Dr. Rachel Hardeman on building outside the ivory tower

Dr. Hardeman applied the academic toolbox to health care’s thorniest problems. Now she’s setting her sights beyond the academy.

Photo courtesy of Chris Cooper, University of Minnesota School of Public Health

In the movement for health equity, Dr. Rachel Hardeman is the equivalent of a Billboard 100 chart-topper. Transcending genres and audiences, she pivots seamlessly from vaulted national stages to humble community birthing centers. Her superpower is revealing systemic inequities in unexpected ways. Her ideas tend to linger, elicit necessary discomfort, and then provoke change.

Dr. Hardeman’s greatest hits, in no particular order: a landmark paper finding that Black newborns cared for by Black physicians are a third less likely to die than those cared for by white physicians. Or another paper, finding that Black women in densely policed neighborhoods are twice as likely to have preterm births. Or, in one of the most daring articles written in the New England Journal of Medicine, a piece that devastatingly recounts George Floyd’s murder, and then puts the onus on doctors to actively deconstruct the systems of racism that caused it. 

Since then, Dr. Hardeman’s voice has eclipsed the halls of academia. This year, she was named a TIME 100 Most Influential Person, with a profile written by Rep. Lauren Underwood. 

And now, Dr. Hardeman is spending a well-earned sabbatical year here with us at Maven Clinic. As our newest visiting scientist, she is embedded with our clinical outcomes team, applying the same momentum she helped galvanize in Black maternal health to Black menopausal health. 

She recently joined me to explain what wired her to solve big problems, how university centers aren’t so different from startups, and why her research questions always begin, as she earnestly tells everyone, with love.

If you’ll allow me, I’m going to be a little provocative. In a STAT profile not so long ago, you said that academia isn’t necessarily the best place to get racial equity work done. That’s part of how you ended up as a Visiting Scientist at Maven. What did you mean by that?

I was really compelled by how Maven was leveraging science and data and research to inform how you do the day to day work of providing care in the digital health space. I have sat in academia and pushed boundaries and questioned the status quo for a good decade or longer, with some progress, certainly…and also just not enough progress. I was beginning to wonder, what does it look like to do this work outside of the ivory tower? Is there more space to be nimble and flexible and responsive to what's in front of us versus sort of the end? So I am here to learn and to think and collaborate, and get a new and different perspective.

One of the things I admire about you is that you're willing to take on questions, no matter how big they are, and throw this scientific toolbox at them. What attracts you to big, systemic problems like this, and what made you the kind of researcher that can take them on?

My parents will attest that I’ve always been a kid that takes the hard path. So part one is just that it’s my nature. And part two is watching my maternal grandmother throughout my childhood struggle with the health care system. She had kidney failure at a fairly young age, and my sister and I spent a lot of time with her at the dialysis center at our safety net hospital here in Minneapolis.

Ultimately, just before I turned 16,  my grandmother announced to our family that she was discontinuing dialysis, which meant that she was making the choice to end her life. In addition to being profoundly sad, I was confused. And I said, why are you doing this? And she gave me a letter one of her physicians had written. The letter was addressed to her broader care team. It started with just a laundry list of comorbidities, and then why she's not a good candidate for a bunch of different interventions. By the end of the letter, you're just like, well what’s the point? And she said: This is why. I can't keep fighting and asking this health care system to love me and care for me in the ways that I deserve. So I watched all of that play out as a kid and was like, there has to be something better. 

The perfect example of those big, meaty research questions in action is a famous paper you have about what we at Maven call care matching, which is matching people to providers not just based on technical expertise, but on some form of lived experience. Can you tell us a little bit about that paper? What did you find? What was surprising?

I started digging into this idea of care matching, or what we call in the paper racial concordance, because of qualitative work I was doing with Roots Community Birth Center, here in the Twin Cities. One of the primary things that we kept hearing was that families were choosing Roots because it was Black-led, Black-owned, with Black midwives and doulas on staff. I think just at a very basic level, seeing someone who looked like them, who was caring for them felt really important. I'm a mixed methods researcher, so I'm always thinking about, okay, we have these really important qualitative stories and data. But the large secondary data sets are also really important. So in this paper we looked at 1.8 million births in the state of Florida.

And what did you find? 

What we found suggests that newborn physician racial concordance—care matching—is associated with improved mortality rates for Black infants, meaning that when a Black infant is cared for by a Black provider in the hospital setting just after being born, they are more likely to survive that hospitalization phase if they are cared for by a Black physician. We also found that those same benefits manifested during more challenging births. Interestingly, we did not find the same association as statistically significant for moms and the provider, which I think is really, really important to raise.

