Linda Villarosa on the hidden toll of racism on health (Transcript)

[00:00:00] Steven Johnson:
Welcome to the TED Interview. I'm your host Steven Johnson. Martin Luther King Jr. once said, “Of all the forms of inequality, injustice in health is the most shocking and the most inhuman.” The COVID crisis has made that injustice in the United States all too apparent with much higher rates of hospitalization and death per capita in Black and brown communities all around the country.

I think it's fair to say that our guest this week, Linda Villarosa, has become the most important journalistic voice reporting on the crisis of health inequality in the country. Villarosa is a contributing writer to the New York Times Magazine where she covers race, inequality, and health. Her 2018 cover story in the New York Times Magazine, “Why America's Black Mothers and Babies Are In a Life or Death Crisis”, was a finalist for the National Magazine Award.

She's got a new book that builds on some of that earlier reporting: Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of our Nation. It's a book that both documents the current state of things with powerful in-depth portraits of individuals and families struggling in health deserts around the country.

And it's a story of a genuine scientific revolution that has occurred over the past two decades as researchers have come to understand the biological and cultural forces that have created the gap in health outcomes. But despite the bleak reality that we currently face, as you'll hear, Villarosa remains an optimist about our ability to reduce these health inequalities in the coming years, and she has some fascinating ideas about how we can do it. That's next on the TED interview.

[BREAK]

[00:01:59] Steven Johnson:
Linda Villarosa, congratulations on the book Under the Skin. You put this out there very clearly in the opening chapter of the book because it, it's called “Everything I Thought was Wrong”, which is a, you know, a confession right up, right up front that, that you've changed your mind over time. And so, you know, take us back to those early years at Essence, when you started writing about health and specifically about the health of Black Americans. Um, what was your mindset back then and, and how has it evolved?

[00:02:30] Linda Villarosa:
I think that I was the perfect person in the late eighties to be the health editor of Essence. I knew a lot about health. I was very interested in individual health, in my own body, being a former college athlete.

When I got there, it was this magazine of uplift. It was, to say, “each one teach one, lift as you climb.” All those kinds of things about bettering the Black community as a whole. I, I was perfect for that, and that's what I believed in. That's what my parents and my grandparents had taught me. So I thought, if you know better, you do better, which I still believe, I still believe if you are trying to do everything right with your health, your nutrition, doctor's appointments, exercise, you will, as an individual, be healthy.

However, that was not the only thing, and to have a sort of a one-track mind about health, to say “Oh, if all individuals in the Black community just know better and do better, the whole health status will lift,” was a fallacy. And it had never happened. It still hasn't happened.

And, um, I began to change the more I learned about public health, the more I learned about health inequality. And it took me a minute, and it wasn't all at once. It was kind of gradual. When I started writing up, reporting and writing about environmental justice, I'm thinking, you know, “Oh, if everyone just does better…” and it's like, wait, this is not their fault.

Why are people getting sick, um, with sort of respiratory diseases? Well, because they live right by a refinery or something like that, No matter what they do, short of moving from their homes, they can't change that. And I started looking at HIV/AIDs similarly, and it started to be like, “Wait, this is 1996. There's an actual, you know, remedy for HIV. It's not a death sentence.” Now that there's a, a, um, cocktail to make people better, suddenly Black people are the people who are getting sick and dying the most, so something's wrong when there's, there is something to save your life, but you don't have access to it.

That is beyond what individuals can do, and it's also beyond poverty. So I was looking at, I remember in 1992 or 93, I saw a study that my professor at the Harvard School of Public Health gave me. It was in the New England Journal of Medicine, and it was about educated Black parents and infant mortality. I was in shock. I was like, wait, “Why are educated Black parents have such high levels of, um, low birth weight leading to infant mortality?” And I kept asking that professor, “Why, why, why, why?” And he didn't have an answer. And his thing was finally he said, “We're not sure. We think it has something to do with stress.”

And I just thought, “Wait, that's the answer? There, this is scary.” And it went against everything that I thought I knew.

[00:05:18] Steven Johnson:
Yeah. It's so interesting watching this new concept really beginning to emerge of, of explaining these health outcomes and it, it, on some level, it's kind of a detective story, right? And slowly over time, science and journalists start to piece together the solution to this. I, I thought it'd be helpful before we get into your investigation, into the causes behind those inequalities. Uh, I just think it's important that you give us a picture of just how dramatic the gap is in terms of health outcomes.

[00:05:52] Linda Villarosa:
It starts at birth and ends with death. So all of American history, Black people have always had worse health outcomes, dramatically worse than white people and generally other people of color. And it starts with infant mortality. So Black parents are much more likely to have a low birth weight child or a child born early, which can lead to infant mortality. Black women are three to four times more likely to die or almost die in childbirth. And then at the opposite end of the spectrum, Black people live, it used to be 3.5 years less than white people. And now because of COVID, it's six years less.

