Of all the forms of inequality, injustice in health is the most shocking and inhuman.

—Martin Luther King Jr., scholar, minister, and leader of the American civil rights movement

FOUR

Racism Literally Makes You Sick: It Is a Preexisting Condition

Fannie Lou Hamer, a Black civil rights activist, said in 1964, “I am sick and tired of being sick and tired.”¹ She was referring to the fatigue associated with fighting for rights that were supposedly guaranteed by the Constitution. This is now an iconic refrain that many Black and Brown people understand at their core and repeat to each other with no other words necessary because there is a collective understanding of exactly what it means. Racism exhausts Black people. We live in a world that for centuries has dehumanized, ostracized, murdered, and otherwise violated our human rights. The intergenerational fatigue that comes from enduring structural racism literally makes you sick.

This chapter is for both Black and white readers. I must admit that I was not in tune with the impact of racism on my physical and mental health until recently. The millennials on my team started to talk about rest as a form of resilience, the Nap Ministry,² and self-care. I felt confident that I took care of myself. I exercise, follow nutrition guidelines, and get eight hours of sleep most nights. However, as someone who does diversity, equity, inclusion, and justice work for a living and lives while Black, I had to do some serious self-reflection on whether I was really attending to my well-being. And while I initially pooh-poohed the millennials’ focus on the extra self-care Black people may need, I came to understand the merit in their wisdom. At the height of the 2020 Black Lives Matter protests, I experienced palpable pain, stress, and rage and witnessed the same in some of my colleagues. There was crying and hyperventilating, and a few acknowledged they were on the brink of a meltdown. While these were unusually stressful times because those of us in the work were being bombarded with requests for urgent healing and listening sessions to quell the tensions and being in the middle of COVID-19, I now acknowledge the low-level, ongoing stress that I described at the beginning of chapter 1, “My Black Fatigue.”

As Black people, we need to pay attention to our health.

Racism Leads to Health Disparities

There is a common saying in the Black community that when the world gets a cold, Black people get pneumonia, and when the world gets pneumonia, Black people die. The recent coronavirus pandemic put a spotlight on this unfortunate reality. In many communities, Black people died at two to four times their representation in the population.³ This chapter details the glaring health disparities between Black and white people and their causes.

According to Families USA, a national, nonpartisan voice for health care consumers, in 2019, these major health disparities existed between Black and white people:⁴

• Black people are 44 percent more likely to die from a stroke.
• Black people are 20 percent more likely to have asthma and three times more likely than white people to die from it.
• Black people are 25 percent more likely to die from heart disease.
• Black women are 40 percent more likely to die from breast cancer.
• Black women are 52 percent more likely to die from cervical cancer and 40 percent more likely to die from breast cancer than white women, even though the incident rate of breast cancer is comparable for the two groups.⁵
• Black women are 243 percent more likely than white women to die from pregnancy- or child-birth-related causes.⁶ College-educated Black women have worse birth outcomes (e.g., infant mortality, low birth weights, dying in childbirth) than white women who have not finished high school.
• Black women represent more than 66 percent of new HIV/AIDS cases.
• Black men are 30 percent more likely and Black women 60 percent more likely to be diagnosed with high blood pressure.
• Black men are 1.3 times more likely to be diagnosed with colon cancer and 20 percent more likely to die from it.
• Black people are 20 percent more likely to report psychological distress.
• Black infants are 3.5 times more likely to die at birth because of low birth weight.
• Black infants have 2.2 times higher infant mortality rates, regardless of the socioeconomic status of the mother.
• Black children are twice as likely to die from sudden infant death syndrome.
• Black children are twice as likely to have asthma.
• Black children are 56 percent more likely to be obese.
• Black children are 61 percent more likely to attempt suicide as high schoolers as a result of depression.

Health disparities result in lower life expectancies for Black people than any other ethnic group. According to data from the Centers for Disease Control and Prevention,⁷ in 2017, the life expectancy in the United States for all races was 78.6 years and the lowest for African Americans at 75.3 years—even lower for African American men at 71.9 years, compared with the life expectancy for whites at 78.8 years.⁸ Figure 4.1 compares white, African American, and Hispanic life expectancy.⁹ The life expectancy for Black men has declined since 2011, when it was 72.2 years.

