This is an excerpt from Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation. The book, by journalist Linda Villarosa, examines the inequities that quietly wear on Black Americans’ health from before birth, causing them to “live sicker and die quicker.” Villarosa, former executive editor of Essence magazine, is a journalism professor at the City University of New York and a contributing writer at the New York Times Magazine. You can pre-order the book from Penguin Random House before it goes on sale June 14.
This is the story of two women, a mother and her daughter, and two births over two generations. One mother was raised with a dozen other children by her grandmother who scratched out a living in rural Jamaica. The other, her daughter, grew up in a wealthy ZIP code in Southern California and attended private school, an elite college, and a top-ranked medical school before becoming a physician. One mother gave birth, easy as a finger snap, in a Black community at a hospital that has since been closed. The other’s child was born in a facility affiliated with the renowned Cedars-Sinai, and the birth almost ended in tragedy. Their experiences support the findings of the Chicago-based neonatologists Richard David, MD, and James Collins, MD, who, over two generations, studied the birth weights of babies of hundreds of thousands of U.S.-born Black women, comparing them with the babies of Black women who had emigrated from some of the poorest countries in Africa and the Caribbean.
In the end, Dr. David concluded, “Something about growing up in America seems to be bad for your baby’s birth weight.”
The first mother was Avril Francis, an immigrant from the St. Andrew Parish just north of Kingston in Jamaica. In the 1950s, she grew up on a farm with her eleven cousins and two sisters, raised by their grandmother Lena, herself an immigrant from Panama. Lena cared for the houseful of children on the funds their parents sent home to support the boys and girls they had entrusted her with when they left the island to seek better lives. There were times when Avril and her cousins went to bed hungry or when she cut holes in the toes of shoes to make them last another few months. Avril finished high school and then managed to find her way to New York City, where she worked as a domestic and a nanny. Eventually, she realized her American dream — marriage to her high school sweetheart, Lennox Miller, an Olympic sprinter also from Jamaica, who had come to the United States to run track at the University of Southern California. In 1967, Avril and Lennox Miller settled in Altadena, a pastoral, upper-middle-class community in Southern California at the foot of the San Gabriel Mountains. When they bought their home on the mostly white East Side of town, they became the first Black family on their block. In 1971, while working as a flight attendant for TWA, Avril became pregnant with her first daughter, Inger, and again, four years later, with Heather. The young couple didn’t have much money, so she wasn’t able to afford the full complement of prenatal appointments, but both of her pregnancies, as well as the labor and deliveries, were free from complications. The older daughter, Inger, was born at normal birth weight and would go on to be an Olympic sprinter, like her father. Her younger sister, Heather, weighed a healthy 7½ pounds at birth in 1976. Nearly four decades later, Heather was living her mother’s dream for her. A graduate of an elite private high school, Stanford University, and USC Medical School, she had become a physician and practiced not far from where she was raised. In 2014, she was married to a college professor and pregnant with her second child. As an OB-GYN, the daughter of an elite runner, and a high school and college athlete herself, Heather knew how to take care of her body; she did everything right. She stuck to a strict schedule of prenatal visits, ate healthfully, and took a cocktail of vitamins. She had planned to have a scheduled C-section, the baby delivered by a physician friend, with her husband and mother by her side.
Then, in her third trimester, Heather couldn’t feel her infant moving. As she advised her patients, she lay on her side, had a snack, drank some water, and waited to feel her baby kick. If she really concentrated, Heather could feel the infant inside, but only faintly. She visited a high-risk specialist who told her the baby was small for her gestational age and ordered weekly monitoring. But toward 38 weeks, Heather’s gut told her something was wrong with her baby. If this child doesn’t come out of my body, she thought, I’m going to have a demise. She was so terrified that her baby’s heart would stop beating that she insisted on an induction; if she wasn’t induced immediately, she told her doctor, she would induce herself. On October 14, Heather delivered Naia, weighing 5 pounds, 12 ounces, almost 2 pounds less than she herself had been at birth. While technically a few ounces over the official classification for low birth weight, Naia was small for her gestational age and not out of the woods; she experienced neonatal hypoglycemia, sometimes found in preterm and small babies. Low blood sugar in the first few days after birth raises the risk of neurological damage, including to the brain. In her early years of life, Naia was slow to meet most of her growth and developmental milestones and also had problems sleeping and eating. She had allergic reactions to most of the normal food babies consume, sometimes life-threatening ones. Eventually, she was diagnosed with eosinophilic esophagitis, a chronic condition that causes inflammation of the esophagus. Six years old when I spoke to her mom, she is a sweet little girl who is both playful and a fighter. She loves animals and adores her big brother, Jaden, but is also tiny for her age. She takes medication to control her condition, avoids foods that kick up her allergies, and works with a therapist to help with delayed speech.
