As she drives research on structural racism in health care, Rachel Hardeman faces a painful reckoning

MINNEAPOLIS — It’s been almost four years since George Floyd was murdered here at 38th Street and Chicago Avenue, a South Minneapolis corner anchored by a convenience store, its red awning still achingly familiar from once-saturating news coverage. Now, the legions of teddy bears placed in Floyd’s honor are dusty, the paint on street murals has chipped away, and community-built planters are overgrown. There are entire afternoons when no one visits; the city even tried to bulldoze this monument. The national and collective urgency to save Black lives this site once sparked has faded, but Rachel Hardeman is still hard at work.

A professor at the state’s preeminent educational institution, the University of Minnesota, she grew up here, just blocks from where Floyd was killed. Hardeman, who interrogates the many ways in which structural racism contributes to poor health for Black people, has published a stream of eye-opening and unsettling research, including findings that Black newborns are less likely to die when cared for by Black physicians and that U.S.-born Black women who live in intensely policed neighborhoods are twice as likely to have preterm births than those residing in other areas.

It’s work that Hardeman started long before her city became a flashpoint in the movement for racial justice. But widespread anguish over Floyd’s death, and a powerful essay she co-wrote in the New England Journal of Medicine shortly afterward, thrust her into the national spotlight.

The essay, “Stolen Breaths,” is peppered throughout with George Floyd’s last words, “Please — I can’t breathe.” It calls for health care systems to think far bigger than they have and to help dismantle systems of structural racism — from police violence, to segregated hospitals with poorer care, to neighborhoods full of air pollution — that are stealing the breaths, and lives, of Black people.

Hardeman is quick to say she is not the first person to link racism to poor health; she stands on the shoulders of scholars like Camara Jones, Lisa Cooper, Chandra Ford, David Williams, and going back more than a century, W.E.B. Du Bois. But there was a new power to her words — the timing, the surgically precise way she presented them, and the fact they appeared in medicine’s most prestigious platform, one that long shied away from even printing the term structural racism, let alone examining its role in medicine.

Hardeman’s argument is clear: To end the deep inequities that underlie health disparities, society must transform and dismantle the effects of unjust practices, like redlining of neighborhoods, restricted educational opportunities, and environmental racism.

“She is one of the few people that unapologetically is tying structural racism to health outcomes,” said Monica McLemore, a professor at the University of Washington School of Nursing who studies antiracism and birth outcomes. “She’s a vanguard in that work.”

As the nation rose up in protest that summer of Floyd’s death, many people were for the first time really listening to Hardeman’s arguments, and wanting to hear more.

Since then, her career has seen a stratospheric rise. She became a full professor at the University of Minnesota in just seven years. She started a Center for Antiracism Research for Health Equity, funded with $5 million from Blue Cross Blue Shield of Minnesota, and she’s inundated with requests — from researchers who want to work with her, students who want her mentorship, journalists who want to interview her, blue ribbon panels that want her on board, and just about every group imaginable that wants her, and only her, to give a talk at their event.

“All of the sudden,” Hardeman told STAT, “all these people who had dismissed my work said, ‘Oh you should read her.’ My thought was yes, people are listening. In my mind it was go go go to the windows, open the doors, you have to grab that moment.”

Requests have been so nonstop, though, that she’s had to scale back. Hardeman has set up an automated email response politely telling people that no, she cannot consult for them; no, she cannot write with them; and no, she cannot teach them the history of racism in the United States.

“I get emails basically asking, ‘Can Rachel solve our institution’s racism?’” said Keelia Silvis, the antiracism center’s communications manager who — tattooed, magenta-haired, and nearly 6 feet tall — calls herself Rachel’s “white lady buffer.” “I’ve become fiercely protective of Rachel’s time.”

Yes, the abundant funding, the national news outlets dubbing her a visionary, the invitations to write for premier journals and speak before audiences who weren’t comfortable openly discussing racism in medicine just a few years ago are wonderful. But all the attention has come at a cost. Now, Hardeman is facing not only exhaustion and burnout, but also a reckoning of her own. She has been quietly grappling with the dispiriting realization that the change she wants to see can’t happen in the short time allotted by academic grants and other funders.

