Misinformed Care: On Uché Blackstock’s “Legacy” and Constance Hilliard’s “Ancestral Genomics”

BILLY WOODBERRY’S BLESS Their Little Hearts (1984), written and filmed by Charles Burnett of Killer of Sheep (1978), follows a Black family living in Los Angeles. The husband, Charlie (Nate Hardman), has been unemployed for 10 years, and during that time, his wife, Andais (Kaycee Moore), has been carrying the couple and their three children. In one scene, Charlie works as a day laborer, scything down a hilly tangle of weeds. Once he’s finished, he climbs aboard the rickety pickup truck of the man who hired him and they drive down South Central Avenue, rolling past block after block of rubble, hollowed-out buildings, naked steel girders, and concrete lots reverting to grassland. Charlie takes in the grim scene while smoking. He is bearing witness to the demise of the Goodyear Tire & Rubber Company’s 74-acre site, which employed nearly 600 people until it closed in 1977. The flight of hundreds of thousands of industry jobs represented by Goodyear’s dissolution was a crushing blow to the social and economic life of Black Los Angeles. The ravages of their neighborhood are reflected in Charlie’s and Andais’s personal lives. The erosion of social structures has intimate consequences, as cultural critic Brittney Cooper has described. When Andais explodes in anguish and frustration at Charlie’s failure to provide (on top of his ongoing affair), time’s cruelties are laid bare. Andais is bone-tired.

The problem of being Black in the United States is, in part, one of time. In Between the World and Me (2015), Ta-Nehisi Coates puts it well: “[P]erhaps the defining feature of being drafted into the black race was the inescapable robbery of time, because the moments we spent readying the mask, or readying ourselves to accept half as much, could not be recovered.” Whenever sundown towns come up in public discourse—which happens with surprising frequency—I think about how they represent an extreme robbery of time: Black people could not exist publicly for the duration of a full day. Sundown municipalities decreed that Black persons appearing on city streets after sundown could be arrested, violently expelled, or murdered. In Marlow, Oklahoma (today 0.16 percent Black), a porter named Robert Johnigan was shot by a white man in 1923 after a gathering mob threatened to lynch him for defying, as The Rock Island Argus reported, “a rule which forbids negroes to stay after sundown […] Marlow’s unwritten law, exemplified by public signs commands: ‘Negro, don’t let the sun go down on you here!’” Sundown towns may represent extreme cases, but they serve to illustrate the more mundane robbery of time at play in routine Black life, and the additional layer of friction that stops Black folks from living well, or fully.

Dr. Uché Blackstock’s new memoir Legacy: A Black Physician Reckons with Racism in Medicine melds her own story with an incisive analysis of why Black people in the United States are disproportionately sick and die early. The book is an homage to her mother, a Black woman and physician in whose footsteps she (and her twin sister Oni) followed, and a compelling insider perspective from a doctor who has worked in various New York City health institutions. The kind of time deficits and distortions that haunt Black life appear early and often in Legacy’s pages.

Blackstock’s mother, Dr. Dale Gloria Blackstock, was an attending physician who specialized in nephrology at Kings County Hospital Center in Brooklyn. She had grown up in poverty, lacking access to routine medical care, and was taught by Catholic school nuns who laughed outright at her professional ambitions. The first in her family to obtain a college degree, she then went on to graduate from Harvard Medical School in 1976. She and her husband Earl Llewellyn, an immigrant from rural Clarendon, Jamaica, raised the two girls in Crown Heights in the 1980s and ’90s. Dale Blackstock died from acute myelogenous leukemia at the devastatingly young age of 47, leaving behind two bereft daughters halfway through their undergraduate studies at Harvard, and a legacy of Black women mentees who now occupy leadership positions in medicine.

As a child, when Uché Blackstock and her family had to travel to predominantly white spaces in the city like Park Slope in order to obtain fresh produce, and when she was exposed to classmates’ environments—clean, fecund, expensive—she realized that “a good life was available to us, just not where we lived, nor among people who looked like us,” nor, I would add, without additional expenditures of time. The house they grew up in was “a wreck” that consumed her father’s time for a decade after purchase; the rest of the block was tottering towards ruin. Both trajectories were products of redlining policies, which wasted time—creating more friction in Black lives and more opportunities for failure. During Blackstock’s youth, crack infiltrated Crown Heights. Here the state’s lack of investment of time in quality education, jobs, and social opportunities came home to roost in an epidemic that devastated families and communities across New York City and the country. The epidemic garnered the only thing for which the United States has a surfeit of time when it comes to Black folks—policing.

A visceral, harrowing incident in which Blackstock nearly ran out of time occurred during her first year of medical school, when she had a near-death experience over an inflamed, and then burst, appendix. In a diagnostic scenario in which time was utterly of the essence, residents wasted it by offering causes for her symptoms that failed to see Blackstock as an individual but rather as their stereotyped notion of a Black woman. The attending physician ruled out the possibility of appendicitis, saying that Blackstock “didn’t seem to be in that much pain.” And then he left. By the time all was said and done, Blackstock had cheated death, survived two surgeries, and missed five weeks of medical school for something that most people recover from in a few days. As she ponders how biases clouded her treatment, she muses on Toni Morrison’s dictum about the distraction of racism, and the fact that “you waste hours of your life trying to figure it out.”