On the face of it, this outcome would seem unexpected. Though many factors come into play when it comes to individual births, education, wealth, healthy lifestyle, and quality prenatal and obstetric care are associated with infants born on time and at normal birth weight. Bigger babies generally signal robust health, while low-birth-weight infants are more likely to die in the first year of life. Conventional wisdom has it that the middle-class upbringing, education, and wealth that her immigrant mother struggled to create for Heather should have protected daughter and granddaughter from the kind of troubled birth outcome that Avril herself managed to avoid.
Our country, the richest in the world, is an international leader in newborn intensive care, spending an estimated $26 billion a year to save babies born small and early. In general, in the United States health care costs eat up 17% of our gross national product. Health care expenditures account for only 6% of the GNP for Jamaica, where medical technology and innovation lag. America spends nearly $11,000 per person for health care compared with $320 in Jamaica. Money may buy good health care, but when you’re Black in America, it cannot buy good health.
While the case of one mother-daughter pair is just that — a case study — their experiences sync up with the thousands of cases examined by Drs. David and Collins. I learned about their work while conducting research for my 2018 New York Times Magazine cover story, “The Hidden Toll: Why America’s Black Mothers and Babies Are in a Life-or-Death-Crisis.”
Beginning in the 1990s, the two neonatologists set out to unravel the mystery of why in America Black infants are more than twice as likely as white babies to die before reaching their first birthdays. At the time, the high rate of infant mortality in Black women was widely believed by almost everyone, including doctors and public health experts, to affect only poor, less educated women who do have disproportionate numbers of lost babies. The underlying assumption was that poor Black teen moms had driven up rates of preterm and low-birth-weight babies, leading to increasing numbers of infant deaths. However, when the research pair analyzed the records of more than 100,000 births in Chicago between 1982 and 1983, they found that while income and education offered some protection, babies of more educated, higher-income Black parents were still more likely to be born small compared with their white counterparts.
Next, they wondered if the problem could be related to genetics: Could a preterm birth or low-birth-weight gene be the reason? If a defect in the Black body was causing infants to be born small, then women from the West African countries where the ancestors of African American women had been captured should have a similar problem of small babies. What’s more, if the problem was produced by an inherited racial trait, shouldn’t it be less pronounced in Black American women, who, as a population, had more European ancestry than their African-born counterparts? To test their theory, Drs. David and Collins examined the records of tens of thousands of babies born in Illinois between 1980 and 1995, homing in on three groups of women: U.S.-born Blacks, African-born Blacks, and U.S.-born whites. In their 1997 study, published in The New England Journal of Medicine, they found that the infants of the immigrant women from Africa were closely matched in size to the white, not the Black, U.S.-born babies. In other words, despite the disadvantages they experienced by being brought up in poorer, less developed nations, their newborns were larger and more likely to be full term than babies born to African American women. In 2002, the research pair and their colleague Shou-Yien Wu, MD, revisited the mystery of racial disparities in infant mortality. This time around they dismissed the preterm gene theory and were also careful to note that age, education, marital status, income, cigarette smoking, and the interval between pregnancies fail to account for African American infants’ birth-weight disadvantage. For this study, published in the American Journal of Epidemiology, Drs. David and Collins looked at the birth records of infants born in Illinois between 1989 and 1991, along with those of their mothers who were born between 1956 and 1975 — a total of approximately 328,000 infants. The researchers added two more groups of women along with their mothers: white immigrant mothers from Europe and Black moms from the Caribbean. To their surprise, the grandchildren of the Caribbean and African immigrant women were born smaller than their mothers had been at birth. The bottom line: the Black immigrant women’s grandchildren were more likely to be small, just like African American babies. In contrast, once the daughters of white immigrant women became “Americanized,” the weight of their infants shifted upward.
