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What ails the health of the richest nation in the world? Why is the U.S. the only high-income country in the world to not have universal health coverage? Why are millions of Black people struggling to access humane and affordable care? The diagnosis, as well as the prescription, can be found in Legacy, a powerful, thoughtful, and impactful new book, by Dr. Uché Blackstock, a physician and thought leader on racism in healthcare.
Using her own experience of growing up in New York, attending Harvard Medical School, practicing medicine as an ER doctor, and becoming an academic professor at NYU, Dr. Blackstock traces her personal journey in fully comprehending the historical origins of racism in the American health system, and its pervasive, ongoing impact on the health and well-being of Black people today.
Consider some of the sobering facts presented in the book. Although Black people make up 13% of the U.S. population, only 5.4% of all U.S. doctors identify as Black. Black men in America have the shortest life expectancy of any major demographic group. Black babies have the highest infant mortality rate. Black birthing people are three to four times more likely to die than their white peers. Black people are 1.5 times more likely than whites to be without health insurance. From 2019 to 2020, due to the Covid-19 pandemic, Black people in the U.S. experienced a life expectancy decrease of 2.9 years, while white Americans experienced the smallest decline, of 1.2 years.
“We are living in two Americas because of systematic racism,” writes Dr. Blackstock, who does an excellent job of connecting the various inter-connected systems (from lack of adequate opportunities for education and housing, to fear of police brutality) that continue to oppress Black people in the U.S.
Legacy comes at a time when diversity, equity and inclusion initiatives are under attack in the U.S., and institutional commitment to the Black Lives Matter movement seems to be faltering. In the book, Dr. Blackstock writes about her own experience of leaving academia, despite her DEI leadership role at NYU. She writes about the lack of mentorship and institutional support, and the toxic environment that makes it hard for Black academics, especially women, to speak truth to power.
During two years of the Covid-19 pandemic, Americans got a partial glimpse of what many other high-income countries have had for years: free or affordable healthcare. Sadly, medical and social protections afforded to vulnerable communities during the Covid-19 pandemic have already been rolled back by the U.S. government, which ended the public health emergency in May 2023. “If the pandemic taught us anything, it’s that we can no longer continue as the only high-income country in the world leaving millions of people without proper access to health care,” she writes.
The book makes a strong case for not only expanded healthcare coverage for Black communities, but also culturally centered care that is delivered by Black healthcare workers. The Roots Community Birth Center model is offered as an exemplar of this approach with excellent impact on maternal and neonatal outcomes.
I asked Dr. Blackstock about her hopes for the book. “My hope is that the book is will help readers connect the dots as to why in 2024 we see these appalling racial health inequities in this country that we do. In the last chapter, I give a call to action to various groups, including health professionals, academic institutions, and policy makers, so that each group understands what they need to do to make a difference,” she said.
In fact, the most impactful part of the book is the final chapter, “The Way Forward: Actions Speak Lounder Than Words.” This inspring chapter is pure gold and deserves to be widely read, discussed, and acted upon. It offers lucid, clear, and actionable guidance on what various stakeholders need to do, to turn empty anti-racism promises into action.
To U.S. politicians and leaders, Dr. Blackstock offers a checklist that includes expansion of Medicaid, introduction of single-payer, universal health coverage, provision of paid sick and medical leave for all essential workers, and expansion of the K-12 pipeline for Black students, among others.
To the healthcare institutions in the U.S., Dr. Blackstock’s call includes provision of structurally competent and culturally centered care to Black communities, and treatment of Black patients with the humanity they deserve. She asks healthcare institutions to be intentional about earning the trust of Black communities. She asks them to fix technologies (e.g. pulse oximeters that do not work well in people with darker skin tones) that can exacerbate racial inequities.
To medical schools and academic centers in the country, Dr. Blackstock’s call includes a commitment to invest in the pipeline of Black physicians and commit to a meaningfully diverse, inclusive and anti-racist learning environment. She also warns against placing all the anti-racism work on the shoulders of Black professionals or DEI staff. “Every individual should feel like the work of dismantling racism is their responsibility,” she writes.
To white Americans, including white physicians, Dr. Blackstock asks what they will do to “become collaborators in dismantling racism?”
“Racism is not the problem of Black people to solve,” she writes. She hopes white people will go beyond hollow promises, training or self-reflection and demonstrate their commitment through action. “You must actually do the work of anti-racism beyond reading books and also be held accountable.” The first step is to acknowledge that systemic racism exists.
And, lastly, for people like me (people of color who are not Black), her advice is for us to understand that anti-Blackness is a global concept that has “pitted us against each other when we should be joining together.”
‘We need you to have our backs,” is her clarion call, and I am grateful for Dr. Blackstock’s guidance.
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