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Listen to Black Women: Do Black Feminist and Womanist Health Policy Analyses

  • Jameta N. Barlow
    Correspondence
    Correspondence to: Jameta N. Barlow, PhD, MPH, University Writing Program, 2100 Foxhall Rd NW, Ames Hall, Rm. 210, Washington, DC 20007. Phone: 202.242.6595.
    Affiliations
    University Writing Program, The George Washington University, Washington, DC

    Women’s, Gender, & Sexuality Studies, The George Washington University, Washington, DC
    Search for articles by this author
  • Breya M. Johnson
    Affiliations
    University Writing Program, The George Washington University, Washington, DC

    Women’s, Gender, & Sexuality Studies, The George Washington University, Washington, DC
    Search for articles by this author
Published:November 20, 2020DOI:https://doi.org/10.1016/j.whi.2020.11.001
      In 1851, during the Women's Convention in Akron, Ohio, Sojourner
      • Truth S.
      Sojourner Truth: Ain't I a woman?.
      to explain how her Blackness resulted in differential treatment as a woman in the United States. In her famous speech at the 1964 Democratic National Convention, Fannie Lou Hamer heavily sighed “I'm sick and tired of being sick and tired” (2011) when she described violence targeting Black communities and voter suppression. Alicia Garza, Patrisse Cullors, and Opal Tometi reminded us that #
      • Black Lives Matter B.L.M.
      United States.
      when Trayvon Martin was murdered in 2012, subsequently building a grassroots movement to combat police violence in Black communities. #SayHerName (
      • Crenshaw K.
      • Ritchie A.
      • Anspach R.
      • Gilmer R.
      • Harris L.
      Say her name: Resisting police brutality against black women.
      ) highlights the intersectionality that exists even within police violence, noted by the killing of Sandra Bland, Breonna Taylor, and so many other Black women killed by police. When Black women use their experiences to theorize and organize, movements begin.

      Black Women's Health Status

      Black girls' and women's health is pathologized in a way that rarely addresses the structural determinants of health, such as gendered racism, which can influence health, health care interactions, delivery, access, and care. With more than 40% of Black teen girls and more than 80% of Black women being diagnosed with overweight or obesity, they make up the largest percentage of children and adults dealing with this epidemic, respectively (
      • Winkler M.R.
      • Bennett G.G.
      • Brandon D.H.
      Factors related to obesity and overweight among Black adolescent girls in the United States.
      ). Accumulating evidence suggests that obesity is strongly associated with prolonged and excessive activation of the stress system (
      • Cortese S.
      • Comencini E.
      • Vincenzi B.
      • Speranza M.
      • Angriman M.
      Attention-deficit/hyperactivity disorder and impairment in executive functions: A barrier to weight loss in individuals with obesity?.
      ). When you experience racism as part of your daily lived experience, you are in a constant state of danger; thus, racism becomes a social exposure. Cumulative stress may contribute to increased levels of cortisol. High cortisol levels increase the risk for cardiovascular disease and high blood pressure (
      • Whitworth J.A.
      • Williamson P.M.
      • Mangos G.
      • Kelly J.J.
      Cardiovascular consequences of cortisol excess.
      ), and hypertensive disorders in pregnancy—namely, preeclampsia and eclampsia—are two of the leading causes of maternal death (
      Centers for Disease Control and Prevention
      Health United States, 2017. Table 46.
      ;
      • Gupte S.
      • Wagh G.
      Preeclampsia-eclampsia.
      ). These hypertensive disorders are not only 60% more common in Black women, but also more severe (
      • Fingar K.R.
      • Mabry-Hernandez I.
      • Ngo-Metzger Q.
      • Wolff T.
      • Steiner C.A.
      • Elixhauser A.
      Delivery hospitalizations involving preeclampsia and eclampsia, 2005–2014. HCUP Statistical Brief #222.
      ).
      Black women have persevered in education and civic participation despite systems of oppression, social vulnerability, and adverse risk to violence. Black women's citizen voting-age population increased by 31% between 2000 and 2017, with approximately 3.5 million more voters than in 2000 (
      • Solomon D.
      • Maxwell C.
      Women of color: A collective powerhouse in the U.S. electorate.
      ). Most of this growth has occurred in Alabama, Connecticut, Georgia, Maryland, and Mississippi, where Black women's votes have been integral to transforming the racial/ethnic, gender, and political landscape. Black women represent the “largest and most consistently engaged demographic groups in American politics” (
      • Solomon D.
      • Maxwell C.
      Women of color: A collective powerhouse in the U.S. electorate.
      ) and are more likely to support government expansion of affordable health care and uphold comprehensive reproductive health care. As we counter the COVID-19 pandemic, Black women continue to experience more health inequities than ever before, especially around mental health, maternal health, gender-based violence, cardiometabolic diseases, and breast cancer. Living while a Black woman is detrimental to Black women's health and the weathering process (
      • Geronimus A.T.
      • Hicken M.
      • Keene D.
      • Bound J.
      “Weathering” and age patterns of allostatic load scores among blacks and whites in the United States.
      ) contributes to several health inequities (
      • Barlow J.N.
      • Smith G.P.
      What The Health (WTH)? Theorising Southern Black Feminisms in the US South.
      ) they experience. Organizations like the
      Black Women’s Health Imperative
      Black Women Vote: National Health Policy Agenda.
      are not only asking (
      • Blount L.G.
      The secret to Black women's health: Ask, listen, do.
      ) Black women about their health, but also listening and doing. The use of social listening tools and data science is informing their approaches to address Black women's health. This commentary uses Black Feminism and Womanism as epistemologies (
      • Bowleg L.
      Towards a critical health equity research stance: Why epistemology and methodology matter more than qualitative methods.
      ) to critically address Black women's health policy.

