Say Their Names Page 10

  “With COVID-19, if you are expressing these vulnerabilities over time, you’re more prone to get sicker. Your immune system is already primed to react, and the inflammatory response is so severe in your lungs that you can’t breathe and [eventually] die from it.”

  The damage of the relationship between law enforcement and the Black community extends beyond the officer-involved shootings or brutalizing people of color that sparked the nationwide protests. In some cases, simply coming in contact with police causes stress that impacts health.

  Contrast that with this: Myriad videos on social media in 2020—amid the array of shootings of Black men—showed white people’s volatile encounters with law enforcement, where they attack officers at worst, and issued profanity-laced tirades at best…with no physical consequences. No stun gun. No choke hold. No shooting. In one case, a white man refused to lie on the ground as commanded at gunpoint, assaulted the white officer, who ran away from the person he was attempting to arrest. The man jumped in his car, drove off, whipped a U-turn, and intentionally crashed his vehicle into the police cruiser. He lived to tell about it, without a shot being fired.

  With Black people, the idea of asserting themselves verbally, even for questionable traffic stops, is not a possibility. There is no doubt that assaulting an officer would amount to a violent reaction. Understanding this, tension arises in people of color when the lights of a police car flash in the rearview mirror.

  “If you’re worried about getting pulled over by the cops and getting shot by police—like you see on TV every day—when you interact with authority figures you’re going to have a much more significant stress response than someone who doesn’t relate to that experience,” Holloway said. “Stress is not based on how an event may have actually happened, but on how you perceive it to happen. And so, in regards to racism and how people experience it, there are effects of chronic unpredictable stress that the Black population has because we see ourselves or our family members or friends when we see George Floyd or Trayvon Martin and so many others.”

  As a result, numerous studies, including a 2019 report by the Centers for Disease Control and Prevention in Atlanta, show that though African Americans have gained in education and wealth over the last decade and are living longer, their life expectancy on average is seventy-five years, which is the lowest among all ethnic backgrounds in the United States. It also is six years shorter than whites’.

  Doctors are able to measure one’s aging through the study of telomeres, which are sections of DNA found at the end of each chromosome. They protect the DNA by allowing replication without damaging chromosomes. When aging occurs, the telomeres shrink. And when they become too short, they cannot serve their purpose, and chromosomes can no longer replicate and reach a “critical length.”

  At this stage, cells die, and apoptosis, also known as programmed cell death, occurs. Anything with “death” in its title is not a good thing. And as a result of daily racial trauma, Black people’s telomeres diminish at a faster rate than those of whites and other races.

  “With Black people, the telomere you’d expect to be a certain length at a particular age is often shorter than it should be. And it’s completely related to the amount of stress and racism they [experienced],” Holloway said. “There are two types of aging: chronological and cellular. Your cellular age is determined by the length of telomeres. And every time a cell divides, those telomeres shorten. So, you can measure telomeres to extrapolate how much stress someone has experienced over time. In Black people, telomeres tell the story.”

  The stress level—and health concerns—for Black people during the era of the coronavirus and the social justice demonstrations told a story of compounded stress exacerbated by the consistent inflammatory behavior and rhetoric of President Trump. His questionable response to COVID-19 helped the virus to reach pandemic levels in America. And his inability or unwillingness to attempt to offer a conciliatory voice to calm the racial discord pumped stress into Americans as if through an IV.

  He called African nations “shithole countries”; he called Black athletes who took a knee in opposition of police brutality “sons of bitches”; he said there were “very fine people on both sides” of the Charlottesville, Virginia, rally where white supremacist militia members chanted racist threats and ideology; he Tweeted that several Black and brown members of Congress—Representatives Alexandria Ocasio-Cortez (D-NY), Ayanna Pressley (D-MA), Ilhan Omar (D-MN), and Rashida Tlaib (D-MI)—are “from countries whose governments are a complete and total catastrophe” and that they should “go back” to those countries—a common racist trope, among other affronts.

  The Washington Post reported in 2017 that the U.S. population’s stress levels were the highest in the world, eclipsing Iran, a country rife with war. A study by a medical resource website Care Dash on Trump’s impact on people’s heath six months after the 2016 election revealed that much of the country dealt with many Trump-induced health concerns: anger, resentment, depression, weight gain, insomnia, suicidal thoughts, relationship distress, and anxiety—and that people exhibited “negative behaviors” like drinking alcohol, smoking, making poor food choices, or arguing with loved ones.

  There’s more. Two Harvard physicians published an article in the New England Journal of Medicine that crystallized how it came to be that Black people’s stress levels were heightened since Trump’s election. Two paragraphs bring home the point:

  There has been an increase in racial resentment, animosity, and political polarization in the United States in recent years. The election of President Obama played a key role: research indicates that Obama’s election led to increases in the rate of belief among white Americans, especially conservatives, that racism no longer exists. At the same time, in the wake of his election, one third of white Americans indicated that they were “troubled” that a black man was President, the Tea Party movement emerged with anti-minority rhetoric, resentment toward Democrats increased, support among whites for the Democratic Party declined, and white support for addressing racial inequities decreased. Obama’s election also led to a marked increase in racial animosity expressed in social media: there was a proliferation of hate websites and anti-Obama Facebook pages, with the widespread use of historical racial stereotypes that are no longer seen in mainstream media.

