The impact of COVID-19, a million deaths in : Code Switch A new book by Linda Villarosa looks at how racial bias in healthcare has costs for all Americans. Spoiler: Poverty counts — but not as much as you'd think.

The impact of COVID-19, a million deaths in

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KAREN GRIGSBY BATES, HOST:

This is CODE SWITCH from NPR. I'm Karen Grigsby Bates. It's a milestone no one ever wanted to reach, but recently, the United States passed the 1 million mark in COVID deaths. And that's a conservative estimate. Many experts believe that number might be considerably higher, the result of undercounting and misdiagnoses. If COVID has taught us anything in the past two-plus years, it's that racial disparities in health care are even more acute than we could have guessed. During the early days of the pandemic, before vaccines became available, poverty and the underlying conditions that accompany it often - diseases like asthma, diabetes and high blood pressure - all made it more likely that COVID patients of color would, as our guest today says, live sicker and die quicker.

Our guest is Linda Villarosa. She's just published a book, "Under The Skin: The Hidden Toll Of Racism On American Lives And The Health Of Our Nation." Linda knows hospitals. As an award-winning health and science reporter, she's been in and out of them for decades. Currently, she writes long-format stories about the nexus of health and race for The New York Times. And she comes from a sciencey (ph) family. Her dad, Andres, was a bacteriologist - her mom, Clara, a hospital administrator. So in the late '90s, when Clara Villarosa called from Denver to tell Linda her father was hospitalized and she was urgently needed at his bedside, she flew to him immediately and was astonished at what she found.

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LINDA VILLAROSA: I was working at The New York Times' newsroom - editor of the health pages - and I was pregnant. And my father was really sick. So he was sick in the hospital with colon cancer. And I knew that, but he took a turn for the worse. My parents were living in Colorado, and my mother said to me, you need to come home. I didn't know how bad it was. So I was getting on a plane, and my mother said, you need to dress up in really nice clothes, and you need to put your New York Times business card in your pocket. I didn't know exactly what she was talking about, but I jumped on the plane pregnant, got off the plane, all dressed up, and I said, Mom, what is going on? And she said, your father is really sick, and he's in the hospital, and they're treating him like - and she said the N-word.

I was totally alarmed. My father is a bacteriologist. He also is a very well-dressed, very kind, courtly kind of person. But when I got to the hospital, he was in this dirty gown. He was really disheveled. His hair was all over the place. He was super upset. And he was also shackled, basically, to the bed. He had restraints. I went to him to give him a hug or kiss, and he whispered to me, get me out of here. And my mother understood hospitals. She had been a hospital administrator. She understood why we needed to get dressed up because we needed to make them respect us, and in turn respect him.

BATES: So they explained to people at Andres' VA hospital that if the staff gave her father clinical explanations for what they needed to do and why, he'd get it. He'd be much less agitated. There'd be no need for restraints. That advice worked, but her father's hospital experience was a life-changing one for Linda. The racial discrepancies she'd heard about in theory suddenly became very real and painfully personal.

VILLAROSA: My father passed away not long after that, but that really turned a corner for me to understand that that was real - that we had to do that in order to get them to humanize him and treat him well. It just seemed to confirm so much of what I had read about what happens to Black people in the health care system.

BATES: And it turns out Linda Villarosa wasn't alone in experiencing that racial gap up close.

VILLAROSA: Many, many, many studies have confirmed that people of color - particularly Black people - are treated unequally in our health care system. If you add the layer of the lack of education or the lack of money or health care insurance, it makes everything worse.

BATES: Linda says it makes us invisible, or, at the least, it places us on the margins of the medical community's attention. That was especially obvious when COVID began to blaze through the United States.

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BATES: I heard - I don't know - I mean, just me, half a dozen stories of people who died because they went to the ER and they said, I can't breathe. I'm not feeling well. I - you know, I'm wondering if I have it. And they were sent back home, basically, and then they ended up dead. Is that still happening? I mean, that happened two years ago, and we heard it a lot. Is it still happening now, or do - are people a little more sensitive to that?

