People of color, and particularly Black folks, suffer higher rates of disease in America. That has less to do with anything about personal characteristics — like genetics or behaviors — and more to do with the way society treats people because of the color of their skin. In her new book “Under the Skin,” health journalist Linda Villarosa explores how racism gets under the skin. She sat down with Abdul to talk about that — and what we do about it.

TRANSCRIPT

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Dr. Abdul El-Sayed, narrating: [music break] New York City nurses went on strike and showed that people power can defeat the excesses of corporate health care. The Biden administration renews the COVID emergency declaration for an 11th time. Under-vaccinated seniors have now emerged as the epicenter of COVID deaths. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] Yesterday was Dr. Martin Luther King Day. You know, I’ve always found it incredible that we’ve dedicated a whole day to Dr. King. And that’s because before he was beatified in the Church of Civic Religion, Dr. King was vilified by the American political and economic establishment for daring to stand up for the rights of Black folk across the country. But it wasn’t just that. It was that he dared to connect the suffering of Black folks here to so much of the excesses of corporate capitalism or the militarism abroad. Though he preached nonviolence, his was an aggressive form of nonviolence. He understood just how radical his own teaching was. He saw the connections between war and poverty and racism, and he worked to dismantle them all. Sometimes I wonder what Dr. King would make of where we are now. What he’d say about the subterranean racism that lurks around us. How he’d view his own unexpected ascent to the American pantheon of Hallmark heroes, or what he’d think of the deliberate defanging of his teachings, where so much of his original depth has been completely ignored. I’m sure he’d have a lot to say. A bit of tough love for sure to put us back on the path he’d originally guided us toward. And so today, in the shadow of Dr. King, I want to talk again about the ways racism permeates every aspect of our health in this nation. And so we’re talking quite literally about the ways racism gets under the skin. But in order to do that, I want to make sure we understand how deep racism actually goes. And that means making sure we understand just how flawed, how dangerous so many of the narratives we feed ourselves to explain away racial differences in health and health care really are. I sat in more meetings than I can count about health inequities, and I have no doubt that the folks in those rooms are committed to addressing the challenge to eliminating inequities entirely. But what too often becomes clear within minutes is that few people sitting in those rooms have taken the time to truly understand how inequity works. In America we’re taught to understand our society as the collective outcomes of individual behaviors. A few great people do great things. A few bad people do bad things. And most of us just do average things. We’re taught to ignore how our attitudes and behaviors affect one another, or how they shape the institutions of society and how those institutions of society affect people. Look, it’s a nifty emotional trick. If greed or racism aren’t society wide challenges, then, well, none of us have to act to take on the responsibility for them. That’s just a few bad apples, after all we tell ourselves. But because this narrative completely misses how our shared structures and institutions impact each other, we conveniently ignore how bent and misshapen they become. Instead of understanding the consequences of greed or racism as the result of the design of our structures, we attribute their consequences to quote, “bad choices” made by individuals. We compare those suffering to the consequences of a few outliers who didn’t. People who’ve made it beyond all odds, who we celebrate as the picture of individual strength. We contradict ourselves implicitly. We marvel at how extraordinary it is to defeat all odds. And then we ask why everyone else didn’t too. Which is why, in so many of these meetings, you hear things like, well, you can’t help people who don’t want to help themselves. Or at the end of the day, people make their own choices. But do they? It’s been two and a half years since the uprisings following the murders of George Floyd and Breonna Taylor. And while there’s been a lot more attention paid to equity, much of that continues to be built around the same broken framework, that racism is a thing that happens between two individuals. The consequence of a couple of bad apples. Today my guest is Linda Villarosa, longtime health journalist and author of Under the Skin. Her work plumbs the depths of the epidemiology literature to demonstrate all the ways that racism shapes the environments in which people of color live, learn, work and play, and how that penetrates the skin to shape health. I’ve been working in this space for more than a decade, and one of my frustrations with it is that we too often dress our concepts in jargon that overcomplicate what we’re talking about. What I love about Villarosa’s book is that it’s unique because it brings those concepts to life, demystifying and explaining them with stories, anecdotes, and clear, concise language. And that’s why I wanted to have her on the show today to talk about health inequities, how they’re created, and the urgent need to do something about them. Here’s my conversation with journalist and author Linda Villarosa. 

Dr. Abdul El-Sayed: Let’s uh jump in. Can you introduce yourself for the tape? 

Linda Villarosa: I am Linda Villarosa. I’m a contributing writer at the New York Times magazine and the author of the book Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation. 

Dr. Abdul El-Sayed: I want to ask you, um this is both a um conceptually critical book, but also a really personal book. And uh you share a bit about it uh in in the book. But your pregnancy, um there’s a clear throughline between your own pregnancy and in the book itself. I want to ask you, you know, why did you write the book and you know what did your own pregnancy teach you about health inequities in our country? 