      Black Feminism and Womanism

      Black women have historically built a collective voice around the interlocking systems of domination and the politics of disposability. Black women move from the singular toward the collective by telling one's own story and critiquing the larger structures at hand. These structures include issues that fall under what Black Feminist bell hooks calls “imperialist-white-supremacist-capitalist-patriarchy” (
      • hooks b.
      bell hooks cultural criticism & transformation. Media Education Foundation.
      ). This phrase speaks to a consistent theme of resisting single-issue conceptions and single-issue solutions within Black Feminism because Black women and girls simply do not live single-issue lives. The Black Feminist analysis can be traced to as early as 1892, when Anna Julia Cooper put forth a call to action requiring African Americans to move toward a depiction of African American life from the “negro standpoint,” an incredible intervention that would later be taken up by many Black women to come. Black Feminism and Womanism do the work Cooper calls for.
      Womanism, “imagined by Zora Neale
      • Hurston Z.
      Their eyes were watching God.
      , rediscovered by Alice
      • Walker A.
      In search of our mothers’ gardens: Womanist prose.
      , and characterised by Layli (Phillips) Maparyan” (
      • Barlow J.
      Black women, the forgotten survivors of sexual assault. American Psychological Association in the Public Interest [Newsletter].
      ), is “a social change perspective rooted in Black women's and other women of color's everyday experiences and everyday methods of problem solving in everyday spaces, extended to the problem of ending all forms of oppression for all people, restoring the balance between people and the environment/nature and reconciling human life with the spiritual dimension” (
      • Phillips L.
      The Womanist reader.
      ). Black women like June Jordan, Toni Morrison, Toni Cade Bambara, Alice Walker, Ella Baker, Audre Lorde, Kimberlé Crenshaw, Patricia Hill Collins, and others have used Feminist and Womanist frameworks to illuminate social change perspectives. Audre Lorde, Pat Parker, June Jordan, and Toni Cade Bambara all died from some form of cancer, but before that they devoted their lives to developing Black Feminist thought and standpoint theories. The same systems of domination they extensively wrote about are the same systems and circumstances that contributed to their health outcomes. Black women are usually diagnosed in the later stages of cancer, receive inadequate care, and die in disproportionate numbers. “Collectively, [B]lack people have the highest death rate and shortest survival of any racial/ethnic group in the US for most cancers” (
      American Cancer Society
      Cancer facts & figures for African Americans, 2019-2021.
      ). The Black Feminist and Womanist (BFW) analytical path to health equity merges these frameworks and provide the strongest analysis as it builds on the legacy of Black women's experiences, theories, and knowledge production.

