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Too many black women like Erica Garner are dying in America’s maternal mortality crisis

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Too many black women like Erica Garner are dying in America’s maternal mortality crisis

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"She was born at seven-and-a-half months, 4 pounds, 11 ounces, but she proved to be a giant," said Esaw Snipes-Garner. She was speaking about her daughter, activist Erica Garner, who diedDecember 30 after a heart attack. Garner wentinto cardiac arrest following an asthma attack a week earlier, and was later placed in a medically induced coma. She reportedlysuffered extensive brain damage due to a lack of oxygen.

"She lived on her own terms," Snipes-Garner said at her daughter's Harlem, New York, funeral Monday evening. "And she died on her own terms."

For those who knew Garner well or followed her activistwork, her death has been difficult to process. That she died at 27 is a tragedy. That she became an activist to seek justice in the wake of her father Eric Garner's death from an NYPD officer's fatal chokehold is painful.

During her funeral, those who gathered in her memory said that Garner was one of many who gave their lives to the fight for racial justice, a person whose life and death stand as a reminder of both the resilience of those who lose loved ones to police violence and the long-term effects that trauma often has on black women.

"When her father died, she was the one going out there in Staten Island every Tuesday and Thursday," Rev. Kevin McCall said. "She was the one to bring this to a national level."

But as a young mother who gave birth in August to her second child, a boy named after her late father, Garner is among an alarming number of women in the US who die during pregnancy or within one year of childbirth.

The ongoing maternal mortality crisis disproportionately affects black women, who the Centers for Disease Control and Prevention notes are three to four times more likely than white women to die from complications related to pregnancy.

Why is this happening? The medical field is seeking answers, but one of the most obvious solutions is ensuring black women's access to quality, unbiased medical care.

"The combination of institutionalized racism, chronic stress, and the physical stress of childbirth can be deadly, and some believe that this was the case for Garner, as it is for so many Black women in the United States," Katie Mitchell wrote for Bustle. "And as we mourn [Garner's] loss, we need to have a conversation about why maternal mortality disproportionately affects Black women in the US, and what can be done about it."

The US has failed to deal with its high rates of maternal mortality on many fronts - particularly for women of color

The US has very high maternal mortality rates compared to the rest of the developed world. As Vox's Julia Belluz has reported, maternal deaths have been on the rise in the US, increasing by 27 percent, to 24 deaths per 100,000 births, between 2000 and 2014. Belluz notes that this rate is more than three times the maternal death rate of the United Kingdom, and about eight times the rate of Netherlands, Norway, and Sweden.

In recent years, a growing number of maternal health-focused organizations and academics have dedicated more time and resources to better understand the crisis.

But there is still plenty that we don't understand, particularly when it comes to the growing gap between the deaths of black mothers and their white peers.

Research has shown that a number of factors, including poor access to pre- and postnatal care, chronic stress, and the effects of racism, and inadequate medical treatment in the years preceding childbirth are all likely to play a role in a black woman's likelihood to suffer life-threatening complications in the months that come before and after childbirth.

These issues might appear to suggest that the disparity between black women and white women dying from pregnancy-related causes is due to economic differences, but research has found that black women in higher economic brackets are still more likely than white women to die from pregnancy- and childbirth-related problems.

A recent story from ProPublica's Annie Waldman illustrates why black women in cities like New York cannot simply educate or earn their way out of the crisis:

Even when accounting for risk factors like low educational attainment, obesity and neighborhood poverty level, the city's black mothers still face significantly higher rates of harm, the agency found. Of note, black mothers who are college-educated fare worse than women of all other races who never finished high school. Obese women of all races do better than black women who are of normal weight. And black women in the wealthiest neighborhoods do worse than white, Hispanic and Asian mothers in the poorest ones.

The health department has even mapped where the most maternal harm occurs, dividing the city into community districts. The highest rates of complications are concentrated in a swath of land in Central Brooklyn, in an area largely untouched by the wave of gentrification that has swept other parts of the borough. Here, mothers face up to four times the complication rates of neighborhoods just a few subway stops away.

In all, black women are 243 percent more likely than white women to die from pregnancy- or childbirth-related causes, producing one of the largest racial disparities in women's health, according to ProPublica.

The problem is further exacerbated by the American health care system's history of disparate treatment of black women, whose health struggles have been systemically minimized or dismissed, funneling them into medical facilities that are less equipped to handle their pregnancies.

As journalists Nina Martin and Renee Montagne explained in a story on black maternal mortality in December, black women still report facing bias when receiving pregnancy-related care:

The feeling of being devalued and disrespected by medical providers was a constant theme. The young Florida mother-to-be whose breathing problems were blamed on obesity when in fact her lungs were filling with fluid and her heart was failing. The Arizona mother whose anesthesiologist assumed she smoked marijuana because of the way she did her hair. The Chicago-area businesswoman with a high-risk pregnancy who was so upset at her doctor's attitude that she changed OB-GYNs in her seventh month, only to suffer a fatal postpartum stroke.

Over and over, black women told of medical providers who equated being African American with being poor, uneducated, noncompliant and unworthy. "Sometimes you just know in your bones when someone feels contempt for you based on your race," said one Brooklyn woman who took to bringing her white husband or in-laws to every prenatal visit.

But if some of the problems have been identified, there are others that remain opaque. Much of our understanding of maternal deaths focuses on women who die from complications in the period preceding and immediately following childbirth, leaving those who die in the weeks and months after delivery, like Garner, less known.

Because of the structure of the US maternal care system, which ProPublica has noted is largely focused on the health of infants and less on their mothers, women predisposed to the conditions that make a pregnancy high-risk can fall through the cracks.

While limited and often inadequate health care access is certainly an issue, there have been disagreements about exactly how cuts to women's health programs have affected the crisis in states like Texas, which has the highest rates of maternal mortality in the US.

It's not really an urban versus rural issue either. ProPublica notes that in New York City, Erica Garner's hometown, "black mothers are 12 times more likely to die than white mothers."

Only one thing is certain: The crisis affects black women more than any other group.

"This is a national tragedy, [but] we aren't doing the research that's needed and could hold hospitals accountable nationwide," Patrisse Khan-Cullors, a senior fellow studying maternal mortality with MomsRising and a co-founder of Black Lives Matter, told Vox.

While Garner's death wasn't officially deemed a result of her pregnancy, we know that her pregnancy exacerbated already present health issues.Snipes-Garner told the New York Times in December that her daughter's first heart attack occurred shortly after giving birth to her second child in August. Doctors said the pregnancy strained Garner's enlarged heart, a condition she was previously unaware of.