Linda Villarosa: Well, I think I ended up writing the book because I’ve been looking at these issues for decades, um since I was a young editor at Essence magazine, when at that time in like the late eighties and early nineties, I was really focused on self-help and self-health and the idea that individuals, if we were all doing the right thing all the time, we could change health outcomes for African-Americans as a demographic. And I really believed that. And my job at Essence was to encourage um mostly Black women to take better care of ourselves and our children and our families so that our health outcomes would get better and the racial health disparities would close. And I think I first started seeing that that wasn’t the answer in some studies, but really in my own pregnancy. And I was the health editor of Essence. So that meant I was like a poster child for good health. I was very careful about taking care of myself, doing everything right once I got pregnant. Um. I had a great doctor who was not only at Mount Sinai Hospital in New York City, but also my friend. Uh. So we were both shocked when I had inner uterine growth restriction, which is typically associated with someone who’s maybe not taking such good care of themselves, which is someone who’s having a problem. And I was surprised. She sent me to a perinatologist. The perinatologist was asking me about all of the illicit drugs I was using. Was I drinking? How was I eating? You know, did I have these underlying health conditions? And I’m kind of looking at her like, are you kidding? I would never be using crack cocaine. Um. And then I realized that what happened to me is unusual. Um. Once I had my baby, she’s a young adult now and fine, but she was one day short of being pre-term and she was low birth weight at four pounds, 13 ounces. And I started thinking about that. It’s like I wasn’t doing anything wrong. I was taking good care of myself. I don’t have any underlying conditions. I have great access to health care. Yet something happened in my pregnancy. Was it because of some kind of stress of being a Black person in America? 

Dr. Abdul El-Sayed: Hmm. That is a harrowing story. And I think there are two pieces to that that um you highlight that I think are really important to to pull and tease out. I think you do a great job of that in the book. The first is the assumption that we are the masters of our own destiny when it comes to health, that um everything that happens to us from a health standpoint is attributable to either something that is um individual and uh in our bones, so to speak, in terms of um genetics or it’s individual, and it’s a function of our choices. You can see why that idea is um so attractive, right? It gives you a sort of sense that um there’s parts of what you do that you cannot change, but they’re still embedded in you. Um. And then there are parts of what you do that you can change that are going to change your destiny. And I think what you’ve um outlined is the recognition that in so many ways health is environmental. But then there’s a second piece of that that I think is so profoundly important, which is to say that when you um attribute all of the health outcomes uh of a individual to that individual’s doing, um there’s a certain sense of moral blame that can be passed along. But beyond that, you know, if you take racism as a function of our environment, then what we have done is taken the impact of racism on the health of a whole population of people and reduced it down to a set of things that are blameworthy if not done. And um I want to ask you, you know, what do you understand, having written uh as a journalist your entire career in some of the most prestigious papers and magazines about that rush for control or around that temptation to attribute health outcomes to individual action or genetics? 

Linda Villarosa: Well, I think one thing it’s the easiest answer, and it’s the one that both medical providers can control to say, if you just do better, um then you will be better and then everyone will be better as a race or as a demographic or as Americans. And that is the easiest thing. It’s harder to say, Oh, wait a minute, this may be something happening in the environment that you live in every day and or the environment of the medical system. That’s much harder to deal with. It’s much harder to admit if you’re a health care provider. Um. And that’s the harder part. And to be honest, I actually do, you know of course, think that everyone should take great care of themselves. But I don’t love that that’s the only answer to say if everyone just takes care of themselves, that is not enough. And um that’s where and I think we’ve overcorrected in that area to say, you know, you go to whatever American Health Association, it’s all the tips of how people should take care of themselves. And less is an interrogation of how is a kind of toxic stress in American society, you know, contributing to high levels of high blood pressure, especially among people who are most marginalized. 

Dr. Abdul El-Sayed: Yeah, I really appreciate that point. And I don’t mean to say that there aren’t aspects of what you do um that will influence your health. Certainly, I feel like what happens because frankly, there’s an entire industry built around managing you as an individual, um that that’s what we always do. And then one of the things that I think your story illustrates so well is the implicit both frustration, shame, and helplessness that comes out of having done, quote unquote, “everything right” and still experiencing a particular outcome that you were trying to prevent. And then, you know, you think about folks who are substantially less privileged than even you had um as as someone with uh a good income and um and a and a career that was prestigious, uh that opened up opportunities. Um. You can imagine then the the sort of collective consequence of that. And I think you write so beautifully about it. Can you talk a little bit about that sort of implicit frustration and the shame that is sort of put upon a group of people uh when we fail to acknowledge that collective ether in which all of us swim? 

