The writer: Olga Khazan
Date first published: July/August 2018
One morning this past September, Kiarra Boulware boarded the 26 bus to Baltimore’s Bon Secours Hospital, where she would seek help for the most urgent problem in her life: the 200-some excess pounds she carried on her 5-foot-2-inch frame. To Kiarra, the weight sometimes felt like a great burden, and at other times like just another fact of life. She had survived a childhood marred by death, drugs, and violence. She had recently gained control over her addiction to alcohol, which, last summer, had brought her to a residential recovery center in the city’s Sandtown neighborhood, made famous by the Freddie Gray protests in 2015. But she still struggled with binge eating—so much so that she would eat entire plates of quesadillas or mozzarella sticks in minutes.
As the bus rattled past rowhouses and corner stores, Kiarra told me she hadn’t yet received the Cpap breathing machine she needed for her sleep apnea. The extra fat seemed to constrict her airways while she slept, and a sleep study had shown that she stopped breathing 40 times an hour. She remembered one doctor saying, “I’m scared you’re going to die in your sleep.” In the haze of alcoholism, she’d never followed up on the test. Now doctors at Bon Secours were trying to order the machine for her, but insurance hurdles had gotten in the way.
Kiarra’s weight brought an assortment of old-person problems to her 27-year-old life: sleep apnea, diabetes, and menstrual dysregulation, which made her worry she would never have children. For a while, she’d ignored these issues. Day to day, her size mostly made it hard to shop for clothes. But the severity of her situation sank in when a diabetic friend had to have a toe amputated. Kiarra visited the woman in the hospital. She saw her tears and her red, bandaged foot, and resolved not to become an amputee herself.
Kiarra arrived at the hospital early and waited in the cafeteria. Bon Secours is one of several world-class hospitals in Baltimore. Another, Johns Hopkins Hospital, is in some respects the birthplace of modern American medicine, having invented everything from the medical residency to the surgical glove. But of course not even the best hospitals in America can keep you from getting sick in the first place.
It was lunchtime, but Kiarra didn’t have any cash—her job, working the front desk at the recovery center where she lived, paid a stipend of just $150 a week. When she did have money, she often sought comfort in fast food. But when her cash and food stamps ran out, she sometimes had what she called “hungry nights,” when she went to bed without having eaten anything all day.
When I’d first met Kiarra, a few months earlier, I’d been struck by how upbeat she seemed. Her recovery center—called Maryland Community Health Initiatives, but known in the neighborhood as Penn North—sits on a grimy street crowded with men selling drugs. Some of the center’s clients, fresh off their habits, seemed withdrawn, or even morose. Kiarra, though, had the bubbly demeanor of a student-council president.
Now, though, a much more anxious Kiarra sat before her doctor, a young white man named Tyler Gray, who began by advising Kiarra to get a Pap smear.
“Do we have to do it today?” she asked.
“Is there something you’re concerned about or nervous about?,” Gray asked.
“I don’t want to be fat,” she added, “but I don’t know how to not be fat.”Kiarra’s struggles with her weight are imbued with this sense, that getting thin is a mystery she might never solve, that diet secrets are literally secret. On a Sunday, she might diligently make a meal plan for the week, only to find herself reaching for Popeyes fried chicken by Wednesday. She blames herself for her poor health—as do many of the people I met in her community, where obesity, diabetes, and heart disease are ubiquitous. They said they’d made bad choices. They used food, and sometimes drugs, to soothe their pain. But these individual failings are only part of the picture.
In Baltimore, a 20-year gap in life expectancy exists between the city’s poor, largely African American neighborhoods and its wealthier, whiter areas. A baby born in Cheswolde, in Baltimore’s far-northwest corner, can expect to live until age 87. Nine miles away in Clifton-Berea, near where The Wire was filmed, the life expectancy is 67, roughly the same as that of Rwanda, and 12 years shorter than the American average. Similar disparities exist in other segregated cities, such as Philadelphia and Chicago.
Except in the case of a few specific ailments, such as nondiabetic kidney disease, scientists have largely failed to identify genetic differences that might explain racial health disparities. The major underlying causes, many scientists now believe, are social and environmental forces that affect African Americans more than most other groups.
