Keisha Ray was 21 years old when she learned she had hypertension, commonly known as high blood pressure. Her doctor prescribed Norvasc, a medication frequently used for the condition. But after a month, her blood pressure remained above normal. When Ray sought another treatment, her doctor insisted on keeping her on the drug simply because health care guidelines suggested it was especially effective for Black patients like her, adding, “Plus it’s cheap, so it’s good for poor Black people.”
Ray felt shocked by her doctor’s seeming assumption that because she was Black, she must be poor. Then a senior majoring in philosophy at Baylor University, in Waco, she knew her family wasn’t poor and that her mother, who worked as a nurse and had hypertension herself, could pay for whatever medication she needed. Ray left the appointment strangely wondering whether she should have done something differently—dressed nicer, or even worn her Baylor sweatshirt, to signal that she was educated, middle class, and deserving of the highest level of care.
Seventeen years later, Ray has her hypertension under control—although she still sees a cardiologist annually—and she works as an associate professor of bioethics at the McGovern Center for Humanities and Ethics at UTHealth Houston. In the years since her diagnosis, she has spent much of her time studying the health of Black people, and she’s come to realize that this experience with her original doctor was not unusual, but representative of common biases. The incident is just one example that she describes in her book Black Health: The Social, Political, and Cultural Determinants of Black People’s Health. Published earlier this year, it explores the reasons why Black Americans often have worse health outcomes than white Americans.
The pandemic brought this reality into stark relief. According to a 2021 report by the Centers for Disease Control and Prevention, Black Americans experienced almost three times the rate of COVID-19 hospitalizations and almost two times the rate of deaths as their white counterparts. They are also more likely to develop cardiovascular disease at a younger age and have higher rates of mortality from the disease compared to white Americans, according to studies by the Heart Foundation and the U.S. Department of Health and Human Services. And Black women are more than twice as likely as white women to die during or up to one 42 days after childbirth, according to a 2021 study by the CDC. In Texas, which has one of the highest rates of maternal mortality in the U.S., the likelihood that Black pregnant women will suffer from obstetric hemorrhage—that is, pregnancy-related blood loss—rose nearly 10 percent between the years 2016 and 2020, despite the rate falling among all women statewide, according to a 2022 report by the Texas Department of State Health Services.
In Black Health, Ray aims to dispel any notion that Black people are biologically predisposed to worse health than those of other races. According to one estimate, the health of any individual is only 20 percent based on medical care, compared with the 80 percent determined by environmental, political, and social factors. This matters for everyone, but many Black Americans lack access to what bioethicists call “the social determinants of health.” These factors include clean air and water, educational opportunities, and—by far the most important, according to Ray—not having to face racial discrimination, among many others. “It’s not that Black people have bad bodies. It’s that they live in bad environments,” she says.
Ray points out that a disproportionate number of Black Americans live in poorer neighborhoods, characterized in part by noise pollution, excessive artificial light, and homes with inadequate heating and cooling. Living in such circumstances can lead someone to have trouble sleeping, which in turn can result in poor cardiovascular health or stress-induced issues during pregnancy that can lead to premature labor. This is true even among Black Americans whose income places them firmly in the middle class.
Racism is the reason, Ray writes, citing a study by the Markup showing that in 2019 lenders were less likely to offer home loans to Black people than white people even when their finances, including credit scores, were identical—making it more difficult for Black people to purchase homes in neighborhoods with better health outcomes. A 2021 study by Science Advances, meanwhile, found that Black people had a greater-than-average exposure to air toxins than white people—a phenomenon that Ray says is, in part, caused by the likelihood that landfills will be built near predominantly Black neighborhoods as opposed to predominantly white ones. For example, a study conducted by an urban planning and environmental policy professor at Texas Southern University found that, from the 1930s through 1978, three of the four privately owned landfills in Houston were in predominantly Black neighborhoods.
Ray also discusses how many Black Americans face challenges within the health care industry itself. “Physician bias sort of boils down to not trusting Black people to be trustworthy narrators of their own health,” she says. The rate of physician mistrust of Black patients is difficult to quantify, as it has not been sufficiently studied, but Ray writes about a collection of first-person narratives by Black patients describing their experiences of discrimination in health care, as well as a 2023 study in the Journal of the American Medical Association that followed 25 Black patients with serious illness throughout their treatment. All of the patients in the study reported high levels of discrimination and mistrust during their care.