“What we actually know from working with communities is you can’t undo 400 years of damage and trauma and disinvestment in a year or two years,” said Hardeman, who speaks in a measured cadence, often pausing to pull back her long braids and look upward as she frames her thoughts. “It means sitting with the pain and struggle and thinking strategically and listening carefully to people who are suffering. The timeline for all those dollars does not allow for that.”

She’s also realizing that the work of antiracism may not be possible from within academia and at a predominantly white institution, even one as liberal and progressive as the University of Minnesota is. And that it will be far more difficult as right-wing attacks — like the one that just brought down Harvard’s first Black president, Claudine Gay — continue as part of a concerted effort to wipe out diversity, equity, and inclusion programs. “It’s very painful to watch unfold,” said Hardeman.

Hardeman is not alone. Across the country, antiracism centers and similar programs that were hastily created at predominantly white institutions are having growing pains in a world that may be ready for slogans, but not transformation.

Celebrated race scholar Ibram X. Kendi was criticized (but later cleared) for the way he has managed an antiracism center at Boston University, while others working on initiatives to improve diversity and inclusion in health care and science are facing their own workplace battles and internal struggles. McLemore, for example, just stepped down from a position as interim associate dean of diversity, equity, and inclusion at her school.

Now, she’s one of many closely watching what path Hardeman will take: “This,” she said, “is a cautionary tale.”

It’s unusual to hear in academia, but Hardeman often centers the words love and joy in her research talks. This last year, though, and particularly the last few months of public attacks on Black scholars, has been filled with a different emotion: grief. Because doing the work she thinks is necessary to save Black lives may mean leaving not only the university that trained her, but also the groundbreaking center she birthed, and even this city she loves so dearly.

What breaks her heart even more are the darker moments when she fears it may not be possible at all.

Hardeman’s family has left its mark all over Minneapolis, ever since her grandfather, a railway porter, settled here from Kansas City in 1949. Her uncle worked for the Urban League Twin Cities; his wife, Sharon Sayles Belton, became the city’s first Black and first female mayor. Hardeman’s mother, Sherri Belton Hardeman, served on the jury that convicted police officer Derek Chauvin of George Floyd’s murder. Hardeman’s twin sister worked in the Obama administration and now runs a nonprofit in the city; her father worked for decades at the Boys & Girls Club of the Twin Cities. She can’t go many places in town without being asked, “Aren’t you John Hardeman’s daughter?”

But the family member that may have influenced Hardeman’s career the most is her grandmother Ernestine Belton — a community activist who zipped around town in a red Mercedes and was so beloved, a park is named after her. Because of chronic kidney disease, Belton needed dialysis three to four times a week; Hardeman, then a teen, would often sit with her and do homework though the hourslong appointments. “I still remember the machine, the blood going through,” recalled Hardeman.

“Outside of dialysis, she was invincible,” Hardeman said of her grandmother. She started a Saturday morning club to teach Black history, and when Hardeman and her sister desperately wanted American Girl dolls, she urged them to write to the company to request they make a Black doll. But her life did not end well. Belton, in constant pain, was refused a joint replacement surgery she needed. Hardeman still remembers the denial letter from her physician, which listed a host of comorbidities before saying she was not a good candidate for orthopedics.

She’s an example of what a large study last year found: Black Medicare beneficiaries are less likely to receive joint replacements than white ones. “What I walked away with was these people have no hope she can live a healthy, full life,” Hardeman said.

A few months after that, Hardeman’s grandmother decided to die. She gave away her most treasured possessions. She rented a limo to take her grandchildren out for a grand last pizza meal. Then she stopped going to dialysis and died at home. She was in her mid-60s. Hardeman, then 15, had learned a hard lesson early on: Health care was not equal for all people.

“Obviously things aren’t linear, but it certainly planted the seeds that we, particularly Black people, are trying to live and thrive in a system that doesn’t love us,” said Hardeman, now the school of public health’s Blue Cross endowed professor of health and racial equity. “I didn’t have language at the time, I didn’t know what public health or health policy was, but it was very clear to me, from a young age, that things weren’t fair.”

Hardeman was in the perfect place to study that unfairness — in the middle of what’s known as the Minnesota Paradox. The state is renowned for the good health and longevity of its citizens: It’s consistently ranked as having some of the nation’s best health care, is home to the acclaimed Mayo Clinic, and is considered one of the best places in the country to live.