And then when I started looking at the statistics for America as a nation, I began to realize, wait, this inequality is taking a huge toll on the country as a whole. And I wasn't thinking of it only as this Black problem, but as this American problem where the number of women who die or almost die in childbirth is rising, even though we spend more on healthcare than any other country, and we are one of the wealthiest, if not the wealthiest country in the world. So there's a disconnect. Something's wrong there.

[00:07:01] Steven Johnson:
And one of the things that the book is very careful to point out at, at a number of different points is to show the, the, the way in which this is not just a question of poverty. Um, that, that, obviously there's a strong correlation between poverty and, and poor health outcomes, but even if you control for poverty, Black Americans are faring worse, um, in terms of their long-term health outcomes. That's an important part of the story here too.

[00:07:26] Linda Villarosa:
And that was a long-standing belief and in many ways still is. So sometimes when I'm speaking to groups, it kicks right over to “Oh, well it's because of poverty”, and then I have to stop and back up and explain that it isn't always. Certainly, poverty is a huge problem in the United States, and poverty makes everything worse.

So any kind of problem you have becomes worse if you are poor. However, poverty isn't the main reason, or it's one of the reasons, but not the only reason. And you have to look at race in and of itself as a factor for poor health outcomes.

And it's hard to understand this, especially, you know, c—bringing we're Americans, and we were taught to, oh, “You just have good care of yourself and then you will be healthy for life. And then if all people do that, then everyone will be healthy.” And certainly, that is not patently true. It can be true, but it is not the only reason, and what I think about is if you're looking at the wrong reasons, then you will come up with the wrong solutions.

[00:08:30] Steven Johnson:
Right. And so much of this is really using the, the really fascinating investigative studies and empirical studies, um, to tease out these causal effects. And we're gonna get to some of those studies later. But I wanna start with your kind of personal journey, because part of your book really belongs to this, a, a genre that I love, which is a story about a very smart person changing his or her mind about something important.

One experience you had more recently, I think that, that some of our listeners probably are familiar with, because it resulted in a very powerful article in the New York Times magazine, involves you, you following the story of, of two women named Simone Landrum and Latona Giwa, um, in New Orleans, right?

[00:09:16] Linda Villarosa:
Yes. In New Orleans.

[00:09:18] Steven Johnson:
Yeah. Tell us how, how you got involved with these two women and, and what really happened over the course of that interaction.

[00:09:25] Linda Villarosa:
Well, I heard about the statistics about maternal mortality in Black women, the fact that we're three to four times more likely to die or almost die, and what should be the best time of your life, pregnancy and childbirth.

And that education wasn't protective, that a, a Black woman with a master's degree or more was still more likely to have a poor birth outcome, which could be as bad as death or the death of her baby than a white woman with an eighth-grade education. And I was interested in it from a solutions angle. So I was looking, I was thinking: “Doulas and other kind of social justice birth workers are saving people's lives.”

So I went about finding a doula to work with and I met Latona Giwa. And she was wonderful. A doula. She was a, she's a labor and delivery nurse by training who got fed up with the system and started a social justice-oriented doula collective. I ended up going to New Orleans. She said, “Oh, I'd like you to meet my client, Simone Landrum.”

Simone had lost a baby. She had two children already. She lost a baby the year before in a really tragic sort of miscarriage, but very near to the… when her baby was due. It was a stillbirth and it was terrible, and part of the reason it was so terrible is because her doctor did not listen to her legitimate complaints about what was going on with her.

Now she's pregnant again. Thank God she's met Latona. And I just really had a great connection with Simone and saw that she was trying so hard. She really wanted to have a healthy pregnancy and healthy baby. She had gotten a new doctor. She was at a new hospital. She had Latona, and I interviewed her about her story, which was so beautiful, and I loved the relationship between the two of them.

And as I was leaving after that interview, Simone was trying to say to me, and that was, “Come back for my baby’s birth.” So I did. I came back. I accidentally came back too early, so I was out there for three weeks before the baby was born. So I got to know her other kids, her doctor. When it was time for the baby to come, and it looked like there was gonna be another crisis, I was right there, and Latona was right there.

And that is a very unusual position for a journalist to be in, seeing these medical providers behave really poorly and treat this woman who had had a tragic birth the year before, really, um, poorly and inequitably, and I just took note of everything. The best part about it was the birth, eventual birth of Kingston Landrum.

He's a cute, healthy baby boy, but the way she was treated was really, really unfair. And the worst part to me was that she, her doctor did not show up. And so she met the doctor who was really not that attentive to her for the first time when he put his hands inside her body.