Blackstock’s patients were themselves aware that, as Black persons seeking care, time was not on their side. At the beginning of the COVID-19 pandemic, Blackstock was a practicing physician in a Brooklyn urgent care clinic. Donning full head-to-toe personal protective equipment (PPE) that obscured her physical features, she greeted a young Black woman. The patient tentatively responded, “Can I ask you something? […] Are you Black?” When Blackstock affirmed that she was, the woman sighed with relief and said, “At least I know you’ll listen to me.” Physicians routinely fail to allot the requisite time in encounters with Black women. We know the stories: Serena Williams had to diagnose her own blood clot; Susan Moore, herself a physician, was treated with contempt and dismissed by a white physician, because of which she died of COVID-19 at the age 52. Racialized time in medical care casts asunder protocol, empathy, and common sense.

As an academic, Blackstock encountered racism that will provoke shudders of recognition among Black women in many professional settings. At New York University’s medical school, patients doubted her expertise or credentials, seemingly incredulous that she was the doctor. It got worse over time:

Ever since Trump’s election in 2016, there had been a marked uptick in explicitly racist incidents within hospitals. Whereas in the past the racism we encountered from patients tended to be more covert, now they felt emboldened, asking outright, for example, to be treated by white physicians.

The patients, like the country, were backstroking to the freer, full-bodied buoyancy of racism of times past. A time when Black people had much shorter lifespans. A time very much like … now. Contemporary childbirth statistics smirk at figures from the early 20th century. In 1915 (the year The Birth of a Nation was released), “Black birthing people were almost twice as likely to die from pregnancy-related complications as their white peers.” Blackstock tells us that today the ratio has climbed to three to four times more likely. These glaring inequities radicalized her. She saw them disrupting lives time and again. One mother missed follow-up appointments for new onset kidney failure because her kids were sick—and she would have to wait another six months for the next available appointment. Blackstock explains, “Once I began to see the failures of our health-care system to take care of Black people, I couldn’t stop seeing them. There were examples everywhere.” Legacy is a searing indictment of those failures.

Meanwhile, Blackstock’s description of typical medical training suggests that the profession is stuck in a time machine. The proportion of Black to non-Black physicians has not changed much from what it was 100 years ago: “In 1910, 2.5 percent of all US physicians were Black. By 2008, that number had increased to 6.8 percent.” Eager students continue to endorse racist tropes about Black people’s bodies, including early 19th-century ideas that Black people have thicker skin and are less susceptible to pain. Blackstock recounts:

Throughout our medical school education, we learned that there were different standards of normal for different patients […] When diagnosing kidney dysfunction, for example, we were taught that Black patients had higher normal kidney function than non-Black patients, based on the racist presumption that Black people have a higher amount of muscle mass. Much later in my career I learned that this particular race-based testing has horrifically led to kidney function being underestimated in Black patients, leaving them less likely to receive the specialty kidney care they need or being excluded from the kidney transplant waitlist because their kidney function may appear normal.

In Ancestral Genomics: African American Health in the Age of Precision Medicine (2024), evolutionary historian Constance B. Hilliard also considers kidney function. This book is not a memoir, although a medical encounter serves as its point of departure. While traveling in Japan, Hilliard was startled when a doctor diagnosed her with advanced kidney failure. When she returned home, her primary care physician rejected the diagnosis and explained that her lab results revealed perfectly healthy kidneys. The problem was that the Japanese doctor had not applied a race correction that scales African American renal function differently. This bizarre state of affairs sent Hilliard on a quest to understand how and why race, the social construct that it is, could insert itself into medical care and constitute the axis around which a diagnosis of renal failure could turn. Where Legacy critiques the racist tropes that undergird medicine’s normative metrics, Ancestral Genomics looks back in time, seeking to recover a historical understanding of misinformed care. Alas, it offers a theory that has been repeatedly debunked. Hilliard argues that the problem is fallaciously assuming that two people who identify as Black share something called “race” that would make their kidneys operate similarly. Instead, these two hypothetical people “would have dramatically different kidney readings if one hailed from the salt-rich coast and the other was genetically adapted to the sodium-deficient interior of the African continent.”

With this claim, the unfortunate focus of the book comes into view—to reanimate a variation of the “slavery hypothesis,” which holds that Black people today are prone to hypertension because their centuries-old African heritage comes with an abnormal physiological regulation of salt. One version of the hypothesis holds that the African persons who underwent the Middle Passage excreted excessive amounts of salt in sweat, waste excretions, and vomit, and those who survived passed down a genetic propensity to retain salt, which, the theory says, was beneficial for surviving the hold but damaging to descendants living on land. Another version, which is what Hilliard offers, contends that the African people who were taken captive from “sodium-deficient” lands bore descendants ill-equipped to live in the salt-laden society of contemporary America. I couldn’t help but wonder what nephrologist Dale Blackstock would make of this theory.