Researchers have coined a term—“excess deaths”—to explain the difference in life expectancy. If Blacks and whites had the same mortality rate, nearly 100,000 fewer Black people would die each year in the United States. Even educated Black people are sicker and die younger than their educated white peers. A Black person will live, on average, about three fewer years than a white person with the same income.¹⁰

Figure 4.1. Life expectancy by race and sex, 2017
Source: The Winters Group based on data in “USA Life Expectancy,’’ USA Health Rankings.¹¹

Racism Causes Chronic Stress

There is a plethora of research to support the health disadvantage related to the harmful effects of chronic experiences with race-based discrimination, both real and perceived. These stressful experiences are thought to set into motion a process of physiological responses (e.g., elevated blood pressure and heart rate, production of biochemical reactions, hypervigilance) that eventually result in disease and mortality.¹² For example, researchers found that factors that predispose individuals to negative mental health outcomes include unfair treatment and social disadvantage, as well as other social stressors, such as inadequate levels of social support, and the occurrence of everyday life events. Other studies examined the possible consequences of perceived discrimination and found that just the anticipation of being treated badly or unfairly had as powerful an impact on individuals’ mental and physical states. Medical experts report that being socially rejected, experiencing stereotypes, and suffering discrimination trigger the same neural circuits that process physical injury and translate it into the experience we call pain.¹³

The social determinants of health established by the World Health Organization include access to social and economic opportunities; resources and supports available in homes, neighborhoods, and communities; the quality of schooling; the safety of workplaces; the cleanliness of water, food, and air; and the nature of our social interactions and relationships (including the effects of racism).¹⁴ For a disproportionate number of Black and Brown people, these basic requirements for good health are absent because of structural racism, contributing to greater stress and more fatigue in pursuit of them.

Auburn University released the results of a study in February 2020 that concluded that African Americans who reported more experiences with racial discrimination aged faster,¹⁵ adding to the evidence that racism is not only a “social and moral dilemma” but also a public health issue. Nearly 400 African Americans from Birmingham, Chicago, Minneapolis, and Oakland, California, participated in the study, which began in 2000, and the participants, on average, were 40 years old at the study’s inception. According to the results, encountering racism led to higher levels of stress, which in turn caused cells to age more rapidly. This study focused on its effects on telomeres, pieces of DNA that protect cells. The study proves that a particular type of social toxin that disproportionately affects African Americans becomes embedded at the cellular level.

Another study, conducted in 2019 by Georgia State University, corroborates the findings of the Auburn University study. This study found that experiencing discrimination early in life led to chronic worrying about it, which can cause significant “wear and tear” by increasing one’s allostatic load, the lifelong buildup of stress, which accelerates aging and puts African Americans at greater risk for chronic illnesses.¹⁶

In summary, racism contributes to Black people’s getting sick at younger ages and having more severe illnesses, which leads to more rapid aging. Scientists call this the “weathering hypothesis,” or the result of cumulative stress.

While we might think that higher socioeconomic status mitigates these outcomes, according to a study done by Ohio State University researchers, the self-reported health status got worse for Black people as they climbed the socioeconomic ladder as opposed to whites, who reported better health based on higher socioeconomic status.¹⁷ The pressure of navigating a white power structure to maintain your status can be daunting. Middle-class, educated Black people may fare worse in health because they are exposed to increased opportunities for discrimination, some of it subtle and in the form of microaggressions discussed in chapter 6, that multiply and increase stress. There may also be a higher chance for tokenism as upwardly mobile Black and Brown people find themselves as the only one or one of a few who have risen to their status in the organization. The pressure, real or perceived, that we represent the race adds to the level of stress. Even with all the rhetoric that we are individuals and do not represent or speak for the entire race, the reality is that often we feel we do. During healing sessions we conducted for several clients at the height of the Black Lives Matter protests in 2020, we consistently heard the following from Black employees about their experience in corporate America:

• There is no room for mistakes.
• We have to justify our reason for being.
• I am forever standing on a soapbox screaming for equality.
• I am on the defensive all of the time.
• I am stressed to the max trying to fit in and be myself at the same time.
• Black people run from the narrative of being lazy so we overwork ourselves, fearing that stereotype.
• I am isolated, alone, and misunderstood.
• We have to speak for all Black people.
• Whether we like it or not, we represent the race.

