Saidy Brown was born and grew up in Itsoseng, a small township in South Africa’s North West province. The youngest of four siblings, Saidy had a happy childhood. “I was always the baby of the family,” she told me. But in 2004, when Saidy was just nine years old, her family was hit by a tragedy. Her father suddenly and unexpectedly became seriously ill and passed away. Soon afterward, her mother became ill too, dying the following year and leaving Saidy and her siblings in the care of their aunt. The sudden loss of her father and then her mother was made even more painful by the mystery surrounding both of their deaths. Saidy had no idea what had made her parents so ill. “I just [knew] that they got sick, and they passed on,” she said.
Saidy wouldn’t learn what killed her parents until several years later, in 2009. That year, in June, she received life-changing news while hanging out with friends on a school trip to a Youth Day event. “We got there and there were people from this NGO, and they said, ‘Guys, we are doing HIV testing for free.’ ” All around fourteen years old at the time, Saidy and her friends decided to get tested for fun. “I wasn’t expecting my results to come back positive,” Saidy told me. “I kept on saying, ‘But I’m just fourteen, I didn’t do anything,’ ” she said. “I also wanted to cry. But I thought that if I cry, the moment I walk out everyone will know my result. So, I didn’t cry.”
Ashamed and terrified about what her aunt and her peers would think, Saidy kept her diagnosis to herself. She had received no counseling at the time of her first positive test and believed that the diagnosis was a death sentence. To try to distract herself, she threw herself into her schoolwork and extracurricular activities. She joined a local drama club, which kept her busy with rehearsals after school. “For the next five months or so I was quite busy,” said Saidy. “I didn’t have time to be thinking about HIV or AIDS or death.”
But it was unavoidable. As December approached, her drama club began working on projects related to HIV and AIDS in preparation for AIDS awareness month. “I kind of got triggered to tell someone,” explained Saidy. She decided to tell her teacher, who immediately asked her if she had told her aunt. When Saidy replied, “No, you are the first person I’m telling,” her teacher was very understanding and offered to come home with her so that they could talk to her aunt together. Saidy summarized how that conversation went: “We sat down, we told my aunt, and she’s the one who said, ‘I knew about your parents—I didn’t know that you could have been born with HIV.’ ”
It would take another four years for Saidy to start antiretroviral therapy—a combination of medicines that treat HIV and prevent AIDS. Her aunt took her to a clinic as soon as she learned of Saidy’s diagnosis, where her HIV status was confirmed, and she was given medicines to take home. But Saidy said it wasn’t made clear to her that she would need to continue taking medication for the rest of her life. She didn’t return to the clinic until several years later when she was eighteen. Since she hadn’t been on treatment, her health had started to deteriorate. She had developed sores on her chest, which had begun spreading upward onto her neck. She had just started dating and was becoming self-conscious about her appearance.
“I was like, no, I’m trying to look pretty,” said Saidy. “I don’t want these sores on my face.” So, she decided to return to the clinic, although she was apprehensive about taking antiretrovirals long-term because she had read about possible side effects on the internet. “I don’t know what the page I landed on was, but this page said something like my hair was going to fall off, my teeth were going to fall off, my body was going to change. And I remember just going through the list and crying,” recalled Saidy. “I’ve literally always been that person with the big hair. I was like, there’s no way my hair’s falling. And I love smiling, I love laughing,” she said. “I texted my best friend and I said I’m just eighteen, I’m not doing this […] These pills are just made to make me feel ashamed for living with HIV and to humiliate me. And I’m not about to subject myself to that. Rather I die.”
Fortunately, on this particular visit to the clinic, Saidy received counseling. The counselor tried to reassure her that the side effects were not as drastic as what she had read online. Somewhat reluctantly, Saidy agreed to try taking the medication for a month. “Fortunately for me, I really started seeing changes,” she said. The sores began to disappear, and she started to feel better. “Years later, I’m here and I’m still on treatment,” she told me proudly when we spoke during AIDS Awareness Month in 2021.
Saidy’s experience getting diagnosed with HIV as a young Black girl in South Africa and her journey accessing treatment exemplify long-standing and persistent racial disparities associated with what for years has been a completely preventable and treatable infection. These inequities exist not only in the context of infectious diseases like HIV, but also across several of the other most prevalent health conditions affecting humanity today. From infectious diseases to non-communicable health conditions such as cardiovascular disease, cancer, and mental illness, there are significant racial and ethnic inequities in terms of who is getting ill and who is dying. The racial and ethnic gaps in maternal and infant health are just the tip of the iceberg. As I discovered, gaps in physical and mental health exist throughout life—and illness is far from the great equalizer it is often touted as being.
Saidy is now an award-winning HIV activist who shares her experiences of living positively with HIV through videos and posts on social media. And while she is grateful that she has access to lifesaving treatment, she is painfully aware that this isn’t the case for everyone. “Fortunately for me, I started treatment at a time when treatment had already been made free in South Africa. I’m also aware that that’s not the experience of every person in the world,” said Saidy. “The access aspect of things was not that difficult for me. But also, we don’t know what happened with my parents,” she added. “That’s probably why I really got born with HIV, because there was no treatment [accessible to them] at the time.”
