On April 13, 2026, I arrived at the doctor’s office for a cardiac stress test. The technician, Josh, casually asked why I was even being tested. “You look too healthy to be here,” he said. I thought the same. Then the feeling I had previously experienced returned. The heat. The spasm. “I’m getting the symptoms,” I said. “I need to stop.”

We shifted to a pharmacological method of stress testing. But while I was resting afterward, the spasms returned along with a heaviness in my chest that would not subside. A technician called for Josh, who held my arm when I felt faint. And when my heart stopped, he was the one who kept me alive by performing CPR until the defibrillator could work its miracle.

I wouldn’t learn the full details of what happened until three weeks later, when the medical team felt I was ready to hear them. My heart had stopped for more than five minutes. I had no pulse. My breathing had become agonal. Josh administered two and a half rounds of chest compressions before the defibrillator could deliver its shock. For over five minutes, I was clinically dead.

The doctors found no structural cause. No electrical cause. No clean medical explanation. My body had survived what it should not have survived, and I was left with a question: If I have been spared, what for?

I have been thinking about what the heart carries.

Less than two months before I went into cardiac arrest, my dear friend Nyesha, an artist, organizer and advocate for environmental justice, died suddenly and unexpectedly. In doing so, she may have saved my life even after she was gone. Her death shifted something in me. It made me more attuned to my body, more willing to listen and more willing to act. 

Grief, stress, trauma, loss, disappointment and exhaustion accumulate in ways we cannot see. The hesitation before answering the phone. The tiredness that sleep does not touch. The strange loneliness of discovering that the places where you expected solidarity had become the places where you felt most alone.

In 1992, Dr. Arline Geronimus introduced the weathering hypothesis to describe how cumulative socioeconomic disadvantage can become embodied, contributing to premature deterioration in the health of African-American women. Her work gave public health the language for something many Black women had long understood in their bodies.

I am a public health scientist. I understand weathering. I cite the research. And still my own body was carrying what I had not fully named. As I reflected on my anatomy, I found myself asking another question: What is the physiological cost of leadership rooted in conviction?

When conviction repeatedly collides with institutions built for self-preservation, I have begun to ask what the body absorbs from that collision. The stress of refusing silence when silence is demanded. The stress of staying in rooms where your presence is managed rather than welcomed. The stress of watching narratives constructed about you that you cannot stop and can barely see forming.

Medicine can record the moment a heart stops. Weathering asks what was happening to that heart long before anyone attached the monitors.

As a public health leader, scientist and statewide elected official in Michigan, I have spent nearly three decades studying how chronic stress becomes embodied. I have also spent those decades living that stress, making the repeated decision to lead by conviction inside institutions not built for it.

These are not separate facts.

Like many of our mothers, my mother raised me to believe that as a Black woman, I had to be at least three times better than the next person. I followed that instruction faithfully. Chemical engineering degree. Master’s in public health. Doctorate in public health. A 14-year career building childhood lead-poisoning prevention programs in Saginaw, Michigan. 

My credentials did not lessen the obligation I felt to answer when communities called.

When leaders of the Democratic Women’s Caucus told me I needed to run for office and a colleague asked me to join her on the State Board of Education, I answered the call.

When Flint’s mayor asked me to help fight for families during the water crisis, I answered the call. When Detroit students asked the courts for something as fundamental as access to literacy, books, teachers and heat in winter, I stood with them even when doing so meant breaking with the legal position of the institution I served. When educators and parents faced efforts to erase history and make schools less safe for vulnerable children, I stood with them.

I cherished those moments of progress. But I also began noticing what speaking clearly could cost.

One of the clearest examples came in the summer of 2020. As the vice-presidential selection process intensified, national attention turned to Michigan Governor Gretchen Whitmer as a potential candidate. At the same time, Black women across the country were making clear that the moment called for something historic. Joe Biden had committed to selecting a woman, but Black women, long the most loyal base of the Democratic Party, believed the moment demanded more.

I wrote an op-ed arguing that Biden should select a Black woman as his running mate. The piece drew attention from Politico, CNN and other outlets. The response was swift. On the political talk show Off the Record, a panel discussed the column. No one denied the issues I raised, but the focus shifted to my criticism of the governor.