"What we're seeing with Erica Garner is not just complications because of birth, but a larger conversation around her lack of access to health care," Khan-Cullors said. "Black women don't receive the health care we deserve from the moment we are born. And our mothers didn't receive the health care they deserve. By the time that we get pregnant and go to have children, the [absence of] care that we should have received [has had an effect] and our bodies are aged beyond our years."

When health disparities go beyond medical issues

According to researchers, obesity, diabetes, cesarean births, and delayed prenatal care are some of the risk factors that increase a woman's chances of dying from pregnancy-related complications. Black women are particularly likely to deal with many of these issues.

That's not to mention other problems that black women are statistically more likely to face in their daily lives, like poverty, limited or infrequent access to health care, harsher discipline in schools, and lower pay - all of which can contribute to high stress among black women.

Such stress can make a pregnancy deadly for expectant and new black mothers and their children. Black infants are more than twice as likely as white infants to die within the first year of life.

"It's chronic stress that just happens all the time - there is never a period where there's rest from it, it's everywhere, it's in the air, it's just affecting everything," Fleda Mask Jackson, an Atlanta researcher and member of the Black Mamas Matter Alliance, told ProPublica last year.

If chronic stress, largely driven by the daily effects of racism and discrimination, playsa role in killing black mothers, then particularly stressful incidents, like those brought on by the trauma of police violence, could be particularly aggravating.

Christen Smith, an associate professor of African and African diaspora studies and anthropology at the University of Texas at Austin, argues that the aftermath of police violence is particularly harmful to black women, who are forced to deal with lingering trauma that may very well be killing them slowly.

"When we think of police lethality, we typically consider the immediate body count: The people that die from bullets and baton blows. The death toll gives the impression that black men are the disproportionate victims of police killings. But these numbers do not reveal the slow death that black women experience," Smith wrote in a recent op-ed about Garner's deathand the long-term effects of police violence on black women.

Garner's case, Smith says, fits this pattern. In the years since Eric Garner's death, Erica Garner became a prominent activist and outspoken critic of misconduct in policing.

A few months after her father's death, she staged a "die-in" on the same corner where he had been placed in a chokehold by NYPD officer Daniel Pantaleo. She consistently shared her father's story at protests and in the media in the years since, and started the Garner Way Foundation to preserve his legacy and advance a racial justice agenda.

In an interview three weeks before her death, Garner herself commented on the toll stress was taking on her. "I'm struggling right now with the stress and everything. . . . This thing, it beats you down. The system beats you down to where you can't win."

As Smith wrote, "the long-range trauma police brutality causes can be as deadly as a bullet." For the Garner family, this truth now echoes for generations.

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Too many black women like Erica Garner are dying in America's maternal mortality crisis

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"She was born at seven-and-a-half months, 4 pounds, 11 ounces, but she proved to be a giant," said Esaw Snipes-Garner. She was speaking about her daughter, activist Erica Garner, who diedDecember 30 after a heart attack. Garner wentinto cardiac arrest following an asthma attack a week earlier, and was later placed in a medically induced coma.

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Black Mothers Keep Dying After Giving Birth. Shalon Irving's Story Explains Why

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Black Mothers Keep Dying After Giving Birth. Shalon Irving's Story Explains Why

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On a melancholy Saturday this past February, Shalon Irving's "village" - the friends and family she had assembled to support her as a single mother - gathered at a funeral home in a prosperous black neighborhood in southwest Atlanta to say goodbye.

The afternoon light was gray but bright, flooding through tall, arched windows and pouring past white columns, illuminating the flag that covered her casket. Sprays of callas and roses dotted the room like giant corsages, flanking photos from happier times: Shalon in a slinky maternity dress, sprawled across her couch with her puppy; Shalon, sleepy-eyed and cradling the tiny head of her newborn daughter, Soleil. In one portrait, Shalon wore a vibrant smile and the crisp uniform of the Commissioned Corps of the U.S. Public Health Service, where she had been a lieutenant commander. Many of the mourners were similarly attired. Shalon's father, Samuel, surveyed the rows of somber faces from the lectern. "I've never been in a room with so many doctors," he marveled. "... I've never seen so many Ph.D.s."

At 36, Shalon had been part of their elite ranks - an epidemiologist at the Centers for Disease Control and Prevention, the pre-eminent public health institution in the U.S. There she had focused on trying to understand how structural inequality, trauma and violence made people sick. "She wanted to expose how people's limited health options were leading to poor health outcomes," said Rashid Njai, her mentor at the agency. "To kind of uncover and undo the victim-blaming that sometimes happens where it's like, 'Poor people don't care about their health.' " Her Twitter bio declared: "I see inequity wherever it exists, call it by name, and work to eliminate it."

Much of Shalon's research had focused on how childhood experiences affect health later on - examining how kids' lives went off track, searching for ways to make them more resilient. Her discovery in mid-2016 that she was pregnant with her first child had been unexpected and thrilling.

Then the unthinkable happened. Three weeks after giving birth, Shalon collapsed and died from complications of high blood pressure.

The researcher working to eradicate disparities in health access and outcomes had become a symbol of one of the most troublesome health disparities facing black women in the U.S. today: disproportionately high rates of maternal mortality. The main federal agency seeking to understand why so many American women - especially black women - die, or nearly die from complications of pregnancy and childbirth had lost one of its own.

Even Shalon's many advantages - her B.A. in sociology, her two master's degrees and dual-subject Ph.D., her gold-plated insurance and rock-solid support system - had not been enough to ensure her survival. If a village this powerful hadn't been able to protect her, was any black woman safe?

The sadness in the chapel was crushing. Shalon's long-divorced parents had already buried both their sons; she had been their last remaining child. Wanda Irving had been especially close to her daughter - role model, traveling companion, emotional touchstone. She sat in the front row in a black suit and veiled hat, her face a portrait of unfathomable grief. Sometimes she held Soleil, fussing with her pink blanket. Sometimes Samuel held Soleil, or one of Shalon's friends.

A few of Shalon's villagers rose to pay tribute; others sat quietly, poring through their funeral programs. Daniel Sellers, Shalon's cousin from Ohio and the baby's godfather, spoke for all of them when he promised Wanda that she would not have to raise her only grandchild alone.

"People say to me, 'She won't know her mother.' That's not true," Sellers said. "Her mother is in each and every one of you, each and every one of us. ... This child is a gift to us. When you remember this child, you remember the love that God has pushed down through her for all of us. Soleil is our gift."

The memorial service drew to a close, the bugle strains of taps as plaintive as a howl. Two members of the U.S. Honor Guard removed the flag from Shalon's coffin and held it aloft. Then they folded it into a precise triangle small enough for Wanda and Samuel to hold next to their hearts.

