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The Hidden Health Toll of Racial Inequality

Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation, by Linda Villarosa (Doubleday: 2022)

Reviewed by Matthew Adarichev

In Under the Skin, veteran journalist Linda Villarosa explores the disproportionately poor health outcomes of Black Americans compared to Whites. Borrowing on decades of experience as a journalist covering race and health for magazines like Essence and The New York Times, as well as expert testimony and research on the intersection of health and race in America, she explores the various ways that Black Americans suffer in the realm of health compared to their White counterparts, whether it be higher rates of certain diseases, a higher rate of death for Black mothers in childbirth, and shorter lifespans. The author explores how Blacks suffer from these penalties on their health due to varying forms of racism and explains in detail how higher incomes are, in fact, unable to save Black Americans from these poor outcomes.

Villarosa narrates how she came to care about the intersection of health of race in the opening pages of the book. As a health editor for Essence magazine in the 1980’s, she recounts how she felt morally obligated as a college-educated Black woman to educate poorer Blacks on how to best take care of their bodies so that Black Americans could emerge as a “healthy community” through selfimprovement. An encounter with a doctor in the historically-Black New York City neighborhood of Harlem caused her to reconsider her views on “self-improvement” as a solution to the health woes of Black Americans. The author began to investigate wider factors in American society that may be leading to Black Americans being less healthy than their White peers.

Villarosa’s investigation leads to a grim reality. Compared to Whites, Blacks are more likely to suffer from high blood pressure and asthma, receive a cancer diagnosis, and die at a younger age than Whites. Perhaps most troubling, Black mothers are more than twice as likely to die in pregnancy compared to White mothers. As the author herself explains, a common, popular, and quick explanation is to blame these outcomes on poverty within the Black community or lack of access to healthcare, whether it be a lack of health insurance lack of access to healthcare facilities like hospitals. While Villarosa acknowledges this to be a factor, she notes in her research that wealthier or more highly educated Blacks suffer from worse healthcare outcomes as well. Education and income are not able to protect Black Americans and that is because, as the author eloquently asserts over the course of the book, racism itself is plaguing Black Americans. American history, medical discrimination, persistent feelings of not belonging, and environmental racism harms their health and thus the health of America in general.

In writing the book, Villarosa draws from a wealth of experience in journalism, specifically journalism on the topics of race and

healthcare. In addition to serving as an editor for the healthcare section at Essence, Villarosa has also written for The New York Times since 2017. She is a contributor to the 1619 Project, a historical archive relating to African-American history. In addition to Under the Skin, Villarosa has written two other books: Passing for Black (2008) and Body & Soul (1994). A 2018 article of hers on maternal and infant mortality in the Times was a finalist for a National Magazine Award. In addition to her journalistic plaudits, she is also Professor of Journalism at the City University of New York. She holds a Bachelor’s in Journalism and is a graduate of the CUNY Graduate School of Journalism. She also received a Fellowship from Harvard’s School of Public Health in Health Communications.

The author’s book can be seen as a tale of self-discovery. Villarosa is an expert on the intersection on health and race and uses Under the Skin as an opportunity to chronicle the information that she has compiled in her decades of exploration of the topic. The author also wishes to shed light on the topic and uses the book as an expose. Given the clear prose, frequent use of personal anecdotes and observations, and lack of academic-speak of the book, Under the Skin is intended for a general audience. In that regard, Under the Skin is excellent for education. I can only imagine that, writing as a Black woman herself on the topic of the health of Black Americans, the book can also serve as a particular source of education, solace, enlightenment, and “closure” for Black Americans who may have had a similar lived experience to that described in the book, and may be looking for an explanation for the phenomena they observe.

Under the Skin can be considered part of a new intellectual and academic movement by Black Americans to document the racism they experience in their daily lives. The book came out three years after the 1619 Project emerged, and eight years after the birth of the BlackLivesMatter Movement. The book emerged under the Biden administration, when issues of discrimination against Blacks in daily life gained relevance. The book brought up the issue of high maternal mortality rates among Black mothers, a particularly painful and prominent issue in the Black community. Around the time Under the Skin was published, laws to ban discrimination on hair styles worn by African-Americans, funding for historically Black colleges and universities was a political issue, and the Biden administration sought to settle with Black farmers over discrimination done by the Department of Agriculture. Likewise, Under the Skin was published amidst a reactionary movement against the alleged teaching of Critical Race Theory in elementary schools, “wokeness”, and Diversity, Equity, and Inclusion programs, which some allege were smokescreens for racist backlash to the discussion of issues important to Black Americans.

