Race Is Not a Risk Factor

Within these four walls I have wrecked the lives of far too many Black mothers. The family room is a windowless, white-walled cell in the hospital, with hazy fluorescent lighting, hard-bottomed plastic chairs, and a worn end table with a box of tissues. Four of us have filed into this cramped space, tucked away from the emergency department’s main hallway, twisting our torsos to let the door exhale shut behind us.

A public safety officer stands sentry in one corner. He is Black. Beside me, in an opposing corner, is the chaplain. She is Black. Sitting beside the two family members is the violence recovery specialist. She is Black. I am also Black: too Black for some, not Black enough for others. But still Black enough for this story to be meaningless were I anything but.

As a trauma surgeon, I have worked at some of the most stressful and difficult hospitals in the country: Tampa, Boston, Atlanta, Dallas, Chicago. Working to save patients from life-threatening acts of violence brings me tremendous job satisfaction.

Seated across the family room, two women stare at me, their fingers intertwined in a knuckle-whitening grip. “I’m Dr. Brian Williams,” I say with somber formality. “I’m the trauma surgeon working tonight.” Showing deference to the elder of the two women, I confirm her relation to my patient. Yes, she is indeed the mother. I’m sure the presence of the hospital chaplain must reveal something. She has only one reason to stand solemnly beside me, which the mother may have already deduced. Why else would the chaplain bring them to this private room, away from the mayhem of the emergency department?

“I’ll walk you through what happened with Malik after he arrived at the hospital,” I continue. “You can stop me at any time if you have any questions.” I always use the first names of their injured loved ones, the wounded and dead who cannot speak for themselves.

Speaking in a measured monotone, I don’t use confusing medical terms, and I enunciate each word for clarity. There must be no misunderstanding of what I have to say. “Malik sustained several gunshot wounds and arrived in critical condition,” I tell them. “The paramedics were already doing CPR in the ambulance when they brought him to us. When he arrived, his heart was not beating, and he wasn’t breathing.

“I’m sorry. We did everything we could, but despite our best efforts, your son Malik died from his injuries.” I always say it like this—“He died,” “She died”—with no Hollywood drama. Direct. Succinct. Clear.

I’m sorry. He died from his injuries: it’s a phrase I have said hundreds of times, and it sounds hollower each time I say it.

The mother ratchets open her fingers, freeing her daughter’s hand. Her head drops into her ashen palms, which smother her face now slick with tears. Shaking her head and rocking back and forth, she leans into her daughter, who rubs her back with soothing maternal strokes. “No, no, no, no, no,” she moans without end.

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The mother of my patient lives in a neighborhood within walking distance of one of the premier medical centers in the nation, and yet she is trapped in a web of disenfranchisement and death. Despite our hospital’s noble mission, our neighbors’ proximity to first-class healthcare does not guarantee access to routine, preventative care.

In treating these patients, I see myself. In comforting their families, I see mine. My cousin was shot and killed in front of her three young children. For me, working to end the epidemic of gun violence is more than an academic pursuit or my vocation. It is personal. I wrestle with the futile feeling that the nobility of my work does not have a sustainable impact. The essence of my job is plugging bullet holes in young Black men and women, at least the ones I can save—and then sending them back to an environment where they remain at high risk of reinjury and death.

For much of my life, I’d viewed healthcare as the great equalizer. Black or white, rich or poor, we all likely need to see a doctor at some point in our lives, and I thought that medical care, like education, was designed to level the playing field. Even as a doctor who witnessed otherwise, I maintained that fallacious view for many years. But now I see the ways institutional racism undermines our healthcare infrastructure and patient care.

Trauma Deserts

The University of Chicago Trauma Center, where I worked while writing this book, opened in May 2018 as the city’s newest Level 1 center. Located on Chicago’s South Side, it is proximal to some of the worst gun violence in the country. Nearly 50 percent of the gun violence in Chicago¹ occurs within a five-mile radius of the trauma center. Black people are less than one-third of the city population but more than 80 percent of the gun homicides,² 86 percent of gun homicide victims are male, and most of the gun violence is hyper-concentrated in racially segregated neighborhoods.

