What It Costs
On Power, Structural Racism, and the Real Price of Building While Black and Female in Medicine
Part One: The Gunman in the Room
Let me start with the thing that is obvious once you see it, and invisible until you do.
Black maternal mortality in the United States is not a medical problem. It is a power problem.
And that distinction is everything.
I know what you’re thinking. You’re thinking this is where the essay turns political. Where it becomes about race as ideology, about systems as theory, about fighting injustice as moral imperative. I understand why you’d think that. But I want to offer you something different — the view from an engineer who also happens to be a physician. The view from someone trained to deconstruct complex problems into their most basic components. The view from someone who looked at enough data, enough patterns, enough trends, until something undeniable surfaced.
Here is what that data says.
In a modern American medical system, an intraabdominal hemorrhage progressing over 12 hours to a patient’s death should be impossible. There are protocols. There are tools. There are trained professionals. There are multiple layers of protection built specifically to prevent this outcome. And yet it happens. Women die of complications that medicine knows how to treat. They die with the intervention sitting unused, down the hall, within reach. They die in hospitals with every technology and credential required to save them.
How does that happen?
Think about a firefighter standing in front of a burning house. He has a hose. He has training. He knows exactly what to do. And he refuses to use the hose. He just stands there and watches the house burn and does not deploy what is in his hands.
That is what sending a woman home with the worst headache of her life looks like. The brain scan exists. The neurologist is down the hall. The protocol is unambiguous. And she went home. Not because medicine failed. Because a human being standing inside a system with every resource available made a calculation — conscious or not — that her urgency was negotiable.
That is not a monitoring problem. That is not a blood pressure app problem. The woman dying today is not the woman with slightly elevated readings at home who got missed on a screening. The woman dying today came to the emergency room and was sent away. She is the one the system saw and dismissed.
Power asymmetry is not a theoretical concern. It is not a talking point. It is a clinical variable. And it is lethal.
Now here is the data point that closes every other argument: a wealthy Black woman and a poor Black woman die in childbirth at rates that converge. Serena Williams. Beyoncé. Women with every resource, every advocate, every credential, every dollar — and still, the story is the same. When socioeconomic status, education, institutional access, and personal wealth all fail to explain a disparity, you have isolated the variable. You have found the thing that money cannot buy out of, that credentials cannot protect against, that excellence cannot override.
That variable is structural racism. Not racism as personal prejudice — racism as a systemic orientation of the medical institution toward some bodies and away from others. An orientation so deep that it overrides the protocols, the training, the tools, and the explicit oath that physicians take. An orientation that does not yield even to Beyoncé.
Once you see that clearly, the implications for what a solution must look like are equally clear.
We have been investing — hundreds of millions, soon billions — in maternal health technologies premised on the idea that the problem is medical. Blood pressure monitors. Remote monitoring platforms. Prenatal apps. Postpartum check-in tools. These are not wrong. They will help on the margins. And I want to be clear: I want those companies to succeed. I want to live in a world where maternal health innovation is the frontier we’re all working on together. But we cannot get there yet. Because those solutions are sequenced incorrectly. They are downstream of a problem they cannot reach.
You cannot innovate around a gunman. You have to remove him first.
Imagine you are about to perform surgery, and there is someone with a weapon in the room. You can have the best hands in the world. You can have the right tools, the right team, the right protocol.
None of it activates until the gunman is gone.
You do not work around him. You do not upgrade the surgical suite. You get him out. Then the medicine can do its job. That logic — the logic of sequencing, of identifying the actual limiting factor before optimizing everything downstream of it — is what engineers do. It is what I did. And the answer it produced is not comfortable, but it is correct.
Diosa Ara exists to get the gunman out.
What we build is emergency obstetrical infrastructure — not telehealth, not a clinic on a screen, but a coordinated system that arrives at the moment of crisis and rebalances the power equation in real time. An OB as team leader. MFM consultation immediately available. Legal advocacy embedded in the care model. Doulas on the ground. Clinical and institutional authority, deployed at the precise moment when the system is most likely to fail the patient.
