Linda Villarosa explores racism in health care in 'Under the Skin' : Shots - Health News Linda Villarosa says bias in the health care system and the "weathering" affect of living in a racist society are taking a serious toll on African Americans. Her new book is Under the Skin.

'1619 Project' journalist lays bare why Black Americans 'live sicker and die quicker'

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DAVE DAVIES, HOST:

This is FRESH AIR. I'm Dave Davies, in for Terry Gross, who's off this week. It's no secret there are problems with health care in America, and it's no surprise that Black people have poorer health outcomes in the United States than whites, given disparities in income, wealth and insurance coverage. Our guest, Linda Villarosa, is an author and journalist who's been writing about the intersection of race and health for years. She says for a long time she thought poverty was the explanation for why Blacks were less healthy than whites. But over time, her thinking has changed. She now believes something else is making Black people sicker, and that something is racism. In a new book, she argues that while poverty certainly matters in health, studies show that Black people suffer long-term health effects from the daily stress of living in a racist society, and that the health care system itself is infected with racial bias among providers, administrators and policymakers.

Linda Villarosa is a journalism professor at the City University of New York, the author of two previous books and a contributor to the 1619 Project. Her writing on race and health has appeared in The New York Times Magazine since 2017. Her new book is "Under The Skin: The Hidden Toll Of Racism On American Lives And On The Health Of Our Nation." Well, Linda Villarosa, welcome back to FRESH AIR.

LINDA VILLAROSA: Thank you. I'm so happy to be here.

DAVIES: You know, this book is - a lot of it is about studies and your own research and reporting. You also draw on your own experience as a Black woman. When your family moved to Denver - you were in a predominantly Black community in the South Side of Chicago. When you moved to Denver, how much overt racism did you experience?

VILLAROSA: Oh, the racism was overt in some instances. So when we moved there, we were driving. My family was driving up to our new home. And we were so excited to get - my sister and I were really happy to get our own rooms. And then as my parents drove up, our car was packed with all of our stuff from Chicago. And one of the neighbors had written N-word, go home, on the garage. So that was our welcome to the community. When I first started - I started in third grade at my elementary school. And I realized that none of the children were talking to me.

And eventually, one of my classmates told me, well, before you came, we had a assembly with all the kids in the school. And they said, you're getting your first Black children. That was my sister and me. And so they said, be careful about what you say to them because you might say the wrong thing or hurt their feelings. So the other kids were so scared to say the wrong thing that no one talked to me for probably a month or more. And I just thought no one liked me. So eventually, you know, I smoothed that out. But it was a really difficult way to start in a new community.

DAVIES: Yeah. I mean, part of what we'll talk about deals with the effect of the daily stress of living in a racist world. That's something that, you know, you from a kids' age really had to deal with.

VILLAROSA: I also think of my parents, the strain that they both had to try to cover it up to me and my sister because we were so young. And they - this was such - supposed to be such a happy moment. So I know it was really stressful for them to try to make it OK for us.

DAVIES: Right. In the mid-'80s, you became a contributing nutrition and fitness writer for Essence magazine. And you said your mission was to fix the health crisis in Black America. What did you see as the problem?

VILLAROSA: Well, the problem was very clear. So it was clear that there were racial health disparities so that Black Americans had higher rates of so-called lifestyle diseases is what we called them then. And it was heart disease, diabetes, stroke, asthma, things that were considered - shouldn't make people that ill and certainly shouldn't be deadly. And so we knew that, but we just didn't understand the cause, exactly why this was happening.

And so the explanation was it's our own fault. So either that it was something about our genetic makeup that was making us more sick and to also lower life expectancy, higher rates of infant mortality, or it was something we were doing wrong. So at Essence, the idea was, well, we can fix racial health inequality by just getting all the people in our magazine - because those are the people we had access to - to just do better. And what we said is, if you know better, you do better.

DAVIES: So make smarter choices about nutrition, about health, all of that stuff, smoking, drinking, all of that.

VILLAROSA: Exercise, yes.

DAVIES: Yeah. I mean, poverty surely had to figure into all of this, too, right? I mean, people that don't have - you know, it's harder for them to take care of themselves. They have less access to the medical system. Right?