The extra emotional toll that it requires to succeed in corporate America is stressful and can affect one’s physiological and psychological health.

Place-Based Fear Exacerbates Stress

Race-based health effects are often unrecognized and therefore are an unacknowledged phenomenon. There are many aspects of living while Black that can induce negative health consequences. The most serious source of this is fear for our lives. It is stress inducing to worry about your safety and that of your loved ones.

We can look throughout history at many situations in which Black people have been killed for being in the wrong place, allegedly doing the wrong thing. I mentioned the numerous lynchings throughout history in chapter 3 and Emmett Till in the preface. As mentioned in the last chapter, there are a number of high-profile cases in recent history, such as those of Trayvon Martin (2012), Michael Brown (2014), Tamir Rice (2014), Botham Jean (2019), Philando Castile (2016), Eric Garner (2014), and the most recent ones that sparked the 2020 Black Lives Matter protests—Ahmaud Arbery (2020), Breonna Taylor (2020), and George Floyd (2020). Less publicized cases of Black women being killed by police include those of Shelly Frey (2102), Eleanor Bumpurs (1984), Margaret Laverne Mitchell (1999), and Sandra Bland (2015), among others. These incidents are devastating for the families and for other Black people who empathize with the victims of brutality and hold the fear that it could have been them or someone close to them. Compounding the devastation is the fact that in most cases there is no justice. The police officers who perpetrate these heinous crimes are most often acquitted based on self-defense or stand-your-ground claims. Between 2005 and April 2017, 80 officers had been arrested on murder or manslaughter charges for on-duty shootings. During that 12-year span, 35 percent were convicted, while the rest were pending or not convicted, according to work by Philip Stinson, an associate professor of criminal justice at Bowling Green State University in Ohio.¹⁸

There can be a great deal of anxiety associated with daily concerns about how the color of your skin will affect even the simplest interactions. I call this “place-based” fear—when you find yourself in a place where you might not be welcome. It is common for Black people to ask, Is it OK to go to that part of town? Is it OK to visit that country? How do they treat Black people there? There is a fear of being in a place where you will experience racial profiling and the dire consequences that might result.

While a student at Harvard, my son, Joe, and some friends (all Black) were studying late at night in an on-campus lounge. Apparently, someone called security and they were questioned about their right to be there, doubting that they could possibly be Harvard students. While maybe not a life-threatening fear, I am sure that these young men experienced some level of anxiety as to what might happen to them.

Right around that same time in 2018, three Black people were checking out of a California Airbnb when seven police cars arrived and demanded that they put their hands in the air; a neighbor had reported a robbery in progress because she saw them loading luggage into a car. The ordeal took 45 minutes to resolve and included a helicopter being summoned and the need to show proof that they had rented the house. One of the three, a filmmaker, chronicled the ordeal on Facebook. “We have been dealing with different emotions and you want to laugh about this but it’s not funny,” she wrote. “The trauma is real. I’ve been angry, frustrated and sad. I was later detained at the airport. This is insanity.”¹⁹

Place-based stress manifests even with seemingly innocuous daily events like shopping. Black people are targeted and followed in department stores more often and profiled as thieves. There may also be assumptions about their ability to pay. Oprah encountered this situation in a Swiss department store several years ago where she was considering purchasing a very expensive purse ($38,000!) and the salesperson did not recognize her and refused to let her see it because it was too expensive.²⁰ I had this happen numerous times when I was trying to purchase items—not anywhere close to Oprah’s league, mind you, but apparently to the salesperson I looked like I could not afford them. These situations affected how I approached salespeople. When they were younger, my kids would ask me why I was so mean when I entered a department store. I would say, “What are you talking about? I am not mean.” I realized that because I had been treated so poorly in past situations, I had my defenses up. Unconsciously, I was thinking, “Nobody is going to mistreat me today.” These race-based experiences elicit not only fear but also frustration and even anger, inciting the “angry Black woman” stereotype and adding stress.