VILLAROSA: It's so sad and - that COVID happened, and then, at the same time, George Floyd's murder happened. And then people are saying the same thing. George Floyd was saying, I can't breathe. Black people are going to an emergency room and saying, I can't breathe, and that is the same cry for help for two different issues that are also related. Yes, I think it's still happening. I think, because we brought some awareness, it's better, but the basic underlying problem hasn't been solved.

BATES: And it's not just for us so-called civilians.

VILLAROSA: I am brought to the case of Dr. Susan Moore, who was a physician in Indiana. She went to the hospital with COVID. She is a doctor. So the very system that she was educated in and that she worked in didn't help her and, in fact, may have harmed her. So she said, I have COVID, and she said, I'm in a lot of pain. And she was treated as though she was drug-seeking when she asked for pain relief.

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SUSAN MOORE: I was crushed. He made me feel like I was a drug addict, and he knew I was a physician.

VILLAROSA: She also wasn't listened to when she talked about - this is the treatment I should have, and she was shut down. She recorded herself for her Facebook Live with tubes in her nose, lying in her hospital bed. And what really struck me is, throughout that recording, her refrain was, this is how Black people get killed.

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MOORE: This is how Black people get killed.

BATES: Dr. Moore went home, but died of complications of COVID-19 days later. She was 52 years old. Her death made national headlines. People were shocked. They wanted answers from her employer, Indiana University Hospital. The head of the hospital said one factor that led to Dr. Moore's experience was that the nursing staff may have been intimidated by a knowledgeable patient.

VILLAROSA: So knowing more didn't help her.

BATES: She's too smart to treat?

VILLAROSA: Too smart to treat because she was a Black woman, and that wasn't the expectation. And if you look at the research in how doctors behave, I don't think it is people going into medicine because they want to do harm. Their very motto is do no harm. But I think, you know, what the research says is people have trouble relating to people that aren't like them. And so there is a relatability question because we just don't have enough health care providers of color - mainly physicians, who have the most power. And that's what we need to change, along with getting people to look at people as humans and not as races.

BATES: Mmm hmm. It's a touchy matter, but I have to ask - do you think COVID would have been handled differently if, in the beginning, say, we were hearing that it was sickening and killing white people disproportionately?

VILLAROSA: Right at the beginning of COVID - so let's call it March 2020 - we were starting to get a whiff that Black people would get it worse. And we started seeing in cities these disproportionate numbers of Black and brown people, especially Black people, getting really sick and dying. And everyone's like, uh oh. And I remember there were these conversations underground where people were saying - because the statistics weren't out yet, and there was a fear that, when the statistics got out, that you would see this sort of turning away from helping people, turning away from caring for people because it's a Black thing, and also a lack of sympathy. Right away, you saw the lack of sympathy. You saw, oh, well, you know, Black people have these underlying conditions that are their own fault.

BATES: We've been told that, before vaccines, COVID recovery was determined largely by a number of factors that are described as comorbidities - you know, factors that many Black and brown people often have to live with daily and often have a connection to residential segregation - things like high blood pressure, diabetes, asthma, obesity. As you said earlier, in the beginning, doctors were saying, well, why aren't you taking better care of yourself? I'm wondering if there's been some nuance, now, applied to thinking about that.

VILLAROSA: I think that right now there is more of a textured understanding, but I think still the basic problem is, to me, three-fold. One is the problem of the health care system itself. Even though there's plenty of resources, there's not enough empathy, and there's discrimination baked into it.

The second thing is like what you were saying - is we live in segregated communities. We live in places that were harmed a century ago, partly through redlining, partly through contract buying in Chicago, where my mother was from, and nobody could really own a home - couldn't get a mortgage. So these communities - many communities of color, especially Black communities - are ones that aren't that healthful. In other words, the air might be dirty because they are near a polluting facility. There might be a lack of safe place to exercise and green space. The housing isn't in good shape. There isn't healthy food. They're food deserts. So rather than blaming people for being sick, for having these so-called underlying conditions, why not look at what has been done to them and their communities?