When African Americans face relentlessly constrained access to what sociologists including Bruce Link and Jo Phelan define as the flexible resources that fundamentally drive health—“money, power, prestige, and beneficial social connections”—a genetic explanation for racial chasms in life and death is unlikely to be persuasive. To understand why, consider that between 2016 and 2020, the rate of new lung cancers among Black men was 11 percent higher than in white men. One need only look to risk factors like aggressive menthol cigarette marketing, which has blanketed Black communities for decades. Over the past 40 years, approximately 40 percent of the excess deaths attributable to menthol cigarette smoking landed among African Americans. Black men are not disproportionately stricken with lung cancer because their genes are different from men categorized as white. The Biden administration is, as I write this, considering a further delay to an already postponed ban on menthol cigarettes, fearful that it will hurt his reelection campaign. It is taking the ghoulish gambit that Black votes are more pressing than excess Black sickness, suffering, and premature death. It’s a calculus that sounds like it came from the computerized voice activated when pedestrians push the beg button at a crosswalk: “Wait. It’s not a good time.”

The crux of the argument in Ancestral Genomics rests on the notion that African Americans descend from farmers who lived in “stateless societies” in the “West African interior,” occupying lands too far from the coast to reliably access sea salt. The lands, according to Hilliard,

were perceived as worthless even by the standards of their African neighbors (because this geographic region lacked even the most minimal deposits of sodium that most humans need to survive). […] Its inhabitants had subsisted on 200 milligrams (mg.) of sodium a day while coastal West Africans, Europeans, and later Americans consumed between 3,400 and 5,000 mg. of sodium a day.

No scholarship is cited to support these assertions, and researchers have pointed out that any society close enough to the coast for its members to be abducted into slavery is close enough to have access to sea salt. African Americans have physically embodied history, but it’s not the history of salt. It is labor history, and the history of housing, education, voting rights, and criminal justice. Black health directly reflects the history of racism in the United States, which is why the political Right doesn’t want that history taught. As scholar Elizabeth Alexander has asserted, “If any one aphorism can characterize the experience of black people in this country, it might be that the white-authored national narrative deliberately contradicts the histories our bodies know.”

Hilliard rejects the essentializing of race that underwrites the renal correction, but then turns to genetics in an equally essentializing way, taking as a given that Black people have a “hypersensitivity to sodium.” Oddly, in an effort to refute racial essentialism, the text recounts 19th-century craniometry research—which invariably found that people from Africa had underdeveloped skulls—but not to say that the whole thing was malarkey. Rather, Hilliard asserts that “[w]e now know that the African continent, because of its greater genetic diversity, boasts skulls of all shapes and sizes.” I can imagine that someone like phrenology enthusiast Dr. James Mortimer from The Hound of the Baskervilles (1902) might be impressed (he effused to Sherlock Holmes, “A cast of your skull, sir, until the original is available, would be an ornament to any anthropological museum. It is not my intention to be fulsome, but I confess that I covet your skull”).

Hilliard contends that the pendulum in medical literature has swung inappropriately to a “colorblind” approach that fails to consider how population-specific gene variants trigger disease. She defines “Ecological Niche Populations” as groups that “shared a similar health disparity triggered by the same adaptive gene variant.” To be sure, the shorter, sicker lives of African Americans as a population is not, in her view, because of “race.” But neither is it because of gene variants. It’s because of racism. Hilliard suggests that there is disproportionate time and money spent on investigating stress and inequality as causes of hypertension, and hints that the harder-hitting promise of genetic hypotheses on salt have been left by the wayside in favor of sexier theories about racism. The reality is that the National Institutes of Health are deeply invested in explaining and addressing health through processes that go deeper and deeper into the body, rather than outside the body to social structures. Consider cancer, which prematurely took the lives of both Blackstock’s and Hilliard’s mothers (for the latter, breast cancer at age 51). Over the past 10 years, the NIH’s National Cancer Institute has funded three studies on the health effects of racism. But for projects on genes and cancer, they supported 6,080—6,080 versus three.

Together, Legacy and Ancestral Genomics demonstrate how badly the nation’s health institutions need reworking from the ground up. Black people don’t have time to wait for medicine or biomedical research to commit to undoing excess deaths, because time is not money but life. That’s why when Dale Blackstock was nearing death, she instructed her daughters to care for themselves by taking time off before medical school. That’s why we find resistance to racialized time and time loss. Curator Meg Onli’s 2019 exhibition Colored People Time interrogated a “collective performance of refusal: A refusal to disavow our embodied sense of time, beyond capital’s demands. […] A refusal to adhere to Western time as the only time.” Away with oppressive time signatures. Away, timeless racism. Away, time’s tally lost. Black life on its own time.