Linda Villarosa: Well, I think it was interesting because when um my book was reviewed in The New York Times Book Review by a wonderful writer, and I didn’t I don’t know her, but I know her work. And the review is wonderfully written. And right in the middle of it, she starts telling this harrowing story of her own pregnancy where it really went bad and she was really afraid. Um. She was suffering. She felt like she was wasn’t treated well within the health care system. And then she talked about the profound shame she felt and blame for herself. And I thought, you know, in a book review isn’t the usual place where you would tell your own personal story. But I really appreciated it. But I think there are so many stories like that where people feel really guilty that they’ve done something wrong if something goes wrong. I think the second thing is when I wrote America’s Black Mothers and Babies are in a life or death crisis for the Times magazine in 2018, I really saw how um the woman I was following had almost lost her life and lost her baby the year before. Now she’s back in the system and it was partly because she wasn’t listened to. She’s a person who is definitely not privileged, but she knew more about her own body and her own circumstances than anyone else. I saw her when she was pregnant again, uh it was me in the room, in the labor and delivery room and her doula. I saw her being treated really badly. 

Dr. Abdul El-Sayed: Mmm. 

Linda Villarosa: And um it was shocking because I was like, wait, one is why would you treat anyone badly who already had a trauma the year before? And then why would you do it in front of two people who can really like they may have looked at her and thought, well, and you know, she came from an abused background. She wasn’t. She, highly educated, but you’ve got these other two people watching you. And so what I thought was in the end that they didn’t notice, they didn’t understand that what they were doing was wrong by being shady to her, by ignoring her, you know, ignoring her and paying more attention to their own needs by making comments that weren’t very kind. I don’t think they got it. They didn’t see it. It wasn’t intentional, but it was still harmful. 

Dr. Abdul El-Sayed: Yeah, well, one of the things you’re highlighting is the role that um racism among clinicians and in the health care system has in shaping these kinds of outcomes. Can you talk a little bit more about why I mean I hate to say it, why um that is tolerated in the health care system? What are the excuses that people make for themselves? 

Linda Villarosa: Um. I just heard the story yesterday and it was about it was at a big hospital where there was a woman who she was pregnant, but she also had had a history of STDs and she had an STD. And one of the health care providers in the room said, mmm called her a W-H-O-R-E. 

Dr. Abdul El-Sayed: Wow, wow. 

Linda Villarosa: [laugh] So unkind um and not to her face, but saying it behind her back. And one of the other health care providers reported the person. And then there was a little mini investigation. And the person who was a doctor said, oh, I was just kidding. And then, you know, it was sort of like, well, please don’t talk about your patients that way. And she the woman could have overheard. But also, why are you doing that? And she just said, I didn’t mean it. I was just kidding. So but that’s not funny. It’s um you know, that isn’t how physicians should be behaving. And this was just I heard this, you know, recently. So that’s surprising. But I think that it’s an implicit bias. It’s and not knowing your own power, even though you do know your own power as a health care provider. I think it’s a kind of casualness when it comes to people’s feelings. And I think partially, you know, you would know this more than me, but, you know, scientific education and certainly medical school sometimes drums out the humanity and focuses much more on the science, um looking at people as bodies and, you know, as anatomy as opposed to human beings with real feelings, especially if those human beings have something different, you know, about them. They don’t have so much in common with you, whether it’s skin color, religion, culture, education, all kinds of things like that and it’s harder to relate to them as humans. And I think that, you know, if I see a change that I’d love to see in medicine. It’s toward a more humanistic education and training for people with, you know, hopefully as much um focus on technology and clinical skills, but, you know, at least as much on bedside manner and kindness and um compassion. 

Dr. Abdul El-Sayed, narrating: We’ll be back with more of my conversation with Linda Villarosa after this break. 

[AD BREAK]

Dr. Abdul El-Sayed: You know, one of the things that I saw a lot in my training, it’s a big reason I don’t practice uh clinically, is that there was a gatekeeping that happened at the institutional and structural level against patients who needed care the most. And you could tell that this directly offended people’s baseline morality. The reason that many of them got into medicine, but they felt powerless to do or say anything about it. So what happens is they, in effect, imbibe this and you get, you know, what a lot of folks are calling moral injury. And the way that that shows up is in language and in behavior that almost exists to justify something that you already know is wrong. And um I saw it, you know, day in and day out uh clinically while I was training where people would use this language, you know, language like like what you shared to basically excuse themselves from having to do their best work because, you know, largely either they were completely overworked and understaffed for the kinds of institutions that um showed care for uh marginalized folks, or because um they knew uh that the problems were a lot bigger than the solutions that they could offer. And it demonstrated a sort of, you know, a space where, you know, people sort of revert to their worst selves in their worst circumstances. And so you sort of see the way that the marginalization of a set of people as a function of the color of their skin and their circumstances then um starts moving people who got into the work to to try and do the right thing into positions where they’re actually almost agents of exactly what it is they said they wanted to solve. 