The other thing is the idea of weathering. So weathering is a phrase coined by Dr. Arline Geronimus at the University of Michigan, and it is the idea that fighting against discrimination day in, day out, ages you prematurely. Each time an incident happens, it fires up the systems of your body, including your blood pressure, your cortisol, your stress hormones and even your pulse rate. So if that happens over and over and over, as it does in the case of people who are Black in this country, it weathers the body the way a storm might weather a home - knocks the shutters off, chips the paint, messes up the roof. It also means that we have weathered this storm, which is kind of the beautiful flip side of it. But if we are weathered, which is a kind of premature aging, then it's not a shock why we would have worse COVID outcomes at younger ages. So we get sicker from COVID 10 years younger than the average white person.

And so that came out during some of the - you know, when COVID happened, it was like weathering just was proven by this terrible statistic. The other thing is it just shortens our life.

BATES: Huh.

VILLAROSA: And that is - you can't keep blaming people for that. That is something beyond. And so until we really face up to sort of what society does to Black people's bodies, what the health care system itself does, and what historically has happened to us, we're going to be coming up with the wrong solutions, which continue to be - just do better and you'll feel better, which is not enough.

BATES: A lot of people don't think that AIDS/HIV, which you covered extensively, and COVID are related beyond the fact that they're both viruses that seem to be killing Black and brown people in higher proportions. What are the reasons for that, do you think?

VILLAROSA: Well, I think, in our current, you know, society and how we think about medicine, we think about it as an individual choice to be healthy. So it's about - each person should take responsibility for their own health in order to have a positive health outcome, which unfortunately is a fallacy in a society and in a health care system that's riddled with inequality and discrimination. And so you - so both HIV/AIDS and COVID, people think, oh, you could avoid that. It's your own fault you got either of these diseases. And so that is - that kind of unsympathetic lack of compassion, treatment and framing is very unhelpful and makes the inequality worse.

BATES: And maybe makes the patients that the medical community could have had reluctant to even go through those doors.

VILLAROSA: I think that's really true. We'll be talking, having these questions about Black folks not wanting to go to - you know, being involved in the medical system, and then it turning out to be harmful. Then the conversation goes to, oh, well, no wonder, because of Tuskegee. My thing is, it's not about Tuskegee. It's what happened to you last time you were there...

BATES: Yeah.

VILLAROSA: ...Or what happened to someone you love last week. Our medical system is the most expensive and, you know, certainly the most technologically advanced in the world, and it doesn't always go wrong. But certainly, if there's this layer of discrimination that people are met with if you're Black and brown, then you don't want to seek medical treatment, you don't want to get a vaccination, you don't want to get an HIV test, and it's not your fault. If something legitimately is happening - you have a reason to be afraid - then it's not your fault.

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BATES: Coming up - hope for the future?

VILLAROSA: I'm really excited by these medical students who are trying to make a difference. When I was talking to a group, I started getting really emotional to say thank you for what you're doing, and you're not alone.

BATES: Stay with us.

Karen - just Karen - CODE SWITCH from NPR.

Another space where we see racial health disparities is in infant and maternal mortality rates. We've long known the statistics on these things. Recent government reports say Black babies are more than twice as likely to die as white ones. But it's hard to figure out exactly what's going on inside doctor's offices and delivery rooms and how that's driving the gap. Linda followed one subject in New Orleans, Simone Landrum, through her pregnancy, all the way up to the delivery room, to chronicle one woman's experience. Simone was traumatized from what had happened to her a year earlier, when she sensed problems in her pregnancy - problems that kept being ignored or dismissed by her doctors at the hospital she was using. They ignored her raging headaches and her rapidly swelling hands and feet, classic signs of pre-eclampsia, a potentially fatal development.

Full disclosure - years ago, I had pre-eclampsia, too, and my doctor, a Black OB/GYN, paid attention and hospitalized me. My baby was delivered by C-section a few days later and is now a healthy young adult. Simone wasn't so lucky. Before they got her blood pressure under control, her baby died in the womb because her placenta detached, and she lost a frightening amount of blood. That baby girl that Simone had named Harmony wasn't old enough to survive outside her mother's body, and this was a problem that could have been treated while the baby was in utero if anyone had believed Simone - if they had listened.

