CARDIFF GARCIA, BYLINE: How much would you pay to avoid morning traffic? Why are plane tickets to Boise so expensive? I'm Cardiff Garcia, co-host of The Indicator. In every episode we take on a new, unexpected idea to help you make sense of the day's news. Listen every afternoon on NPR One or wherever you get your podcasts.
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GENE DEMBY, HOST:
So imagine you're walking through a department store like our voice actor here.
UNIDENTIFIED VOICE ACTOR: (As store patron) Weekend sale.
DEMBY: You want to buy something to wear for this thing you have coming up - a date, maybe it's a job interview.
UNIDENTIFIED VOICE ACTOR: (As store patron) I do need some new shoes.
DEMBY: Anyway, whatever it is, it doesn't really matter. The point is you want to look good. So you're looking around and you're shopping, when you notice that one of the security guards is staring at you. Like, full-on gritting on you.
UNIDENTIFIED VOICE ACTOR: (As store patron) Oh, my God.
DEMBY: And you get that knowing feeling in the pit of your stomach. You can't prove it, but you know what it is. He's looking at you because he thinks you're stealing something or about to steal something, and he thinks you're stealing something because you seem like you don't belong there, and you seem like you don't belong there because you're black.
UNIDENTIFIED VOICE ACTOR: (As store patron) OK. This is really ridiculous.
DEMBY: And you're annoyed. You're angry.
UNIDENTIFIED VOICE ACTOR: (As store patron) Come on.
DEMBY: And you want to leave, but you also want to be like...
UNIDENTIFIED VOICE ACTOR: (As store patron) I can afford this shirt, and those shoes.
DEMBY: But also, you're like...
UNIDENTIFIED VOICE ACTOR: (As store patron) Even if I couldn't afford this shirt, I still get to be in the store without you clocking me.
DEMBY: So maybe you go buy the shirt. You cop that shirt and pointedly eyeball the security guard on the way out. You showed him.
UNIDENTIFIED VOICE ACTOR: (As store patron) Hashtag capitalism.
DEMBY: Or maybe you put that shirt down and walk out because why would you want to patronize a store that would treat you like that?
UNIDENTIFIED VOICE ACTOR: (As store patron) This is trash.
DEMBY: So that encounter is one of those little indignities that make up the tapestry of American racism. Some folks call them microaggressions. I personally hate that word so I don't say it. But, you know, it's not like mass incarceration or forced displacement, and when you recount that story to someone, maybe they say, you know, you should let it go, just get over it, that's just the other people's ignorance. You might even say that to yourself.
But here's the thing. When you were in that store and all that stuff was going on, your body had a stress response. It's evolutionary. Your heartbeat picked up. Your body unleashed glycogen so you had energy to fight or to flee. You might have felt anxious, you might've felt aggressive. We're now learning that the toll from this constant drumbeat could ruin your health. It might even cost you your life.
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DEMBY: You are listening to CODE SWITCH. I'm Gene Demby. Shereen is out this week. And on this episode, the high health costs of discrimination. We're going to hear from a researcher who was one of the first people to discover just how discrimination erodes your health. But first we're going to start with a story about a woman named Shalon Irving. She was a black woman, a Ph.D., she worked at the Centers for Disease Control and Prevention, and she was actually looking at this very question about the ways that racism affects our health. We begin with a letter that Shalon wrote to her mother, Wanda.
LEAH DONNELLA, BYLINE: (Reading) I am sorry that I have left you. On the particular day that I am writing this, I have no idea how that may have occurred, but know that I would never choose to leave. I know it seems impossible right now, but please do not let this break you. I want you to be happy and smile. I want you to know that I am being watched after by my brothers and Grandma and that we are all watching you. Please try not to cry. Use your energy instead to feel my love through time and space. Nothing can break the bond we have, and you will forever be my mommy, and I, your baby girl.