Linda Villarosa: Yeah, and I think that’s what we mean by systemic or institutional change. And that that the way the our health care system is set up, beginning with training and education, as you know, into practice and sort of in larger systems especially is not good. [laugh] And there needs to be a bigger look at it. I think we can have kind of Band-Aid solutions to some of these issues. We can have um the opposite kind of gatekeeping that you’re seeing. Um. I was sitting in on this group. I say their name a lot because I love them. It’s the Institute for Healing and Justice in Medicine. It’s a group of medical students who are at UCSF. You know, UC California in San Francisco for medical school. They’re getting a joint degree, an MPH at Berkeley, and they started this group in 2000 of medical students who wanted to do things differently. And their first thing is abolishing uh race in medical practice and training. So I sat in on this group of them and they were brainstorming how to push back so when they’re in settings where they don’t agree with what’s happening, whether it’s in the classroom or it’s in some of their early clinical practice, how do they push back? Because as students, they’re basically lack the power. And I was super excited to see different kinds of ways of pushing back. One person was like, you know, something happened, they were talking about the EGFR and they were still using this race correction um for kidney function, teaching it. So she went to the Title nine office right there and she got that changed at her college. Then somebody else was like, asked the professor, could we have coffee and talk about some of these issues? And it was a softer way. And I loved that they were brainstorming with each other because when you’re in that position, you know you are in medical school, plus you’re trying to make a difference in the future of the whole, you know, profession. It’s hard. 

Dr. Abdul El-Sayed: Yeah. 

Linda Villarosa: And you do need strategies and you need strategies from your peers. 

Dr. Abdul El-Sayed: Yeah, I really appreciate that. And I want to ask you to um explain a bit more about EGFR, but just to square the circle, one of the the things that um when I was in medical school, I had a pretty early interest in in health care policy. And one of the things that I always found really frustrating was that we individualized a lot of the circumstances that we were in to things that um that that doctors or professors were doing. And in some respects, it sort of it took off the hook the bigger, broader structure of how we even value bodies in America. Right. If you want to have health care in this country, you have to have health insurance. And for the lowest income people in America, there is a program called Medicaid, which is differentially funded across states. And if you look across the country, something like 60 to 65% of Black children are insured via Medicaid or the children’s version, which is called uh CHIP. And then um about 30 to 35% of white children are. But the thing about it is that not every doctor actually has to take Medicaid because Medicaid reimbursement is so much lower than private reimbursement. And so if you actually look at the amount of money that is reimbursed to treat the average Black child, it’s about 85% as much as we pay to treat the average white child, we are literally saying that the value for the exact same health care indexes on the color of the skin, of the body of the child that we are caring for. And the hard part is that until we decide that the value for caring for a Black human being in our society is the same as the value for caring for a white human being, everything that follows is a function of the economic incentives that we’ve created. And there are heroic people who act against those incentives. But the majority of people yeah we pretty well know are going to act in favor of their incentives. And so a lot of these folks say, you know what? Like well, given the fact that because of structural racism, Black folk are on average substantially less likely to be insured and poorer than white people, you know what, I’m just not going to take Medicaid patients. Right. It’s not it’s not about race. It’s just I’m not going to take Medicaid patients because, well, you know, I’m trying to keep my my practice open, trying to  make some money. And the implications of that are that they just are less likely to welcome Black patients into their clinics. And hospitals do the same thing. Right? They’re required in most cases to take Medicaid patients, but they certainly reflect on those patients and say, well, you know, we’ve got to pay more attention to quote unquote, “paying customers”, which is what I heard all the time. And so, you know, in thinking about the way that racial injustice comes out, I think we’ve got to be a lot more serious as a racial justice uh movement in health care to really, really be advocating at the very top of the incentive structure of how we pay for health care in our country. 

Linda Villarosa: Mm. You know, what’s interesting is um I was at a conference and it was about Physicians for National Health Care. Okay. So it was really um fun because I was speaking to this, you know, the choir and but I didn’t come to talk about that. So I had to start with I agree with everything that you agree with. Okay. Obviously, the main issue in our country is that our medical system is built on capitalism and it isn’t fair. And health care should be a human right. And that goes without saying. And we I started with that because I think they thought that it was, my lecture was going to be about that and I was like, but even if we had access for everyone, we would still have racial health disparities. 

Dr. Abdul El-Sayed: Right. 

Linda Villarosa: And it was interesting because everybody was like, okay, all right, come on, you’ve got to show us what’s going on, because this is our whole mission. And I said, I have that as the first thing. That’s the given. But after that, still so much um damage to our health comes outside of the health care system. It happens in our communities. You know, in the so-called social determinants of health. And by the way, I think I’m going to have this new mission to get a new term instead of social determinants of health, which no one really knows like–

Dr. Abdul El-Sayed: Thank you! 

Linda Villarosa: –why is it called that, that’s some [?], terrible um word [laughing] for the environment. And then also it happens because of a toxic stress that comes from just having to cope with the daily insults of being a marginalized person in our country. So that’s two. You’re coming in with two strikes. Then you get into a health care system that’s built on all this unfairness that you’ve talked about and where people have implicit bias. And that’s, you know, built on people can’t afford it and are treated badly in the system. And it’s kind of like, okay, [laughing] there’s a lot going on. So they were like everybody’s head was exploding at this conference. And I was like, well, I think the solution is like that movie that came out last year. Everything everywhere, everyone all at once. I think we have to look at the big picture and maybe it’s a divide and conquer, like groups have to look at how can we make our access to health care more equitable. Then we have to look at how can we build wealth and, you know, in communities so that they aren’t lacking the, you know, social determinants of health. And then how can we, you know, fight racism [laugh] in our current society, especially when, you know, we can’t even get our Congress working right because of polarization? Um. So I think that there’s a lot to say. Um. But, I you know, my job as a journalist is to just make sure that everyone understands what the real problems are. 

