Legacy

How can you tell whether a health setback is about your body—or about the world your body lives in? In Legacy, Uché Blackstock, MD, argues that health in America is inseparable from history, policy, and power. She contends that racism isn’t a side note to medicine; it’s a structuring force that shapes who becomes a doctor, who gets listened to, and who survives. To heal patients, she says, you must learn to see (and treat) the structures that make people sick—what scholars Jonathan Metzl and Helena Hansen call structural competency.

Blackstock braids her family story—especially the life and early death of her mother, Dr. Dale Gloria Blackstock—with a sharp diagnosis of American medicine. As a child roaming SUNY Downstate’s halls in Brooklyn, she watched her mother practice what today we’d call structurally competent, culturally responsive care. Years later, she felt that legacy—and the forces working against it—when she was misdiagnosed as a Black medical student, trained on curricula that erased harmful histories, and worked in underfunded ERs serving the very communities most harmed by systemic racism. The book builds to a reckoning with segregated care, the maternal mortality crisis, and the pandemic’s disproportionate toll, then offers a path forward grounded in policy, practice, and community power.

What This Book Argues

Blackstock’s core claim is blunt: racism in medicine is not just interpersonal bias; it’s embedded in training pipelines, hospital financing, clinical algorithms, and public policy. From the Flexner Report that shuttered most Black medical schools, to redlining and the GI Bill’s exclusions that harmed Black neighborhoods’ health for generations, to race-corrected tests that deny Black patients transplants or timely interventions, the profession has repeatedly coded inequality as science. Changing inequitable outcomes requires both clinical humility and structural change: more Black physicians, anti-racist training, race-explicit quality improvement, investment in community-based care (like midwifery and doulas), and universal coverage that treats health care as a right.

What You’ll Learn

You’ll meet the “original Dr. Blackstock,” a Harvard-trained nephrologist who returned to serve the Brooklyn community that raised her. You’ll see how her example seeded two daughters’ medical careers—and how a system designed without them in mind made those careers harder. You’ll tour the “hidden curriculum” that erased the Tuskegee syphilis study’s truths, Henrietta Lacks’s story, and J. Marion Sims’s experimentation on enslaved women—while naturalizing modern race-based equations in nephrology and pulmonology. You’ll sit in two New York City ERs—NYU Tisch (private, largely white, VIP-ready) and Bellevue (public, incredibly diverse, chronically under-resourced)—and feel what “medical apartheid” looks like in one city block.

You’ll follow cases that make policy painfully concrete: Jordan, a young Black man with sickle cell disease disbelieved as “drug seeking”; a pregnant woman who miscarried in a hallway while the team searched for a clean room; and Uché herself, discharged with “gastroenteritis” when a rupturing appendix demanded surgery. You’ll then move into the era of COVID-19, where urgent care lines wrapped around blocks, pulse oximeters read oxygen inaccurately in darker skin, and Dr. Susan Moore recorded on Facebook how, as a Black physician-patient, her pain and breathlessness were dismissed before she died.

Why It Matters Now

The book lands in the aftermath of George Floyd, Breonna Taylor, and a pandemic that cut Black life expectancy by nearly three years in months. Black maternal mortality remains three to four times that of white peers (as journalist Linda Villarosa also documents in Under the Skin), and segregated hospital markets quietly steer the best-resourced care away from Black communities. Blackstock shows how the same logics that let police violence flourish—surveillance, neglect, devaluation—also shape where ambulances deliver, how ERs are staffed, and what gets counted as a “quality” outcome. To improve health, she insists, you can’t treat biology without treating the body politic.

How This Summary Is Organized

First, you’ll see how representation and mentorship—“you can’t be what you can’t see”—collide with history’s choke points (the Flexner Report) to explain today’s tiny share of Black physicians. Then you’ll unpack how policy becomes physiology—redlining, GI Bill exclusions, and environmental racism turning zip codes into destiny. Next, you’ll look inside medicine’s hidden curriculum and race-based algorithms, and at the bedside where bias shows up in pain management, triage, and “protocols” that forget people. You’ll walk through two ERs to see segregated care up close. Finally, you’ll explore solutions—from birth justice and midwifery-led models to structural competency, organizational change, and universal coverage—alongside Blackstock’s own pivot from academic constraints to public advocacy.

A through-line worth holding

“Of all forms of discrimination and inequalities, injustice in health is the most shocking and inhuman.” —Martin Luther King Jr., a line Blackstock cites to remind you that equitable care is not charity; it’s justice.