DEMBY: That was the voice of Leah Donnella reading a letter that Shalon's mother found not long after her death. Shalon passed away last year, just a few weeks after giving birth to her daughter. NPR's Renee Montagne and ProPublica's Nina Martin learned about Shalon's story while they were investigating the high rates of maternal deaths in the United States. Within that high rate, black women are three times more likely to die than white women. Here's Renee with a story that originally aired on All Things Considered.
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RENEE MONTAGNE, BYLINE: By any measure, Shalon had accomplished a lot. Highly educated and well-paid, she owned her own home and had access to the finest health care. Yet none of that protected her from becoming part of the shockingly high rate of black maternal mortality.
WANDA IRVING: Soleil? Can you say hi? Hi.
MONTAGNE: On a recent afternoon, we joined Shalon's mother, Wanda Irving, in her home outside of Atlanta. She was surrounded by photos and mementos and caring for the baby Shalon left behind when she died from complications of childbirth.
IRVING: There's a picture of her and Soleil with the same outfits. That was taken the day she collapsed, the morning of the day she collapsed. Soleil is French for sun. She just lights up a room when she smiles. She's the only reason I have for getting out of bed every morning.
MICHAEL LU: The fact that in 2017 America a black woman is still three to four times as likely to die in pregnancy and childbirth and that they are twice as likely to suffer a life-threatening complication, I think that's a national disgrace.
MONTAGNE: Dr. Michael Lu spent years as head of the Maternal and Child Health Bureau. That's the main federal funder of programs for mothers and infants. He and others have done studies showing that an important cause of poor outcomes in childbirth for all black women is prolonged exposure to the indignities and dangers of discrimination.
LU: We're talking about African-American doctors and lawyers and business executives, and they still have a higher maternal mortality rate than white women who were high school drop-outs. It's the experience of having to work harder than anybody else just to get equal pay and equal respect. It's being followed around when you are shopping at a nice store, or being stopped by the police when you're driving in a nice neighborhood. Those types of experiences create the kind of chronic stress that continues to gun the engine, which over time create the wear and tear on your body's systems.
MONTAGNE: There is a word researchers use for this accelerated deterioration of the body. It's called weathering. And some studies suggest it can be measured at the level of chromosomes. One study looking at the chromosomal markers for aging found that middle-aged African-American women on average appear 7.5 older than their white counterparts. The lead author was a pioneer in the study of weathering, Arline Geronimus, of the University of Michigan School of Public Health.
ARLINE GERONIMUS: Long-term exposure to cascades of stress hormones causes a lot of different health vulnerabilities, and it increases your susceptibility to infection but also the early onset of chronic diseases, in particular - hypertension, diabetes, morbid obesity.
MONTAGNE: Weathering and chromosomal indications of aging can occur in anyone. One study, for example, showed similar weathering in white mothers caring for autistic children. The core problem is lifelong, unrelenting stress. And for African-American women, pregnancy becomes an even more dangerous time.
LU: Pregnancy is a big stressor on the body, and a healthy body can adjust and adapt to it, but a body that's worn out will have a much harder time and therefore putting the woman at greater risk.
MONTAGNE: Photos of Shalon Irving show a vibrant woman river-rafting with friends, posing in a silky evening gown. And beneath Shalon's broad smile and healthy glow lurked many of the same issues that beset less-privileged black women. Shalon had already lost both of her siblings, a baby brother in a car accident, and then her beloved older brother, Sam, died slowly from MS. As a primary caregiver, Shalon fretted over what she saw as sub par treatment being offered to Sam because he was black and on Medicaid.
Then last year, Shalon got news she had long hoped for. She was pregnant, but soon found herself single when her relationship with the baby's father fell apart. These traumatic life events do add to the risk of pregnancy. Along with Shalon's history of surgery for uterine fibroids, which meant she would have to have a cesarean, she was overweight and taking medication to control a blood clotting disease. Still, her mother says, Shalon managed to overcome all these risk factors through to the very end of her pregnancy.
