Like many others around the world, I have been horrified and appalled at the events happening around this country. This has become more than just protests about the systemic racism that exists, this is a movement. This (I hope) will reshape generations to come. As we as individuals and as a society try to figure out how we can move forward and act, we would be remiss not to point out another glaring issue that has come to light during this movement which is the profound inequalities facing minorities in this country.
African Americans have an increased risk of hypertension, obesity and diabetes compared to white individuals. When we look specifically at black women, we find continued disparities in fertility, obstetrical, and cancer health. It has become a true public health emergency that deserves a conversation. As we delve into possible reasons for this, it is not enough to “just provide better care.” The entire system needs to change to improve health outcomes.
Black women and infertility
Infertility impacts approximately 12 percent of women each year and it has been documented that black women may have 2x the rate of infertility compared to white women, however, they are almost 50 percent less likely to seek out care (8 percent vs. 15 percent in one study). Why is this happening?
One reason is shame. Many black women feel ashamed for not being able to become pregnant because infertility is not a commonly discussed topic in the black community. Additionally, there is a long-standing stereotype that the black community is hyper-fertile going back to notions from the slave days. These common stereotypes and misconceptions may lead black women to keep silent on their struggle with infertility.
Studies have also demonstrated black women have a higher rate of tubal factor infertility, as well as uterine fibroids, both of which can decrease the chance of conceiving naturally. Additionally, many black women do not have access to fertility either due to location or due to resources. IVF costs may run anywhere from $10,000 to $20,000+ and black women are more likely to live below the poverty line, and thus are significantly less likely to be able to afford treatment costs.
Black women and obstetrical care
Once black women are pregnant, they face staggering differences in maternal care, morbidity, and mortality. Black women are more than 3x as likely to experience a pregnancy-related death and are more likely to have a preventable maternal death. There are several reasons for these outcomes and which may include the fact that black women are approximately 20 percent less likely to receive first trimester prenatal care and are twice as likely to receive late or no prenatal care at all (10.2 percent vs. 4.5 percent).
Black women and breast cancer
Even outside of fertility and pregnancy, black women face disparities in other aspects of their healthcare. Black women are diagnosed with breast cancer at similar rates to white women but are 40 percent more likely to die from breast cancer. Possible reasons for this may include that white women are more likely to be diagnosed at an earlier stage which has a major impact on treatment and long-term survival. Additionally, black women may be at a higher risk of being diagnosed with triple negative breast cancer, which is a more aggressive form of breast cancer with lower survival. Reasons for this may include genetics, but are not entirely known.
These are some of the many examples of profound health inequalities that black women face. But, why do they exist?
Contributing Factors: Lack of physician diversity
African Americans make up approximately 13 percent of the U.S. population, yet according to data from the AAMC in 2018, physicians who identify as black made up approximately 5-6 percent of physicians in the U.S. and the percentage of black female physicians is even lower. The ratio of black and other minority physicians in healthcare is appallingly low and studies have shown that minority patients may do better with completing preventative healthcare when they are seen by a doctor of the same race. These reasons vary and may include increased trust and comfort in physicians who are of the same race.
Another factor impacting care that has been well documented in studies is implicit (unconscious) bias that physicians may have towards black patients. One study, in particular, noted that non-black clinicians were less likely to use patient-centric language with black patients, which resulted in lower levels of patient trust and confidence in their physician. This in turn may lead to lower levels of compliance and overall poorer health outcomes.
Approximately 13.7 percent of black women are uninsured based on data from 2017, in comparison to 8 percent of white women. Studies have suggested a lack of insurance may lead to an inability to afford care when needed as well as gaps in care, including prenatal care, without which pregnancy related outcomes can worsen. Another component that likely adds to the lack of coverage is that black women, on average, earn 61 cents to the dollar compared to white men. These pay disparities are another way that socioeconomic disadvantages have impacted the healthcare of black women.
Another concept that has been suggested to explain the overall poorer outcomes of black women is “weathering.” Weathering is a term coined by Arline Geronimus that noted that black women may experience accelerated aging of their bodies and thus poorer health outcomes as a “physical consequence of chronic and systemic injustice and socioeconomic disadvantage.”
How can we do better?
It will take real (and uncomfortable) conversations about race in this country as well as education and action. I don’t have all of the answers, but I hope to at least spark a conversation about how we can do better as a society and as women helping other women.
To start, we need increased diversity in medicine. This will take colleges, medical schools, and residency programs making a concerted effort to improve diversity in their admission process. Additionally, medical schools and residency programs need to do a better job of discussing race and the systemic bias that exists in the medical field.
We need more representation of different races on medical boards, foundations, and in medical societies. With regards to fertility treatment, we need specific grants and scholarships tailored to minority patients who lack access to care. We also need specific education of medical students on minorities and their unique health challenges and implicit bias they face in the healthcare system.
Improve access to care and equal income
The Affordable Care Act was a significant step in providing coverage for millions of men and women who lacked affordable healthcare. Minorities, in particular, blacks and Hispanics benefited significantly.The uninsurance rates of black women went from 19.5 percent, prior to the ACA, to 13.7 percent after the initiation of the ACA. We need to take further steps to improve access to healthcare for minority women. In addition, we need to shine a light on the income inequality between men and women and especially between black women and white men.
As hopeful as I am regarding the conversations that are occurring in this country, we have to use these conversations to educate ourselves and then take action to improve the public health emergency of racial inequalities in healthcare.