Think of it this way:
Imagine a Black man being pulled over. His rights are being violated. He is alone against the full institutional weight of the state. What does he need in that moment? Not an essay. Not a think piece. Not a policy proposal. He needs a lawyer to materialize at his window and say, clearly, with the full weight of consequence: if you do not stop, there will be legal action, and I will make you pay. That presence — institutional, credentialed, ready — is what changes the calculus of the person holding the power. That is what we are. In the delivery room. At the moment the system looks at a Black woman and decides, consciously or not, that her urgency is negotiable.
The hypothesis — confirmed by the literature and by every preventable death — is this: the power asymmetry is what leads to the danger. The medicine exists. The tools exist. The protocols exist. None of it deploys reliably for a patient whose suffering the system does not register as real. We are not here to debate that. We are here to close the gap.
We know 84% of pregnancy-related deaths in the United States are deemed preventable. We know 117 rural labor and delivery units have closed since 2020 — two every month. We know the United States has the highest maternal mortality rate of any wealthy nation, nearly double the OECD average, and Black women die at 3.2 times the rate of White women regardless of ZIP code, income, or education.
This is not a failure of medical innovation. This is a system doing what systems do when the power asymmetry goes unchallenged. The trillion dollars flowing toward maternal health technology will not produce what it should until someone addresses what none of it can reach. That is what we are here to do.
This is not ideology. This is engineering logic applied to a medical crisis. The answer was always there in the data. It just required someone willing to follow it to its conclusion without flinching.
Part Two: Why I Can Say This 🔓
Before I go further, I need to name something that almost no leader with institutional backing will say — because institutional backing changes the risk calculus, and changed risk calculus produces censored truth.
Once you have something to protect — funding, board relationships, a reputation built over decades — there is an internal calculation that runs before every public statement: what will this cost me? That calculation is rational. It is also the reason most leadership thinking is safe. It resonates but doesn’t cut. It has been polished into something that offends no one and therefore changes nothing.
I do not have that problem. Not because I’m brave in some abstract sense, but because I have already been through the fire. I have already lost the things that were supposed to protect me, and I am still here. That experience — surviving what should not be survivable and converting it into something useful — is the source of whatever clarity I have. The freedom to say exactly what is in the room exists precisely because I have nothing left to protect by hiding it.
This is also why I write. Why I publish. Why I am building a leadership framework in public, through the Labora Collective, in real time.
Here is the thing about operating outside the existing frameworks: you become illegible. Elon Musk can be intelligible to people even when he does things that are morally reprehensible, because he exists inside a framework that already has cultural currency. The demanding CEO. The relentless builder. The visionary who doesn’t tolerate mediocrity. People can slot that archetype into a category. They can disagree with it, they can be harmed by it, they can write op-eds about it — but they can read it. The behavior maps onto something they already have a name for.
I exist outside that framework. The behavior is often identical — the standards, the pace, the demand, the devotion. But there is no pre-existing cultural category that makes a Black woman founder’s version of that legible. So it reads as difficult. As too much. As something that needs to be explained, softened, justified.
The writing is my solution to a problem that Elon never had to solve. He didn’t need to publish an essay explaining why he expects everything from his team. The framework already existed. I am building the framework from scratch, in public, in real time, so that the people who enter this company can understand the belief system they are entering. Not to justify myself. Not to manage my reputation. To create the cultural infrastructure that makes my leadership readable — so that the people who would thrive here can recognize themselves in it before they arrive, and the people who wouldn’t can know that too.
This is radical transparency as strategy. Not as vulnerability. Not as confession. As competitive advantage.
And the competitive advantage is real. What we have that cannot be reconstructed — what no one can steal by reading this essay and copying the recipe — is not a technology or a process. It is the specific accumulation of this: MD, PhD, Black woman, this moment in medicine, this particular anger at systems that have failed the people I love, this particular capacity to see the problem clearly because I have been the patient. You cannot reconstruct that. It is inherently, inseparably built from my direct set of experiences. The more visible I make those experiences, the more legible the company becomes — and the more impossible it is to replicate without having lived what I have lived.
