Keisha Ray, PhD, is an Associate Professor of medical humanities and bioethics at McGovern Medical School in Houston, Texas. She is also an associate editor at the American Journal of Bioethics.
Sarah L. Berry // This interview series features educators, scholars, artists, and healthcare providers whose work is vital to the growth of the health humanities. On Monday, May 22, I interviewed Dr. Keisha Ray about her new book, Black Health: The Social, Political, and Cultural Determinants of Black People’s Health (Oxford, 2023).
Sarah Berry: Thank you for speaking with us about Black Health: The Social, Political, and Cultural Determinants of Black People’s Health. Can you briefly describe your book and tell us what inspired it?
Keisha Ray: Black Health for me is really the culmination of all the things I’ve been working on for the past few years around the problem of moralizing Black people’s health. There’s a need to stop making it seem like we have biological deficiencies, or that there’s something inherently “bad” about Black bodies and minds that make them susceptible to disease and illness.
Black Health is really focusing on shifting pathologization [away from] Black people, and instead looking at how the environments around us can either contribute to poor health or exacerbate poor health.
The book takes our health as a case study for examining all of the ways our social, political, and sometimes cultural environments can contribute to bad or poor health through specific examples of pregnancy and birth, cardiovascular disease, sleep, and pain management. I look at these very specific areas where Black people tend to have poor health outcomes and poor access to healthcare specialists. For instance, thinking about how Black people tend to live near places where there is pollution in the air and water, and how that can contribute to poor sleep or even higher rates of cardiovascular disease.
In these areas where Black people have poor health, it’s not just because they’re “bad,” or our bodies are “bad,” but it’s because our environments are bad. So it’s looking at the lived experience of these poor health outcomes at the population level and then looking at individual people to put a face to those aggregate experiences. I wanted to make it readable and accessible to people who want to learn about this but don’t want to read philosophical jargon.
SB: The cover invites the reader to think about the collective and individual implications of Black health. Did you choose the cover art?
KR: I did. Art is of course essential to the humanities, and I wanted a cover that elicited some emotion going into the book.
I was very thankful for the Charles Henry Alston estate that allowed me to use this without hesitation—they were very kind. It’s a painting called Walking from 1958, representing the women and the youth who were essential to the Montgomery bus boycotts but were overlooked. Their work was just not the main focus, not something that we tend to remember when we talk about the history of that time in Black people’s fights for civil rights in the fifties, sixties, and seventies.
I really like this painting, too, because the colors are just beautiful and bright and there’s great blending and flow. So that’s the first thing that drew me [to it], but then when I started looking at the actual people, I liked that the faces sort of blend in but yet there are these very distinct figures there. That was very representative of the kind of work that we do in bioethics and medical humanities where we have a collective goal and sometimes we get sort of lost in that. Sometimes you get overshadowed, overlooked, but there are people doing this work and they deserve to be highlighted.
So that was also a project in the book, making sure that I’m using different kinds of scholars, citing women and people of color. How do I make sure that these stories that often get overlooked are brought to the forefront? How do I make sure that the people who are out there doing the work are getting the attention that their work deserves? So this painting is very representative to me of the people who are doing the work in Black Health and need a little bit more spotlight, and if I can use my small little space here to do that, then that was something important to me to do.
SB: The book is really gorgeous on the outside and invites readers to pick it up and look closely at the painting and open the book. Thank you for sharing the significance of the image for you and your project. Turning to your background, you’re trained in philosophy with a concentration in bioethics and you have built an academic career as a bioethicist. For the past three years or so, you’ve been actively contributing to Black bioethics. What links Black Health with your different writing projects and how does Black bioethics inform it?
KR: Black Health takes the approach that I do with all of my bioethics work, but also all of my medical and my health humanities work, and puts it together. My bioethics work can be very practical. That’s the aim: how do we make this accessible in the classroom? But then how do we make it accessible to clinicians? How do we make it so they feel like they can implement this for better patient care? They can implement our studies of humanities, our studies of ethics, and actually feel empowered and not feel put off or like this is something that’s solely theoretical or inaccessible to them. This practicality idea in the classroom and clinical settings is one aspect of the book format of Black Health.
