But months of intense back pain eventually landed her in the emergency room, where a doctor suggested that Hunter might have multiple myeloma. Hunter’s first question was, “What is that?”

Multiple myeloma is a cancer that develops in bone marrow plasma cells, crowding out healthy blood cells and damaging the bones. It is one of the most common blood cancers — and the most diagnosed among African Americans. The mortality rate from multiple myeloma also is higher among African American patients than white people, with a number of studies showing that, in addition to disease biology, societal factors such as socioeconomic status and to health insurance or medical services delay timely diagnoses.

A belated diagnosis is what happened to Hunter, a Black woman in Montgomery, Alabama. She said her primary care doctor dismissed a recommendation from her endocrinologist to refer her to a hematologist after finding high protein counts in her blood. Then, she said, he also refused to order a bone marrow biopsy after the ER doctor suggested she might have multiple myeloma. Fed up, she said, she found a new doctor, got tested, and learned she indeed had the disease.

, a multiple myeloma researcher at the in Boston, said Hunter’s experience is fairly common, particularly among Black patients who live in underserved communities.

“On average, patients see their primary doctor three times before being accurately diagnosed,” Hartley-Brown said. “The delay from symptom onset to diagnosis is even longer for Black Americans. Meanwhile, the disease is wreaking havoc — causing fractures, severe anemia, fatigue, weight loss, kidney problems.”

Black and Hispanic patients are also less likely to receive the newest therapies, according to the Multiple Myeloma Research Foundation, and, when they do, they are more likely to do so later in the course of their disease than white patients. An of racial and ethnic disparities in multiple myeloma drug approval trials submitted to the FDA concluded that Black patients made up only 4% of participants despite being roughly 20% of those living with the disease.

Now, even though significant progress has been made in understanding the biology of multiple myeloma and how to treat it, those racial gaps may grow larger amid and the . While few multiple myeloma experts were willing to talk on the record about the impact of the funding cutbacks, , president and CEO of the Multiple Myeloma Research Foundation, has written that cuts to the National Institutes of Health and its National Cancer Institute put future innovations at risk.

“Even before these potential cuts, funding for myeloma lagged behind,” before the cuts were finalized. “The myeloma specific budget has decreased significantly. Myeloma is almost 2% of all cancers, yet receives less than 1% of the NCI’s budget.”

The disease is already hard to diagnose. Because multiple myeloma is when a patient is over 65 (African Americans tend to be , on average), common symptoms such as lower back pain and fatigue are often chalked up to just getting older.

That’s what happened to Jim Washington of Charlotte, North Carolina. He was 61 when excruciating hip pain brought his regular tennis games to a sudden stop.

“I figured I’d done something to injure myself,” Washington said. “But I’d been playing tennis all my life, and this pain was different from anything I’d ever felt before.”

Washington was fortunate to have a concierge doctor and premium health insurance. In quick succession, he underwent X-rays that revealed a lesion on his spine and received a referral to an oncologist, who identified a cancerous tumor. A subsequent biopsy and blood tests confirmed he had multiple myeloma.

Washington had weeks of high-dose chemotherapy, followed by what is known as an autologous stem cell transplant, which used his own stem cells to regrow healthy blood cells in his body. It was a grueling process that ultimately left him with a clean bill of health. For the next several years, his doctors monitored him closely, including conducting an annual bone marrow biopsy.

Before treatment, he said, myeloma had infiltrated 60% of his blood cells. The stem cell transplant brought those levels down to zero. After about five years, however, his multiple myeloma level had crept back up to 10% and required more treatment.

But Washington had closely followed the latest research and believed he had reason to be optimistic. The FDA had approved the first in 2021.

Hartley-Brown said the lack of Black patients in multiple myeloma drug approval trials raises concerns about whether the trial results are equally applicable to the Black population and may help explain why treatment advances have been less effective in Black patients.

She cited multiple causes for the low trial participation rate, including historical distrust of the medical establishment and a lack of available clinical trials. “If you are living in an underserved or underrepresented area, the hospital or community doctor may not have clinical trials available, or that patient may have limitations getting to that location affiliated with the clinical trial,” she said.

Washington, a Black patient, appears to have avoided this trap, having benefited from the latest treatments both times. In January, he began six weeks of chemotherapy with a three-drug combination of Velcade, Darzalex, and dexamethasone before undergoing CAR T-cell therapy.

For that, doctors collected Washington’s T cells, a type of white blood cell, and genetically modified them to better recognize and destroy the cancer cells before reinfusing them into his body. He didn’t require hospitalization post-transplant and could do daily blood draws at home. His energy levels were much higher than during his first treatment.

“I’ve been in a very privileged position,” Washington said. “The prognosis is very positive, and I’m feeling good about where I am at this point.”

Hunter, too, considers herself lucky despite receiving a delayed diagnosis. After her diagnosis in January 2017, she underwent five months of immunotherapy with a three-drug combination (Revlimid, Velcade, and dexamethasone) followed by a successful stem cell transplant and two weeks in the hospital. She has been in remission since July 2017.

Hunter, now a support group co-leader and patient advocate, said that stories like Washington’s and her own provide hope despite the research cuts.

In the eight years since her treatment, she said, she’s seen the thinking around multiple myeloma — long described as a treatable but incurable disease — begin to shift as a growing subset of patients remain disease-free for many years. She said she has even met people living with the disease for 30 years.

“The word ‘cure’ is now being heard,” Hunter said.

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As recently as five years ago, the event might have attracted an overwhelmingly white crowd.

But the gathering on the last day of the month at the Valerie C. Woodard Community Resource Center drew large attendance from Black people eager to learn more about a crisis that now has them at the center.

In recent years, the rate of overdose deaths from opioids — originally dubbed “Hillbilly heroin” because of their almost exclusive misuse by white people — has among Black people. This is to the introduction of fentanyl, a synthetic opioid 50 to 100 times as powerful as morphine, which is often mixed into heroin and cocaine supplies and can be consumed unknowingly. In North Carolina, Black people died from an overdose at the rate of 38.5 per 100,000 residents in 2021 — more than double the rate in 2019, according to .

Terica Carter, founder of Hajee House Harm Reduction, a Charlotte-based nonprofit that co-organized the event with the county’s public health office, has been working to change that statistic. Seven years ago, she founded Hajee House after the overdose death of her 18-year-old son, Tahajee, who took an unprescribed dose of Percocet that he didn’t know was laced with fentanyl. Her nonprofit has since focused on addressing a critical issue in the fight against the opioid epidemic: that resources, treatment, and policy prescriptions have not followed the surge in addiction and overdoses among Black people.

“Nobody was acknowledging it, and I felt so alone,” Carter said. “That pushed me into not wanting anybody else to go through what I went through.”