      BFW Analytical Path to Health Equity

      Widely accepted and cited as an approach to policy analysis, the Bardach EightFold Path (
      • Bardach E.
      • Patashnik E.M.
      A practical guide for policy analysis: The eightfold path to more effective problem solving.
      ) is deficit-based and has power differentials and inherent biases that can negatively impact successful policy implementation for Black girls' and women's health. Other critical policy approaches (
      • Chow J.C.C.
      • Austin M.J.
      The culturally responsive social service agency: The application of an evolving definition to a case study.
      ;
      ;
      • Lejano R.P.
      Frameworks for policy analysis: Merging text and context. Moser’s approach to gender policy implementation.
      ;
      • McPhail B.A.
      A feminist policy analysis framework: Through a gendered lens.
      ;
      • Moser C.
      Gender planning and development: Theory, practice and training.
      ;
      • Ross A.
      “I am not free while [anyone] is unfree”: A proposal and framework for enmarginalized feminist policy analysis.
      ;
      • Schiele J.H.
      Afrocentricity: An emerging paradigm in social work practice.
      ) have subverted the policy analysis process to address marginalized populations. To our knowledge, no existing critical policy analysis approach focuses exclusively on Black girls' and women's health. The BFW Analytical Path to Health Equity (Figure 1) balances the decision-making power between Black girls and women on one side and the analyst on the other.
      Figure thumbnail gr1
      Figure 1The Black Feminist and Womanist (BFW) Analytical Path to Health Equity.
      Public policy analysis should begin with a focus on health equity that is community informed (step 1) and take a strength-based approach (step 2) to the health policy issue. Next, the role of gendered racism should be described and assessed (step 3) with the intention of a community informed (step 4) approach to addressing the issue. This process must center the experiences of Black girls and women and reflect their experiences when considering policy solutions and alternatives (step 5). As policy recommendations are refined (step 6), Black girls' and women's collective agency over the bodies must be centered. Recommendations must augment the everyday decisions and solutions Black girls and women engage in regularly, for and with one another.
      The following examples demonstrate the utility of the BFW Analytical Path to Health Equity.
      COVID-19 is illuminating the fragmented health systems and public health approaches in the United States. Black communities are home to many essential workers and often have high rates of housing insecurity, unemployment, and cardiometabolic syndrome. Public health messages encouraging the public to stay home rarely discuss what essential workers can do. Many essential workers reported their employers have failed to provide hazard pay or personal protective equipment and, in many cases, prohibited workers from bringing in their own homemade masks (
      • Portnoy J.
      Inova bans hospital workers from wearing PPE they bring from home. The Washington Post.
      ). Solutions to address the lived experiences of essential workers or Black communities experiencing adverse health outcomes could be co-created (steps 1 and 6).
      Breast cancer mammography screening recommendations are for women 40 years and above. Although White women are more likely to be diagnosed, Black women are more likely to die of breast cancer (
      • Richardson L.C.
      • Henley J.
      • Miller J.
      • Massetti G.
      • Thomas C.C.
      Patterns and trends in black-white differences in breast cancer incidence and mortality—United States, 1999–2013.
      ), and at a younger median age than White women (
      American Cancer Society
      Breast cancer facts & figures 2017-2018.
      ). Black women more often experience a diagnosis of triple negative breast cancer (
      • Richardson L.C.
      • Henley J.
      • Miller J.
      • Massetti G.
      • Thomas C.C.
      Patterns and trends in black-white differences in breast cancer incidence and mortality—United States, 1999–2013.
      ). Policy analysis must engage the daily lived experiences of Black women to better understand the determinants of health (step 3) and potential areas of additional inquiry (step 4).
      Black maternal health in the District of Columbia is overshadowed by Black women having the highest rate of maternal mortality in the country. Local leaders attribute this to food and medical deserts (
      • Perez M.Z.
      A maternity care desert threatens lower income women in Washington, D.C. Colorlines: Race Forward.
      ), as well as insufficient availability of “centering” social support networks and technologies (
      • Schmidt S.
      How to solve D.C.’s maternal health crisis? A health advocacy group proposes some ideas. The Washington Post.
      ), specifically in the first trimester. Black women are three to four times more likely than White women to die owing to childbirth in the United States. Maternal mortality (
      • Curtin S.C.
      • Hoyert D.L.
      Maternal morbidity and mortality: Exploring racial/ethnic differences using new data from birth and death certificates.
      ) and pregnancy-related outcomes, such as low birth weight and infant mortality rates, among Black women across all incomes (
      • Jackson F.M.
      • Phillips M.T.
      • Hogue C.J.R.
      • Curry-Owens T.Y.
      Examining the burdens of gendered racism: Implications for pregnancy outcomes among college-educated African American women.
      ) suggest a direct relationship between the social exposures they all share on a daily basis: institutionalized gendered racism. Any policy analysis exploring this issue must engage with Black girls' and women's pregnancy and birth narratives (step 1).
      If health policy engaged with these communities and centered their experiences, appropriate and effective policies at all levels—from workplaces and institutions to federal agencies—can be developed. Policy decision makers committed to real structural and sustainable change must consider the role of decoloniality in the multiple systems affecting Black women's health. To accomplish this, we challenge decision makers to 1) decolonize science and health, 2) defund the police and invest in under-resourced communities, 3) pay reparations for uncompensated work and historical and psychological trauma and distress, 4) fund Black women-led research to assess gaps that relate to Black women's health and inform policy on the science and health care agendas, 5) mobilize a sustainable Black political party, and 6) listen to Black women.