Now, a year later and pregnant again, Simone was in labor, and she reluctantly returned to the hospital. This time, she came with a doula - a birth coach - and with Linda as her silent observer.

VILLAROSA: She was treated badly - so badly in front of me...

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VILLAROSA: ...And in front of the doula who was with us. The three of us were the only black people in the room in New Orleans. And I saw them, you know, not listening to her, arguing with her, but also treating her very unkindly, given that their job is to care for her. One of the things that struck both the doula, Latona Giwa, and I at the beginning was they interviewed her multiple times, and they said, how many children do you have? And she said, I have two children, and then I lost a baby last year. And then they said, oh, how - when was the demise? And they kept calling the baby she lost the demise. And that baby was a little girl who she named Harmony. And when she died, Simone herself almost died. And so to repeatedly keep asking the same questions, but also referring to this painful, traumatic experience in her life as a demise while she's in labor - and the labor wasn't going great. The current baby was at risk.

If you know that someone has been traumatized the year before and things aren't going great right now, you should not be calling the baby the demise. Part of the reason, at least, that there's distress here - with mother and baby - is because of the way she's being treated. And so I could see that. The doula could see that. So they were looking at the machines, and, clearly, the baby was, you know, in somewhat - was in some distress. There were lines all over the place. I could look at the machines. But they weren't looking at her.

BATES: And update - this story had a happy ending. Simone Landrum delivered a healthy baby boy she named Kingston. But back to my conversation with Linda.

Is part of it that Black and brown patients in general aren't believed? You know, that - we have that Serena Williams story. Serena Williams, of all people, you know, talking - she's Black, but she's very wealthy and pretty much known around the globe. And yet, when she had her C-section and was recovering and said something doesn't feel right, something isn't right, you need to do more tests because something's not right, she was pretty much blown off. And she was staying in a very fancy hospital.

VILLAROSA: When I talk about racial health inequality or racial health disparities, the first assumption is that I'm only talking about poor people. And so certainly, poverty is - I have complete compassion, and it does worsen anyone's situation - makes things hectic and stressful and difficult. However, even when class isn't a factor and the person is in a really nice hospital, like Serena Williams, she still wasn't believed. And so this has been played out in research. However, it's hard for people to really believe it because it's - we've been so ingrained to think Black equals poor. But then, you know, Serena Williams goes in - a person who knows her body better than any human being on the planet...

BATES: Yeah.

VILLAROSA: ...And she wasn't believed. It's almost like speaking up for yourself doesn't really help and may even hurt if you're Black.

BATES: You had someone at Harlem Hospital, I believe, tell you to not conflate poverty with race or race with poverty. Is this an example of that?

VILLAROSA: It is, and that was Dr. Harold Freeman. And that was so long ago in my career. That was, like, in the '90s. So I have been learning this lesson over and over, but also seeing it continually happen. And it's hard for some people to not do that because of the stereotypes that are floating around in our culture and in American society. But, still, it's harmful to patients if you're tackling the wrong problem. So if you're saying, well, if we just tackle poverty, then the issue of racial health inequality will go away. But that doesn't help, and that's one of the things that I really emphasize in my own reporting - to say, don't conflate race and poverty. They're two different - can be related problems, but they are different, and race, in itself, is also a risk factor for health inequality and health problems in America.

BATES: Are there big studies that pop into your mind immediately when I ask about studies that indicate that bias is a problem?

VILLAROSA: The one that really gets to me is - it was in that big unequal treatment document from 2002, and the one that hit me was about amputation for diabetes. So they looked at amputations for diabetes. The other thing is people have the same level of diabetes, so - you know, the same severity. Still, Black people, even when other parts were equal - everything was equal - Black people were still more likely to get a foot amputated. And so I don't think individual doctors go in being racist. However, somebody made a decision to too often cut off the foot of a Black person. And that was the one that really hit me. I just kept picturing that - picturing someone made that decision.