Hajee House seeks to fill the gaps in resources and information about opioid overdose, substance use, and treatment. It also provides syringes, safe-use toolkits, the overdose reversal drug naloxone, fentanyl test strips, and recovery referral services — all in a familiar, neighborhood environment.

Despite efforts by groups like Hajee House, a lot of work remains in North Carolina. In 2019, for instance, white people accounted for 88% of those served by the opioid use prevention and treatment services funded by a $54 million grant from the federal Substance Abuse and Mental Health Services Administration, reported. Black people, meanwhile, made up about 24% of North Carolina’s population but only 7.5% of those served by the state assistance.

Nationally, Black people are half as likely as white people to be referred to or get treatment — even after a nonfatal overdose, according to the .

“If you are a Black person and have an opioid use disorder, you are likely to receive treatment five years later than if you’re a white person,” said Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health. “Five years can make the difference between being alive or not.”

According to the CDC, only 1 in 12 non-Hispanic Black people who died of an opioid overdose had been engaged in substance use treatment, while non-Hispanic white people had been treated at nearly twice the rate. Even those who seek care are less likely to complete the program and have poorer outcomes — which studies to implicit bias and a lack of diversity and empathy for Black patients among treatment providers.

Daliah Heller, vice president of Drug Use Initiatives at Vital Strategies, a global health nonprofit, said she’s troubled by the lack of equal access to the full range of medications for opioid use disorder, which is considered the gold standard for care.

Those medications have the potential to reduce overdose risk by half and double a patient’s chances of entering long-term recovery. The FDA has approved three medications: buprenorphine and methadone, which are synthetic opioids that reduce cravings and withdrawal symptoms, and naltrexone, a post-detox monthly injectable that blocks the effects of opioids.

Black people are overwhelmingly . While methadone patients stay in treatment at higher rates compared with those prescribed buprenorphine, they face significant drawbacks, including difficulty finding a clinic, waitlists, and a requirement to visit the clinic every day to receive the medication under the supervision of a practitioner.

Meanwhile, buprenorphine can be prescribed in an office setting and filled at the pharmacy. A found that white patients received buprenorphine three to four times as often as Black patients due to geographical availability and ability to pay.

“When buprenorphine came online in the early 2000s, we thought we could integrate that treatment alongside health care, and you wouldn’t need to go to a special program anymore,” Heller said. “That didn’t happen.”

Edwin Chapman, who runs an addiction clinic in Washington, D.C., said he must overcome many prescribing challenges to effectively treat his mostly Black patient population.

“The insurance companies in many states put more restrictions on patients in an urban setting, such as requiring prior authorization for addiction treatment,” Chapman said, speaking from his own experience working with patients. “The dosing standards were based on the white population and people who were addicted to pills. Our surviving Black population often needs a higher dose of buprenorphine.”

Heller said the lack of access to treatment is also driven by broader, systemic issues. She said many Black people fear that, by seeking social services, they might become ensnared in the criminal justice system and ultimately lose their employment, housing, or even custody of their children.

“Drug use occurs at the same levels across racial and ethnic groups, but Black Americans are more likely to be arrested and incarcerated on drug charges,” Heller said. “The more hyper-criminalized experience levied against Black communities interferes with access to care.”

All this is why there’s an increasing need for nonprofits like Hajee House that can provide information and a low-barrier access to services in the Black community, Carter said.

She credits the success of Hajee House to her personal connections and a keen understanding of the needs and cultural preferences of the Black community. When she holds overdose awareness events, for instance, she features cookouts, bouncy houses, and DJs to make them look more like block parties.

“We focus on making the events and outreach a comfortable, familiar environment for the Black community,” Carter said. “We’re Black, so we keep it Black.”

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So when the University of North Carolina-Charlotte professor learned that Ozempic — developed to treat Type 2 diabetes — helped people lose weight and keep it off, Blanchard was determined to try it.

The state employee’s health insurance initially covered the prescription with Blanchard kicking in a $25 copayment. Over the next seven months, she said, she lost 45 pounds and lowered her blood pressure and cholesterol. The most significant benefits, though, were psychological.

“It stopped the food noise in my head, relieved my anxiety, and I was no longer drinking like a fish,” said Blanchard, now 60. “I’d have a glass of wine, and then that’s it.”

But North Carolina suffered from sticker shock as Blanchard shed pounds and thousands of others on the state insurance program — which covers more than 76,000 employees across 178 agencies, plus their dependents — tried to do the same. Ozempic and other glucagon-like peptide-1 (GPL-1) agonist medications accounted for 10% of the state employee health plan’s annual prescription drug spending, according to a North Carolina State Health Plan fact sheet. The state treasurer projected the class of drugs would cost the state this year, with costs jumping to more than $1 billion over the next six years.

“This exceeds the amount the State Health Plan spends on cancer, rheumatoid arthritis, and chemotherapy medications,” the said in a March statement.

The health plan’s board of trustees eliminated coverage of this class of medications for weight loss starting in April. The plan continues to cover the drug for Type 2 diabetes management.

But in a twist this August, a separate part of North Carolina’s government allowed the Medicaid program to start covering the drugs for weight loss — not just diabetes — for the state’s poorest residents, who are disproportionately affected by obesity and related diseases. The state’s Medicaid program covers more than 2 million people.

And now the outgoing Biden administration wants to follow suit, proposing on Nov. 26 for the federal government to cover the medications to treat obesity for Medicaid patients nationwide, in addition to Medicare patients.

Still, the North Carolina coverage change left state employees like Blanchard facing a stark choice — stop taking what she views as a miracle drug or pay as much as $1,200 out-of-pocket each month.

“They know diets don’t work long-term for weight loss, yet they are denying coverage for a medication that has been effective,” Blanchard said. “It’s indicative of a profit-driven mindset that is more about cost savings than prioritizing patients’ health.”

The coverage switch highlights concerns about the cost of these medications and ongoing questions about who should get to have such drugs covered by insurance.

Several other states are also trying to reel in the expense of the medications. West Virginia to cover the drugs for its state employees. Connecticut state employees who are prescribed the drugs must .

The high prices have also raised concerns about the cost for taxpayer-funded health care programs, such as Medicare. The Centers for Medicare & Medicaid Services estimated that coverage under the Biden proposal would cost about $40 billion over 10 years, including an extra $3.8 billion for states. But the requirement wouldn’t take effect until after President-elect Donald Trump takes office Jan. 20, giving his administration a chance to change it.

GLP-1 agonist medications, known by the brand names Ozempic, Trulicity, and Wegovy, have proved to be effective for weight loss as well as managing Type 2 diabetes. They work by triggering the pancreas to release insulin, slowing the rate at which the stomach empties, increasing satiety, and regulating appetite by sending signals to the brain to tell the body it is satisfied. But patients typically need to stay on the medications to maintain their weight loss, meaning they face long-term costs.

