health crisis in Black America. At the time, from the late 1980s to the end of the last millennium, I understood that Black America was experiencing a life-crushing constellation of health problems; Black people were contracting serious illnesses at younger ages than other Americans and living fewer years. I was sure, as so many others believed then and still believe today, that poverty was solely to blame. In 1985, I was transfixed by the Heckler Report, issued by the U.S. Department of Health and Human Services (HHS) and released that October, which took a research deep dive into racial health disparities. The ground-shattering document was pulled together by a nineteen-member task force of senior scientists and officials at HHS who analyzed existing data about race, death, and disease in the United States. They examined the underlying factors and consulted with experts outside the government who specialized in the health of people of color. This publication marked the first time the government had comprehensively studied the health status of people of color, and it elevated the issue of health inequality to the national stage. I ordered a print copy of the 239-page study and read it like a novel.

Named for the HHS secretary at the time, Margaret Heckler, the report estimated that there were more than eighteen thousand “excess deaths” each year among Blacks because of heart disease and stroke, compared with the number of deaths that would occur if their health was on par with that of whites. It also pointed to 8,116 excess deaths from cancer, 6,178 from infant mortality, and 1,850 from diabetes. It made me ache to consider the thousands of Black men, women, and babies dead every year from medical problems we knew how to prevent and treat. Heckler, a pro-life Reagan Republican, called this shameful inequality “an affront both to our ideals and to the ongoing genius of American medicine.”

The Heckler Report recommended no new government funding to attack the crisis. The report did discuss what we now call the “social determinants of health,” conditions like poor housing, crime, pollution, shortage of healthy food, and lack of medical services that affect mental and physical health. But it neglected to mention the Reagan administration’s cutting or freezing federal dollars for Medicaid, food stamps, family planning, and other supportive services, which would make health disparities grow, not shrink. Heckler insisted that “money was not the answer.” There was no mention of discrimination and bias either inside or outside the medical-care system. Instead, the report advised Black Americans to save themselves by improving their health through education, self-help, and self-care. The government’s role was to bolster data collection and communication between agencies and expand health education. Heckler lay the blame bluntly at a press conference following the release of the report: “Progress depends more on education and a change in personal behavior than it does on more doctors, more hospitals, or more technology.”

Within this largely well-meaning report lurked the assumption that Black people, individually and collectively, were irresponsible, careless, uneducated, and making thoughtless choices that led to this health crisis in the first place. Edith Irby Jones, MD, then the president of the National Medical Association, the professional organization for Black physicians, called out Heckler on this point in a 1986 essay in her group’s journal. Dr. Jones wrote that Heckler’s “implication, of course, is that if Black people would only ‘behave’ their health problems would be solved…Well, as Black Americans we know it is not as simple as that. Blaming the patient will not cure the ills of America’s underserved minorities.” She also recommended “hope in place of hopelessness, service in place of self-serving moralizing.”

At the time, I didn’t question the report. I was excited to see a document full of evidence of racial health disparities, developed by experts and blessed by the federal government, and used it as a mandate, firmly believing that if we—Black Americans—know better, we do better. The report also dovetailed perfectly with my own belief in self-help and the mandate of the magazine. I approached Essence’s mission with passion and steely focus, through a Washingtonian (Booker T.) lens of individual self-improvement—helping people help themselves and uplifting those who couldn’t. I never strayed from the belief that people had the power to save their own lives in the face of the health disparities described in detail in the Heckler Report. I understood that my life’s work at the time was to provide our readers with solid, practical self-help information about diet, exercise, and other kinds of self-care so individuals could be healthier, which would raise the health status of the entire Black community. I imagined a kind of trickle-down effect from the health information our magazine provided: I promoted an each-one-teach-one mentality that encouraged readers to make sure all the “sisters” in the lives of our largely middle-class audience (read: your less educated and privileged friends and family) understood the importance of good health and how to achieve it. It was us and them—us, the educated middle-class Blacks like me and my relatives, and them, the economically challenged Blacks whose image shone brightly in full-spectrum dysfunction in the American media, then as now dominated by upper-middle-class, largely white male producers, editors, reporters, and writers. At Essence, our staff of mainly Black women did not just feel responsible for those less fortunate Blacks; we were actually tasked with saving them. I recall being in an Essence staff meeting where our editor explained that each of us was responsible for the lives of eight Black women. I remember coming home late one night, and as I was walking up the subway steps, exhausted on my way back to Brooklyn from Manhattan, I thought, “No wonder I’m so tired. I’ve got eight women tethered to me, and I just dragged them up the stairs!”