Even scarier is being in the wrong place at the wrong time and facing the threat of being misidentified. In 2018 a 21-year-old Black man was killed by a police officer who thought he was involved in a melee in a mall. They very soon afterward realized that he was not the shooter ²¹ and in fact was trying to deescalate the situation. In February 2020, I was in the Moline, Illinois, airport working on this book when I started to listen to a news report about a Black young man who attended Eastern Illinois University. Illinois police officers wrongfully arrested, detained, and threatened to shoot 19-year-old Jaylan Butler while pointing a gun to his forehead at a rest stop as he traveled with the school’s swim team.²² These are just two examples of many situations that I hear about on an almost daily basis that engender fear, increasing the stress of living while Black.

Constantly living with the perceived or real threats associated with the color of our skin leads to greater internalized stress, which in turn leads to physiological and psychological illnesses that disproportionately affect us.

Unfortunately, many may not associate their physical and emotional symptoms with race-based stress, which can manifest as the more serious condition of trauma.

Racism Leads to Race-Based Intergenerational Trauma

Race-based trauma has been getting more attention over the past decade. Robert Carter, professor of psychology and education in the Department of Counseling and Clinical Psychology at Teachers College, Columbia University, is an expert in what he has termed race-based traumatic stress injury, defined as the emotional and psychological trauma caused by discrimination and racism that elicit responses comparable to those associated with posttraumatic stress injury. One may express the trauma through anxiety, anger, rage, depression, low self-esteem, or shame, and it may manifest as depression, fatigue, diseases such as high blood pressure or diabetes, or mental disorders.²³

Author and former college professor in social work Joy DeGruy coins the term “posttraumatic slave syndrome” in a book by the same name, defining it as “a condition that exists when a population has experienced multigenerational trauma resulting from centuries of slavery and continues to experience oppression and institutionalized racism today. Adding to this condition is a belief (real or imagined) that the benefits of the society in which they live are not accessible to them.”²⁴ She asserts that survivor syndrome manifests in the second and third generations as stress, self-doubt, problems with aggression, and a number of psychological and interpersonal relationship problems with family members and others.

Social scientists have also coined the term “historical trauma”²⁵ to refer to the multigenerational, communal trauma that oppressed and marginalized groups have faced. In a 2013 article in the Atlantic called “How Racism Is Bad for Our Bodies,” the author points out that the cyclical effects of discrimination lead to “embodied inequality,” which creates poor health outcomes that are passed down from generation to generation. The result is a vicious cycle in which the sickest and poorest remain sick and poor.²⁶ The cycle starts with young children, which I discuss in chapter 8.

A growing and somewhat controversial branch of science, epigenetics, studies the extent to which our social environments can alter gene activity that can be passed down from generation to generation. Shannon Sullivan, chair and professor of philosophy at the University of North Carolina at Charlotte, penned an article, “Inheriting Racist Disparities in Health: Epigenetics and the Transgenerational Effects of White Racism,” which outlines how people of color can biologically inherit the harmful effects of racism. She uses preterm birth rates as an example. Black women (16.8 percent), regardless of income, are more likely than other groups (10.3 percent for white women) to deliver early, and this has been connected to accumulated stress. This disparity has not improved since the 1970s.²⁷

Implicit and Explicit Bias Contribute to Lower-Quality Health Care

In 2003, the Institute of Medicine, now called the National Academy of Medicine, released a landmark report called Unequal Treatment, which outlined stark health disparities for nonwhite populations. Among the findings were that poverty, lack of insurance, or lack of access did not totally account for the fact that Black people are sicker and have shorter life-spans than white people. The study found that “racial and ethnic minorities receive lower-quality health care than white people—even when insurance status, income, age, and severity of conditions are comparable.” The National Academy of Medicine reported that people of color were less likely than white people to be given appropriate cardiac care, to receive kidney dialysis or transplants, and to receive the best treatments for strokes, cancer, or AIDS. Its conclusion: “Some people in the United States were more likely to die from cancer, heart disease, and diabetes simply because of their race or ethnicity, not just because they lack access to health care.” This study shed light on the stark reality that race is a determinant of the quality of health care in this country.²⁸