If you’re a clinician, policymaker, or patient navigating American health care, Legacy offers a usable lens: ask how history built the exam room you’re standing in—and what you can change right now to make the next visit safer, fairer, and more humane.

Blackstock’s compass is her mother, Dr. Dale Gloria Blackstock—a petite, Afro-wearing Harvard-trained nephrologist who returned to serve Brooklyn. As kids, Uché and her twin Oni rifled their mother’s black leather doctor bag, imitated knee-jerk reflex taps, and wandered SUNY Downstate’s halls for red Jell-O. What they witnessed was old-school, high-touch medicine: a physician who knew her patients’ blood pressures and their grandchildren’s nicknames. Today you might call it structurally competent care—treating the person inside the place they live, work, and pray.

Seeing Is Becoming

“You can’t be what you can’t see” (Marian Wright Edelman) is more than a slogan here—it’s a pipeline strategy. The twins’ pediatrician, Dr. June Mulvaney, and a neighbor OB-GYN, Dr. Mildred Clarke, populated their world with Black women physicians. Saturdays meant violin lessons and museum trips; summers meant science programs where their mother taught nephrons in chalk and lifted a dialysis filter like a lifesaving wand. Mentorship, in this telling, is both deliberate and tender—Dr. Dale practiced 6 a.m. case presentations with a nervous student for weeks until confidence bloomed, a kindness that student carried into leadership later. If you mentor, this shows you the multiplier effect of time, attention, and representation.

How History Shrunk the Pipeline

That loving blueprint collides with a brutal bottleneck: the 1910 Flexner Report. Abraham Flexner’s quality push, underwritten by the Carnegie Foundation and AMA, shut down five of seven Black medical schools and dismissed training Black physicians as a “waste”—arguing Black trainees should be “sanitarians,” chiefly to protect white health. A 2020 estimate suggests those closures cost the U.S. 25,000–35,000 Black physicians who would otherwise be practicing today. Imagine the colleague who never mentored you, the neonatologist who never delivered your baby, the family doc whose clinic never opened on your block. (For context, see historian Harriet A. Washington’s Medical Apartheid for the broader pattern of scientific racism.)

Blackstock discovers this history years into her own career, weeping at the numbers. The loss isn’t abstract: racially concordant care improves outcomes—Black newborns’ mortality falls under Black physicians; Black physicians disproportionately serve underserved communities. Legacy reframes Black doctors not as diversity optics but as survival infrastructure.

Carrying the Bag Forward

Dr. Dale dies of leukemia at forty-seven, when the twins are nineteen. The doctor bag, with her name in gold, passes to her daughters—and becomes a charge. Both attend Harvard Medical School, the first Black mother-daughter legacies there, and both choose safety-net hospitals (Uché at Kings County in Brooklyn; Oni at Montefiore in the Bronx). The point is less pedigree than place: they follow their mother to the patients who need them most, even as the system demands they bear more work with fewer resources.

Mentorship as medicine

Dr. Dale’s daily choices—coaching a student at dawn, organizing neighborhood health fairs, knitting community with clinical care—become a transferable clinical skill: turning care into belonging.

For you, this chapter is a reminder to treat representation as a clinical intervention—one that alters trust, adherence, and outcomes. Build pathways that let more Black kids hold the bag. Then fight the bottlenecks—testing regimes (like the MCAT) whose predictive value is overstated and racial bias documented, honor societies (like AΩA) where selection skews white, and admissions processes that underweight lived experience. A mother’s blueprint is necessary. The system also has to stop tearing up the floor plan.

Blackstock’s childhood in Crown Heights holds a paradox you may recognize: a home brimming with love and ambition, on a block shaped by drugs, disinvestment, and police sirens. As a teen she felt shame when a Park Slope classmate’s mom offered a ride home; she asked to be dropped six blocks away to hide the boarded houses and crack vials. Legacy turns that shame outward. The question isn’t why her block looked like that; it’s why federal policy made it so.

Policy to Physiology

Start with redlining. In the 1930s, federal maps marked Black neighborhoods in red as “high risk,” starving them of mortgages and insurance. Add the GI Bill’s discriminatory implementation after WWII—Black veterans were often blocked from VA-backed home loans that built white wealth. The result was a forced geography: fewer trees and parks; more heat islands; fewer supermarkets and more bodegas; longer commutes; older, mold-prone housing; and fewer clinics. That ecology shows up as physiology: higher rates of asthma, diabetes, hypertension, stroke, kidney disease, preterm birth, and mental health stressors—evidence that your zip code can be a stronger predictor of health than your genetic code. (See also Matthew Desmond’s Evicted on housing-health links.)

