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For Lisa Peyton-Caire, the founding CEO and president of the Wisconsin-based Foundation for Black Women’s Wellness (FFBWW), the fight for health equity started after losing her 64-year-old mother to heart disease. Peyton-Caire soon realized middle-aged Black people were not only dying prematurely of cardiovascular disease. They were dying at a younger than average age from nearly every cause of death.
“What happened to my mother was not the exception, but the norm for far too many women in my family and extended community,” says Peyton-Caire. “Yet, I didn’t hear any alarm bells going off.”
It starts at gestation — Wisconsin has the highest racial birth disparities in the United States. These disparities are starkest in Dane County, where from 2016 – 2018 the Black infant mortality rate was 12 deaths per 1,000 births, compared to a nationwide average across race and ethnicity of 5.8 deaths per 1,000 births. Statewide, Native and Black infants are two to three times more likely to die than white infants, and Native and Black parents who give birth are three to five times more than likely than white parents to die from pregnancy-related causes.
New legislation introduced in early 2021 by U.S. Representative Gwen Moore (D‑Wis.) and Senator Tammy Baldwin (D‑Wis.) could reduce these disparities. Re-introduced as part of the Black Maternal Health Momnibus Act, this new package of bills from Wisconsin legislators aims to diversify the prenatal workforce and expand healthcare coverage.
Meanwhile, state healthcare systems are pursuing their own solutions to closing health equity gaps. In July, the Medical College of Wisconsin (MCW) and the University of Wisconsin School of Medicine and Public Health announced a three-year $3 million project to “study, measure and recommend solutions for health inequities” across urban and rural Wisconsin. Some advocates and medical professionals are concerned, however, that the funds will continue to go towards cosmetic solutions that do too little to eliminate disparities.
One increasingly common solution to combatting disparities in health systems, already adopted by the MCW and UW Medical School, is implicit bias training, or programs designed to expose healthcare providers to their unconscious biases. But, advocates and researchers say that tapping into individual bias, as if to unspoil the few bad apples, ignores the ever-present conditions where people live, learn and work. Rather, a deeper, structural transformation is what’s needed to narrow the racial chasm in infant and maternal outcomes.
In a 2019 FFBWW report, generated from nine months of focus groups with over 300 Black residents of Dane County, the organization found that of the 10 factors that lead to low birth weight (the main cause of infant death) the three large contributors to premature death are systemic barriers to family advancement, limited access to resources like quality healthcare and housing insecurity. Closing these disparities will require complex solutions that foster the “whole life well-being of Black families.”
According to a 2021 consensus statement from a multi-disciplinary work group convened by the March of Dimes, living in cities with a history of redlining — such as Milwaukee, Racine, and Madison— is associated with higher risk of premature delivery. Redlining, a federally sanctioned system of residential segregation that started in the 1930s, cemented inequity in hundreds of U.S. cities, relegating Black Americans to the least desirable municipalities around the country.
The resultant segregation continues to influence how resources, like green spaces, well-funded schools and access to quality healthcare and nutritious food, are allocated, and how hazards like lead exposure, pollution, and extreme housing density are distributed. In Milwaukee, a city reported as “the most racially segregated metro area in the country,” tracts with the highest percentage of Black residents also have the worst pregnancy and birth outcomes.
Tiffany Green, an assistant professor of population health sciences and professor of obstetrics and gynecology at UW-Madison, says wealth disparities are also an important factor. In addition to quality healthcare access, “if you’re worried about being unhoused, if you’re worried about being unemployed, it’s harder to carry a pregnancy to term.”
In a May 2021 commentary in Obstetrics & Gynecology that she co-authored, Green argues that while it may be well-intentioned, the data show that existing implicit bias training “is unlikely to produce the intended outcome.” One problem is that current programs focus on prejudice, or negative feelings or fear about a group, while neglecting stereotyping, or false beliefs about a group’s inherent traits.
For example, consistent undertreatment of pain in Black as compared to white patients is thought to stem in large part from the belief that Black skin has fewer nerve endings, a belief that stems from experimentation on enslaved women. That age-old stereotype may help explain why Black individuals are less likely to receive epidurals in labor or inpatient opioids postpartum, Green and her co-authors write. While not the primary source, Green says, “healthcare is something that we can intervene on.”
Green says one promising aspect of the Momnibus Act is investment into social determinants. In a letter that Tammy Baldwin co-signed on June 17, Senate and House members urged that the next Covid-19 recovery package expand Medicaid to provide a full year postpartum coverage. “[I]n America, every family has a right to thrive — a principle that begins with a safe and healthy pregnancy and birth,” write the members. The legislation also incorporates funding for safe housing, nutrition, and transportation for pregnant and postpartum individuals, and studies into the impacts of water and air quality and exposure to environmental hazards on maternal and infant health outcomes.
Beginning in childhood, people’s health and wellbeing in the years leading up to pregnancy have cumulative effects, playing an inextricable role in immediate and long-term health outcomes. “If we just intervene during pregnancy, it’s just too late,” says Green.
According to David Crowley, an organizer and the current Milwaukee County Executive, expanding Medicaid is the “single most important step” to reducing racial health disparities in healthcare nationally. Closing the coverage gap, Crowley writes in UpNorthNews, means that “an estimated 2.2 million people — 60% of whom are people of color, and 324,000 of whom are disabled — would get access to quality insurance at little or no cost.”
In Wisconsin, however, the expansion of the state’s Medicaid program, known as BadgerCare Plus, has been blocked in the state legislature for more than a decade. In May, the Republican-controlled legislature voted against accepting a $1 billion bonus from federal coronavirus relief funding to expand BadgerCare, which would have increased access to another 91,000 residents.
While waiting on legislative efforts to advance, says Shiva Bidar-Sielaff, a former Madison city council member and UW Health Chief Diversity Officer, individual healthcare workers do need to contend with racism within themselves. “It’s easy to talk about systems,” which allows people to convince themselves that racism is “separate from your own actions,” she says. One way UW Health is addressing these disparities, Bidar-Sielaff adds, is by working to diversify its clinical workforce, first level and middle management.
Preclinical education is also evolving. According to Jose Franco, M.D., a professor of Medicine, Gastroenterology and Hepatology at MCW, starting in 2023 the medical school will begin new curriculum to “address diversity, equity, and the social determinants of health and racism,” which “will be included in all four years.”
Even with all of the momentum, Green says that “it’s very difficult to disrupt the status quo.” Too many diversity efforts are cosmetic and not doing anything except “making people feel good… It treats inequality like an intellectual exercise, rather than one that is disrupting people’s lives every day and keeping them from reaching their highest potential.”
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Kavin Senapathy is a freelance journalist based in Madison, WI who covers science and health.