Racial disparity across incomes

In recent years, as high rates of maternal mortality in the U.S. have alarmed researchers, one statistic has been especially concerning. According to the CDC, black mothers in the U.S. die at three to four times the rate of white mothers, one of the widest of all racial disparities in women's health. Put another way, a black woman is 22 percent more likely to die from heart disease than a white woman, 71 percent more likely to perish from cervical cancer, but 243 percent more likely to die from pregnancy- or childbirth-related causes. In a national study of five medical complications that are common causes of maternal death and injury, black women were two to three times more likely to die than white women who had the same condition.

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That imbalance has persisted for decades, and in some places, it continues to grow. In New York City, for example, black mothers are 12 times more likely to die than white mothers, according to the most recent data; in 2001-2005, their risk of death was seven times higher. Researchers say that widening gap reflects a dramatic improvement for white women but not for blacks.

The disproportionate toll on African-Americans is the main reason the U.S. maternal mortality rate is so much higher than that of other affluent countries. Black expectant and new mothers in the U.S. die at about the same rate as women in countries such as Mexico and Uzbekistan, the World Health Organization estimates.

What's more, even relatively well-off black women like Shalon Irving die and nearly die at higher rates than whites. Again, New York City offers a startling example: A 2016 analysis of five years of data found that black, college-educated mothers who gave birth in local hospitals were more likely to suffer severe complications of pregnancy or childbirth than white women who never graduated from high school.

The fact that someone with Shalon's social and economic advantages is at higher risk highlights how profound the inequities really are, said Raegan McDonald-Mosley, the chief medical director for Planned Parenthood Federation of America, who met her in graduate school at Johns Hopkins University and was one of her closest friends. "It tells you that you can't educate your way out of this problem. You can't health care-access your way out of this problem. There's something inherently wrong with the system that's not valuing the lives of black women equally to white women."

For much of American history, these types of disparities were largely blamed on blacks' supposed susceptibility to illness - their "mass of imperfections," as one doctor wrote in 1903 - and their own behavior. But now many social scientists and medical researchers agree, the problem isn't race but racism.

The systemic problems start with the type of social inequities that Shalon studied - differing access to healthy food and safe drinking water, safe neighborhoods and good schools, decent jobs and reliable transportation.

Black women are more likely to be uninsured outside of pregnancy, when Medicaid kicks in, and thus more likely to start prenatal care later and to lose coverage in the postpartum period. They are more likely to have chronic conditions such as obesity, diabetes and hypertension that make having a baby more dangerous. The hospitals where they give birth are often the products of historical segregation, lower in quality than those where white mothers deliver, with significantly higher rates of life-threatening complications.

Those problems are amplified by unconscious biases that are embedded in the medical system, affecting quality of care in stark and subtle ways. In the more than 200 stories of African-American mothers that ProPublica and NPR have collected over the past year, the feeling of being devalued and disrespected by medical providers was a constant theme.

There was the new mother in Nebraska with a history of hypertension who couldn't get her doctors to believe she was having a heart attack until she had another one. The young Florida mother-to-be whose breathing problems were blamed on obesity when in fact her lungs were filling with fluid and her heart was failing. The Arizona mother whose anesthesiologist assumed she smoked marijuana because of the way she did her hair. The Chicago-area businesswoman with a high-risk pregnancy who was so upset at her doctor's attitude that she changed OB/GYNs in her seventh month, only to suffer a fatal postpartum stroke.

Over and over, black women told of medical providers who equated being African-American with being poor, uneducated, noncompliant and unworthy. "Sometimes you just know in your bones when someone feels contempt for you based on your race," said one Brooklyn, N.Y., woman who took to bringing her white husband or in-laws to every prenatal visit. Hakima Payne, a mother of nine in Kansas City, Mo., who used to be a labor and delivery nurse and still attends births as a midwife-doula, has seen this cultural divide as both patient and caregiver. "The nursing culture is white, middle-class and female, so is largely built around that identity. Anything that doesn't fit that identity is suspect," she said. Payne, who lectures on unconscious bias for professional organizations, recalled "the conversations that took place behind the nurse's station that just made assumptions; a lot of victim-blaming - 'If those people would only do blah, blah, blah, things would be different.' "

In a survey conducted this year by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, 33 percent of black women said that they personally had been discriminated against because of their race when going to a doctor or health clinic, and 21 percent said they have avoided going to a doctor or seeking health care out of concern they would be racially discriminated against.

Black expectant and new mothers frequently said that doctors and nurses didn't take their pain seriously - a phenomenon borne out by numerous studies that show pain is often undertreated in black patients for conditions from appendicitis to cancer. When Patrisse Cullors, a co-founder of the Black Lives Matter movement who has become an activist to improve black maternal care, had an emergency C-section in Los Angeles in March 2016, the surgeon "never explained what he was doing to me," she said. The pain medication didn't work: "My mother basically had to scream at the doctors to give me the proper pain meds."

But it's the discrimination that black women experience in the rest of their lives - the double whammy of race and gender - that may ultimately be the most significant factor in poor maternal outcomes.

"It's chronic stress that just happens all the time - there is never a period where there's rest from it. It's everywhere; it's in the air; it's just affecting everything," said Fleda Mask Jackson, an Atlanta researcher who focuses on birth outcomes for middle-class black women.

It's a type of stress for which education and class provide no protection. "When you interview these doctors and lawyers and business executives, when you interview African-American college graduates, it's not like their lives have been a walk in the park," said Michael Lu, a longtime disparities researcher and former head of the Maternal and Child Health Bureau of the Health Resources and Services Administration, the main federal agency funding programs for mothers and infants. "It's the experience of having to work harder than anybody else just to get equal pay and equal respect. It's being followed around when you're shopping at a nice store, or being stopped by the police when you're driving in a nice neighborhood."

An expanding field of research shows that the stress of being a black woman in American society can take a physical toll during pregnancy and childbirth.
Chronic stress "puts the body into overdrive," Lu said. "It's the same idea as if you keep gunning the engine, that sooner or later you're going to wear out the engine."

As women get older, birth outcomes get worse. ... If that happens in the 40s for white women, it actually starts to happen for African-American women in their 30s.

Arline Geronimus, a professor at the University of Michigan School of Public Health, coined the term "weathering" for stress-induced wear and tear on the body. Weathering "causes a lot of different health vulnerabilities and increases susceptibility to infection," she said, "but also early onset of chronic diseases, in particular, hypertension and diabetes" - conditions that disproportionately affect blacks at much younger ages than whites. Her research even suggests it accelerates aging at the molecular level; in a 2010 study Geronimus and colleagues conducted, the telomeres (chromosomal markers of aging) of black women in their 40s and 50s appeared 7 1/2 years older on average than those of whites.