The US Food and Drug Administration (FDA) approved the antiretroviral drug AZT, the first treatment for HIV, in 1987. In 1994, the year before Saidy was born, the US public health service recommended that pregnant women with HIV be given AZT to reduce their risk of transmitting the virus to their babies. By 1996, the year after Saidy was born and almost a decade before her parents died, antiretroviral therapy became the standard treatment for HIV—for those who had access to it. The combination of antiretroviral drugs quickly became accessible to people in the world’s wealthier—and generally Whiter—countries, resulting in drastic reductions in deaths from AIDS in those nations. But access to the lifesaving treatment in the world’s less wealthy nations lagged, particularly in countries in sub-Saharan Africa where access to treatment didn’t become widespread until about a decade later because of the high cost. This is a persistent pattern: in 2023—more than two years after the world’s first Covid-19 vaccination campaigns began—there remained significant global inequities in Covid-19 vaccination coverage, with Africa being the least vaccinated and least boosted continent.58
In South Africa, the lag in the rollout of antiretrovirals around the turn of the twenty-first century was exacerbated by Thabo Mbeki’s presidency, as he embraced HIV and AIDS denialism and implemented policies that restricted access to the drugs. It has since been speculated that this appetite for denialism may have been fueled in part by a general suspicion of Western medicine as a result of the actions of the apartheid regime. Following the collapse of apartheid, it was revealed that—under the leadership of a medical doctor—apartheid government laboratories had been developing chemical and biological weapons to use against enemies of the regime, as well as researching methods of covert and selective fertility control. This example barely scratches the surface when it comes to Western medicine’s racist history and legacy worldwide, which we will examine more later in the book.59
Today, the majority of people living with HIV live in Africa, and whereas the prevalence of HIV is about 0.2 percent worldwide, in sub-Saharan Africa it is about 6 percent. As of 2020, South Africa has the world’s largest HIV epidemic with more than seven million people and almost 20 percent of 15- to 49-year-olds living with the virus. HIV prevalence is higher among Black South Africans, compared with their counterparts from other racial groups, and particularly among Black women, like Saidy. “It is something that really affects adolescent girls, young women, Black people, people who are less privileged,” she told me.60
Even within wealthier nations, such as the US, there were stark inequalities in access to HIV treatment from the outset. In 1996, AIDS ceased to be the leading cause of death among all US adults between the ages of 25 and 44 but it remained the leading cause of death among African American adults in the same age range. Many years later, although the overall prevalence of HIV has fallen significantly since the 1990s, racial inequality persists. About 13 percent of the US population is Black, but as of 2019, Black people make up 40 percent of people living with HIV. And despite the higher prevalence of the disease among Black people, they are still less likely than White people to be receiving treatment and to have undetectable levels of the virus in their blood. Black people in the US are also six times less likely than White people to be prescribed pre-exposure prophylaxis or PrEP, which can prevent HIV transmission, and health care providers are less likely to discuss PrEP with Black clients.61
These inequalities are compounded for people with multiple intersecting, marginalized identities, such as Black transgender women. An estimated 14 percent of all transgender women in the US are living with HIV, but among Black transgender women the equivalent figure is estimated at 44 percent. Similar inequalities exist in other multi-ethnic societies globally. For instance, a 2021 study in the UK found that people from Black, Asian, and minority ethnic groups with HIV tend to present to health care services with poorer immune health, spend less time engaged in care, and are more likely to experience a rebound of the virus.62
This affects us all—racial inequities are holding back efforts to halt the spread of HIV and end AIDS globally. In 2022, the UN warned that progress in prevention and treatment was slowing worldwide, noting that racial diagnostic disparities were exacerbating HIV risks and pointing out that declines in new HIV diagnoses had been greater among White populations than among Black and Indigenous populations in countries such as the UK, the US, Canada, and Australia.
In a sad irony, racial and ethnic inequalities in HIV prevalence contribute to racism and racialized HIV stigma, which discourages people from getting tested and taking treatment where it is available to them, perpetuating existing inequalities further. I will never forget the moment when I was doing some outreach work at a school in the Oxfordshire area in the UK, talking to seven- and eight-year-olds about my research on viruses and the immune system, when one of the kids suddenly shouted, “HIV comes from Africa because African people are dirty.” I felt taken aback and disturbed. In her book Divided, UK-based sexual and reproductive health doctor Annabel Sowemimo recalls feeling similarly unsettled after she was approached by a young Black gay man at an event she attended with her nonprofit organization Decolonising Contraception, who told her he had stopped using dating apps after several users had refused to engage with him due to fears that “Black men have HIV,” as one user told him.
Racist, homophobic, and stigmatizing perceptions like these are not only morally offensive, they actually harm people’s health. As Sowemimo goes on to illustrate in her book, racialized stigmatization and stereotyping contributes to wider inequalities in sexual and reproductive health, by discouraging those affected from engaging with health services. Health harms can be particularly acute for those who are living with HIV. According to a 2020 UNAIDS report, between about 2 and 21 percent of people living with HIV across 13 countries with available data reported being denied health care in the previous 12 months because of their HIV status. Separate research has linked HIV stigma to low rates of HIV testing and lack of knowledge about HIV treatment.63
Saidy said she thinks stigma and racism influenced her decision to keep her diagnosis to herself for several months and to delay seeking treatment for years. “I literally felt like people were going to judge me,” she said. “I do think that racism and HIV stigma overlap.”
As an HIV activist, Saidy now works hard to fight against discrimination, stigma, and misconceptions about people living with HIV. In an anecdote she shared with me about some time she spent volunteering with a student activist organization, she highlighted how racialized stigma harms people of all races. “They [the organization] did a lot of HIV advocacy on campus. And we would have these wellness weeks where we would test students. And we would have these White boys who would feel like, ‘No, I can’t even test for HIV. Why would you ask me? I don’t even look HIV positive,’ ” explained Saidy. Anything that discourages people from getting tested is harmful. “HIV affects everyone,” she said, regardless of race.
Although the stigma surrounding HIV is particularly pronounced, it is far from the only infectious disease to be stigmatized and connected to discrimination against particular racial or ethnic groups. The UK, the US, and Australia were among countries that saw surges in anti-Asian hate speech or other racist incidents within the first two years of the Covid-19 pandemic. And in November 2021, as reports emerged about the detection of the omicron coronavirus variant by researchers in Botswana and South Africa, the Spanish newspaper La Tribuna de Albacete published a comic depicting viruses as cartoon characters with dark skin and Afro hair, packed into a boat labeled with a South African flag and heading toward land marked with a European Union flag. WHO director-general Tedros Adhanom Ghebreyesus criticized the depiction in a tweet, writing: “It pains me that shows of racism like this still plague the challenges facing the world today. Caricaturing people crammed in a boat bringing a virus to Europe is disgusting. We can only advance, as one [global] community, by promoting solidarity, not stigma.” I was similarly disappointed, as a Black person living in Germany, to see German newspaper Die Rheinpfalz am Sonntag publish a front-page article on the same day with the headline “The virus from Africa is with us,” above a photograph of two Black people. Both newspapers subsequently apologized. Yet in May 2022, the Foreign Press Association Africa felt compelled to issue a statement criticizing European and North American media outlets for repeatedly using images of Black people to illustrate articles about mpox outbreaks in Europe and North America. (The WHO renamed the disease from monkeypox to mpox in November 2022, saying that the original name played into “racist and stigmatizing language.”)64
Unfortunately, there is often stigma associated with infectious diseases, particularly in the context of emerging epidemics or pandemics where there are many unknowns and fears. The 2013–2016 Ebola virus epidemic in West Africa was also associated with significant stigma, for instance, including racialized stigmatization of African immigrant populations in other parts of the world, such as the US. And as we have already seen with HIV, it isn’t only stigmatization that affects marginalized racial and ethnic groups disproportionately during epidemics or pandemics—these groups often also experience disproportionate rates of disease and death.65
This latter trend was impossible to miss when the world was gripped by the Covid-19 pandemic in 2020. It was around this time that I first came across Nishi Chaturvedi, a clinical epidemiologist at University College London in the UK, who has done extensive research on ethnicity and health. In May 2020, Chaturvedi and I had both been invited as guests on the VICE UK podcast, VENT Weekly, to speak about why people from Black, Asian, and minority ethnic backgrounds in the UK were disproportionately getting ill and dying with Covid-19. In introducing the discussion, our adept podcast host, Amelia Mya, touched on a question many people were asking at the time: Is the coronavirus racist? “I do feel like a lot of people have said that this virus doesn’t discriminate in terms of race, but I have a feeling that it does,” said Mya.