Dr. Abdul El-Sayed: Yeah. 

Linda Villarosa: Because if you don’t understand the problems, you’re solutions are never going to be right. 

Dr. Abdul El-Sayed: I really appreciate that point. And I think the point I’m trying to make about universal health care and I you know, I know you agree with me um is that if you want to do something about racism in health care, then you have to do something about who gets let in in the first place. But if you want to do something about about racism and its impact on health, you have to appreciate that actually, people spend most of their lives outside of our health care system. And, you know, it’s almost like saying, you know, the reason people are getting wet is because they don’t have umbrellas. Well, no, the reason people are getting wet is because it’s raining. 

Linda Villarosa: That’s right. 

Dr. Abdul El-Sayed: And the fact that that people don’t have umbrellas, that that’s also an issue. Right. But the distribution of umbrellas is just a part of the issue. The bigger part of the issue is it’s raining outside and that rain is systematically hitting a group of people and it’s like invisible to everyone else. And that’s what racism is. It’s this thing that exists in the ether that’s put out there. It doesn’t just exist in the ether. It’s put out there in the ether, and it systematically affects groups of people as a function of um their race and at times their ethnicity. And I think that is the key point that I appreciate you making. I am very close with my friends and colleagues at uh PNHP, the Physicians for National Health Care Program, and I’ve made similar points because most of my work is not in health care, it’s in public health for that exact reason is that you all like if we are serious about about addressing inequities, we actually have to be more concerned with where people spend 99% of their time, which is in the communities where they live and they learn and they work and they play rather than in our clinics and hospitals, as if we are like playing God and we are the ones who single handedly control people’s health status. And that’s just not the way it works. You did mention EGFR, which is just such a profound example of racism, institutional and structural racism in the House of Medicine. Can you talk about what that is and where it’s been headed? 

Linda Villarosa: Um EGFR is a test to measure kidney function, and um because it has a race correction on it, that assumes that Black people actually have slightly better kidney function. And it’s like weird. The roots of it may be in enslavement that made this assumption that Black people have more muscle mass. And it has to do with creatinine, then you can probably explain it better than I can, but it’s a false measurement that depends on race. And I was trying to explain this to someone who was like, basically, I don’t believe you. So I helped. I had a kidney function test about eight months ago, so I brought it out. I held it up and it said, If you are Black, this is your measurement. If you are white, this is your measurement. And my Black was circled and I was like, how do they? What about the rest of me? I am like really tiny and thin and I don’t have a lot of muscle mass so that it makes zero sense. But because of this race correction, it means that Black people who have more um kidney disease as a demographic in America may be being left off of transplant lists, you know, may be moved down in the order. And, you know, it’s not right. But there is a movement to um get rid of this. And there’s been movement in the last probably two years, more than there had been previously in the Institute of Healing and Justice of Medicine. If you go to their website, they have the kids. The students made a very good white paper about this issue. 

Dr. Abdul El-Sayed: Yeah, you did a great job um explaining it. So, you know, GFR stands for Glomerular filtration rate. Um. The glomerulus is the functional unit of the kidney, and it’s just an estimate of how well your kidneys are filtering, because that’s what kidneys do. They filter your blood and they help produce urine by taking the bad stuff out. And um the way we measure it is a function of a byproduct of muscle breakdown called creatine, that gets transferred into creatinine. And so we’re measuring people’s creatinine. And the explanation you had was spot on is that if you systematically assume that Black people [laugh] uh have a differential muscle mass, either making more creatinine um than what you’re basically doing is you’re changing the threshold at which you treat someone uh for kidney disease. And if you do that right, what what happens is people who need treatment are less likely to be treated and people who have fundamentally failing kidneys and need a transplant are less likely to be transplanted. Um. And so, you know, you’re using a flawed assessment of race to then fundamentally change who gets treatment in our country um and who doesn’t. And it’s just one example of the way that, um unfortunately, science has so often been bastardized, not because science itself is biased, but because scientists are biased and seek to leverage science to explain their biases away. [laugh] And it is um this one is just is just so extremely profound. There is a piece of the conversation that we sort of been circling around but haven’t quite got to, which is the burden of living in a racist society. And one uh author whose work you cite, she was someone whose work I really leaned on when I was a researcher uh is Arline Geronimus, who coined this idea of weathering. Can you talk a little bit about weathering and what it tells us about the impact of racism on our our health throughout a life course? 