In clinical trials, patients taking Ozempic also showed significant reductions in cardiovascular problems such as heart attacks and strokes, even those without diabetes, or before weight loss started, said Duke University cardiologist and researcher .

Making these drugs available through Medicaid is in the state’s long-term financial interest, said Kody Kinsley, secretary of the North Carolina Department of Health and Human Services, which doesn’t oversee the state employee health plan. Unlike private or employer insurance plans, the Medicaid program receives generous rebates on these types of drugs, significantly reducing the cost, he said.

Calling North Carolina the buckle of the “Barbecue Belt,” Kinsley noted that state’s obesity rate exceeds the national average. The latest analysis from at the University of Chicago showed that 45% of adults in the state had a body mass index above 30, the threshold for clinical obesity, compared with 42% nationwide. That number was 55% for non-Hispanic Black adults in the state.

In addition, Kinsley said, with Medicaid the primary payer for long-term care, covering the drugs helps Medicaid’s bottom line by reducing the need for nursing home care often driven by unmanaged chronic diseases.

“We’re trying to put our dollars where they will lower costs in the long run,” he said. “I spend almost a billion dollars a year on obesity-related diseases. If I can reduce that spend by even 1%, then these drugs are a no-brainer.”

But what about people who aren’t on Medicaid? Duke’s Shah said the U.S. health care system needs to eliminate hurdles that make it difficult to obtain the drugs. Besides making the medication more affordable, he said, it should encourage the use of weight loss drugs and treatment of obesity as a chronic disease instead of stigmatizing it as a moral failing.

“Whether it is drug cost, conditions that require the payer to approve them, the patient’s health insurance plan, or the unaffordability of a plan that would cover weight loss, there are real-world barriers in our health care system,” Shah said.

Family medicine physician Melissa Jones of Charlotte said she has often seen a bias against people in her weight management practice when they try to get these medications covered by private insurance.

“There’s no shame in saying ‘I have high blood pressure’ or ‘I inherited this condition from my family,’” Jones said. “But for some reason, there’s shame associated with saying, ‘I struggle with my weight.’”

Although Blanchard can’t get her Ozempic covered anymore as a state employee, a concierge doctor gave her a prescription for a nonbrand version of the anti-obesity medications from a compounding pharmacy, available for now because of shortages of the brand-name versions. Though she believes it is less effective, she pays $225 a month for it.

“I can handle that,” she said.

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Así que cuando esta profesora de la Universidad de Carolina del Norte-Charlotte se enteró de que Ozempic —desarrollado para tratar la diabetes tipo 2— ayudaba a las personas a perder peso, y mantenerlo, Blanchard supo que tenía que probarlo.

El seguro de salud para empleados estatales inicialmente cubrió la receta, y Blanchard solo tuvo un copago de $25. Dijo que en los siguientes siete meses perdió 45 libras y bajó su presión arterial y su nivel de colesterol.

Sin embargo, los beneficios más significativos fueron psicológicos.

“Paró el ruido que hacía la comida en en mi cabeza, alivió mi ansiedad, y dejé de beber como un pez”, dijo Blanchard, quien ahora tiene 60 años. “Ahora tomo una copa de vino y ya”.

Sin embargo, Carolina del Norte tuvo un shock al ver que Blanchard bajaba de peso y miles de otros empleados en el mismo seguro de salud estatal, que cubre a 76.000 empleados de 178 agencias, más a sus dependientes, intentaban hacer lo mismo.

Ozempic, y otros medicamentos similares, representaron el 10% del gasto anual en medicinas recetadas del seguro estatal, según una hoja informativa del Plan de Salud de Carolina del Norte. El tesorero estatal proyectó que esta clase de medicamentos costaría al estado , y los costos aumentarían a más de $1,000 millones en los próximos seis.

“Esto supera la cantidad que el Plan de Salud del Estado gasta en medicamentos para el cáncer, la artritis reumatoide y la quimioterapia”, dijo el en una declaración en marzo.

La junta de fideicomisarios del plan de salud eliminó la cobertura de esta clase de medicamentos para la pérdida de peso a partir de abril. El plan continúa cubriendo el fármaco para el manejo de la diabetes tipo 2.

Pero, en un giro de los acontecimientos en agosto, otra parte del gobierno de Carolina del Norte permitió que el programa de Medicaid comenzara a cubrir estos medicamentos para la pérdida de peso, no solo para la diabetes, para los residentes más pobres del estado, que están desproporcionadamente afectados por la obesidad y enfermedades relacionadas. En el estado, Medicaid cubre a más de 2 millones de personas.

Ahora, la administración saliente de Biden quiere seguir su ejemplo: el 26 de noviembre propuso que el gobierno federal cubra los medicamentos para tratar la obesidad en pacientes de Medicaid en todo el país, sumándose a los pacientes de Medicare que ya pueden utilizarlos.

A pesar de esto, el cambio en la cobertura en Carolina del Norte dejó a empleados estatales como Blanchard enfrentándose a una dura elección: dejar de tomar lo que ella considera un medicamento milagroso o pagar hasta $1,200 de su bolsillo cada mes.

“Saben que las dietas no funcionan a largo plazo para la pérdida de peso, sin embargo, están negando la cobertura de un medicamento que ha sido efectivo”, dijo Blanchard. “Resalta una mentalidad orientada a las ganancias, más enfocada en ahorrar costos que en priorizar la salud de los pacientes”.

El cambio en la cobertura destaca preocupaciones sobre el costo de estos medicamentos y las preguntas sobre si las aseguradoras deben cubrirlos.

Varios otros estados también están tratando de controlar el costo de estos medicamentos. West Virginia para cubrir a sus empleados estatales. En Connecticut, los empleados estatales a los que se les han recetado estos medicamentos de manejo del estilo de vida.

Los altos precios también han suscitado preocupaciones sobre el costo para programas de salud financiados por los contribuyentes, como Medicare.

Los Centros de Servicios de Medicare y Medicaid (CMS) estimaron que la cobertura bajo la propuesta de Biden costaría alrededor de $40,000 millones en 10 años, incluyendo un costo adicional de $3,800 millones para los estados.

Sin embargo, el requisito no entraría en vigencia hasta después que el presidente electo Donald Trump asuma el cargo el 20 de enero, dándole a su administración la oportunidad de cambiarlo.

Los medicamentos agonistas GLP-1, conocidos por los nombres comerciales Ozempic, Trulicity y Wegovy, han demostrado ser efectivos para la pérdida de peso y para el manejo de la diabetes tipo 2. Funcionan desencadenando la liberación de insulina por el páncreas, ralentizando el vaciado del estómago, aumentando el nivel de saciedad y regulando el apetito al enviar señales al cerebro para indicar que el cuerpo está satisfecho.

Sin embargo, los pacientes suelen necesitar seguir tomando estos medicamentos para mantener la pérdida de peso, lo que implica costos a largo plazo.