VILLAROSA: That is certainly right. But the people at Essence, the readership of Essence, was more made of striving Black people. So it was sort of more of a middle class magazine. So although we were discussing poverty and discussing, you know, marginalized lives, we were mostly talking to a middle-class group of women to say, well, make sure that you're really taking good care of yourself and also taking care of the people in your family and also taking care of the people in your church and in your community. So in some ways, we were, you know, we didn't realize it at the time, but we were really burdening people to say, oh, you have to take care of everyone, including yourself, to make all Black people healthier and have better well-being as a race.

DAVIES: You write that you met a surgeon at Harlem Hospital who'd written an article in the New England Journal about racial disparities in health. He changed your thinking some?

VILLAROSA: And that was Dr. Harold Freeman. And he is a magnificent, really smart, hardworking, thoughtful person who had a research study in the New England Journal of Medicine. And he looked at the health of men in Harlem and compared them to men in the impoverished country of Bangladesh. And it turned out that Black men in Harlem lived fewer years than men in Bangladesh. And it was shocking. It was in the New England Journal of Medicine. So he came to speak to my class at the Harvard School of Public Health, my fellowship class. And I was so interested in everything he had to say. I was all over him. And I was insisting to him that this is a problem of poverty.

And one thing he said to me was, wait a minute. Look at the population of Harlem. The population of Harlem isn't all impoverished, one. So if you are thinking that the health problems of Black people in America are only because of poverty, you're making a mistake. And you're - all your thinking is going to be wrong. And what I learned from him is if you're looking at the problem through the wrong lens, you're coming up with incorrect and ineffective solutions.

DAVIES: You also describe an experience of your own when you were in New York. I think you were working for The New York Times then. And your mom called about your dad, who was ill. And your parents were divorced by then, but they were still in touch. And she was helping with his care. She said he's in the hospital. And she asked you to come to Denver right away. Tell us why and, you know, the instruction she gave you.

VILLAROSA: So it was very strange. My mom called me. And she was quite frantic. And she said, you have to come to Denver now. And I was also pregnant, so I wasn't trying to get on a plane. And then I said, why? What's going on with dad? - because I didn't know how advanced his problems were. And she said, oh, he's in the hospital. You need to come now. So she said, I will pick you up at the airport. Dress nicely. And put your New York Times business card in your pocket. I'll pick you up at the airport. So I'm on the plane thinking, why am I doing this? I get off the plane. My mom is dressed up really nicely, too. And I said, Mom, what's going on? And she said, they're treating your father like an N-word. We need to go and take care of this.

So we went to the hospital. And my father was a very well-dressed man. He studied bacteriology in college, so he was a scientist. He really cared about his grooming. He was very kind. We found out he had colon cancer. And he was very distressed by the care he was receiving. When we got there, he was in restraints on the bed. And I leaned down to give him a hug, and he said - he whispered to me, get me out of here.

So what my mother did - she had been previously a hospital administrator. So we went home. We got pictures of him, how he looked before in his nice clothes, well-dressed. We got his college degree. He was a veteran. We brought his proof of his military service, his medals, and showed them that if you speak to this man who's highly educated, though really upset right now, he'll listen to you. But don't restrain him. Don't yell at him or whatever has been going on. He was clearly being mistreated.

When we came with our sort of middle-class respectability, he was treated better, and people saw him as a human being. But I never forgot that 'cause I thought, why should we have to do that? Why do we have to go through that just to get the kind of care, treatment and really respect and dignity that everyone should get when they come in to health care facilities?

DAVIES: Let me reintroduce you. We are speaking with Linda Villarosa. She's a journalist and author. Her new book is "Under The Skin: The Hidden Toll Of Racism On American Lives And On The Health Of Our Nation." We'll continue our conversation in just a moment. This is FRESH AIR.

(SOUNDBITE OF AHMAD JAMAL'S "THE LINE")

DAVIES: This is FRESH AIR. And our guest is Linda Villarosa. She is a journalist and author who's been writing about the intersection of race and health for many years. Her new book is "Under The Skin: The Hidden Toll Of Racism On American Lives And On The Health Of Our Nation."

You know, you note that there've been a lot of medical myths about Black people, some held by such presumably rational thinkers as Thomas Jefferson - that Black bodies were different from white bodies. What are some examples of this?