The book offers data and street-level detail. In 108 U.S. cities, formerly redlined areas run up to 13 degrees hotter than others (fewer trees, more asphalt). In food deserts, 23.5 million Americans face limited access to fresh produce; “supermarket redlining” favors suburban placement of chains. During COVID’s rollout, early vaccination sites mirrored these older maps—what some dubbed “vaccine redlining.” Once you see the pattern, you see it everywhere.

Two Family Stories

The book juxtaposes two migration arcs. Her Jamaican-born father, Earl, grows up where most people look like him; racism first hits as a segregated Texas bar’s bartender screams for him to leave. In New York, he climbs via the VA loan and sweat equity to rehab a derelict brownstone—only possible thanks to a narrow window: the Community Reinvestment Act, a community development corporation, and veteran status. Meanwhile, her Brooklyn-born mother navigates childhood poverty and a severe stutter (slapped at home when she stumbled—“therapy” her mother knew), then a Harvard class where doors were literally held open for white classmates and let slam in her face. Both arcs converge on the same structural lesson: the “American dream” asks Black families to thread needles white families are handed.

From Internalized Shame to Structural Sight

Legacy shows you what it feels like before you have the words. As a teen, Blackstock internalizes the message that “good choices” live outside her zip code—better parks, schools, and doctors are elsewhere. Later she names the disease: structural racism. That shift matters. When a neighborhood lacks OB visits, when a dad avoids care for insurance fears, when a grandmother won’t call 911, you avoid blaming “noncompliance.” You ask: which policy made the healthier path the harder one?

Clinician takeaway

Write social history like it matters. Housing stability, transport, food access, exposure to violence, wage protections, immigration status—these aren’t “nice to know.” They are vital signs of place.

If you design care, design for neighborhoods, not individuals alone. Co-locate legal aid with pediatrics; partner with food co-ops; fight for heat-mitigation and tree canopy; bring vaccination and prenatal care to churches and barbershops. Structural problems have structural fixes. The first move, Blackstock argues, is seeing your patient not as a set of labs—but as a person in a policy-built place.

In four years at one of the world’s most prestigious medical schools, Blackstock rarely heard lectures about racism’s role in American medicine. She remembers detailed chalk talks on the Krebs cycle—but silence around Tuskegee, Henrietta Lacks, and J. Marion Sims. That silence matters. It teaches you—implicitly—that medicine’s harms to Black communities are either past or peripheral, not central. The book calls it what it is: the hidden curriculum.

Erased Histories, Present Harms

She learns from Rebecca Skloot’s bestseller—years after histology class—that the HeLa cells she studied belonged to Henrietta Lacks, a Black woman whose cervical tissue was taken without consent at Johns Hopkins and then commercialized in research for decades. She later learns that J. Marion Sims, the “father of gynecology,” perfected techniques (and the speculum) by operating without anesthesia on enslaved women—Anarcha, Betsy, and Lucy—whose names were never on the plaques. And she learns the real story of the Tuskegee syphilis study: hundreds of Black men denied treatment for forty years so white researchers could “watch” natural history, even after penicillin worked. (Read Harriet A. Washington’s Medical Apartheid or Dorothy Roberts’s Fatal Invention for fuller accounts.)

When you don’t teach this, you’re not protecting students; you’re priming them to repeat patterns. What gets framed as “mistrust” among Black patients is better understood as institutional untrustworthiness—the rational response to a system that has repeatedly devalued Black lives, from grave-robbing of Black cemeteries for anatomy labs to modern inequities in care.

Race-Based Algorithms Are Not Biology

More subtle—and more pervasive—are race “corrections” that look like science but encode bias. Blackstock was taught that the estimated glomerular filtration rate (eGFR) should be adjusted upward for Black patients (supposedly more muscle mass), which can understate kidney disease severity and delay referral or transplant eligibility. She was taught spirometry percent-predicted values set lower “normals” for Black patients—an inheritance traceable to a plantation doctor, Samuel Cartwright, who claimed enslaved Africans had lower lung capacity and needed forced labor. Even myths like “Black patients feel less pain” persist; in one survey, a third of white med students and residents endorsed biologically false statements and were likelier to undertreat pain.

