Why health outcomes in Black women and people of color typically diverge from those of white women, often for the worse, was a recent Sunday morning sermon topic for the Rev. Dr. Ann Marie Bentsi-Addison Posey of the Warwick AME Church on Zoom.
American slavery’s origins
Beginning with the history of the arrival of enslaved Africans to the American colonies and continuing through the era of chattel slavery, Jim Crow, the Civil Rights era, to the present time of COVID-19, the Rev. Dr. Posey provided the virtual audience with a history of how Black women have been treated in this country: initially as property and livestock to continue bearing children to use as free labor, and as human guinea pigs for doctors and medical students through the early 20th century.
The pastor used this history to explain why Black women often mistrust the medical establishment, in addition to socioeconomic disparities in health care access. She also noted laws that kept enslaved mothers with their children only as long as it was profitable.They were often raped aboard slave ships and abused sexually in the New World.
“There was rape, there was prostitution,” Posey said, beginning on the slave ships: these women were absolutely unable to advocate for themselves, much less for their health and well-being.
Importing humans, vs. “growing” them domestically
In 1807, with the closing of the Atlantic Slave Trade by an act of Congress, wealthy white planters needed to replace the slaves that they would no longer be able to acquire overseas; the result was development of breeding farms on certain plantations in the South.
“Slaves were examined on the auction block the way one examined cattle,” said Posey. African women were often subjected to invasive medical exams in public, with doctors conducting exams of their most intimate parts, to determine if they had previously borne children – which would increase their value to slave-holders.
Posey pointed out the irony of Thomas Jefferson owning more than 600 slaves, even as he penned the famous words found in the Declaration of Independence, that ‘all men are created equal’.
“We can see the intersection of race and gender,” Posey said, “that excludes us twofold.”
“We understand,” she continued, “that at that time...he began raping one of his slaves when she was 14; she bore her first child at 16. Her story is written by one of her six children (four of whom survived),” that she bore to Jefferson.
No compassion or exemptions for pregnant women
Contemporary accounts tell of enslaved women trained as midwives, or who had experienced childbirth, and were called upon to help these women through the process of labor and delivery.
When both mother and child were endangered, the decision was made to save the mother, as “the mother in her reproductive years was more valuable than the child,” Posey said.
Still, pregnancy provided no downtime for enslaved Black women.
Slavery in the United States began in the upper South – Maryland and Virginia – as the white planter class needed cheap labor to build up the tobacco crop. Tobacco’s depletion of the soil necessitated a transition to sugar cane and cotton, which led to the use of more enslaved Black people, as the white aristocracy sought a greater return on their investment.
As white owners needed more Black slaves, they turned to breeding farms in the South; one of the more notorious of these was Lumpkin Jail, which served two purposes: an above-ground jail for holding captured runaway slaves, and a series of underground rooms where enslaved Black women were forced to have sex with enslaved Black men, in order to increase the number of slaves.
The men were hooded, not knowing if the women with whom they were having sex were their sisters or even their mothers and aunts.
A footnote to this ugly historical chapter: Lumpkin Farm was converted to a much more positive use - it is the site of Virginia Union College, an HBCU (Historically Black College/University).
Even as enslaved Black women were treated like livestock, expected to breed as long as they were biologically able, neither they nor their children were given adequate nutrition, leading to some of the children dying in childhood, as the mothers were not permitted to nurse or feed their children if it conflicted with the performance of their labor.
These children were often left in the care of elderly slave women, or even in the care of other children, who were themselves too young to work.
‘Sacrifices of Anarcha, Betsey, and Lucy: Mothers of modern gynecology’
The early practice of obstetric/gynecological medicine in this country used enslaved black women as living mannequins, where the doctors, their medical students – and occasionally, wealthy white men who paid for the privilege to watch – would examine women slaves who were completely naked, with no concern for their privacy or dignity (by contrast, white women patients of the time were examined, fully-dressed, beneath their clothes, in the custom of the Victorian Era). Contemporary accounts tell of three enslaved women in particular: Anarcha, Betsey, and Lucy, who were repeatedly operated on – without anesthesia or antibiotics – so that future OB/GYNS would be able to perfect their examination and surgical techniques for their white patients.