Finally, in 2007, Drs. David and Collins combined their previous studies into one deep dive that appeared in the American Journal of Public Health. For this study, they not only considered the effects of race but also looked at the more provocative question of what impact racism had on Black mothers and their babies. The pair spoke with Black women who had babies with normal weights at birth, comparing them with those whose babies were born under 3 pounds. They asked the mothers if they had ever been treated unfairly because of their race when looking for a job, in an educational setting, or in other situations. Those who experienced discrimination had a twofold increase in low birth weights. For those who reported discrimination in all three areas, the increase was nearly threefold. The researchers’ conclusion: Low birth weights among African American women have more to do with the experience of racism than with race.
I first began thinking about the Black-white disparity in preterm birth, low birth weight, and infant mortality as the health editor of Essence magazine from the late 1980s to the mid-1990s. At the time, I followed the conventional wisdom: that only poor women who lacked knowledge experienced tragic birth outcomes. This reflexive explanation for the death of a baby boiled down to blaming the mother, particularly if she was poor and Black. Was she eating badly, smoking, drinking, using drugs, not taking prenatal vitamins or getting enough rest, afraid to be proactive during prenatal visits, skipping them altogether, too young, or unmarried?
I revised my thinking in the early 1990s when a piece of research shook my core belief that we could educate our way out of the problem of poor birth outcomes plaguing Black America. In 1992, The New England Journal of Medicine contained what is now considered the watershed study on race, class, and infant mortality, unique because it isolated race in itself as a risk factor for poor birth outcomes. The study mined a database of close to a million previously unavailable linked birth and death certificates and found that infants born to college-educated Black parents were twice as likely to die as infants born of similarly educated white parents. In 75% of the cases, low birth weight was to blame. I was confused and skeptical: why would educated Black parents who could afford health care suffer from this issue? The only partial answer: stress.
In 1996, I became pregnant, and the research became all too real for me. At the time, I had been promoted from health editor of Essence to executive editor, the success of my book Body & Soul continued, and I had a contract to co-write a self-help book aimed at Black parents. Without a doubt, I was a role model for Black women’s health and wellness. Because I was in the public eye — and lecturing others in print and in person about the importance of health education and taking care of yourself — I was extremely careful to practice what I was preaching. I exercised nearly every day, adhered to a low-fat, high-vegetable diet, drank a lot of water, and saw my doctor once a year for a medical checkup and tests. So, it came as a total shock that though I had been doing everything right, something went wrong in the early months of my pregnancy. First I had a near miscarriage, and my doctor — a Park Avenue OB-GYN and female friend whom I trusted implicitly — put me on bed rest. After that first crisis was averted, she discovered that like Naia, Heather Miller’s baby, my baby was far smaller than her gestational age would predict, even though I was in excellent health. My OB-GYN sent me to a specialist, where I was diagnosed with a condition called intrauterine growth restriction (IUGR), generally associated with mothers who have diabetes, high blood pressure, malnutrition, or infections including syphilis, none of which applied to me. During an appointment with a perinatologist — covered by my excellent health insurance — I was hounded with questions about my “lifestyle” and whether I drank, smoked, or used a vast assortment of illegal drugs. I wondered, “Does this doctor think I’m sucking on a crack pipe the second I leave the office?” In the absence of a medical condition, IUGR is almost exclusively linked with mothers who smoke or abuse drugs and alcohol. As my pregnancy progressed, but my baby didn’t grow, my doctor decided to induce labor just short of one month before my due date, believing the baby would be healthier outside my body. My daughter was tiny, born at 4 pounds, 13 ounces, classified as low birth weight. Though she would grow to be a bright, athletic, healthy young woman, I wondered if the less than healthy environment inside my uterus that had endangered my baby’s life might have had something to do with stress. Had my own lived experience as a Black woman in America been bad for her birth weight?
In the mid-1990s, I was part of a study and its advisory board that hoped to answer this question. A team of female researchers from Boston and Georgetown Universities had noticed that most large, long-term medical investigations of women’s health overwhelmingly comprised white women, so they launched the Black Women’s Health Study (BWHS). The investigators contacted me at Essence to help recruit subjects, and I also signed on as one of 59,000 participants. They were interested in looking at a large group of Black women over time, taking the approach of the Nurses’ Health Study. That long-term investigation, conducted by researchers from Harvard Medical School and other institutions and funded by the National Institutes of Health, began in 1976 and examined 120,000 educated, largely healthy women with access to medical care. However, the study’s pool of subjects lacked diversity; the first cohort of nurses was 97% white.