Linda Villarosa: Um. I love Dr. Geronimus, who’s right there in Michigan, and also um really appreciate her poetic sense to name this concept weathering. So it works similar to the way that the, you know, rain or a storm might weather a house. And it means that the impact of living in a racist or any kind of society, whoever you are and you’re being discriminated against creates a kind of premature aging of the body so that you go into fight or flight too often. Fight or flight makes sense if there’s danger. You want your the systems of your body to rev up. You need a little bit more blood pressure. You need a higher heart rate, you need um the stress hormones to, you know, flood your system. But in the day to day, you don’t want that to be happening so often. And when it does too much because you’re fighting against discrimination and marginalization, it creates a kind of weathering the same way a storm weathers a house. The flipside of weathering is that people weather that storm and that people through kinship and community and love can fight against it. It isn’t inevitable, but it’s difficult to sense. Um. And I think it was interesting because Dr. Geronimus, at the beginning of her career, she was widely pilloried for being strangely for encouraging teen pregnancy because her first look at weathering was in infant mortality. And um in the past, teenagers were blamed. Black teenagers were blamed for having the high rates of infant mortality in Black community. But instead, what she found was actually infant mortality was worse in slightly older ages of women, not in teenagers, but in older. So people thought she was saying, oh, teen pregnancy is fine. That wasn’t what she was saying. She’s saying this is off, that it’s older because Black people, Black birthing people in this country have had the, you know, the lived experience of living longer as a marginalized person, has created this um infant and then later a sort of maternal mortality. Now, when COVID happened, it was super interesting because she and other people that talk about racial disparities and me as a journalist became much more lifted up because it was clear that um Black people had worse health outcomes at earlier ages. So if the health outcomes were worse at like um 60 to 70 in white Americans, it was the same poor health outcomes were 50 to 60 in Black Americans. So then this idea of weathering or this premature aging made sense. Dr. Geronimus has a book coming out in March called Weathering, um so I’ll send you her number so that you can have her on the show. But I’m really excited for this, and it’s really important that her work becomes, you know, much more accessible in this book and also celebrated. 

Dr. Abdul El-Sayed: Her work has been a long time inspiration for me. Um. And, you know, I remember reading those studies back in graduate school, and so much about about racial inequities in health clicked at that point um about the role of a consistently more hostile environment on you. And of course, part of the implication there is that the physical consequences that we see, whether it’s in infant or uh maternal mortality or in chronic disease outcomes, that a lot of that is mediated by um the socio emotional and mental impact of living in a society that pushes hate toward you and on you. We don’t talk as much about health disparities, in part because I don’t think we do a great job measuring uh mental illness in a in a helpful way. Um. But uh what are we starting to learn about um differences in uh mental health risk and certainly mental health care access? Um. And what role do they play in physical outcomes? 

Linda Villarosa: I mean, I think weathering really helps in the concepts because she talks about the daily insults that African-Americans and other marginalized groups have to deal with. And I think that the, you know, when you think about um mental health and Black people, it’s quite complex. Part of it is such a lack of access of providers that look like us. And it’s even more important to have a provider that’s from your own culture when you’re doing something that you may not feel comfortable with, which is going into to see a therapist or some kind of mental health care provider. And um so that there’s I think it’s 3% of um mental health care professionals are Black, talking about psychiatrists and psychologists, and that’s very low given that we’re 13% of the population. Um. And I think that makes it really difficult to seek help. But there’s also this myth that we can have really high pain tolerance, and that includes um emotional pain. And and the flipside is that when um you know, if a community or a demographic is knows about these stereotypes and this has ingested them like we all have, then you ingest it yourself. So part of it is I’m strong and I don’t need this kind of help. I’m invulnerable. I would never enter this system. But then also we are, you know, left out of the system with the assumption of strength/sometimes violence. And I was thinking about it because I was looking at Black suicide statistics and young um people and suicide. Those statistics have ticked up and they’ve been ticking up, but they’ve been a little bit under the radar. I looked closely at them and I saw that most um young Black people who make a suicide attempt that involves hospitalization or even the E.R. have never been evaluated for mental health problems. And that is, you know, like most have never. And that’s not true with young white people. And so that was saying that something about Black mental health in young people has gone under the radar and aren’t getting seen, aren’t getting treated, aren’t getting help. And um I think in my book, what I did was sort of looked at some worst case scenarios. And the one is when, uh Black people and policing so that already it’s people, you know, including law enforcement don’t really understand mental health. Mental health crisis may look like anger and violence if it’s a Black person. So instead of getting treatment and care, the person gets policed. And in the story in my book, it was a man who was dealing with bipolar disorder. He had so much trouble getting treatment, even though his family was really trying. He was really trying. He was using drugs to sort of counteract the down of bipolar disorder. He ended up having a run in with the police um on his way to starting a restaurant in Martha’s Vineyard. I mean, you know, that’s what his path was. And he got murdered by the police in Boston. And he really didn’t deserve that. He deserved treatment. And at one point he was incarcerated. And that’s what happened. You know, that’s what happened because he did not receive his bipolar meds when he was incarcerated. Then he came out and he wasn’t right still. And so then he continued medicating with drugs. 