VILLAROSA: I think the one that really struck me - and I covered this in my reporting for the 1619 Project - was the idea that Black people have an extreme tolerance to pain, almost a superpower against pain. And that myth started during the years of enslavement. And it was pushed by doctors and scientists at the time who also had a hand in keeping slavery intact. So the idea that if Black people had extreme tolerance to pain, that you could hurt our bodies - you could beat us, whip us, take our children away and work us from sunset to sundown, and it wouldn't matter. And so that was started during enslavement. And what I learned was that myth was pushed using evidence, in data, in medical journals.

So then fast forward for me to 2016. And it was a study out of the University of Virginia that looked at myths that medical students still believed. And it looked at 220 white medical students. And over a third of them, about 40% of them, believed at least one myth about the Black body, including the idea that Black people have a different kind of pain tolerance. This was 2016, so I looked at more recent data. This was about a year ago. It was a look at cesarean sections, clearly major surgery. But again, medical students and residents thought that Black women did not need as much pain management during a C-section as white women, even when you know, everything else was the same. That is alarming because those are the future doctors of America. And so that means that we need to do things differently here.

DAVIES: Yeah, I have to say that's shocking that you'd hear that in 2016.

VILLAROSA: And other myths were, like, that black skin is thicker than white skin. Certainly, that is a myth. That's not true. Skin comes in all (laughter) degrees of thickness. But if you believe that, you - it sort of speaks to a kind of a false invulnerability that Black people have that would allow us to have - not have our pain treated in the same way.

DAVIES: Right. There's also one about pulmonary weakness, weaker lungs, right?

VILLAROSA: There was a myth that, again, started during the years of slavery that Black people had inferior lung function. So it was sort of the opposite of the pain tolerance one where we had a superpower. And this was an inferiority. And so that was the idea that because of these weak lungs, it was good for us to work in the fields because it was like a form of exercise, free labor as exercise. And this was a myth that was believed by doctors and, again, pushed forward to - you know, in medical journals, at medical conferences.

Fast-forward to today, and there's a machine called spirometer that measures lung function. And often in these same machines that are used today, there's a race correction that assumes that Black people have inferior lung function. And I was thinking about this for myself not long ago. A couple of years ago, I had a lung function test because I was getting over bronchitis. And then I started thinking, I wonder if I got the race correction, which would have been really unfair because I was raised in Denver, which is the Mile High City. So I have really good lungs. So it would be - it's incorrect to say - to assume a racial inferiority without looking at other ways that I might be different, including having been raised in the Mile High City.

DAVIES: Did you find out? Was the correction used on your test, the racial correction?

VILLAROSA: I never found out. But recently, I had a kidney function test. So that's another - you know, I went to the doctor about six months ago, and I had a kidney function test. Kidney function is another way that there's a race correction. So I was telling someone - I said, you know, there's a race correction for kidney function. And my friend - you know, and we were on Zoom. She said, no, there isn't. I said, yes, there is. And I held up my own test. And it had if you're Black, this is the reading you use. If you're white, this is the reading you use. And mine was - my Black one was circled because I'm Black. And I said, this is 2022, and I'm still - we're still having this. There are not these kind of biological differences that you can just assume that Black people have a different racial - genetic makeup or race than white people in medicine.

DAVIES: You also write about a study done by Kevin Schulman - I think was the name - a physician who also had an MBA from Wharton and looked at whether doctors would treat white and Black patients the same who present certain cardiac symptoms. You want to describe what he did and what he found?

VILLAROSA: Dr. Schulman is a really - did a really interesting experiment. He's now a professor at Stanford. And so I called him to hear about - you know, sort of to hear him tell me how it worked when he did it. So he looked at cardiac catheterization, which is - you know, if you have a heart problem, that's a treatment for it. And he used actors, and there were four groups. So it was white women, white men, Black men, Black women. And everyone had the same job, they had the same kind of health insurance, and they had the same degree of health problems. Yet the Black women were the ones least likely to get this really lifesaving treatment, and white men were the most likely to get it, even though everything else was balanced.

DAVIES: You write about a pair of sisters, Minnie Lee and Mary Alice Relf from Alabama, who were at the center of a famous case of forced sterilization. Tell us who they were, what happened to them.