OB/GYN practices were perfected by practicing “on the sick bodies of slave women,” Posey said.
“Doctors had free reign,” with the only stipulation that the enslaved women still be able to bear children.
Dr. Francois Marie Prevost, the so-called “father of the C-Section,” pioneered the procedure by practicing on enslaved Black women – without the use of either anesthesia or antiseptics (antibiotics did not yet exist in the early 19th century).
Often, these women were held down by their fellow slaves during the surgeries.
A stereotype from the time that persists to this day is that Black women either have a higher tolerance for pain – or don’t feel it at all – as white women do.
After Emancipation – suffering in silence
In 1865, policies were implemented to help struggling mothers, except that “Women who were Black were restricted and denied access to such care,” according to Posey. “Laws were written in such a way to deny Black women access to social insurance.”
So enmeshed as these women were in the need to provide for their families, “combined with the horrors of being subject to medical experimentation,” Black women were more likely to remain silent about their pain, as well as their health needs, lest they become victims of quack doctors of the time, with their medically questionable “treatments.”
“These so-called ‘doctors’ may have practiced ‘procedures’ on 4 or 5 women, it worked on maybe 2,” then they’d publish their results, hoping to gain notoriety/prestige as others adopted their techniques.
Even after slavery ended, Black women’s silence continued (as a way of self-preservation), but “acts of degradation were still propagated against their persons.”
Attitudes by white society against Black people persisted after slavery ended, from the Jim Crow period through at least the Civil Rights era, and included views on rape (as Black women weren’t considered fully human, they couldn’t legally be victims of rape) and the false notion that Black women were promiscuous (and therefore “were asking for it”). Also, Black women often worked at jobs in the lower end of the socio-economic spectrum, often leaving them vulnerable to physical and sexual abuse.
From 1880 through 1968, more than 4,000 African Americans were lynched by white mobs in the US. While it was common at the time in New York for placards saying ‘X number of Black men were lynched today,’ to bring attention to the horror, Posey said, “At no time has there ever been attention brought to the fact that our bodies have been violated since we set our feet on these shores involuntarily until today.”
She stressed that it’s important, then, to take into account the “somatic effects” of this historical violence, and added that recent research supports that Black people carry the scars of generational trauma.
Eugenics: “improving” humans, and family planning
Beginning in the 1920’s, people associated with the medical and scientific communities sought to “improve” the human race through eugenics, with the goal of eliminating “negative” traits with a particular focus mainly on people of color and the poor, by regulating both marriage and procreation.
People as disparate as Sir Francis Galton, a multi-disciplinary scientist and early proponent of eugenics, and Margaret Sanger, a pioneer in family planning and head of the Birth Control League of America, both focused much of their efforts on the Black community.
It was the influence of the eugenics movement in the early 20th century that led to inordinately high sterilization rates of Black women: non-medically necessary hysterectomies became so common at one point that they were known as “Mississippi appendectomies.”
Several states enacted laws to severely restrict Black women’s reproduction. Black women had higher sterilization rates than white women, Black men or white men. It was not uncommon for Black women to go into the hospital to give birth, Posey said, “or for some other health concern,” and “somehow not realize” that they had been sterilized until they sought out medical help after undergoing “multiple failed attempts” to become pregnant.
Sometimes children who were deemed “slow” and considered not worthy of becoming parents themselves were also similarly sterilized without their consent.
Margaret Sanger created the Birth Control League of America – the forerunner of Planned Parenthood - in the 1940s.
She went into poor communities where women kept having “child after child,” as they had no access to birth control. While on the one hand, Sanger helped these women have more control over their bodies and the size of their families, she was another eugenics proponent, and felt that “Black people, because of who they were, should not propagate to such an extent,” Posey said.