And I just kept thinking this is not how people should be treated, especially when they are having such a hard time and had a previous hard time. When I wrote the story, I didn't expect for that birth to be the beating heart of that piece, but it ended up being that, and the photographs were beautiful too. These people were really honest and open in everything that they shared with me and the photographer.

And the piece did make a big impact. There was legislation. It brought awareness to the fact that there was this problem and that we needed to find solutions for this problem in America.

[00:12:55] Steven Johnson:
One of the things that's clearly very powerful about the story and that made an impression on you is the, the role that Latona Giwa plays in, in this harrowing scene in the hospital during the delivery where she's encouraging, uh, Simone, but she's also serving as her kind of interface and representative in, in terms of the face of the patient to the hospital. Um, talk about that, that role and, and why it's so important.

[00:13:22] Linda Villarosa:
I think I noticed it right away when we were in the labor and delivery room, and Latona being a labor and delivery nurse by training, they kept asking… The nurses and other providers, one by one would ask Simone, who was in distress, “How many children do you have?”

So she said, “I had two, and then I had a stillbirth.” And then they would say, “When was the demise?” Each time they said the word demise, for her baby who died and who she named, I could see her get more and more freaked out, and they just didn't see it, because they weren't paying enough attention to her. So Latona took them aside and said, “Please stop referring to this tragedy as a demise, and stop asking her about it. It's right there in the medical records. Y'all have asked her over and over. You should know the answer.”

And I just thought that was such a beautiful thing to do to just really stop what was causing her harm. The other thing, when things were getting kind of hairy, I noticed that Latona was the person who was really focused on Simone. The rest of us, and I'm including myself, ‘cause I was really scared. We were looking at the machine, we were looking at the, you know, the lines on the machine and not really paying as much attention to Simone as she needed because it was her body, it was her baby, and it was her. And I never forgot that. It just was such care and kindness and focus that Latona gave that, you know, that few hours.

[00:14:52] Steven Johnson:
There's one other personal story that I wanted to just talk about briefly, which is a visit you paid back to your mother's old neighborhood in Chicago, which is partially a story about disparities and life expectancy. Tell us a little bit about that return back to your roots.

[00:15:11] Linda Villarosa:
In 2020, just before the beginning of the pandemic, I had an event for the 1619 project and I said, “Mom, why don't you come with me?” ‘Cause we can, you know, I'll rent a car, we can take a tour around Chicago, where she was born and raised and where I spent the first 10 years of my life. And so it was really sweet.

She made a list of places we could go and it was like, “This is the church where your dad and I got married. This is where we lived when I was a little girl. This is where we lived when, when you were born. This is where my grandparents bought a house. This is the school I went to.” So we had the little list and we were driving around and at each place, I mean almost all of them were gone. And it was a neighborhood that looked less like the middle of Chicago, a large city, and more like Mississippi, where my mother's parents had come from.

And I kept thinking, “Mom, why is your school boarded up?” And this is the school where she went to elementary school with Lorraine Hansberry, the playwright, Gwendolyn Brooks, the poet. They all went to the same high school, and the high school was gone. The elementary school was boarded up. The house where my grandfather had bought.

One of them was there, the other one, she said, “Oh, this is the window where I used to watch the train go by.” Well, the train was still there, but the building was gone and it was just an empty lot. And I would later find out that my mother's community of Englewood in Chicago, people lived to age 60, and then the neighborhood nine miles north, Streeterville, people lived to age 90, and it's the largest life expectancy gap in the country.

And I just kept thinking “What happened here?” And I was interviewing Helene Gayle, who is now the president of Spelman College, but was the head of Chicago Community Trust, and she's a doctor, and what she said was, “Look at redlining in that community.” So that meant there was disinvestment. People couldn't get mortgages, they couldn't buy homes. Black people.

Then I remember I hung up with Dr. Gayle, and then she had her assistant call me back. The assistant said, “Oh, Dr. Gayle wanted to remind you to look into contract buying.” Contract buying was the, I guess, law or the rule in the thirties in Chicago, but in other places, and through I think the seventies, where Black folks could not get a mortgage. You had to buy, if you bought a house, you bought in on contract. So many of the people had come up from the south to, to a promised land to have a better life. Homeownership is the best way to wealth because that's the biggest thing you're gonna buy is your house. Black people couldn't buy. Getting a mortgage, you had to buy on a contract, and that meant your house was always in jeopardy of losing it if you missed a payment.

And I remember asking my mom after I did the story, “How did grandfather own that house? The one that was still standing?” And she said, “I don't remember. He bought it on some kind of contract.” And I just thought, “Oh my God, that is what Dr. Gayle told me.” And that buying sapped away billions of dollars from the Black community that remains lost in many ways, and that explains why communities like my mother's community, which was such a bright and shining hope, looks destroyed in in many places.