That is why I open up. That is what the writing is for.
Part Three: What It Costs to Build This 🩺
Three years. Self-funded. No venture capital. No institutional backing. No safety net. Building on call. Building post-shift. Building while managing a team, reviewing strategy, onboarding people, rebuilding what breaks, and grieving what doesn’t work.
From the outside, it looks like freedom. A founder who says exactly what she thinks. A mission that matters. A boss who, when there’s a family emergency, says go — and means it. A leader who doesn’t cheat you, doesn’t disappear on you, doesn’t treat you like a line item on a spreadsheet.
All of that is true. Every word of it.
But here is what you don’t see from the outside. You don’t see the call rooms — the ones where I’ve finished an overnight shift, still in the hospital, dead tired, and I’m getting on a 6 AM team call because the work doesn’t stop just because my body needs rest. You don’t see the extra shifts I’ve taken — work I didn’t have to take, hours I didn’t have to give — because someone on my team needed to stay paid while we figured out the next revenue milestone. You don’t see the nights I’ve spent not sleeping, not because I’m disorganized, but because I am running at maximum efficiency, using every tool, every leverage point, every hour I have, and it is still not enough hours in the day.
You don’t see me crying in a call room. Alone. So no one else has to carry it.
I want to be honest about what this looks like from the inside. Not because I want sympathy, and not because I want to perform struggle for credibility. But because there are people who look at what we’re building and ask: how does she do it? Like there is a secret. Like there is a quality I have that they lack, some reservoir they haven’t found yet.
There isn’t a secret. What I have is a specific discipline I learned the hard way, and I want to name it clearly.
I have bad days. I lose afternoons to what I can only call a negativity spiral — the feeling that everything is impossible, that the system always wins, that nothing will be enough. That feeling comes. I know it intimately. What I have learned — not innately, but through years of being forced to learn it — is how to pick myself up and use that experience as fuel for the next thing. Not just recover. Convert. The spiral becomes the engine. The energy has to go somewhere, and I have learned over time to aim it at the work rather than let it settle into my body as something that kills me slowly.
I know this because Diosa Ara itself was built inside a spiral. An institution that should have protected me — one I came to with every credential, every protection, every qualification a person can assemble — dismantled what I had built there with a thoroughness that most people would not believe possible without something catastrophic on my part. That is the particular cruelty of institutional power when it turns against you: it does things that should not be possible, and it does them so quietly that the person on the receiving end can barely find language for what happened.
That is also what it feels like to be the husband on the floor of the delivery room. To have done everything right. To be screaming into a system that will not respond.
I did not build Diosa Ara from an academic interest in maternal health. I built it because I know — in my body — what it feels like when a system that should protect you turns against you instead.
When you have every armor a person can assemble, and none of it is enough. I survived that. And I converted it. The diagnostic tool it gave me — I know exactly what this woman needs, because I have been this woman — is the foundation of everything we do.
The Tax 💸
There is a concept called the authority gap — documented by journalist Mary Ann Sieghart and rooted in decades of psychology research. [1] It describes the distance between being granted authority and having that authority felt by the people around you. Female Supreme Court justices are interrupted four times more often than male justices, 96% of the time by men. [2] Women are 30% less likely to be called for a job interview than an identically qualified man. [8]
But those numbers describe the gap from the outside. What it feels like from the inside is this: your title is acknowledged and your authority is not. People can say the words “you’re the CEO” and still, in their bodies, in their reflexes, in how they move through a room — not register what those words mean.