Dr. Abdul El-Sayed: I really appreciate um you sharing that story. And that’s just an awful, awful illustration of the disastrous consequences of what happens when A., we stigmatize mental illness, but B., uh we do so in a world where we’ve created a carceral system and a uh criminal legal system that de facto criminalizes people by race. In the context where we have not adequately or sufficiently created either the permission structure or the opportunity set to treat mental illness. And then the other big insight um that I really appreciated was this notion that, you know, people imbibe a stereotype and so it serves to stigmatize um mental illness treatment um in the community. I want to ask you, you know, as you think about this, you already commented about um one of my bugaboos, which is the social determinants conversation, because, you know, you have a conversation with people in public health and you start talking about um health inequities with the goal of a solution. And somebody will be like, well, that’s just the social determinants. Everybody shakes her head and walks on and there is no real solution. And so I really would love to scrub that from um everyone’s vernacular because it’s not particularly helpful if we were serious about solving these problems, really investing in addressing inequities in in health. Um. So much of your intervention has been about how we talk about them. What should we be doing about the way we talk about them? How should we be talking about them? 

Linda Villarosa: Well, I think that I don’t mean to. I want to make it clear that it took me a minute to understand this and it took me not a minute. It took me like a decades to understand social determinants of health and what it meant, because it is easily dismissed, is, you know, poor, communities are poor. It’s their fault that something, you know, that the communities ended up like this. And what I did was I looked at my own community of the South Side of Chicago, where I lived until I was ten and my parents are from and all my my grandparents and I went to the community of Inglewood and looked at its history. The life expectancy in Inglewood is age 60 and nine miles north is age 90. So I’m like, why are people only living to age 60 in this community in the middle of Chicago? So my mom and I went there and we went back to all the places that, you know, our our grandparents and their siblings came up from Mississippi to these communities that were middle class um and they owned their own homes. And they were you know, they weren’t scary and dangerous as or barren as they are now. And I looked at the history and, of course, these communities were redlined. You can put a map across communities that were redlined and then Black communities, it’s the same. You can put that same map around the COVID. It’s the same. Poor health outcomes, same. And then I went deeper and thought, well, is it just redlining? Was that the only thing that happened? And then my mom was really the one who helped me come to this conclusion. And I learned about contract buying in Chicago specifically, but it happened in other places. So places that were redlined meant that in the past Black people couldn’t get a mortgage. So that meant these predators came in and offered contracts. If you could buy a home, that meant that you could get it on a contract. So what it meant was you never really owned it. You couldn’t sell it. 

Dr. Abdul El-Sayed: Wow. 

Linda Villarosa: You couldn’t give it to your um you couldn’t give it to your children. And that and obviously a home that you’ve saved all your money for and invested in is your biggest asset. Um. So if you lack that, then you don’t you know, the community never gains real wealth. So in this community, I looked it up and there was an estimate that $3 billion dollars of Black wealth was sucked out of this community because of predatory contract buying and redlining. So then when I went and looked at it again and it looked like, you know, it was dangerous, it was the schools were crumbling. Some of them were closed. My mother’s elementary school was just completely closed and the building still there. But it was just a shadow. And this is where Lorraine Hansberry went to school. And Gwendolyn Brooks. 

Dr. Abdul El-Sayed: Wow. 

Linda Villarosa: These are, Lorraine Hansberry wrote about this in Raisin in the Sun. And I was just thinking about it, it’s like, whoa. And I called my friend Eric Whitaker, who used to be the commissioner of health for the state of Illinois. I went to graduate school with him and he’s from he grew up around the corner from where my grandparents lived. I said, what happened here? And he said, what he did was he felt so bad about what was going on in this community in Chicago that, he’s a physician, that he started a Black men’s clinic in the in Woodlawn in the Woodlawn section. And he was I mean, I remember I was like, what happened to that clinic that was so cool that you did it. And he got all of his Black male physician friends to volunteer. He said, Oh, we closed that. And I said, What happened? And he said, It just wasn’t being used. And what he came to the conclusion that we don’t need health care facilities in a community that is devasted. What we need is wealth building. And he switched his whole focus. Even though he’s a doctor, he’s working on this other way of um fixing up the community, of building the community because it really ha– it lacks everything, including safety, which is and um housing and education and jobs and clean air and water and everything. And I love that that you know, that this even a physician could figure out throwing health care at a problem that is so vast isn’t going to make a difference. But also looking at, you know, I’m back patting myself on the back for looking at that history to say, let me make sure I’m understanding what happened here and making sure– 

Dr. Abdul El-Sayed: Yeah. 

Linda Villarosa: –That I explain it correctly. 