But there’s also another aspect: How do we make it so that people feel these topics are real? I think that’s a very big problem when we talk about Black people’s health. Whenever we’re talking about them in the classroom, whether to physicians, nurses, dental students, or undergrads, most of the scholars talking about Black health will not be Black because we don’t have that many Black scholars. Also, most of the students that we talk to won’t be Black. So then how do we make it so that they see this experience that’s so very different from their own, but see it as real and see it as a call to justice? [Can they] see it as a call for them to do something in their respective field, or to be a better practitioner or a better dentist, for instance?
Taking this combination of making it practical, but also so that they feel it, [the writing is designed to access] emotion and lived experience and help learners see the faces behind these numbers and statistics.
Science students in particular know the numbers. They can tell you 25% of Black women have X and 30% of Black men have Y, right? They know all the percentages that represent poor health outcomes for Black patients but they don’t know how that affects their lives. They don’t know how that affects how Black people see themselves, individually, and within their family or friend groups. They don’t see how it affects their hobbies and overall well-being and happiness.
Black Health encompasses all of it: Let’s look at the numbers. Let’s look at the people behind those numbers. Now let’s look at what this means for those individuals.
I felt like bioethics wasn’t giving enough attention to the ways that our work can affect access to justice for Black people. We talk about justice a lot, right? It’s one of the pillars of bioethics. We talk about it in so many different ways all the time, until we’re blue in the face. But often when we talk about Black health, it’s relegated to either those scholars that specifically talk about it or it’s not discussed at all. It’s never just incorporated [into] the basic thread or foundation of bioethics.
For me, Black bioethics is thinking about how everything that we do in our bioethics work can either promote or help eliminate anti-Black racism. We have to think about whatever study we’re doing, empirical research or theoretical work, [in terms of] how can it negatively impact an already marginalized population. I think that just has to be a basic question that we think about. But also it can be its own field, right? For anyone who’s interested in talking about this population of people and their health, then Black Bioethics gives you a way to say, “Okay, I’m going to focus on this group. I’m going to look at how political movements and medical technology and environmental factors and all parts of our social lives can affect Black people. And now what can I do about it? What do I have to say about it?” But that doesn’t mean that if you don’t specifically study Black people that you can just ignore us because it affects everything that we talk about, whether we’re talking about the physician-patient relationship, or environmental health, or abortion, or physician–assisted death. These all affect Black people in unique ways because of our political standing in America and our global political standing.
Black bioethics is saying, “Hey, you can’t ignore us. You have to talk about how your work affects people in their real life. You can’t just talk about it in this theoretical sense because there are people for whom it’s going to have very practical effects.”
It’s making a concerted effort to talk about a marginalized group like Black people without just relegating them to the side or forgetting about them completely.
SB: Yes. The thing that’s interesting to me in this endeavor is the unique intersection between health humanities and bioethics in your book. There are particular ways in which bioethics, which can be very applied or very principlist, can be infused with health humanities, which lend a contextual awareness and critical interpretation of different forms of cultural representations (including storytelling and data narratives). Then this intersection potentiates the political power to make actual change in people’s lives, which your book advances. Shifting gears a little, I think it’s important to acknowledge that you’re doing this anti-racist health humanities and bioethics work while also living in this social position and having the experiences, yourself, in society and in healthcare settings, that you’re examining in the book. What were the challenges or rewards of writing about issues that you’re also experiencing?
KR: Right. It’s hard when you see yourself and family and friends on the pages of your writings. One of the exceptionally hard parts of this work was that I had to read a lot of journal articles by physicians who were treating enslaved Africans. I read all of the horrible things that they said about their bodies and all of the false beliefs that they had about them. And then I started drawing connections between my own contemporary experiences and those of my Black family and friends. When I started to see connections and that these old ideas have been repackaged into different kinds of racist beliefs and behaviors, that was really the troubling part for me. I’ve had my own experiences with physician biases, whether that is [based on] gender, race, or their assumptions about class, and of course, all the ways that those intersect. I’ve written about that here.
One thing that writing about my experiences did was make me very careful with how I handle other people’s stories. I know how open and vulnerable sharing personal stories can make you. I handle my own story with care so I wanted to have that same delicate handling when telling other people’s stories. I don’t want to marginalize an already marginalized person.
In the introduction, I discuss how the writing of this book was delayed by my own medical issues, including two major surgeries for issues that are fairly common to Black people. I was dealing with the thought that I could easily tell my own story in this book or see my own story in these pages. I am the stories I am telling in Black Health. I picked the topics in the book partially because they are topics where Black people have some of the poorest health outcomes, but they’re also personal to me.