Weathering has profound implications for pregnancy, the most physiologically complex and emotionally vulnerable time in a woman's life. Stress has been linked to one of the most common and consequential pregnancy complications, preterm birth. Black women are 49 percent more likely than whites to deliver prematurely (and, closely related, black infants are twice as likely as white babies to die before their first birthday). Here again, income and education aren't protective.

The repercussions for the mother's health are also far-reaching. Maternal age is an important risk factor for many severe complications, including pre-eclampsia, or pregnancy-induced hypertension. "As women get older, birth outcomes get worse," Lu said. "If that happens in the 40s for white women, it actually starts to happen for African-American women in their 30s."

This means that for black women, the risks for pregnancy start at an earlier age than many clinicians - and women- realize, and the effects on their bodies may be much greater than for white women. In Geronimus' view, "a black woman of any social class, as early as her mid-20s should be attended to differently."

That's a concept that professional organizations and providers have barely begun to wrap their heads around. "There may be individual doctors or hospitals that are doing it [accounting for the higher risk of black women], but ... there's not much of that going on," Lu said. Should doctors and clinicians be taking into account this added layer of vulnerability? "Yeah," Lu said. "I truly think they should."

A high-pressure life

Shalon Irving's history is almost a textbook example of the kinds of strains and stresses that make high-achieving black women vulnerable to poor health. The child of two Dartmouth graduates, she grew up in Portland, Ore., where her father's father was pastor of a black church. Even in its current liberal incarnation, Portland is one of the whitest large cities in the U.S., in part a vestige of the state's founding by Confederate sympathizers who wrote exclusion of blacks into their constitution.

Thirty years ago, Portland was a much more uncomfortable place to be black. African-American life there was often characterized by social isolation, which Geronimus' research has shown to be especially stressful. Her father, Samuel Irving, spent years working for the railroad and later for the city but felt his prospects were limited by his race. Her mother, Wanda Irving, held various jobs in marketing and communications, including at the U.S. Forest Service. In elementary school, Shalon was sometimes the only African-American child in her class. "There were many mornings where she would stand outside banging on the door wanting to come back into the house because she didn't want to go to school," her mother recently recalled.

Shalon's strategy for fitting in was to be smarter than everyone else. She read voraciously, wrote a column for a black-owned weekly newspaper, and skipped a grade. Books and writing helped her cope with trauma and sorrow - first the death of her 20-month-old brother Simone in a car accident when she was 6, then the fracturing of her parents' marriage, then the diagnosis of her beloved older brother, Sam III, with a virulent form of early-onset multiple sclerosis when he was 17. Amid all the family troubles, Shalon was funny and driven, with a fierce sense of loyalty and "a moral compass that was amazing," her mother said.

She was also overweight and often anxious, given to daydreaming (as she later put it) about "alternative realities where people hadn't died and things had not been lost." When it came time to go away to college, she chose the historically black Hampton University in Virginia. "She wanted to feel that nurturing environment," Wanda said. "She had had enough."

By then, Shalon had noticed that many of her relatives -her mother's mother, her aunts, her far-flung cousins - had died in their 30s and 40s. Her brother Sam III sardonically joked that the family had a "death gene," but Shalon didn't think that was funny. "She didn't understand why there was such a disparity with other families that had all these long lives," Wanda said. Shalon nagged her father to stop smoking and her mother to lose weight. She set an example, shedding nearly 100 pounds while managing to graduate summa cum laude. At the start of graduate school at Purdue University, she was a svelte 138 pounds, "very classy and elegant, a lot like her mom," said Bianca Pryor, a master's student in consumer behavior who became one of her closest friends.

West Lafayette, Ind., felt as white as Portland. For support, Shalon relied on a cherished circle of "sister friends," as she called them. "There's this feeling that we're carrying the expectations of generations, the first ones trying to climb the corporate ladder, trying to climb in academe," Pryor said. "There is this idea that we have to work twice as hard as everyone else. But there's also, 'I'm first-generation; I don't know the ropes; I don't how to use my social capital.' There's a bit of shame in that ... this constant checking in with yourself - am I doing this right?"

Much of Shalon's pressure was self-imposed: She was pursuing a double Ph.D. in sociology and gerontology, focusing on themes she would return to often - the long-term effects of early-childhood trauma and maltreatment, the impact of the parent-child relationship on lifelong health. She finished in under five years, once again with highest honors - "one of the best writers I've had in my academic career," her adviser, sociologist Kenneth Ferraro, said.

Next, Shalon decided to pursue a second master's degree, this time from Johns Hopkins. She was also juggling family responsibilities. Wanda had followed Shalon around the country, working in nonprofit management. "They were like the Gilmore Girls," Pryor said. In 2008, Sam III joined them in Baltimore to take part in a study for an experimental MS therapy. With his family's support, he had managed to finish college and run a poetry-slam nonprofit for kids. His next goal was to walk across the stage to receive his diploma instead of using his wheelchair. In February 2009, while he was doing physical rehab to regain strength in his legs, a blood clot traveled to his lung, killing him at the age of 32. Afterward, Wanda and Shalon clung to each other more tightly than ever.

What Shalon wasn't prepared for was how unfulfilled she was. After Johns Hopkins, she had worked on the front lines helping at-risk infants, teenage girls, and mothers with HIV/AIDS. She was passionate about improving food and housing security to reduce people's risk for high blood pressure and other cardiovascular problems. At the CDC, it bothered her that she rarely met the people behind the data she was analyzing. As a consultant for Michelle Obama's anti-obesity initiative Let's Move! "she might see the numbers, but I don't think she actually saw that little girl or little boy have a healthier lunch," Pryor said.

The stress and frustration triggered the old corrosive self-doubts. But gradually, Shalon saw a way out of the box. She joined the CDC's Division of Violence Prevention, refocusing on issues around trauma and domestic abuse - a mission she saw as "liberating" for African-American women, Wanda said. She started a coaching business called Inclusivity Standard to advise young people from disadvantaged backgrounds who wanted to get into college or grad school and organizations seeking to become more diverse. And she decided to write a self-help book, on the theory that many people in the communities she cared about couldn't afford psychotherapy or didn't trust it. "She was one of those people - one thing is just not enough," said her co-author, Habiba Tran, a therapist and life coach with a multicultural clientele. "One modality is just not enough. One way of [reaching people] is just not enough."

Becoming a mother

Shalon couldn't remember a time when she didn't want to be a mother. But her romantic life had been a "20-year dating debacle," she admitted in the manuscript of her self-help book, in part because "I am deathly scared of heartbreak and disappointment, and letting people in comes with the very real risk of both."

