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editor of the prestigious Journal of the

American Medical Association in a 2021

podcast. “Structural racism in an unfortunate

term,” this editor said. “Personally, I think

taking racism out of the conversation will

help. Many people like myself are offended by

the implication that we are somehow racists.”

JAMA’s Twitter account posted a tweet about

the podcast: “No physician is racist, so how

can there be structural racism in health care?”

The podcast and the tweet were deleted, and,

Villarosa writes, “the deputy editor and the

editor in chief — both white male physicians

— resigned.”

Some people are offended by what the hard

research on health-care disparities shows.

Villarosa provides the facts in abundance,

perhaps none more alarming than this one:

Black women, including those “whose income

and education should protect them,” are three

to four times more likely than White women

to die from pregnancy-related causes.

Tennis star Serena Williams was nearly one

of those fatalities. The day after delivering her

daughter by Caesarean section, Williams was

struggling to breathe and knew from previous

experience that she was having a pulmonary

embolism. She told the medical staff what was

happening and the treatment she required,

only to be ignored. Her persistent coughing

ultimately ruptured her C-section sutures,

sending her back into surgery; it was then

that a large hematoma was discovered in her

abdomen, which required still further sur-

gery. Villanova documents a number of simi-

larly harrowing stories, should facts alone not

suffice in convincing us of the crisis at hand.

But some need no convincing. Alas, we

have stories of our own.

care parity.

Equal treatment within the health-care

system, Villarosa argues, regardless of class or

social status, remains elusive because of three

primary obstacles: long-standing institution-

al and structural discrimination; implicit

biases in the medical profession resulting not

only in misdiagnoses but even blame for

being unwell; and “weathering,” which, Villa-

rosa writes, refers to the “struggle with anger

and grief triggered by everyday racist insults

and microaggressions... [which] can, over

time, deteriorate the systems of the body.”

The female reproductive system is not

immune. Villarosa cites a 2007 American

Journal of Public Health study that demon-

strates that Black women who reported

experiencing racial discrimination had dou-

ble to triple the rate of low-birth-weight

babies compared with Black women who did

not report incidents of discrimination. Sum-

ming up, Villarosa writes, “The researchers’

conclusion: low birth weights among African

American women have more to do with the

experience of racism than with race.”

A decade earlier, Villarosa stringently fol-

lowed all prescribed prenatal care during her

own pregnancy but had to ask herself if her

“lived experience as a Black woman in

America” had resulted in her daughter being

born at only 4 pounds, 13 ounces. She

recounts that a doctor “hounded” her with

questions about her lifestyle, as if she were a

habitual user of alcohol and drugs. Villarosa

wondered, “Does this doctor think I’m suck-

ing on a crack pipe the second I leave the

office?”

To combat racism in health care, Villarosa

advocates implicit-bias training for medical

personnel and champions expanding the

diversity of students, faculty and curriculums

in medical schools.

Racism cannot be combated, however, if its

existence is denied. Signs of its persistence

were apparent in remarks made by the deputy

trimester presents an elevated danger of

significant bleeding. When we told hospital

staff that we had strong misgivings about

seeing and handling our child’s remains at

home in the throes of our grief, perhaps — if

we had been a White couple — we would not

have been given the callous and untrue

response: “There’ll be nothing to see of the

demise, other than gray matter.” And when I

called our doctor when my wife developed

chills and a high fever during her labor,

perhaps I would have been instructed to bring

her to the hospital immediately.

In a searing New York Times Magazine

article in 2018, headlined “Why America’s

Black Mothers and Babies Are in a Life-or-

Death Crisis,” Linda Villarosa wrote, “People

of color, particularly black people, are treated

differently the moment they enter the health

care system.” Race, in other words, in terms of

health care in this country, is the story.

Villarosa, a journalism professor at the City

University of New York, reported on studies

that show, for example, that Blacks are less

likely than Whites to receive kidney dialysis

or transplants, coronary bypasses, appropri-

ate cardiac medications, or pain medications,

yet they are more frequently given amputa-

tions for diabetes.

In her brilliant, illuminating book, “Under

the Skin: The Hidden Toll of Racism on

American Lives and on the Health of Our

Nation,” Villarosa expands on the theme. She

discovers that racial bias within the health-

care system is a compounding factor to racial

bias in America. Meticulously researched,

sweeping in its historical breadth, damning in

its clear-eyed assessment of facts and yet

hopeful in its outlook, “Under the Skin” is a

must-read for all who affirm that Black lives

matter. It will be especially eye-opening for

anyone who believes that wealth, education

and access to quality medical services are the

great equalizers, the attainable means by

which Black Americans can achieve health-

M

y wife was 20 weeks pregnant when

she experienced a gush of rose-colored

liquid, and we sensed that our first

child was no longer moving inside her. A

panicked call to 911 brought paramedics. As

they examined my wife, the paramedics had a

casual conversation with us about our work as

graduate students at the University of Iowa.

The tenor seemed odd at that moment, but it

offered hope; surely paramedics would not be

making small talk if our child was in trouble.

After the exam was completed, we had

reason for more hope still; we were advised to

go to the hospital “for observation,” but no

need to rush. An hour later we drove ourselves

and learned, contrary to what the paramedics

intimated, that our child had died. We were

told to return home and “let nature run its

course” — that is, my wife was to deliver our

lifeless child at home into a bucket we were

given.

Two days later, my wife went into labor.

When she spiked a fever and had chills, I

called our doctor; he told me to give her an

aspirin. But she got worse. I called paramed-

ics. I was terrified that along with our child I

would lose my wife, who was now in our

bathtub, unconscious and hemorrhaging,

alongside “the demise” she had delivered. She

was rushed to the hospital for emergency

surgery to try to save her life.