She had a valid point. A few weeks before the podcast recording, one of my editors at New Scientist had asked me to investigate and report on emerging data on the race and ethnicity of Covid-19 cases in the US and UK. Figures published by the UK’s Intensive Care National Audit and Research Centre as early as April 2020 were already showing that people from Black, Asian, and minority ethnic backgrounds were overrepresented among critically ill Covid-19 patients relative to their share of the population. Data published by the CDC in the US around the same time revealed a similar pattern, with Black people particularly overrepresented. On April 18, 2020, for instance, when I was preparing my report, 30 percent of confirmed Covid-19 cases where race was known had been found to be among Black or African American people, who comprise just 13 percent of the US population. Similar inequalities were also detected in other countries that collected the relevant data, such as Australia and Brazil.66
These patterns of inequality were unfortunately nothing new. “This isn’t a new phenomenon that’s specific to Covid-19—it’s something we’ve seen before,” commented Chaturvedi at the time. Indeed, ten years before Covid-19, the world was hit by the H1N1 influenza virus pandemic, also known as swine flu. That virus was a lot less deadly than the coronavirus responsible for Covid-19, but there were similar inequalities in terms of who died. A study in England found that people of non-White ethnicity had nearly twice the risk of dying compared with White people, for instance.67
Similar racial and ethnic disparities exist for tuberculosis, or TB, one of the oldest diseases affecting humanity. “I think diseases like TB, like Covid-19, invariably they hold a mirror to us and explain to us the overt racism and the inequities that are just rampant. They’ve always been there,” said Madhukar Pai, an epidemiology and global health researcher at McGill University in Canada, who studies TB.68
In a similar vein, back on the podcast, Chaturvedi told listeners: “When Covid goes away this story will remain, that people who are disadvantaged in some way are at greater risk of some conditions. So, I’m hoping that one of the positives that will come out of this is that recognition—and that will play through into government policies and communities and how we live our lives.” Indeed, as we will see when we return to the issue of Covid-19 inequalities in the next chapter, it isn’t viruses or diseases that are racist—it is our societies. Racism in societies damages health overall, leaving people more vulnerable to infectious assaults. And, as we are about to learn, one of the major ways this damage manifests itself is on the heart and circulatory system.
In January 2018, Carol Ighofose was wrapping up a shift at her work as a GP, or family doctor, in the Leicestershire area of England, when she began to feel a slight discomfort in the upper part of her stomach—like heartburn. It’s probably a bit of indigestion, she thought to herself, as she prepared to drive home. She had been fasting for religious reasons, so she made a mental note to herself to eat something when she got home and before returning to work for her next shift later that afternoon. Carol got into her car and called her husband, Simon, to let him know that she was on her way home. She then called one of her friends, Tracey, using the hands-free Bluetooth system in the car, so that she could chat to her during the drive home. Tracey, who was working as a GP trainee at the time, had finished a night shift earlier that day but had stayed up because she had wanted to speak to Carol about something. As they were chatting, Carol realized that her indigestion symptoms still hadn’t settled.
“Trace, you know, I don’t usually get chest pain but this discomfort in my chest that I have been experiencing is not shifting,” Carol told her friend. Both doctors, they went straight into diagnosis mode. “[Tracey] started asking me all the questions about, you know, what the pain is like, how would I grade it, how would I describe it, all those sorts of things,” Carol recalled a few years later. They concluded that something didn’t quite add up and that if Carol’s symptoms persisted, she should go and see a doctor. “At this time, even though we were thinking heart, and she did ask all of the heart things, it just didn’t add up,” Carol explained. “Thinking about the risk factors, I wasn’t overweight, I wasn’t diabetic, I didn’t have high blood pressure, my cholesterol was normal, I did my exercises every morning before I’d go to work. It just didn’t fit.”
But as Carol continued driving, her symptoms worsened. She was still on the line to Tracey but was struggling to concentrate on what her friend was saying, and the discomfort she had been experiencing had developed into more of a chest pain. “This is not right, I need to pull over,” Carol told her friend.
“Pull over, I’ll call 999,” Tracey replied.
As Carol pulled over on the side of the road, and her symptoms continued to worsen, it dawned on her what was happening. “At this time, in my head, I realized I’m having a heart attack,” she said.
Carol waited in her car for what felt like an eternity for the paramedics to arrive. By this point, she was experiencing crushing central chest pain and was feeling extremely disoriented and confused. She decided to call 999 herself. “I am a doctor and I believe I’m having a heart attack,” she told the operator. She was relieved when the paramedics arrived about ten minutes later, but she was surprised that they appeared to be quite laid-back. “In my head, I’m having a heart attack, so I expected when they came that they would be like on mission, urgent, but they were quite lackadaisical,” she recalled later.
“They parked the ambulance a little way down from where my car was and then came to me and got me to secure my car, i.e., wind up the windows et cetera, and then walk to the ambulance from where my car was. I don’t know how I did all of that, because I was in a disoriented state, and that in itself told me these people aren’t taking me serious. If you’ve got a heart attack, you don’t want the patient to walk, you want the patient to rest as much as possible,” Carol explained, slipping into doctor mode. Even as she was being walked to the ambulance from her car, experiencing what must have been excruciating pain, Carol had her doctor’s hat on. She remembers emphasizing to the paramedic, “I am a doctor, I do believe I’m having a heart attack.” The paramedic just looked at her and said, “Oh, you doctors always think of the worst.”
In the ambulance, the paramedics did start the correct treatment for a heart attack, according to Carol. “They did give me an aspirin, they started putting a vent flow in my vein for venous access so I could get fluids,” she remembered. She was also given morphine and some medication to treat nausea and the paramedics did an electrocardiogram, or ECG, to measure the electrical activity of her heart. “What they said they found was what we call a high takeoff in medicine,” said Carol. “That could be the first sign of a heart attack,” she explained, so she expected that she would be taken straight to a heart specialist hospital for treatment. “If I were a GP, having me as a patient in front of me, I would want the patient to go to the heart specialist hospital which we have in Leicester where I’m from. So, I asked them to take me there,” she said. But her ECG result was dismissed as something else, and Carol was instead taken to the nearest hospital, which was about five minutes away.