Villarosa tells her tale first by explaining her background and shift in viewpoint away from personal to systemic in Chapter 1. She goes on to dispel myths that Black bodies are genetically different from other bodies, and details how Blacks are ignored in the medical system. Following, the author devotes Chapter 4 to detailing the phenomenon of babies born to otherwise healthy, educated, and higher-income Black women dying at higher rates than babies born to similarly situated White women, explained by stress from continual exposure to racial discrimination and disrespect. In Chapter 5, Villarosa discusses the geography of racism and how Blacks end up living in areas with dirty air and water. In Chapter 6, Villarosa turns to the issue of mental health in the Black community, the pressure that Blacks often feel to conform in majority-White spaces, and the “silent burdens” Black Americans must face. In Chapter 7, she proposes that the feelings of hopelessness, discrimination, and economic destitution could affect anyone, not just Black people. She does this by visiting West Virginia, a state with a high White population, to see how poverty similarly wears down the health of those there. Finally, Villarosa closes her book with solutions, including the training of certain healthcare workers, the implementation of guidelines during pregnancy emergencies, implicit bias training for those delivering pregnancies, and a call for an end to racism in medical school education.

The book is written from the perspective of a Black woman who is college-educated. Villarosa came from a middle-class background, and she herself notes throughout the book that this background of relatively high education and income informs her writing and perspective. Her background was the main reason for her initial belief in “bootstrapping” advice for Black Americans as health editor for Essence, and her audience itself was mostly middle-class Black women. As such, some of the anecdotes and stories that Villarosa relates deal with Black individuals who are of a high income or have achieved high status in society or in their careers. As such, I imagine some stories may be lost to a lower-income audience. While the author talks about health disparities amongst the Black community in America, most stories focus on Black women specifically, and not necessarily Black men. While Villarosa still provides a compelling narrative and there is great utility to her work, it would be useful to have included some stories of Black men. Considering Villarosa devoted a chapter to Black maternal mortality, it would have been similarly useful to have a chapter on an experience common to Black men that affects their health, for example, the rapidly rising suicide rate amongst Black men and boys, rising faster than in any other ethnic group.

The author writes her book as a form of narrative. She explains issues facing Black Americans using “case studies”. She interviews and writes about an individual, or several individuals, in each Chapter that is afflicted with the issue the Chapter is about. She then uses the anecdote to explain the issue in further depth and bolsters the anecdote with research. Research is not directly cited whilst reading the text, but is instead alluded to, and is fully cited in a lengthy notes section at the end of the book. This provides a dual benefit: the book both readable and personal, whilst being strenuously complemented with studies, expert testimony, and statistics.

We can summarize Villarosa’s arguments as such: first, Black Americans are suffering disproportionately worse health outcomes compared to Whites. Next, this disparity cannot be explained solely by higher poverty rates and lower average incomes compared to Whites, seeing as educated and higher-income Blacks are afflicted with the same ills. Rather, racism against Blacks, geographically, interpersonally, sociologically, and psychologically “weathers” Black bodies. However, Blacks are simply at the forefront of racial abuse, and any population subjected to the same treatment would face the same fate. So, the issues faced by Black Americans are really an American and even worldwide problem, and it is a problem that needs to be seriously addressed. A number of solutions proposed to address the problem.

As previously mentioned, the author is not simply expanding on anecdotes. Villarosa supplies almost thirty pages worth of notes after the end of the main text that meticulously detail every single factual claim made throughout the book and its accompanying reference. Tens, perhaps even over a hundred studies, surveys, and journal articles are cited to ironclad the author’s claims made throughout the book. It is for those reasons that we can safely assume that many of the arguments made by Villarosa are true. Blacks are suffering disproportionately worse health outcomes compared to Whites; this disparity cannot be explained solely by high poverty rates or lower average incomes compared to Whites; educated and higher-income Blacks face the same ills; and there is evidence of a phenomenon referred to as “weathering” that occurs to Black bodies. These arguments are empirically supported throughout the text.

We are left with more philosophical and subjective arguments. Would any other racial group end up in the same situation as Black people if they had undergone the same treatment? Perhaps. The author makes such a case by examining White poverty and the experience of allegedly undocumented Latinos in Chapter 7. There is no denying that discrimination faced by non-Blacks also harms their health. Nevertheless, while I do not dispute the author’s overarching claim that discrimination can harm health, we don’t actually have any other population to compare the Black population’s experience to, and to some extent, I struggle to believe that being abused because one is poor, or being separated from your family because you are supposedly an undocumented immigrant can compare to being a descendant of a group of people that was, as one point, enslaved for close to 250 years. The two examples appear to be in different classes of their own, and I’m not sure they can be compared.

