Black lives matter: thoughts from the delivery ward in St. Louis

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Anita Chary

Anita Chary

Anita Chary, MD PhD, is an anthropologist and resident physician at the Harvard Affiliated Emergency Medicine Residency. She is Research Director of the non-governmental organization Maya Health Alliance | Wuqu' Kawoq, which provides health care and development services in rural indigenous communities of Guatemala.

I live in St. Louis, Missouri, which since 2014 has most notably been in the news for the tragic shooting of Michael Brown in Ferguson.

“Black lives matter” is an activist movement, widely popularized in hashtag form, that emerged from a palpably heightened national awareness of acts of violence committed against black people all over the US—people like Trayvon Martin, Michael Brown, and the nine victims of the Charleston Church massacre, among many others. “Black lives matter” is a reminder to all of us of the ways that black people are marginalized—all of the systemic inequalities, grotesque histories, and petty brutalities that limit their life chances and lead them to die prematurely, whether through murder or abandonment. “Black lives matter” is also a protest, a redemption song of sorts; it is a call to action that things don’t have to be this way, and can and must change.

The idea that “black lives matter” both haunts and inspires me in daily life in St. Louis. Most of the homeless and folks with mental illnesses I encounter on the streets in my neighborhood are black. When I pass through decaying decrepit areas of the city—streets more potholes than concrete, boarded-up condemned houses, and sidewalks overgrown with weeds—I notice they are mostly populated by black people. This is a city that is racially segregated and divided along striking geographical lines, as highlighted by numerous articles on Delmar Boulevard by the BBC and Washington Post, among others.

Citation: This figure appears in the report For the Sake of All, freely available at: http://forthesakeofall.org/publications/report/

Citation: This figure appears in the report For the Sake of All, freely available at: http://forthesakeofall.org/publications/report/

 

You can choose to ignore “black lives matter” in St. Louis. In fact, it’s actually fairly easy to do so if you are socioeconomically privileged, live in a mostly gentrified neighborhood or a suburb, and find alternative routes around the sketchy parts of town. This is, of course, not unique to St. Louis.

It’s harder to ignore “black lives matter” if you are a health care provider in St. Louis.

I am a medical student training in a hospital system in St. Louis City where clinical encounters with poor black people who are suffering are inevitable and overwhelming. Racial disparities stare us down on a daily basis. The statistics about African-American health in St. Louis are alarming: as published recently in the important report For the Sake of All, African Americans in St. Louis have a higher burden of chronic diseases, lower rates of health insurance, higher rates of death by homicide, and poorer access to prenatal care, among many other outcomes.

Citation: This figure appears in the report For the Sake of All, freely available at: http://forthesakeofall.org/publications/report/

Citation: This figure appears in the report For the Sake of All, freely available at: http://forthesakeofall.org/publications/report/

We see the human beings who live those statistics everyday. Physicians try in vain to manage the poorly-controlled comorbidities of their black patients, who have unreliable transportation to clinic visits and useless insurance plans that never seem to approve needed treatments. Nurses clean and feed the babies of poor black single mothers who, after months without adequate psychiatric care, attempt to commit suicide. Social workers counsel yet another black family that has needlessly lost a young son to gunshot wounds.

Citation: This figure appears in the report For the Sake of All, freely available at: http://forthesakeofall.org/publications/report/

Citation: This figure appears in the report For the Sake of All, freely available at: http://forthesakeofall.org/publications/report/

For many, these encounters become so routine that they are no longer remarkable, but simply part and parcel of daily clinical practice. Poverty and racism form the backdrop of the practice of medicine, whether we providers talk about it or not. And we often don’t, because we’re too busy or, somewhat practically, feel defeated by it.

This is of course not unique to St. Louis, either.

But I feel driven to write about it here and now because I often find myself, in clinical encounters, momentarily paralyzed by a weighty recognition of the suffering of poor black patients.

Where I have most ostensibly felt this way is the Labor & Delivery unit.

Until now, most of my experience with pregnancy, childbirth, and women’s health care in general has been in rural Guatemala, where maternal outcomes tend to be poor. Access to emergency obstetric care is severely lacking, and poor women’s lives are all too often incredibly difficult. They often start reproducing at a hungry, malnourished, teenage baseline, lack access to family planning, and gradually become depleted by serial pregnancies and breastfeeding. In some cases, they are also depleted by spousal abandonment or physical violence perpetrated by male partners, relatives, and other assailants.

In rural Guatemala, when I ask women how they are doing in the clinic or during home visits, they often respond, “Pues, aquí estamos luchando.” “Well, we’re here struggling,” they say, matter-of-factly. I have never been able to shake off the weight of this statement, no matter how many times I hear it, because it is true, has always been true, and will continue to be true for the foreseeable future. They are eating nothing but day-old reheated tortillas—recalentados—with salt and coffee because there is nothing else. They farm, they sew, they sell in the market with their babies on their backs, on top of taking care of the household their exploited husbands’ earnings can’t support alone, all in a feeble effort to cobble together a paycheck-to-debt existence. Their children die from preventable illnesses. They have been, are, and will continue to be poor and struggle to raise their children, one by one.

