The literal cost of racism

When you look at a paycheck, that tells you what someone is earning now. When you look at wealth, that tells you what a family has been able to build and keep over time. It may be a home bought years ago, land passed down from a grandparent, savings divided among children or grandchildren in a will, money held in a trust, or even cash found under a mattress that can help with school, childcare, a down payment, or an emergency. One opportunity can make the next one easier.

The lack of wealth can grow in the same way. A family without savings has less room for a job loss, an illness, or a hard pregnancy. Money spent getting through the month cannot also be invested. A home that was never bought cannot rise in value. Help that one generation could not give becomes a cost the next generation has to carry by itself.

Wealth builds over time. So does being shut out of it.

The racial wealth gap is sometimes shown as a simple comparison of who has more money today. That leaves out how the gap was made. There are two different parts of that history that are useful to name. The first is wealth Black people created or built and then had taken from them. The second is wealth-building support — land, loans, education, public investment, and other opportunities — that Black families were blocked from receiving while other families were being helped forward.

For nearly 250 years, enslaved Africans and their children created great wealth by growing valuable crops, building roads and homes, working in skilled trades, and keeping households and businesses running. But they had no control over that wealth. They had no claim to the value of what they produced, or even to the value of the work they were doing to produce it. All of that stayed with the people and institutions that claimed ownership over them, and then moved on to children and grandchildren in those family lines.

Near the end of the Civil War, there was a short-lived plan to give some newly freed families land. General William T. Sherman's Special Field Order No. 15 set aside abandoned and confiscated coastal land in the South and allowed families to settle on parcels of up to 40 acres. Some families also received the use of Army mules, which is where the phrase "40 acres and a mule" came from. But later that same year, President Andrew Johnson returned much of the land to former Confederate owners. Thousands of Black families who had begun farming and building communities there were removed. So formerly enslaved people entered freedom without the broad transfer of land, money, or protection that might have given them a real foundation to begin from.

Even in the face of that, Black families built anyway. They found ways to buy land, open businesses, create schools, and form strong neighborhoods under very hard conditions. Even those hard-earned gains were often attacked through violence and purposefully restrictive lending rules, zoning, and taxes. Greenwood in Tulsa is the best-known example. In 1921, a white mob attacked the thriving Black community, killing residents and burning homes and businesses across the district. But Greenwood was not the only Black community that was burned, taken, flooded, bulldozed, or stripped of value. When these stories are viewed together, the same pattern appears: Black families built wealth, and that wealth was repeatedly put at risk or taken away.

This part of the story is about programs and opportunities that helped families build wealth, but that Black families were blocked from using in the same way. Governments made choices about who could receive land, home loans, business support, education, veterans' benefits, roads, and neighborhood investment. Those choices shaped which families could buy homes, start businesses, send children to college, and leave something behind.

The examples below did not all work in the same way or affect every group in the same way. But their effects built on one another. Some families could buy homes with government-backed loans and watch those homes grow in value. Others were blocked from the same neighborhoods or denied the same loans. Hard work mattered, but laws and public money helped decide whose hard work could become something their family owned and passed on.

Ending a policy does not erase what it already produced. A home bought in 1950 may help pay for a grandchild's education today. A neighborhood denied loans may lose businesses, tax money, strong schools, and healthcare services at the same time. Families who were shut out did not lose only the first chance. They lost many of the things that chance might have made possible later.

Economists have tried to estimate the size of the racial wealth gap and what the country loses by allowing it to remain. The numbers vary because the studies ask different questions, but the scale is clear. The gap represents trillions of dollars in homes, savings, safety, and choices that some families have and others do not.

During pregnancy, wealth often shows up in how we make our choices — what choices we have the ability to make based on how much money is available to us. It can shape whether someone can miss work for an appointment, travel to a hospital with the services they need, pay for a doula, find childcare, get another opinion, or leave a provider they do not trust. It can shape where someone lives, what food they can buy, how they get around, whether they can access mental healthcare, and how much time they have to recover after birth. It can make a medical bill stressful instead of life-changing.

These things are often referred to as "social determinants of health," which is a useful way to create shared language around a complicated reality, but can also take away from the human role in bringing that reality to be. Housing, schools, transportation, jobs, the environment, and healthcare access did not end up this way on their own. People made choices about where to spend money, which neighborhoods to support, who could get loans, and what services would be available.

By the time someone reaches a prenatal appointment, a lot of the major things that are going to affect that pregnancy are already in place. A clinician may see high blood pressure, a missed visit, or a risk listed in the chart. Behind it may be a job with no paid leave, a bus ride with two transfers, a closed birth unit, an unsafe home, old debt, or no family savings to fall back on.

That does not reduce the responsibility of healthcare systems. It makes the responsibility clearer. We need good clinical care. It's essential. So is understanding why many health concerns inside the exam room carry the effects of decisions made far outside it.

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