En ensayos clínicos, los pacientes que tomaron Ozempic también mostraron reducciones significativas en problemas como ataques cardíacos y accidentes cerebrovasculares, incluso aquellos sin diabetes o antes de comenzar a perder peso, dijo , cardiólogo e investigador de la Universidad de Duke.

Hacer que estos medicamentos estén disponibles a través de Medicaid es un interés financiero a largo plazo para el estado, dijo Kody Kinsley, secretario del Departamento de Salud y Servicios Humanos de Carolina del Norte. A diferencia de los planes privados o de empleadores, Medicaid recibe generosos descuentos en este tipo de medicamentos, reduciendo significativamente el costo, explicó.

Apodando a Carolina del Norte “el cinturón de la barbacoa,” Kinsley señaló que la tasa de obesidad del estado supera el promedio nacional. El último en la Universidad de Chicago mostró que el 45% de los adultos en el estado tenían un índice de masa corporal superior a 30, el umbral para la obesidad clínica, en comparación con el 42% a nivel nacional. Para los adultos negros no hispanos en el estado, esa cifra era del 55%.

Además, Kinsley dijo que, siendo Medicaid el principal pagador del cuidado a largo plazo, cubrir estos medicamentos ayuda a reducir la necesidad de atención en hogares de adultos mayores, a menudo impulsada por enfermedades crónicas mal manejadas.

“Estamos tratando de invertir nuestros recursos donde reduzcan costos a largo plazo”, afirmó. “Gasto casi mil millones de dólares al año en enfermedades relacionadas con la obesidad. Si puedo reducir ese gasto incluso en un 1%, estos medicamentos son lo más lógico”.

Pero, ¿qué pasa con las personas que no están en Medicaid? Shah, de Duke, dijo que el sistema de salud de Estados Unidos necesita eliminar las barreras que dificultan la obtención de estos medicamentos. Además de hacer que los medicamentos sean más asequibles, agregó, debería alentarse el uso de medicamentos para la pérdida de peso y el tratamiento de la obesidad como una enfermedad crónica, en lugar de estigmatizarla como un fracaso moral.

“Ya sea el costo del medicamento, las condiciones que requieren la aprobación del pagador, la cobertura médica del paciente o la inaccesibilidad de un plan que cubriría la pérdida de peso, hay barreras reales en nuestro sistema de salud”, explicó Shah.

Melissa Jones, médica de familia de Charlotte, dijo que a menudo ha observado un sesgo contra las personas en su práctica de manejo del peso cuando intentan que los seguros privados cubran estos medicamentos.

“No hay vergüenza en decir ‘tengo presión arterial alta’ o ‘heredé esta condición de mi familia,’” comentó Jones. “Pero, por alguna razón, hay vergüenza en decir, ‘Lucho con mi peso’”.

Aunque Blanchard ya no puede obtener la cobertura de Ozempic como empleada estatal, un médico de atención personalizada le recetó una versión del medicamento anti-obesidad producido en una farmacia de compuestos, disponible por ahora debido a la escasez de las versiones de marca. Aunque cree que es menos efectivo, paga $225 al mes por ella.

“Puedo manejar eso”, dijo.

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In both instances, her energy bills reached hundreds of dollars a month.

“Sometimes I have to choose whether I’m going to pay the light bill,” Freeman said, “or do I pay all the rent or buy food or not let my son do a sport?”

As a regional field organizer for PowerUp NC, Freeman’s job is to help people properly weatherize their homes, particularly in the Sandhills region, where she lives and works and where poverty and rising temperatures make residents vulnerable to the health impacts of climate change.

But Freeman’s income is too high to benefit from the very services she helps others attain from that grassroots sustainability, clean energy, and environmental justice initiative.

Like a growing number of Americans, Freeman struggles with what is known as , including the inability to afford utilities to heat or cool a home. Households that of their income on energy bills are energy-poor, some researchers suggest.

Energy poverty can increase one’s exposure to extreme heat or cold, which raises the risk of developing respiratory issues, heart problems, allergies, kidney disorders, and other health conditions. And the burden falls disproportionately on households in communities of color, which experience it at a rate 60% greater than those in white communities.

Public health and environmental experts say that as climate change continues to create extreme weather conditions, more policy efforts are needed to help vulnerable communities, especially during heat waves.

“Energy poverty is just one example of how climate change can exacerbate existing inequities in our communities,” said Summer Tonizzo, a spokesperson for the North Carolina Department of Health and Human Services.

Extreme heat is the No. 1 cause of weather-related deaths in the U.S., a risk that grows as temperatures rise. Last year, 2,302 people in the U.S. , a 44% increase from 2021. In one week in early July this year, extreme heat killed at least 28 people, , based on reports from state officials, medical examiners, and local news reports.

Yet, 1 in 7 households spend about 14% of their income on energy, according to RMI, an energy and sustainability think tank. Nationally, are in energy poverty, concluded an analysis co-authored by Noah Kittner, an assistant professor of public health at the University of North Carolina-Chapel Hill.

“Old, inefficient buildings and heating systems are prompting people to supplement their energy needs in ways that increase the costs,” Kittner said.

Pregnant women, people with heart or lung conditions, young children, older adults, and people working or exercising outdoors are most at risk for heat-related health concerns. High temperatures are also correlated with mental health issues such as suicide and severe depression.

Location is another risk factor. For example, in a historically Black community in Raleigh, known as Method, temperatures can be 10 to 20 degrees hotter than nearby areas with more vegetation and less development, said La’Meshia Whittington, an environmental justice and clean energy advocate. Interstate 440 runs through Method, and the city stores shuttle buses there, often with engines running.

“That creates a lot of pollution that heats up the neighborhood,” Whittington said. “There’s no land to soak up the heat. Instead, it bounces off shingles, roofs, pavement and creates a stove.”

Method residents frequently complain of chronic headaches and respiratory problems, she said.

While rural areas tend to have lower temperatures than nearby urban areas because they have less asphalt and more trees, they often lack resources, such as health care facilities and cooling centers. Substandard housing and higher rates of poverty contribute to high rates of heat-related illness.

Energy poverty “is the layering of burdens without a means, at the individual level, to combat those burdens,” said Ashley Ward, director of the Heat Policy Innovation Hub at Duke University.

In many parts of the country, extreme heat is a relatively new concern. Policymakers have historically focused on threats from colder temperatures.

The federal government’s Low Income Home Energy Assistance Program, established more than four decades ago, has a funding formula that over those that experience extreme heat, according to research from Georgetown University. Florida, Georgia, Arizona, Texas, and Nevada have the lowest proportional allocations of federal funding, while North Dakota, South Dakota, and Nebraska have the highest.