The Heckler Report’s conclusions also fit comfortably with what I’m ashamed to admit were my own narrow views of Black communities in America. While I wasn’t crass enough to blame poor African Americans for their plight, I fell prey to limiting, media-driven stereotypes of Black people. I had spent my early years growing up on the South Side of Chicago in the all-Black neighborhood near where my mother had been born and raised, and we lived in a building my grandparents owned. As a child, I was influenced by my parents’ complaints about Chicago and whisper-hiss conversations about how they needed to get out of the city and start their own life. By the time I was in third grade, the city’s homicide rate had more than doubled from a decade before, and nearly a third of all Black residents lived below the poverty level. At first, my parents wanted to move to a predominantly white suburb near my father’s job as a bacteriologist at Edward Hines Jr. VA Hospital. But while looking for a home, my mother asked a police officer if the area would be safe for a Black family, and he told her, “I can’t guarantee that we could protect you and your family.” Finally, in 1969, my father requested a transfer to Denver, and my parents packed up our Rambler station wagon and moved the family to the suburb of Lakewood, Colorado. We were part of a larger trend of Black suburbanization that began to reverse the tendency of Chocolate Cities and Vanilla Suburbs. In the 1970s, the overall Black population in American suburbs increased by 70 percent as African American families like mine moved to the suburbs, taking advantage of a world newly expanded by civil rights legislation that finally dislodged some of the institutional discrimination in housing and education. Leaving Chicago, the only city she had ever known, and moving far away from her parents and extended family, was gut-wrenching for my mother. But like so many Black parents of the era, mine wanted to get out of the hood and give my sister and me a better childhood than they had had. To them that meant we would grow up in a house with a backyard, not an apartment near the Dan Ryan Expressway, and go to a school with a cafeteria, not run to the church across the street at noon to eat a free lunch served by Christian volunteers in the basement. We would learn alongside the white kids, play outside with them in the safe streets of our suburban community, and get all of the privileges generally reserved for them. We were what are sometimes called Integration Babies.

The year after Martin Luther King Jr. was assassinated, as we drove up to our new ranch house just west of Denver—so much larger than the apartment where we had lived with my grandparents in Chicago—I asked, “Daddy, do we have to share it with another family?” My little sister was even more amazed: “Are we rich?” Then we saw it. Somebody had written “Niggers Get Out” on the garage door and on the pavement on the driveway. Some of the neighbors—all white—were trying to scrub off the words before we arrived. But it was too late. My father wanted to get right back in the car and drive home to Chicago, but my mother—and the neighbors—persuaded him to stay. We later found out it had been the twin boys two houses down who delivered the newspaper who had defiled our new home on a dare. Their father made them apologize and deliver the paper for two months for free, paid out of their allowance, as punishment.

A few days later, when I started third grade, no one spoke to me at all for two weeks. I later learned that the principal had called a school-wide assembly the Friday before I arrived to explain to my classmates that Alameda Elementary was getting its first Black students. The other third graders were so afraid of saying the wrong thing that they said nothing at all. Finally, months later, a little girl with large brown eyes, freckles, and pigtails asked if she could walk home from school with me. I exhaled, and she became my first friend. I worked hard to hold on to my white friends. Like many of us who grew up in predominantly white spaces, I understood that I needed to be twice as good as everyone else to receive half as much respect, and I became the poster girl for overachievement. In high school, I earned nearly straight As, was captain of the track team, an editor of the yearbook, and president of my class. What I would later understand as high-effort coping never prevented me from feeling like a fly in the buttermilk, but it did allow me to find a place. Fitting in demanded a kind of Stockholm syndrome trade-off: it meant absorbing the stereotypes about Black people and communities, pervasive in every corner of American culture, that most white people accept as truth. To reconcile these images with my reality, I had to believe my family and I were exceptions, an idea thoroughly endorsed by others. I can no longer recall how many times people said to me, “You don’t seem Black,” or “You aren’t like other Black people.”