IRVING: It was a great birth. It was just a beautiful time. So the problem didn't come in until after the birth, and she didn't have an afterbirth plan.
MONTAGNE: In fact, few new mothers do. Obstetrician Elizabeth Howell is known for her work on racial disparities as a professor at Mount Sinai's Icahn School of Medicine in New York.
ELIZABETH HOWELL: We've had a longstanding history in this country of just sort of sending moms out. You know, they've done the big thing. They've delivered the baby. And now they'll heal, they'll be fine. And, you know, that's actually not true, right?
MONTAGNE: In fact, the CDC finds that more than half of America's maternal deaths occur postpartum. Fully a third of those happen at least a week or more after giving birth. Monica McLemore is a nursing professor at the University of California, San Francisco, now leading a major effort to reduce premature births among black women. Her research involves scores of focus groups with black mothers.
MONICA MCLEMORE: And so one of the things that has been very striking from the focus groups that I've conducted is that people feel disrespected during their care. They talk about not being believed. They talk about reporting signs and symptoms of deterioration and not having any real action that occurs.
MONTAGNE: Numerous studies do support the existence of implicit bias in the treatment of black patients. And in a survey recently released by NPR, the Robert Wood Johnson Foundation and Harvard's Chan School of Public Health, one-third of black women said they had been discriminated against because of their race when going to a doctor or a health clinic. One in 5 avoided going to a doctor or seeking health care out of concern that they would be racially discriminated against. Monica McLemore has found that anticipation of bias can also disrupt key communication between a mother and her provider.
MCLEMORE: One of the patients who was talking through her birth story was going on and on and on about how she has no game face. And she says, people who know me know that I have very emotional reactions, and as a black woman I've learned to curtail that because I don't want to appear to be angry all of the time. But one of the things that was really difficult during her birthing experience was she was working so hard to not appear to be angry or to not appear to be in pain that every time she spoke to the nurses and requested pain medicines, they didn't believe her. And so she really was trying to suppress what her natural facial expressions and responses were because she didn't want people to be buying into stereotypes about black women, and particularly whether or not we're angry.
MONTAGNE: Among the more than 200 stories ProPublica and NPR collected about black mothers, inadequate care after birth was a constant theme. When we reviewed Shalon Irving's medical records we discovered a cascade of complications after birth. Within days, the wound from her cesarean became badly infected. It was treated, but a week later she had to be seen again. The wound wasn't healing well and so painful she couldn't sleep. Reflecting Shalon's mounting distress, her medical records quote her, "it just doesn't feel right." Her legs were swelling until one became bigger than the other, and she was gaining weight, not losing. When a visiting nurse noticed Shalon's blood pressure suddenly spiking, she made another appointment.
IRVING: And she went in. It was just sort of, oh, that's to be expected. You just had a baby. Don't worry about it.
MONTAGNE: She was tested for a blood clot - it was negative - and given a new prescription, pills for high blood pressure. But when Wanda looks back now, all she sees is a series of missed opportunities to save Shalon.
IRVING: Because there is something wrong with this lady. Why not check it out instead of just sending her home? She's got a swollen limb. She's not feeling well. She's got high blood pressure. Why wouldn't you put that person in the hospital? She thought they were not paying attention. She did indicate that, yeah, Mom, they never listen to us.
MONTAGNE: That night, after her fourth visit in the three weeks since she'd given birth, Shalon collapsed.
IRVING: She just, you know, reached up one arm as if she was trying to grab something, and she just made a - I don't know - a gargling kind of sound like she was trying to say something and passed out.
MONTAGNE: Paramedics found her without a pulse and not breathing. She never regained consciousness. An autopsy later concluded Shalon Irving died from complications of hypertension. We can't know if Shalon would have survived had she been white, but hers is a story that does fit into the larger picture described by researcher Arline Geronimus of why black mothers too often die after giving birth.