Thinking of race as mostly genetic or biological—with little to no regard of unjust environmental, political, and social factors—also contributes to bias in health care, writes Ray. According to a 2016 study in the Proceedings of the National Academy of Sciences, 40 percent of first-year medical students and a quarter of medical residents erroneously believe Black patients have thicker skin than white patients—a belief that can lead to the mismanagement of Black people’s pain. Until recently, most laboratories measured kidney health for Black people differently than for white people—a standard based on the unfounded assumption that Black people have more muscle mass than white people. In 2021, the National Kidney Foundation began advocating for changing this practice, which can result in Black patients’ kidneys looking healthier than they are, and Black patients in need of kidney transplants more likely to be deemed ineligible.
Overcoming such institutional biases can seem daunting, but it’s a challenge to which Ray has chosen to devote much of her work. At UTHealth Houston’s McGovern Medical School, she educates physicians and future physicians about racism in medicine. She also often guest-lectures elsewhere about Black health, serves as a medical discrimination expert for a law firm, and sits on several federally convened committees working to eliminate discrimination in health care policy.
Her interest in health care started at an early age. Born and raised in San Antonio, she attended the highly ranked Health Careers High School. While her peers seemed most intrigued by the scientific and hands-on aspects of medicine, Ray found herself drawn to larger questions, such as the best ways for doctors to interact with patients, and what a just health care system might look like. Later, after her time at Baylor, she went on to earn a doctorate in philosophy from the University of Utah, where she focused on bioethics, which is the study of ethical issues related to human health. Bioethicists confront quandaries raised by modern medicine, such as abortion rights, stem cell research, and organ donation.
“I feel like philosophy gets a bad rap,” says Ray in a phone interview from her office at the McGovern Center. She’s amiable and lively, talking around a candy she’s just popped in her mouth. “It gets the idea of some old man just walking around, head in the clouds, falling in a pothole because all he does is think, and he’s not looking at the world around him.”
For Ray, however, the pursuit is inherently practical—a means of understanding one’s identity and relationships with others. She hopes to broaden the understanding of how best to promote the flourishing of life. “I want people to think less about medicine when they’re talking about health and more about well-being and resources,” she says.
Ray devotes much of her energy toward educating people about the barriers to good health that Black Americans face. She also encourages state and federal officials to enforce stricter regulations for clean air and drinking water and to reinvest the money collected from fining companies that violate these laws into the communities that suffer most from pollution. “We have to hold businesses accountable for pollution and demand that our president, senators, congresspeople, and house reps pass laws that protect the environment which will also protect marginalized people like Black people and others,” she says.
Ray suggests what she admits are imperfect but nonetheless helpful ways to cope with racism in health care. These include race-matching, when Black patients are paired with Black physicians who are less likely to exhibit bias against patients of the same skin color. Studies suggest that race-matching could reduce the mortality gap between Black and white cardiovascular patients by nearly 20 percent and increase the likelihood that Black men would consent to preventative measures such as screenings for diabetes and cholesterol. But the effectiveness of race-matching also highlights the urgent need for more Black doctors. According to a study by the Association of American Medical Colleges, Black physicians made up only 5 percent of all doctors in the United States in 2018, while Black Americans represent more than 13 percent of the nation’s population. Ray also recommends Black patients bring a white friend to their doctor’s appointments to help ensure that physicians provide them with the same quality of care that white patients receive.
Despite the challenges, Ray remains hopeful that change is possible. Many of her students at UTHealth Houston are passionate about reversing physician bias and creating a more just health care system overall. In 2021, the McGovern Medical School announced that social justice and advocacy would be one of the overarching goals woven throughout the medical school curriculum. “I definitely see change,” Ray says. “People are aware of the problems and want to be agents of change.”
It’s not just Black Americans who should care about these issues. Concern for the health of all people is a matter of justice, according to Ray. “All of our health is connected,” she says, pointing to the pandemic as an example of how the illness of even one person can affect everyone else. “No one has good health in a world where there’s a large group of people that have poor health.”