But not for Black people. The state is ranked the second most unequal in the nation. In addition to documented racist police brutality, and household incomes that are less than half for Black people compared to white, racial health disparities are dire. Black Minnesotans make up 13% of the population, but 23% of pregnancy-associated deaths. Black babies are twice as likely to die before their first birthday as white babies. Black people here die seven years earlier than white people.

The paradox doesn’t get discussed much, though. Minnesota prides itself on being a beacon of progressiveness with its history of openness to Somali and Hmong immigrant communities and strong Medicaid policies. “We’re constantly patting ourselves on the back,” Hardeman said. “That can lead to blinders.”

Hardeman is not only trying to understand and fix these disparities, she’s also seeing them run through her family. Hardeman was in the hospital room when one of her aunts, still in her mid-30s, died of heart failure, and more recently, she lost two uncles to Covid-19. “I have watched far too many people that I love not be loved by our health care system,” she said. “That is exhausting.”

Many people assume Hardeman’s deep interest in birth equity is due to a personal experience, which wouldn’t be unusual given the statistics. But it’s not. She couldn’t find a Black OB-GYN as she’d hoped — not surprising given that just 2.6% of the state’s physicians are Black — but she had a positive experience with the white doctor who cared for her and safely delivered her daughter, Leila.

“Everyone wants to hear the story of my traumatic childbirth,” she said. “I didn’t have one.” She wants more Black women, not just ones married to doctors or with doctorates like her, to have the same positive experience. “I know what’s possible,” she said. “I’ve seen it.”

It was early in the summer of 2016 when Hardeman got an angry phone call. It was a midwife, complaining about Hardeman’s latest research paper on doulas. Instead of rushing off the phone, Hardeman listened. “Other academics might have been offended and hung up,” said Rebecca Polston, the caller. “Rachel said, ‘We’ll have to do better next time.’”

What started as an uncomfortable confrontation ended up turning into one of the most productive, and welcome, collaborations of Hardeman’s career. Polston is a midwife who eight years ago opened one of the nation’s first Black-owned midwifery businesses, Roots Community Birth Center. It’s in Camden, a North Minneapolis neighborhood with the state’s highest infant mortality rate for Black babies and an average household income of less than $35,000 per year. Roots sits less than a mile from where Jamar Clark, a 24-year-old Black man, was killed by police in 2015. “This is a place where women are scared to bring boys into the world,” Hardeman said.

Yet Polston was seeing amazing outcomes: healthy babies born full term, and mothers who were thriving. In her call to complain, Polston urged Hardeman to broaden her scope beyond doulas and look at how the larger health care system was failing Black mothers and babies. Hardeman agreed to study what was happening at Roots.

She wanted to center the community in the research, not give lip service to the idea of community research by swooping in to gather data on marginalized patients and then returning to her ivory tower. She relied on Polston, her staff, and her patients to propose what questions to address in the research and, as she puts it, “to lift up the voices closest to the pain.” But the project didn’t go as expected.

Hardeman developed surveys and bought shiny new iPads for moms to fill out. But few did. It didn’t matter that she looked like them. People were wary of Hardeman and of her university’s past history of racism and antisemitism, which included monitoring Black and Jewish students and forcing them to live in segregated housing.

Hardeman scrapped her plans and looked for a new approach. Her team decided on a community baby shower. There was food, free diapers, joy — and, to Hardeman’s relief, a lot of filled-in surveys. “For me, it was seeing for the first time how when working with the community, sometimes you have to pivot,” she said.

In a paper on that research published in 2020, Hardeman found that Roots had delivered 284 babies in four years — all safely and full term. These were astonishing numbers for a population where 75% of patients are insured through Medicaid and many had poor experiences with previous births; many clinicians were eager for the findings.

“When I talk to physicians and OBs, they want the secret sauce,” Hardeman said. But it wasn’t as simple as adopting a new checklist or procedure when there were far more fundamental problems like rushed prenatal visits or patients having concerns dismissed by their physicians.

“Unless we’re willing to completely dismantle that system, pay people differently, and have more than 15-minute visits, there’s very little we can take from the Roots model,” Hardeman said. “Ideally there would be a Roots in every neighborhood across the Twin Cities.”

Roots is as unlike a hospital as can be. It’s peaceful, with a lobby full of plush chairs, photos of families holding newborns, and shelves of free prenatal vitamins. There’s a yoga studio, a kitchen, and elegant birthing suites with large beds and tubs that look more like hotel than hospital rooms. Just outside is a fire pit; keeping a fire burning during birth is an important custom for some local tribes.

