Chapter One Everything I Thought Was Wrong Although the United States has the most advanced medical technology in the world--­and spends more on health care than anywhere else--­we lag behind all other wealthy nations in key measures of health that serve as a proxy for our overall well-­being. It starts at birth and ends with death. The United States has the highest rate of infant mortality and the lowest life expectancy in comparison with other wealthy countries. An American woman is more likely to die as a result of pregnancy and childbirth than women in other countries of comparable wealth. That rate is higher now than it was in the 1990s, even though most of these deaths of mothers are avoidable. The poor health outcomes of the world''s wealthiest nation are often presented as a mystery, yet their root causes are hiding in plain sight: these disparities are driven by inequality and discrimination, which lead to poor health in people of color in the United States, particularly African Americans. The health outcomes of Black Americans are by several measures on par with people living in far poorer nations. At every stage of life, Blacks have poorer health outcomes than whites and, in most cases, than other ethnic groups.

Black babies are more than twice as likely as white babies to die at birth or in the first year of life--­a racial gap that adds up to thousands of lost lives every year. Blacks in every age-­group under sixty-­five have significantly higher death rates than whites. Black life expectancy at birth is several years lower than that of whites. African Americans have elevated death rates from conditions such as diabetes, stroke, and heart disease that among whites are found more commonly at older ages. In a phrase, African Americans "live sicker and die quicker," which, if you estimate years of life lost because of deaths that could''ve been prevented, adds up to tens of thousands of lost years. Too often this story of inequity and disadvantage in health gets dismissed as "only" affecting the poor, or being one of class, not race. It is indisputable that poverty creates emotional disruption, inequality, and fear. Health-­care facilities in lower-­income communities are often underfunded and left to waste away.

The poorest communities lack access to healthy food, clean water and air, and outdoor space--­as well as jobs, safe living conditions, and quality education. This in itself is unfair and tragic and affects people of all races and ethnicities who live in pockets of rural, urban, and suburban poverty across the country. Too frequently, rather than taking into account these structural inequities, we blame the individuals, by insisting they wouldn''t be poor if they worked harder and wouldn''t be sick if they were educated and simply took better care of themselves. However, poverty is not the sole factor in who gets sick and who doesn''t, in who survives and who passes away; it just makes the situation that much worse. Even when income, education, and access to health care are matched, African Americans remain disadvantaged and racial disparities in health cut lives short. College-­educated Black mothers, for example, are more likely to die, almost die, or lose their babies than white mothers who haven''t finished high school. I am a Black American and have been a journalist and author in both ethnic and mainstream media for several decades. Most of my work has looked at the health of African Americans, particularly Black women, and at racial health disparities.

Of course, I have long understood that something about being Black has led to the documented poor health of Black Americans. But in recent years I have come to understand that much of what I believed about health disparities and inequality in the United States was wrong. The something that is making Black Americans sicker is not race per se, or the lack of money, education, information, and access to health services that can be tied to being Black in America. It is also not genes or something inherently wrong or inferior about the Black body. The something is racism. Income, education, determination, and self-­empowerment can help individual Black Americans but cannot entirely erase the negative effects of centuries of discrimination, and ongoing bias, on the health of African Americans. To put it in the plainest terms, from birth to death the impact on the bodies of Black Americans of living in communities that have been disadvantaged by long-­standing racial discrimination, of a deeply rooted and dangerous racial bias in our health-­care system, and of the insidious consequences of present-­day racism affects who lives and who dies. These factors create physical vulnerability and systemic disadvantage that education, income, and access to health care cannot erase.

This inequality, born more than four hundred years ago and embedded in every structure and institution of American society, including the health-­care system, is driving our country''s poor national health outcomes relative to the rest of the developed world. It has taken me three decades of reporting on the health of African Americans and several disturbing personal medical crises to understand the ways discrimination and bias contribute to poor health outcomes primarily in African Americans, but in reality in all oppressed people. In the mid-­1980s, I became a contributing nutrition and fitness writer for Essence magazine, and eventually the publication''s health editor. Like so many other Black women before and after me, I remember seeing Essence at my grandmother''s bedside and on my mother''s coffee table when I was growing up. It was first published in 1970, during the intersection of the Black Power and women''s liberation movements and served as a bible for Black women. The mission, instilled in everyone on the staff by our editor in chief, Susan L. Taylor, was clear: in a world full of negative representation and damaging mythology, give Black women positive images of themselves and empower what would eventually grow from a circulation of fifty thousand to more than one million and a reach of more than eight million women and some men with information about relationships, finances, careers, travel, family, spirituality, food, health, and, most important, self-­love and acceptance, to make their lives better. At Essence, my personal mission was unambiguous: fix the health crisis in Black America.

At the time, from the late 1980s to the end of the last millennium, I understood that Black America was experiencing a life-­crushing constellation of health problems; Black people were contracting serious illnesses at younger ages than other Americans and living fewer years. I was sure, as so many others believed then and still believe today, that poverty was solely to blame. In 1985, I was transfixed by the Heckler Report, issued by the U.S. Department of Health and Human Services (HHS) and released that October, which took a research deep dive into racial health disparities. The ground-­shattering document was pulled together by a nineteen-­member task force of senior scientists and officials at HHS who analyzed existing data about race, death, and disease in the United States. They examined the underlying factors and consulted with experts outside the government who specialized in the health of people of color. This publication marked the first time the government had comprehensively studied the health status of people of color, and it elevated the issue of health inequality to the national stage.

I ordered a print copy of the 239-­page study and read it like a novel. Named for the HHS secretary at the time, Margaret Heckler, the report estimated that there were more than eighteen thousand "excess deaths" each year among Blacks because of heart disease and stroke, compared with the number of deaths that would occur if their health was on par with that of whites. It also pointed to 8,116 excess deaths from cancer, 6,178 from infant mortality, and 1,850 from diabetes. It made me ache to consider the thousands of Black men, women, and babies dead every year from medical problems we knew how to prevent and treat. Heckler, a pro-­life Reagan Republican, called this shameful inequality "an affront both to our ideals and to the ongoing genius of American medicine." The Heckler Report recommended no new government funding to attack the crisis. The report did discuss what we now call the "social determinants of health," conditions like poor housing, crime, pollution, shortage of healthy food, and lack of medical services that affect mental and physical health. But it neglected to mention the Reagan administration''s cutting or freezing federal dollars for Medicaid, food stamps, family planning, and other supportive services, which would make health disparities grow, not shrink.

Heckler insisted that "money was not the answer." There was no mention of discrimination and bias either inside or outside the medical-­care system. Instead, the report advised Black Americans to save themselves by improving their health through education, self-­help, and self-­care. The government''s role was to bolster data collection and communication between agencies and expand health education. Heckler stated the blame bluntly at a press conference following the release of the report: "Progress depends more on education and a change in personal behavior than it does on more doctors, more hospitals, or more technology." Within this largely well-­meaning report lurked the assumption that Black people, individually and collectively, were irresponsible, careless, uneducated, and making thoughtless choices that led to this health crisis in the first place. Edith Irby Jones, MD, then the president of the National Medical Association, the professional organization for Black physici.