Challenging Racism in the Healthcare System: A Conversation with Dr. Uché Blackstock, MD

Despite spending more than any other country on healthcare, Americans are significantly less healthy than people living in peer countries—profoundly so when it comes to Black Americans in particular. From shorter life expectancy to abysmal rates of child mortality to higher incidence of chronic health conditions, Black Americans continue to see poorer outcomes from medicine than their White peers.

In her new book, Legacy: A Black Physician Reckons with Racism in Medicine, Dr. Uché Blackstock, MD, confronts a medical system that has failed and continues to fail BIPOC Americans and with which she, as a Black physician, has struggled personally in her own journey into some of the country’s most venerated halls of medicine.

A graduate of Harvard University and Harvard Medical School, and the latter’s first ever Black legacy graduate, following in the footsteps of her physician mother, Blackstock rose to a position of prominence within the medical field only to see it continually fall short when it came to the ongoing “legacy”—a word Blackstock plays on masterfully—of racism in American medicine.

Black Americans continue to see poorer outcomes from American medicine than their White peers.Both a memoir and a call to action, Legacy portrays the inequalities, hypocrisy, and racism of American medicine and demands that this legacy of racism be recognized so that it may eventually be ended.

“We can’t fix the problem until we can see it clearly,” writes Blackstock. “It took me many years to fully understand the centuries of history underpinning racism in medicine today.…It took me well into my career as a physician to recognize the sheer scale of the problem, to free myself from the institutional status quo so that I could begin to fully speak my truth.”

In this conversation with NPQ, Blackstock reflects on how she came to write Legacy and, more broadly, her journey to becoming an outspoken critic of the very system in which she matriculated and her work with Advancing Health Care, a consultancy firm of which Blackstock is founder and CEO.

Isaiah Thompson: What were you hoping to achieve in writing Legacy?

Uché Blackstock: I wrote the book to help readers connect the dots as to why…in 2024, we are still seeing these horrific statistics in terms of Black health outcomes despite advances in innovation, technology, and research. We spend the most of any high-income country on healthcare, and overall, we have the worst health outcomes—especially for Black people and people of color. The book is a memoir, but it also gives historical context and social commentary because I, as a Black woman who lives in this country and as a Black physician, I felt like my experiences, in all aspects of my life, really help inform how I see this problem. Even for me, despite my Harvard undergraduate degree and medical degree, I am still five times more likely to die of pregnancy-related complications than my White peers. So, my socioeconomic status, my income, my profession [are] not as protective…as [they] would be for my White counterparts.

Uché Blackstock, MD, confronts a medical system that has failed and continues to fail BIPOC Americans.

A lot of times, people look at these issues and they say, oh, this is about socioeconomic status, right? But we know, we know it’s not just about economics, that it’s about systemic racism. It’s about interpersonal racism. It’s about racism.

For so long, especially within healthcare, especially within medicine, we have not named racism as the source and the root cause of these inequities. And so that’s what I wanted to do in this book, just kind of to lay it all out for folks that people understand, from A to Z. This is why we’re seeing what we’re seeing. And then obviously ending the book with a call to action, because I think there’s something every one of us can do, whatever our level of power and influence is in the society.

IT: Where does responsibility lie for the continued legacy of racism in medicine and where are opportunities to change things?

UB: There’s obviously a very significant role for medical schools in terms of how they’re educating our students. You know, there’s a lot that I did not learn in medical school. As a practicing physician, I had to unlearn and relearn things on my own.

I learned about how federal policies like redlining, for example—neighborhoods that were redlined in the 1930s are today the same neighborhoods that have the very worst health outcomes. Even that whole notion of how systemic policies can impact health—that’s something that I never learned about in medical school. I learned in medical school what I say to a patient, like, take your medication. Exercise, eat well. Like that’s my job, right? But it’s not recognizing that my patient lives in a neighborhood that was redlined.

Growing up, we didn’t have a grocery store in our neighborhood in Crown Heights. We had to go to Park Slope. My parents weren’t happy with the quality of schools in my neighborhood, again, a result of redlining.

“We know it’s not just about economics, that it’s about systemic racism.”

Medical schools need to think about how they’re educating our future physicians; hospitals and hospital systems, I think, have to actually be intentional and develop structured processes for keeping track of these racial health inequities in real time. If they’re discrepancies in how patients are being prescribed or which patients are being prescribed pain medications and which ones aren’t, that should be something that we are disaggregating by racial demographics in our patients. And then what is the response? What are you going to do? Are you going to do extra training for that? Are you going to have a policy in place?

