How Do We Eliminate Health Inequities for Black Mothers?

People are still grieving the death of Erica Garner. She died last December at the young age of 27. Why did she die? And what is our role in preventing this type of premature death?

Erica was an outspoken activist against police brutality after her father’s death at the hands of a New York City police officer in 2014. Shortly after the birth of her son, Erica suffered a heart attack. Four months later, an asthma attack triggered another heart attack and she was declared brain dead. On December 30, Erica passed away.

Her death is tragic proof of how our healthcare system is failing Black mothers.

• Like her father Eric Garner, who died while a police officer put him in an illegal chokehold, Erica lived with asthma. According to the National Asthma Control Initiative, the rates of hospitalizations and deaths due to asthma are both three times higher among African Americans than among whites.
• She died of a heart attack. Black Americans are 33 percent more likely to die from cardiovascular disease than the overall population in the United States, according to the American Heart Association.
• This was the second heart attack she suffered since the birth of her second child in August. Because she died within a year of giving birth, the Centers for Disease Control counts Erica’s death is as a pregnancy-related death. According to the CDC, Black mothers are about 3.4 times more likely to die from pregnancy-related causes.

These tremendous inequities are not biological in nature; rather, they are a result of our current and historical social structure and the multiple ways in which racism directly and indirectly affect health. Dr. Camara Jones has a powerful framework for understanding how racism impacts health outcomes:

 

	Institutional Racism: Differential access to the goods, services, and opportunities of society by race.	Unequal material conditions (access to employment, housing, education) and imbalance of power (information, resources, and voice) profoundly impact the health and reproduce what Jones calls “race-associated differences” in outcomes.
	Personally Mediated Racism: Prejudice and discrimination, where prejudice means differential assumptions about the abilities, motives, and intentions of others according to their race, and discrimination means differential actions toward others according to their race.	In health care we see bias impact how doctors prescribe medication or how an ectopic pregnancy is managed, for example.
	Internalized Racism: Internalized racism is defined as acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth.	There is evidence that internalized racism is associated with poorer cardiovascular health and with depressive symptoms and serious psychological distress.

 

For those working in the healthcare safety net — working to prevent heart attacks and strokes everyday, grappling with social determinants of health, and providing pre- and post-natal care to people with multiple barriers to health services — there is a lot more work to be done to prevent these inequities.

How many of us are thinking about disparities in the work that we do? How many of us are actively trying to address them? To what degree are people most impacted by those disparities involved/centered in/driving that work? How can people start if they have never thought about this before?

A little over a year ago, the New England Journal of Medicine published an important perspective on the role of health professionals in supporting Black lives. In it, the authors recommend that health professionals:

1. 1. Learn about, understand, and accept the United States’ racist roots, which have shaped both clinical research and practice.
   2. Understand how racism has shaped the narrative about disparities, including the false belief that there are biological differences between Black and White people.
   3. Define and name racism so that we can fight against it.
   4. “Center at the margins” — shift our viewpoint from a majority group’s perspective to that of the marginalized group or groups.

In our programs, we often measure our success by looking at the degree to which we reduce morbidity and mortality. We must also consider the degree to which we are decreasing and eliminating gaps in  health outcomes by race. This means stratifying our data by race/ethnicity to understand the current state of racial health disparities in our quality and outcome measures. And when we find disparities, we can investigate why and shift our focus to what we can do about them.

Some of the teams we work with are already doing this. San Francisco Health Network’s PHASE team realized that while they were making significant improvement in blood pressure control among their patients diagnosed with hypertension, a disparity gap between their Black/African-American patients and their overall patient population remained at 8 percent. Patients with uncontrolled blood pressure are at higher risk of heart attacks and strokes. To address this disparity, they tested several changes, including working with clinic managers to design and implement an outreach plan focused on prioritizing Black/African American patients for nurse and pharmacist visits, coupled with providing home blood pressure monitoring cuffs to patients without insurance.

At CCI, we are early in our thinking about how we might apply an “equity lens” to our work, but I feel hopeful and inspired by efforts already underway by passionate and dedicated people working in health care to achieve equity.