By Tonya Russell,
Rachel Hardeman has dedicated her career to fighting racism and the harm it has inflicted on the health of Black Americans. As a reproductive health equity researcher, she has been especially disturbed by the disproportionately high mortality rates for Black babies.
In an effort to find some of the reasons behind the high death rates, Hardeman, an associate professor at the University of Minnesota School of Public Health, and three other researchers combed through the records of 1.8 million Florida hospital births between 1992 and 2015 looking for clues.
They found a tantalizing statistic in the Florida births. Although Black newborns are three times as likely to die as White newborns, when Black babies were cared for by Black doctors after birth — primarily pediatricians, neonatologists and family practitioners — their mortality rate was cut in half. They found an association, not a cause and effect, and the researchers said more studies are needed to understand what effect, if any, a doctor’s race might have on infant mortality.
“Strikingly, these effects appear to manifest more strongly in more complicated cases,” the researchers wrote, “and when hospitals deliver more Black newborns.” They found no similar relationship between White doctors and White births. Nor did they find a difference in maternal death rates when the race of the doctor, usually an obstetrician, was the same as the mother’s.
“It is the first empirical evidence to describe the impact of the physician’s race on an outcome such as infant mortality,” Hardeman says.
With 5.7 deaths per 1,000 live births, the United States has a high infant mortality rate, and Black babies are in the gravest danger, with an infant mortality rate in 2018 of 10.8 deaths per 1,000 live births, compared to a rate of 4.6 White babies per 1,000 live births.
Infant mortality is defined as death during the first year of life, and 66 percent of those deaths, for all races, occur in the neonatal period in the first 28 days of life, with 14 percent within the first hour and another 26 percent within one to 23 hours.
Under the care of Black doctors, Black babies’ mortality rate was more than halved from 430 per 100,000 live births to 173 per 100,000, Hardeman says.
Although infant mortality in the United States has been decreasing, the gap between Black and White infants has persisted, Hardeman says. The root, she says, lies in structural racism.
She defines structural racism as the “normalization and legitimization of an array of dynamics — historical, cultural, institutional and interpersonal — that routinely advantage Whites while producing cumulative and chronic adverse outcomes for people of color.”
Hardeman and the other researchers — Brad N. Greenwood, associate professor of information systems and operations management at George Mason University; Laura Huang, an associate professor at Harvard Business School; and Aaron Sojourner, an associate professor at the University of Minnesota’s Carlson School of Management — wrote that more research was needed to understand why Black physicians outperform their White counterparts.
They cautioned that it wasn’t practical for all Black families to seek Black doctors to care for their babies, not only because there are too few of them but also because the reasons for the disparity in care need to be understood and addressed.
“Key open questions include the following: 1) whether physician race proxies for differences in physician practice behavior, 2) if so, which practices, and 3) what actions can be taken by policymakers, administrators, and physicians to ensure that all newborns receive optimal care,” they wrote. “Reducing racial disparities in newborn mortality will also require raising awareness among physicians, nurses, and hospital administrators about the prevalence of racial and ethnic disparities, their effects, furthering diversity initiatives, and revisiting organizational routines in low-performing hospitals.”
Common causes of infant mortality are premature birth, low birth weight, maternal complications and sudden infant death syndrome, according to the Centers for Disease Control and Prevention. Some of these deaths are caused by complications related to the mother’s health. Historically, Black maternal health has always been concerning, with Black women four to five times more likely to die during pregnancy and childbirth than White women, regardless of income, education or lifestyle. A Black woman does not have to be poor for her life or her baby’s life to be at stake.
The most recent figures, for 2016, show 40.8 pregnancy related deaths per 100,000 live births for Black women and 12.7 per 100,000 for White women. Most pregnancy related deaths, the CDC says, are preventable.
Health disparities have been well documented in the medical literature. In 2002, the Institute of Medicine published Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, a book-length study that concluded that: “A large body of published research reveals that racial and ethnic minorities experience a lower quality of health services, and are less likely to receive even routine medical procedures than are White Americans.”
Citing numerous examples, the authors wrote: “Significantly, these differences are associated with greater mortality among African-American patients.”