GERONIMUS: Weathering itself just leads to a greater health vulnerability. So you could think of it as we'll patch up this problem and we'll patch up that problem, but overall, you're in a weakened physiological state. And so all sorts of different manifestations in your health can show up, and some very quickly.
MONTAGNE: In the 11 months since Shalon has been gone, Wanda's sorrow has never abated.
IRVING: I never really cry in front of Soleil.
MONTAGNE: Except once, recently, when she received a book put together by Shalon's friends and colleagues at the CDC, called, "Letters To Soleil," telling her how great her mother was.
IRVING: I was trying to read a couple of the letters to Soleil, and I just totally lost it. And she just looked at me like, this puzzled look, cocked her head a couple of times, and then she just put her head on my chest and started patting me like I do for her when she's crying. It was just the sweetest thing. She's just an amazing little girl. She understands so much.
MONTAGNE: Wanda Irving is in her 60s now, raising the daughter her own daughter had so longed for. And Soleil, she will have her first birthday on January 3. Renee Montagne, NPR News.
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DEMBY: After the break, we dive deeper with Arline Geronimus, the researcher who coined the term weathering. Stay with us.
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DEMBY: And we are back. We're talking with Arline Geronimus. She's a public health researcher and professor at the University of Michigan's Population Studies Center. You heard her in Renee Montagne's story just now. She's one of the people who first started this research. Thank you for coming on CODE SWITCH, Arline.
GERONIMUS: My pleasure.
DEMBY: So can you tell us a little bit about how you came to this research?
GERONIMUS: Yes. I actually started to come to this research when I was college age and when I started to see real differences in the life experiences and also the physical health of my college classmates who were from a more privileged population and young women I got to know quite well when I taught at a school for pregnant teenagers as a part-time job in Trenton, N.J., which was a more working class and largely minority population. I began to wonder about why I was seeing those differences and what did they mean. And that's when I coined the term weathering as a metaphor to suggest that what I was seeing was both weathering as in the idea of bodies being eroded by their environment but also it also means people being able to withstand that or survive it. And so I've always sought to be mindful of both aspects - the structured experiences that can erode health and the strength employed collectively by affected populations to sort of mitigate, resist or undo them.
Just yesterday, I heard in an interview with Emerald Snipes-Garner, who was talking about her - the death of her beloved sister Erica. She used a metaphor that I also think would be a great description of weathering. She talked about the stresses that she felt led to Erica's death at age 27 as being like - you know, being stressed in a way like - if you're playing the game Jenga, they pull out one piece at a time at a time (laughter) another piece and another piece until you sort of collapse. I'm paraphrasing her. But I thought the Jenga metaphor was very apt because you start losing pieces of your health and well-being, but you still try to go on as long as you can, even if you're disabled, even if you're, you know, even if it's hard, that you have a certain tenacity and hope and sense of collective responsibility, whether that's for your family or community. But there's a point where enough pieces have been pulled out of you that you can no longer withstand and you collapse.
DEMBY: Can we get into the science of this a little bit?
GERONIMUS: People have thought that health - you know, I mean, there have been folk notions and laypeople have thought that health differences between populations, such as black versus white in the U.S., were somehow related to differences in our DNA, that we were sort of molecularly programmed to have this disease or that disease. And one of the great advances I'd say of the last 10 or so years is the idea that differences that are at the molecular level don't have to be essential to you as a black person or a white person or Latino. But that instead, social and environmental factors can through what's called DNA methylation - which occurs when a group - I don't know how technical you want to get, but that occurs when a group of molecules attach methyl groups to specific areas of a gene's promoter region - either prevent the reading of certain genes or express certain forms of a gene product and you have genetic expression of that gene.