Thirty- to 60-minute prenatal visits are treated more like conversations than exams. Women are asked for permission before they are touched, even to have blood pressure taken. Women can conduct routine vaginal swabbing themselves rather than submit to stirrups. Postpartum care extends for six weeks and includes several home visits, a far cry from the single six-week office visit standard in most health systems.

While it’s still a financial struggle, the approach and high success rates have enabled Polston to push for higher reimbursement rates from insurers to support the center’s model, and brought other researchers streaming to Polston’s door to see what they can learn. Too often, Polston said, these researchers write up what she calls “problem porn” — studies that use her resources and time to rehash disparities well known to exist, or worse, blame Black women for their health problems. Because of this, Hardeman is now the only researcher Polston will work with.

“For so long, I felt I was shouting into the wind,” Polston said. “But finally I can work with someone attached to a major university who said, ‘Let me quantify this.’ She’s giving voice to this work.”

Sitting with Polston on a sofa in the cozy room where family members can rest when births are occurring, Hardeman started to cry.

While the University of Minnesota should have been a storybook setting for Hardeman, it hasn’t always been easy. She sensed prejudice from the start. When she interviewed for the doctoral program, she said she was repeatedly asked if she truly understood what it took to complete a Ph.D. and was told she might not be a good fit. Those words still sting. The program she entered had no other Black students at the time. She didn’t have a single class with a Black professor.

More recently, she’s been asked if she belongs in her own building by a staff member (even though a large portrait of Hardeman hung in the building at the time).

When Philando Castile, yet another name on the long list of Black men killed by police in the area, was shot dead in a traffic stop in 2016, she was alone in her office, crying.

“I’m in pain and everyone else is acting like this is business as usual,” she recalled. Only one colleague, she said, stopped in to check on her, and urged her to write about what she was feeling. That essay “Structural Racism and Supporting Black Lives — The Role of Health Professionals” was published soon afterward in the New England Journal of Medicine. It was one of the first times the 211-year-old journal had used the term structural racism in its pages.

When she was hired, Hardeman was the only Black faculty member in her division and one of only two Black faculty in the school of public health. The other is Rhonda Jones-Webb, a professor in the school of public health’s division of epidemiology and community health, who was hired in the early 1990s and knows firsthand Hardeman’s journey has not been easy.

“I wouldn’t call it a burden, but it’s a responsibility you feel, to foster social change, to address structural racism,” she said. “It’s an additional responsibility you feel that your white peers don’t have.”

Hardeman has prioritized helping bring more Black professors to the school of public health; there are now seven Black faculty in the school and four in her division of health policy and management.

As part of her work on antiracism, she works with younger Black students, wanting to make sure they don’t endure what she did. She’s mentoring scholars like Asha Hassan, a Somali immigrant and doctoral student who is researching, after looking for questions the community urgently wanted answered after years of protests here, the effects of tear gas on maternal health.

Hassan said Hardeman’s mentoring has kept her happy and successful. “I don’t think I’d be in a Ph.D. program without her,” she said. “So many people come into a Ph.D. and are traumatized. I have not had those issues.”

Kathleen Call, a professor in the division of health policy and management, first met Hardeman when she was a master’s student, served on her dissertation committee, and watched as she helped launch a health equity minor — possibly the first at any American school of public health — while still a student. “She has been a change agent ever since grad school,” she said.

Call praises Hardeman for calling out racism within public health but also within her own department, something that can derail careers. “Some people can bring their truth forward despite the political environment,” said Call, who is white. “Rachel is one of those.”

It may be the way she presents her ideas to white audiences. Aware of the discomfort, fear, and defensiveness many white Americans carry about race, she often disarms people by talking about herself as a Black woman, a Black academic, and a Black mother. “I’m a third-generation Minnesotan. My heart is in my backyard,” she often tells audiences. “My most important title is Leila’s mom.” She is authentic and even vulnerable. “I hope my work matters,” she said during one talk.

Hardeman makes it clear that she is not pointing fingers, not talking about individuals as racist, but talking about systems and institutions that need to change. She speaks slowly but directly when talking about topics that can instantly rile. “We need to talk about white supremacy,” she said at one talk. “I know it’s a lot to process.”