Lakeshore Drive, a major multi-lane highway, extends from the wealthy northern suburbs to the impoverished neighborhoods on the South Side. It’s a main vein connecting two opposing manifestations of economic mobility—or immobility. An eight-mile southerly drive—from the predominantly white neighborhood of Streeterville, which abuts the high-end shopping district known as the Magnificent Mile, to the majority-Black neighborhood of Englewood—means a 30-year decrease in life expectancy.³

The trauma center is located in a former “trauma desert,” an area where no trauma services are geographically close to the neighborhood. A study published by my colleagues at the University of Chicago, using census tract data from several US cities, found that “Black majority census tracts were the only racial/ethnic group that appeared to be associated with disparities in geographic access to trauma centers.”⁴

In the same way that food deserts—areas where there are not enough grocery stores per capita—increase health and nutritional disparities between poor and rich, and Black and white, trauma deserts also worsen healthcare disparities.

But the term “trauma deserts” is a misnomer because deserts are a naturally occurring phenomenon. We now know that resources in these racially segregated areas—such as food, education, and healthcare—are frequently absent by intent, not accident. Between 1990 and 2005, 339 trauma centers closed across the country,⁵ a higher rate of closure than in previous decades, and the authors of one study found that “hospitals in areas with higher shares of minorities face a higher risk of trauma center closure.”⁶ 

In other words, the neighborhoods most in need of a trauma center were also the most likely to have theirs taken away. As part of a wave of such closings, the previous trauma center on the South Side shuttered in 1991. The closing of that hospital left another racially segregated community to fend for itself. For three decades, gunshot victims died from survivable injuries because they had no place close enough to go. When seconds mattered, they spent minutes in ambulances racing to the north side of town, many dying during transport. I had witnessed endemic healthcare inequity while working in Dallas, Atlanta, Boston, and Tampa and had become numb to what I saw. In those early days I was an eager participant in the healthcare system, ignoring the ways my actions perpetuated the inequities we must eliminate.

During the early years of my career, saving the life of a gunshot victim—or trying to—was exhilarating. But in recent years I kept thinking: by the time patients are lying on the gurney in front of me, it’s too late. I might be able to save them from immediate death, yes. But what about the circumstances that led them to my trauma bay? What about the forces that shape where they live, work, learn, worship, and play? What access to transportation and banks and grocery stores and parks do they have—or not have? Did my work as a trauma surgeon truly help transform the communities I served?

In 2002, the National Academy of Medicine published the first systematic review of racial and ethnic healthcare disparities in the United States. The landmark report found that, even after correcting for socioeconomic conditions, “race and ethnicity remain significant predictors of the quality of health care received.”⁷ Healthcare systems and providers contribute to these disparities, the report said, and it provided a framework to correct the inequities. This included increasing the number of underrepresented minorities in medicine, educating society at large about racial and ethnic disparities, and collecting better data to guide interventions and resource allocation. Two decades after the report’s publication, during the worst of the coronavirus pandemic, not much had improved. Black Americans continued to die at rates higher than white Americans, and the healthcare system was clearly part of the problem.

The problems of healthcare disparities and racism in medicine are not limited to a once-in-a-century pandemic. When admitted to a hospital, Black patients experience more adverse events than white patients. In reviewing patient safety according to 11 different indicators,⁸ a report by the Urban Institute and Robert Wood Johnson Foundation found that “Black adult patients experienced significantly worse patient safety in six indicators when compared to white adult patients who were in the same age group, of the same gender, and treated in the same hospital.”⁹ These disparities occur more frequently in surgery, my specialty, than in some others.

By underinvesting in the health of poor and Black citizens, the infrastructure of the entire nation suffers—which, in some way, impacts all of its citizens. And these healthcare inequities are connected to other types of injustice. But here’s the thing: history is not inevitable. People in power make choices, and just because the United States now has massive health disparities does not mean that it had to be that way. Nor does it have to continue.

That is why we must talk about structural racism and how it binds us all.

Unlike what I internalized in medical school, race itself is not a risk factor for health disparities. Race is not a risk factor in chronic diseases, medical errors, or life expectancy.

It’s racism.

One review of 293 studies found that racism contributes to worse mental and physical health. Simply put, “being Black is bad for your health,” the Pew Research Center recently declared, with the critical addition: “And pervasive racism is the cause.”¹⁰

When we talk about physical health, we usually focus on choices, habits, cause, and effect. A lack of sleep, no exercise, and an unhealthy diet lead to poor health—in other words, poor individual choices. And healthy choices do matter. But health is more than just exercising, eating right, getting regular checkups, taking your medications, and visiting the doctor when sick. Health is shaped by the context in which we live. And the context in which we live binds together every sector of American life: housing, education, employment, and more. We may not live in the same neighborhoods, our children may not attend the same schools, and we may not shop at the same grocery stores, but we can all appreciate how much our lives, and our health, would suffer if any of these resources were absent or compromised. You don’t have to believe that the systems in which we live are explicitly rigged to see that a system negatively impacts some groups more than others.