Several years into the study, the BWHS investigators decided to examine the health effects of not just race but racism. In 1997, they added several questions about everyday race-related insults, based on a scale created by David Williams, Ph.D., a prolific scholar in the area of racial health disparities. Those completing the scale are asked to check yes or no to the following statements:
- You are treated with less courtesy than other people are.
- You are treated with less respect than other people are.
- You receive poorer service than other people at restaurants or stores.
- People act as if they think you are not smart.
- People act as if they are afraid of you.
- People act as if they think you are dishonest.
- People act as if they’re better than you are.
- You are called names or insulted.
- You are threatened or harassed.
Williams, the Florence Sprague Norman and Laura Smart Norman Professor of Public Health and chair in the Department of Social and Behavioral Sciences at the Harvard T. H. Chan School of Public Health, created this set of questions in 1995, basically on a dare, after having been told that there was no way to measure racism. His scale has now been universally accepted, and also adapted and amended and used all over the world to measure the ways in which discrimination hurts health and shortens lives.
The researchers from the Black Women’s Health Study used Williams’s scale and also included three questions about institutional discrimination: Have you ever been treated unfairly due to your race at work, in housing, or by the police? When I filled out my survey, I answered yes to six out of the nine everyday insults and two of the three more hardcore examples of bias. In the end, BWHS research showed higher levels of diabetes, obesity, asthma, and preterm birth among women who reported the greatest experiences of racism.
When I first talked to Heather Miller, I was struck by our similar backgrounds — daughters of high-achieving Black mothers, hers from the Caribbean, mine from the South Side of Chicago, who had managed to overcome disadvantaged upbringings. Each of them sought better lives for their daughters, raising us in white suburban communities, which they understood offered opportunities that they didn’t have. Like Miller’s, my family integrated our neighborhood, and I was one of the only Black children in my elementary school, middle school, and high school. We both attended predominantly white universities and have spent most of our lives navigating white environments where we have lived and worked. Still, the trappings of the middle class weren’t enough to protect us from the slow-burn damage of racism.
I felt a familiar sting as she described the experiences of her childhood and early adulthood. As a young immigrant Black couple in a predominantly white environment, her parents were outsiders. Heather Miller attended the Westridge School for Girls in Pasadena. Though she remembers receiving an exceptional education, she was also the only Black girl in her class the entire nine years she attended, from fourth to twelfth grade. She rarely felt attractive. Miller was brown-skinned, fairly tall, and thin, but she also had curves — a round bottom and breasts — that stood out in a sea of thin white girls with long, straight hair, the mainstream look of the 1980s and 1990s. Her otherness was unambiguous and a source of curiosity. Girls kept up a steady stream of questions about her Jamaican parents, her skin color, and, of course, her hair. “Can I touch it?” she was asked constantly.
Miller was a rule-following, straight-A student who enjoyed reading and writing and was strong in science and math. She did her best to work hard in school, fly under the radar, and avoid either sticking out or disappointing her strict parents. But as she grew older, the slights from her classmates turned from innocent to hostile. She applied to Stanford and was accepted on the basis of her grades, college entrance test scores, and athleticism. Still, she recalls peers and their parents who insisted that she only got in because she was Black. “You’re lucky,” a classmate said to her, “you’re Black, so you’ll be able to get in wherever you want.” Another told her, “You don’t have to worry; you’ve got affirmative action.” At Stanford, Miller studied psychology but fulfilled her science requirements with an eye on medical school. She was almost dissuaded from pursuing medicine after an adviser told her she probably wasn’t smart enough to be premed. In med school at the University of Southern California, the aggressions turned from micro to macro. Some of the instructors and attendings made it clear that neither Black students nor Black doctors were as smart as their white peers. Miller remembers sitting in the cafeteria with a group of her white classmates and an attending pointing out that the only reason the dozen Black students — out of two hundred in the class of 2003 — had made it to med school was affirmative action. The feeling of invisibility and erasure was stark and the pressure immense. She felt terrified of making any mistake, because she would never be given the benefit of the doubt.
Though she considered pediatrics, ultimately Miller chose OB-GYN. During her four-year residency between 2003 and 2007, she was attacked with a toxic mix of racism and sexism. She calls the program malignant. “If you were a woman who wasn’t traditionally feminine, a person of color, [or] spoke with an accent, the mainly older white men who ran the residency treated you horribly,” she recalls.
