When I started my intern year, that is my first year of training in medical residency, I noticed something peculiar about the epidemiology of disease in our hospital. The Black patients on the medical wards would often present with the morbidity of their diseases almost ten to twenty years earlier than their white counterparts. A Black person with leg swelling and shortness of breath who presented with advanced heart failure would be in their sixties, whereas a white person with the same symptoms would be in their eighties. Of course, my observations are anecdotal, the n is not high enough to constitute evidence, and one person’s perception does not constitute reality.
Still, those individual observations and patient experiences may represent a few dots on a stipple drawing. Each patient and their experience are integral to the larger whole. Rather than dismissed as anecdotal, they should be both highlighted for their individuality and aggregated to form a cohesive and complete narrative. In her book, Under the Skin, journalist Linda Villarosa does just that. Specifically, she demonstrates how racism at both a systemic and local level affect Black people, causing them to “live sicker and die quicker.”
Villarosa is no stranger to the intersection of race, health, and inequality. She began her career writing for Essence, where she served as executive editor, and published numerous award-winning articles. She went on to work as the health editor for the New York Times. Her illustrious writing career includes seminal pieces on reproductive inequality for Black mothers and babies, the toll of the HIV epidemic on Black lives, and the disproportionate and unequal effects of pollution, among many other critical and insightful pieces.
Under the Skin covers these topics and many others. The book opens with Villarosa’s turn from her own previous misconceptions on race and health. The year is 1991 and Villarosa is in her Harvard journalism fellowship, attending a lecture by Dr. Harold Freeman, the director of surgery at Harlem Hospital and co-author of groundbreaking article, “Excess Mortality in Harlem,” published in the New England Journal of Medicine. When she questions that the racial inequities described are a result of poverty, Dr. Freeman looks her straight in the eye and says, “If you really care about these issues and want to make a difference, you must not use race as a proxy for poverty or poverty as a proxy for race … Look deeper, think differently.” And look deeper is exactly what she does.
At its core, Under the Skin takes the reader through a journey where racial health inequities are not solely attributed to poverty. Certainly, poverty plays a role, but there is something deeper. There is an inherent flaw in the system that cannot be fixed with money. While the claim seems bold on the surface, Villarosa provides a plethora of evidence through her meticulous research.
The book follows Black lives from birth to death and demonstrates the injustices throughout. Even when income, education, and access to health care are matched, African Americans remain disadvantaged. For example, college-educated Black mothers are more likely to die, almost die, or lose their babies compared with white mothers who haven’t finished high school. Court cases and media, as recently as the 1970s, have unearthed an estimated 100,000 to 150,000 poor, mostly Black women sterilized each year in the U.S. under federally funded programs. Aside from reproduction, during their lives, African Americans are 75 percent more likely than the average American to live in so-called fence-line communities, that is, areas near facilities that emit hazardous waste.
Through nearly 300 pages of detailed research, Villarosa enumerates the many aspects of living in the U.S. that harm African American health. She explains the concept of weathering, first introduced by scholar Arline Geronimus, in which struggling against discrimination routinely frays a person’s mental and physical health. Black women, for instance, suffered the highest “allostatic load” scores – a measure using a set of biomarkers, such as blood pressure, heart rate, cholesterol, and body mass index, that become disrupted when the body releases hormones in the face of sustained stress. Such stress may manifest in lower birth weight for Black infants. Disheartening statistics show that infants born to college-educated Black parents were twice as likely to die as infants born of similarly educated white parents.
Under the Skin is unflinching in its analysis on the impact of race on health. Through Villarosa’s grounded journalism, the reader is introduced to hard data on health inequities in the U.S., as well as the implications of this data on the lives of individuals. In medicine, we only get full knowledge of a disease by understanding both the reductive biologic pathophysiology, as well as the effects of that pathophysiology on an individual’s subjective experience. Diseases do not happen in a vacuum; they happen to living beings. Villarosa gives us both the data and the experiences. In this way, the reader is meant to understand what is at stake, and how we must all work towards a more equitable future.
John Paul Mikhaiel is a neurology resident.