I would not have a true understanding of the breadth and depth of structural racism for another few decades, when I became a college professor and had to first learn about, then teach, a version of critical race theory to my Black studies students. Without a more sophisticated racial justice framework, our family members lived by a pieced-together set of principles that included hard work, determination, education, and religious conviction that we believed made us better Blacks, the good Negroes. While this philosophy improved our lives, it was not the full picture.

I was most influenced by the story of my grandparents, who each managed to flee the limited opportunities and racial terrorism of the South and get out of two different cities in Mississippi during the Great Migration in the late 1920s to land in the South Side of Chicago. My grandmother was particularly inspiring. She left Iuka, Mississippi, following her seven siblings, and most of this extended family settled on or near South Vernon Avenue, where they created a kind of warm, familiar Mississippi cocoon, relying on each other for comfort and support. They bought their homes and, in my grandparents’ case, buildings, got educated, and launched businesses and careers, overcoming what I believed were only personal challenges. I was proud of my grandparents, inspired by our family lore of individual grit and success. My family judged those who either didn’t get out of the South or didn’t find success in the North as less smart, motivated, and hardworking. Later, after my immediate family moved out of Chicago, my mother, father, sister, and I created a walled-off microcosm of four in Denver so that we were able to at first merely survive living in an all-white community and eventually actually thrive. We believed Black people like my family had the responsibility to give back to those who had less ingenuity, education, money, and work ethic, because that was the price of success, Black success.

About five years after I became health editor of Essence—and after writing and editing a whole lot of articles with advice about “self-health”—I would begin to understand that those less fortunate sisters and brothers of my experience and imagination were not to blame for the health disparities that plagued Black America and being middle class didn’t entirely protect any of the good Negroes. In other words, I got an early inkling that though being poor matters greatly where health is concerned, race, even in the absence of poverty, matters too. Something began to shift when I met Harold Freeman, MD, the director of surgery at Harlem Hospital who had recently served as the national president of the American Cancer Society. He had co-written a groundbreaking article, “Excess Mortality in Harlem,” published in the January 1990 issue of The New England Journal of Medicine. The piece explained that even as life expectancy was rising in the United States for people of all races, Black men in Harlem lived fewer years than their counterparts in the impoverished country of Bangladesh. This framing put racial health disparities into sharp focus, and the article received widespread media attention.

Like most readers, I was shocked by this dire situation, which I still understood as affecting only poor Black people who lived in impoverished communities, lacked access to health care, and either didn’t understand how to take care of themselves or were unable to because of their economic circumstances. In those days, Harlem was scarred by an epidemic of crack, violence, and HIV/AIDS. In the neighborhood—at the time, still majority Black as it had been since its sparkling Renaissance days at the beginning of the twentieth century—40 percent of families lived below the government-defined poverty line, and the death rate from homicide had quadrupled in the previous twenty years. Neither the city, state, nor national government offered a real lifeline.

I met Dr. Freeman in 1991 when he came to Harvard to talk to my fellowship program about his New England Journal of Medicine article. With calm deliberation, this tall, elegant physician disrupted my vision of Harlem and other Black communities throughout the United States. He detailed a cascade of health conditions triggered by inadequate facilities, lack of access to health insurance, and a shortage of medical personnel, healthy food, safe neighborhoods, and basic education. He called the problem a national tragedy, an emergency analogous to a hurricane, flood, or other ruinous natural disaster, yet one for which no one was sounding the alarm. Afterward, I introduced myself and asked him to confirm what I thought I knew: that the issues he described were strictly a result of poverty. But Dr. Freeman took me aside and patiently corrected my thinking. Yes, being poor mattered, because poverty is synonymous with lack of education, inadequate housing, insufficient nutrition, barriers to medical services, and focus on day-to-day survival rather than long-term and preventive care. But he also pointed out that the image of Harlem in the popular imagination as a broken-down, crime-riddled battleground was incomplete. In fact, he said, Harlem was economically diverse—much like my neighborhood in Chicago—with a quarter of the community comprising middle- to upper-class African Americans, like my grandparents and great-aunts and great-uncles.

He looked me straight in the eye and said, “If you really care about these issues and want to make a difference, you must not use race as a proxy for poverty or poverty as a proxy for race. They intersect and overlap, but to really understand the health of this country, you have to be more sophisticated than assuming that only poor Blacks are affected by this crisis. Look deeper, think differently.” He warned me that many scientists and researchers conflate race and class, under the assumption that all Black people are poor, and all poor people are Black. “Don’t let that be a blind spot,” he told me.