Racism manifests in healthcare not only in the way that Black people are treated when they arrive in the emergency room (if they arrive); it’s also in the conditions that shape the lives of Black people in America that influence their life chances in the first place. There is no individual to hold accountable, no individual threat we can lock up to prevent the violence from happening, so change requires systemic transformation. Yes, asthma and diabetes put one at more risk of dying of COVID-19, both of which occur at higher rates in Black communities; but so do environmental injustices like exposure to hazardous waste and air pollution, housing inequality, and food deserts.

Structural racism, figuratively and literally, exists in the air we breathe.

Transformation

How do we transform systems resistant to transformation—systems that are actually functioning exactly as they were intended?

First, we begin by asking different questions. Our healthcare and social safety-net systems are replete with old ideas.

One old idea we must discard is the dominant narrative about the lack of leadership in Black communities, which have been systematically disadvantaged for centuries, and actually watch, listen, and learn from the amazing solutions emerging from them. I spent much of my career referring to communities I served with terms I now consciously avoid: underserved, urban poor, at risk, marginalized. We must push back against multiple narratives that are false and destructive.

I now refer to the communities in which I work as communities of opportunity.¹¹ Colloquialisms like urban poor and at-risk communities diminish the humanity of my neighbors and tend to erase the creativity and agency of the communities themselves. Those closest to the problem are often closest to the solution. Therefore, it is time for us to listen.

Another important step is to enact local, state, and federal laws and policies to dismantle structural racism. First, these policies must dismantle de facto barriers intended to exclude Black Americans from mainstream society. Second, they must promote economic reinvestment in communities through federal collaboration with local businesses, public officials, and community leaders. Last, they must acknowledge the role systemic racism plays in our society. Name it. Demystify it. Eliminate it. Radical inclusion through economic reinvestment is needed to ensure every American, regardless of race or ethnicity, has the opportunity to live safely, and thrive, within their communities.

The Centers for Medicare & Medicaid Services defines health equity as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.”¹² Policy makers did, and can continue to, make a difference.

Community leaders, academics, politicians, activists, and more are working together to create health equity. And it is important to understand that the root causes of health inequity are the same root causes of endemic violence, which means that the solutions are similar.

I am not the same person I was when I began my career. Age and experience conjoin to transform us all, I suppose. My own transformation includes moving from assimilation, code switching, and separating myself from the realities of my patients—all in the name of career advancement and acceptance—to now claiming all the ways that my experiences as a Black man connect me to my patients.

As I have changed, so has the scale of my ambitions. My goal, audacious as it may sound, is to work myself out of my job as a trauma surgeon. To never have to tell another mother she has lost a child to gun violence. To stop the flow of bodies arriving in our emergency rooms and trauma centers because of preventable injuries, treatable diseases, and avoidable death. Treating individual patients occurs within the hospital, but healing entire communities occurs beyond it.

Anger has become the fuel that propels me on this journey of justice. The best I can do is dial it down and channel that energy in service of the greater good. Anger can be destructive or productive. We can allow it to hold us in a state of inaction, or we can let it inspire us to challenge the injustices around us. I have long identified my anger with shame. No more. Naming it and embracing it has guided me forward. And now I know what triggers my anger most of all: persistent injustice. Anger ignored can consume us, but anger acknowledged can transform us.

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This young Black body before me: he is the reason I am here. His life has ended, while mine goes on. So, if only for a moment, I ask my coworkers to unite in silence to honor this stranger. Together we recognize that tomorrow is never promised, and we honor our shared humanity.

At the end of our moment of silence we resume our work. Each member of the team does their part in removing intravenous lines, disconnecting ventilator tubes, and discarding bloodied equipment. Another Black body to be tagged and bagged. Those closest to him will have a funeral, but his death will not receive any national reckoning.

But it’s not true that his story will never be told. I am telling it here. It is a partial story, more about his death than his life. But by reading you know he lived. You know he died. You and I: we can’t unknow these things.

Having spoken to the medical examiner, I have a final duty to complete: the death note. It’s a final version of this young man’s life that I must document. The disembodied voice overhead breaks into my typing. It blares with a reminder that although this young life has ended, our work has not. “Code yellow, level 1, multiple GSW to chest and abdomen, traumatic arrest, ETA 4 minutes.”

