‘Under the Skin’ examines racism as a public health emergency

Linda Villarosa studies how ‘the lived experience of being Black in America’ can make people sick.

Linda Villarosa writes for The New York Times Magazine and teaches at the City University of New York.Nic Villarosa

When she became pregnant with her daughter in 1996, Linda Villarosa had recently been promoted from health editor to executive editor of Essence magazine. (She now writes for The New York Times Magazine, where she was a contributor to the 1619 Project, and teaches journalism at the City University of New York.) Villarosa led an extremely healthy lifestyle, from diet to exercise to hydration — “I was a role model for Black women’s health and wellness,” she writes — and she had access to excellent health insurance and financial resources unavailable to many Americans. Still, she was diagnosed with intrauterine growth restriction, had her labor induced a month before her due date, and gave birth to a baby weighing under 5 pounds.

As Villarosa recounts in her gripping, incisive new book, “Under the Skin,” researchers have long been aware that Black mothers are more likely than white mothers to bear low-birthweight babies, to die in childbirth, and to give birth to children who die before their first birthdays. Her personal story quietly hums underneath the experiences and individuals she reports on throughout the book, from the teenage sisters who were forcibly sterilized in Alabama, to a North Carolina woman whose brain cancer can be traced to the polluted pond in which she swam as a child, to a Massachusetts man killed by police during an episode of acute mental illness. What binds their stories together is the recurrence of racial discrepancies in health risk factors, diagnoses, treatments, and outcomes.

How, in a country that touts its wealth and health care supremacy, to account for this level of unequal outcomes?

For ages, two explanations prevailed. One, which has been thoroughly, scientifically discredited but that still lingers in medical education and care standards, is that there is something genetically different about Black bodies. These theories, invented during slavery, are often difficult to read about — Thomas Jefferson’s description of enslaved people made my lip curl. Many of the ideas about Black inferiority, disgustingly, seek to excuse white people’s cruel treatment of enslaved people, as when Jefferson wrote of Black people, “their griefs are transient.” Such beliefs (or excuses) led to not only unequal care but often to Black people being used by white doctors as test subjects in gruesome experiments, Villarosa points out. The Tuskegee syphilis study is only the most famous of these, but it’s hardly an outlier: Villarosa writes of Dr. J. Marion Sims, who “practiced painful surgeries without anesthesia on enslaved women” in Alabama, using their unconsenting bodies to work out a complex surgery before trying it on white women.

“For centuries, white physicians and scientists went to great lengths to prove that Black people were biologically and physiologically different from white people,” Villarosa writes, and some of their theories, while ludicrous, still find their way into today’s medical profession. She cites a 2016 University of Virginia study that found half of surveyed medical students believed one or more debunked racial stereotypes, including that Black people feel less pain than white people, or that Black people’s skin is thicker — ideas born in our antebellum past.

Among those too sophisticated to fall for the Jeffersonian view of race differences, another explanation for medical inequality holds sway. This theory, which Villarosa writes that she once believed herself, argues that poor outcomes for Black patients could be accounted for because Black people tend to have lower income, wealth, and access to health care than white people. “Something began to shift,” she writes, when she talked with Dr. Harold Freeman, of Harlem Hospital, who had recently published a study showing that, “even as life expectancy was rising in the United States for people of all races, Black men in Harlem lived fewer years than their counterparts in the impoverished country of Bangladesh.” Freeman reminded her that Harlem is economically diverse — not all the Black men studied were poor or working-class — and cautioned Villarosa to look deeper.

As she digs into the research, Villarosa finds her own attitude shifting away from the narrative that poor Black people suffer bad health outcomes only because of poverty or their own life choices. In “Under the Skin,” she deftly pivots between individual cases — like Serena Williams, by any measure a privileged patient, having to advocate for herself during a series of postpartum medical crises — and studies that demonstrate the widespread obstacles in seeking equal health care for Black people.

Implicit bias within the medical community is part of the issue, of course, but as scientists are beginning to understand and measure, Villarosa writes, “the lived experience of being Black in America, regardless of income and education, also affects health.” Perhaps the most intriguing theory is one put forth by Arline Geronimus, a professor of public health at the University of Michigan, who argues that “coping from fighting against racism leads to chronic stress that can trigger premature aging and poor health outcomes.” A project called the Black Women’s Health Study at Boston University “showed higher levels of diabetes, obesity, asthma, and preterm birth among women who reported the greatest experiences of racism.”

“I have long understood that something about being Black has led to the documented poor health of Black Americans,” Villarosa writes. We know it’s not genetic or biological; research shows that it’s not purely economic. With the authority of long experience, both professional and personal, Villarosa concludes, “the something is racism.”

UNDER THE SKIN: The Hidden Toll of Racism on American Lives and on the Health of Our Nation

By Linda Villarosa

Doubleday, 288 pages, $30