By Victoria A. Cargill, M.D., M.S.C.E., Senior Director, Health Equity, Milken Institute

Black History month arrived after the news of the beating of yet another Black man at the hands of police officers. In this case, there were five police officers, every one of whom was Black. Violence became the subtext of the month and yet another national conversation. The cycle of handwringing, calls for change, community anguish and family sorrow began again while another Black man was laid to rest. Violence had once again come to call.

Against this backdrop, there continues to be an ongoing and enlarging health disparity in the prevalence and outcome of many diseases. For example, between 2018 and 2019, it is estimated that 1 in 5 Americans with diabetes was unaware of their diagnosis, and 12.1% of US adults aged 18 and older with diagnosed diabetes are Black, non-Hispanic. Only ..American Indian or Alaska Native populations had a higher prevalence (14.5%), and the category of Hispanic overall was a close third (11.8%).      

Hypertension, an important precursor to congestive heart failure, atherosclerotic heart disease, and other cardiovascular conditions, is more common among non-Hispanic Black adults than in non-Hispanic White adults (56% versus 48%). Hypertension is unevenly distributed geographically: Areas such as the deep South have a higher reported prevalence of the condition. Obesity, a common denominator among these conditions, is more prevalent in Black populations, with 49.9% of Black adults rated as obese compared to the national average of 41.9%.

Black communities are and have been under siege. The cumulative effects of prolonged stress on the body are clear and well documented, affecting all systems, from the musculoskeletal, respiratory, and cardiovascular to the nervous and reproductive. No organ system is spared the effects of short- and long-term unrelenting stress. Just as concerning is the epigenetic transfer of the effects of stress from the mother to the unborn, with outcomes ranging from effects on learning to emotional/behavioral problems, and even differences in the cortisol levels (a stress hormone) in pre-adolescent children.

In 2023, there is no shortage of stressors in the Black community: poverty, racism, gun violence, police brutality, food insecurity, unemployment and underemployment, unequal health care access, health disparities —the list seems (and feels) endless. These stressors not only feel insurmountable, but will remain so if we continue to approach them as one unique challenge at a time, from the safety and sanctity of our self-imposed silos. 

With over 74,000 excess Black deaths annually and Black mortality rates higher than any other racial or ethnic group in the US, the stakes could not be higher. Black populations experience an assault on their health from in utero to the grave. The effects of maternal stress on the unborn fetus, the environmental stressors during childhood and adolescence, and the cumulative effects of the social determinants of health all contribute to this assault. Easily accessible and highly processed fast food, especially in areas with limited access to fresh groceries, is linked to physiologic changes such as blood vessel stiffening, heart thickening, and hypertension—which can begin in childhood. There are more than sufficient data to shift the question from what we know to how we utilize what we know to make effective and sustained change.

We need targeted and sustained action from leaders across the public health ecosystem.  

First, we must approach these issues at their root cause and common denominators. That requires committing to meaningful collaboration across sectors, dismantling silos, and engaging in true community partnership and dialogue. Those with the lived experience of these challenges must be full and equal partners with those who seek to address the issues through intervention, policy, and research. These partnerships are only limited by our determination (or lack thereof) and creativity, and include academic-community partnerships, public-private partnerships, and community-regional-state- and federal partnerships. The frontal assault of COVID-19 has receded into the rear-view mirror, but it proved how creative and innovative our responses could be when the stakes were perceived to be high.

Second, we must see the individual/community through a socioecological lens, recognizing that the effects on Black health are a result of countless intersections—such as violence intersecting with trauma and maternal stress intersecting with fetal outcomes and emotional/behavioral issues in progeny.

Third, funders must recognize the importance of these intersections and fund efforts accordingly. That means requiring and rewarding intersectional collaborative work, as opposed to the “expert” in isolation with a few community endorsers included to check the community input box.

Fourth, it means going beyond examining and tracking the geographic variations in mortality and disease outcomes. It means tracking these with the goal of targeted action—including robust evaluation of those policies that not only facilitate but perpetuate health disparities and dismantling them. This will necessitate the creation of coalitions to drive the political will to force change. It will not be easy, but it is essential.

Finally, there must be a long overdue self-examination in many sectors of our society, expanding the diversity of our advocacy, legislative, medical, public policy, and public health bodies so that they reflect all citizens of the United States proportionately.  

These efforts will not only take time but also require funding and collective will. It is a public health imperative, it is a social justice imperative, and it is a moral imperative. To stop the ongoing trauma endured by countless generations in Black communities will require that we never be afraid to make some noise and to get into some good trouble.

---

Victoria A. Cargill, M.D., M.S.C.E.
Dr. Victoria Cargill is currently a Senior Director at the Milken Institute for health equity and a subject matter expert at the Milken Center for Public Health. A former Assistant Commissioner of Health at the Baltimore City Health Department, Dr. Cargill also served as a senior policy official and program director for 20 years at the National Institutes of Health (NIH) in the Office of AIDS Research (OAR), and the Office of Research on Women’s Health (ORWH). A former member of the DHHS Adult and Adolescent HIV Treatment Guidelines panel, and acting chair of the FDA Antiviral Advisory Committee, expanding HIV treatment options for all affected populations remains an area of interest and advocacy for her. A graduate of Mt Holyoke College and Boston University School of Medicine she completed an internal medicine residency at the Brigham and Women’s Hospital, and an Andrew Mellon Fellowship at the University of Pennsylvania where she received a Master of Science in Clinical Epidemiology. The author of over 150 scientific articles, research presentations, book chapters and popular press educational materials, Dr. Cargill considers patients and communities her best teachers.