Even today, Posey added, 85 percent of Planned Parenthood clinics are in communities of color: “It’s a blessing and a curse...(women) can have a chance at optimal healthcare,” but there’s “always a thin line between coercion and consent.”
Sanger had support from civil rights activists W.E.B. Du Bois and the Rev. Dr. Martin Luther King, Jr, because they supported the idea that poor people should not be allowed to increase the number of children they had, “thereby increasing or decreasing their chances of getting out of poverty.”
Meanwhile, sterilization programs continued into the late 1980s, as surgical residents were required to have performed a given number of caesarian sections and hysterectomies in order to complete their medical programs and take their boards.
Understanding causes of disparities
The three main causes of disparities in health care – both treatment and outcomes - are, Posey said:
1. Patient level factors – which refers to patient preferences and attitudes, and general adherence to treatment plans; frequency of genetic variations (such as Sickle Cell Anemia in Black patients); and diet and physical activity (or lack);
2. Health care system level factors – As the US has a for-profit based medical system, the cost of services, specialists, etc., is market-driven; in general, people who are under- or uninsured, or who live in a geographically disadvantaged area (particularly in the South) tend to have lower-quality care – if they can get care at all;
3. Practitioner level factors – stereotyping and implicit bias, for example; mistakenly thinking that black people feel less pain; disparaging and a culturally-derived mistrust of the system
As a result, some health care professionals tend to ignore Black people’s – particularly, Black women’s – pain until it is out of control, virtually guaranteeing higher morbidity/mortality than should be the case.
Posey cited a 2016 study that found that when four actors - a Black woman, a white woman, a Black man and a white man - playing patients with the identical complaint went to an ER, each had a very different outcome: the Black woman received the least attention, her symptoms, she was told, were all in her head, and she was sent home. Her white male counterpart, by contrast, was given the “million-dollar workup:” his complaints were taken seriously and thoroughly investigated.
Big picture takeaway
Black women are more than twice as likely as white women to live in poverty (1/4 of all adult Black women live below the Federal poverty level); across the South, the proportion of Black women in poverty is higher.
The Great Recession of 2007 – 2009 hit low- and middle-income families hard; the median family income is still 6.5 percent lower than when the recession started.
Black women are unemployed at twice the rate of their white counterparts; a fully-employed Black woman earns an average of $0.63 to a white man’s dollar.
While the Affordable Health Care Act (ACA) has been helpful to millions of Americans, women of color are still more likely than white women to lack health insurance: 86 percent of Black women (18-64), v. 92 percent of white women are insured. Ninety percent of the people in the coverage gap live in the Southern US. Black women are less likely to have a primary health care provider, lack access to family planning; are more likely to have an unintended pregnancy; are less likely to get recommended care for disease prevention and management.
The COVID-19 pandemic also exposed the socio-economic gaps in the US health care system, as well as revealed similar gaps world-wide between the haves and have-nots: 218 million women in low- and middle-income nations who wanted to avoid pregnancy but didn’t have access to modern birth control had 111 million unplanned pregnancies and 35 million unsafe abortions. 16 million women and 13 million newborns did not receive care for major complications of pregnancy and childbirth.
These same populations experienced 299,000 pregnancy-related deaths; 2.5 million newborn deaths; and 14 million adolescent women (ages 15-19) in these countries had unmet needs for modern contraception.
The long-term negative effects of these unplanned pregnancies include disruptions to girls’ and women’s education; lost professional opportunities; a lack of reproductive autonomy.
The COVID-19 pandemic led to delays in cancer screenings, including 285,000 missed breast exams: excess breast cancer deaths could reach 2,487 over the next decade as a result.
The bottom line
Posey stressed the importance of better health education; improved access to health care; the need for both patient and provider to have timely, accurate communication, where each really hears and understands the other.
“Better education leads to better outcomes...The struggle is not ended...When we know better, we can do better.”