And then I also think that there’s a role for our policymakers. This is not just about access to healthcare. It’s not just about access to quality healthcare. We know that what makes people healthy is what is going on in their neighborhood. So, that other piece of it is thinking about health more holistically and what policymakers can do actually on a hyperlocal and local level.

I talk about this birthing center in Minneapolis, the Roots Birthing Center. Minneapolis has…the worst racial health inequities—the worst. And so, a Black midwife opened this birthing center, specifically the mission is to care for Black birthing people with respect and dignity. I like that. You know, it’s not rocket science, but they’ve actually found that having that birthing center has improved pre-term labor outcomes [and] pregnancy complications. So, I think we also can look at what’s happening locally and hyper-locally. How can we invest? How can we donate [to] these efforts? There’s a lot of really great work happening at a community level.

IT: In the book, you describe your journey into—and eventually out of—academia, where you encountered the legacy of racism yet again, this time in the academic setting. Can you talk about that experience?  

UB: I thought I would spend my entire career in academic medicine because that’s all I knew….My mom had been in academic medicine. I actually really loved it. I loved being able to teach medical students and residents, do research, see patients. It’s the perfect mix.

But really, here I was, at NYU and Bellevue in the middle of New York City, one of the most diverse cities in the country—And I was always either the only, or one of the only, Black faculty in one of the largest departments in the hospital. So that was always a red flag for me, that obviously this is not a priority to have more people that look like us or look like our patient population, at least a little bit.

Then I got into a DEI role—but I didn’t recognize that it actually was like a figurehead role. It really was just a role that was created to appease some concerns that came out from the faculty, from the students. And that was a really a radicalizing moment for me because I was super excited to do this work. But then it ends up that I was silenced. I couldn’t really speak about the issues that meant a lot to me. And I felt almost like I was being suffocated.

IT: You point out that you were being stifled on the one hand, but on the other hand there’s this irony in placing the burden of promoting those kinds of goals on the people who have been historically excluded in the first place. Do I have that right?

UB: We didn’t create the problem [in] the first place! Why should this be on us? But I also think, you know, because it impacts us so much, you’ll find so many of us who want to commit our lives to making this better because we know if things are better, that people can thrive. People can thrive professionally. They can thrive personally. We know there’s a huge return on investment for doing this work.

Instead, I felt really scared, and I was like, okay, I guess either you’re going to make things so untenable for me here that I’m going to have to leave, or I’m going to have to figure it out. And so, I started my company Advancing Health Equity, which is a consulting firm I started while I was there. I had to take that leap of faith and leave. It probably was the best decision I ever made.

IT: Tell me more about that transition. What have you learned since founding Advancing Health Equity?

UB: I feel like it was like me doing my piece to make a difference, but in a way that was felt really authentic and aligned with what was important to me. Initially, I was doing trainings internally at NYU, and then I started getting invited to do trainings and talks at other academic institutions. And I always got such a great reception, I was like, okay, maybe I should take this show on the road and form my own LLC.

It soon became very clear that trainings don’t change organizations. Trainings are not sustainable. They don’t really change organizational culture that much. And so when I left academic medicine, I said, you know what? I really want to start doing other things with the organization. I want to go in and do equity assessments. So we talked to leadership. We talked to staff. We come up with strategic reports based on the feedback…what do they need to do around equity, racial equity, and health equity within their organizations to be more inclusive and diverse and to treat patients better and make sure they receive equitable care?

So for me, it’s amazing because this is like, this is the work that I wanted to do at NYU, that I couldn’t do, that I wasn’t empowered to do. But now I can actually do it on a larger scale with multiple organizations.

IT: Do you find organizations receptive? I would imagine that sometimes organizations invite that input, but that’s not the same as welcoming it once they get it.

UB: Definitely, I realized that some organizations are trying to check the box. So, we do a lot of vetting of who we work with. We ask, you know, who’s doing the asking? Why are you coming to us? Why do you want us to do the work? What are the power dynamics within your organization? Did something happen that made you reach out to us? It’s not like we say yes to everybody. We want to make sure the organizations are really prepared to do the work with us. And then also there’s a selection bias because obviously some of them actually want to do the work, so that’s why they’re coming to us.