“Unfortunately, I went to that hospital, waited there for fourteen hours, even though I was constantly in pain—they had to keep giving me morphine,” she remembers. Then, at around four o’clock the following morning, Carol was finally moved to Glenfield Hospital, the specialist hospital where she had asked to be sent initially. When she got there, the doctors confirmed her worst fears. “It was confirmed that I did have a heart attack,” she said solemnly. “I had a total blockage of my left anterior descending artery,” she added, slipping back into doctor-speak to refer to a critical blood vessel that usually supplies oxygenated blood to the left side of the heart. Blockage of the left anterior descending artery is extremely dangerous: it is sometimes referred to informally as a “widow-maker” because it carries such a high risk of death (and presumably also because, well, sexism). Despite Carol’s serious condition, it took a further six hours—a total of twenty hours from the time she first recognized she was having a heart attack—before she had a stent put into her artery to relieve the blockage.
The next day, an ultrasound revealed that Carol had experienced significant damage to the left side of her heart. The amount of blood that her heart was able to pump out with each beat was extremely low. “Usually, we need about 65 percent of blood to perfuse all our body. Mine was pumping out 18.18 percent,” Carol explained. “As a doctor, when I heard that I started crying, because for me that meant heart failure and a life of—a different life, basically.”
When I heard Carol share her experience at a British Heart Foundation event in April 2021, part of me was shocked. This woman was a doctor, who had somehow had the presence of mind to diagnose herself and work out what kind of treatment she should be getting while she was having a heart attack, and yet she had still somehow been doubted by the medical professionals who were caring for her. Another part of me wasn’t that surprised: it was unfortunately yet another example of a Black woman being disbelieved and dismissed about what was happening inside her own body.69
Carol believes that the delay in diagnosing and treating her heart attack meant that she suffered damage to her heart that might not have occurred had she received more timely treatment. She finished her talk with a message: “I’m grateful to be sharing my story and I hope that women in particular and people of ethnic minority and whoever—you know your body, if you think something is different, do, I always say, be nice, be polite, but please insist, because we know when something is not right with us.”
Unfortunately, knowing our own bodies and being nice and polite sometimes isn’t enough. Nishi Chaturvedi, the clinical epidemiologist whom I had met a year earlier on the podcast about Covid-19, was also a speaker at the same British Heart Foundation event, and during her talk, she illustrated why.
“Getting care for cardiovascular disease is a complex process that involves both the patient and the health care system,” said Chaturvedi. “So, for example, if we’re thinking about something like a heart attack, it requires the individual to recognize they’re having an event, recognize that it’s serious, choose to seek help and to seek help immediately, and to accept the interventions offered. The doctor has to make the correct diagnosis, do the right tests, perform the right investigations and provide the right treatments. And we do see some evidence that people from ethnic minorities experience delays in getting appropriate health care,” she said. Chaturvedi and her colleagues have put a huge amount of effort into investigating why people from ethnic minority backgrounds in the UK, and particularly people of South Asian ethnicity and people of Black African or Black Caribbean ethnicity, such as Carol, not only experience a greater risk of cardiovascular disease compared with White people but are also more likely to experience delays in getting the urgent care that they need.70
“One of the studies we did was to send out a questionnaire to people of South Asian and European descent—middle-aged folk—and to give them a vignette, a story, of an individual walking upstairs carrying a heavy load and experiencing central chest pain, putting down the load and feeling a bit better, but concerned because they’d had that event before. And we asked our respondents, what do they think the pain is? Do they think it’s serious? Would they seek help? Would they seek help immediately? And would they accept an intervention if it was offered? And, overwhelmingly, the South Asians were equally likely to recognize that this pain was coming from the heart as the Europeans and, in fact, even more likely to wish to seek help urgently and to accept interventions, be they medical or surgical,” said Chaturvedi.
Chaturvedi then pulled up a PowerPoint slide with images showing the so-called standard symptoms of a heart attack. “When I was at medical school we were taught how to spot when someone had a heart attack, and the symptoms you see on the left hand of the slide here are the kind of things we were taught to look out for,” she explained. “Chest pain, shortness of breath, the pain radiating up to the jaw, the neck, or down the shoulder—so that’s what we expect to see when someone’s having a heart attack,” she said. Chaturvedi continued: “It’s now clear that there are non-standard symptoms, things like dizziness, heartburn, cold sweat, unusual tiredness, and there’s evidence to suggest people with diabetes, women, and ethnic minorities are more likely to present with these nonstandard symptoms.”
Rewatching Chaturvedi’s talk later, I thought back to Carol’s experience. The first symptom Carol noticed that day when she was preparing to leave work was heartburn, but even though she is a doctor—and was on the phone to her friend at the time who is also a medical professional—it wasn’t immediately obvious to either of them that this could be a heart event. Perhaps if there was more awareness about these so-called “nonstandard” symptoms of a heart attack, it would have been easier to work out what was happening to Carol. Even as Carol’s symptoms persisted, she and Tracey initially dismissed the possibility that it might be a heart attack because none of the common risk factors—being overweight, being diabetic, having high blood pressure, or having high cholesterol—seemed to apply to Carol, who was just forty-eight years old at the time and led an active lifestyle. At a health checkup eight years before her heart attack, she had even been told that she could expect to live well into her eighties without having a heart attack or stroke.
In fact, both Carol’s experience and Chaturvedi’s research suggest that the standard symptoms and risk factors for cardiovascular disease might not be so standard after all. “These guidelines [for the diagnosis and treatment of cardiovascular disease] have largely been developed and deployed in people of White European origin and may not work so well with people of South Asian and African-Caribbean origin where […] the constellation and interplay of risk factors is very different. Those guidelines do try to take account of different ethnicities, but our work suggests that they don’t do it particularly well and that perhaps some ethnic minority groups are being undertreated,” Chaturvedi went on to explain. “In terms of health care, the standard symptoms and guidelines might miss diversity in expression of symptoms and might miss diversity in risks of cardiovascular disease and interplay of different risk factors.” This is not to say that people of different ethnicities have inherently different biology, emphasized Chaturvedi, but environmental risk factors can impact our biology.
