As ethnic diversity increases in the United States, it is important for physicians (and all in the health care delivery workforce) to keep in mind what factors play significant roles in the matter of ethnic health disparities.

With a U.S. population of over 330 million, Hispanics—inclusive of Mexicans, Cubans, Puerto Ricans, and South Americans—now number 62 million, according to the 2020 Census. This equates to almost 19 percent of the country’s population. Blacks in the U.S. are holding steady at 12-13 percent of the country’s populous, with 40 million people, and Asians number almost 19 million, approximately 6 percent of the population.

For Hispanics, major issues include being the least likely to have medical insurance. Many don’t speak English, which makes it difficult when expressing symptoms. There are higher rates of obesity, diabetes, and maternal mortality in Hispanics compared to whites.

Asians number 18-19 million in the U.S. While heart disease is the number one killer of all other citizens, Asians are primarily spared from that fate. Many attribute that to the difference in dietary intake. Asians do have higher rates of lung diseases, hepatitis, tuberculosis, some cancers, and liver disease. Asians are more highly educated than Hispanics and Blacks, and they have a higher median income, which mostly leads to higher medical insurance coverage rates.

Blacks number 12 to 13 percent of the population, yet they carry the least successful health care outcomes for practically all medical conditions. Per HHS’ Office of Minority Health, “the death rate for Blacks is generally higher than whites for COVID-19, heart disease, stroke, cancer, asthma, influenza and pneumonia, diabetes, HIV/AIDS, and homicide.” NOTE: Homicide is listed as the 6th leading cause of death for Blacks, but is not at all listed for any other demographic.

Black men have higher death rates from all cancers and heart disease and the shortest life expectancy of all males. Community initiatives such as the Black Men’s Health Project are hoping to abate those outcomes.

Of great concern however, is the state of Black women’s health. In practically every household regardless of race, the woman is usually the health guardian of the family. She may be the one to regularly take the kids to the pediatrician, or insist that her spouse go to the doctor for a checkup. Oftentimes, as Black women are so busy caring for others, their own health is neglected, preventative checkups are postponed, and health risks advance.

In short:

• Black women have the highest mortality rate from heart disease compared to all American women.
• Black women have the highest death rate from stroke of all women, at 37.9 deaths per 100,000 (in contrast to 22.5 for Caucasian women).
• Black women have the highest mortality from breast, lung, and other cancers.
• Diabetes mellitus is the fourth most common cause of death for Black females, and health outcomes of Black women who have diabetes are far worse than those of whites.
• Overweight women are at increased risk for hypertension, heart disease, diabetes, and some types of cancer. More than two-thirds (66.6 percent) of Black women are classified as overweight, and almost 50 percent are classified as obese.
• Blacks have almost three times the rate of maternal mortality and more than twice the rate of infant mortality as whites and Asians.
• Black women are the fastest-growing segment of the population to acquire HIV. Most cases are due to having sex with high-risk male partners.

What accounts for these striking numbers? As I (and I’m sure all clinicians) would attest, the normal human female—regardless of race—is the same anatomically and physiologically. Her hair may have a different texture and skin tone, but the inner workings are all the same when normal. So, if structure and function are the same, why are health care outcomes terribly different in many cases? Why do Black women still carry a poorer prognosis, and higher mortality rate, for many conditions that others are readily cured of in significant numbers?

Many times, the go-to explanation for ethnic health disparities is “Blacks lack access to medical services” or “many lack medical insurance.” Yes. Those are applicable factors. But those same studies fail to report that, even for Black women with access to medical care and services; even those with insurance and higher education, they also often suffer the same medical fate as those without said benefits. So, what’s the issue that traverses all economic and educational lines?

Black women must make their health care a priority. They must start prenatal care early, get regular preventative checkups; and yes, reallocate funds, if necessary.

But additionally, I  suggest it is the psychosocial stressors—the microaggressions—that bear a great and most enduring burden and responsibility for the ongoing, unchanging state of Black women’s health.

It is not hard to conclude that Black women face the most disparaging judgments and comments about appearance and attitude. White women can do a,b,c; but if a Black woman does it, she’s called “classless,” angry, and unkempt. Just by entering a store, suspicion is often raised. (Trust me! I’ve had it happen to me: being followed around a store to make sure I’m not going to steal a $20 pair of earrings from a twirl display.)

Black women are the least married female demographic. Black women exceed their Black male counterparts in areas of education and entrepreneurial advances. Even in some factions within the Black community, Black women still are subjected to “colorism”: Where the “light skin” ladies may be deemed more desirable as mates than the brown-skin women.

A key factor I’ve identified that plays a role in the health of Black women is the psychosocial stress from constant rejection, disrespect, maligning, and misrepresentation of Black women by the media, advertisers, and men—alas, even Black male counterparts.

How does one quantify such constant social rejection’s effect on Black women’s physical health? I call it the “rejection connection.” But does science support my hypothesis?

In the book Black Women’s Wellness: Your “I’ve Got This!” Guide to Health, Sex & Phenomenal Living, there is a flowchart entitled, “Societal Stress and Black Women’s Health: The ‘Rejection Connection.'” Follow this corollary: Constant rejection, disrespect, and denigration can cause stress. Stress causes the release of cortisol and other stress hormones in the body. High cortisol levels can lead to high blood pressure, stroke, diabetes, and central obesity, all of which can lead to death.

Prolonged stress also severely affects the immune system, diminishing its ability to fight against life-threatening diseases. Black women have a very high incidence and death rate from these killer conditions; hence—connecting the dots—it’s very likely that the widespread social disregard of Black women contributes to the sad state of Black women’s health in this country and around the world. In a word, one could say it boils down to respect.

The late comedian, Rodney Dangerfield, made a career and enjoyed a life of fame and fortune by saying, “That’s the story of my life; I don’t get no respect.” Even now, despite an untold number of Black women attaining professional heights, many of today’s Black women can make that same claim…but hardly any are laughing because a lifetime of “no respect” is not funny.

Disrespect can cause anxiety, emotional pain, and excess stress to the body, mind, and spirit. While some stress is expected, too much unrelenting stress is harmful. Also, the sense of being rejected and cast aside.

My theory is supported by objective data gathered by Dr. Naomi Eisenberger, a neuroscience researcher at the University of California at Los Angeles. She looked at how the brain responds when people feel excluded. Using functional MRI scans, Eisenberg found that the parts of the brain that lights up—responds—to physical pain, lights up in the same areas when one experiences emotional pain. This indicates that rejection and social pain cause the near-same physical response.

When one considers the effect of racism, societal stress, and social rejection on a Black woman’s mental health, it is not a stretch to see how, in turn, it affects her physical health.

In caring for non-whites, it is helpful for clinicians to keep these ethnic considerations in mind in order to consider the totality of a patient’s life experiences, challenges, and perhaps unspoken concerns. These and other concerns are addressed in the CDC Foundation’s latest podcast, Contagious Conversations.

Melody T. McCloud is an obstetrician-gynecologist and can be reached on Twitter @DrMelodyMcCloud.