The racism below the waterline

When many people hear the words white supremacy, they picture its clearest forms: white hoods, burning crosses, racial slurs, or organized hate groups. Those are real examples, and they are easy to name because the hatred is open. Most people can look at them and know right away that what they are seeing is racism.

The problem is that this can become the only version people fully recognize. If no one used a slur, if a policy did not mention race, or if the person involved had good intentions, a harmful outcome is often treated as unrelated to racism. Quite frankly, that often could not be further from the truth.

Psychotherapist Dwight Turner uses an iceberg to illustrate this idea. The part of the iceberg above the water is the part everyone can see. Below the surface is much more ice — and much more weight. Racism can work in a similar way. The loudest and most obvious examples are often the easiest to recognize. The quieter ones are easier to miss, even though they may shape people’s experiences every day.

One reason this image resonates with so many people is that it helps explain why conversations about racism can feel so confusing. One person may be thinking about racial slurs, hate groups, or openly discriminatory laws. Another may be thinking about assumptions that influence everyday decisions — who seems trustworthy, whose expertise is respected, who is seen as cooperative, whose pain sounds believable, or whose behavior is interpreted as threatening. Both conversations are about racism, but they’re happening at different parts of the iceberg.

In healthcare, it all matters. If a clinician never says anything openly racist but still interrupts Black patients more often, dismisses their concerns more quickly, or spends less time explaining procedures with them, it's as disruptive to their care and outcomes as obvious bias or hostility. And this is essentially what many Black families report is happening to them — they describe being told that concerning symptoms are normal, that they may be overreacting, or that it's okay to wait longer than they're requesting before someone takes a closer look. They describe consent becoming a signature instead of a conversation, or honest questions being interpreted as resistance. None of those interactions look like the racism many people were taught to recognize. But over the course of pregnancy, birth, and postpartum, they can shape the care someone receives and what happens to them next.

In recent years, a handful of videos have gone viral after Black women were forced — sometimes physically guided — out of hospitals while clearly expressing that they were far enough along in labor to be admitted. Some gave birth in triage rooms, hospital elevators, parking lots, or their cars just minutes later. Audio and video have captured interactions that, in earlier years, often came down to one person’s word against another’s — and sometimes seemed almost too shocking to believe without evidence. Even with that evidence, some people continue to question whether race had anything to do with what unfolded. That raises an important question: What gets in the way of believing some patients, even when they’re telling us exactly what they’re experiencing — and sometimes even after the outcome shows they were right?

Looking below the waterline changes the questions we ask. Instead of only asking whether someone intended to be racist, we can also ask whether Black patients are more likely to have the same harmful experience, how often that pattern appears, and what might be contributing to it. Intent matters. But impact has to matter too.

This doesn’t mean every mistake is racism or that every person contributing to harm is doing so knowingly. Some harm comes from open prejudice. Some comes from assumptions a person has never been encouraged to question. Some comes from following policies or routines that seem ordinary but produce harmful, unequal results. Understanding those distinctions helps us understand where change is needed and what kind of change is most likely to make a difference.

The point of the iceberg is to encourage us to look more closely — at the systems around us, the interactions we have with one another, and the assumptions we may not even realize we’re carrying. The most visible form of racism is not always the form having the greatest impact. In maternal health, some of the strongest forces shaping families’ experiences can be found in moments that appear routine, ordinary, and easy to overlook.

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