We can see how this happens by considering the relationship between ethnicity, environment, and biology in cardiovascular disease. People of Black and South Asian ethnicity in the UK are disproportionately affected by type 2 diabetes, which is not only a major risk factor for cardiovascular disease but is also associated with an increased likelihood of experiencing some of those “nonstandard” heart attack symptoms we considered earlier. And although more than 120 gene variants have been identified as being associated with an increased risk of type 2 diabetes, research by Chaturvedi and her colleagues suggests that it is environmental factors, such as socioeconomic status, which make the strongest contribution in accounting for ethnic differences in type 2 diabetes risk.71
In a 2022 study, Chaturvedi and her team analyzed data from the UK biobank, a large-scale biomedical database containing genetic and health information from approximately 500,000 people aged between 40 and 69. Their analysis confirmed findings from previous studies that the incidence of type 2 diabetes among people of Black and South Asian ethnicity is higher than among White people in the UK. If this difference was mostly due to genetic differences, we would expect that it would remain largely unchanged between generations. But instead, the team found that among Black and South Asian ethnic groups, second-generation migrants to the UK had a 20 percent lower risk of type 2 diabetes compared with first-generation migrants. This was associated with reductions in socioeconomic deprivation and measures of body fat between generations.72
As Chaturvedi put it: “The genetic makeup hasn’t changed that much but the environment has.” These results are hopeful, as they suggest that the persistent gaps in type 2 diabetes incidence between Black and South Asian ethnic groups and White ethnic groups can similarly be reduced by focusing on environmental risk factors such as ethnic disparities in access to healthy food and to green space for exercise, which are both enormously protective against obesity, type 2 diabetes, and cardiovascular disease.
In the next chapter, we will examine in more detail how systemic racism contributes to racial and ethnic inequalities in diet and exercise in the UK and elsewhere, but right now I want to return to Carol. When she attended her health checkup eight years prior to her heart attack, she didn’t have any of the risk factors we have just been exploring. She wasn’t obese and she didn’t have diabetes. But she had been experiencing something else, which may have adversely impacted her health. “I think looking back, for me personally, of course I’m a busy GP and my life is generally, from that perspective, stressful and there are other stresses, so I think that stress does play an important role,” reflected Carol, during a Q&A session after her talk. Putting her medical hat back on, she added: “Stress is not listed as an independent risk factor for heart attacks, but it’s listed more as an association. I personally feel that some more work needs to be done on that.”
Carol’s speculation about the potential impact of stress on her heart reminded me of research I had come across previously, exploring the connections between racism, chronic stress, and cardiovascular disease. To understand these connections, it helps to remind ourselves of our basic plumbing.
The heart is one of the most amazing organs in the human body. It is also kind of a glorified pump, channeling oxygen-rich and oxygen-poor blood to and from the body’s organs with every beat, through a spectacular network of fleshy pipes. Those pipes are the unsung heroes of this circulatory dance—a fact that becomes obvious when one becomes blocked, and even more startlingly so when the blockage happens in a vessel supplying a crucial organ such as the brain or the heart itself. Indeed, strokes and heart attacks are mainly caused by blockage of blood flow to the brain or heart, most often due to a buildup of fatty deposits in the inner walls of the blood vessels that supply these organs. These buildups tend to happen in regions of the blood vessel wall that have been damaged for some reason. Once damage has occurred, substances traveling in the blood, such as cholesterol and fat, may accumulate inside the damaged area and trigger a runaway cycle of inflammation and further damage. This process can culminate in the formation of a plaque—a chaotic lump of gunk that bulges out into the blood vessel, restricting the flow of blood and potentially resulting in the formation of dangerous blood clots that can block blood flow through the vessel entirely. Having high blood pressure significantly raises the chances of all these things happening, because the large force exerted by the circulating blood increases the likelihood of damage to the blood vessel walls. It also puts strain on the heart. As a result, hypertension—consistently elevated blood pressure—is one of the biggest risk factors for cardiovascular disease.
Chronic stress has been identified as one of a number of factors, also including genes, unhealthy diet, and physical inactivity, which can contribute to the development of hypertension. We have all experienced those telltale physical sensations associated with increased heart rate and blood pressure during a stressful situation. These effects are driven by a rush of hormones, such as cortisol and adrenaline, which usually subside once the stressful situation ends. The problem comes when the stresses—and the associated hormones and elevated blood pressure—don’t end.73
Over the past few decades, a number of studies have identified racism as a chronic stressor that may contribute to hypertension and negatively impact cardiovascular health. We will explore this research in more depth later in the book, but broadly, perceived discrimination and racism-related vigilance—an anticipatory stress associated with living in a racist environment—have both been associated with hypertension prevalence among Black people in the US, among whom the incidences of hypertension and cardiovascular disease are higher than those among the wider US population. In the UK, the incidence of hypertension is also higher among people of Black ethnicity, as well as among people of South Asian ethnicity, relative to that among White ethnic groups. And although Carol’s blood pressure had appeared normal at the time of her health checkup, she had experienced high blood pressure in the past.74
“I had in both my pregnancies, pregnancy-induced hypertension,” a form of high blood pressure in pregnancy, she recalled. “Looking back, I have discussed and I’ve wondered whether that played any role at all,” she added. Hypertensive disorders in pregnancy are a leading cause of pregnancy-related death, which as we saw in the last chapter is more common among Black women than White women in both the US and UK, and there is evidence that women who experience hypertension during pregnancy have an increased risk of developing cardiovascular disease later in life.75
From listening to Carol speak, it is clear that she is a person who takes a lot of responsibility for her health—and her medical background means that she approaches everything with clinical precision. She explained that after her heart attack, she looked back through her medical records and noticed that although she hadn’t been diagnosed with diabetes before, her blood glucose had been slightly above normal in the past. Since the heart attack, she has been struggling to get her blood glucose level down. “I’ve lost even more weight, my lifestyle is—I don’t know what more I can do, but those things,” she said.
I sympathized with Carol’s need to understand the factors that led to the serious and life-altering damage sustained to her heart. Was it her “nonstandard” symptoms? Was it her being disbelieved when she sought treatment? Was it stress? Like Carol, we can’t know for sure. But her experience points toward a nexus of factors, many of which have racism at their center. This has broad implications: cardiovascular disease is the world’s biggest killer, even though most cardiovascular diseases are preventable by addressing environmental risk factors. As we will see in the next few chapters, improving access to healthy living conditions, equitable medical care, and an environment free from the stresses of daily discrimination would all go a long way toward reducing racial and ethnic inequalities in cardiovascular disease. This applies to other diseases too, including the world’s second biggest killer—a disease that can take hold almost anywhere in the body.