One panelist put it plainly. “Pamela Pugh, the vice chair of the State Board of Education, very forceful in the pushback against her own state governor. Basically, Black women in Michigan saying, ‘Joe Biden, do not pick Gretchen Whitmer.’” Another framed it this way. “You don’t go after your friend. You don’t go after an ally. And you don’t burn the bridge that you may have to cross one day down the line.”

There it was. The expectation that preserving relationships should outrank accountability.

I had not written the op-ed to burn a bridge. I wrote it because Black women deserved to be heard, deserved leaders with demonstrated qualifications and the courage to meet the moment, and because the selection of a vice president was too important for me to remain silent.

Biden ultimately selected Kamala Harris, a historic decision. But the lesson remained. Speaking clearly changes how you are seen, not only by opponents but also by allies. Support became conditional. Conversations became cautious. When the time came for re-nomination, I was told by party leadership that I might not be supported for another term on the State Board of Education.

We are expected to carry our communities with us as we pull up to decision-making tables. And I did. Every time. I chose principle over preservation. I stayed in rooms where decisions were being made about people who were not in them. I spoke when silence would have been safer. That choice has a name now: conviction-led leadership. And it has a cost that we have not yet fully measured.

Institutions often reward preservation. They reward those who protect existing relationships, positions and arrangements even when those arrangements no longer serve the people the institution exists to serve.

When conviction disrupts that equilibrium by demanding accountability, the response is not always overt hostility. Sometimes it is quieter. Conditional support. Managed unity. Narrative testing. The expectation that proximity to power should be mistaken for power itself. We are encouraged to mistake performative relationships for partnership and recognition for influence.

There is a physiological cost of conviction-led leadership, and Black women have been paying it for generations. At this moment, we are being asked to absorb more.

That burden is not confined to elected officeholders. Black women lead across public service, corporate America, philanthropy, education, faith institutions, advocacy organizations and communities. We carry a consciousness shaped by the people, communities and histories we bring with us.

In the aftermath of George Floyd’s murder, institutions across sectors created diversity offices, equity initiatives, advisory councils and leadership positions. For a moment, it seemed that the experiences, analysis and ideas Black women had been carrying for generations were finally being valued, not simply our labor, our turnout, our organizing or our ability to hold institutions together.

That opening has narrowed sharply. Commitments have been dismantled or abandoned. Positions have disappeared. Public-sector employment has contracted. Black women have been disproportionately affected. The Institute for Women’s Policy Research found that Black women experienced a net loss of 113,000 jobs during 2025. The Economic Policy Institute found one of the sharpest one-year declines in Black women’s employment in a quarter century, with particularly significant losses among college-educated and public-sector workers.

That matters beyond employment statistics. Black women can carry advanced credentials and still confront wage and wealth gaps. Many are both breadwinners and caregivers. We lead institutions while caring for children, parents, partners, congregations, neighborhoods and movements. We are asked to be resilient so often that resilience itself becomes another demand.

But here is what I have come to understand: The monitor recorded the moment my heart stopped. It could not record the years it spent carrying what could not be measured. My body kept a record long before I wrote one. 

Zora Neale Hurston once said, “If you are silent about your pain, they’ll kill you and say you enjoyed it.” Silence does not protect you. It protects the system that demands it. The heart carries more than we acknowledge. And sometimes it stops. Mine did. And then it started again.

I have learned that survival does not erase the pain. It changes your relationship to it. The pain did not take me. It gave me another opportunity.

We spend years fearing a pain that has already come. Then one day we realize we survived the thing we thought would destroy us. Different. Scarred. Changed. But still here.

Medicine eventually gave me a name for what happened inside my arteries: coronary artery spasm. I am grateful for that answer. But public health has taught me not to stop at the diagnosis. We must also ask about the conditions in which bodies live, work, lead, grieve, fight and survive.

I am not suggesting that conviction stopped my heart. I am asking whether we understand enough about what sustained conviction can cost a body already weathered by race, gender, responsibility, grief and institutional resistance.

That question matters because Black women are still being asked to carry extraordinary burdens while appearing extraordinarily capable of carrying them. I do not want us to stop leading with conviction. I want us to stop requiring leadership to mean carrying everything alone.

My heart stopped. My purpose did not. But survival has taught me that purpose needs protection too.

Pamela L. Pugh, Ph.D., is President of the Michigan State Board of Education and a public health leader specializing in environmental justice. She is the author of the upcoming book The Cost of Silence: A Witness and a Record.

Read the original article on Essence.