This book is personal. There’s a chapter on gynecology, and I’ve had my own gynecological surgeries and issues. I’ve had my own cardiovascular issues with poor health, and that’s a chapter in the book as well. I’ve had insomnia since about age 14, and there’s a chapter on sleep. I’ve had to deal with all these things as I was writing this book, and it’s telling the story of people who look like me, but I am one of those people. My story is in this book. It can be difficult but it can also be rewarding because I’m telling our story. It’s not just someone else’s story. It’s not even just my story. It’s a collective story, and I’m easily in those statistics. And I want to make sure that they are seen through the appropriate social, political, and cultural lens and not just that my body is “bad” or “failed” me, but instead to look at all of the environments around me that contributed to these experiences that I’ve had. My own health issues were the reason I couldn’t even finish this project that I really loved in the time frame that I normally could have because I had to deal with taking time off work and pain and surgeries and doctor visits. That brought it to life, too. Look at all the things that I could be doing, but instead I’m having to take care of my health. I have this career that I love. I have these hobbies I love. I have these people in my life that I love and I had to put all of that on hold so that way I could take care of myself. It was a reminder of self-care and that all these other things can wait so I could get healthy and keep doing the work that I am passionate about and that I believe can help other people.
SB: Thank you so much for sharing your perspective and for including your own experiences in this book. It raises a crucial point: the way that we write about different groups and their health matters. A writer has to identify somehow, and you’re identifying as part of the “we” about whom you’re writing, to other people. The language in your book is really important.
KR: Yes, I think so. The language actually was something I struggled with because there are some things in this book that are personal to me and that I’m a part of and so I felt like using the “we” was appropriate. I can’t say “Black people” and then use “they” because I am a Black person. But then there are other topics where I don’t want to co-opt other people’s experiences.
There are some things in the book that are not personal to me, and I also don’t want to center myself when I’m telling someone else’s story, especially if it’s something foreign to me. So I thought about using “they,” but then that sounds weird because I am still a part of this community.
I did have to go back and forth about the language choices and I ultimately decided to do a little bit of balancing and say this is me and use the “we” language: this is me telling your story, but it’s also me telling my story. But then when it’s clearly not about me and I want to focus on someone else like Black men and their poor sleep quality and quantity, I need to make that section about them. This is something that’s important to me. It doesn’t get enough attention. We’re talking about Black men’s health. And so I wanted to make sure that this particular section was not centering myself but showed how it’s an important topic for me.
SB: Each chapter opens with a person’s health story, and then you apply lenses of social, political and cultural determinants of health to illustrate the lived experiences of health problems and their clinical implications. This format is very effective, I think, for communicating difficult-to-grasp concepts about structural and race-based inequity working on individuals. At the same time, there’s a tradition in bioethics of case-based learning. In this book, are you revising the case study to be more effective for Black bioethics and learning about Black health?
KR: I’m a medical school instructor, so I am very familiar with the case study format of teaching. I think that they’re very helpful when they’re real. So all of the case studies in Black Health are real people and their very real stories. I didn’t add anything. Sometimes [in medical education] we’ll take a case study and for pedagogical reasons, we’ll add in some other things to bring out certain kinds of questions and conversation among learners. I did not do that. I took the story exactly for what it is and just gave the facts. I did not shy away from putting in age. I didn’t shy away from putting in race or gender because I wanted people to take that intersectional lens and to really focus on the way that I approach Black health by looking at all of Black people’s identities with regard to race, class, gender, and other factors, and look at how the institutions that govern our lives intersect with those identities. But to do that intersectional analysis, the case has to include that information and it has to give learners a way to say, “Okay, now let me do some critical thinking. Let me use what I know.” In Black Health, within each chapter, I return to the initial story so learners can see that it’s not just this one-off person, but instead begin thinking about how this person’s experiences fit within a larger conversation about social determinants of health. And I think that’s one way to approach case studies—giving learners a little bit more information so they’re not going into the case study blind but they are getting a little bit of guidance and then they can use critical thinking to discuss the case study and why it matters to whatever lesson that they’re learning at the moment. It’s more like real life and real experiences in health care settings, and I think that’s a great pedagogical tool for future caregivers.