Dr. Abdul El-Sayed: Yeah, I really appreciate that. And, you know, I, I asked you, how do we talk about it? And you you answered, how do we do something about it? And I think that that broader point, right, the idea of the social determinants was the recognition that if we’re serious about addressing health, we have to be serious about all of the antecedents of health in a serious way. And I think what happens is so many of us who are concerned about the health outcomes downstream of poverty, lost income, and wealth, we look upstream and say, well, what we do is health. So I guess we just have to we just have to throw our hands in the air and, you know, that we’ve got to solve poverty. And the problem with it is that there are actually real solutions to poverty. You can’t just say, well, you know, what are you going to do, solve poverty? Yes, yes, we should solve poverty. That’s exactly what we should do, in fact. Um. And and we have to address in particular all of the mechanisms by which race predicts the pulling of wealth and resources away from folks. Now this is exactly what um what you’re talking about in the way that you you sort of end uh your book. And I just really appreciate you coming um through to to talk about your book, about um how to understand racial disparities and inequities and really what we can do about them um if we think comprehensively about the challenge. Our guest today is Linda Villarosa. She is uh a journalist and author of the new book Under the Skin. I really hope that you all check it out. Linda, thank you so much for taking the time. 

Linda Villarosa: Thank you. It’s been really interesting and fun talking to you. 

Dr. Abdul El-Sayed, narrating: As usual. Here’s what I’m watching right now. Over 7000 nurses in New York City went on strike at two major health systems in the city. Beyond pay raises, the nurses struck over safe staffing conditions. See, for decades, hospitals have been trying to squeeze nurses. Skimping on their salaries and requiring more of them in return. That’s pushed more and more nurses out of hospitals into places like urgent care centers or outpatient surgical centers. But that squeeze, well, it hit a breaking point during the pandemic, when staffing conditions were exacerbated by the inherent risk of providing hospital care in a pandemic and absence due to illness. During 2021 alone, it’s estimated that 100,000 nurses left the profession. And that’s made that work that much harder on the ones who stayed. And then hospitals haven’t relented, trying to press more and more out of fewer and fewer nurses. That’s left many nurses working in understaffed settings under arrangements that make mandatory overtime a regular occurrence. At first blush, this might seem like any other labor issue, but remember what hospital nurses do. They care for people in their most acute times of need. These are the folks we rely on to administer medications to flip patients over so they don’t develop bedsores. To make sure that our surgeries are safe and sterile. The nurses at Montefiore and Mount Sinai Medical Center’s had had enough, so they went to the streets. They were able to negotiate a 19% pay raise, but more importantly, a commitment to safe staffing levels. It’s a huge win for nurses around the country and for their patients, and I’d expect other locals to follow suit. Watch this space. This week, the Biden administration reauthorized the pandemic emergency declaration for COVID 19. Remember, nearly 4000 people died of COVID last week. And by that metric alone, this remains a public health emergency. And yet it’s been nearly three years now, meaning this is no longer emerging. It’s been our situation now for nearly a third of a decade. But the emergency declaration is a tool that government has used to open doors and bring down resources to fight the pandemic. Things like enabling telehealth, requisitioning PPE, or buying vaccines and treatments on behalf of the American people. You might think the government should be able to do these things without an emergency declaration anyway. After all, it shouldn’t require a state of emergency to be able to do basic things that government should do. But this tension, well, it highlights two critical things about the state of American government in the first place. First, we have a nonfunctional public health system that doesn’t really allow us to do very basic things to protect the public’s health unless there’s a, quote, “emergency”. And second, we don’t have universal health coverage that guarantees people access to necessary meds like vaccines and treatments for pandemic infectious diseases, unless, well, there’s a state of emergency. And if you don’t believe how important this is. Take a listen to this. 

[unspecified news reporter] Americans getting their COVID shots in the future could be in for a surprise. Moderna says it could charge as much as $130 per dose for its vaccine. That is significantly more than it had been charging the government who had been footing the bill. 

Dr. Abdul El-Sayed: Right now, considering the pandemic state of emergency, Moderna sells vaccines to the federal government that contracts on all of our behalf. It’s the reason why every COVID vaccine you’ve ever had has been free. But as soon as that ends, Moderna, which by the way, started out as a government research project to use MRNA to create vaccines, will raise its prices to somewhere between $110 to $130 a shot as it starts selling its vaccines on the open market. That’s right. You and I, who pay taxes to create Moderna and its vaccine in the first place, will now be required to pay over $100 a shot when it goes on the private market. And that’s a problem because well the virus is still evolving and so our vaccines will need to evolve with them. Well, that’s assuming we take them. And that’s the problem right now. Is that seniors, well, they’re just not taking them. Nine in ten of those nearly 4000 COVID deaths last week were among seniors over 65. And the majority of them, they’re vaccinated. They’re just under vaccinated. They haven’t had their most recent dose. And so their immunity is waned and isn’t caught up to where the virus has evolved. And that leaves them vulnerable. So if you have a senior in your life, make sure they’re not just vaccinated, but up to date on their vaccines. And of course, as always, a well-fitting N95 mask is a great tool to protect against transmission as well. That’s it for today, on our way out. Don’t forget to rate and review. It really does go a long way. Look rate and review like just go to the app right now just boom rate five stars. Abdul’s great. Love him. Great show. Crooked Media is awesome. Blah blah alright. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some America Dissected merch. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illic-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz and Ines Maza. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Sandy Girard, Michael Martinez, and me, Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing specific health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.