I feel the same knot in my gut form when poor black pregnant women in St. Louis show me their lives—when I bear witness to their version of “pues, aquí estamos luchando.”

There are the women who eagerly and ceaselessly press their call buttons for graham crackers, apple juice and ice cream—standard patient snacks—because they have no food at home. There are the women for whom the difference between the Gs and Ps, in their obstetric history, is explained by their children being murdered. There are the women who tell me they have been fired from their low-paying jobs, essentially because they are pregnant, but their employers’ lawyers will inevitably be better than theirs. There are the women who live with their kids tenuously in shelters, leaving occasionally for prenatal appointments, fearing their former partners, their names blacked out and anonymous on the patient census when they come to the hospital for labor pains. There are the women who demand warm blankets, water, and ice chips, not only because they want those things, but also because they so rarely have the experience of being waited on.

Citation: This figure appears in the report For the Sake of All, freely available at: http://forthesakeofall.org/publications/report/

Citation: This figure appears in the report For the Sake of All, freely available at: http://forthesakeofall.org/publications/report/

The worst feeling to me is witnessing these women give birth alone.

I use the word “alone” to signify multiple things.

In some cases, women are actually without company. Their partners have been murdered, incarcerated, or have abandoned them. Other relatives who might have otherwise been able to be present for these women are at home taking care of their other kids. They cry out in pain and the only people who hear them, who push count with them, who support their legs and hold their hands, are strangers—the nurses, the doctors, me. Soon after their babies are handed off to the pediatrics team, the OB team leaves to see other patients, and mom lies recovering alone.

In some cases, black women are alone in a metaphorical sense: they are young girls, teenagers who were sexually abused or assaulted, or they entered desired relationships but had inadequate sex education, if any, and no access to contraception. And they are alone at birth because they have no idea what lies ahead, regardless of who is physically present in the room with them. They are scared despite or because of whatever information they are receiving. The seasoned nurse’s patient explanation of the Foley catheter goes in one ear and out the other; the discussion of pain and breathing techniques turns the adolescent parturient into a deer in the headlights.

These situations feel cruel to me. Unconscionably cruel. I freely recognize my own ethnocentric assumptions of birth as a pro-social process—a time for solidarity that can bond women and families together. I also know that my upper-middle class bias leads me to expect people to shower love and joy upon mom and baby before, during, and after a birth. I embrace that in some societies, giving birth alone is a cultural ideal. In anthropology, my other discipline, we classically learn about the Ju/’hoansi, a group of hunter-gatherers in Southern Africa, among whom stoic solo birth in the bush was traditionally a rite of passage into womanhood.

But giving birth alone as a poor black woman in St. Louis is different. The unaccompanied woman, the adolescent mother-to-be: here they are, struggling.

In some ways, my discomfort with what these women have lived through—are living through—is more unsettling than what I feel in Guatemala. Poverty, hunger, violence, abandonment, discrimination—these are things no clinician would ever wish for any patient, anywhere in the world, but they are easier for me to associate with Guatemala—distant “developing” Guatemala—than my own backyard. My own backyard is the Global South.

Citation: This figure appears in the report For the Sake of All, freely available at: http://forthesakeofall.org/publications/report/

Citation: This figure appears in the report For the Sake of All, freely available at: http://forthesakeofall.org/publications/report/

Yes, I concede: in many ways, things are much better in St. Louis than in Guatemala. The poor black parturients I speak of will immediately receive life-saving treatments or be wheeled into a world-class operating room if anything goes wrong.

But in a way, so many things have already gone wrong.

This is where “black lives matter” assumes a deeper meaning for me.

In the delivery room with poor black women, we as clinicians are living and breathing “black lives matter.” We will do anything and everything it takes to keep mom and baby safe. We know and swear their lives matter.

But our technical medical interventions are only the tip of the iceberg. There is something so paradoxical about a lone laboring black woman, hooked up to monitors, pushing a baby into a cruel world that does not care for it. A world that does not care for either of them beyond the twenty hours of monitoring contractions and a fetal heart rate. A world where WIC and food stamps are not enough to guarantee mom and baby won’t be hungry. A world where mom and baby are less likely to have health insurance and more likely to develop chronic, debilitating diseases. A world where baby could grow up to be shot to death by police despite being unarmed. A world where mom might melt in grief and horror as her baby’s body lies on the street uncovered for four hours.

Black lives matter. This ideology is easy to embrace in medicine, which, in theory, strives to protect and value all lives. It demoralizes me, however, that our best intentions in the clinic are at odds with the realities of the structural inequalities that make life so predictably cruel for the poor. For so many poor black patients, we clinicians provide nothing but a bandaid for a difficult life of being here in St. Louis, struggling.

Many thanks to Nora King and Tim Laux for their feedback on this post.