This is what psychologists Alice Eagly and Steven Karau documented in 2002 as Role Congruity Theory: the perceived incongruity between the female gender role (warm, communal, accommodating) and the leader role (assertive, decisive, directive) produces prejudice in two directions. Women are perceived less favorably as leaders, and identical leadership behavior is evaluated more negatively when enacted by a woman. Butler and Geis demonstrated in 1990 that both male and female subordinates displayed more negative nonverbal affect toward female leaders showing identical behaviors to male leaders. The authority is intellectually present. The body doesn’t comply. [3, 4]
For Black women, the compounding is multiplicative, not additive. Rosette and Livingston’s research established “double jeopardy” — Black women leaders are evaluated more harshly than any other group under conditions of organizational difficulty. The margin for error is functionally zero. [18] And as Bertrand and Mullainathan demonstrated, a White-sounding name on a resume receives 50% more callbacks than an identical Black-sounding name — the equivalent advantage of eight extra years of experience. [7]
Let me be concrete about what this means in practice: when those same qualities — the relentlessness, the precision, the refusal to accept preventable death as acceptable — are visible in a White man in a corner office with a term sheet, they are remarkable. They are studied. They generate Harvard Business Review profiles and keynotes and books about visionary leadership. In me, right now, they are expected. Dismissed. Or worse — met with well, that’s just how she is. The same traits that would generate admiration in one body generate eye rolls, or HR complaints, or feedback about my leadership style, in mine. The invisibility of Black women’s excellence is its own specific punishment — separate from and in addition to everything else.
This is what Catalyst calls the Emotional Tax — documented in 2016 by Travis, Thorpe-Moscon, and McCluney. More than half of Black women in professional settings report constant vigilance at work: monitoring others’ perceptions, anticipating responses, managing how they are read in real time. This vigilance consumes cognitive bandwidth. It is bandwidth that white male counterparts spend on the actual work. It is what sociologist Arlie Hochschild called emotional labor — except that for Black women it is not optional and it is not compensated. [9, 10]
What this means practically: building this company, in my body, costs more than the same work would cost someone else. Not metaphorically. Structurally. I pay a tax that does not appear on any ledger and is not factored into any projection. Naming that is not complaint. It is accounting.
The Double Bind ⚖️
Here is the mechanism that makes this particular form of leadership so costly.
Catalyst’s Double-Bind Dilemma for Women in Leadership (2007) names it precisely: women are expected to be communal and warm, but leadership requires assertiveness. Be communal — you’re overlooked as weak. Be assertive — you’re penalized as cold. There is no path through that doesn’t extract something. [5]
Brescoll and Uhlmann demonstrated in 2008 that men who expressed anger in professional contexts were conferred higher status. Women expressing identical anger were conferred lower status — by both men and women. An angry female CEO in their study was assigned an average salary of $32,902. An unemotional woman: $55,384. Men: $73,643, regardless of how they expressed themselves. [6]
The feedback that women in leadership receive most often is not about the work. It is about the experience of working with them — style, tone, intensity, approachability. It is feedback about the cost of working for a woman who refuses to perform her gender while also performing her authority.
Here is something almost never said aloud: most feedback is not given for the recipient’s benefit. It is given for the giver’s benefit — to feel heard, to feel powerful, to assert that their perception is valid, to reframe a situation in their favor. Real feedback — the kind that actually changes someone — can only come from someone who genuinely loves you enough to spend their own limited emotional capital on your growth. Everyone else is editorializing. [20, 21]
No one asks Elon Musk if he’s open to feedback about his leadership style. No one asked Jeff Bezos to be more emotionally available.
The threshold at which a leader’s authority becomes a subject for public commentary is dramatically lower for women, and lower still for Black women. And when a woman leader does not accept the unsolicited feedback being offered — when she names it as editorial rather than developmental — the response is often fury. The entitlement to give feedback and have it received is itself an expression of the authority gap. People pitch fits when their feedback isn’t accepted because they have confused “I have an opinion about how you lead” with “you are obligated to incorporate my opinion.” Those are not the same thing. Not even close.
What I have to say back is this: tomorrow I will wake up and still run this company. Diosa Ara will still exist or not exist based on decisions I make. And the one truth that cannot be missed — the one thing that has no margin — is that this company only exists as long as I am able to show up for it. If I burn out accommodating everyone’s feedback, there is no company. If I deplete myself trying to become someone’s idea of a more palatable leader, there is no infrastructure. There is no one getting the gunman out of the room. That is not ego. That is structural reality. Protecting my capacity is the most mission-critical decision I make.