In 2014, when Shalon was 34, medical problems forced the issue. For years she had been suffering from uterine fibroids - nonmalignant tumors that affect up to 80 percent of black women, leading to heavy menstrual bleeding, anemia and pelvic pain. No one knows what causes fibroids or why blacks are so susceptible. What is known is that the tumors can interfere with fertility - indeed, black women are nearly twice as likely to have infertility problems as whites, and when they undergo treatment, there's much less likelihood that the treatments will succeed. Surgery bought her a little time, but her OB/GYN urged her not to delay getting pregnant much longer.

Shalon had spent her adult years defying stereotypes about black women; now she wrestled with the reality that by embracing single motherhood, she could become one. The financial risk was substantial - she had just purchased a town house in the quiet Sandy Springs area north of Atlanta, and her CDC insurance covered artificial insemination only for wives using their husbands' sperm. In Portland, no one would have blinked an eye at an unmarried professional woman having a child on her own, but in Atlanta, "there is very much a vibe there that things should happen in a certain order," Pryor said. "And Shalon was not having that at all. She was like, 'Nope, this is what it is.' "

The gamble - funded with her parents' help - ended in a series of devastating failures. In September 2015, in the midst of an unsuccessful fertility treatment, Shalon was alarmed to discover that her right arm had become swollen and hard. Doctors found a blood clot and diagnosed her with Factor V Leiden, a genetic mutation that makes blood prone to abnormal clumping. Suddenly a part of the family's medical mystery was solved. Wanda's mother had died of a pulmonary embolism; so had Sam III; so had other members of their extended family. But no one had been tested for the mutation, which is primarily associated with European ancestry. Had they known they carried it, maybe Sam's deadly blood clot could have been prevented. It was a what-if too painful to dwell on.

By April 2016, Shalon had given up. She had a new boyfriend and was on her way to Puerto Rico to help with the CDC'S Zika response, working to prevent the spread of the virus to expectant mothers and their unborn babies. There, she discovered she'd gotten pregnant by accident. Her excitement was tempered by fear that the baby might have contracted Zika, which can cause microcephaly and other birth defects. But a barrage of medical tests confirmed all was well.

More good news: A few weeks later, her friend Pryor learned she was pregnant, too. "All right," she told Shalon, "let's finally go after our rainbows and unicorns! Because for so long it was just dark clouds and rain."

In reality, Shalon's many risk factors - including her clotting disorder, her fibroid surgery, the 36 years of wear and tear on her telomeres, her weight - boded a challenging nine months. She also had a history of high blood pressure, though it was now under control without medication. "If I was the doctor taking care of her, I'd be like, 'Oh, this is going to be a tough one,' " her OB/GYN friend McDonald-Mosley said.

Shalon got through the physical challenges surprisingly well. Her team at Emory University, one of the premier health systems in the South, had no trouble managing her clotting disorder with the blood thinner Lovenox. They worried that scarring from the fibroid surgery could result in a rupture if her uterus stretched too much, so they scheduled a C-section at 37 weeks. At several points, Shalon's blood pressure did spike, Wanda said, but doctors ruled out pre-eclampsia and the numbers always fell back to normal.

Wanda blamed stress. There was the painful end to Shalon's romance with her baby's father and her dashed hopes of raising their child together. There were worries about money and panic attacks about the difficulties of being a black single mother in the South in the era of Trayvon Martin and Tamir Rice. Shalon told everyone she was hoping for a girl.

Steeped in research about how social support could buffer against stress and adversity, Shalon joined online groups for single mothers and assembled a stalwart community she could quickly deploy for help. "She was all about the village," Njai, her CDC mentor, said. "She'd say, 'I'm making sure that when I have my baby, the village is activated and ready to go.' "

She poured more of her anxious energy into finishing the first draft of the book. She sent Tran the manuscript on Jan. 2, the day before the planned C-section, then typed one last note to her child. Boy or girl, its nickname would be Sunny, in honor of her brother Sam, her "sunshine." "You will always be my most important accomplishment," she wrote. "No words have been created to adequately capture the fear and love and excitement that I feel right now."

Sporadic postpartum care

Until recently, much of the discussion about maternal mortality has focused on pregnancy and childbirth. But according to the most recent CDC data, more than half of maternal deaths occur in the postpartum period, and one-third happen seven or more days after delivery. For American women in general, postpartum care can be dangerously inadequate - often no more than a single appointment four to six weeks after going home.

"If you've had a cesarean delivery, if you've had pre-eclampsia, if you've had gestational diabetes or diabetes, if you go home on an anticoagulant - all those women need to be seen significantly sooner than six weeks," said Haywood Brown, a professor at Duke University medical school. Brown has made reforming postpartum care one of his main initiatives as president of the American Congress of Obstetricians and Gynecologists.

The dangers of sporadic postpartum care may be particularly great for black mothers. African-Americans have higher rates of C-section and are more than twice as likely to be readmitted to the hospital in the month following the surgery. They have disproportionate rates of hypertensive disorders and peripartum cardiomyopathy (pregnancy-induced heart failure), two leading killers in the days and weeks after delivery. They're twice as likely as white women to have postpartum depression, which contributes to poor outcomes, but they are much less likely to receive mental health treatment.

If they experience discrimination or disrespect during pregnancy or childbirth, they are more likelyto skip postpartum visits to check on their own health (they do keep pediatrician appointments for their babies). In one study published earlier this year, two-thirds of low-income black women never made it to their doctor visit.

Meanwhile, many providers wrongly assume that the risks end when the baby is born - and that women who came through pregnancy and delivery without problems will stay healthy. In the case of black women, providers may not understand their true biological risks or evaluate those risks in a big-picture way. "The maternal experience isn't over right at delivery. All of the due diligence that gets applied during the prenatal period needs to continue into the postpartum period," said Eleni Tsigas, executive director of the Preeclampsia Foundation.

All of the due diligence that gets applied during the prenatal period needs to continue into the postpartum period.

It's not just doctors and nurses who need to think differently. Like a lot of expectant mothers, Shalon had an elaborate plan for how she wanted to give birth, even including what she wanted her surgical team to talk about (nothing political) and who would announce the baby's gender (her mother, not a doctor or nurse). But like most pregnant women, she didn't have a postpartum care plan. "It was just trusting in the system that things were gonna go OK," Wanda said. "And that if something came up, she'd be able to handle it."

