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As the United States enters the second year of the COVID-19 pandemic, advocates and researchers are predicting that racial disparities will further exacerbate infection and mortality rates. Some say structural racism in medicine will not only reduce access to quality health care among communities of color, it could also further undermine the well-being of Black Americans and mitigate the potential benefits of the vaccine.

Individual prejudice and unconscious and conscious bias from medical providers, combined with the lack of understanding of how environmental risks and structural conditions shape the health and experiences of marginalized patients, create lethal conditions that harm communities of color, especially Black women.

These staggering inequalities were perhaps most evident in the experience of Dr. Susan Moore, a Black physician who died in December battling both COVID-19 and racist medical care in Indiana. Even though she was a doctor herself, she said a doctor ignored her complaints of pain and requests for medication, dismissing her cries for help.

In a video she posted to Facebook two weeks before her death, she says from her hospital bed: “I put forth and maintain, if I was white, I wouldn’t have to go through that. … This is how Black people get killed, when you send them home, and they don’t know how to fight for themselves.”

Moore’s treatment—the lack of understanding by her doctors and the blatant neglect of her symptoms—sheds light on the psychological burden and physical consequences of explicit and implicit racial bias in health care—especially for Black women. Black Americans like Moore are undertreated for pain, not only compared to white patients but also relative to World Health Organization guidelines. In a study published in 2016, University of Virginia researchers reported that white medical students and residents often believed incorrect biological fallacies about racial differences in patients. How are Black Americans expected to receive quality and compassionate care when future doctors are entering their studies with implicit racial biases that are not addressed?

Meanwhile, there’s a health crisis—yet another pandemic—that doesn’t get nearly enough attention and where Black women’s pain is not prioritized: maternal mortality.

Just months before Dr. Moore’s death, 26-year-old Sha-asia Washington died while giving birth to her daughter Khloe at Woodhull Medical Center in Brooklyn, New York. A few days past her due date, Washington went in for a routine stress test, was later induced, and died as a result of an epidural administered during the delivery. Her partner said she felt pressured into having an epidural, the City reported. Washington was at least the third Black woman in New York City to die during childbirth in the first half of 2020, according to the City.

In the United States, the maternal mortality rate is abysmal, and it’s even worse for Black women. According to the Centers for Disease Control and Prevention, Black women are two to three times more likely to die from pregnancy-related causes than white women; in New York City alone, Black women are eight times more likely to die due to pregnancy-related complications than white women.

Little attention is given to the systemic and societal racism that creates psychological stress, resulting in chronic conditions such as hypertension and preeclampsia, two of the leading causes of maternal deaths.

The maternal health crisis and COVID-19 pandemic have both reinforced the active silencing of Black women’s voices—at the hands of their doctors—and the belief that they are unworthy of the care and investments necessary to live.

And there’s no signs of improvement.

An expert from the Harvard T.H. Chan School of Public Health predicted that maternal mortality among Black women in the United States will increase during the pandemic, citing the already disproportionate maternal mortality rates among Black women and the growing burden of COVID-19 in Black communities.

Dr. Tamorah Lewis uses the term “cumulative de-prioritization” to describe the ways medical providers make many small decisions that lead to Black women receiving inferior care. These actions and practices are not always overt and tangible, but they do build up over time to determine who is valuable and, by extension, who is deserving of life-saving care. As we’ve seen, the maternal health crisis cuts across socioeconomic lines—Serena Williams has been vocal about her pain being ignored during childbirth.

The conditions that accumulate to affect Black women’s health outcomes include prolonged experiences with racism and sexism, as well as lack of financial assistance and fewer economic resources, preexisting health conditions, and an ever-changing social safety net that also heightens Black women’s vulnerability to state supervision and policing.

As health equity researcher Maggie Hickens notes, excessive “vigilance,” or the chronic stress and psychological burden of anticipating racism, can lead to hypertension—just one of the measurable health risks that stem from structural racism, alongside poor neighborhood quality, mass incarceration, and high unemployment.

Even in death, Black women face ongoing denigration. After Dr. Moore’s passing, outrage grew when Dennis Murphy, the president and CEO of Indiana University Health, said nursing staff “may have been intimidated by a knowledgeable patient who was using social media to voice her concerns and critique the care they were delivering.”

Nationwide, Black people die of COVID-19 at 1.5 times the rate of white people. In two of the 20 counties with the highest COVID-19 death rates across the country, Black people represent the largest racial group. According to a CDC report published in September, children of color made up the vast majority (78 percent) of children who died of the virus: 45 percent were Hispanic, 29 percent were Black, and 4 percent were American Indian or Alaska Native.

Together, the structural, interpersonal, and environmental contexts of medical neglect and underinvestment expose striking and bitter truths: that the devaluation of Black women in life and in death is as American as apple pie. And that self-advocacy in predominantly white medical institutions can result in lethal outcomes marked by the calculated violence that is often reserved for women of color.

While the inferior care and treatment that Black women experience in medical facilities is not new, what is striking is the way reproductive justice activists continue to organize to address these systemic problems on grassroots, interpersonal, and institutional levels. Organizations like SisterSong and the Afyia Center address Black women’s holistic needs and well-being by working across different issues, like access to health care and reproductive health services, domestic violence, food services, housing, and immigration.

The road to closing racial disparities in health care is long, but it must start in two ways.

1. Lawmakers, hospital administrators, nursing staff, and physicians need to divest from health inequalities by taking concrete actions to offer optimal care to women of color in general, and Black women in particular. In order to actively disrupt institutional and interpersonal situations that systematically harm Black women, organizational routines in low-performing hospitals must be revised and improved. And hospitals must develop and maintain infrastructure and technical assistance to provide deep reviews of the causes of and possible solutions to these deaths.
2. Since structural racism is further institutionalized by the ways physicians are educated and licensed, we must pair current diversity initiatives with timely interventions and training for hospital staff and with anti-racist curriculum in medical schools, so that the historical disparities in care, treatment, and health outcomes are fully understood.

The same health system that Dr. Moore was so proud to be a part of failed her. The callous dismissal of both Moore’s and Washington’s concerns and needs catalyzed their deaths. And their own efforts to survive amid illness and inequality were ignored as part of a broader cultural and structural racism whereby Black women’s bodies and lives are denigrated and disposable.