      Decolonize Science and Health

      Race is used in clinical decision making, without rationale, in cardiology, cardiac surgery, nephrology, obstetrics, urology, oncology, breast cancer surveillance risk, endocrinology, and pulmonology (
      • Vyas D.A.
      • Eisenstein L.G.
      • Jones D.S.
      Hidden in plain sight—reconsidering the use of race correction in clinical algorithms.
      ). For example, diagnostic formulas such as the estimated glomerular filtration rate, which measures kidney function level to determine kidney disease stage, is potentially problematic because a Black patient's race is part of this estimated, not measured, rate and is based on average assumptions of muscle mass and creatinine level (
      • Eneanya N.D.
      • Yang W.
      • Reese P.P.
      Reconsidering the consequences of using race to estimate kidney function.
      ). Implications are vast when considering these medical biases, misjudgments, and practices that are a part of health care and medical training. We must call out the professional associations and their guideline decision-making bodies to ameliorate systemic racist practices. Decolonizing science includes the interrogation of research, clinical practices, and/or approaches to transform knowledge production.

      Defund the Police and Invest in Under-resourced Communities

      The call to “Defund the Police” is an abolitionist strategy and a way of seizing and subverting power away from the police state and back into community-based solutions to potentially address structural health inequities. Possible solutions include creating community health centers and clinics when so many Black communities are seeing hospitals leave their areas; installing maternity wards (as advocated by DC activist Nene Tay,
      • Black Lives Matter B.L.M.
      United States.
      , DC Chapter, as heard by a co-author at the In Defense of Black Women March on June 19, 2020), led by locally trained birth workers, midwives, herbalists, doulas, and other nontraditional health professionals, to support pregnant Black women throughout the pregnancy; and expanding programs to address interpersonal, community, and police violence, especially for those most affected by police violence such as trans women of color, and including the active elimination of sexually coercive practices that often occur within housing developments for Black women (
      • Wenger Y.
      Tenants to share up to $8 million in settlement of sex-for-repairs lawsuit. The Baltimore Sun.
      ). Other solutions include partnering with community businesses and faith-based institutions to address trauma, mental health, and well-being. One example is nationwide training, implementation, and dissemination of Black women informed interventions such as PsychoHairapy (
      • Mbilishaka A.
      PsychoHairapy: Using hair as an entry point into black women’s spiritual and mental health.
      ), which uses hair as an entry point to address mental health. Transforming dilapidated buildings into urban centers or community gardens and using urban gardening to educate intergenerationally and address food apartheid (
      • Reese A.M.
      Black food geographies: Race, self-reliance, and food access in.
      ) and deserts has the potential to create jobs and opportunities for community members, as well as reinforce community social support, which drives community health. Last, implementing recidivism prevention training to ensure those returning from prison do not find additional barriers to creating a new life after serving their time and eliminating the cash bond jail system for those being detained for pretrial is another viable solution.

