Under the Skin

Linda Villarosa, a journalist and professor who has covered African American health for several decades, argues that racism, not race itself, is the root cause of the racial health disparities that drive the United States to lag behind every other wealthy nation in key measures such as infant mortality and life expectancy. She traces this argument through personal experience, historical documentation, scientific research, and the stories of individuals whose lives have been shaped by discrimination in medicine, the environment, mental health care, and the broader structures of American society.

Villarosa opens by establishing a stark paradox: Despite spending more on health care than any other country, the United States has the worst health outcomes among wealthy nations, and Black Americans bear the heaviest burden. These disparities persist even when income, education, and access to care are equal; college-educated Black mothers are more likely to die or lose their babies than white mothers who have not finished high school. As health editor of Essence magazine in the late 1980s, Villarosa initially embraced the framework of the 1985 Heckler Report, a landmark government study that documented tens of thousands of excess Black deaths but recommended no new funding, instead advising education and behavior change. Her own upbringing as one of the few Black students in a predominantly white Colorado suburb reinforced a philosophy of individual self-improvement. Several encounters dismantled this framework: Harold Freeman, a surgeon at Harlem Hospital whose research showed that Black men in Harlem lived fewer years than men in Bangladesh, urged her not to conflate race and class. At a gathering of the National Black Women's Health Project, women described being harmed by providers, including sterilization without consent. In 1999, Villarosa's father, a college-educated retired federal manager, was hospitalized at a veterans' hospital, where she found him restrained, disheveled, and spoken to disrespectfully, his dignity invisible to staff who could not see past his race.

Villarosa devotes a full chapter to the history of medical abuse of Black bodies, centering the story of Minnie Lee and Mary Alice Relf. In 1973, the sisters, aged 14 and 12, were taken from their home in Montgomery, Alabama, and surgically sterilized at a federally funded clinic without their parents' informed consent. The resulting lawsuit, Relf v. Weinberger, revealed that an estimated 100,000 to 150,000 poor, mostly Black women had been sterilized under government programs. Villarosa traces a line from slavery-era pseudoscience to modern practice, detailing how Thomas Jefferson's 1785 catalog of supposed physiological differences between Black and white bodies and Samuel Cartwright's 1851 claims of darker blood, smaller brains, and higher pain tolerance in Black people laid the foundation for racially distorted medicine. These myths persist: A 2016 study found that half of white medical students endorsed at least one false belief about biological differences between Black and white people, and commercially available spirometers, devices used to measure lung capacity, still contain a "race correction" rooted in Cartwright's discredited work.

In her reporting on maternal and infant mortality, Villarosa follows Simone Landrum, a young woman in New Orleans whose doctor dismissed her complaints of headaches, swelling, and elevated blood pressure during pregnancy. Landrum hemorrhaged, and her daughter Harmony was delivered stillborn. Villarosa also recounts how tennis champion Serena Williams's medical team disregarded Williams's concerns about blood clots after a cesarean delivery despite her history of the condition, demonstrating that wealth and fame do not protect Black women from dismissal.

The best current explanation for how racism becomes biology, Villarosa argues, is Arline Geronimus's concept of "weathering." Geronimus, a professor at the University of Michigan School of Public Health, hypothesizes that high-effort coping against racism triggers chronic stress that prematurely ages the body through sustained release of hormones like cortisol and adrenaline. Her 2006 research demonstrated that Black women had the highest allostatic load scores, a composite measure of cumulative physiological wear and tear, compared with any other demographic group, and that these differences were not explained by poverty. Supporting this framework, neonatologists Richard David and James Collins found across multiple studies that babies of Black immigrant women from Africa and the Caribbean were similar in size to white babies, not to African American babies, demolishing the genetic explanation for racial disparities in birth weight. When the researchers studied the next generation, the grandchildren of immigrant women were born smaller, mirroring African American patterns.

The book broadens its scope to examine how place shapes health. Villarosa tells the story of Danielle Bailey-Lash, who grew up near a Duke Energy coal-fired power plant in Walnut Cove, North Carolina, unaware that coal ash, a toxic byproduct of coal combustion, had contaminated her community. Diagnosed with aggressive brain cancer at 35, Bailey-Lash became an environmental activist, won election to the town's Board of Commissioners in November 2019, and died days later at 45, never able to serve. Villarosa documents the broader pattern of environmental injustice, drawing on sociologist Robert Bullard's pioneering research and reports from the United Church of Christ Commission for Racial Justice establishing that race, not income, is the most significant predictor of proximity to toxic waste. She traces how redlining, a federal policy beginning in the 1930s that used color-coded maps to discourage mortgage lending in communities of color, created entrenched segregation with lasting health consequences, including higher rates of chronic illness and shorter life expectancy in formerly redlined neighborhoods.

Villarosa argues that the same structural forces erode Black Americans' mental health. She profiles Mark McMullen, the son of a university professor, who had bipolar disorder that was never consistently treated. After decades of cycling between recovery and relapse, McMullen was shot and killed by Boston police officer Christopher Carr in 2011 while unarmed and trapped in a damaged car. The district attorney's office cleared the officers, and Carr later received the department's highest honor. Items recovered from the car included a seven-month sobriety chip and AA meeting records. Villarosa connects McMullen's story to broader patterns: Black Americans who use drugs are two and a half times more likely to be arrested for possession, and the criminal justice system has historically treated Black substance use as a moral failure deserving punishment rather than a health condition requiring care.

Villarosa extends her argument to poor white communities in Appalachia, where life expectancy is the nation's lowest and opioid deaths are the highest. She suggests that the same mechanisms of weathering documented in Black communities may affect any population facing sustained discrimination and economic collapse, drawing parallels between structural abandonment in West Virginia and the forces she has traced throughout the book.

The final chapter surveys solutions: community health workers like Cedric Sturdevant, who serves young Black gay and bisexual men and transgender women at risk for HIV in Mississippi; Ethiopia's health extension worker program, which dispatched more than 38,000 women and helped reduce child deaths by 69 percent; hospital initiatives in New Orleans using restorative justice practices, which bring together patients who have been harmed with providers to repair relationships and find solutions, to redesign maternal care; and medical students pushing to eliminate racial bias from curricula, including Naomi Nkinsi at the University of Washington, who successfully ended her school's use of a kidney function test that produced artificially better results for Black patients based on the false assumption of greater muscle mass.

In the afterword, Villarosa traces the COVID-19 pandemic as the latest embodiment of these disparities. She tells the story of Cornell "Dickey" Charles, a 51-year-old member of New Orleans's Zulu Social Aid and Pleasure Club who fell ill after Mardi Gras and died of COVID in March 2020, his positive test arriving the day after his death. Black Americans were hospitalized and died at disproportionate rates, a toll Villarosa connects to every theme in her book: weathering, essential work that prevented social distancing, environmental pollution, and bias in medical devices and treatment. She closes with cautious optimism, arguing that the pandemic and the murder of George Floyd together forced a shift in willingness to confront racism as a public health crisis, even as resistance persists.