Book Club: Under the Skin by Linda Villarosa

On January 23, AMWA New England chapter members gathered on Zoom for our annual book club. Ellie Lin and Peter Stein hosted the meeting and provided thought-provoking questions about Under the Skin, a book written by award-winning health journalist Linda Villarosa.

Villarosa reported exhaustive clinical research about racial disparities in health spanning centuries of United States history and told evocative personal stories of medical harm in action. Her book examined why racial health inequities still exist today and why interventions aren’t working well enough; Villarosa spotlighted maternal and infant health in Black Americans.

The book began with several absurd yet persistent medical myths about Black individuals’ physiology that adversely affect their quality of care. Because of the myth that Black people have lower pulmonary capacity, spirometers deliver readings that are "corrected" for race and adversely affect COVID treatment. Similarly, myths of higher pain tolerance and lower baseline kidney function add to systemic racial biases in health delivery.

The book club attendees discussed how to break down barriers that prevent medical professionals from understanding that the origin of racial health disparities is oppression, not biology. While the group was not able to solve this centuries-old problem in one night, the conversation brought up another idea: continuing research on health disparities should be focused on implementing solutions.

We should focus on solutions because collectively, we already know this problem is real. Systematic reviews of racial health disparities already include hundreds of references because that was the number necessary to combat clinical inertia and internalized bias.

One proposed explanation for maternal health disparities in Black populations is the term weathering, coined by Dr. Arline Gironomus, that refers to premature health decline in populations exposed to physical and social stressors. Prompted by a discussion question about how to avoid race as a proxy for racial oppression in research, the group brainstormed different ways to ask patients about their weathering history.

Another discussion topic that came up was selection bias in clinical research against populations who have experienced weathering. The patients privileged enough not to fear the medical system are less likely to have experienced weathering and more likely to volunteer for clinical studies.

Medical writers and clinicians can learn from Linda Villarosa, a clear and compelling medical communicator. The book club brought up difficult, multifactorial problems that don’t have easy answers, but—like Villarosa herself—we can feel hope for the future because these discussions are happening out loud and in public.

Historical references of interest:

Geronimus AT, Hicken M, Keene D, Bound J. "Weathering" and age patterns of allostatic load scores among blacks and whites in the United States. Am J Public Health. 2006;96(5):826-833. doi:10.2105/AJPH.2004.060749

Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press (US); 2003.