BATES: Mmm. And if I remember correctly, that while amputation may save the patient sort of in the short term, they have other ancillary medical problems that are attendant to the amputation as time goes on, right?

VILLAROSA: True. Very true. And also, you have an ambulatory problem...

BATES: Well, yeah.

VILLAROSA: ...When you don't have your (laughter) - so that is a, you know, a terrible thing to happen, especially if it's being handled in a way that isn't fair. And there's some bias baked into this very system. This document is the gold standard, but many more studies have come after that, including the ones that are the most infamous, around pain tolerance. Even in cases where we're complaining more of the pain, we were getting medicated for it less because of an old assumption that we have super high pain tolerance and that we don't feel pain the same way. And so because I'm Black and there's an assumption floating around that's maybe been left over since the 1600s that I have higher pain tolerance, that's unfair, and we have to address that.

BATES: I'm thinking that if people are not given the pain relief that they need - that it's not adequate to actually assuage the pain that they're having - then they find other ways, perhaps to self-medicate, which may not help the pain much. It may take the edge off, but may provide other problems that hadn't been on the board before. Is that a thing?

VILLAROSA: That is really a thing. And, you know, the thing that really strikes me is not only - like self-medicating, very true, but also just being depressed 'cause long-term chronic pain is - you know, makes you sad, makes you angry, makes you depressed. And so that's not fair for someone, you know, because of some form of discrimination in our health care system, to be living with chronic pain, that they self-medicate, they're sad, they're depressed, they can't work. That's wrong.

BATES: Having done this for several decades and also at this COVID-intensive time, I'm wondering, Linda, if you think that there's any hope at the end of all of this. I mean, COVID kind of shone a pretty glaring spotlight on the just radical inequities along racial lines that exist still in this country. Is there any hope that that illumination has maybe been the starting point for starting to correct some of those inequities - for maybe putting policies in place that might change some of those inequities? Or is this - you know, we're just going to keep continuing as we have?

VILLAROSA: I think there has been movement. In California, certainly, health care providers that work with pregnant women and birthing people have to go through some kind of anti-racism training. And that was expanded to be - almost everyone in the health care system in the state has to go through some kind of anti-racism training. So certainly, it comes in different flavors. Some of it isn't the best, but at least there's this nod toward saying, yes, we understand and we see this problem, and we're trying to do something. It may not be enough, but it's something.

The other place where it's very - there's a lot of energy is in medical school. And so I did a lot of interviewing of medical students, and many of them in this generation were politicized by Black Lives Matter when they were in undergraduate college. So then they went to medical school and they brought that same kind of activism and that spirit with them. And it's very exciting to see groups of medical students pushing back against parts of their education - that they say, well, this is old. I don't want to be a doctor like this. I want to confront my biases and not enter the field with them.

The other place is on the ground. I've seen so many people saying, how do I get doula training so I can be the partner - the birth partner of a person at her most vulnerable, at a place where we've seen it go south for Black women? Let me be there in the room, like I was in the room with Simone Landrum, like, as well as her doula. And I find that really exciting. So, you know, there are bits of hope, but I think we have to just keep this issue on the forefront and not shy away from it.

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BATES: That was health journalist Linda Villarosa. Her latest book is "Under The Skin: The Hidden Toll Of Racism On American Lives And On The Health Of Our Nation."

Linda, thanks so much for your time. And it was great talking to you.

VILLAROSA: Thank you. I really appreciate you. And thank you for having me. I love your show.

BATES: And that's our show. You can follow us on IG and Twitter at @NPRCodeSwitch. I'm @KarenBates. Subscribe to our newsletter at npr.org/newsletters. This episode was produced by Kumari Devarajan, edited by Steve Drummond and fact-checked by Taylor Jennings-Brown. Shout-out to the rest of the CODE SWITCH fam - Christina Cala, Gene Demby, Alyssa Jeong Perry, Leah Donnella, Summer Thomad, and Diba Mohtasham. I'm Karen Grigsby Bates. See ya.

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