How zip codes decide who lives and who dies.
Geography is not neutral. In the United States, especially in the rural South, where someone lives, the color of their skin, and their gender together influence how long they will live, how likely they are to die in pregnancy or childbirth, and whether a curable cancer will ever be treated (Human Rights Watch, 2022; World Health Organization [WHO], 2025). Rural Black women experience these forces at their sharpest intersection, and evidence shows that this is not accidental but reflects policy choices, racialized economics, and patriarchal control over whose health is protected (Mississippi Today, 2025; Yale Law School, 2018).
When Your ZIP Code Hunts You
In regions such as the Mississippi Delta and the Black Belt, Black women often live in communities that public officials allowed to become health care deserts (Mississippi Today, 2025). Hospitals have closed, labor and delivery units have shut down, and obstetric providers have left, leaving huge distances between patients and essential services (Word in Black, 2023). The nearest site for a Pap test, prenatal visit, or emergency obstetric care may be more than an hour away, and accessing that care assumes reliable transportation, money for fuel, and the ability to take time off work without losing income.
Cervical cancer is widely recognized as a disease that can be prevented and treated effectively through human papillomavirus vaccination, regular screening, and timely follow up (American Cancer Society, 2022; Human Rights Watch, 2022). Despite this, Black women in parts of the rural South are more likely to be diagnosed at advanced stages and more likely to die from cervical cancer than white women in better resourced areas (American Journal of Managed Care, 2025; Human Rights Watch, 2022; Mississippi Today, 2025). Similar patterns appear in maternal health, where rural Black women face higher risks of severe complications and maternal death, in part because they live in maternity care deserts and must travel long distances to receive prenatal and delivery care (Word in Black, 2023; Yale Law School, 2018). When a state allows hospitals to close, declines to invest in rural infrastructure, and underfunds clinics, the result is not a random gap but a predictable distribution of preventable deaths.
Policy as a Weapon, Not a Glitch
Medicaid expansion provides a clear example of how policy choices can extend or shorten lives. Research indicates that states that expanded Medicaid improved access to primary care, cancer screening, and chronic disease management, and some analyses have found reductions in cancer mortality and narrowed racial disparities in survival after expansion (Soni et al., 2021; Soni et al., 2025; Zhao et al., 2022). In contrast, states that chose not to expand Medicaid, many of which are in the South, left large numbers of low income adults uninsured, including Black women of reproductive age (Human Rights Watch, 2022; Yale Law School, 2018). For these residents, routine Pap tests, contraception, prenatal visits, and chronic disease management are more likely to be delayed or forgone because of cost.
These policy decisions interact with gender and race. Public narratives often invoke the protection of fetal life and traditional family roles, while the same political structures decline to finance the basic services that would keep Black women alive during pregnancy and beyond (Word in Black, 2023; Yale Law School, 2018). Scholars of reproductive justice argue that this pattern reflects a longstanding devaluation of Black women’s bodily autonomy, in which their reproduction is monitored and constrained, yet their survival is not prioritized when budgets are written or programs are cut (Human Rights Watch, 2022; Yale Law School, 2018). In this sense, policy operates less as a neutral administrative tool and more as an instrument that shapes whose lives are safeguarded and whose are treated as expendable.
Social Determinants and Decades of Life Lost
Global and regional health agencies have documented that social determinants of health, including income, education, housing, employment, and exposure to discrimination, contribute to large differences in life expectancy between and within countries (Pan American Health Organization [PAHO], 2025; WHO, 2025). Recent analyses highlight that, in some contexts, there can be more than 30 years of difference in life expectancy between populations that benefit from favorable social conditions and those that face concentrated disadvantage (United Nations, 2025; WHO, 2025). These differences are driven largely by conditions such as cardiovascular disease, cancers, maternal causes, and injuries that are sensitive to policy and system design, rather than by genetic variation (Braveman et al., 2017; PAHO, 2025).
For rural Black women in the American South, multiple social determinants often stack together. Many work in low wage, unstable jobs that do not provide health insurance, paid leave, or predictable schedules, making it difficult to attend appointments or follow up on abnormal results (Human Rights Watch, 2022; Mississippi Today, 2025). Schools in their communities may be underresourced, which shapes health literacy and economic opportunity over the life course (Braveman et al., 2017). Housing may be older and of poorer quality, and communities may face environmental hazards and limited access to healthy foods. On top of these material factors, Black women frequently encounter racism in health care and other institutions, leading to chronic stress and physiological “weathering” that contribute to worse outcomes in pregnancy, cancer, and chronic disease (Braveman et al., 2017; PAHO, 2025).