      Pay Reparations for Uncompensated Work and Historical and Psychological Trauma and Distress

      Black reproductive justice focuses on the ways in which Black women's bodies have been used for capital during and after enslavement and demands that Black women, girls, and femmes have full agency and bodily autonomy. Reproductive rights, health, and justice practitioners have called for the repeal of the Hyde amendment and for an end to counseling laws and laws that create forced delays. Black radical reproductive justice practitioners have called for reparations for Black women's reproduction. There should be an immediate review of every company and organization in the United States that has benefited from Black women's reproduction, as well as the creation and funding of a task force of organizations committed to Black women's reproductive health to monitor this analysis and oversee this process. We recommend the following organizations: the Black Women's Health Imperative, The Afiya Center, Black Women for Wellness, New Voices for Reproductive Justice, Sisterlove, SisterReach, Spark Reproductive Justice Now, Women with a Vision, SisterSong Women of Color Reproductive Justice Collective, Black Mamas Matter Alliance, and the National Birth Equity Collective.

      Fund Black Women-Led Research to Assess Gaps that Relate to Black Women's Health and Inform Policy on the Science and Health Care Agendas

      The research to practice/praxis paradigm is essential to improving medical care—if Black health concerns are not being adequately funded by groups intimately aware of the issues, it stands to reason that Black health concerns are not being addressed by those providing care, even if they are Black. We must convene a funded research and clinical practice task force, organized and led by the Black Women's Health Imperative, composed of Black researchers and health care professionals, to review guidelines by all medical, specialist, and government organizations.

      Mobilize a Sustainable Black Political Party

      Black women are loyal to our communities. We are also loyal to organizations that offer us a seat at the table and welcome our co-laborers. Many Black women are optimistic about the current platform of the Democratic candidates, especially the focus on the maternal mortality crisis. However, there are more maternal health outcomes and other Black girls' and women's health inequities. This may require developing a Black women's health super political action committee to garner influence.

      Listen to Black Women

      Shirley Chisholm said, “If they don't give you a seat at the table, bring a folding chair” (
      • Carr G.
      Unbought and unbossed, Shirley Chisholm stands as a timely lesson on claiming a seat at the table. The Huffington Post.
      ). Chisholm did not let this stop her from running for president in 1972. Similarly, Black women not only bring a folding chair, they bring their own table, as well as other Black women as co-laborers in their work. Black women do not wait for others to do for them; we do what keeps us and our families surviving in a system that capitalized off our wombs and continues to capitalize off of our community's bodies within other systems such as the prison industrial complex. This persistence is what continues to propel Black women to exceed expectations. U.S. Vice President Kamala Harris is very familiar with this persistence. As the first Black woman (and person of Asian heritage) to be nominated as vice president to a major party's ticket, she recognizes that it is persistence, not simply ambition, that motivates her many “firsts.” Although we celebrate these herstories, we also recognize that the real work extends beyond the elections. The attack on women's health can be seen in the rolling back of reproductive health rights, the dismantling of the Affordable Care Act, and all the historical legacies of removing agency from Black women's lives. Black women are the most active civic participants in this country, despite the gendered racist policies, laws, and reports that continue to influence our health outcomes.

      Conclusions

      The BFW Analytical Path to Health Equity is necessary. This approach benefits not just Black women, but all marginalized groups. Ida B. Wells Barnett, Sojourner Truth, Recy Taylor, Fannie Lou Hamer, Alicia Garza, Patrisse Cullors, and Opal Tometi already told us. Listen to Black women. This means ensuring that Black women are at the table, creating their own tables and building additional spaces for other women, allies, and co-conspirators to join them at their tables. It is past time to listen to Black women. We are at the table, America, the one we bought with our wombs. We insist you address your debt. We are done waiting.

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      Biography

      Jameta Nicole Barlow, PhD, MPH, is a community psychologist and Assistant Professor of Writing, Women's Leadership, and Health Policy and Management at The George Washington University. She employs decolonizing methodologies to disrupt cardiometabolic syndrome and structural policies affecting Black girls’ and women's health.

      Biography

      Breya M. Johnson, MA, is a Black Feminist and Womanist practitioner. She is an organizer, writer, and interdisciplinary scholar. Her research interrogates the pedagogy of disposability, radical love, the Black radical imagination, prisons, and Black women's health.