The Name for What This Does to You 🧠
When women describe the cumulative effect of this — the tax, the bind, the credibility deficit, the unsolicited correction — they almost always reach for the same word: burnout.
It is the wrong word. Burnout locates the problem in the individual’s failure to manage stress. It does not name the structure producing the injury.
Psychiatrists Wendy Dean and Simon Talbot argued in 2018 that physicians are not burning out — they are experiencing moral injury: a betrayal of what is right, by someone in legitimate authority, in a high-stakes situation. The wound comes not from working too hard but from being prevented from doing what you know is right by a system that overrides your judgment. [14]
Philosopher Miranda Fricker named epistemic injustice — the experience of having your knowledge dismissed because of who you are, and the gap in collective language precise enough to name what is being done to you. [15]
Dr. William A. Smith coined racial battle fatigue — the cumulative physiological and psychological toll of navigating racially hostile environments: chronic anxiety, elevated blood pressure, suppressed immunity, insomnia, depression. A systemic racism-related repetitive stress injury. [13]
Dr. Arline Geronimus spent decades documenting weathering — the biological aging that results from carrying chronic stress inside racist structures. Her research found Black women’s bodies in each age group match the biological age of White women a decade older. Wealth did not protect against it. Education did not protect against it. The cells keep the score. [11, 12]
Dr. Cheryl Woods-Giscombé named the Superwoman Schema — the obligation to manifest strength, suppress emotion, resist vulnerability, and prioritize others’ needs before your own regardless of personal cost. Sherman James named John Henryism — the strategy of working harder and harder against structural obstacles. It improves mental outcomes. It exacts cardiovascular damage. The body eventually presents the bill. [16, 17]
What all of these frameworks share: what is being described is not a personal failure. It is a predictable, documented, physiological and psychological response to systems that were not designed for the authority of a Black woman. Naming it is not self-pity. Naming it is precision.
I name it here because there are women reading this who have called it burnout and wondered what was wrong with them. Nothing is wrong with you. You are responding correctly to an environment designed to extract more than it returns. The question is not how to carry less. The question is whether you can learn to convert what you carry — to aim the energy somewhere rather than let it settle into your body as disease.
That conversion is the discipline I have learned. Not chosen. Learned. It is painful and unglamorous and required. And it is what happens when the MD/PhD selects for something that most people don’t fully understand: the trained capacity for delayed gratification. The ability to go years without external signs that things are working and keep moving anyway. That is a mental discipline of the highest order. It is also the thing that makes this company possible.
The Line 🚧
There is a difference between a hard boss and an abusive one. I have lived on both sides of this and I want to name it clearly.
A hard boss has high standards. Moves fast. Requires full commitment. Does not apologize for the pace or the pressure. That’s me. I own that completely.
An abusive boss uses their power to strip you of your basic humanity. Your dignity. Your body. Your right to exist as a full person inside the work. I have experienced that kind. I know exactly where the line is. And I have never asked anyone on my team to cross it. I will not ask you to sacrifice your children. I will not ask you to disappear your human needs in service of mine. When I say I need your full commitment, I mean your professional full commitment — your focus, your presence, your dedication to this mission. I do not mean your soul.
That distinction matters. I hold it carefully.
Part Four: The Bargain 🤝
Here is what I am offering you, honestly.
I will care about you. Genuinely, not performatively. When something happens in your life, I will be a human being about it. I will not cheat you. I will not disappear on you. I will show up — at 6 AM, post-call, exhausted, still showing up — because that is who I am and I do not know how to be different.
What I need from you in return is complete devotion to the work.
Not perfection. Devotion. The kind that means when your CEO is on a call with something important to share, you don’t make a calculation about whether it’s the best use of your time. You show up. Fully. The kind that means when your boss is in a call room somewhere dead tired at 6 AM and has an exciting update, you don’t just decide it’s not efficient use of your time. You know what that means. You feel what that means. And you respond accordingly. Because emotional intelligence — the real kind, the kind that changes outcomes — is the ability to see what’s happening in another person and let it inform how you move. That skill is as bidirectional as any other. It is not just what I owe you. It is what you owe the work.