The birth was "a beautiful time," Wanda said. Shalon did so well that she persuaded her doctor to let her and Soleil - French for "sun" - leave the hospital after two nights (three or four nights are more typical). Then at home, "things got real," Pryor said. "It was Shalon and her mom trying to figure things out, and the late nights, and trying to get baby on schedule. Shalon was very honest. She told me, 'Friend, this is hard.' "

C-sections have much higher complication rates than vaginal births. In Shalon's case, the trouble - a painful lump on her incision - started a week after she went home. The first doctor she saw, on Jan. 12, said it was nothing, but as she and her mother were leaving his office, they ran into her regular OB/GYN, Elizabeth Collins, whom Shalon trusted completely. Collins took a look and diagnosed a hematoma - blood trapped in layers of healing skin, something that happens in about 1 percent of C-sections. She drained the "fluctuant mass" (as her notes described it), and "copious bloody non-purulent material" poured out from the 1-inch incision. Collins also arranged for a visiting nurse to come by the house every other day to change the dressing.

What troubled the nurse most, though, was Shalon's blood pressure. On Jan. 16 it was 158/100, high enough to raise concerns about postpartum pre-eclampsia, which can lead to seizures and stroke. But Shalon didn't have other symptoms, such as headache or blurred vision. She made an appointment to see the OB/GYN for the next day, then ended up being too overwhelmed to go, the visiting nurse noted on Jan. 18. In that same record, the nurse wrote that Shalon had to change the dressing on her wound "sometimes several times a day due to large amounts of red drainage. This is adding to her stress as a new mom." Her pain was 5 on a scale of 10, preventing her from "sleeping/relaxing." Overall, Shalon told the nurse, "it just doesn't feel right." When the nurse measured her blood pressure on the cuff Shalon kept at home, the reading was 158/112. On the nurse's equipment, the reading was 174/118.

Under current ACOG guidelines, those readings were high enough to warrant more aggressive action, Tsigas said, such as an immediate trip to the doctor for further evaluation, possibly medication, and more careful monitoring. That is especially true for someone with a history of hypertension and multiple other risks. "We need to look holistically at the risk factors irrespective of whether or not she had a diagnosis of pre-eclampsia," Tsigas said. "If somebody has a whole plateful of risk factors, how are you treating them differently?"

"It would have made sense to admit her to the hospital for a complete work-up," including chest X-ray, an echocardiogram to evaluate for heart failure, and titration of her medication to get her blood pressure to normal range, wrote one doctor, a leading expert on postpartum care, who agreed to look at Shalon's records at ProPublica's request but asked not to be identified. The doctor said that the communication about signs of stroke seemed insufficient and that it would be more "common practice" to assess her that day to find out what was wrong.

Instead, Shalon was given an appointment for the next day, Jan. 19, with an OB/GYN at Women's Center at Emory St. Joseph's, which handled her primary care. By then, Shalon's blood pressure had fallen to 130/85 - considered on the high end of normal - and there were "no symptoms concerning for postpartum [pre-eclampsia]," the doctor wrote in his notes. He wrote that Shalon was healing "appropriately" and thought her jumps in blood pressure were likely related to "poor pain control." Wanda and Shalon left feeling more frustrated than ever.

At home over the next couple of days, Wanda noticed that one of Shalon's legs was larger than the other. "She said, 'Yeah, I know, Mom, and my knee hurts, I can't bend it.' "

When McDonald-Mosley looked over the voluminous medical records a few months later, what jumped out at her was the sense that Shalon's caregivers (who declined to comment for this story) didn't seem to think of her as a patient who needed a heightened level of attention, despite the complexity of her pregnancy.

"She had all these risk factors. If you're gonna pick someone who's going to have a problem, it's gonna be her. ... She needs to be treated with caution." The fact that her symptoms defied easy categorization was all the more reason to be vigilant, McDonald-Mosley said. "There were all these opportunities to identify that something was going wrong. To act on them sooner and they were missed. At multiple levels. At multiple parts of the health care system. They were missed."

Shalon's other friends were growing uneasy, too. Pryor had her own pregnancy emergency - her son was born very prematurely, at 24 weeks - so she couldn't be in Atlanta. But she and Shalon talked often by phone. "She knew so much about her body one would think she was an M.D. and not a Ph.D. To hear her be concerned about her legs - that worried me." Pryor encouraged her, " 'Friend, are you getting out of the house? Are you going for your walks?' She told me, 'No, I'm on my chaise lounge, and that's about as much as I can do.' "

Life coach Tran was so upset at Shalon's condition that she took her frustrations out on her friend. "I was cussing her out. 'Go to the f****** doctor.' She's like, 'I called them. I talked to them. I went to see them. Get off my back.' "

"There is something wrong"

On the morning of Tuesday, Jan. 24, Shalon took a selfie with her father, who had been visiting for a few days, then sent him to the airport to catch a flight back to Portland. Toward noon, she and Wanda and the baby drove to the Emory Women's Center one more time. This time, Shalon saw a nurse practitioner. "We said, 'Look, there's something wrong here; she's not feeling well,' " Wanda recalled. " 'One leg is larger than the other; she's still gaining weight - 9 pounds in 10 days - the blood pressure is still up. There's gotta be something wrong.' "

The nurse's notes confirmed Shalon had swelling in both legs, with more swelling in the right one. She noted that Shalon had complained of "some mild headaches" but didn't have other worrisome symptoms, like blurred vision. She checked the incision - "warm dry no [sign/symptom] of infection" - and noted Shalon's mental state ("cooperative, appropriate mood & affect, normal judgment").

" 'You guys have to realize she just had a baby. Don't worry about it, things are calming down,' " Wanda recalled the nurse telling them. " 'We'll send her down for an ultrasound to see if she has a clot in her leg.' " Shalon's blood pressure was back up to 163/99, so the nurse also ordered a pre-eclampsia screening.

Both tests came back negative. "So they're saying, 'Well if there's no clots, there's nothing wrong,' " Wanda recalled. As Wanda remembers it, Shalon was insistent: "There is something wrong, I know my body. I don't feel well, my legs are swollen, I'm gaining weight. I'm not voiding. I'm drinking a lot of water, but I'm retaining the water." As Wanda recalls it, the nurse told them, "There is nothing we can do; you just have to wait, give it more time." Before sending Shalon home, the nurse gave her a prescription for the blood pressure medication nifedipine, which is often used to treat pregnancy-related hypertension.

Shalon and Wanda stopped at the pharmacy, then decided to go out to dinner with the baby. While they ate, they talked about a trip Shalon had planned for the three of them to take in just a few weeks. Ever since Sam III had died, Wanda and Shalon had made a point of traveling someplace special on painful anniversaries. To mark his 40th birthday and the eighth anniversary of his death, Shalon had gotten the idea of going to Dubai. ("It's cheap," Shalon had told Wanda. "The money is worth so much more there. It's supposed to be beautiful.") She had long ago purchased their tickets and ordered the baby's passport. Now Wanda was worried - would she be feeling well enough to make such a big trip with an infant? Shalon wasn't willing to give up hope just yet. Wanda recalls her saying, "I'll be fine, I'll be fine."