GERONIMUS: That's a pretty powerful idea, and it sort of refutes the kind of more DNA centric that you are, you know, destined by the literal DNA you have, by the genome rather than the epigenome to have certain diseases or not. But what I've seen over the years of my research and lifetime is that the stressors that impact people of color are chronic and repeated through their whole life course, and that in fact may even be at their height in the young-adult through middle-adult ages rather than in early life, and so increases a general health vulnerability, which is what weathering is. It's not that you get this disease or that disease. What's really happening is you're kind of worn down or weathered both by the chronic and repeated exposures to stressors and also by the high-effort coping with them, such as the vigilance in certain circumstances.
DEMBY: When you coined the term weathering, what was the initial response from the academic and medical community to that idea?
GERONIMUS: There have always been some people, you know, who found it interesting and intriguing and even started to pursue it in their own research programs. But initially, it was pretty well dismissed by a broader group of people. And...
DEMBY: Who were those people?
GERONIMUS: Who were those people?
DEMBY: I mean, you don't have to name names, but where was the locus of sort of pushback?
GERONIMUS: Well, there were - there were actually several loci - you know, pushback. One was there were - many in the medical community really seemed to think that there were just essential or intrinsic genetic, you know, black-white differences in health, that there must be some hypertension gene or, if it wasn't a literal gene back in Africa, there may be something about how hard the Middle Passage was the people who survived it had this gene for salt retention. And all of this has been debunked.
DEMBY: I remember hearing that growing up, that it - that hypertension and that black people had high blood pressure because of salt retention in the Middle Passage.
GERONIMUS: Right. Well, it's been very well debunked both on anthropological grounds but also on - if you compare hypertension rates, for example, between American blacks and blacks in the Caribbean, the American blacks have far higher rates of hypertension, yet they both went through the Middle Passage. So - but some people just thought that was the truth and they already had the answer and there was just something - you know, if black skin was genetically determined, well maybe there's some bundle of genes that also include hypertension and diabetes, you know, sickle cell, et cetera.
Others didn't necessarily think in those terms, but they might think in a kind of - economists were thinking more behaviorally and sociologists more sensed (ph) there was a cultural - an essential pathological culture that led to bad behaviors and weak families was that story. And that was a very strong narrative in the '70s, '80s and '90s. And even - I think it's a narrative that still exists, though more contested. So this idea of weathering in its metaphorical aspects and, you know, it didn't sound technical enough and it didn't fit any of those narratives 'cause it doesn't fit any of those narratives.
DEMBY: What was that like for you when people were dismissing the - when you coined this term?
GERONIMUS: Oh, it was so much fun.
GERONIMUS: It was very hard, especially because some of them dismissed it very publicly, you know, in newspapers, in - another reason I think people dismissed it is I first observed - in terms of scientifically observing it as opposed to having this impression - in seeing that young black women were more likely to have, you know, poor pregnancy outcomes if they were in their mid-20s than if they were in their late teens. And this flew in the face of a lot of advocacy organizations that were working very hard to prevent teen childbearing and who thought that - you know, I think there was a Time magazine cover at one point that said something like all social problems stem from teen childbearing. There was certainly a whole narrative that teen motherhood somehow caused perpetual poverty...
GERONIMUS: ..Lack of education, et cetera and poor birth outcomes. So even though I was able to show - you know, the data spoke for themselves that the risks were higher in black young women the later they waited to have children. And that was not true for whites. Whites had the lowest risk around the mid-20s and the highest risks in their teens.
DEMBY: And the rates were higher because the black women who waited later were more weathered.
DEMBY: They had been basically in America for a longer time. America had been happening to them for a longer period of time.
GERONIMUS: Exactly, and the impacts on their bodies had been happening for a longer time.
DEMBY: Right. So when did the conversation start changing? I mean, was that just a function of better scientific understanding of genomics or - when did this idea of weathering start to gain more traction?