By the end of the event, he had agreed to allow me to spend the day with him at Harlem Hospital to see where and how he worked and to listen to his patients to get a deeper understanding of the issues.

On the day I was to shadow him, I followed Dr. Freeman down the corridor to his office, looking like a very quiet medical student. I teared up, struck by how he looked like my father in so many ways, down to his long-legged, wide-stride gait, spit-shined shoes, his back slightly rounded in the way of tall, kind men. At the end of that day, I couldn’t shake the image of one of his patients. She was a well-dressed, professional woman, a soft-spoken single mother in her forties who lived in Harlem and worked as an administrator in a Manhattan office. Her appointment was in the late afternoon, because she was nervous about leaving her job early. She had come to see Dr. Freeman because her breast was “bothering” her. When she lowered her gown, it was obvious what was wrong: she had a large lump on her left breast, darkened like a bruise, pushing through the skin, and painful to the touch. As he examined her, Dr. Freeman asked her gently, without a shred of judgment, only concern, why she hadn’t come to see him sooner, when treatment might have made a difference. Her answer surprised me: she hadn’t avoided addressing this obvious issue out of ignorance or lack of access to health care, the standard explanations for the racial disparities that plague African Americans in Black communities. This woman had health insurance and access to Dr. Freeman, one of the world’s most renowned cancer specialists and a caring Black physician who chose to practice in Harlem. “I was afraid,” she said, very slowly, looking down. She paused, before continuing. “I was afraid that if this was serious, I would die and there would be no one to take care of my son.” And then she began to cry.

Later, Dr. Freeman told me that she had advanced breast cancer and that she probably wouldn’t survive to see her son’s next birthday. In her eyes I saw a tragedy that was much more complicated than a Black single mother in Harlem who was dying of breast cancer. Instead, I was able to see, in the body of one woman, several of the complicated themes I would later examine in my work: fear and avoidance of the health-care system, stress, the precariousness of the Black middle class, and the thoughtful heroism of individual provider/researchers like Dr. Freeman. With these concepts in mind, he had founded the Harold P. Freeman Patient Navigation Institute in Harlem to help eliminate barriers to supportive medical care that intersect with race and discrimination and transcend class. Though his insights didn’t budge my commitment to self-help advice, Dr. Freeman helped open my mind to a new understanding of the origins of the Black health crisis.

Beginning in the 1990s—the era of the Human Genome Project—scientific research began to drift in the direction of a genetic explanation for Black health problems. If serious diseases were more common among all Black Americans, not just those who were poor and thought to be doing something wrong, then it stood to reason that these health problems could be inherited. In other words, something about being Black was bad for health. In the Black community, most of us had heard of the slavery hypothesis, formed by the hypertension researcher Clarence Grim and others, to explain why African Americans had long had much higher rates of hypertension compared with all other races in the country, and among the highest in the world. This theory was so widespread that as late as 2007, when Mehmet Oz, MD, on The Oprah Winfrey Show, asked the talk show host why Blacks have hypertension, Oprah told her audience, “African Americans who survived [the slave trade] were those who could hold more salt in their bodies.” Dr. Oz, a physician, replied, “That’s perfect.” As the theory goes, enslaved Africans who endured the grueling Middle Passage to America had a genetic predisposition to retaining sodium. That is why, while others died of dehydration, they lived to bequeath the gene to their descendants, where it wreaks havoc with their blood pressure. According to the American Heart Association’s current website, in the section on African Americans, “In people who have this gene, as little as one extra gram (half a teaspoon) of salt could raise blood pressure as much as 5 mm Hg.”

For decades, all of the mainstream health organizations and government agencies warned American Blacks specifically to cut down on salt at all costs. Of course, limiting sodium intake is sound advice, and our family followed it to extremes. In my childhood home, when my father was diagnosed with high blood pressure, salt became the enemy—“It will kill Dad,” we were told. To this day, everyone reaches for the saltshaker when I cook, because I am still in the habit of under-seasoning food. At Essence, we treated salt like crack cocaine; I can’t remember how many times I wrote or edited in the words “put down the saltshaker.” We stripped recipes of salt, substituting lemon juice, herbs, onion, garlic, and non-salt substitutes to lower sodium content, accompanied articles on hypertension with illustrations of menacing saltshakers, celebrated readers who had made the transition to low-salt diets, and highlighted the cottage industry of cookbooks that explained how to make traditional soul food more healthy by cutting down on salt, fat, and sugar.