North Carolina has largely relied on private donors and local nonprofits, such as PowerUp, to distribute fans and air conditioning units in the summer, but the state doesn’t contribute to costs of energy bills.

On extremely hot days, Freeman and her PowerUp NC colleagues work with state health officials to direct vulnerable people to cooling centers.

On a personal level, staying cool this summer meant sending her son to a free, open recreational center, rather than paying for him to join a sports league.

“We’re doing stuff that doesn’t cost,” she said. “Just trying to keep up with the electric bill.”

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“Nuestra agua ha estado turbia y burbujeante, y parece lechosa”, dijo Barrett, que culpa al , un mineral que comunidades de todo el país han agregado durante décadas al suministro de agua para ayudar a prevenir las caries y mejorar la salud dental.

“¡No quiero flúor en nada!”, dijo Barrett, haciéndose eco de un número creciente de personas que no sólo dudan de la eficacia del mineral sino que también creen que puede ser perjudicial a pesar de décadas de datos que destacan sus beneficios económicos y para la salud pública.

En febrero, la Junta de Comisionados del Condado de Union, cuya sede es Monroe, votó 3-2 para dejar de agregar fluoruro al agua potable en la Planta de Tratamiento de Agua del Río Yadkin, la única fuente de agua operada por el condado, que es de su propiedad. Pero la decisión se produjo después de fuertes discusiones entre residentes y funcionarios.

“Mis hijos tuvieron la bendición de crecer con fluoruro en el agua y… tienen muy pocos problemas dentales”, dijo el comisionado Richard Helms antes de votar. Un colega lo vio de otra manera: “Dejemos de poner en el agua algo que esté destinado a tratarnos, y demos a la gente la libertad de elegir”, dijo David Williams.

El agua de Barrett proviene de la ciudad de Monroe, no de las instalaciones de Yadkin. Así que, por ahora, seguirá bebiendo agua enriquecida con fluoruro. “Sospecho de por qué agregan eso a nuestra agua”, dijo a Ñî¹óåú´«Ã½Ò•îl Health News.

Es un escenario que se desarrolla a nivel nacional. Desde Oregon hasta Pennsylvania, en los últimos años cientos de comunidades han dejado de agregar fluoruro a sus suministros de agua o han votado para evitar agregarlo.

Los partidarios de estas prohibiciones argumentan que a las personas se les debería dar libertad de elección. Dicen que la amplia disponibilidad de productos dentales de venta libre que contienen el mineral hace que ya no sea necesario agregarlo al suministro público de agua.

Los Centros para el Control y Prevención de Enfermedades (CDC) dicen que si bien los productos que se compran en tiendas reducen las caries, la mayor protección se produce cuando con la fluoración del agua.

El resultado de un caso federal en curso en California podría obligar a la Agencia de Protección Ambiental (EPA) a crear una norma que regule o prohíba el uso de fluoruro en el agua potable en todo el país.

Mientras tanto, la tendencia está haciendo sonar las alarmas entre los investigadores de salud pública que temen que, al igual que con las vacunas, el fluoruro pueda haberse convertido en víctima de su propio éxito.

Los CDC sostienen que la fluoración del agua comunitaria no sólo es segura y eficaz, sino que también en los costos de tratamientos dentales. Los funcionarios de salud pública dicen que eliminar el fluoruro podría ser particularmente perjudicial para las familias de bajos ingresos, para quienes el agua potable puede ser la única fuente de atención dental preventiva.

“Si tienes que salir y recibir atención por tu cuenta, es un juego completamente diferente”, dijo Myron Allukian Jr., dentista y ex presidente de la Asociación Americana de Salud Pública. Millones de personas han vivido con agua fluorada durante años, “y no hemos tenido problemas de salud importantes”, afirmó. “Es mucho más fácil prevenir una enfermedad que tratarla”.

Según el grupo anti-fluoruro Fluoride Action Network, desde 2010, más de en todo el mundo han eliminado el fluoruro de su agua potable o han decidido no agregarlo.

Sólo hay que mirar al condado de Union para ver cuán intensas pueden ser las discusiones. Generalmente cuando los comisionados se reúnen en el primer piso del Centro de Gobierno en el centro de Monroe, la mayoría de los asientos están vacíos. Pero las sesiones sobre la prohibición del fluoruro en los suministros públicos de agua estuvieron colmadas de gente, y los residentes que se inscribieron para hablar estaban divididos.

Una persona que habló el 5 de febrero comparó la fluoración del agua con un cinturón de seguridad. No “previene el accidente automovilístico, pero limita el daño causado”, dijo. Otro argumentó que no hay pruebas de que el fluoruro sea seguro o eficaz. “Es un hito potencial significativo para revertir más de 60 años de envenenamiento del público”, dijo, utilizando una afirmación no probada que a menudo utilizan los opositores a la fluoración.

Los opositores al fluoruro afirman que el mineral es responsable de todo, desde el acné hasta la presión arterial alta, desde los problemas de tiroides hasta el cáncer de huesos.

Los Institutos Nacionales de Salud (NIH) reconocen que, cuando se ingiere en cantidades extremadamente grandes, el fluoruro de los productos dentales o suplementos dietéticos puede causar náuseas, vómitos, dolor abdominal, diarrea, dolor de huesos e incluso la muerte en casos extremadamente raros.

Los bebés y niños que reciben demasiado fluoruro pueden sufrir decoloración o pequeñas lesiones en los dientes. En los adultos, el consumo excesivo de fluoruro puede provocar fluorosis esquelética, una afección muy rara que causa dolor y rigidez en las articulaciones, huesos débiles, pérdida de masa muscular y problemas nerviosos.

Sin embargo, la dosis recomendada en el agua potable siempre ha sido pequeña. En 2015, el Departamento de Salud y Servicios Humanos (HHS) de 1,2 miligramos por litro a 0,7 mg/L.

Juneau, en Alaska, votó a favor de eliminar el fluoruro de su agua potable en 2007. Un en 2018 comparó los registros dentales de niños y adolescentes que recibieron atención dental por caries cuatro años antes y cinco años después que la ciudad dejara de agregar fluoruro al agua. El estudio encontró que los procedimientos relacionados con las caries y los costos de tratamiento fueron significativamente más altos en el último grupo.

Portland, en Oregon, es la ciudad más grande del país que a agregar fluoruro a su agua potable. Los votantes han rechazado repetidamente las medidas para agregarlo, primero en 1956 y la última vez en 2013.

A pesar de la fuerte recomendación de los médicos y dentistas locales, los votantes de Wichita, Kansas, han rechazado agregar fluoruro al agua varias veces, .

El Distrito Municipal de Servicios Públicos de Brushy Creek en el condado de Williamson, en Texas, estuvo agregando fluoruro a su sistema de agua desde 2007, pero puso fin a esta práctica en diciembre pasado.