Race is a social construct with biological consequences—not a genetic category that predestines organ function. (See Dorothy Roberts’s Fatal Invention.) The fix isn’t to pretend race doesn’t exist in the data; it’s to distinguish when it’s a proxy for lived racism (e.g., exposure, access) versus an assumed genetic difference. That subtlety should be part of every training, every quality dashboard.

Training for Structural Competency

Metzl and Hansen’s framework—structural competency—asks clinicians to recognize how upstream forces (housing, immigration law, wage policies) manifest as symptoms. Blackstock’s education largely skipped this. So she learned later, on the job, that “nonadherence” can be a frozen debit card; a missed postpartum visit can be lack of paid leave; a “no-show” can be a subway shut down. Integrating this lens into cases, OSCEs, and M&M conferences is not “add-on” DEI; it’s core clinical reasoning.

If you teach, try this

Pair every pathophysiology lecture with a structural vignette. After COPD physiology, ask: how would redlining, eviction risk, or language access alter this patient’s course—and what would you do differently?

Legacy’s lesson for you: replace the hidden curriculum with an explicit one that tells the whole truth—and audit your tools. If your calculator “adjusts” by race, ask who benefits, who’s harmed, and what better proxies exist (e.g., cystatin C for kidney function). The goal isn’t political correctness. It’s better, safer medicine.

Policy shows up as protocol—and as a clinician’s snap judgment. Blackstock shares three cases you won’t forget: her own ruptured appendix, a young man with sickle cell disease dismissed as drug-seeking, and a pregnant woman who miscarried in a hallway. Together they show how bias and under-resourcing compound risk for Black patients.

“Gastroenteritis” with a Rupturing Appendix

As a first-year medical student at Harvard, Blackstock sprints from pharmacology lecture to the bathroom with explosive GI symptoms and severe abdominal pain. In the ER, a white resident pivots quickly to sexual history, insists on a pelvic exam, and anchors on PID or an STI—despite Blackstock’s clear history of no current sexual activity. The attending glances at her abdomen, rules out appendicitis (“doesn’t look in that much pain”), and discharges her with “gastroenteritis.” Two agonizing days later, a nurse practitioner who listens sends her for imaging: a perforated appendix, OR now. She survives—but only after a second hospitalization for a postoperative abscess that should never have happened.

Was the error “just” a miss? Possibly. But the pattern matches studies showing Black patients are less likely to receive opioids for fractures, more likely to have pain dismissed, and more likely to be discharged with serious conditions. If you hear this story and feel defensive, try curiosity instead: When do you assume a Black woman’s abdominal pain is sexual? What would you ask differently?

Jordan and the “Frequent Flyer” Frame

At Kings County, Blackstock regularly cares for Jordan, a lanky Knicks fan in his thirties with sickle cell disease. Weather shifts, dehydration, or stress trigger excruciating vaso-occlusive crises. Some seniors tell interns to give two IM morphine shots, no IVs (to avoid “highs”), then discharge. Others require lab proof of “real” sickle cell (versus trait) before treating pain. Meanwhile Jordan’s risk of acute chest syndrome or early death ticks upward. One winter he’s admitted to the ICU and dies at thirty-four. The grief in the resident lounge is palpable; the stereotype of “drug seekers” in sickle cell—tied to a disease labeled Black, neglected in research, and under-resourced in clinics—feels like malpractice by narrative.

Compare the funding: Hemophilia (mostly white, ~20,000 patients) has 28 drugs; sickle cell (>100,000, mostly Black) long had just two FDA-approved treatments. The message from the system—and sometimes the staff—is received.

A Miscarriage in a Hallway

On a crowded shift, Blackstock searches a jammed waiting area for a petite, brown-skinned patient curled under sheets. “I think I’m miscarrying. Again,” the woman whispers. Only four pelvic rooms exist; all are full. By the time Blackstock finds one and sets up for the exam, the fetus—about fourteen weeks—slips silently into her hands. She wraps the tiny body, places it in the mother’s arms, and gives her privacy. Later she wonders: would earlier triage have changed the outcome? Maybe not. But Black women face higher miscarriage, preterm birth, and infant mortality—even when controlling for education and income—driven by chronic stress (“weathering”), differential monitoring, and less responsive care.

From cases to commitments

Standardize where bias hides (e.g., pain protocols co-designed with patients), personalize where humanity heals (e.g., time, touch, language). And staff to demand—not the budget—so waits don’t decide outcomes.

If you run an ED, track disparities by race/ethnicity: door-to-provider times, pain scores and dosing, admission rates for similar presentations, return visits. If you’re a clinician, practice the counter-stereotype: say out loud, “Patients with sickle cell have severe pain; my job is relief and safety.” Protocol is a floor, not a ceiling. Don’t let it substitute for care.