Nothing is wrong with reducing salt, avoiding processed food, and finding creative ways to season foods, especially for African Americans, given our high rates of cardiovascular disease. However, at its core, the genetic explanation for those rates lacks evidence. In fact, no data proves that salt-depleting illnesses like dehydration and diarrhea were responsible for a significant number of deaths on slave ships. Instead, countless studies show that along with a diet high in salt and fat, being overweight and a lack of exercise can raise blood pressure. Less discussed, often ignored, but also proven is the link between hypertension and stressful environments and situations, including living with bias and discrimination. Though genetic explanations for poor Black health outcomes have been disproven, they linger in medical education and practice and in the media.

At Essence, I operated under the firm belief that Black people weren’t paying attention to health information or making positive lifestyle changes because the information was dry, complicated, poorly packaged and explained, and culturally tone-deaf, and to be honest, much of it was. The solution then was “self-health” information packaged specifically for African Americans and presented in a “culturally competent” way—a buzz phrase popular in health and medical circles. If individual Black people could understand how to take care of themselves, and their families, the health crisis would be solved.

In 1992, I signed a contract with HarperCollins to write Body & Soul: The Black Women’s Guide to Physical Health and Emotional Well-Being, which I pitched as a kind of Our Bodies, Ourselves–style self-help manual for Black women. It would include topics covered by mainstream health books, including nutrition, fitness, sex, sexuality, pregnancy, parenting, and aging, but from a unique Afrocentric perspective. It also discussed more serious topics such as abortion, domestic violence, HIV/AIDS, sexual abuse, and workplace discrimination, mainly through my self-health lens. In meetings with publishers who asked, “Why do Black women need their own health book?” I answered, “Because we don’t see ourselves in other health and wellness books.” I asked them to consider what it felt like for a Black woman to page through a pregnancy manual and see sections like this: “Will [your baby] have blond hair like Grandma? Green eyes like Grandpa?” Or a skin-care book that describes a rash as turning the skin from pink to red, leaving out the range of shades of Black skin. I pointed to a number of health books targeted to “all women” that showed only photographs and illustrations of white women. “If you’re Black and don’t see yourself in the pages of a book, it makes you put it down,” I said to the editors I met with.

I wrote the book with the National Black Women’s Health Project (NBWHP), mentored by the group’s founder, the MacArthur genius Byllye Avery. Her organization pointed to a conspiracy of silence in the Black community around both physical and emotional health concerns that made all of our medical problems worse. This silence led to isolation, low self-esteem, and unhealthy lifestyle choices. Byllye, others in the NBWHP leadership, and the activist Angela Y. Davis and the author June Jordan, who wrote the foreword to Body & Soul, had been involved in the civil rights and Black Power movements and understood that structural racism and health-care discrimination contributed greatly to the health problems that Body & Soul covered. But as a child of the generation that benefited from earlier struggles but was too young to be involved in the movements, I stayed in my sweet spots—information, education, and self-help.

I revised my thinking in the early 1990s when I learned more about the effects of stress on the bodies of mothers and babies during my year at the Harvard School of Public Health, and after having a low-birth-weight baby of my own. I began to think more deeply about the mind-body connection and the link between health and stress. For most of us at that time, stress was synonymous with being stressed-out, which meant having too much to do in too little time. For Black women, this was our burden. In my work at Essence and in my books and lectures, I discussed the heavy toll of being “strong” Black women who sacrifice our physical and emotional health to tend to the well-being of others—children, parents, spouses, lovers, elders, friends, the community itself. Around that time, based on a national survey, the California Black Women’s Health Project estimated that 60 percent of African American women experienced depression that resulted in weight loss or weight gain, sleep disturbances, lack of energy, feelings of inadequacy, and/or thoughts of suicide or death and escaped through food, smoking, heavy drinking, drug abuse, and unhealthy relationships. Because, the thinking went, it was our responsibility to take care of others, it was our duty to heal ourselves by reducing stress so we could be better caretakers. The best way was through self-love and self-care. Look in the mirror and repeat these words from the (late) poet/playwright Ntozake Shange, I suggested:

i found god in myself

& i loved her

i loved her fiercely.