All of the literature prior to this paper talked about racial concordance or care matching as this sort of communication piece—that when you're able to have a conversation with someone who looks like you, or shares your lived experience or background in some way, then that sort of level of communication improves your likelihood of coming back for another visit or reporting higher levels of patient satisfaction. But what we found here is that with infants who don't have the ability to communicate outside of crying, that racial concordance matters. That forces us to ask: what else is going on here? I think that forces us to have to really sit with the history of race and racism and, and social and structural inequity in our country. 

You recently opened your very own center, the Center for Antiracism Research for Health Equity. For academics, I think it’s fair to say that’s kind of like reaching the very top of the mountain. I imagine that building a center from the ground up isn’t so different from scaling a startup, which is quite different from being a researcher. What have you learned? 

I always knew that I wanted to create an intellectual home for folks told that their research ideas were outside of the academic canon and paradigm. And, I knew I wanted to create something that facilitated stronger and more authentic relationships with community. So I put together this one-page document, kind of slid it over to a friend at Blue Cross Blue Shield, and didn't hear anything for like three months. I didn't even think about it. And then three months later, I got a phone call saying, Blue Cross Blue Shield of Minnesota is gifting you and the University of Minnesota $5 million to launch the center. I was blown away. I will say this: my proposal went to Blue Cross prior to George Floyd's murder, but the launch of the center came after. I think we were in a moment where the urgency of doing something was incredibly important.

To the start-up piece: my skill set is as a researcher. I can write a hypothesis, I can run a logistic regression. I also am a thought leader: I like to really think big. Some would argue that, well, you're in a university setting. So why aren't you just plugging in to the probably 25 different centers that could help you? The difference for me is that the whole mission was to do this differently. I have a lot of reflections now, sort of three years in, but I think I was trying to build an anti-racist focused startup within an institution that is inherently racist. People take great offense to that sort of thing, so let me explain. This is the insidiousness of inequity and racism—it's so baked into our day-to-day lives that we don't realize it's there. The result is that the same things I'm trying to change and undo are also what hold up the institution that I am working within. And so try trying to build within that…none of it is conducive with how most of us operate.

I think the work that we do, and the work that you do in particular can be very heavy. You say at the center that the work of antiracism is “fueled by love.” What does that mean? And what does it mean in practice?

I have to give credit to Dr. Rhea Boyd, who is so brilliant, because she brought it up through one of Toni Morrison's books. Toni Morrison had talked about because of the way Black people and people of color are dehumanized so often in our society, that it’s not actually just sort of implied that we are loved. For me, in framing the work of antiracism and antiracist research through this lens of love, it's a level set. It allows us to say, okay, we are all human, we all honor each other's humanity, and, to that end, we're going to work together to do things differently. It also is very much about the insane amount of love I have for my daughter, and the fact that we have to keep going because the children that we love deserve better. I think that's such a way to ground, even those of us who may be skeptical of the questions or the work—and there's many of those folks out there. What I know for a fact is that everyone for the most part is going to say yes, I love my children, and yes, I want the best for my children. So I think it’s a really important place to start the work from. 

What my team is reading, building, and thinking against:

• In Bloomberg’s newest series of their health care podcast Prognosis, reporter Kristen V. Brown gives the fertility industry its own Serial treatment. The first two episodes will be familiar ground to many Preprint readers, covering the high costs of fertility treatments juxtaposed with what can often be predatory marketing practices. What’s most remarkable is the kaleidoscope of patient voices Kristen finds. It’s a reminder that every embryo has a story.

• Drugs reviewed by women on WebMD are more likely to be recalled than those reviewed by men. Why? The answer, examined by researchers at Indiana University, is that female reviewers tend to be far more descriptive and detailed about how the drugs affected them. Consider this a louder drumbeat for a recurring rhythm: men can be better socialized to communicate how they are feeling.

• A randomized control trial published in Human Reproduction found something we at Maven have suspected for awhile: women who were offered co-designed, evidence-based education about AMH fertility testing were less interested in the test than those who were offered online direct-to-consumer misinformation. Sometimes empowering consumers means guiding them to do less, not more.  

• As promised, I left the ABIM Foundation Forum last week with lots to chew on regarding the broader opportunity to combat misinformation. One of the most fascinating people I met was Professor Dannagal G. Young, a political scientist at the University of Delaware who studies conspiracies. Her work is a product of both empirical scientific inquiry, and her own lived experience falling victim to conspiracy theories when her husband was diagnosed with brain cancer.

  You can read her remarkable account in this Vox piece, which reminds us that belief in misinformation is not just a matter of ignorance or intelligence–it very well may be an instinctive coping mechanism, a way that we as humans assign blame and impart order in a world that eschews both. This means that as with most solutions, addressing misinformation must begin from a place of empathy.