I have never been especially interested in superhero movies or comics, even as a child. But in February 2018 when the first Black Panther movie started showing in UK cinemas, I absolutely could not wait to watch it. I finally went to see it one weekend with a friend in Oxford, and the movie more than lived up to my expectations. I remember feeling a bit emotional and overwhelmed. It was a movie I wished I could have watched as a child, growing up and going to school as one of few Black kids in a predominantly White environment. I used to feel ashamed of my skin, my hair, my general Blackness and “otherness,” but I think watching that movie—a blockbuster with a Black director featuring a star-studded, mainly Black cast wearing dashikis and kente cloth and natural hairstyles—would have helped my child self to feel seen. This memory of watching Black Panther came flooding back to me two years later, in the summer of 2020, when I heard the news that the actor Chadwick Boseman—the Black Panther—had died from cancer at the age of just forty-three.
“It was the honor of his career to bring King T’Challa to life in Black Panther,” his family said in an emotional statement shared to his Instagram account shortly after his death. Boseman had been diagnosed with stage III colon cancer in 2016, which later progressed to stage IV. His family revealed this in their Instagram post, to the shock of Boseman’s fans, and explained that he had privately been undergoing countless surgeries as well as chemotherapy treatment, all the while continuing filming for multiple movies.
Boseman’s death shattered so many people who, like me, saw him as a literal superhero. In a year during which Covid-19 had already exposed vast racial and ethnic health inequities in the US, the UK, and elsewhere in the world, his death also put a sharp spotlight on how these inequities manifest in cancer—the second biggest killer globally after cardiovascular disease. Just as cardiovascular disease encompasses a range of different conditions, cancer also refers to a diverse group of diseases. These diseases can appear almost anywhere in the body, because of the key feature that connects them: uncontrolled cell growth.
Usually, our cells grow and multiply through a meticulously controlled process called cell division (the first time I had the privilege of looking down a microscope and witnessing a cell in the midst of this highly choreographed routine, I was in awe). Cancers can develop in cases where this orderly process has broken down due to genetic mutations—changes to DNA—which are rare, but which tend to accumulate with age. Environmental exposures play the lion’s share of the role in influencing the likelihood of these changes occurring, although they can also sometimes be inherited. Cancer cells look a lot like normal cells, but they can behave very differently: growing when they haven’t been instructed to, ignoring signals to stop growing, spreading throughout the body, persuading blood vessels to grow toward them, and hiding from the body’s immune system. The sooner these dangerous cells are detected, the better. Boseman’s cancer was diagnosed at stage III, meaning it had most likely already started to spread from his colon to invade nearby parts of the body. When he died, within less than five years of his diagnosis, the disease had already progressed to stage IV, indicating that the cancer had disseminated further.
Boseman’s experience unfortunately reflects a broader pattern in the US, which his wife, Taylor Simone Ledward, highlighted during a heartfelt speech she gave as she accepted her late husband’s NAACP Image Award in 2021. “He was an uncommon artist and an even more uncommon person, but the manner in which we lost him is not uncommon at all—not in our community,” said Ledward, fighting back tears. She was referring to the fact that Black people in the US are 20 percent more likely to develop colorectal cancer and 40 percent more likely to die from it, compared with most other racial and ethnic groups. In fact, Black people experience higher death rates and lower five-year survival rates for most cancers compared with other racial and ethnic groups in the US. This is particularly striking given that the incidence of cancer overall is similar if not slightly higher among White people compared with Black people, with White people experiencing the highest rate of cancer of any racial or ethnic group in the country.76
For instance, despite a similar incidence of breast cancer—the most common type of cancer—among Black and White women, the death rate from the disease is 41 percent higher among Black women. This seeming paradox is at least partly explained by disparities in cancer diagnosis and access to timely treatment. Black people are more likely than White people to be diagnosed at an advanced stage of disease—as Boseman was—by which point treatment is usually more expensive and less likely to be successful. Ledward addressed this during her speech, emphasizing the value of routine screening in catching colorectal cancer before it’s too late. “If you are forty-five years of age or older, please get screened. Don’t put it off any longer,” she said. “This disease is beatable if you catch it at its early stages, so you don’t have any time to waste,” she added.
While efforts to encourage people to get screened for cancer regularly are laudable, this alone won’t be enough to eliminate disparities in disease outcomes. It will also be crucial to make certain that access to screening is equitable in the first place. Black people and other people of color in the US are more likely than White people to be uninsured and to face other barriers that may limit access to health care, including routine cancer screening. And even beyond diagnosis, there is evidence that Black people and people from other racial and ethnic minority backgrounds are more likely to experience delays in their cancer treatment relative to their White counterparts.77
At this point it probably won’t surprise you to learn that racial and ethnic disparities in cancer have also been documented elsewhere in the world. In 2021, New Zealand politician and member of parliament Kiri Allan shared her cervical cancer diagnosis on social media, in an effort to encourage more people to get screened. “Please, please, please—encourage your sisters, your mothers, your daughters, your friends—please #SmearYourMea—it may save your life—and we need you right here,” she wrote, using a slogan created by the late cervical cancer campaigner Talei Morrison to encourage Māori women in particular to get screened for the condition.
The vast majority of cervical cancer cases are caused by infection with human papillomaviruses, or HPV, and the combination of HPV vaccination with regular cervical screening has been shown to significantly reduce the risk of disease and death. In 2020, about 90 percent of the new cases and deaths globally happened in low- and middle-income countries, where access to these interventions is more limited. But even within wealthier nations, disparities in cervical cancer remain—and they often fall on racial and ethnic lines.