Blackstock splits her time between NYU’s private Tisch Hospital ER and Bellevue, the country’s oldest public hospital. The buildings sit next door. The care might as well be worlds apart. Walking both is like putting on X-ray glasses for American health care’s segregated core.

The Private Abundance of Tisch

At Tisch, every patient has a private room. CT orders seem to fulfill themselves. A VIP call—sometimes literally from a billionaire benefactor—can mobilize an admission in minutes. Most patients are white, commercially insured, and already plugged into the system via specialists who send them to the ER. Interns are kept away (wealthy patients might complain). Physicians are told to wear white coats and business attire—signals of status to match the marble lobby.

Yet here, too, bias sneaks in: a white patient asks for “the other doctor” after hearing Blackstock’s plan, or the chief of service gets a complaint that the “attending” hasn’t been in—because the patient didn’t recognize that the Black woman in the white coat was in charge. It’s subtle, exhausting, and routine. “Where did you go to medical school?” “Harvard.” “Oh.” The interrogation ends—but the message lands.

The Public Crucible of Bellevue

At Bellevue, the waiting room is a United Nations of need: people living in shelters next door, new immigrants, trauma victims, those arrested awaiting clearance, and families without primary care. Staffing is lean; waits can run into the next shift. Paramedics sometimes bark at patients in ways they’d never dare at Tisch. A young man arrives weeks after a leg fracture from a different ER, now with necrotizing fasciitis because follow-up slipped through the cracks. An older woman with psychosis hurls the N-word—and Blackstock stays focused on safety because the system that closed psychiatric beds left the ER as default.

Residents like Kamini, an Indo-Caribbean New Yorker, start naming aloud what leadership won’t: ambulances rarely bring unhoused patients to the private ER; Bellevue patients wait hours while Tisch patients wait minutes; the same city block enforces two standards. Reports back this up: in NYC, only ~9% of Tisch discharges are Black versus 26% at Bellevue; across U.S. metro areas, patients of color remain less likely to be treated at elite academic centers even after Medicaid expansion. (See Bronx Health REACH’s “Separate and Unequal” and modern updates.)

Complicity and Courage

The hardest part may be the silence. Leadership rarely names the segregation for fear of donor backlash or institutional risk. Students hold die-ins at Bellevue after Ferguson because protesting at Tisch might trigger disciplinary action. Progress often comes from those most harmed. As Kamini puts it: “Medicine is political.” Legacy asks white colleagues to stop outsourcing that courage: if you benefit from a two-tier system, you have a duty to dismantle it.

Design Mandates

One emergency department standard for the system: same staffing ratios, same wait-time targets, same access to imaging and consults, and transparent dashboards by race/insurance—published quarterly.

If you lead a health system, test whether “where you enter” determines “what you get.” Then change incentives so executive bonuses hinge on equity metrics, not just RVUs and margins. The neighbor hospitals on First Avenue prove it: proximity is no guarantee of parity.

Blackstock’s own career becomes a case study in how institutions neutralize would-be reformers—then what it looks like to build power outside. Recruited to NYU as its first Black woman faculty member in Emergency Medicine, she rises as an educator (launching a four-year ultrasound curriculum and a fellowship) and takes on a diversity leadership role. Then comes the slow-motion squeeze: under-resourced DEI work, vetting speakers to avoid “polarizing” topics, and even a scolding after she tweeted that removing a wall of white male portraits might be progress, not erasure.

Pet to Threat

Psychologist Kecia Thomas describes a pattern where Black women are initially embraced (“pet”) and later penalized as they gain influence (“threat”). Blackstock lives it. After a denied promotion (reversed months later), whispered warnings about her “political” stances, and censorship of a newsletter that sought to highlight women’s accomplishments (“not inclusive of men”), she quits—choosing self-preservation over slow erosion. Her op-ed, “Why Black doctors like me are leaving academic medicine,” goes viral. Some white colleagues stay silent. Black peers flood her inbox: “You said what I can’t.”

A Pandemic Megaphone

She launches Advancing Health Equity (AHE) months before COVID-19. Suddenly, she’s back in urgent care in Bed-Stuy, seeing 80–100 patients per shift, swaddled in PPE, watching the line around the block change from mixed to “everyone looks like us.” Affluent New Yorkers flee to second homes; essential workers—largely Black and Latinx—have no such option. Testing is scarce; CDC criteria privilege international travelers; she’s allowed two tests a day for a hundred sick people. She writes and talks—Slate, MSNBC, Congress—naming what the data soon confirm: the virus follows the fault lines of race, job, housing, and insurance.