More recent studies show bias is still being documented, and that people of color have disproportionate rates of preventable death and illness than Whites.
Hardeman says that by adulthood so many disadvantages have accumulated to affect a Black woman’s health that the race of the doctor may not make a difference.
She says that, by adulthood, structural racism has already been at play, and that racial concordance is not enough to counteract the “cumulative” disadvantages that often benefit White women and lead to adverse outcomes for Black women.
“It also means the cumulative experience of racism and sexism, throughout the lifecourse, can trigger a chain of biological processes, known as weathering, that undermine Black women’s physical and mental health.”
Hardeman recognizes that most babies and mothers statistically will be cared for by White physicians, but she says that they are equally responsible for “divesting from health care inequities.”
In a report from July, she writes, “We believe that medical schools and training programs should equip every clinician, in every role, to address racism. And licensing, accreditation, and qualifying procedures should test this knowledge as an essential professional competency.”
This could look like mandating education about implicit bias and social justice, which can better prepare doctors of any race to properly treat at-risk patients, regardless of their socioeconomic backgrounds or race. Medical schools have come under increasing pressure to include such education and counteract training that in the past wrongly taught doctors that there were genetic differences among different races.
And the health of babies, even before conception, can be improved by addressing the needs of Black mothers and creating programs that improve prenatal care and provide timely interventions to alter the course of the health of Black babies and their mothers, according to the National Birth Equity Collaborative.
And it remains important, Black doctors say, to increase their numbers.
“Government doesn’t have your back, neither does health care,” says Khayriyyah Chandler, a Black doctor practicing in New Jersey.
According to the Association of American Medical Colleges, only 5 percent of doctors identify as Black, and 4.9 percent of pediatricians do so. That is compared to the 579,174 Black babies born in 2018, 15 percent of all births. While medical schools are seeing a steady increase of Black students, as of 2020 they only make up 7 percent of students.
Enrollment is affected by the wealth gap of Black households, Chandler says, as well as the cost of maintaining a private practice.
“It is harder to keep a private practice, particularly based on higher percentages of Medicaid and Medicare, especially when you have more debts than your predecessors,” she says. “When there’s more debt, there tends to be less risk, and I suspect it is harder to find abundant practices, and a variety of practices, in Black neighborhoods. That is why authentic efforts must be made with Black people, and they must lead efforts in their own communities.”
Many factors play into a student’s career choice, and for a child of color, especially in low-income areas, not seeing Black professionals may make certain career choices seem unattainable. Organizations such as the Big Homie Project are hoping to bridge the gap. Founder Jacqueline Diep knows what the lack of positive influences can feel like. A child of the foster care system, she credits a teacher for changing her life’s trajectory, as she went from having a modest GPA to eventually getting an MBA and landing jobs at companies like Google.
“People helped me, success didn’t just magically happen,” she says. “And what I realized was that a lot of these kids in the community aren’t hopeless, but it’s just much harder. And I realized that I’m an example of what is possible if you just surround yourself around the right people.”
The Big Homie Project pairs professionals, including doctors, with children of color. One of the mentors, Fernandino Vilson, a resident urologist at Stanford, knows what it is like to be told you can’t succeed by those in a position to help you.
“My love for anatomy, physiology and science sparked my interest in medicine, along with being told that I wouldn’t be a doctor and to choose another route,” he says. High school guidance counselors and career advisers discouraged him, he says, but instead of changing course, he was determined to prove them wrong. His mentoring includes his two young brothers, who are now pursuing medicine.
Vilson says that, throughout his journey, mentorship has always been on his mind and he began acting on it in medical school: “We’ve put on premed conferences inviting underrepresented minorities in North Carolina. We’d give mock interviews, put them in front of recruiters for med schools. The Big Homie Project is a way for me to continue.”
While creating channels for more Black doctors is a major step for survival of Black infants, Hardeman says, change is needed throughout the health-care system.
Organizations such as the National Birth Equity Collaborative are advocating for more research into the health concerns of Black families as well as for governmental agencies to provide more resources to address health disparities.
Hardeman and the other three researchers put it this way:
“We hope this study provides a basis for additional work that advances our understanding of inequality, its origins and how practitioners can work toward creating better and more-equitable birth outcomes.”
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