She tries to connect to people through their children and frequently brings up her own daughter, now 10. Like a true Minnesotan, she’s also unfailingly polite. “I have a deep desire to make people happy and not rock the boat,” she said. “It’s not in my nature to show up and be the angry Black woman.”

It seems to work. Cheers and applause meet many of her talks. “You spoke words that aren’t often spoken and it was courageous. Thank you,” one person stood up and said after a talk she gave to a largely white audience in Colorado. Sometimes people rush up to hug her.

She has her critics too. Much of it is political; there is hate mail and online attacks on her work in abundance, citing her wokeism, calling her studies political activism instead of research, and questioning her ability to do such work or lead her center without a medical degree. Others are angry that she sits on the board of Planned Parenthood North Central States. Some scholars took issue with her study on how intensive policing affects birth outcomes, saying the study only showed a correlation, not causation, and that many other factors could be at play.

Criticism comes from within her school, too. Hardeman is 44. Many of the younger students or people she’s hired, she said, fault her for not pushing harder or faster on issues. Her fiercest critic may be herself. “I have made mistakes. I have realized after the fact that I have not done the right thing plenty of times,” she said. “It’s so tied up with my perfectionist tendencies it can be debilitating.”

Despite what may be happening around the country, Hardeman has not lost the sense of determination she had in 2020 — and long before. “To me, the urgency is my people are dying,” she said. It’s her optimism that’s waning.

When the antiracism center was announced in 2021, she said, everything seemed possible — for her and the Black population she wanted to serve. “The center for me was my love letter to my community,” she said. Three years later, the growing pains are wrenching. It’s taken a toll on her mental health and outlook.

It’s a combination of so many things. There’s the difficulty of trying to do transformative work from within academia with its rules, slow timelines, intellectual silos, and focus on publishing research papers rather than pushing for change, like working on the Dignity in Pregnancy and Childbirth Act Hardeman helped her state pass in 2021.

There’s the pressure of being an academic running a center, which is basically a nonprofit, without any training in human resources, management, and budgeting.

There are real-world pressures as well. She’s a dance mom, and spends much of her free time getting her daughter to practices and competitions in distant states, as well as helping her aging parents. Her phone is abuzz with texts, calls, and requests. What self-care she can fit in comes in the shape of walks with her husband, Eduardo Medina, a family medicine physician and sometimes co-author, plus tennis and CrossFit. She sees a Black female therapist weekly.

One thing she’s grappling with is the particular burden of Black exceptionalism — of having to be a successful role model no matter the cost to her own well-being; it’s life on a pedestal where she feels she has to be perfect, or seem so when no one can be.

“How do you take care of yourself in a society that tells you to just keep going?” she asks. “It’s a recipe for disaster.”

She wants to encourage younger Black students, and at the same time she wants to warn them to run. “I’m watching a lot of young scholars who want to emulate me, which is uncomfortable,” she said. “I don’t wish this on folks. It’s been a heavy burden.”

Many who applauded the rise of the center and the way Hardeman ran it and created a national magnet for other scholars are now watching as she navigates the path ahead. What they are applauding now is how open she is about her struggles, both professionally and personally.

“She’s exactly the kind of scientist we want, but not the kind of scientist that always thrives,” said Paris “AJ” Adkins-Jackson, an assistant professor of epidemiology and sociomedical sciences at the Mailman School of Public Health at Columbia University who studies the effect of structural racism on aging populations. “It’s through watching her in this struggle that I admire her most.”

Hardeman is open about the fact she doesn’t know how best to continue this work. She’s now focused on resting, healing, and strategizing to ensure the future of the center. She insists it has to survive; too many Black people are still dying.

“Being able to do this work in the community that raised me felt, and feels, very important,” Hardeman said as she walked over a bridge across a section of the Mississippi River that flows slowly and steadily alongside downtown, stopping to marvel as a bald eagle soared overhead.

Hardeman recalled pushing her daughter in a stroller here, past the hulking mills that produced Pillsbury and Gold Medal flour a century ago when Minneapolis was the flour capital of the world. Those long-abandoned mills are now being converted into artist lofts and gleaming condominiums. It’s clear, on this historic stretch of a storied river and city, and in this historic moment, that everything changes. Hardeman is counting on it.

This is part of a series of articles exploring racism in health and medicine that is funded by a grant from the Commonwealth Fund.