The bodies—they just keep coming. We have to make them stop.

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Brian H. Williams, MD, is a trauma surgeon, working most recently as a professor of trauma and acute care surgery at the University of Chicago Medicine. An Air Force veteran, he was a Robert Wood Johnson Foundation health policy fellow in 2021–22 working with Senator Chris Murphy to increase health equity and reduce gun violence. This article was excerpted from the 2023 book The Bodies Keep Coming: Dispatches from a Black Trauma Surgeon on Racism, Violence, and How We Heal by Brian H. Williams with permission from Broadleaf Books.

Endnotes

1. Crime Lab, Urban Labs, “Violence Reduction Dashboard,” University of Chicago, September 12, 2022, crimelab.uchicago.edu/projects/violence-reduction-dashboard.

2. City of Chicago, Our City, Our Safety: A Comprehensive Plan to Reduce Violence in Chicago (Chicago: Office of the Mayor, September 2020), chicago.gov/city/en/sites/public-safety-and-violence-reduction/home/our-city-our-safety.html; D. W. Rowlands and H. Love, “Mapping Gun Violence: A Closer Look at the Intersection Between Place and Gun Homicides in Four Cities,” Brookings Institution, April 21, 2022, brookings.edu/articles/mapping-gun-violence-a-closer-look-at-the-intersection-between-place-and-gun-homicides-in-four-cities; and Chicago Data Portal, “Gun Crimes Heat Map,” City of Chicago, accessed August 3, 2022, data.cityofchicago.org/Public-Safety/Gun-Crimes-Heat-Map/iinq-m3rg.

3. Robert Wood Johnson Foundation, “What Makes a Long Life? Look to Your ZIP Code,” rwjf.org/en/insights/our-research/interactives/whereyouliveaffectshowlongyoulive.html.

4. E. Tung et al., “Race/Ethnicity and Geographic Access to Urban Trauma Care,” JAMA Network Open 2, no. 3 (2019): e190138.

5. Y. Shen, R. Hsia, and K. Kuzma, “Understanding the Risk Factors of Trauma Center Closures,” Medical Care 47, no. 9 (2009): 968–78.

6. Shen, Hsia, and Kuzma, “Understanding the Risk Factors.”

7. B. Smedley, A. Stith, and A. Nelson, eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington, DC: National Academies Press, 2003).

8. A. Gangopadhyaya, Do Black and White Patients Experience Similar Rates of Adverse Safety Events at the Same Hospital? (Washington, DC, and Princeton, NJ: Urban Institute and the Robert Wood Johnson Foundation, July 20, 2021), urban.org/sites/default/files/publication/104559/do-black-and-white-patients-experience-similar-rates-of-adverse-safety-events-at-the-same-hospital_0.pdf.

9. A. Gangopadhyaya, “Do Black and White Patients Experience Similar Rates of Adverse Safety Events at the Same Hospital?,” rwjf.org/en/insights/our-research/2021/07/do-black-and-white-patients-experience-similar-rates-of-adverse-safety-events-at-the-same-hospital.html.

10. Y. Paradies et al., “Racism as a Determinant of Health: A Systematic Review and Meta-Analysis,” PLoS One 10, no. 9 (September 23, 2015); and C. Vestal, “Racism Is a Public Health Crisis, Say Cities and Counties,” Stateline, June 15, 2020, stateline.org/2020/06/15/racism-is-a-public-health-crisis-say-cities-and-counties.

11. See A. Vaidya, A. Poo, and L. Brown, “Why Community Power Is Fundamental to Advancing Racial and Health Equity,” NAM Perspectives, June 13, 2022, nam.edu/why-community-power-is-fundamental-to-advancing-racial-and-health-equity; M. Pastor et al., “Community Power and Health Equity: Closing the Gap Between Scholarship and Practice,” NAM Perspectives, June 13, 2022, nam.edu/community-power-and-health-equity-closing-the-gap-between-scholarship-and-practice; and L. Farhang and X. Morales, “Building Community Power to Achieve Health and Racial Equity: Principles to Guide Transformative Partnerships with Local Communities,” NAM Perspectives, June 13, 2022, nam.edu/building-community-power-to-achieve-health-and-racial-equity-principles-to-guide-transformative-partnerships-with-local-communities.

12. CMS Framework for Health Equity 2022–2032 (Baltimore: Centers for Medicare and Medicaid Services), cms.gov/files/document/cms-framework-health-equity.pdf.

[Illustrations by Diana Ejiata]