Next, we ought to examine the solutions Villarosa proposes to combat the disparities between Whites and Blacks. She proposes the employment of certain healthcare workers, known as community healthcare workers, as one solution. She also proposes implicit bias training for hospital staff, including emergency workers, to allow physicians, who are mostly White, to empathize with Black patients. The discussion of race and White supremacy in the healthcare setting is essential, the author contends, as broad-based interventions to reduce maternal mortality based only on health

outcomes have not been shown to help Black mothers. Finally, the author discusses how it is important for medical students to unlearn unconscious bias and highlights the grassroots efforts of medical students to push for classes, working groups, workshops, and discussions on race and healthcare and an end to the teaching of biological differences between the races and the use of “race corrections”, algorithms meant to adjust for supposed differences in medical measurements due to race that are still used today.

I first wish to applaud Villarosa for avoiding easy solutions. It would have been exceedingly simple for her to simply argue for a publicoption or a universal healthcare system as a solution to healthcare disparities. The author instead pushes the envelope and proposes innovative solutions that one may not see in other books on healthcare disparities. On the other hand, given the systemic angle that she provides throughout the book, I am surprised that the author does not provide any comment on the effectiveness of reforming the United States’ healthcare system in her Chapter on solutions. I believe some commentary on broader healthcare reform, whether it be the Affordable Care Act, the movement for a public option, or the single-payer model proposed by Senator Bernie Sanders, is warranted; necessary, even, for such a topic.

I am also left unconvinced by Villarosa’s arguments for implicit bias training. She begins by explaining how a “race-blind” approach to reducing certain healthcare outcomes, such as maternal mortality, does not reduce maternal mortality for Black mothers. She uses this claim as evidence for why it is necessary to include implicit bias training as part of medical outcome prevention. Yet the author admits that in a case where implicit bias training was implemented, maternal mortality for Black mothers was still unchanged. Villarosa then goes on to state that implicit bias trainings are oftentimes ineffective due to their lack of uniformity and differing implementations. I am not sure why, then, implicit bias training is being suggested as an effective solution. Perhaps the author is implying that implicit bias training should be kept as an option as implicit bias trainings improve in efficacy.

I will make one small note on the suggestion of improvement of medical school education. While Villarosa makes a good case for teaching about equity in medical school, and while I was horrified to learn that many medical students believe that there are genetic medical differences between Blacks and Whites and that many medical schools still include racial corrections in medical measurements to account for supposed differences between Blacks and Whites, the discussion seems to be focused on individual grassroots efforts across the country, rather than some kind of systemic public policy solution. I would have liked to hear if the author believes that some kind of governmental or market solution can coordinate a broader movement towards more equitable health education in medical schools, or whether if she believes that grassroots efforts are sufficient.

I believe a comparative study would be a useful next step. There are other countries where there is a minority population that undergoes discrimination, whether it be the Muslims in India, Palestinians in

Israel, or even individuals of African descent in other countries like Brazil. Do they face the same “weathering” effects that Blacks face in the United States? Is weathering limited to just race? I think it would provide a rigorous test for Villarosa’s theory that any population, not just Blacks, would face the same outcomes as Blacks do in America if that population was subject to the same conditions as Blacks face in America.

The book is not political, per se. The book is an empirical review of a phenomenon in America. As such, it would be better to categorize the book according to the sociological theory that informs its research and assumptions. In that regard, the book argues from a perspective of the Systemic Racism school, which argues that disparate outcomes in American society between races are due to racism within institutions. The book also subscribes to Social Determinants of Health, or that social characteristics one has in a society will impact one’s health. For those who believe that social class is a greater determinant of health than race, such as the Socialist or Marxist school, they will likely contest Villarosa’s perspective. The class versus race perspective on inequality is a long-standing debate in the United States, and for a differing, classbased perspective, books like Class Notes by Adolph Reed are a useful contrast. Two decades of Neo-Marxist class analysis and health inequalities: A critical reconstruction by Muntaner et. al is another useful scientific article on health outcomes from a Marxist perspective. Another book that discusses health outcomes and race from a perspective closer to Villarosa’s is Race, Ethnicity, and Health: A Public Health Reader by Thomas A. LaVeist.

Concise, well-written, harrowing, yet enlightening, Linda Villarosa’s book on the intersection of race and health can safely be considered necessary reading for anyone who is serious about becoming an expert on the topic. Effortlessly wielding her experience on the topic, and bolstered by thorough and extensive research, the author presents a compelling case on the layers of racism that lead to worrying disparities in health outcomes between Black and White Americans. In clear prose that is at once forceful and understandable to the public, the author makes a case for how any abused population will see their health become degraded. Villarosa helps us see how racism against Black Americans leading to poor health outcomes is a problem that affects all of us and lays out how such a problem may be resolved. I believe Under the Skin may, in future decades, come to be regarded as an authoritative text on the intersection of race and health in the United States of America.

Mathew Adarichev is a double major in Economics and Public Policy at Hofstra University