UNDER THE SKIN by Linda Villarosa, Doubleday,
269 pages, $30
Jerald Walker I For The Washington Post My wife was 20 weeks pregnant when she experienced a gush of rose-colored liquid, and we sensed that our first child was no longer moving inside her. A panicked call to 911 brought paramedics. As they examined my wife, the paramedics had a casual conversation with us about our work as graduate students at the University of Iowa. The tenor seemed odd at that moment, but it offered hope; surely paramedics would not be making small talk if our child was in trouble.
After the exam was completed, we had reason for more hope still; we were advised to go to the hospital “for observation,” but no need to rush. An hour later we drove ourselves and learned, contrary to what the paramedics intimated, that our child had died. We were told to return home and “let nature run its course” — that is, my wife was to deliver our lifeless child at home into a bucket we were given.
Two days later, my wife went into labor. When she spiked a fever and had chills, I called our doctor; he told me to give her an aspirin. But she got worse. I called paramedics. I was terrified that along with our child I would lose my wife, who was now in our bathtub, unconscious and hemorrhaging, alongside “the demise” she had delivered. She was rushed to the hospital for emergency surgery to try to save her life.
Thank goodness my wife survived, but 30 years later she and I remain haunted by our experience and the conviction that race played a role in this story. Had we been White, like all the medical personnel who’d attended us, rather than Black, maybe the first paramedics would have leveled with us. And maybe, at the hospital, we would have been given the option of a surgical evacuation instead of being sent home to endure a risky second-trimester fetal demise. According to the University of California at Davis department of obstetrics and gynecology, a fetal demise delivered at home in the second trimester presents an elevated danger of significant bleeding. When we told hospital staff that we had strong misgivings about seeing and handling our child’s remains at home in the throes of our grief, perhaps — if we had been a White couple — we would not have been given the callous and untrue response: “There’ll be nothing to see of the demise, other than gray matter.” And when I called our doctor when my wife developed chills and a high fever during her labor, perhaps I would have been instructed to bring her to the hospital immediately.
In a searing New York Times Magazine article in 2018, headlined “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis,” Linda Villarosa wrote, “People of color, particularly black people, are treated differently the moment they enter the health care system.” Race, in other words, in terms of health care in this country, is the story. Villarosa, a journalism professor at the City University of New York, reported on studies that show, for example, that Blacks are less likely than Whites to receive kidney dialysis or transplants, coronary bypasses, appropriate cardiac medications, or pain medications, yet they are more frequently given amputations for diabetes.
In her brilliant, illuminating book, Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation, Villarosa expands on the theme. She discovers that racial bias within the health-care system is a compounding factor to racial bias in America. Meticulously researched, sweeping in its historical breadth, damning in its clear-eyed assessment of facts and yet hopeful in its outlook, Under the Skin is a must-read for all who affirm that Black lives matter. It will be especially eye-opening for anyone who believes that wealth, education, and access to quality medical services are the great equalizers, the attainable means by which Black Americans can achieve health-care parity.
Equal treatment within the health-care system, Villarosa argues, regardless of class or social status, remains elusive because of three primary obstacles: long-standing institutional and structural discrimination; implicit biases in the medical profession resulting not only in misdiagnoses but even blame for being unwell; and “weathering,” which, Villarosa writes, refers to the “struggle with anger and grief triggered by everyday racist insults and microaggressions ... [which] can, over time, deteriorate the systems of the body.”
The female reproductive system is not immune. Villarosa cites a 2007 American Journal of Public Health study that demonstrates that Black women who reported experiencing racial discrimination had double to triple the rate of low-birth-weight babies compared with Black women who did not report incidents of discrimination. Summing up, Villarosa writes, “The researchers’ conclusion: low birth weights among African American women have more to do with the experience of racism than with race.”
A decade earlier, Villarosa stringently followed all prescribed prenatal care during her own pregnancy but had to ask herself if her “lived experience as a Black woman in America” had resulted in her daughter being born at only 4 pounds, 13 ounces. She recounts that a doctor “hounded” her with questions about her lifestyle, as if she were a habitual user of alcohol and drugs. Villarosa wondered, “Does this doctor think I’m sucking on a crack pipe the second I leave the office?”
To combat racism in health care, Villarosa advocates implicit-bias training for medical personnel and champions expanding the diversity of students, faculty, and curriculums in medical schools.
Racism cannot be combated, however, if its existence is denied. Signs of its persistence were apparent in remarks made by the deputy editor of the prestigious Journal of the American Medical Association in a 2021 podcast. “Structural racism in an unfortunate term,” this editor said. “Personally, I think taking racism out of the conversation will help. Many people like myself are offended by the implication that we are somehow racists.” JAMA’s Twitter account posted a tweet about the podcast: “No physician is racist, so how can there be structural racism in health care?” The podcast and the tweet were deleted, and, Villarosa writes, “the deputy editor and the editor in chief — both white male physicians — resigned.”
Some people are offended by what the hard research on health-care disparities shows. Villarosa provides the facts in abundance, perhaps none more alarming than this one: Black women, including those “whose income and education should protect them,” are three to four times more likely than White women to die from pregnancy-related causes.
Tennis star Serena Williams was nearly one of those fatalities. The day after delivering her daughter by cesarean section, Williams was struggling to breathe and knew from previous experience that she was having a pulmonary embolism. She told the medical staff what was happening and the treatment she required, only to be ignored. Her persistent coughing ultimately ruptured her C-section sutures, sending her back into surgery; it was then that a large hematoma was discovered in her abdomen, which required still further surgery. Villarosa documents a number of similarly harrowing stories, should facts alone not suffice in convincing us of the crisis at hand.
But some need no convincing. Alas, we have stories of our own.
Meticulously researched, sweeping in its historical breadth, damning in its clear-eyed assessment of facts and yet hopeful in its outlook, Under the Skin is a must-read for all who affirm that Black lives matter.