Over the years, she has been part of several OB-GYN practices, all but one time as the only Black person and sometimes the only woman; the Association of American Medical Colleges reports that only about 2.6% of physicians are Black women. In her current practice in Minneapolis, where she is still the only Black doctor, but one of several women, and where there is a diverse pool of patients, the slights continue to grate. Beginning in the early years of her medical career, she knew always to wear her white coat and introduce herself as Dr. Miller, to lock in her legitimacy. Otherwise, patients and even colleagues would assume she was a nurse or receptionist. Even after identifying herself as Dr. Miller and spending half an hour examining a patient and discussing a procedure, a patient might ask, “When will I talk to a doctor?” Or, “Who’s doing the surgery?” Other times, after completing her rounds, a patient would complain, “I never saw a doctor.”
Miller pauses after going through the inventory of mistreatment and listing the insults. She describes the pain of being undervalued and erased, and the isolation of a lifetime of being an “only,” often forced to represent the entire race in all-white spaces. “Sometimes, I would know that something wasn’t right or that I was being mistreated,” she says. “But I had so few people to share it with. When you try and explain it to someone who doesn’t understand what you’re going through, they tell you you’re being sensitive, or imagining it or making it racial. It’s very confusing and isolating to not have people around who allow you to feel yourself or comfortable in your own skin.” That constant vigilance, coping, and suppressed anger takes a toll. For Miller, stress manifests itself as splitting headaches that throb hard and hot and crushing exhaustion. She describes the feeling as wearing; I immediately think of weathering.
Research conducted by Drs. David and Collins as well as the investigators behind the Black Women’s Health Study has shown that something about being a Black woman in America is bad for her body and her baby. Taking it a step further, Arline Geronimus, a professor at the University of Michigan School of Public Health, provides the best current explanation of how lived experiences can become biology. I spoke to her extensively when conducting research for my Times Magazine article on Black mothers and babies and we have stayed in touch. Her concept of weathering explains that high-effort coping from fighting against racism leads to chronic stress that can trigger premature aging and poor health outcomes. It works this way: Stress, the body’s response to a perceived threat, prompts the brain to release hormones, including adrenaline and cortisol. This, in turn, causes blood pressure to increase and the heart rate to speed up. Short, infrequent bursts of this fight-or-flight response are normal, but when it happens again and again, it can turn deadly, eroding health and accelerating aging. Also, as the stressors pile up and feed on each other, they can lead to unhealthy coping mechanisms — drinking, smoking, poor food choices, and drug use. Those who are economically disadvantaged have added stressors in their day-to-day fight for survival, but even educated, well-off African Americans struggle with anger and grief triggered by everyday racist insults and microaggressions. These can, over time, deteriorate the systems of the body.
Geronimus, who coined the term “weathering,” chose this metaphor, leaning into its double meaning. To weather means to wear down, but it also means to withstand, as in weathering a storm. Though discrimination and bias wear away the bodies of those who must continually beat them back, she notes that the positive forces of family, friendship, and community support can help a person withstand, resist, and undo the negative effects. And while chronic stress interferes with the health of an average person, it can upend a pregnant person. Pregnancy is already a stress test for the body, and the added and cumulative strain of fighting against racial bias and discrimination, and its weathering effect, far too often turns what should be the happiest day of a woman’s life into tragedy or near tragedy. Black women, more frequently than other women, enter pregnancy with health disadvantages; studies have found that disproportionate numbers of African American women of childbearing age, in their twenties and early thirties, already suffer from chronic diseases, including high blood pressure, that show up in other Americans later in life. Though the vast number of Black women have healthy pregnancies and babies, Geronimus and others believe that the cumulative impact of battling back racism drives up their risk of preterm birth, low birth weight, and infant and maternal death.
Heather Miller, her husband, her son, and her mother, Avril, who has relocated to Minneapolis, love little Naia fiercely and are doing everything they can as a family to correct what happened to her at birth. Heather learned from her immigrant parents not to complain, not to look back, not to blame others, not to be weighed down by regret, but instead to put her head down, work relentlessly, and soldier ahead. But she does wonder, as I do, if something about being a Black woman in America affected her body and her baby.