  The presidential candidacy of Donald Trump appeared to bring further to the surface preexisting hostile attitudes toward racial and ethnic minorities, immigrants, and Muslims. In a national (nonrepresentative) survey of 2,000 elementary and high school (K–12) teachers, more than half of respondents said that since the 2016 presidential campaign began, many of their students had been “emboldened” to use slurs and name calling and to say bigoted and hostile things about minorities, immigrants, and Muslims. Not surprisingly, 67% of these teachers reported that many U.S. students (especially immigrants, children of immigrants, and Muslims) were scared and worried and had expressed concerns or fears about what might happen to their family after the election. Even some native-born black children whose ancestors have been in the United States for centuries expressed concerns about a return to slavery or being sent back to Africa.

  For Holloway, the study points out how differently Black people and non-Black people live in America.

  “It’s another way, a significant way, that stress hurts Black people in ways other races do not have to deal with,” Holloway said. “Living in perpetual fear that the man [Trump] is going to Tweet or do something that’s going to put you in danger…or during the pandemic, seeing people constantly dying that did not have to die—family and friends…It’s stressful. His position on race and divisiveness puts Americans in general and African Americans in particular at risk, on edge. That’s stress that others in this country don’t have to deal with—on top of the daily levels of racial trauma we experience. And then you throw in that Black people so often—because of structural racism—were the ‘essential workers’ who had to go to work during a deadly pandemic that at
tacked them the most, and it’s a lot. It’s all interconnected.”

  Joseph B. Hill, the principal of JBrady5 Consulting, a diversity and inclusion consulting firm in Atlanta, said he noticed a change in his health during Trump’s term. “I can honestly say that there came a point where just hearing his name created tension and anxiety in my body,” he said. “I had to stop watching the news because at times I literally felt sick to my stomach. My heart rate increased. That’s stress.

  “His rhetoric incited his base—and created so much stress for our communities—to the point that you could not feel safe as a Black man or woman in America, even more so than we already felt. That’s extra stress. So, we have stress just from walking out of our front door into a world that puts and keeps us at a disadvantage. Stress. We go to work and deal with issues on the job that are too often race-related. Stress. You want to buy a house, but are charged higher interest rates. Stress. Our schools are troubled so we worry about how our kids are going to flourish. Stress. And on and on.

  “But then you have him, the president of the United States, seemingly every day doing or saying something that either rouses up his base or insults African Americans—in both cases, it is stressful and unhealthy for us.”

  The Shame of Infant Mortality

  Seven years ago, Dr. Rachel Hardeman wrote an article in the New England Journal of Medicine, “Structural Racism and Supporting Black Lives—The Role of Health Professionals,” that called America’s racism “a public health crisis” and used the phrase “white supremacy” in explaining her position. It was the first time those expressions were printed in the most prestigious medical publication in the world.

  For her daring, Hardeman—a reproductive health equity researcher and tenured associate professor at the University of Minnesota in the Division of Health Policy and Management—received emails that questioned and challenged her argument, all from white doctors who failed or were unwilling to see beyond their internal biases. Her peers placated her.

  She said: “Some said, ‘Oh, that’s nice. The Black girl studying racism.’ There was a lot of disinterest and blank stares. ‘I don’t get it.’ So, certainly there was some backlash: ‘This is not a medical issue. This is not a health care issue. This is not a public health issue. Why is the top medical journal in the world publishing this sort of thing?’ It was all so predictable.”

  But Hardeman continued to publish as she established herself as a foremost scholar on race, gender, and health. She studied and researched reproductive health, an area that illuminates the disheartening infant and maternal mortality rates that are higher among Black babies and Black mothers.

  “There was not a single moment that drove me to my emphasis,” Hardeman said. “I’ve been building toward this my whole life. I’ve always been interested in public life based on watching my parents and grandmother in particular struggle with a health care system that very clearly was not serving her in a way that it should have. As a result, she had a premature death.

  “I actually had a good birthing experience. What it made me realize is that it is possible for a Black woman. We see all the horror stories and know the statistics around infant mortality and maternal mortality for Black women. I am an example of what can be done the right way. So I have been focusing on how we can transform the structures to make that a common reality for everyone else.”

  But the struggle was real, as they say. Elements of being a woman that whites did not consider dogged her.

  “I could not find a Black OB-GYN,” she said. There was a sense of sadness in her having to articulate that dilemma.

  “I searched for a Black doula and eventually found one,” Hardeman said. “That’s one piece of the issue. Not enough Black doctors—and it’s particularly hard in places like Minnesota [where the Black population is low].”