Sadly, not much has changed in health outcomes for Black and Brown people in the almost 20 years since that report was released. A number of newer studies show that Black and Brown people continue to have disparate health outcomes, as presented at the beginning of this chapter, and continue to be subjected to the racial biases, conscious or implicit, of health care providers. Here are a few examples:

• According to an October 2015 report in JAMA Internal Medicine, published by the American Medical Association, on average, white Americans spent 80 minutes waiting for or receiving care, while Black Americans spent 99 minutes and Latinos 105 minutes waiting for or receiving that same care.²⁹
• Black and Hispanic patients in US emergency rooms are less likely to receive medication to ease acute pain than their white counterparts. Researchers examined data from 14 previously published studies in American emergency rooms that included 7,070 white patients, 1,538 Hispanic patients, and 3,125 Black patients. The study found that compared with white patients, Black patients were 40 percent less likely to receive medication to ease acute pain and Hispanic patients were 25 percent less likely. The study’s authors concluded that while the reasons are complex, unconscious bias was likely a contributing factor.³⁰
• A study of 400 hospitals in the United States showed that Black patients with heart disease received older, cheaper, and more conservative treatments than their white counterparts. Black patients were less likely to receive coronary bypass operations and angiography. After surgery, they are discharged earlier from the hospital than white patients—at a stage when discharge is inappropriate.³¹
• Black women are less likely than white women to receive mastectomies in general and radiation therapy in conjunction with a mastectomy.³²
• Black people are less likely to be prescribed newer medicine for mental disorders. Rather, they tend to be offered older medicine with worse side effects. Specifically, a drug called clozapine, which is considered to be superior psychiatric medicine, is prescribed less in minority patients with serious mental illness when compared with white patients.³³
• Middle-class black women are still three to four times more likely to die in childbirth than white women. Lack of access to quality medical care and other social factors being ruled out, experts say racism, not race, is the cause.³⁴

Evidence that implicit bias, defined as unconscious attitudes or stereotypes about a particular social group that influence behaviors, contributes to these disparities comes from results of administering the Implicit Association Test to physicians. The Implicit Association Test,³⁵ developed by Harvard researchers, measures the strength of associations between race and evaluations (e.g., good or bad). One study showed that physicians with Implicit Association Test scores that revealed them to have prowhite implicit biases were more likely to prescribe pain medications to white patients than to black patients. In another study, physicians with pro-white biases were less likely to prescribe thrombolysis to black patients and more likely to prescribe the treatment to white patients.

Environmental Racism Disproportionately Impacts Black Communities

One of the social determinants of health is where you live, and many poor Black and Brown people live in what are called “food deserts.” Studies show that poverty and race both matter in having access to healthy food options. When comparing communities, research shows that Black and Hispanic neighborhoods have fewer large supermarkets and more small grocery stores than their white counterparts with similar poverty levels.³⁶ Many major grocery chains and restaurants choose not to locate in Black neighborhoods. Persistent redlining and economic inequality, as mentioned in chapter 3, limit opportunities for where many Black people can live. Many of the neighborhoods are packed with unhealthy fast-food restaurants and small convenience stores (with higher prices), which leads to high rates of childhood obesity and other chronic conditions such as high blood pressure and heart disease.

Not only are many of these neighborhoods food deserts, they also have poor-quality drinking water, high levels of lead, and fewer green spaces, all contributing to poorer health outcomes. The Environmental Protection Agency’s National Center for Environmental Assessment released a study in 2018 indicating that people of color are much more likely to live near polluters and breathe polluted air. The study found that Black people are exposed to about 1.5 times more pollutants than white people, and that Hispanics had about 1.2 times the exposure of non-Hispanic whites.³⁷

These findings were against a backdrop of the Environmental Protection Agency’s and the Trump administration’s plans to dismantle many of the institutions built to address those disproportionate risks.