En 2016, los comisionados del condado de Collier, en Florida, optaron por no eliminar el fluoruro del sistema de agua. Pero revocaron por unanimidad esa decisión luego de una Declaración de Derechos de Libertad de Salud de 2023 en respuesta a covid-19 que emitió el condado a través de , “para salvaguardar los derechos y libertades de atención médica de los residentes del condado de Collier”.

La Autoridad del Agua de State College Borough, en Pennsylvania, de sus 75,000 clientes en marzo de 2023. Los funcionarios citaron razones que habitualmente usan los activistas anti-fluoruro: la posible contaminación ambiental, preocupaciones sobre la libertad médica y posibles efectos adversos para la salud.

Un en 2019, realizado en seis ciudades canadienses, asoció la exposición al fluoruro durante el embarazo con puntuaciones de coeficiente intelectual más bajas en los niños. Pero el estudio se basó en informes propios y ha sido criticado por sus aparentes deficiencias metodológicas.

En 2016, varios grupos de defensa del consumidor, incluidos Fluoride Action Network, Food & Water Watch y Moms Against Fluoridation, solicitaron a la EPA que pusiera fin a la fluoración del agua en virtud de la Ley de Control de Sustancias Tóxicas, alegando que importantes investigaciones demostraban que el fluoruro era neurotóxico en las dosis usadas actualmente. El mismo grupo presentó una demanda federal contra la EPA al año siguiente, después que la agencia denegara la petición.

Durante un juicio de 10 días en San Francisco, que concluyó a mediados de febrero, las dos partes debatieron los riesgos y las áreas de incertidumbre. Si el juez federal de distrito Edward Chen determina que la fluoración del agua presenta un “riesgo irrazonable” para la salud humana, la EPA se verá obligada a crear una norma que regule o prohíba la fluoración del agua en Estados Unidos. Se espera una decisión pronto.

Por el momento, las decisiones sobre la fluoración de los sistemas de agua comunitarios todavía se toman principalmente a nivel local, lo que Barrett espera que cambie.

“De todas las cosas, lo que más quieren es que nuestros dientes estén sanos cuando faltan las necesidades básicas de vivienda y alimentación”, expresó.

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“Our water has been cloudy and bubbly and looks milky,” said Barrett, who blames fluoride, a mineral that communities across the nation have for decades added to the water supply to help prevent cavities and improve dental health.

“I don’t want fluoride in my nothing!” said Barrett, echoing a growing number of people who not only doubt the mineral’s effectiveness but also believe it may be harmful despite decades of data pointing to public health and economic benefits.

In February, the Board of County Commissioners in Union County, whose seat is Monroe, voted 3-2 to stop adding fluoride to drinking water at the Yadkin River Water Treatment Plant, the only water source wholly owned and operated by the county. But the decision came after heated discussions among residents and county officials.

“My children had the blessing of growing up with fluoride in their water and … they have very little dental issues,” said Commissioner Richard Helms ahead of the vote. A fellow commissioner saw it differently: “Let’s stop putting something in the water that’s meant to treat us, and give people the freedom to choose,” said David Williams.

Barrett’s water comes from the city of Monroe, not the Yadkin facility. So, for now, she will continue to drink water enhanced with fluoride. “I’m suspicious as to why they add that to our water,” she told Ñî¹óåú´«Ã½Ò•îl Health News.

It is a scenario playing out nationwide. From Oregon to Pennsylvania, hundreds of communities have in recent years either stopped adding fluoride to their water supplies or voted to prevent its addition. Supporters of such bans argue that people should be given the freedom of choice. The broad availability of over-the-counter dental products containing the mineral makes it no longer necessary to add to public water supplies, they say. The Centers for Disease Control and Prevention says that while store-bought products reduce tooth decay, the greatest protection comes when they are with water fluoridation.

The outcome of an ongoing federal case in California could force the Environmental Protection Agency to create a rule regulating or banning the use of fluoride in drinking water nationwide. In the meantime, the trend is raising alarm bells for public health researchers who worry that, much like vaccines, fluoride may have become a victim of its own success.

The CDC maintains that community water fluoridation is not only safe and effective but also in dental treatment. Public health officials say removing fluoride could be particularly harmful to low-income families — for whom drinking water may be the only source of preventive dental care.

“If you have to go out and get care on your own, it’s a whole different ballgame,” said Myron Allukian Jr., a dentist and past president of the American Public Health Association. Millions of people have lived with fluoridated water for years, “and we’ve had no major health problems,” he said. “It’s much easier to prevent a disease than to treat it.”

According to the anti-fluoride group Fluoride Action Network, since 2010, around the world have removed fluoride from their drinking water or decided not to add it.

One needs only to look to Union County to see just how intense discussions can be. Usually when the commissioners meet on the first floor of the Government Center in downtown Monroe, there are more vacant seats than attendees. But sessions about the prohibition of fluoride in public water supplies were packed, and residents who signed up to speak were divided.

One person who came to the microphone on Feb. 5 compared water fluoridation to a seat belt. It does not “prevent the car crash, but it limits the harm done,” he said. Another argued that there is no proof fluoride is safe or effective. “It’s a significant potential milestone to reverse 60-plus years of poisoning the public,” he said, using an unproven claim often made by opponents of fluoridation.

Fluoride opponents claim the mineral is responsible for everything from acne to high blood pressure and thyroid dysfunction to bone cancer.

The National Institutes of Health acknowledges that, when ingested in extremely large amounts, fluoride from dental products or dietary supplements can cause nausea, vomiting, abdominal pain, diarrhea, bone pain, and even death in extremely rare cases.

Infants and children who receive too much fluoride can develop discoloration or small dents in their teeth. In adults, consumption of can lead to skeletal fluorosis, a very rare condition that causes joint pain and stiffness, weak bones, muscle loss, and nerve problems.

However, the recommended dosage in drinking water has always been small. In 2015, the Department of Health and Human Services from 1.2 milligrams per liter to 0.7 mg/L.

Juneau, Alaska, voted to remove fluoride from its drinking water in 2007. A in the journal BMC Oral Health in 2018 compared the dental records of children and adolescents who received dental care for decaying teeth four years before and five years after the city stopped adding fluoride to the water. Cavity-related procedures and treatment costs were significantly higher in the latter group, the study found.

Portland, Oregon, is the largest city in the nation that has consistently its drinking water. Voters have repeatedly rejected measures to add it, first in 1956 and the latest time in 2013.

Despite the strong recommendation of local doctors and dentists, voters in Wichita, Kansas, have rejected adding fluoride to the water several times, .

The Brushy Creek Municipal Utility District in Williamson County, Texas, had been adding fluoride to its water system since 2007 but ended the practice in December.

In 2016, Collier County, Florida, commissioners opted not to remove fluoride from the water system. But they unanimously reversed that decision following a 2023 Health Freedom Bill of Rights in response to covid-19 “to safeguard the healthcare rights and freedoms of Collier County residents.”