They got home and sat in Shalon's bedroom for a while, laughing and playing with the baby. Around 8:30 p.m., Shalon suddenly declared, "I just don't know, Mom, I just don't feel well." She took the blood pressure medication from Wanda and got ready for bed. An hour later, Wanda heard a terrifying gasping noise. Shalon had collapsed.

The news spread quickly among her colleagues at the CDC. William Callaghan, chief of the maternal and infant health branch, recalled in March that his boss, who had visited Shalon at the hospital, called to let him know. "It was a chilling phone call," said Callaghan, one of the nation's leading researchers on maternal mortality. "It certainly takes, in that moment, what I do, it made it very, very, very concrete. ... This was not about data, this was not about whether it was going up or it was going down. It was about this tragic event that happened to this woman, her family."

Northside decided against an autopsy, telling Wanda and Samuel that there was nothing unusual about Shalon's death, they recalled. (The hospital declined to comment.) So Wanda paid $4,500 for an autopsy by the medical examiners in neighboring DeKalb County. The report came back three months later. Noting that Shalon's heart showed signs of damage consistent with hypertension, it attributed her death to complications of high blood pressure.

Raising Soleil

Wanda moved into Shalon's tidy town house to care for Soleil. Even though Shalon's villagers fulfilled their pledges at the memorial service, coming by often to give Wanda a break, the first months were borderline unbearable - the baby was colicky, prone to gastric problems that kept both of them up all night. Wanda's grief was endless, bottomless, but she couldn't let it interfere with her duties to Soleil. "She's the only reason I get up every morning, pretty much," Wanda said.

Eventually the colic went away and Soleil thrived. In June, Wanda and her 5-month-old granddaughter drove to Chattanooga, Tenn., for the annual meeting of U.S. Public Health Service scientists. A new honor - the Shalon Irving Memorial (Junior) Scientist Officer of the Year Award- had been created to celebrate Shalon's legacy, and Wanda had been asked to say a few words. She handed the baby to one of Shalon's CDC colleagues and took the small stage.

"Striving for excellence is a choice," she told the audience through barely suppressed tears. "It is a commitment. ... It's a struggle to become the person you want to be. It's harder than you want. It takes longer than you want. And it takes more out of you than you expected it should."

Shalon personified excellence, Wanda said. "I don't know if Shalon became the woman that she ultimately wanted to be. But I do know that she wanted to be the woman she was."

One Saturday afternoon in October, Wanda received a book that friends of Shalon's from the Epidemic Intelligence Service had compiled, titled Letters to Soleil. She put Soleil on her lap and said, "I'm gonna read you some letters about your mom." One thing Wanda has tried never to do is cry in front of Soleil. But as she began reading the letters, she was sobbing. "And Soleil just kept looking at me - she couldn't understand what was going on. And about a minute later she took my glasses off with her hands and put them down and then laid her head right on my chest and started patting me. Which made me cry all the more."

As Soleil got older, Wanda looked forward to doing the kinds of things with her that Shalon had looked forward to: reading to her, traveling with her, taking her to gymnastics and music classes. "She wanted Soleil to go to Montessori school, so I'm looking for a Montessori school for her," Wanda said. "She wanted her to be christened; we got her christened."

Now 10 months old, Soleil has her mother's eyes, energy and headstrong yet sweet disposition, coming into Wanda's bed every night and waking her early to play. "She'll bite my nose and kick me - 'Nana, time to get up! Time to get up!' That's what keeps me motivated."

A week or so after the memorial service, Wanda came across a letter that Shalon had written to her two years earlier, around the sixth anniversary of Sam III's death. Shalon had left it among the other important items on her computer, trusting that if something ever happened to her, Wanda would find it. The letter reads like a premonition: Shalon was contemplating the prospect of her own premature death - and of her beloved mother having to endure one more unbearable tragedy.
I am sorry that I have left you. On the particular day that I am writing this I have no idea how that may have occurred but know that I would never choose to leave. I know it seems impossible right now, but please do not let this break you. I want you to be happy and smile. I want you to know that I am being watched after by my brothers and grandma and that we are all watching you. Please try not to cry. Use your energy instead to feel my love through time and space. Nothing can break the bond we have and you will forever be my mommy and I your baby girl!

# data[].attributes.attachment_link.title
Black Mothers Keep Dying After Giving Birth. Shalon Irving's Story Explains Why

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Black women are three times more likely to die from complications of childbirth than white women in the U.S. Racism, and the stress it causes, can play a leading role in that disparity.

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Genes Don't Cause Racial-Health Disparities, Society Does

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Genes Don't Cause Racial-Health Disparities, Society Does

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Researchers are looking in the wrong place: White people live longer not because of their DNA but because of inequality.

Dimitry B./Flickr

Duana Fullwiley, an anthropologist at Stanford, took an even closer look at how AIMs were dreamed up and used in the laboratories of some prominent researchers-Mark Shriver at Penn State and Esteban González Burchard at UCSF. What she found is that this new system is no better than a find-and-replace of "race" with "ancestry." In one striking example, she unearthed a patent application that straight-up defines biogeographical ancestry as simply "the heritable component of race." In her 2008 article, "The Biologistical Construction of Race," Fullwiley concludes that "the very continents and peoples chosen for this product were selected due to their perceived proximity to what we in North America imagine race to be."

Related Story

How Racism Creeps Into Medicine
Even if scientists could get ancestry right, and pry it apart from society's tightly held beliefs about race, it still wouldn't account for enough disease to explain health disparities. "If you look at overall health disparities across the board," Kittles said, "the bulk of those disparities are not due to any biological difference. The vast majority of health disparities are due to social, behavioral, and environmental components."

Why hasn't attention turned, then, to social inequality, not genetics, as the source of health disparities? The main reason is the political ramification. "If you show that this is a predisposition that is genetically determined- black people just have this gene, there's nothing we can do about it, this is just nature -then society is completely absolved. We don't have any responsibility to solve this problem," Kaufman said. "If you show that it is because of racism and injustice and people's living conditions, well, then, there is some responsibility and we have to do something about this."

# data[].attributes.attachment_link.title
Genes Don't Cause Racial-Health Disparities, Society Does

# data[].attributes.attachment_link.description
Researchers are looking in the wrong place: White people live longer not because of their DNA but because of inequality. Duana Fullwiley, an anthropologist at Stanford, took an even closer look at how AIMs were dreamed up and used in the laboratories of some prominent researchers-Mark Shriver at Penn State and Esteban González Burchard at UCSF.