VILLAROSA: These were two young girls. They were 12 and 14. And they were from a large family that had relocated to Montgomery, and they were living in a field. They were living out in the open with their other family members and their parents, who were uneducated and illiterate and didn't have jobs. So a social worker named Ms. Bly got assigned to their case, brought them into - they got - she got them - arranged housing for them. She arranged health care for them. She arranged the children to go to school.

And so now, they're living better. They're in public housing. They're in school. But they also came to the attention of the public health service. And at the time - this was in the early '70s - they had begun sterilizing people - young women mostly - who were disabled, who were uneducated as well. And so they ended up getting sterilized without the consent of their parents.

DAVIES: Right. They were told they were - their mom says that they were told that they were going to be - go to get some shots, but they, in fact, were sterilized then, right?

VILLAROSA: Their mother understood that they were getting shots to keep - immunizations to keep them healthy, and she signed an X on the consent form because she couldn't read or write. In retrospect, she then said, wait, I had no idea that I was getting my daughters sterilized. They're - they were - one of them was not even a teenager. So something really sinister happened to that family.

DAVIES: Yeah, and we know the names because it became a famous lawsuit, right?

VILLAROSA: It became the case Relf v. Weinberger. And the Relfs won that case, which changed the law and changed history, to say that you can no longer just sign an X for sterilization, that the government shouldn't be sterilizing people, and that you have to have informed consent in order to sterilize a human being.

DAVIES: Did that pretty much put an end to the practice? I mean, it - we - I think as many as 100,000 Black women, you think, this may have happened to?

VILLAROSA: It was 100,000 to 150,000 women, most of them poor, a majority of them Black. What happened is it continued. It continued even after eugenics laws were changed. Most of them died out by the '70s. The practice was still going on. As recently as a few years ago, women in California - incarcerated women - were being sterilized. And even a year ago, women in ICE facilities - they were in immigration detention centers - were being sterilized without informed consent. So it hasn't ended.

DAVIES: You decided you wanted to check in on these two - they were teenagers at the time, would be much older now. What did you find?

VILLAROSA: I was doing research on the ground in Montgomery, and I hadn't been able to find the Relf sisters. And I had a researcher that I was working with, and she asked me to do a parenting class for her. I said no three times. I really didn't want to do the parenting class 'cause I was tired, and I wasn't there for that.

Then, I finally agreed. And while I was speaking to the group of parents, I noticed that one of their nameplates had Relf. Her name was Debbie Relf. So I said, I know this is going to sound crazy, but do you know a Mary Alice and a Minnie Lee Relf? They would be in their 60s now. And the young woman said, yeah, they're my aunts. So she introduced me to them, and I got to meet them. I got to know them. And I was really moved by who they were, how kind they were, how humbly they were living, and how much they had sacrificed.

DAVIES: And what did they recall of, you know, the controversy of the case? Did they have a sense of the stakes of all this?

VILLAROSA: What they recalled was - they recalled Ms. Bly, their social worker. They recalled Joe, their lawyer. They remember the only time they were on a plane was to fly to Washington to testify at hearings with Ted Kennedy. But they don't really understand exactly how it changed history. They don't understand what a huge part of history they are. But they are clearly scarred. They're scarred physically. They have giant scars from their surgery. They're scarred emotionally because they wanted to have children. And it was really unfair, and it's an unaddressed wound.

DAVIES: We're going to take another break here. Let me reintroduce you. We are speaking with Linda Villarosa. Her new book is "Under The Skin: The Hidden Toll Of Racism On American Lives And On The Health Of Our Nation." She'll be back to talk more after this short break. I'm Dave Davies, and this is FRESH AIR.

(SOUNDBITE OF BOBBY HUTCHERSON AND MCCOY TYNER'S "ISN'T THIS MY SOUND AROUND ME?")

DAVIES: This is FRESH AIR. I'm Dave Davies, in for Terry Gross, who's off this week. Our guest is journalist and author Linda Villarosa, who's written for years about the intersection of race and health in the United States. In a new book, she argues that poorer health outcomes for Black people in America aren't solely attributable to higher rates of poverty. She says the daily stress of living with racism has long-term health impacts. And studies show plenty of evidence of bias in the health care system. Her book is "Under The Skin: The Hidden Toll Of Racism On American Lives And On The Health Of Our Nation."

