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'Under the Skin' Charts the Steep Toll Racism Takes on the Black Body

“We’re the canaries in the coal mine as Black people,” said Linda Villarosa, whose reporting first put Black maternal mortality into the national conversation.

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Image: Doubleday/Nic Villarosa

When Simone Landrum gave birth in 2017, Linda Villarosa was there to observe as she endured instance after instance of thoughtless and even dangerous care from medical professionals. The anesthesiologist botched the epidural, leaving her with a severe headache and without feeling in her legs. Then, with her OB-GYN unavailable, a team of doctors Landrum had never met before delivered her infant, “taking turns between her legs without addressing her or looking her in the eye,” Villarosa later wrote. Despite all of this, it was a far better experience than Landrum’s prior delivery: Before, doctors had ignored her pain and high blood pressure, and she had nearly bled to death. Her daughter died, six weeks before she was supposed to be born.

What most of the medical practitioners who attended Landrum’s 2017 birth didn’t know, however, was that Villarosa was a writer for the New York Times Magazine. Her article about the treatment Landrum, a Black woman, was subjected to, which Villarosa used to illustrate the broader national crisis of Black maternal and infant mortality, appeared in the publication in 2018 and helped spark a national conversation. It’s just one of many stories of America’s Black health crisis that Villarosa tells in her new book, Under the Skin: The Hidden Toll of Racism on American Lives and the Health of Our Nation, which examines the myriad ways in which Black America’s health suffers under the nation’s racial caste system.

Originally, Villarosa intended to subtitle the book “Race, Inequality, and the Health of the Nation,” but instead decided to use a phrase that made the cause of all this unnecessary suffering and death abundantly clear. “While I was still writing this book, I wasn’t really willing to say ‘racism’ so in your face,” Villarosa told Jezebel via Zoom. “I changed it because I thought, ‘Why am I not saying exactly what it is?’”

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As the country continues to struggle with the pandemic and a mental health crisis, both of which have disproportionately affected people of color, Under the Skin maps the ways racial bias has shaped the health landscape for all Americans. “We’re the canaries in the coal mine as Black people,” Villarosa said. “We’re sounding the alarm to say, ‘This is what’s happening with us, but it can happen to anyone.’”

The statistics around Black maternal health are grim: Black women are more than three times more likely to die before, during, and after childbirth than their white counterparts. Class differences can’t explain this gulf—the maternal mortality rate of Black women with college degrees is higher than that of white women who didn’t finish high school. Black newborns are at increased risk of death as well, and are disproportionately likely to be born at a low weight. Though these stats about pregnancy and birth are now well-known, thanks in no small part to Villarosa’s reporting, the Black health gap is also stark in countless other arenas. Black Americans are twice as likely to die from heart disease, three times more likely to have a leg amputation due to diabetes, and more likely to report experiencing severe psychological distress. Black women, once targets of forcible government sterilization programs, still have their tubes tied at twice the rate of white women. Thanks to environmental racism, which finds landfills, coal-fired power plants, lead paint, and other pollutants disproportionately concentrated in Black communities, Black people are more likely to develop illnesses ranging from asthma, to covid, to certain cancers.

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Among the causes of these disparities are the physical effects of racism itself, which can exact a steep toll on the human body from the sheer hormone-disrupting stress of being subjected to repeated instances of discrimination. It’s a phenomenon that researcher Arline Geronimus dubbed “weathering.” “The effects of everyday racism, in her theory of weathering, create a kind of accelerated aging, or premature aging, on the Black body,” Villarosa, who served as an editor at Essence before joining the Times, said. This physical racial tax is likely a significant contributor to the fact that Black people are almost always at increased risk of death compared to their white age-group peers.

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Then there’s the healthcare provider bias. A 2016 study from the University of Virginia found that half of white medical students and residents surveyed believed at least one racist myth about people of African descent, such as, “Black people’s nerve endings are less sensitive than white people’s.” Forty percent of the first- and second-year med school students believed that Black people literally had thicker skin than whites. False beliefs like these, which have their roots in slavery-era scientific racism that theorized that Black people were uniquely hardy and resistant to pain, and therefore suited to punishing work and brutal treatment, can result in Black patients being misdiagnosed, mistreated, and having their pain disregarded.

During our interview, Villarosa described a 2019 study that examined the pain management care different races of women received at one North Carolina hospital. It found that Black and Hispanic women tended to receive lower doses of morphine and were less likely overall to be prescribed opioids than white women. “The study showed that the medical professionals thought white women needed more pain management,” Villarosa said. “Even when Black people had complained more of pain, they were given less. And that’s the idea that we have this high pain tolerance, or that we’re drug seeking.”

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In Under the Skin, she traces the long history of this kind of racism. In the 19th century, J. Marion Sims, who’d later be dubbed the “father of gynecology,” performed experimental vaginal surgeries on unanesthetized enslaved women. He operated on one 17-year-old girl 30 times before finally perfecting his procedure for repairing vaginal fistulae and using it on anesthetized white patients. Meanwhile, Mississippi doctor Samuel Cartwright theorized the existence of a mental illness that he called “drapetomania.” It was present only in Black people, and its defining feature was the desire to escape slavery. There are also many more recent examples in Under the Skin: During the Civil Rights era, Black men’s participation in protests was taken by some psychiatrists to cause schizophrenia, with doctors theorizing that they were suffering from “protest psychosis.”

It’s a disturbing history, but Villarosa also reports on efforts that may ameliorate the disparities. Many young nurses and doctors in training, members of a generation that came of age during the Black Lives Matter era, are advocating for changes at their colleges and med schools that, they hope, will help make health care providers more aware of the profession’s historic biases and make treatment like Landrum’s less common. Students “are working on the ground at their own medical schools to change their medical training and education,” Villarosa said, “which I find, really, a breath of fresh air.”

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Villarosa also highlights community health workers as a tool that, if deployed more widely, might help improve the healthcare access of the most marginalized Americans. Since the early 2000s, Ethiopia has trained tens of thousands of women to perform services like vaccinations, HIV prevention counseling, and prenatal care. Over the years, Villarosa writes in Under the Skin, the nation has cut its maternal mortality rate by more than half and child mortality rate by 69 percent.

“In other countries where there are fewer doctors and less medical technology, they rely more on people that are community health workers, especially in rural places,” Villarosa said. “We just don’t admit that many places in our country look like countries in Africa, or look like India and Latin America.”

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Since the pandemic, sub-Saharan African countries, some of which have deployed community health workers in the fight against covid, have achieved lower death rates than many nations with far more resources—including the U.S., where more than a million people have died. The pandemic that began in avowals that we were “all in this together” later saw Indigenous, Black, and Pacific Islander Americans perishing at far disproportionate rates. One study showed that, far from being galvanized to try to stop the spread of covid, white people instead cared less about the pandemic after being told that it particularly imperiled people of color.

During the early days of the vaccine rollout, the legacy of the Tuskegee experiment, which found federal researchers withholding life-saving treatment from 400 Black men infected with syphilis, was often invoked to explain vaccine hesitancy in the Black community. But Villarosa knew that Tuskegee was only the tip of the iceberg. “There’s been so much written about medical distrust. People were saying to me, ‘Oh, my God, that’s because of Tuskegee,’” she said. “I was like, ‘No, it isn’t. It’s because of what happened to people yesterday.”