1. Brown, Theresa PhD, RN


Exposing the hidden toll of persistent racism.


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After reading the first chapter of Linda Villarosa's Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation (Doubleday, 2022), I felt sick to my stomach. I kept reading, of course, but it's hard to learn about systemic racism in health care. We clinicians want to think we are better than that, that we treat all patients the same regardless of the color of their skin, but Villarosa's book shows that this ideal is often not lived up to. Under the Skin implicitly asks how we can best protect and care for Black Americans going forward.

Figure. Theresa Brow... - Click to enlarge in new windowFigure. Theresa Brown

The book begins with an oft-cited fact that frequently fails to get the national attention it deserves: the money spent on health care in the United States is not buying health. Villarosa writes, "Although the United States has the most advanced medical technology in the world-and spends more on health care than anywhere else-we lag behind all other wealthy nations in key measures of health that serve as a proxy for our overall well-being." The picture is worse for people of color. Black Americans, specifically, "live sicker and die quicker" than their White counterparts, with "elevated death rates" largely caused by diabetes, stroke, and heart disease.


Under the Skin traces discrimination against Black Americans back to race-based ideas about physiology that were developed during slavery. Perhaps the most pernicious of these was the idea that Black bodies and psyches didn't feel physical or emotional pain to the same degree that Whites did. This belief was used to justify subjecting enslaved people to hard physical labor, brutal beatings, sexual assault, and the violent fracturing of their families. None other than Thomas Jefferson wrote a book on supposed racial differences that legitimated brutality toward Black Americans.


The problem is, those ideas didn't lose their power when slavery ended. For example, a "slavery hypothesis" has circulated for years regarding why Black Americans have higher rates of hypertension than any other racial group. Villarosa describes Mehmet Oz and Oprah Winfrey discussing this discredited theory on her TV show in 2007. As slave ships made the Middle Passage, their "cargo" of captured Africans often died of dehydration. The theory was that those who survived were genetically predisposed to retain more salt and water-thus raising their descendants' risk for high blood pressure. The truth is that Black Americans' elevated rates of hypertension are probably due not to physiological differences, but to racism: "Less discussed, often ignored, but also proven is the link between hypertension and stressful environments and situations, including living with bias and discrimination."


The cumulative effect of racist ideas about Black bodies is that the health care African Americans receive is nowhere near equal in quality to what Whites receive. Villarosa offers abundant proof, citing major studies that have documented bias in various health care settings. She describes a groundbreaking study that revealed stark racial disparities as to which patients received physician referrals for cardiac catheterization. She expands on her own journalistic work exposing the crisis in maternal and infant mortality among Black women in the United States. Regarding mental health, it's often assumed, even by mental health professionals, that Black women aren't susceptible to eating disorders. Black Americans struggling with depression are often misdiagnosed with schizophrenia and classified as violent.


Perhaps the cruelest twist is that, as Villarosa states, Black people "have long been blamed for the health problems that plague them," even when their local environment is obviously at fault. She cites recent findings that, compared with the general population, Black Americans are 75% more likely to live near a hazardous waste-producing site, and are also more likely to "live within one mile of the hundred most toxic areas of America."


Villarosa wants health care that is not racist, and equitable care for all people, Black or White, rich or poor, gay or straight. She wants organizations and providers to see patients as people, and to reach out to those in need with the best possible care. It's a worthy, important, and achievable goal.