The women on my team understand this without being told. They understand it the way women have always understood people management — baked in, instinctive, operated without a handbook, like knowing that when someone is completely dysregulated you don’t explain fairness. You meet the nervous system where it is. Adults are no different from children in this way. They just have better vocabulary for hiding it.
These two things — my generosity and my demands — are not separable. They live in the same body. They come from the same source. You cannot have one without the other, because I am not a corporation with warmth in one department and expectations in another. I am one person, all in. I need people around me who are the same.
Some people have left this team and gone out into the market and discovered what I already knew: most CEOs do not treat you the way I treat you. Out there, you are a line item. Most employers do not lose sleep over whether you are okay. Most jobs do not offer grace for family emergencies or invest in you as a human being alongside your work. People come back humbled by the gap between what they expected and what they found. I am not saying this to hold it over anyone. I am saying it because the bargain is real and rare — and it requires something real and rare in return.
Part Five: What Will Be Written ✍🏾
This company will not always require everything. I do not want to be CEO forever. The MD/PhD selects for delayed gratification — the ability to go years without signs that things are working and keep moving anyway. But the CEO role, the weight of decisions about people’s livelihoods, the full operational accountability — that is not my nature and I am honest about it. My goal is to build Diosa Ara to the point where I can bring in a professional CEO built for scale and hand that weight to someone made for it. And step into what I actually am: the clinical mind, the visionary, the voice, the founder who built this and is now free to deepen it. The CMO. That day is coming. But it is not today. Today is the work.
Someday — and I believe this completely — this period will be studied. Not just the company. The way it was built. Self-funded, by a Black woman physician-engineer, over three years, without institutional backing, in the middle of a maternal health crisis the establishment had been watching accelerate for decades without naming its cause.
The solution was not a new technology. It was a reframing: this is a power problem, not a medical problem. You cannot innovate around a gunman. You have to remove him first.
The call rooms. The 6 AM scrums. The tax paid daily in increments invisible to everyone except the body keeping score. The spiral converted to fuel, again and again, because stopping was not an option. The boss who was simultaneously the most demanding person in the room and the one most likely to lose sleep over whether you were okay.
If these same qualities were visible in a White man in a corner office with a term sheet, they would already be in a case study. In a keynote. In a book about visionary leadership. In me, right now, they look like too much.
I am not asking you to agree that this is unfair. I am asking you to sit with the fact that it is true. And then, if you’re still here, I am asking you to join us.
The data is unambiguous. The hypothesis has been proven by every preventable death, every closed labor unit, every woman sent home with the worst headache of her life, every husband on the floor of a delivery room that had every tool required to save his wife and didn’t use them.
We are here to get the gunman out. We are here because the power asymmetry is lethal — not theoretically, not morally, but clinically, measurably, in bodies, in cells, in deaths that should have been impossible.
Everything else follows from that.
If that’s you — come.
This essay is the first in a series. Each piece that follows takes one argument made here and builds it out fully.
The Gunman in the Room — the system, the power asymmetry, and why this is engineering logic applied to a medical crisis, not ideology.
The Tax — what the research actually calls what you have been carrying, and why precision about the cost changes what you can do about it.
The Well — capacity accounting, feedback as dominance behavior, and why protecting your bandwidth is the most mission-critical decision you make.
The Conversion — where Diosa Ara came from, what productive resilience actually is, and why the spiral is not the enemy.
Why I Can Say This — radical transparency as competitive strategy, the legibility gap, and what becomes possible when you stop protecting a position you were never going to be protected in.
If this landed with, the next one will too.
References
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Dr. Yamicia Connor, MD, PhD, MPH
Founder & CEO, Diosa Ara | Creator & Editor-in-Chief, The Labora Collective
The Labora Collective publishes at the intersection of clinical care, policy, and innovation — because only 10% of your health outcomes come from the exam room. The other 90% is what we cover.
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