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Why The Conventional Social Determinants of Health Must Include Racism (Part 2: Misogynoir)

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Vanessa Lopez-Littleton and Carla Jackie Sampson
October 1, 2020

This is a reflective piece that centers on Black voices. It offers a counternarrative to assumptions about Black women that perpetuate bias and contributes to premature deaths.

As Black women, we often write about the poor health outcomes experienced by Black women in an effort to improve our experiences. Through the years, we have learned that myths and assumptions made about Black women play a role in the way we are treated by doctors and other healthcare professionals. These interactions are not the sole reason for the poor outcomes we experience. Instead, intertwined practices (and policies) combine to form systemic racism, a societal burden we must intentionally work to dismantle.

For Black women, the anti-Black racism we experience is rooted in the social construction of racial categories that seeks to divide ethnic groups based on physical characteristics. As a society, we have accepted the categorizing of race. Yet, we know there is no scientific basis for race. This point is relevant because as Black women across the African diaspora, we are treated differently in the clinical encounter based on our intersecting identities of race and gender. As such, misogynoir, a type of misogyny directed towards Black women, becomes an important concept to understand when examining how the health outcomes of Black women differ so drastically from other women. For Black women, misogynoir translates to being disregarded, deemed non-compliant, demeaned and even berated by providers. All of which contributes to our reluctance, weariness and mistrust of the healthcare system.

The elevated risk Black women experience during and after childbirth is one of the most troubling disparities of all. Black women die from pregnancy-related complications at three times the rate of white women. These differences are remarkable in that college-educated Black women are five times more likely to die from pregnancy-related complications than their white peers. The sad truth about these differential outcomes is that the vast majority of these deaths are preventable. 

The challenge for the healthcare system is understanding how Black women experience healthcare and how to make the system more responsive to our needs. Nearly two decades have passed since Dr. Camara Jones urged public health officials to examine how racism contributes to differential outcomes. Since that time, the United States has spent billions of dollars studying various aspects of racial and ethnic health disparities. Yet, outcomes in several categories, where differences were identified decades ago, have worsened. This is the opposite of what was intended. Health inequities are a pervasive national problem that have made an indelible stain on the fabric of our society. Every American should have access to quality healthcare in a system that holds those responsible for their lives accountable for the services they provide.

Recently, the CDC recommended integrating strategies to identify and address implicit bias to improve the clinical experience. In much the same way, efforts are needed to begin a process of dismantling systemic racism in healthcare. The following are brief examples of intentional strategies to shift the narrative in Black women’s health outcomes from individual health risk factors to the role of the system in contributing to negative health outcomes. 

  • Disease agnostic interventions. Directed efforts are needed to change the risk factors that lead to differential health outcomes. These shifts are needed in both policies and practices at every level of the patient care experience. For instance, recent studies have shown that the race of the doctor is correlated to infant health outcomes. As such, increasing the number of Black healthcare providers is a critical part of this process. #MoreBlackDoctors
  • Centering on the margins. Efforts to drive systemic change will need to begin valuing the voices and perspectives of Black women. The voices of Black women are needed at every level of the policymaking process, including decisionmaking. Black female perspectives must be integrated into service delivery models and evaluation methods in order to build trust, garner buy-in and influence outcomes. #BlackMamasMatter 
  • Rejecting race-neutral policies. Public policies have direct and indirect effects on Black women. Intentional efforts are needed to ensure policies are antiracist. An antiracist policy means the policy does not produce negative effects for Black women. The rejection of race-neutral policies creates opportunities to promote equity, social mobility and well-being while reducing risks of racism, discrimination, bias and mistreatment. This type of thinking can lead to the rejection of the dominant worldview that can fuel the development of the critical consciousness necessary to drive systemic change. #AntiracismCtr

Health inequities are not just an intractable problem for Black women, or Black people in general. They are a problem for the whole of society. As an advanced nation, we must stop grappling with whether systemic racism exists and pivot towards a level of critical consciousness that radically shifts our ability to examine the systems in which inequities occur. We could then begin to examine every aspect of the healthcare system for artifacts of systemic racism. Then, and only then, could we begin to actively dismantle these systems in favor of accountable systems where Black women do not have to suffer in the hands of providers who devalue our opinions, voices and lives. #BlackVotersMatter


Vanessa Lopez-Littleton, Ph.D., RN, is an Associate Professor at California State University, Monterey Bay and Chair of the Health, Human Services, and Public Policy Department. Her research interests include social determinants of health, racial equity, and organizational change. She may be reached at [email protected], DrVLoLil.Com or @DrVLoLil

Carla Jackie Sampson, Ph.D., MBA, FACHE, is a Clinical Associate Professor and Director of the Health Policy and Management Program and online Master of Health Administration Program at NYU’s Robert F. Wagner Graduate School of Public Service. Her research interests include healthcare workforce policy and management, social determinants of health, and anchor mission strategy development. She may be reached at [email protected] or @ProfessorSamps1

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