Access to Quality Care is Still an Issue

While the disparities in access to mental and physical health care have improved greatly over the years, they persist. The Affordable Care Act improved access to care. According to a study by the Commonwealth Fund, between 2013 and 2015, disparities narrowed for Blacks and Hispanics on three key access indicators: the percentage of uninsured working-age adults, the percentage who did not seek care because of costs, and the percentage who did not have a primary care provider.³⁸

Under the Affordable Care Act, uninsured rates for Blacks decreased from 19 percent to 10.7 percent from 2013 to 2017 and from 30 percent to 19 percent for Latinos and from 12 percent for 7 percent for whites for the same time period. However, these gains started to show statistically significant declines under the Trump administration. The Trump administration has made several changes to the act’s implementation, altering the availability of coverage and the likelihood that people would enroll. As a result, both whites and Blacks had small but statistically significant increases in their uninsured rates in 2017, which rose by 0.2 percentage points for whites, from 7.1 percent to 7.3 percent, and by 0.4 percentage points for Blacks, from 10.7 percent to 11.1 percent. These types of changing policies, which are at the whim of changing political ideologies, add to the fatigue of not being assured that gains will be sustained.³⁹

Compounding the access issue is the fact that studies show, for example, that people of color are less likely to seek mental health solutions, even when accessible, as there is a cultural stigma attached. In the African American and Latino communities, many people misunderstand what a mental health condition is and don’t talk about this topic.⁴⁰ This lack of knowledge leads many to believe that a mental health condition is a personal weakness. According to a study by Cigna,⁴¹ Black people are 50 percent less likely to receive counseling or mental health treatment.

Black People Are More Likely to Distrust Medical Professionals

Complicating the access issue is trust. In a 2007 study reported in the American Journal of Public Health, Blacks and Hispanics reported higher levels of physician distrust than did whites. In general, lower socioeconomic status (defined as lower income, lower education, and no health insurance) was associated with higher levels of distrust, and men reported more distrust than women.⁴²

There is a long history of discrimination against and exploitation of Black Americans and other marginalized groups in the health system, which contributes to continued mistrust. The intergenerational memory of medicine’s using Black people for experimentation without our consent is deeply embedded in our collective consciousness. In the antebellum period, Blacks were forced to serve as subjects for dissections, and corpses robbed from graves served as a constant source of surgical experimentation. The psychiatric definition of “drapetomania” (“runaway slave syndrome”) was created as a “diagnosis” for African slaves who fled their slave masters. The treatment was often amputation of extremities.

During Reconstruction, white doctors advanced a theory that former slaves would not thrive in a free society because, psychologically, their minds could not handle freedom. In the civil rights era, psychiatrists called civil rights activists schizophrenic and labeled them as violent, hostile, and paranoid, which is one reason why Black people have an aversion to acknowledging mental health concerns.

The Tuskegee syphilis study, in which hundreds of Black men, without their consent, were intentionally administered syphilis and denied treatment, became the very embodiment of the way medicine and medical research was used against Black Americans. The Tuskegee experiments are a prime example of why the Black community distrusts physicians and research. Just this year, a French scientist recommended using African people as human guinea pigs to test a vaccine for the coronavirus. The doctor later apologized and said that his comments were misinterpreted.⁴³

Henrietta Lacks was a Black woman who died in 1951 at age 31 of cervical cancer. Without her family’s knowledge or consent, her cancer cells, which carried a unique replication quality, were shared with researchers for decades. Known as the HeLa cell line, Henrietta’s contribution aided the development of the Salk polio vaccine and enhanced understanding of bacterial infection, HIV, and tuberculosis, among other diseases. Her cells revolutionized the field of medicine, and it was not until 2010, when a book was published entitled The Immortal Life of Henrietta Lacks,⁴⁴ that this story became known. In 2013 her family reached an agreement with the National Institutes of Health to allow continued use of the cells and to acknowledge Lacks’s contribution. The agreement, however, did not provide any financial compensation.