The State College Borough Water Authority in Pennsylvania to the water of its 75,000 customers in March 2023. Officials used claims often cited by fluoride opponents, such as potential environmental contamination, concerns about medical freedom, and possible adverse health effects, like the potential for the appearance of faint white lines on the teeth and lowered IQ for babies.

A in 2019, conducted in six Canadian cities, associated fluoride exposure during pregnancy with lower IQ scores in children. But the study was based on self-reporting and has been criticized for its perceived methodological shortcomings.

In 2016, several consumer advocacy groups, including the Fluoride Action Network, Food & Water Watch, and Moms Against Fluoridation, petitioned the EPA to end water fluoridation under the Toxic Substances Control Act, alleging that significant research showed fluoride was neurotoxic at the doses now used. The same group filed a federal lawsuit against the EPA the following year, after the agency denied their citizen petition.

During a 10-day bench trial in San Francisco that concluded in mid-February, the two sides debated the risks and areas of uncertainty. If Senior U.S. District Judge Edward Chen determines water fluoridation presents an “unreasonable risk” to human health, the EPA will be forced to create a rule regulating or banning water fluoridation in the U.S. A decision is expected soon.

For the time being, decisions about whether to fluoridate community water systems are still made primarily at the local level, which Barrett hopes will change.

“Of all things, they want our teeth healthy when basic needs of housing and food are lacking.”

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He was 55 years old and a decades-long smoker. So the doctor recommended that Buff schedule time on a 35-foot-long bus operated by the Levine Cancer Institute that would roll through town later that week offering free lung-cancer screenings.

Buff found the “lung bus” concept odd, but he’s glad he hopped on.

“I learned that you can have lung cancer and not even know it,” said Buff, who was diagnosed at stage 1 by doctors in the rolling clinic. “The early screening might have saved my life. It might’ve given me quite a few more years.”

The lung bus is a big draw in this rural area of western North Carolina because some people aren’t comfortable going — and in many cases have no access — to a hospital or doctor’s office, said Darcy Doege, coordinator for the screening program. 

“Our team makes people feel welcome,” she said. “We can see up to 30 patients a day who get referred by their primary care doctor or their pulmonologist, but we also accommodate walk-ups.”

Lung cancer is the . It grows quietly and is usually not detected until it has spread to other parts of the body. Early detection is key to survival, especially for someone at high risk like Buff, who is African American and has a history of smoking.

Although it is well documented that Black smokers develop lung cancer at younger ages than white smokers even when they smoke fewer cigarettes, the guidelines that doctors use to recommend patients for screening have been slow to reflect the disparity. If Buff had the same conversation with his doctor one year earlier, he would not have qualified for the CT scan that detected a nickel-sized growth on his left lung.

But screening is only part of the issue, said experts who evaluate what happens both before and after a person is checked for signs of cancer.

Researchers are concerned about the lack of diverse representation in the clinical studies on which the screening recommendations are based. For example, about 13% of the U.S population is Black, but Black people made up just 4.4% of participants in the , a large, multiyear study in the early 2000s that looked at whether screening with low-dose CT scans could reduce mortality from lung cancer. 

Basing guidelines on trials with so little diversity can lead to delayed disease detection and higher mortality rates, said Dr. Carol Mangione, chair of the U.S. Preventive Services Task Force, a panel of national experts who make recommendations about services such as screenings, behavioral counseling, and preventive medications. Its recommendations play a major role in determining which tests and procedures will agree to pay for.

“We know that Black people get diagnosed with and tend to die more from colon cancer, for example,” Mangione said. “But we don’t have sufficient evidence to say that there should be a different recommendation for Black people, because Black people have not historically been well represented in the clinical trials.”

When Buff was diagnosed with lung cancer, the U.S. Preventive Services Task Force recommended screening for people who were 55 and older and had a smoking history of 30 “pack years,” which means the person smoked an average of one pack of cigarettes a day for three decades. Buff made the cut.

But a published in JAMA Oncology found that under those parameters, 68% of Black smokers would have been ineligible for screening at the time of their lung cancer diagnosis, compared with 44 percent of white smokers. In 2021, the U.S. Preventive Services Task Force lowered the recommended screening age for lung cancer to 50 and reduced the number of pack years to 20.

The make 8 million more Americans eligible to be screened. But that’s not the only problem that needs to be addressed, said Dr. Gerard Silvestri, a lung cancer pulmonologist at the Medical University of South Carolina.

“It doesn’t matter if a bunch more African Americans are eligible if they have no coverage, distrust the medical system, and have no access,” Silvestri said.

“You might exacerbate this disparity,” he said, “because more whites will also become eligible and are likely to have more access.” 

Silvestri co-leads the Medical University of South Carolina’s portion of a $3 million, four-year grant-funded project focused on addressing lung cancer disparities. Researchers in the multicenter collaboration — which also includes the Lineberger Comprehensive Cancer Center at the University of North Carolina-Chapel Hill and the Massey Cancer Center at Virginia Commonwealth University — said better screening rates will improve outcomes in underserved communities.

“Patients of color, particularly Black patients, tend to have less access to care, less timely follow-up when there’s an abnormal finding, and later stages of diagnosis,” said epidemiologist Louise Henderson, principal investigator for the study at the Lineberger center.

It takes concerted community efforts to contend with the suite of health disparities that result in poor outcomes for communities of color, experts said. The lung bus that Buff visited is just one example of how cancer researchers are rolling out programs in rural communities. The Atrium Health Levine Cancer Institute in Charlotte, North Carolina, launched the effort in March 2017 to make screening more accessible to underserved people in vulnerable communities who are either uninsured or underinsured.

The bus operates in 19 counties in North and South Carolina. In an in 2020, the Levine Cancer Institute said the project had identified 12 cancers in 550 patients and called the results “policy changing.”

By September 2021, the researchers said, the bus had identified 30 cancers in 1,200 screened patients. “Of which 21 were at the potentially curable stage,” said Dr. Derek Raghavan, president of the Levine Cancer Institute and lead author of the analysis. About 78% of the people screened were poor and from rural areas, he said, and 20% were Black Americans.

“You can overcome disparities of care if you really want to,” Raghavan said.

The Lineberger center also partnered with federally qualified health centers in the Raleigh-Durham area and recruited community health advisers to educate patients about the risks of lung cancer and the ease of being screened. It also trained patient and financial navigators to assist with the often-overwhelming aftermath of a diagnosis.

Recent studies in and the have found that Medicaid expansion under the Affordable Care Act improves overall cancer survival among all racial and ethnic groups and reduces racial disparities in cancer survival. Among the three research sites participating in the lung cancer disparities project, the Massey Cancer Center in Virginia is the only one in a state that expanded Medicaid.