Thank goodness my wife survived, but 30

years later she and I remain haunted by our

experience and the conviction that race

played a role in this story. Had we been White,

like all the medical personnel who’d attended

us, rather than Black, maybe the first para-

medics would have leveled with us. And

maybe, at the hospital, we would have been

given the option of a surgical evacuation

instead of being sent home to endure a risky

second-trimester fetal demise. According to

the University of California at Davis depart-

ment of obstetrics and gynecology, a fetal

demise delivered at home in the second

Book World

UNDER THE

SKIN

The Hidden Toll

of Racism on

American Lives

and on the

Health of Our

Nation

By Linda

Villarosa

Doubleday.

269 pp. $30

ESSENTIAL

LABOR

Mothering as

Social Change

By Angela

Garbes

Harper Wave.

222 pp. $25.99

Racism’s ill

e≠ects on the

health-care

system — and

the body itself

HEALTH REVIEW BY JERALD WALKER

my mother relaxing in that way. She had nine

babies and 10 pregnancies, and at least 10

years of breastfeeding.

Garbes shows in this book that labor and

ease are both essential acts of care. I find

relaxation difficult, probably in part because I

didn’t see my mother in repose. I don’t want

my own child to struggle as much to balance

work with play, exertion with rest.

Whether our children and the future of our

lives are expansive or stunted is partially

dependent on the acts of leaders — legislators,

executives, others in positions of power — to

enact the kind of change that could begin to

remunerate and support caregiving. I work

for the University of California, one of the

largest employers in the state with a quarter

of a million workers. This year, my union is

fighting for new contract protections, includ-

ing dependent health-care coverage, expand-

ed paid leave and increased access to afford-

able child care. These kinds of protections are

needed by caregivers beyond the UC system

and outside California, too.

But as Garbes makes clear, the quality of

our lives and our children’s lives is also

dependent on all the tiny choices we make

each day. “We can’t afford to wait around for

government support,” she writes. Raising a

child is “a social responsibility.” This book

exhorts us to do it right.

better working conditions? Such withholding

is not without precedent, as Garbes notes,

citing the Iceland women’s strike of 1975. But

these organized actions are understandably

rare.

While I was reading for and writing this

review, my child was cared for by day-care

teachers and by their father, David, who also

cooked and brought me lunch and cleaned

our apartment. I often stopped working to

breastfeed and pump. We could afford day

care because California passed legislation last

July that made this essential service free for

us, as a subsidized family, for the school year.

We are all, no matter our employment

status, race, gender or level of education,

dependent on the care of others both in and

outside the home. This is Garbes’s most

important point — one she reiterates through-

out this book and her 2018 book, “Like a

Mother.”

She consistently returns to the possibilities

of mothering as social change. This change

looks like interdependent relationships with-

in the family and beyond, and communities

that sustain themselves through mutual acts

of care. It looks like recognition of the

pleasures of physical movement, curiosity

about the living things that surround us in

nature, belief in the inherent worthiness of all

people.

I realized a few days ago, lying on my back

on the couch, as my 11-month-old played with

my spouse, that I don’t have any memories of

us to where we are — colonialism and its

afterlives, lack of support for caregivers, racial

disparities — Garbes also looks beyond the

individual to the wider webs enmeshing us

all.

The first part of this book focuses on the

importance of caregiving and how underval-

ued it is in American society. (By “mothering”

she means caregiving, regardless of sex or

relationship to the person being cared for.)

The second half puts forward the idea that

mothering can cure what ails us, that we can

raise a generation of children who will force

change in our values and our politics.

Garbes’s Filipino heritage has given her a

particular familiarity with the subject she

addresses. Filipinos “are the care workers of

the world,” as she puts it. She notes that the

pandemic highlighted the disparities in

American society, particularly regarding im-

migrants. “While Filipina nurses comprise

just 4 percent of all the nurses in the United

States, they account for 34 percent of nursing

deaths from COVID-19,” she writes.

Caring is essential work, and yet, in Ameri-

can culture, it is undervalued. Rectifying this

is a challenge, she acknowledges, since care

work is often motivated by feelings for those

cared for — a fact that both justifies, for many,

its nature as un- or underpaid, and that puts

caregivers in a bind. How do you withhold the

labor that literally keeps your child, others’

children, sickly adults, aging parents and

grandparents alive, to push for higher pay and

F

or Angela Garbes, the pandemic served

as a revelation: Stuck at home with her

husband and two daughters, cut off from

social connections, enraged by the injustices

dominating the news, she realized that the

one place she could make a difference was

there, raising her children. Giving them the

knowledge, values and strength they would

need as adults. And writing a book to spread

the word.

“Over the course of the pandemic many

people came to understand that American life

is not working for families,” she writes in

“Essential Labor: Mothering as Social

Change.” As women dropped out of the

workforce to be with homebound children,

Garbes conceived of the idea that this turbu-

lent period provided a chance to reimagine

our approach to mothering.

Equal parts manifesto, love letter, personal

narrative and cultural history, Garbes’s book

grounds itself in the day-to-day realities of

parenting, that most constant job of caring.

But by tying together the factors that brought

How mothers can be

changemakers, at home

and in the community

PARENTING REVIEW BY SARAH HOENICKE FLORES

Jerald Walker is a professor of African American

literature and creative writing at Emerson College.

His latest book, “How to Make a Slave and Other

Essays,” was a nonfiction finalist for the 2020

National Book Award.

Sarah Hoenicke Flores is a writer in Southern

California.

ISTOCK