GERONIMUS: It's been sort of two steps forward, one step back rather than there being a time it gained traction. I think as we - first of all, it was a hypothesis for me at first and then I started with colleagues doing studies to test it. And as the years went by, we had more and more studies that seemed to be consistent with it. So we had more real evidence. And people would - you know, people would say, well, maybe it's true for poor birth outcomes, but the mothers will be poorer later. And then we showed that - we and other people showed that was not really true or that had been at best way overstated and exaggerated. And then they'd say, well, it's bad for the well-being of the children, and then we did studies looking at the children and found that wasn't true. So we started to gain more and more momentum in terms of actual scientific evidence, including done by other researchers not working with me. So it did start to get a broader sense of support.
In addition, I think this idea of stress - and not just as, you know, the kind of stress, you know, I feel so stressed but this broader sense of stress actually being this physiological process that impacts your health or the strength of your various body systems - that became better understood sort of in the '90s by a variety of neuroendocrinologists, so kind of lab scientists like Bruce McEwen at Rockefeller University or Robert Sapolsky at Stanford. And so they talked about these stress reactions, what they do to your body, how they happen. And, you know, I don't want to sound cynical, but because - you know, instead of it being a metaphor called weathering and being about minority populations and cultural oppression and discrimination, it was instead just about physiological reactions in human beings discovered by, you know, two men - or with many more men and it was women too. But the two people who got I think the most credit - and deservedly - were men who were lab scientists. And so I think that gave it a credibility in our society that talking about weathering and lived experience and racism didn't get.
DEMBY: Right. I want to go back to your Jenga metaphor really quickly. So you said that weathering is like a game of Jenga in which, you know, you routinely have these blocks removed from one level and moved up to a different tier, and so everything becomes more and more unstable and a lot more tenuous. To stay with this metaphor for a second, is there any way to put the blocks back?
GERONIMUS: It's hard to say, but I don't think it's sort of the complete done deal. I certainly don't believe there isn't anything that can be done. One thing that can be done and is done - and this, you know, benefits in particular people who are weathered but in the middle class or more highly educated - is access to health care. So you might be hypertensive from weathering, but if you have good access to health care, you get it diagnosed early, you get it treated, you know, you learn what you need to do with your diet to make it a little less likely to turn into its most pernicious and life-threatening form.
So we've seen evidence, for instance, in some of our studies where we've compared blacks in very high-poverty areas to blacks in more middle-class neighborhoods and what we've seen is that those in the higher class neighborhoods do have much longer life expectancy than those in the poor neighborhoods, but they spend most of that extra life with chronic conditions and possibly disabled or with a variety of morbidities than whites with the same incomes and educations living in the same neighborhoods. So certainly having the longer life expectancy and averting death and averting the worst versions, you know, of hypertension or diabetes or their complications, you know, avoiding amputations and strokes, et cetera, those are good things.
GERONIMUS: But without dealing with the kind of more structurally rooted factors that lead to weathering across class, we're not going to, you know, end weathering.
DEMBY: Arline Geronimus is a public health researcher. She's a member of the National Academy of Medicine. She's a professor at the University of Michigan's Population Studies Center in the School of Public Health. Thank you so much, Arline. We appreciate you.
GERONIMUS: Thank you. Thank you very much.
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DEMBY: All right, y'all. That is our show for this week. We want to hear from you. You can get at us on Twitter. We're @NPRCodeSwitch and our email is firstname.lastname@example.org. Subscribe to the podcast wherever fine podcasts can be found or streamed, and please give us a review on iTunes. It helps other people find the show.
Leah Donnella and Sami Yenigun produced this episode. It was also edited by Sami Yenigun. We had original music this week by Ramtin Arablouei. Special thanks to Bob Little, Nicole Beemsterboer and the rest of the NPR Investigations team and to ProPublica for bringing us Shalon's story. Shout-out to the rest of the CODE SWITCH fam - Shereen Marisol Meraji, Karen Grigsby Bates, Adrian Florido, Maria Paz Gutierrez, Walter Ray Watson, Kat Chow and Steve Drummond. I'm Gene Demby. 'Til next week, y'all, be easy.
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