SB: That’s great. And just to follow up on that real quick, the whole format is highly effective for teaching, with the initial true story, analysis of structural determinants of health and clear connections made with the initial story, followed by a brief conclusion and discussion questions. To my mind as an instructor, the questions are really great because they elicit discussion without feeding answers or binary responses. Who is your ideal audience? Perhaps there is more than one?
KR: Before I started teaching medical students, I taught undergrads for about 10 years and now I do a lot of guest speaking in high schools that are doing health and medical ethics courses. As I started writing this book, I really wanted easy-to-read, short chapters because we know students don’t like to read long texts. I also wanted a book that could be incorporated into classes where instructors may already have a syllabus created that they like. The chapters can stand alone and they can be added into lessons that already have been developed.
My ideal audience is people who are just starting to learn, who maybe don’t know much about the social determinants of health, who don’t know much about Black health or about Black people’s poorer health outcomes and poor access to healthcare and physician bias and medical racism. I also made sure that the sections were easily identifiable and that the language is very simple and accessible. You don’t need a dictionary as you’re reading this book. So my target audience is people who don’t know much about this topic, but who need just one very concise book – readers who don’t want to read five books to learn about James Marion Sims, but just want the basics. They can easily find that section and say, “This gives me all the information.” But then also there’s a little bit of analysis, so there’s an opportunity to reflect, “Now that I know the story, what am I supposed to think about it?”
I really wanted it to be used in classrooms, something that students can take and learn from, whether they go into health sciences or not, just so they know a little bit about this community. It is very, very accessible and has discussion questions that instructors can use for homework assignments or for small group work and class discussion. I really wanted to make it easier for instructors, too, who may not know a lot about Black people’s health or feel that they are not the appropriate instructor but want to incorporate [the subject] in their courses. Maybe they think that, because they’re not Black or a scholar in bioethics or a scholar in Black health, they can’t talk about this topic. So here’s this tool that can make it easier for them and help facilitate this discussion. Even if you don’t know all the parts of Black health, even if you’re not an expert, you can still have these conversations with learners or with your friends. It’s a good book for a book club, in my opinion, too, because it’s easy and short.
SB: What kinds of change in population health and medicine would you hope to see resulting from the book?
KR: [Changes] starting with the self: a little bit more self-analysis, and more analysis of the work that we’re doing and why we’re doing it. Who is benefiting, and are we harming anyone in any kind of way?
How can we use our self-analysis to then affect institutional policy in our own little areas of the world, our own clinics, our own departments, our own academic centers?
I think that’s where it has to start. I think a lot of people get very overwhelmed when they think about all the anti-racism work that needs to be done, all of the changes they want to see at their institutions or even at the state level or at the federal level. There are all these changes that we know need to be made. But I think a book like this encourages people because every chapter ends with solutions and ways we can now talk about this problem.
For example, there is a chapter about pregnancy and birth. It lays out all the problems. Now what can we do about it? The chapter offers some individual actions – some things clinicians can do and that policy makers can do. I wrote those sections to give a little bit of light at the end of the tunnel, a little bit of hope.
We can have this very, very dreary picture of Black people’s health outcomes, but there are ways to think about what we can do: How do I contribute to advocacy groups? How can I give money or my time or my expertise to make change?
For me, I think it has to start with the analysis of our own work and how we are contributing or not contributing to anti-racist work. I think if we can do that, then it can encourage us to go into our larger communities and be agents of change there.
So ideally, what I would like people to take from this book is a really deep questioning of the self and whether they are doing the work and taking this ally-ship seriously because it can’t just be Black people, right?
I would like readers to ask themselves, “What am I doing to educate myself about health justice? What am I doing in my corner of the world?” I think if you can change yourself, you’ll be motivated to go out and create change in a bigger arena.
SB: Agreed. What are you planning to work on next?
KR: That is a good question. So right now I am relaxing. I’m working on vacationing.
Yeah. [laughs] I am working on sleeping and getting outside and relaxing, but after that I am working on a Black bioethics anthology, an edited volume. I’m having Black bioethicists come together and write about these topics that are central to the field from their own perspectives, from their disciplinary lenses, whether that’s law or sociology or medicine, [in order to create a text] that again is accessible, can be used in the classroom for specific race and health courses or incorporated into already developed courses. That’s the next big thing after the resting.
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Black Health can be purchased at Oxford University Press.
Find Professor Ray at www.keisharay.com and on Twitter: @drkeisharay