Vanessa Sheppard, associate director of community outreach engagement and health disparities at the center, said she has seen anecdotal evidence that expanding health care coverage improves cancer screening rates.

Nonetheless, awareness about screening remains low in the Black community. Sheppard believes that may be because general health care providers are not educating patients on the available screening tools.

A low-dose CT scan, for example, is one of the most powerful tools available for detecting lung cancer early and reducing deaths. But according to the from the American Lung Association, nearly 70% of people don’t even know that type of screening is available. And according to Silvestri, only a small percentage of those who are eligible actually get screened.

Perhaps the final hurdle is erasing disparities in who gets follow-up care after screening. A found that Black patients who had been referred to a lung cancer screening program were still less likely than white patients to get screened and that they had longer delays in seeking follow-up care when they did get screened.

Henderson said some patients may mistakenly believe lung cancer is untreatable and simply don’t want to hear bad news.

Sheppard said screening can be used to educate and build trust with patients.

“Once we get people in the system, it’s up to us to make sure they know what’s expected, that it’s not a one-time thing, and that we are embedding them within the system of care,” she said. “I think that’s going to help a lot.”

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“This guy in a pickup truck stopped at the light, rolled down his window, and just started calling us a bunch of N-words,” she recalled.

It wasn’t the only time Bryant has had an experience like this at the overwhelmingly white campus in Boone, a town in one of North Carolina’s most conservative regions. Whether it’s the ubiquity of Confederate flags, Ku Klux Klan members handing out literature, or a parade of pickup trucks flying flags in support of President Donald Trump, she believes they’re all intended to signal that students of color are unwelcome there.

College campuses are a microcosm of racial strife happening across the nation. From 2018 to 2021, the Southern Poverty Law Center of white supremacist pamphleteering on college campuses. The Anti-Defamation League recorded around being distributed on campuses in 2019.

Black students at predominantly white institutions report everything from instances of thinly veiled racism, homophobia, and sexism to outright racial hostility and intimidation.

Experiencing such incidents has consequences that go well beyond feeling uncomfortable. A growing body of research has documented the detrimental health effects of both interpersonal and structural racism. The Centers for Disease Control and Prevention notes that centuries of racism have had a profound and negative impact on the mental and physical health of people of color. The American Public Health Association calls racism a barrier to health equity and a social determinant of health akin to housing, education, and employment.

Racist incidents can take a toll on students’ overall health and well-being, undermine their self-confidence, and affect academic performance, said Dr. , senior medical director for , a nonprofit focused on supporting the mental health of young people of color.

“These kinds of feelings go hand in hand with students at predominantly white institutions, where they may feel isolated or like they don’t belong,” she said. “The experiences are associated with issues such as depression, anxiety, and difficulty concentrating or sleeping.”

A UCLA in 2021 shows that the problems aren’t necessarily transitory. Young adults who experience discrimination are at higher risk for both short- and long-term behavioral and mental health problems that are exacerbated with each new incident.

For a variety of reasons, students of color are not getting the kind and amount of help they need. A recent University of North Carolina-Chapel Hill study of first-year college students found that . However, in the Journal of Adolescent Health found that treatment use is lower among students of color relative to white students, even when controlling for other variables. This is consistent with a from the Steve Fund that said students of color are less likely than their white peers to seek mental health treatment even though white and Black students experience mental health issues at the same rate.

College campuses are having trouble recruiting enough therapists to meet the mental health needs of students overall. And few predominantly white colleges employ counselors and mental health professionals who are representative of the racial, ethnic, and cultural diversity of the students.

This can be problematic for patients of color in any setting who doubt white counselors can provide , which acknowledges a patient’s heritage, beliefs, and values.

When Daisha Williams spoke to a white counselor outside of campus about being alienated from her mother’s side of the family for being biracial, her pain was trivialized: “She was, like, ‘Sorry that happened. That sucks. They really missed out.’ And that was it.”

The history of racism in the fields of psychology and psychiatry makes many Black people leery of seeking help. Last year, for the organization’s “appalling past actions” and pledged to institute “anti-racist practices.” Months later, its own apology.

But even a Black counselor may not be enough to overcome reluctance. In a conducted by the Steve Fund and the United Negro College Fund, 45% of students at historically Black colleges and universities said they would not speak to a mental health professional if they were in crisis.

Primm said a student’s background and belief system may be a factor. “They may have been raised to ‘put it in God’s hands’ or may be told that they could overcome these feelings if they prayed hard enough,” Primm said. “Certainly, prayer and religious activity are important and helpful for mental health, but sometimes you may need some additional support.”

Black students account for nearly 4% of the more than 18,000 undergraduates at Appalachian State, and Black residents make up fewer than 3% of Boone’s population. Bryant, the programming chair for the university’s Black Student Association, believes that having a university with so few Black people— in a town where Black residents are even scarcer — emboldens those who commit racist acts.

Bryant was well aware of the demographics of the school and the region before she arrived. But during a campus tour, university representatives assured prospective students that they valued diversity and would ensure that Black and other students of color felt as if they belonged.

“We were under the impression that they would make sure we are supported, but the reality of how things really are changed that dynamic,” she said. “We did not expect the amount of fight we’d have to contribute towards things that might affect our education.”

And sometimes the racism the students face is more subtle than hurled epithets but still deeply unsettling. In 2017, Williams said, she eagerly anticipated discussing Ta-Nehisi Coates’ essay “The Case for Reparations” in one of her Appalachian State classes, but the conversation soon became upsetting. A white student asserted that any residual economic or social inequality resulted from Black people’s lack of initiative, not the nation’s failure to atone for historical wrongs.

“He kept saying extremely offensive things like ‘They should just work harder’ or ‘They should try to better their lives and educate themselves,’” Williams recalled. “At one point, he made some comment about lynching. Once he said that, I just got up and left.”

Williams was especially disturbed by what she saw as the professor’s encouragement. “Rather than saying, ‘You’re making the students of color feel unsafe and unwelcome,’ she kept saying, ‘Elaborate on that.’”

Although institutions cannot control or eliminate these occurrences, they bear responsibility for how they respond. When asked about what happened to Williams and Bryant, Appalachian State Associate Vice Chancellor Megan Hayes called the incidents “abhorrent” and said the university “is committed to fostering an inclusive, safe and supportive environment for all students, faculty, and staff.”

Still, such incidents continue to happen nationwide. A white University student gave a class presentation on , which has been linked to white supremacist ideology. When Black students complained, the university defended the presentation as free speech.

At in Memphis, Tennessee, pro-Nazi postings were directed at Black students and a banana was taped to the dorm room door of two Black male students. At , the N-word was spray-painted on the Center for Black Studies building. A College of Environmental Science and Forestry posted a video showing two men firing guns at a tree as one yells, “This is what we do to n——.”

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