I also advised exercise, deep breathing, laughing, journaling, exercise, warm baths, and cutting down on or avoiding salt (of course), sugar, red meat, alcohol, caffeine, and refined carbohydrates. “Put down the superwoman cape,” I wrote in an article, “and ask for help.” None of this advice was wrong and I believe it as strongly today, but this frame is also incomplete.

By the time my daughter was walking, I was starting to come to the realization that the stress that affected the bodies of Black people, particularly Black women, came from more than too much to do in too little time. By then, research had mounted—including early work by Arline Geronimus, ScD, who had coined the term “weathering” to explain the toll of racism on health—pointing to the way stress settles in the body, a bone-deep accumulation of persistent insults and traumatizing life circumstances. Today I’m chagrined to think I believed that the impact of insidious discrimination associated with the lived experience of being Black in America can be washed away in a bubble bath or calmed with journaling or meditation and me time.

To promote my book, I frequently attended events hosted by the National Black Women’s Health Project. At a self-help gathering in New York City in the early 1990s, the hundred or so attendees were divided up by race, and the sixty Black women in my group were encouraged to share times when we felt disempowered and unhealthy. I was overwhelmed by what I heard. A woman told the group that she had been rushed to the emergency room, blood gushing from her vagina, because of an IUD embedded in her tissue. When doctors refused to remove it, she yanked it out herself, causing excruciating pain and sterility. Another had a piece of her cervix removed without anesthesia. When she protested, her doctor insisted, “You have no nerve endings down there.” One woman wept as she said she had been sterilized without her consent. When I left the room, I felt sad and overwhelmed. I was forced to shift my own philosophy, confronted with the idea that Black people were being harmed and traumatized in health-care settings and that living in America was hurting Black women of all classes and education levels.

Still, I stuck to my empowerment, self-health lens, but now also advising readers of my books and Essence to be ferocious as lions when dealing with individual health-care providers who may treat Black patients unfairly. The trick, I believed, was to work within the medical system and squeeze everything you could out of the health-care structure that existed. I rarely challenged that system but advised my audiences to self-advocate for fair treatment. My mantra was “health care is our right and we have to stand up for ourselves and others and get the care we want, deserve, and pay for.” I tacked some version of it onto almost everything I wrote—in articles and books—and it was always my coda in lectures about Black health empowerment. I also championed Black physicians and researchers and stressed the importance of having a health-care provider who looked like you. It would take a family medical crisis for me to understand that this advice was insufficient and that our medical system is broken.

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In 1999, my father, a college-educated man who had retired from his job as a manager in a division of a federal agency, became critically ill. In his early seventies, he was diagnosed with colon cancer, and as the disease worsened, he also began to suffer from mild dementia. I lived in New York City, across the country from my hometown of Denver, so though my parents had been divorced for years, my mother agreed to manage his care. One day she called me and said, “You need to come home. Your father needs you; he’s in the hospital.” She instructed me to dress in professional attire and to bring my business cards from The New York Times, where I was the editor of the health pages. When she picked me up at the airport, dressed in extremely corporate attire, looking like the hospital vice president she used to be, I asked her, “What are we doing?” Her reply was blunt: “They are treating your father like a n—— ; we need to let them see who he is.”

When we arrived at the veterans’ hospital he had insisted on, I was shocked by what I saw: My father—courtly, sophisticated, and always impeccably dressed—was frighteningly thin, disheveled, wearing a dirty hospital gown, his hair uncombed. Worse, he had restraints on his legs. As we walked in, an attendant was speaking to him in a disrespectful hiss. When I pushed past the attendant and leaned down to hug my father, he whispered, “Please get me out of here.” Everything changed once we arrived. My mother, flipping into an officious mode I didn’t recognize, set everyone straight—doctors, nurses, and hospital administrators. We showed them my father’s college degree, medals from his military service, and photographs of him pre-illness. I let his caregivers know that he had studied biology in college, so explaining things in a respectful way would help him understand what was going on and prevent him from feeling afraid and angry. We made them “see” him, beyond his race and the ravages of his illness. My father, who died several months after my mother and I visited him, didn’t deserve “special” treatment because of his class and education; class was the only card my mother and I had to play, so we played it. But like anyone, he should’ve been treated with dignity.