Harriet A. Washington forcefully argues in her book Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to Present that racial discrimination has shaped both the relationship between white physicians and Black patients and the attitudes of Black people toward modern medicine in general. She speaks to the cultural memory of medical experimentation and the complex relationship between racism and medicine.⁴⁵

This intergenerational lack of trust caused by the unethical practices of the medical profession targeted at Black people often keeps us from seeking care, exacerbating the disparities.

What Are the Solutions?

The complexities of racial inequities inherent in the health care and associated systems make it very difficult and too often impossible for Black people to sustain healthy minds, bodies and spirits. The problems are intergenerational, interconnected multidimensional and need to be addressed inside and outside the health care system.

Systems-Level Solutions

While there are no easy fixes, continuing to raise awareness helps tremendously. We must continue to fund the academic research that is bringing these inequities to light and ensure that cultural competence and implicit bias training is included in curricula for health care professionals. While studies show that over the last 20 years more medical schools are including cultural competence training in their programs, it is still inconsistent in application and content, and experts admit improvements are needed.⁴⁶

More policies need to be enacted to establish strategies to minimize racism in the health care system. As an example, in 2019, the American Association of Pediatrics issued its first policy on racism’s impact on child health. It establishes practical strategies to mitigate racism at the structural, interpersonal, and intrapersonal levels. Among other things, it calls for trauma-informed care.⁴⁷ Such care reframes the thinking of the caregiver from “What is wrong with this person?” to “What has happened to this person?”

Recognizing that health care professionals do not always receive adequate training in cultural competence, The Winters Group developed a comprehensive training program for large hospital systems, called “Radical Inclusion.” A three-day immersion experience, it is designed to support leaders, physicians, and other medical professionals in enhancing the patient experience. We chose the term “radical” because of its meaning—“relating to or affecting the fundamental nature of something; far-reaching or thorough.” Inclusion incorporates the tenets of cultural competence—the ability to discern, respect, and consider cultural differences in decision-making, problem solving, and conflict resolution. We want participants to think about the needed change as not incremental but transformational. The learning experience focuses on developing cultural self-understanding, understanding cultural differences, building alliances across differences, and engaging in bold, inclusive conversations.

Intrapersonal and Interpersonal Solutions

It is important to address the physiological and psychological toll at the individual level. We often internalize racism, unconsciously or consciously embodying negative stereotypes that white supremacist culture has about Black people. In our interpersonal relationships, we are regularly subjected to racist verbal attacks or worse, heightening stress and anxiety. We have learned a multitude of ways to take care of our mental and physical health.

Ardent Belief in God Black people, as a group, are strong in their Christian faith. According to a Pew survey, 75 percent of Blacks versus 49 percent of whites say that religion is very important to them,⁴⁸ and 54 percent of Black people—both Christian and non-Christian—say they read the Bible at least once a week outside of religious services, compared with 32 percent of whites.⁴⁹ Even though slaves did not come to the United States as Christians, they soon embraced the religion’s tenets. After the Civil War, the Black church movement grew quickly, and it continues to play a key role in strengthening Black communities by providing spiritual as well as socioeconomic support.

Black people rely on our belief in God as a primary way of enduring the pain of racism. From the days of slavery, believing that God would see us through kept us from giving up. During Black History Month, especially, songs like “We’ve Come This Far by Faith” and the Negro National Anthem, “Lift Every Voice and Sing”—“Sing a song full of the faith that the dark past has taught us, / sing a song full of the hope that the present has brought us; / facing the rising sun of our new day begun, / let us march on till victory is won”—are commonly sung. Preacher and politician Adam Clayton Powell’s famous refrain, “Keep the faith,” sums up what many Black people do to survive and thrive in a racist world. Disconnecting from the temporal and operating at a higher level of consciousness that transcends our earthly existence is how we often find joy and peace.