You reported a story in 2018 called "Why America's Black Mothers And Babies Are In A Life-or-Death Crisis." And you write about several Black women who were pregnant and had babies and, in all cases, women who were educated, financially stable, had good health insurance and healthy lifestyles, who experienced complications with pregnancies and births. One of these people was you, but I guess that's a different story, maybe. Tell us what you found.

VILLAROSA: I was really intrigued by this story in the first place because of a statistic that I heard. And the first stat - and I heard this while I was playing soccer on a weekend from a woman who was a lawyer for - she was an international lawyer. And she was telling me - she said, did you know that the United States is the only country where the number of women who die or almost die in childbirth is going up? So I said, oh, no, I didn't know that. Then she said, it's driven and it's by Black women because Black women are three to four times more likely to die or almost die. So I was still under the impression, even in 2017, that this was an issue of poverty. So I was arguing with her. And then she stopped me cold because she said education is not protective. So if you're a Black woman with a master's degree or more, you are still more likely to die or almost die than a white woman with an eighth-grade education. So that struck me.

It also struck me that I had had a low-birth-weight baby, which was really unusual for someone in - that I was so healthy. I was working as the health editor of Essence magazine. I was a public figure as a healthy person trying to do everything right. And then I had this low-birth-weight baby. I've heard so many other stories from other Black women, including Serena Williams, who had a difficult birth. And then even my book is reviewed next Sunday in The New York Times Book Review. And the reviewer herself, when talking about my book, discussed her own difficult pregnancy. And so this is just so widespread. And it's - I think that my article struck a chord for people who had been experiencing this but never heard it discussed.

DAVIES: Now, one explanation might be getting bad treatment from the health care system. But as you looked into this, you discovered there are other explanations. What did you find?

VILLAROSA: I met Dr. Arline Geronimus, who is a public health professor and researcher at the University of Michigan School of Public Health. And she told me about her theory of weathering. So weathering is the idea that something about the lived experience is bad for the body and creates a kind of premature or accelerated aging. And she - I love the word weathering because it's two-fold. So it's the same way that a storm weathers a house and it knocks the paint off. It takes the shingles off the roof, pulls down the shutters. But also a house weathers the storm.

DAVIES: Right. And one of the things that I think that or some other research showed that Black teenage girls actually had healthier pregnancies than Black women in their 20s, I guess the idea being with time, your body just - racism takes a toll on the body.

VILLAROSA: And when Dr. Geronimus first talked about that finding that she had, she was ridiculed. She - people were cruel to her. They threatened her because they thought she was encouraging teen pregnancy. But what she was doing was really reporting on evidence to say older, Black women have had a longer and harder time in America, and it's taken a greater toll on their bodies and created a kind of accelerated aging. And it took her a really long time to get the respect that she deserves.

It's interesting because now when COVID happened, people reached out to her because they started saying, oh, maybe this is part of the reason that Black people have worse COVID outcomes because of this kind of accelerated aging. The other thing that happens with COVID is Black people got worse outcomes at younger ages than white people and some other people of color. And so people really started to listen to Dr. Geronimus.

DAVIES: You know, we've all heard the phrase when talking about research that correlation is not causation. I mean, the things that - the fact that two conditions are associated doesn't mean that one causes the other. What do we know about kind of how racism might affect the bodies of Black people? And is there anything that tells us that people who have had harder experiences in race relations suffer these health effects worse?

VILLAROSA: So when Dr. Geronimus was working, in the early part of her career, she had so much pushback that she started doing - her scientific research changed. And so she started looking at the physical effects. Like, what exactly happens to the body when you're treated poorly? So what she found was what happens during fight or flight. So your heart rate goes up, your cortisol stress levels go up in your body. Your blood pressure rises. So this makes sense if you're in a fight-or-flight situation, but it doesn't make sense if it's happening day in, day out. It's not good for the body. It's not good to get your heart rate up so high all the time. It's not good to get your cortisol levels to go up. It's definitely not good to have your blood pressure going up all the time. But when people are treated badly, that's what happens.