Māori women are diagnosed with cervical cancer at more than twice the rate of New Zealand European women and are three times more likely to die from the disease. Similar inequalities have been recorded in neighboring Australia, where rates of diagnosis and death from cervical cancer are two and three times higher among Indigenous compared with non-Indigenous women. And while the World Health Organization has acknowledged that inclusion of Indigenous populations in cancer registries globally is insufficient, evidence from countries where such data are collected indicate that Indigenous peoples tend to experience a higher risk of cancers and have worse health outcomes than their non-Indigenous counterparts.78
Low uptake of screening is often highlighted as a contributing factor. In New Zealand, for instance, 34 percent of Māori women don’t attend regular cervical screening, compared with 21 percent of New Zealand European women. But again—whether in the US, New Zealand, or elsewhere—closing these kinds of health gaps requires not only encouraging people from marginalized racial and ethnic groups to get screened, but actively identifying and eliminating barriers that are preventing people from accessing these potentially lifesaving health checks.79
A recently trialed intervention in New Zealand provides an example. A 2019 survey identified a desire for bodily autonomy, including whakamā (embarrassment, shyness, or reticence), as the most frequently cited barrier to cervical screening among Māori women, and found that the majority of survey respondents said they would be likely or very likely to do a self-administered HPV test at home and to attend follow-up if they were to receive a positive test result. When these findings were subsequently put to the test in a randomized controlled trial, cervical screening rates were found to be almost three times higher among Māori women who were given the option of doing the screening at home as an HPV self-test, compared to those offered the standard cervical smear. Following the results from the trial, in May 2021 New Zealand’s health ministry announced NZ$53 million ($33 million) worth of funding toward the implementation of a wider at-home cervical screening program.80
In addition to screening, early recognition of cancer symptoms is also vital. Yet as a study from the UK demonstrates, racial and ethnic inequities loom over this stage of diagnosis too. The analysis of more than 126,000 cancer cases in England between 2006 and 2016 found that people of Black or Asian ethnicity had to wait longer than White people to be diagnosed after first presenting to a GP with cancer symptoms. Whereas the median waiting time among White people was 55 days, among people of Asian ethnicity it was 60 days and among Black people it was 61.81
As anyone who has direct or indirect experience with cancer knows, the earlier it is detected the better a person’s chances of survival. Every day counts. That is why screening and early recognition of symptoms are both so important. But cancer is complicated and difficult. The cancer journey doesn’t begin nor end at diagnosis—and neither do the associated racial and ethnic inequities. The authors of the UK study acknowledged this complexity in a 2022 research article summarizing their findings. They pointed out that the observed inequities in waiting times for diagnosis were “unlikely to be the sole explanation for ethnic variations in cancer outcomes,” which have previously been documented in the UK—as in the US, New Zealand, and elsewhere.
Indeed, many factors contribute to cancer risk and outcomes. So far, we have seen how cancer begins with changes to DNA, which can result in dangerous, uncontrolled cell growth. These changes tend to accumulate as we get older, which is why the risk of cancer rises with age, but environmental exposures can accelerate them too. The fact that some of these environmental exposures are very well known, such as radiation or tobacco smoke, can sometimes give the illusion that they are completely avoidable.
But for many of us, avoiding exposure to cancer-causing substances, known as carcinogens, is difficult—if not impossible. What if they are in the air you breathe? What if they are in the water you drink? What if they are in the materials you use to do your job? As we will see in the coming chapters, inequities in societies globally often mean that these sorts of unavoidable environmental exposures disproportionately affect people belonging to marginalized racial and ethnic groups. Racism is harmful to health in all sorts of ways—and it isn’t only our physical health that is suffering.82
In the summer of 2021, I was experiencing some personal challenges and I decided to try seeing a therapist. I was encouraged by my mother, who had recently switched careers to counseling from pharmacy. I had seen an ad on social media for one of those apps where you can find a counselor or therapist online and attend appointments via phone or video call, and I thought, why not give it a go? I answered a few multiple-choice questions in the app, and then I was presented with a long list of potential therapists to choose from.
An initial, introductory video call with my chosen therapist went well. We exchanged some small talk and she told me a bit about her background and how she usually works. I told her about myself, including about some past mental health struggles I had experienced, and explained that I wanted to try counseling to see if it could provide me with some tools to help navigate present and future challenging situations in my life. I left that introductory session feeling positive and I immediately scheduled another appointment for a few weeks later. It was during that second appointment that I sensed something wasn’t quite right.
My therapist, a White woman who I would guess was in her forties or fifties, became noticeably uncomfortable when I started speaking about my experiences of racism. As the conversation continued, I felt the need to start playing down my own experiences in order to protect her feelings. That made it difficult for me to speak freely about what was happening in my life at the time, as racism was a central part of it. After reflecting and talking about the experience with my mother and my partner, I made the decision to stop working with that therapist.
I hadn’t thought much of this experience until I met Alfiee Breland-Noble, a psychologist and the founder of the AAKOMA project, a nonprofit organization in the US focused on illuminating and reducing mental health disparities for diverse communities. Dr. Alfiee, as she is fondly referred to by those around her, founded the AAKOMA project back in 1999. As a professor doing mental health research, she became frustrated at the lack of funding available in the US for research focused on better addressing the mental health care needs of Black people and other people of color. So, she decided to channel her ideas and passion into a nonprofit. At first, “I was funding it out of pocket, paying for everything and doing everything myself,” she said. But, according to Dr. Alfiee, the general attitude toward her work shifted significantly following the murder of George Floyd, an unarmed Black man, by White police officer Derek Chauvin in Minneapolis in 2020.
Floyd’s murder sparked a wave of anti-racism protests in the US and around the world, including in Germany, where I had recently relocated with my partner. “Then it exploded,” said Dr. Alfiee, because the public’s heightened awareness of racism and its harms was accompanied by a sharp rise in donations. The AAKOMA project has been using that donated money to provide free therapy sessions and workshops for teenagers and young adults of color in the US, as well as raising awareness and providing education for young people and their families on the importance of mental health. This kind of work is sorely needed, because, just as with physical health, there are vast racial and ethnic inequalities when it comes to mental health too.
It turns out the difficulty I faced in discussing my experiences of racism with my therapist is not unique—neither in Germany nor elsewhere. A 2020 survey of more than eight hundred Black people living in Germany found that 62 percent of respondents agreed with the statement “In psychotherapy, my experiences of racism are not taken seriously and are questioned.” More than a third said that this was something they experienced “often,” “often,” or “very often.”83
Failure by mental health care providers to acknowledge and process the realities of living in a racist society has been linked to poorer perceptions and experiences of care among people from racial and ethnic minority backgrounds, for instance in the UK and US. These kinds of negative perceptions and experiences can in turn discourage people from accessing such services altogether, contributing to disparities in access to mental health support for people of color and people belonging to marginalized racial and ethnic groups globally. “It’s not our identities impacting our ability to access care, it’s the system’s inability to recognize and understand and incorporate our needs,” Dr. Alfiee pointed out to me, after I told her about my experience with the therapist. “You should never be in a position where you feel like you have to tone down your experience. That’s not why you’re there.”84
I was fortunate enough to be in a position where I felt able to seek support in the first place. The whole subject of mental health is shrouded with stigma, especially when it comes to mental illness, and research from the US, the UK, and elsewhere suggests that such stigma tends to be higher among racial and ethnic minority compared with majority groups. Cost presents another major barrier to accessing mental health support, which Dr. Alfiee explained to me is often a particular issue for Black people and other people of color in the US, where she is based. “Then imagine, on top of that, you get past the hurdle of money, you get past the hurdle of finding, you know, getting access to some of this care. You get somebody, and then you do all of that and they’re making you feel like you need to tone down who you are,” she said. “Come on.”85
A few months after my conversation with Dr. Alfiee, I found a different therapist, through my mother’s network in the Netherlands, where she has her own counseling practice. That therapist, who I ended up doing multiple sessions with, is a White woman, and from the outset she was very open to talking about racism and other issues related to my identity and life experiences—including acknowledging and discussing these dynamics in the context of our therapist-client interaction. I felt really grateful to have found a therapist who could support me fully, in all aspects of my identity. Unfortunately, this kind of support just isn’t accessible for many people belonging to marginalized racial and ethnic groups around the world—and it is even less so for people with multiple intersecting marginalized identities. Tragically, these are often the very people who could benefit from this type of support the most, given the harmful effects that experiencing racism and discrimination can have on mental health and well-being.86
“In the mental health space, we’re a helping profession. You can’t be a helping profession and not help the fullness and wholeness of what a person brings to the table. And so, when we talk about cultural competence, that’s what we’re talking about,” said Dr. Alfiee. “We’re not talking about; you need to know every single thing there is to know about every single culture. What you can do is be open enough and have a skill set, have a knowledge base and have an awareness level that allows you to be present and welcoming and inviting and supportive of anybody who comes into that psychotherapeutic space, seeking your help,” she said. “We all deserve the right to go into that psychotherapeutic space and be seen 100 percent for who we are.”