The discrimination and ill-treatment my father suffered as a patient was a deeply personal experience that mirrored the academic understanding I had of health-care bias, and it was a turning point in my work. Over the next two decades of my career in journalism, I would forcefully infuse what I understood about the effects of discrimination on Black health in articles I wrote about HIV/AIDS, diabetes, mental health, and heart disease. In 2017, I got the opportunity to showcase my years of thinking and learning about race, health, and inequality when I spent nearly a year reporting on the crisis in infant and maternal mortality in America. The story followed Simone Landrum, a woman whose medical treatment led to the death of her baby and her own near death. When the story, “The Hidden Toll: Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis,” was published in April 2018, I was thrilled by the widespread and largely positive response, the feedback, and the actions taken.

After the article ran, book publishers and literary agents approached me about expanding the piece into a book. At first I resisted, and even after I agreed to write this book, I remained quietly unsure that it was necessary. But then something happened to change my mind. In 2018, not long after my article was published, I was invited to a grand rounds with the ob-gyn department of a hospital in a small city in the Midwest. I offered the team of twelve white physicians, who served a large population of women of color, mainly immigrants from East Africa, a snapshot of the article, summarizing the data about racial disparities in infant and maternal mortality. I explained my theses about the influences of social determinants of health, discrimination in health care, and toxic stress fueled by societal racism. I discussed the circumstances under which Simone Landrum lost her baby daughter and almost lost her life, including having her legitimate concerns dismissed and ignored. I described the callous way nurses and physicians treated her right in front of me as she was delivering her baby son the following year. After I finished, the head of the department was the first to respond. “I don’t understand why the medical team let you into the labor and delivery room,” he said. “I know I never would’ve allowed that.”

“Wait, that was your takeaway?” I asked him.

For the next half hour, he and his team pushed back against the work I had spent years compiling, unleashing nearly every myth I had painstakingly dispelled in the article, including the idea that genetics were somehow to blame and that Black American women lacked “kinship circles.” I was trapped in a game of medical smackdown, dismissing, one by one, their either incorrect or incomplete explanations for the racial disparities in maternal and infant health. Between the lines of their cross-examination, it was clear to me that they were blaming Black American women for the deaths of Black mothers and babies, which they believed could be wiped away with education and more “doctoring,” with no regard to the toxic effects of interpersonal and institutional racism. At that moment, in that room of midwestern physicians, I understood that the denial of racial bias can be so extreme that no one believes you even when you have the evidence.

In my years of reporting on public health and race—including interviewing women and men of all classes whose health has been harmed by the medical system and being embedded for months in some of the most disadvantaged communities in the country—not to mention being a slave-descended African American myself, I have seen a race of people who have been mistreated and misunderstood, ignored and blamed, let down and left to fend for ourselves. So we do; we take care of ourselves and each other. This reality shows up in the names and slogans of Black organizations focused on health issues. I wrote about a Black HIV/AIDS services center in D.C. called Us Helping Us, attended a conference called the Saving Ourselves Symposium, and have written about a number of organizations with names like My Brother’s Keeper or My Sister’s Keeper. These names at once represent empowerment and self-sufficiency but also abandonment. “We are the ones we’ve been waiting for,” long one of the slogans of the Black-led reproductive justice movement, is sometimes paired with a quotation from Fannie Lou Hamer, “I’m sick and tired of being sick and tired.”

I remember, a number of years ago, telling my friend Steve Rabin, who is a very smart and thoughtful white man with a long career in health policy and advocacy, about all of the health issues that disproportionately affect African Americans. “That’s terrible,” he said to me. “How can we solve this problem?” I thought, “We? What does he have to do with it?” “We, Black people, know best how to solve these issues—‘our people, our problem, our solution,’ ” I explained to him, referencing the tagline of the Black AIDS Institute in Los Angeles. “FUBU, for us, by us,” I added. “This isn’t a FUBU situation or a Black problem,” Steve said to me. “This is an American problem, so why should Black people be expected to solve it alone?”

That is what I realized while writing this book: we shouldn’t. Since the first African enslaved men, women, and children reached American shores, there has been a Black-white divide in who survives, how they live, and who dies, from birth to the end of life. Despite decades of social, economic, and educational progress and what has unquestionably been the rise of a robust Black middle class, racial health disparities have remained intact. Yes, something about being Black is creating a health crisis, and that something is racism. It is the American problem in need of an American solution.