Then the stories pile up. An elderly Caribbean woman arrives with an SpO2 of 78%, double-sided COVID pneumonia on X-ray—refuses the hospital because she fears the bill and the chaos. Dr. Susan Moore, a Black physician with COVID, films herself describing how a white doctor dismissed her pain and breathlessness; she’s dead weeks later. Pulse oximeters, long known to overestimate oxygen saturation in darker skin, likely delayed escalations of care across thousands. These aren’t footnotes. They’re mechanisms by which inequity kills.

Building Capacity, Not Just Awareness

Through AHE, Blackstock moves beyond keynotes to audits and action plans: interviewing leadership and staff, running focus groups, and recommending policy changes—embedding equity in hiring, QA, and compensation; removing race-corrected tools; collecting and using disaggregated data; partnering with community organizations; and tying executive incentives to equity. A clinician writes after a training, “I felt overwhelmed in the session—but I’m awakened now. What do I do next?” That’s the pivot: from performative statements to measurable change.

A personal note

Leaving a brand-name institution for an urgent care storefront can look like a step down. Legacy argues it can be a step toward purpose—and patients.

If your institution treats equity as PR, build elsewhere or build leverage: publish your data, organize your colleagues, and partner with your community. Influence is not a title. It’s the ability to change what happens at the bedside.

If you want to see the stakes of structurally competent care, look at childbirth. Black birthing people in the U.S. are three to four times more likely to die from pregnancy-related causes than white peers; in New York City, the ratio has been nine to one. Those gaps persist across income and education, suggesting not individual failure but a system calibrated to miss, dismiss, and harm. Blackstock weaves her own pregnancies—one grueling labor ending in forceps and episiotomy, one supported by a Black doula—into a broader case for birth justice.

Deadly Disparities Have Modern Mechanisms

Weathering—the cumulative physiologic wear from racism’s stressors—contributes to hypertension and preeclampsia, conditions that nearly killed tennis star Serena Williams and forced Beyoncé into an emergency C-section. But care dynamics matter too: Black patients are more likely to report being ignored, less likely to receive timely monitoring or escalation. The system’s defaults—C-sections approaching 40% nationally, low breastfeeding support in Black neighborhoods, postpartum follow-up misaligned with paid leave realities—compound risk. When Congresswoman Cori Bush testified about being ignored during early labor (“They called it ‘bad blood’ in Tuskegee; today they call it ‘complaining’”), she put words to a pattern patients already knew.

Old Wisdom, New Models

Before hospital-centric obstetrics eclipsed community birth, Black “granny midwives” safeguarded generations in the Jim Crow South. The Flexner era and the 1921 Sheppard-Towner Act’s implementation stigmatized and regulated midwives out of practice. Today, evidence points back: continuous labor support (often via doulas) reduces C-sections, instrumented deliveries, and epidural use; midwifery-led care for low-risk pregnancies improves outcomes and experience. The Roots Community Birth Center in North Minneapolis—a Black-owned, midwife-led, culturally centered clinic—reported zero preterm births over four years among a predominantly Black clientele.

Blackstock’s second birth, with a Black doula at her side, illustrates why: someone to interpret, advocate, and soothe when a monitor can’t find the fetal heartbeat and fear surges. Her doula stayed through postpartum, helped with latch, and made meals—care that medicalized systems rarely fund but parents always need.

System Fixes that Scale

Policy is catching up. The Black Maternal Health Momnibus proposes investments in housing, transportation, and food access; pays and diversifies doulas and midwives; improves data; and integrates telehealth. But hospitals and plans don’t need to wait. Pay doulas now (Medicaid waivers make it possible in several states). Co-locate legal and social services in prenatal clinics. Build midwifery-led units with seamless transfer protocols. Redesign postpartum to include earlier check-ins and wraparound supports, not just a six-week visit.

Universal coverage as maternal care

During COVID, uninsured patients’ testing and treatment were temporarily covered and vaccines were free—proof that coverage choices save lives. Make postpartum Medicaid continuous for 12 months in all states, then move toward single-payer coverage that prevents gaps altogether.

The broader argument is simple: birth is the canary. If your health system can’t keep Black parents and babies safe, it isn’t safe. Fixing that demands both clinical redesign and community power—honoring the birth workers who have always known how to hold families well.