On top of disparities in access to mental health support, in many countries there are also racial and ethnic inequalities when it comes to the diagnosis and treatment of mental illness. In the US, for instance, research by Dr. Alfiee and colleagues has found that university students of color with mental health conditions are less likely to be receiving treatment compared with White students. Similar inequalities have been documented among children and adolescents. “We know from data that if you take two, let’s stick with young people, with the same set of symptoms, where most of us might associate those symptoms with an illness like depression—if you take two young people, put them in front of a professional with those same symptoms, and one of those children happens to be White, the other happens to be Black, with the same symptoms, the White child is more likely to be referred for services that are behavioral health in nature, the Black child is more likely to be referred for services that are more punitive in nature,” Dr. Alfiee told me. “That’s some of the variance in why so many more Black children end up in the juvenile justice system, end up getting suspended from school, end up getting expelled from school,” she said.87
Inequalities in the treatment of depression extend to the adult population too. According to data for New York City from the Mayor’s Office of Community Mental Health, just 30 percent of Black New Yorkers with depression self-reported receiving mental health treatment in 2017, compared with 58 percent of White New Yorkers. Black, Latinx, and Asian American and Pacific Islander New Yorkers with depression were all less likely than White New Yorkers to self-report receiving mental health care. “Untreated depression, untreated anxiety, exposure to trauma—if those things are left untreated, people behave in ways that are not the healthiest,” Dr. Alfiee explained. “The result of unhealthy behavior, often, for Black people is incarceration. The result of unhealthy behavior for White people is support and help. Not always but often,” she added.88
There are similar inequalities in other countries, such as the UK. A 2021 study reported that the likelihood of receiving treatment among people with common mental health conditions in England—including depression, anxiety, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and social anxiety disorders—was lower among all ethnic minority groups than among White ethnic groups, and lowest among Black people. At the same time, evidence from the UK, the US, and several other countries, including Canada, the Netherlands, and New Zealand, suggests that Black people and people belonging to other minority ethnic groups are more likely than White people to be admitted to the hospital involuntarily for psychiatric care. A study that reviewed data on psychiatric hospitalization in the UK and internationally found that among the most common explanations provided for the higher rates of involuntary hospitalization among racial and ethnic minority groups were an increased prevalence of psychosis, an increased perceived risk of violence, and increased police contact. Separate research indicates that clinicians are more likely to put emphasis on psychotic rather than depressive symptoms when examining Black compared with White patients—something that may be linked to an overdiagnosis of schizophrenia and underdiagnosis of depression among Black people.89
Harmful stereotypes about Black people—and Black men in particular—being dangerous and prone to violence may also contribute to increased police involvement and involuntary hospital admission among those experiencing mental illness, with potentially devastating consequences. An analysis of police killings in the US between 2015 and 2019 found that unarmed Black men exhibiting signs of a mental illness were more likely to be shot and killed by police compared with White men exhibiting similar behaviors. This comes on top of a backdrop of disproportionate police killing of Black people, which itself contributes to racial trauma and harms mental health. Underlying all of this inequality is a historical legacy of racism embedded within the field of psychiatry itself.90
“There was literally a White psychiatrist who made up a name of a psychiatric illness for enslaved Africans who tried to escape,” Dr. Alfiee told me. The psychiatrist she was referring to was Samuel Cartwright, a doctor and slaveholder in the US who in the 1850s hypothesized that enslaved Africans fleeing captivity were doing so because they were experiencing a mental illness that he termed “drapetomania.” “The idea was that if you, as a Black person, wanted to escape bondage, there was something wrong with you psychologically,” said Dr. Alfiee.91
The fight by Black people in the twentieth-century US for civil rights was similarly pathologized by psychiatrists as a supposedly schizophrenia-like condition termed “the protest psychosis,” as US psychiatrist and author Jonathan Metzl illustrates in his book by the same name. “You still have stereotypes, all through history, of Black people, I think in the United States and globally, being seen as everything from savages, to lazy, to ignorant,” said Dr. Alfiee. “If you think about that history, and then if you think about the field of psychiatry overall, and you come all the way up to current day, people have long memories.”92
The examples of racial inequity that we have covered so far, from Serena Williams’s childbirth experience in the US to Saidy Brown’s journey with HIV in South Africa, are by no means an exhaustive list. I have deliberately chosen not to dedicate too much of this book to simply documenting disparities. While documenting inequality is undeniably important, it doesn’t go very far toward identifying underlying causes.
Now that we have established that health gaps exist, I want to start investigating why they exist. I want to examine how racism in society, medicine, and science contributes to health gaps and harms health more broadly. Of course, society, medicine, and science are overlapping spheres—medicine and science exist within society, for one thing—but for the purposes of our investigation we are going to focus on each of them in turn. I hope that in doing so—with help from patients, activists, medical students, doctors, and scientists, who we will meet along the way—we can illuminate potential solutions.
Systemic racism has been lurking behind everything we’ve discussed, but in the next chapter, I want to explore head-on how this insidious form of discrimination contributes toward the health gaps we have learned about so far. Because systemic racism influences every aspect of our lives, from the health care we can access to the very air we breathe.