Racism and African American health

By Liora Engel-Smith and Melba Newsome

Braxton Winston became a symbol of the Charlotte resistance during the September 2016 protests over the police killing of Keith Lamont Scott when he stripped off his shirt to use as a mask against tear gas and stood face face-to-face with police, clenched fist raised in defiance. Winston has since been elected to the City Council twice but his activism and advocacy have not dimmed.

Winston went to Charlotte’s west side in his official capacity to deescalate tensions surrounding the protests sparked by George Floyd’s murder. A video shows the unarmed councilman standing in the middle of the street before being aggressively arrested by more than a dozen CMPD officers.

Winston wasn’t alone. A similar incident occurred in Ohio on May 30, when 70-year-old African American Congresswoman Joyce Beatty (D), was maced and pepper sprayed by police while talking to and meeting with constituents who were protesting the death of George Floyd.

Witnessing the arrest and/or assault of prominent lawmakers by police who are aware of the cameras is just a small window into the type of treatment African Americans routinely endure.

The American Medical Association noted that the harm of police violence is elevated during the remarkable stress people are already facing amidst the COVID-19 pandemic.

“The pressures of dealing with racism and fighting for equality take their toll,” said Kristy Sinkfield, director of strategy and innovation at Vanderbilt University Medical Center at a recent seminar about racism and health. “We get tired, we cannot seem to relax. “Headaches increase, depression and incessant crying. We carry the burden of racism in our bodies, and the burden is heavy.”

Beyond the emotional and psychological burden, a growing body of research shows that racism also takes a physical toll on its victims in myriad ways.

‘A public health issue’

The American Academy of Pediatrics issued a policy statement declaring racism a public health issue.

“Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families,” AMA board chair Jesse Ehrenfeld and president Patricia Harris wrote in a joint statement. “. . . [t]he evidence to support the continued negative impact of racism on health and well-being through implicit and explicit biases, institutional structures, and interpersonal relationships is clear.”

Yet researchers don’t agree on how to classify racism. Some say it’s a social condition or a risk factor that disadvantages people of color in many areas of life, including health. Others say it is a disease. But more than two decades of research points to the fact that the day-to-day stress of living with racism has tangible negative health effects.

NC Health News talked to people attending a demonstration in Chapel Hill on Saturday, June 6 about how the stress of living with racism affects health. Video credit: Rose Hoban

“From the moment of birth, you are more likely to die if you are black in this country than if you are white,” said Chrissy Kistler, a family physician at UNC Health in Chapel Hill and an instructor in the UNC School of Medicine. “You are less likely to have high quality education, access to health care, financial advancement.

“All of that leads to worse health outcomes, mortality, chronic illness disability, and it’s due to systemic racism in this country.”

There’s a biological explanation to these health effects: excessive stress has toxic side effects, resulting in elevated cortisol and increased inflammation. Over time, that inflammation creates wear-and-tear that has been linked to countless ailments, including diabetes, heart disease, obesity and premature death, even in African Americans who had higher incomes. There is evidence that chronic stress from racism can actually change how the body expresses genes, potentially transmitting negative health effects from parents to children.

While some of those negative health outcomes can be attributed to social determinants of health such as poverty and access to health care and nutritious food, these social phenomena only tell part of the story.

“Even if you control for those factors, it’s pretty clear that there’s a lot more going on biologically than the things we understand about either behavior or about poverty,” said Adam Zolotor, who heads the North Carolina Institute of Medicine.

Countless studies parsed out the health implications of racism across the lifespan, beginning even before birth. It appears that some effects are epigenetic, meaning that changes to a mother’s genetic expression, even before conception, places offspring at risk.

Unequal treatment in pregnancy

According to the CDC, black mothers are more likely to be targets of demeaning behavior during their prenatal care, as well as in the delivery room. Researchers use the term “weathering” to describe the overt and structural racism that leads to women of color being dismissed, ignored and discriminated against by health care professionals in greater numbers than white women.

A growing body of research shows racism-induced stress is also linked to health disparities.

“We’ve known … for a pretty long time that preterm birth rates and rates of preeclampsia, severe preeclampsia, severe diseases like HELLP syndrome, diabetes, other diseases, are all more severe for black women,” said Amanda Brown, a midwife at UNC Hospitals in Chapel Hill.

Brown said that her African American patients come into the hospital “wondering how they’re going to be cared for, if they’re going to be cared for.

“They’re apprehensive about how we will receive them, and how we will listen, and whether we will listen when they come to the hospital to have their baby, or if they’re having a loss, or some other complication in their pregnancies,” she said.

In a state where disparities in maternal and infant health are already stark, Buncombe County ranks at the bottom. Black babies in that county die at nearly four times the rate of white babies before reaching their first birthday according to a state analysis. That occurs regardless of a mother’s education or socioeconomic status.

The leaders at MAHEC acknowledged that these disparities can’t be reversed without addressing the racial bias and structural and institutional racism that contribute to them. They organized SistasCaring4Sistas, a doula program run by and for women of color, was implemented as part of a larger social justice movement to eliminate health disparities for mothers and infants.

Cindy McMillian was driven by her own personal birth experience to become a doula. McMillan spent three long, frustrating months in the hospital with her first child. Five years later, she nearly hemorrhaged to death giving birth to twins, only one of which survived.

“The way the hospital and doctors treated me was unreal,” McMillan recalls. “They put me in this room that was like a broom closet for a week and I had to go outside for the restroom. I had a general cesarean and all this pain but nobody explained anything to me.”

Toxic to mental health

Toxic stress can also impact mental health over the lifespan, beginning in childhood. In a June 2 news release, Dan Gillison, the CEO of the North Carolina chapter of the National Alliance on Mental Illness, alluded to that impact.

“Our nation’s African American community is going through an extremely painful experience, pain that has been inflicted upon this community repeatedly throughout history and is magnified by mass media and repeated deaths,” he said.

A policy statement by the American Academy of Pediatrics last year points to some of the effects of racism on children and adolescents, including birth disparities and mental health conditions. Youth of color are more likely to be incarcerated than their white counterparts and trauma borne from their interactions with the criminal justice system amplifies the stress, the academy noted. The stress not only magnifies when children of color experience racism themselves, but can be traumatizing when they observe mistreatment of other people of color.

A rapidly growing body of research into adverse childhood experiences reveals that traumas faced by a child early in life have far-reaching health effects across the lifespan, including greater risk for misusing substances and an increased risk for adverse outcomes such as a higher risk for infections, cancer, diabetes and heart attacks, the incidence of which extend well into adulthood.

In some cases, racism forces those who experience it to resort to coping skills that magnify the stress, said Cheryl Giscombe, a researcher who studies the health effects of racism at the University of North Carolina School of Nursing.

“African American women often respond … with an obligation to present an image of strength, an obligation to suppress emotion and an obligation or perceived obligation to resist help from others,” she said.

Giscombe stresses that while African Americans may be resilient, have support and practice self-care, overcoming stress rooted in systemic and constant discrimination remains a challenge. “Undoing centuries of inequality will take time and deliberate action across all facets of society,” she said. “If we don’t tell people to rise up, the only other option is to lay down. There’s no option if we want to survive.”

Rose Hoban contributed reporting to this story.