Self-Care Self-care is critical for everyone who faces the stresses associated with racism and other isms. Black and Brown people are learning to lean on strategies such as mindfulness to heal the intergenerational fatigue of racism. In her book The Inner Work of Racial Justice: Healing Ourselves and Transforming Our Communities through Mindfulness, lawyer and mindfulness practitioner Rhonda Magee provides practical strategies for individuals “to process the pain that arises when we push ourselves or are pushed by others outside of our racial-identity comfort zone.”⁵⁰ She says the practice of mindfulness can help us in knowing ourselves, becoming more familiar with the habits of our minds and our own emotional reactions of anger, confusion, numbness, and outrage when we see racism. It helps us to become more self-compassionate, she asserts, minimizing the impact of encountering racism. Practices such as meditation, yoga, journaling, and reflection, when done with intention and consistency, can be helpful.

In partnership with My True Self, a socially conscious wellness coaching and consulting practice, The Winters Group launched the Physiology of Inclusion in particular to support people in managing the emotional toll associated with diversity, equity, and inclusion (DEI) work. It is a whole-body system to raise awareness and enable strategies for resilience that improve physical, mental, and emotional health specifically targeted to DEI practitioners. However, this system can support anyone in a marginalized group. This system comprises the three foundational elements of eating, sleeping, and exercising that precede the three enabling elements necessary for enacting inclusion: thinking, being, and interacting. Too often we hear about the emotional, mental, and physical toll DEI can take on a person’s health and ability to stay engaged in the work. It is important to prioritize our well-being if we are truly going to be effective in shifting organizational cultures and influencing systems. Through the partnership with My True Self, The Winters Group offers coaching and virtual and in-person learning experiences.

At the interpersonal level, healing circles have become a popular approach for groups to come together to share individual truths, history, and stories. Based on Indigenous and African traditions, healing circles affirm and validate Black voices. The circle is set up so that each person has an opportunity to share his or her story or truth without judgment and uninterrupted. Borrowing from Native American practices, sometimes a talking stick is passed around and only the person with the talking stick is allowed to speak. With the guidance of a skilled facilitator, the desired outcome is to support each person in the group in his or her healing journey.

As one example, Safe Black Space Community Healing Circles⁵¹ were launched in 2018 in response to increased racial tension and trauma in the Sacramento, California, community after the killing by police of Stephon Clark, an unarmed Black man. The monthly Safe Black Space Healing Circles are for people who self-identify as being of African ancestry and are experiencing racial, stress, anxiety, or trauma. Sessions include African-centered healing strategies such as libations and drumming, mindfulness, and other self-care exercises. There are many other organizations that sponsor healing circles throughout the country.

Healing and Resilience Are Not Cures Healing and resilience techniques are important for staying physically and mentally well. However, such approaches deal with the symptoms and do not fix the underlying systems that cause the need to heal. “Resilience” connotes bouncing back from difficult experiences. If the difficult experiences never go away, the situation begins to bear a resemblance to that of Sisyphus in Greek mythology. His boulder started rolling down the hill right when he thought he was nearing the top. Why are Black and Brown people still required to push boulders up hills anyway? In a post in The Winters Group’s Inclusion Solution blog, Thamara Subramanian, learning and innovation manager at our firm, eloquently points out that “the rise of resilience training in corporate settings has been misconstrued as a sustainable solution to wellness—ultimately putting the burden of problems driven by the organization onto the individual. This is essentially a company saying to its employees: ‘Hey, the discrimination and adversities you face here at work will lessen if you gain the tools to bounce back . . . [because] the -isms you face . . . are just a part of life.’”⁵²

Reframing Our Own Narrative Positive self-talk that transforms into positive attitudes and behaviors can be helpful (figure 4.2).

Figure 4.2. Narrative reframing
Source: The Winters Group.

SUMMARY

Racism is a significant factor contributing to health disparities that affect Black people. And many of these health disparities are not correlated with socioeconomic status. The vicious cycle of racism that causes ill health, compounded by more racism, which causes more ill health, is staggeringly fatiguing. Strategies to heal and bounce back from the pain are important but fail to dismantle the systems that cause the pain. We have to come together as a society to find the keys that open the interlocked systems that are so tightly bound in the history of oppression and violence that there seems to be no way to loosen them, let alone unlock them.