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It took seven years, almost dying, and finally a doctor who listened for Arista Ware II, 28, to get a diagnosis: systemic lupus erythematosus.
She and her family had suspected SLE and told physicians about it from the very beginning. In addition, medical tests had been pointing to an autoimmune disease for years. “I literally [had] blood work showing that something [wasn’t] right in my body and was still told [I was] fine,” recalls Ware, an account director at Insomniac Design in Washington, D.C.
Her diagnosis shouldn’t have taken that long. So, what was the problem?
The reason goes beyond Ware’s case, and it goes beyond health care. Black women in the U.S. are disproportionately affected by myriad health issues and disparities. (See sidebar.) What underlies all of them is the country’s long history of structural and systemic racism—the processes within social, commercial, and government systems that disadvantage Black Americans. They can be seen through inequities in socioeconomic status, segregated communities, and even how Black women’s pain and conditions are disbelieved and dismissed by the medical community.
“Racism is deeply ingrained in our country,” says Charvonne Holliday, PhD, MPH, an assistant professor in Population, Family and Reproductive Health. “And, as we talk more about police brutality through increasing media attention, hopefully, we can draw more light to the impact of racism on health.”
Consider an astonishing example from two Baltimore neighborhoods. The difference in average life expectancy between Upton/Druid Heights, a mostly impoverished, Black neighborhood, and Roland Park, a mostly wealthy, white neighborhood, is 20 years. In Upton/Druid Heights, 54.7% of 10,071 residents are women, 93.3% of which are Black women compared to Roland Park that has a similar percentage of women (50.3%), but only 6.9% are Black women. The two neighborhoods are fewer than five miles apart.
Historic racism and the real estate practice of “redlining” is a significant underlying cause. A now-illegal practice that started in the 1930s and was once backed by the U.S. government, redlining was the denial of mortgages to people of color in urban areas by banks so they couldn’t afford homes in “nicer neighborhoods” or even renovate the homes they were living in. The practice often trapped Black people in deteriorating neighborhoods marked by limited economic, social, and educational resources, and has contributed to persistent food insecurity, poor health outcomes, lack of green spaces, and concentrated poverty, says Chidinma Ibe, PhD ’11, an assistant professor in Health, Behavior and Society and the School of Medicine’s Department of General Internal Medicine.
Redlining led to a generations-long ripple effect of disproportionate negative health outcomes. Black women, for example, are 60% more likely than non-Hispanic white women to have high blood pressure, according to the Office of Minority Health in the Department of Health and Human Services. “That’s a prime example of the legacy of redlining and how structural racism affects not just their lived experiences but their actual mortality and health outcomes,” says Ibe.
For many Black women, the disparities don’t stop once they retreat into their homes. More than 40% of Black women experience intimate partner violence compared to 31.5% of all women, according to the 2017 report “The Status of Black Women in the United States.” Beyond the direct repercussions of physical violence, IPV is associated with a higher risk of HIV, unintended pregnancy, poor mental health, substance use, and other health issues, says Holliday. (Her IPV research focuses mostly on racial and ethnic disparities in women’s health.)
Socioeconomic status enforced by structural racism plays a role in IPV. Black women earn 62 cents per every dollar their white, non-Hispanic male counterparts earn, putting them at a lower level of financial security, especially if they are the top earners of their households. So, Black women often become trapped in these relationships because they don’t have the financial means to leave.
The U.S. health system is hardly immune from racism, especially within a medical community that disbelieves Black women’s pain and dismisses their experiences with their own bodies. This is tragically true in the case of Black mothers who die at a higher rate from pregnancy-related complications than any other racial/ethnic group at 40.8 deaths per 100,000 births—the next highest being non-Hispanic American Indian/Alaska Native women at 29.7 deaths.
U.S. Rep. Lauren Underwood, MSN/MPH ’09, recalls the tragedy of her MPH classmate, Shalon Irving. “After we graduated [she] went on to work at the CDC. She became an expectant mom at 36, she was so excited. She did everything right,” says Underwood, who represents Illinois’ 14th congressional district. “But three weeks after giving birth, she died from complications due to high blood pressure.” And although Irving had repeatedly reported pain and identifiable dramatic swelling to her physicians prior to her death, she was sent home with a prescription and no further follow-up.
Underwood is joining affected communities, medical groups, and others to push back against structural and systemic racism. She, along with Congresswoman Alma Adams, has introduced, for example, the MOMNIBUS Bill that “will fill gaps in existing legislation to comprehensively address every dimension of the Black maternal health crisis.” Some of those fillings include funding for community-based organizations aimed at improving Black women’s maternal health outcomes, improving processes for data collection and quality measures for a better understanding of the causes of the maternal health crisis, and improved care and support for expectant mothers who are incarcerated. Other innovative solutions have emerged, including community health workers’ efforts to help fellow residents navigate the health care system.
“[But] the greatest solution to surmount obstacles that contribute to disparities in Black women’s health,” says Holliday, “is for our country to acknowledge the impact of historic and present-day injustices. Until we collectively denounce racism and understand its entrenched implications on health, inequalities will persist, and our pursuit of liberation will be stifled.”
For her part, Ware struggles on nearly six years after her SLE diagnosis. She often wonders how her life would’ve changed had she and her family been respected and listened to the first time.
“I lost all of those developmental years [where] I could’ve learned how to cope,” she says. All of the “not-knowing” what was happening to her could have been prevented.
“It just wasn’t,” she says.
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