To better understand how these forces work, I spent nearly a year reporting in Sandtown and other parts of Baltimore. What I found in Kiarra’s struggle was the story of how one person’s efforts to get better—imperfect as they may have been—were made vastly more difficult by a daunting series of obstacles. But it is also a bigger story, of how African Americans became stuck in profoundly unhealthy neighborhoods, and of how the legacy of racism can literally take years off their lives. Far from being a relic of the past, America’s racist and segregationist history continues to harm black people in the most intimate of ways—seeping into their lungs, their blood, even their DNA.
When Kiarra was a little girl, Baltimore was, as it is today, mired in violence, drugs, and poverty. In 1996, the city had the highest rate of drug-related emergency-room visits in the nation and one of the country’s highest homicide rates.
With her father in and out of jail for robbery and drug dealing, Kiarra and her mother, three siblings, and three cousins piled into her grandmother’s home. It was a joyous but chaotic household. Kiarra describes her grandmother as “God’s assistant”—a deeply religious woman who, despite a house bursting with hungry mouths, would still make an extra dinner for the addicts on the block. Kiarra’s mother, meanwhile, was “the hood princess,” a woman who would do her hair just to go to the grocery store. She was a teen mom, like her own mother had been.
Many facets of Kiarra’s youth—the fact that her parents weren’t together, her father’s incarceration, the guns on the corners—are what researchers consider “adverse childhood experiences,” stressful events early in life that can cause health problems in adulthood. An abnormally large proportion of the children in Baltimore—nearly a third—have two or more aces. People with four or more aces are seven times as likely to be alcoholics as people with no aces, and twice as likely to have heart disease. One study found that six or more aces can cut life expectancy by as much as 20 years. Kiarra had at least six.
She and others I interviewed recall the inner-city Baltimore of their youth fondly. Everyone lived crammed together with siblings and cousins, but people looked out for one another; neighbors hosted back-to-school cookouts every year, and people took pride in their homes. Kiarra ran around with the other kids on the block until her grandma called her in each night at 8 o’clock. She made the honor roll in fifth grade and got to speak in front of the whole class. She read novels by Sister Souljah and wrote short stories in longhand.
Yet Kiarra also describes some jarring incidents. When she was 8, she heard a loud bop bop bop outside and ran out to find her stepbrother lying in the street, dead. One friend died of asthma in middle school; another went to jail, then hanged himself. (Other people I spoke with around Penn North and other recovery facilities had similarly traumatic experiences. It seemed like every second person I met told me they had been molested as a child, and even more said their family members had struggled with addiction.)
Kiarra told me she got pregnant by a friend when she was 12, and gave birth to a boy when she was 13. Within a year, the baby died unexpectedly, and Kiarra was so traumatized that she ended up spending more than a month in a psychiatric hospital. When she came home, her boyfriend physically and sexually abused her. He “slapped me so hard, I was seeing stars,” she said.
She took solace in eating, a common refuge for victims of abuse. One 2013 study of thousands of women found that those who had been severely physically or sexually abused as children had nearly double the risk of food addiction. Kiarra ate “everything, anything,” she said, “mostly bad foods, junk food, pizza,” along with chicken boxes—the fried-chicken-and-fries combos slung by Baltimore’s carryout joints.
At first, she thought the extra weight looked good on her. Then she started feeling fat. Eventually, she said, “it was like, Fuck it. I’m fat.” As her high-school graduation approached, she tried on the white gown she’d bought just weeks earlier and realized that it was already too tight.
Kiarra didn’t know many college-educated people, but she wanted to go to Spelman, a historically black college in Georgia, and join a sorority. Her family talked her out of applying, she said. Instead, she enrolled in one local college after another, but she kept dropping out, sometimes to help her siblings with their children and other times because she simply lost interest. After accumulating $30,000 in student loans, she had only a year’s worth of credits.
So Kiarra put college on hold and worked at Kmart and as a home health aide—solid jobs but, as she likes to say, “not my ceiling.” She longed for a purpose. Sometimes, she had an inkling that she was meant to be an important person; she would picture herself giving a speech to an auditorium full of people. But she remained depressed, stuck, and, increasingly, obese.
She began doing ecstasy, and, later, downing a pint of vodka a day. She remembers coming to her home-health-aide job drunk one time and leaving a patient on the toilet. “Did you forget me?” the woman asked, half an hour later. Kiarra broke down crying.
Soon after, she checked into Penn North for her first try at recovery. This past year’s attempt is her third.