And I was thinking of the case of one of my former students who was telling me about - he said, I don't really - racism isn't a thing for me. He was telling me. He's from the South Bronx. And I said, really? It's never happened? And he said, no. And I said, really? You've never had a time - you're a young Black man in the South Bronx. You've never had a run in with the police. He said, oh, yeah, I had one recently. I said, tell me about it. And he said he was going to - he and another guy, they were going on a date with two young women. And they - the police - they were walking to go get pizza. Police cars came up to them. They threw them against the police car, handcuffed them, had their guns out and accused them of being involved in a robbery. The young women were taking video of what happened. So then in about - I don't know - 40 minutes, they figured out, oh, we've got the wrong guys, sorry. And they let them go.

And I said, wait. Why did you not say that that was an instance of racism that happened to you? He said, oh, that's - I don't consider that racism. That's just my daily life. That's my everyday. And I started thinking about him. And I thought, if that is his everyday, he is not at all moved by being treated that badly all the time because he's just accepted it. What is that doing to that young guy's body?

DAVIES: You have a chapter where you do some reporting in the state of West Virginia, which is 93% white. And you visit nonprofits that serve people who are without housing, others that are struggling with addiction. These are all white folks. And you posit the hypothesis that this kind of weathering, this daily stress which can undermine health, applies here. What's this? They're clearly not Black people suffering from racism. What's what's the point you're getting at here?

VILLAROSA: I think it was Dr. Geronimus and her colleagues who encouraged me to examine this, to say what we know about weathering and what we know about accelerated aging we know from Black people because we've been through discrimination, which is well documented. It started in 1619. It's been through generations of people. We know this. And she had already proven through her research that this was taking a toll on Black bodies. But in theory, it's not specific to Black people or Black bodies. It's anyone who is treated badly repeatedly will be harmed. It'll hurt their bodies. So I decided to go to West Virginia to an area that was having an HIV outbreak. It was having an HIV outbreak because of opioids.

So West Virginia, as we know, was flooded with opioid pills. And so then they were pulled back from the streets. So people got addicted to heroin, so they started using heroin and sharing needles. So that created an HIV outbreak. So I was just curious to see what happens. You treat people badly, you inundate them with pills, and then you yank them away and then they get addicted to heroin. Then they're blamed for their condition with less interrogation of what actually happened, what pharmaceutical companies did.

What I found was - right away, the first thing I noticed was people looked so much older than I thought. I was always misguessing everyone's age. And I stuck with them. I saw people that were homeless. There was such an extreme amount of shame from the people. There was so much pain. And I just thought, this is weathering, too. When people get treated badly, they blame themselves. They're, you know, they don't get treatment and care. They get ridicule and a lack of support. This is what happens to you. Your body ages. So it's really anyone who's mistreated, marginalized.

DAVIES: We need to take another break here. Let me reintroduce you. We are speaking with Linda Villarosa. Her new book is "Under The Skin: The Hidden Toll Of Racism On American Lives And On The Health Of Our Nation." We'll continue our conversation after this break. This is FRESH AIR.

(SOUNDBITE OF AVISHAI COHEN SONG, "AFTER THE BIG RAIN")

DAVIES: This is FRESH AIR. And we're speaking with journalist and author Linda Villarosa. Her new book is "Under The Skin: The Hidden Toll Of Racism On American Lives And On The Health Of Our Nation." You end the book with some reasons for optimism. One thing you said is the growth of community health workers. Do you want explain what they do and why they matter?

VILLAROSA: Community health workers are much more likely to be used in much poorer country than ours. So I had - I visited a couple of countries in Africa, where I saw community health workers in action. And these were young women who were chosen by a community or often a village. And they were in high school. And then the village sent them off to be educated basically as nurses, and then brought them back to be the community health care providers, to do the kinds of things like dealing with mosquito nets, vaccinating babies, doing prenatal visits, doing HIV screening. It was really wonderful to see these young, trusted women in the community.

So in other countries, we use them. They're sort of a low-tech solution to bigger health problems. But here in the United States, we don't often use that kind of provider. There are community health workers, but we don't use them as much. They're also very low paid. I also - I noticed in my stories the people who help me are patient navigators, social workers, kind of health activists and doulas. These are the kind of people who link our very high tech health care system and our very expensive health care system with patients. And I think that is really important. And there is a growing need for that. There's a growing awareness that this is important.

DAVIES: What about the problem of bias among health care professionals? Do you see steps being taken to address that?