Gender norms further intensify these risks. Rural Black women often occupy roles as caregivers, wage earners, and community leaders, and they may feel pressure to prioritize the needs of children, partners, elders, and congregations over their own health (Word in Black, 2023). Cultural expectations of strength and self reliance can discourage help seeking and reinforce the idea that enduring pain or delaying care is part of being a “strong” woman. When they do present for care, they may encounter disbelief, minimization of symptoms, or fragmented services, which together contribute to later diagnoses and poorer outcomes (Human Rights Watch, 2022; Yale Law School, 2018). Intersectionality in this context is not simply a theoretical concept, but a way of describing how race, gender, and place converge to determine who experiences avoidable illness and early death.
A Radical, Unapologetic Call to Action
An adequate response to these patterns requires language that reflects their severity and action that goes beyond incremental adjustments. First, it is important to name what is happening as structural violence, rather than as unfortunate “disparities.” When states decline Medicaid expansion knowing that lack of coverage is associated with higher mortality from cancer and chronic disease, and when they allow maternity units to close in predominantly Black rural communities, they are making decisions that predictably increase preventable deaths in specific populations (Soni et al., 2021; Soni et al., 2025; Yale Law School, 2018). Using accurate terms clarifies that these outcomes are produced by systems, not by individual failures.
Second, expanding Medicaid in non-expansion states should be treated as a basic public health and racial justice priority. Evidence suggests that expansion can improve access to early diagnosis and treatment of cancers and can reduce mortality, particularly in communities with high poverty and limited resources (Soni et al., 2021; Zhao et al., 2022). In states that have already expanded coverage, advocacy can shift toward ensuring that reimbursement rates and workforce investments are sufficient to sustain primary care, obstetric, and oncology services in rural areas, so that insurance coverage translates into real access (American Journal of Managed Care, 2025; Word in Black, 2023).
Third, rebuilding care where it has been withdrawn is essential. This includes public investments to reopen or maintain maternity units, enhance community health centers, and support models such as midwifery, doula care, and mobile clinics that have shown promise in improving maternal and reproductive outcomes in marginalized communities (South Carolina Children’s Trust, 2025; Word in Black, 2023). Funding should prioritize Black-led clinics and community organizations that have longstanding relationships and accountability to rural communities, rather than concentrating resources in large institutions that are geographically distant or historically inaccessible.
Fourth, shifting power is as important as creating new programs. Rural Black women should have meaningful roles in governing health systems and shaping policy, including seats on hospital boards, health department advisory committees, and grantmaking bodies (PAHO, 2025; WHO, 2025). Approaches such as participatory budgeting can allow communities to decide how health funds are used, whether for transportation vouchers, telehealth infrastructure, local birth centers, or other priorities determined by residents. International and national frameworks on social determinants of health emphasize that reducing inequities requires redistributing power and resources, not only delivering services more efficiently (PAHO, 2025; WHO, 2025).
Fifth, confronting gender norms and patriarchy within health care and communities is necessary to protect Black women’s health. This involves challenging narratives that celebrate sacrifice and resilience while overlooking the costs to women’s bodies and lives. It also includes advocating for reproductive justice frameworks that encompass safe pregnancy and childbirth, cancer prevention and treatment, and chronic disease care, as well as contraception and abortion (Human Rights Watch, 2022; Yale Law School, 2018). Faith communities, workplaces, and social movements can play important roles by supporting Black women in prioritizing their own care, affirming their right to rest, and backing their demands for structural change.
Finally, individuals and institutions across sectors can use their positions to support this work. Clinicians can advocate for telehealth, flexible hours, and partnerships with community organizations to reduce barriers for rural patients. Researchers can design studies that return resources and decision making to the communities most affected and avoid reinforcing deficit-based narratives. Employers can provide paid time off, health insurance, and transportation support for low wage workers, not only for higher income employees. Each of these actions reflects a different side of the same principle: that Black women in rural Southern communities should not bear the cost of decisions they did not make.
Rural Black women are not experiencing higher rates of cervical cancer death and maternal mortality because they lack willpower or knowledge. They are living with the consequences of layered systems of racism, sexism, and neglect that have made their communities less safe and their lives shorter. A just response will require naming that reality clearly and acting as if those lives are nonnegotiable.
References
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Fibroids, reproductive health, and fertility care
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