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Black Americans suffer most from racial trauma, but few counselors are trained to treat it

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Black Americans suffer most from racial trauma, but few counselors are trained to treat it

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Racism can often lead to trauma for people of color - a reality that has confirmed and time again . But few studies have assessed the ability of counselors to treat that trauma.

"With America's climate in the current day and time and all of the instances of oppression and discrimination and hate crimes ... I was curious," said Carrie Hemmings, an assistant professor at Auburn University at Montgomery. "Are counselors really addressing this issue?"

Hemmings co-authored a recent study , published in the Journal of Multicultural Counseling and Development this month, that found that the majority of counselors in the United States are not prepared to identify and treat race-based trauma, which often results from racial harassment, discrimination, violence, or experiencing institutional racism.

In addition to this lack of preparation, the study highlighted existing research pointing to a general shortage of professional training opportunities for understanding and treating race-based trauma.

"Counseling is a field where we are continually learning and developing," Hemmings told ThinkProgress, adding that many counselors are teaching themselves about race-based trauma. "We are in the process of making advancements and treating different situations."

Of the 106 counselors surveyed in the study, 75 reported that they had worked with clients who experienced some form of race-based trauma. Only 35 participants said they had received training to identify race-based trauma and 20 reported that they had received training to treat race-based trauma.

This is especially problematic for black Americans, who endure more mental health problems as a result of overt racial discrimination, perceived racism, and microaggressions, which are subtle degradations of marginalized people. As ThinkProgress has previously reported , black people suffer from higher levels of stress, anxiety, and emotional trauma than white people. According to the study, the extreme consequences of prolonged exposure to racism include suicide, displaced hostility, and substance abuse.

Social and health care disparities exacerbate this problem, the study said. People of color are "less likely to have health insurance, are more likely to experience racist attitudes and discrimination among providers, and are more likely to experience unequal access to quality health care."

Not only are people of color disproportionately affected by race-based trauma, they rarely seek counseling, said , a licensed marriage and family therapist based in Pittsburgh.

"People of color don't feel safe to come to therapy largely because they don't feel they can find people who can relate to their experience," Lee told ThinkProgress.

She said she would often urge those suffering from trauma to seek therapy, "but what I didn't account for was a lot of clinicians would not be helpful ... So it became more of a conversation of advocacy - advocating for yourself in the mental health field."

The study's authors, Hemmings and Amanda M. Evans, an associate professor at Auburn University, recommended that counselors be proactive in providing "multiculturally competent care" to people of color who experience race-based trauma. "These actions include confronting racism; including race-conscious curricula; incorporating models, theories, and methodologies; including training beyond academia; and supporting additional racism-related research."

Hemmings said it was also important to encourage more individuals of color to pursue the field of therapy, and for white white counselors to approach the topic of race more often.

"It's important for white counselors to ... not be afraid of [race], not be afraid that they're going to say the wrong thing," she said.

Even with additional training, Lee said, the work of counselors in educating themselves on race-based trauma is never over.

"You never just get it," Lee said. "It's a constant process.of being in a relationship with people who are different from you."

Lee emphasized the importance of counselors to "stay curious" and said she often conducts trainings and lectures for counselors to this end.

"I have had really great success with working with clinicians and counselors. I have also seen clinicians and counselors get really defensive," she said. "But I believe that defensiveness is an active part of growth."

# data[].attributes.attachment_link.title
Black Americans suffer most from racial trauma, but few counselors are trained to treat it

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Racism can often lead to trauma for people of color - a reality that has confirmed and time again . But few studies have assessed the ability of counselors to treat that trauma. "With America's climate in the current day and time and all of the instances of oppression and discrimination and hate crimes ...

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The disturbing reason some African American patients may be undertreated for pain

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The disturbing reason some African American patients may be undertreated for pain

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African Americans are routinely under-treated for their pain compared with whites, according to research. A study released Monday sheds some disturbing light on why that might be the case.

Researchers at the University of Virginia quizzed white medical students and residents to see how many believed inaccurate and at times "fantastical" differences about the two races -- for example, that blacks have less sensitive nerve endings than whites or that black people's blood coagulates more quickly. They found that fully half thought at least one of the false statements presented was possibly, probably or definitely true.

Moreover, those who held false beliefs often rated black patients' pain as lower than that of white patients and made less appropriate recommendations about how they should be treated.

The study, published in the Proceedings of the National Academy of Sciences, could help illuminate one of the most vexing problems in pain treatment today: That whites are more likely than blacks to be prescribed strong pain medications for equivalent ailments.

A 2000 study out of Emory University found that at a hospital emergency department in Atlanta, 74 percent of white patients with bone fractures received painkillers compared with 50 percent of black patients. Similarly, a paper last year found that black children with appendicitis were less likely to receive pain medication than their white counterparts. And a 2007 study found that physicians were more likely to underestimate the pain of black patients compared with other patients.

Researchers who study health disparities have said that unconscious stereotypes about African Americans likely contribute to this problem, as well as physicians' difficulty empathizing with patients whose experiences differ from theirs.

The University of Virginia study buttresses arguments that physician bias is a factor. Its research had two parts: One looked at a random sample of 92 whites from across the country. The second queried 222 white medical students and residents at the university and elsewhere. In both cases, participants were given a series of statements that contained accurate or inaccurate information about the biological differences between blacks and whites.

"We were expecting some endorsement" of the false beliefs, said Kelly Hoffman, a U-Va. doctoral candidate in psychology who led the study. But she said the researchers were surprised so many in the group with medical training endorsed the false beliefs, some of which she called "more outlandish."

For example, 58 percent of the study's general group said they believed that "blacks' skin is thicker than whites'." About 40 percent of first- and second-year medical students also thought that was true, as did 25 percent of residents -- doctors who recently completed their studies and now are receiving more specialized training.

Also surprising was that so many of the students and new physicians did not believe true statements about biological differences between the races, Hoffman said. For example, only half of residents knew that whites are less susceptible to heart disease than blacks.

The medical group was given one extra test. After reading brief case studies of two patients in pain, one white and one black, the students and physicians were asked to rate each individual's pain as well as make treatment recommendations. The researchers then compared the results with recommendations from 10 experienced physicians who had analyzed the case studies without any racial information included.

"What we found is those who endorsed more of those false beliefs showed more bias and were less accurate in their treatment recommendations," Hoffman said.

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racial stereotypes; pain killers; health disparities; hospitals

# data[].attributes.attachment_link.title
The disturbing reason some African American patients may be undertreated for pain

# data[].attributes.attachment_link.description
African Americans are routinely under-treated for their pain compared with whites, according to research. A study released Monday sheds some disturbing light on why that might be the case.