After decades of reporting on, and editing stories about, Black women’s physical and emotional health, Linda Villarosa has come to realize that everything she thought—everything we all thought—about health disparities in the United States was wrong. In her new book, Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation, Villarosa dismantles the notion of the Black health crisis as an individual problem and exposes the origins of racism in today’s health care system, which she’s gained a deeper understanding of throughout her career, at Essence magazine, as a college professor, as a contributing writer for The New York Times Magazine and the 1619 Project, and through her own experiences living as a Black person in America. We spoke about the impact of a racist health care system on every body and what, in spite of it all, keeps her going. This interview has been edited for length and clarity.

—Regina Mahone

Regina Mahone: How is structural racism taking a toll not just on Black people, but also on “the health of our nation”?

Linda Villarosa: It’s about what’s happening in the country compared to other countries. Why is our country so rich and why is our health care system so advanced, yet if you look at from birth to death, we have among the highest infant mortality rates compared to other wealthy countries. We have among the lowest life expectancy compared to other wealthy countries. And in between, we’re the only wealthy country where the maternal mortality rate is rising. So then I started thinking about those three things, and it also intersects with what’s going on with Black people, which to me equals inequality.

Black people have never had equal health since we came to these shores. And so then it’s like, well, why are we still thinking of this as a Black problem? This is a problem of the whole country. This is a problem we all have to solve in America. And to think of it more broadly helped me to say, “Wait a minute, if this isn’t a problem that Black people have to solve by ourselves, then I need to find a way to communicate what’s going on.”

RM: You’ve written extensively about how the injustices Black people have faced are rooted in false beliefs about our bodies from the days of chattel slavery. Can you talk about those connections between the published theories about Black bodies from centuries ago and the treatment Black people experience today?

LV: For the 1619 Project, I was assigned to look at mythologies that started during enslavement that still exist today. I chose pain tolerance—the idea that we’re immune to pain and we feel less pain than white people and other people, because that was convenient during enslavement to say, so that no one had to feel bad about whipping us, beating us, taking our children away. But that still exists today. I don’t think doctors and other health care providers go into the profession to be evil. I just think that these myths and stereotypes are baked into every system and institution of America including the health care system.

The second one that I was looking at is lung function—the idea that we had weak lungs as Black people, so working in the fields is good for us. But then the idea that the spirometer [a device used to test pulmonary function] was invented by Dr. Samuel Cartwright, who also came up with “drapetomania,” which is a completely ridiculous “disease” that says that the reason [enslaved people] run away is because [Black people] have a mental illness, not because slavery is terrible. We’re still using that spirometer with a race correction for kidney function.

And when students in medical school have pushed back against [the notion of a race correction], just by asking, “Well, why is that?” There’s really not a coherent answer. It’s just the way things are done. But medical students are pushing back and trying to undo some of these old stereotypes that remain baked in current medical practice and education.

RM: How are medical students and practitioners forcing change at these institutions and in the system itself?

LV: A lot of it is Black-led, even at the American Medical Association, and a lot of it is student-led if you’re talking about medical schools. These are students that came of age, even before George Floyd, with Black Lives Matter, and they became politicized. I don’t mean just the Black ones, but students of all races. They came into medical school, and they’re kind of hit with some of the older, even disproven, things that they’re still taught and starting to push back.

For this book, I did a lot of research talking to medical students. I think the problem is, in many cases, the medical schools themselves are not leading the way from the top. It’s medical students who are trying to get an education and at the same time trying to make change in the medical school. But I’m really encouraged by that. I’m encouraged also by different colleges and universities setting up health equity centers and things like that. A lot of that has happened in the last two years, and that makes me excited.

RM: What is it about being Black in this country that is, as you write, bad for the body and the baby?