  Just as in education, where Black students in public schools thrive better when taught by Black teachers, it stands to reason that Black mothers-to-be would fare better under the care of Black physicians.

  “Some of the research has looked at the power of a racially concorded relationship,” Hardeman said. “And what we need, not surprisingly, is that when you have a provider who shares your lived experiences, you get better care and are more satisfied with that care and are more likely to comply with the plans that have been laid out for you.”

  With such a small percentage of Black doctors in America, that critical concorded relationship for Black mothers is unlikely—and it contributes to the increase in deaths at birth.

  “It’s important to note that the United States is the only industrialized, well-resourced country that has a rising maternal mortality rate,” Hardeman said. “And it’s driving up because Black women are three to five times more likely to experience maternal mortality in comparison to their white counterparts.”

  Why is this so? Black doctors break it down this way: There has been and continues to be a lack of access to competent primary care that would prevent the chronic conditions that cause maternal deaths. Those conditions include high blood pressure, diabetes, and obesity, among others, that increase the danger of pregnancy for Black women.

  An effective primary care program could manage or mitigate those issues. But the so-called most advanced nation in the world has a health care system that does not provide equal care for all women. Experts consider this failing one of the primary distinctions between America and other advanced nations that have commitments to improve the maternal mortality concerns with a universal health care system that evenly manages patients, despite race or economic standing.

  According to myriad studies, women in the United States without insurance are four times more likely to die of a pregnancy-related complication compared to their insured counterparts. Worse, the country seems to be moving further away from universal health care, which was a premise of the Affordable Care Act, the insurance plan available for all Americans enacted by former president Barack Obama that had been under attack by the Trump administration for four years.

  “Infant mortality data dates back to slavery,” Hardeman said. “Overall, across centuries, America’s infant mortality rate isn’t great when compared to other industrialized nations, but it has improved. What stayed the same is that Black and Native Americans are twice as likely to experience infant mortality than whites.

  “It’s one of those markers of community health. Frankly, if we can’t keep our most vulnerable healthy, then we have big issues. The two populations of people most historically marginalized and disenfranchised in our history are at the greatest risk for infant mortality. Very disconcerting.”

  The work drives Hardeman, though, as she anchors her work in history, hoping that context will resonate and influence treatment…eventually.

  “Structural racism is a fundamental cause of the inequities we are facing in reproductive health,” she said. “Part of my work is to help people connect the dots to the historical reality of how racism has manifested and persists in our society and how it drives what we’ve known about racial disparities today.

  “All those racist narratives were created to perpetuate slavery and they have become so deeply engrained in how people are taught to practice medicine. And it’s killing us—babies and mothers, too.”

  The lack of commitment has created another health issue in mothers that serve as a precursor to infant mortality. Deeper, the cause and effect of policing in communities of color have taken a physical toll on citizens, including Black babies.

  “Preterm birth, before thirty-seven weeks, leads to Black babies dying. Black women are more likely to give birth before thirty-seven weeks, and that has a whole series of health implications for the child,” Hardeman explained.

  Those implications include a little-known fact: Pregnant Black women who have interactions with law enforcement can face threatening health challenges.

  “Police contact on preterm birth—looking at what it means to live in a community that is disproportionately exposed to p
olice—is significant,” Hardeman said. She used her hometown as an example.

  “Minneapolis has some incredibly segregated neighborhoods, so Black women are most likely to live in Black neighborhoods, and those neighborhoods are more likely to have police presence, patrolling the neighborhood for various reasons,” she explained. “And we see that there is a greater likelihood of preterm birth among women living in those neighborhoods because of the stress involved with those encounters.”

  As a Minneapolis native, Hardeman’s proximity to the Black deaths at law enforcement hands of Jamar Clark in 2015 and Philando Castile a year later inspired her to be vocal about racism in medicine. It was then that she wrote her memorable piece in the New England Journal of Medicine.

  The article focused not only on the tragic shooting deaths of Black men by law enforcement, but also the health impacts of police presence in communities of color—something hardly anyone considered.

  She wrote:

  The term “racism” is rarely used in medical literature. Most physicians are not explicitly racist and are committed to treating all patients equally. However, they operate in an inherently racist system. Structural racism is insidious, and a large and growing body of literature documents disparate outcomes for different races despite the best efforts of individual health care professionals. If we aim to curtail systemic violence and premature death, clinicians and researchers will have to take an active role in addressing the root cause.

  Structural racism, the systems-level factors related to, yet distinct from, interpersonal racism, leads to increased rates of premature death and reduced levels of overall health and well-being. Like other epidemics, structural racism is causing widespread suffering, not only for Black people and other communities of color but for our society as a whole. It is a threat to the physical, emotional, and social well-being of every person in a society that allocates privilege on the basis of race. We believe that as clinicians and researchers, we wield power, privilege, and responsibility for dismantling structural racism.