VILLAROSA: I'm very excited about what's happening in California right now. They looked at maternal mortality in 2006. They began to look at it and said California has the same levels of maternal mortality as the country - and the levels are going up - and the same racial disparities. So Black women, there are 3 to 4 times more likely also to die in - related to pregnancy and childbirth. So what they did is they said, you know what, we're going to fix this. We are going to change the way hospitals work to make sure that if there's a maternal crisis in the delivery room, we're going to have all hands on deck. Everyone's going to have the same information on hand and also the same tools together. So if there's a hemorrhage, here are the tools that are needed. Here are the instructions for what to do.

And over - I think it was a five-year period, maybe longer, the number of women who died in childbirth went down by 55%. This is a wonderful outcome. However, the racial health disparities stayed the same because it turned out that white women benefited more. So what California did, the state - it passed legislation to say that any professional who was dealing with a birthing person had to go through some kind of anti-racism or anti-bias training in order to be, you know, a health care provider for pregnant women and birthing people.

I think that is a really, really good first step. I don't think it's a complete solution. But it's an acknowledgement that you can't - we can't doctor our way out of some of these problems or tech and technology and clinical solutions aren't the only answer, that we have to look at the way people are treating each other.

DAVIES: You know, you note one case where a hospital in Louisiana employed the restorative justice model in dealing with - there was an experience of one Black woman, Rodnika Shelbia (ph), if I have the name right, who had an obstetric emergency and got some very bad care and a year later had a session with the providers and administrators of the New Orleans hospital where she had been treated. Just tell us what happened here.

VILLAROSA: This was a very important moment to have a woman who was harmed by a hospital system go back to the providers - some of the providers were in the room - who gave her care and say what happened to her, just report, this is what happened to me. And to have all of them bear witness to her pain, to the harm that was done to her - I think that doing that is so important.

Certainly, I don't think health care providers of any kind go into the profession to hurt people. But it's a chaotic situation often. There's often - like, it's scary. And people don't behave their best when that is happening. So it was important for them to hear her say, this is what happened to me in the care that you gave me and to have them have to bear witness to her pain and her suffering so that they can do better next time - so that they can hear the damage they've done, not ignore it, not paper over it, but hear and make changes in their own behavior and in their own system.

DAVIES: There's a lot here. And a lot of it's pretty distressing, I mean, you know, to see these disparities that persist. How optimistic or pessimistic are you that we can make progress?

VILLAROSA: I'm always very optimistic. And sometimes it doesn't make sense, but I feel very optimistic. I feel energized by medical students wanting to make a difference. I feel happy about the commitment of people like community health workers, patient navigators, people who are putting kindness and care into health care.

I feel excited by what has happened in the past two years. I remember when I would do panels that we're talking about race and medicine. We were very careful not to say racism because it was hard. I didn't want to hurt people. I thought, people who are going into health and health care and public health, it's unkind to accuse them of being racist. And now I realize it's not. We're not accusing individuals of being racist. But we're saying, there is something wrong with what is happening in America, the experience of health and health care in America for Black people and other people of color and other marginalized people. And we can name it.

So now it's common to go to a panel that's called Racism as a Public Health Threat. Whereas even two years ago, we were kind of tiptoeing around that. I think when you identify the problem, when you discuss the problem, it's easier to address the problem and come up with solutions than it is when you're pretending like it doesn't exist. And what I really like is there are organizations like the Centers for Disease Control. Many of the major universities have created health equity centers. Other organizations, like the American Medical Association, have apologized to the treatment - past treatment of Black physicians. I'm really encouraged by - that there is some movement. We just have to grab onto the movement and hold onto it.

DAVIES: Well, Linda Villarosa, thank you so much for speaking with us again.

VILLAROSA: Thank you. It's good to be here, good to talk to you.

DAVIES: Linda Villarosa's new book is "Under The Skin: The Hidden Toll Of Racism On American Lives And On The Health Of Our Nation." Coming up, Maureen Corrigan reviews a debut novel about a young, gay Black man who gets some supernatural guidance in dealing with the difficulties of his interracial relationship. This is FRESH AIR.

(SOUNDBITE OF THE MIDNIGHT HOUR, ADRIAN YOUNGE AND ALI SHAHEED MUHAMMAD'S "BETTER ENDEAVOR")

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