LV: Arline Geronimus coined the term “weathering.” Her theory started with looking at teen pregnancies. Back in the day everyone was worried about teen girls, but when you looked at infant mortality, it wasn’t the teenagers who were losing their babies. It was slightly older women. Geronimus started looking at the idea that something about the lived experience of being Black in America is bad for the body, and certainly going through labor and delivery for a birthing person is a complete stress test.

If you are already suffering from toxic stress, then it’s not a shock that both can be dangerous for mothers and their babies. And how she puts it is that every time something happens to you and you’re the subject of discrimination, the systems of your body rev up, whether it’s your heart rate, your blood pressure, the stress hormones. And then it really happens if you are subject to discrimination at work, by the police or in housing, but even if it’s the everyday stress described by public health professor David Williams—whether it’s someone thinks you’re stupid compared to other people, they follow you in a store, or you walk into the elevator and people recoil.

All that stuff makes you upset enough that if it happens over and over again, it just simply becomes bad for your body and creates a kind of accelerated aging.

What really struck me was when the Covid numbers came out and we learned that Black people got worse cases of Covid 10 years younger [than their white counterparts]. In my Covid story looking at the Zulu crew, when I took that story to my editor, she said, “How old is the guy you want to follow?” I said, “He died at 50.” We were shocked. Because our bodies were already damaged by living in America, then it struck us worse younger.

When that happened, I just took a breath.

RM: You traveled to West Virginia to investigate the health crisis there. Why was it important for you to connect what’s happening there with the weathering of Black people?

LV: Well, it was again Arline Geronimus and a study of Postville, Iowa, where there was this huge ICE raid in 2008. ICE comes in and they arrest and break up families. They terrorize the people of this town who were mostly all Latinx, working at a meat processing company. But it reverberated to the people in the town.

Geronimus looked at the births of the people in the next year and found that Latinx people had a 24 percent greater risk of low birth weight compared to the previous year. I asked her to explain [her theory] because she had been so grounded in Black birthing people especially.

She explained that it was not about the race of the person; it’s because of how they’re treated because of their race. So it’s not something about being Black is bad for the body. Something about being Black causes people in this country, other people to be cruel to you, and it makes a difference in your health.

So I started thinking, “Well, does that mean anyone who is treated poorly?” And she said yes. It’s just that Black folks have been treated poorly for so long, since 1619. We’ve had a long history of this, and our bodies were commodified. So we’ve been studied more, but it can happen to everybody, she said. And what I heard was “every body.” So that’s why I went to West Virginia.

There’s been an AIDS outbreak there because the pharmaceutical companies flooded West Virginia with opioid pills. Then they had to draw them back. So people got addicted to heroin, and when you’re shooting up, that’s how AIDS can be passed.

When I went there, it broke my heart going there how people were treated so badly, and they were so ill. I noticed the people looked older than they should, and I started thinking about what Arline Geronimus said.

RM: How do you, personally, find balance between knowing too much and living as a Black person in this society?

LV: Clearly this is problem of institutional and structural racism. But I also think people should take real good care of themselves and each other. My family is really close. I grew up with good food in the house. I love to cook. My children have the most high-end taste. We belong to a food co-op. We are all super obsessed with cooking well, eating well. My daughter is a vegan.

So we do take good care of ourselves. If any of us gets sick or if any of us end up in the health care system, we are really good advocates. The last time I was at the hospital with my mom, the doctor turned to me and she said, “Are you a physician?” Because I had researched everything to make sure my mom would be okay, and I was really her advocate because I don’t trust the health care system.

But I try to also compartmentalize a bit my work. You know this work can pull you down, and I don’t want to let it because I want to keep doing it as long as it’s necessary. But I do take care of myself. I play on an intergenerational soccer league, and my daughter plays with me sometimes or against me sometimes. As an individual person and a family member and a member of a community, I do take good care of myself even though I know that is not all you can do. You have to look at the system, and you have to think—the hardest part of this dilemma that we’re in is the part about racism in society. That’s the thing that no one wants to hear about.