[BREAK]

[00:18:35] Steven Johnson:
I wanna turn out to some of these really transformative studies that we've kind of alluded to a bit in the conversation so far. Because, you know, in part, one of the things that this book manages to do is to tell the evolution of your own thinking. Um, and, and you also do a wonderful job as a science writer explaining these studies that have advanced our understanding of what's really going on here.

And one of the ones I was struck by is the study going back, I think, 20 years that looked at birth weight among four different groups. US-born Black women, African Caribbean-born Black women, US-born white women, and European-born white women. And the findings of this study were really quite extraordinary.

First, the researchers found that while all groups had babies that were on average within the healthy weight range, Black American babies had the lowest weights, lower than the babies born to African Caribbean Black mothers. But what's really interesting is that in the next generation of babies, so their, their grandchildren, birth weights of the white Americans increased. The white immigrants increased. The Black Americans increased, all increased in birth weight significantly. All except the grandchildren of the Black American women formally from the Caribbean or Africa. Their birth weights actually began to decrease. So what's going on here?

[00:19:55] Linda Villarosa:
I wanna work backwards to say, the first time I think I saw a news report about the study and there was a quote from one of the scientists in the study and it said something about being Black in America is bad for your baby. And I'm thinking, “Hmm, who said that?” Because scientists from my experience do not speak that bluntly. Usually, they're saying, [sound effects] you know, something really serious and sciencey. They're not just blurting out something about being Black. So I thought, “Ooh, I wanna know what this study is.” So I went back and I looked at it.

These scientists had looked at birth weights over time and over generations, and what they thought was at first, what's going on here? Is this a genetic problem? Well, so the only you know, the obvious conclusion was no. There's something about the lived experience of being Black in America that's bad for your baby's birth weight.

Eventually, this was, it's Dr. Richard David. Dr. David was pretty blunt. He started using the word racism because he had looked at this for so long and there was no other explanation. And I like how you call, like, some of my work in my book a detective story, but I think I'm very fascinated by science that are detective stories like these doctors and these, um, scientists really working hard over time to put these pieces together. And part of the process was seeing what it's not. Yeah, so it's not the, you know, not just poverty, it's not genetics. This is the only explanation left.

[00:21:26] Steven Johnson:
And then the next piece that had to be solved was what is the physiological mechanism that goes from the external lived experience of racism, structural racism, systemic racism, all, all these different factors, environmental issues that, how exactly does that, um, affect the body in a way?

What is the mechanism, um, whereby people are, are suffering or aging prematurely or dying, uh, at an early age? And that really… The, the revolution in, in our understanding of that, came from a woman named Arline Geronimus. Tell us a little bit about her.

[00:22:04] Linda Villarosa:
I love Arline's concept of weathering. So she came up with the term “weathering” to describe what it's like to be a person, and she looked at Black people, and she was relating it to infant mortality earlier in her career only who were like, really, she calls it “hard striving against racism”. Hard striving against discrimination. And each time something happens, whether it's kind of a microaggression, an everyday slight or insult, or it's a macroaggression, something really terrible happens to you, the parts of your, the physiology of your body changes. So your heart rate goes up, your um, pulse goes up, your blood pressure goes up, your stress hormones rise, and that's fine sometimes, but when it happens over and over, it wears away the body the same way a storm, whether there's a house, it knocks the paint off it. The sh—the shingles get chipped, the windows break.

And Dr. Geronimus is a really wonderful, positive person. So she says the flip side of weathering is that the house weathers the storm, and that people in America, Black communities, we have community, we have love, we have family, we have kinship. And so we are still here. We're weathering the storm and I really like that. And she, at the beginning of her career, people misunderstood what she was doing and thought she was trying to somehow defend teen pregnancy because what she was finding that it was… The infant mortality rates weren't highest in the teen years in Black people. It was later, when the lived experience had just been longer. When I first interviewed her in I think 2017, she was not that accustomed to being interviewed. She wasn't accustomed to sort of getting positive attention to her theories.

Now, um, she's doing great and when COVID came out, all people were really interested in her theories because if you looked at COVID rates in Black people, we got sicker and had higher death rates at younger ages, which made sense if there was a kind of accelerated aging because we knew COVID hit older people worse.

[00:24:14] Steven Johnson:
Part of it seems to be that our bodies evolved to handle stress in, in short bursts, right? So we have the kind of cortisol-mediated system to, to deal with. There's, there's a momentary stretch where we're stressed about something, or there's a threat, or we're hungry for a passing period of time or whatever it is, and our bodies work well in those short bursts of stress.

But when you have sustained stress, when, and, and the sustained stress you get from living in a racist society or being poor, um, in a society where you're constantly struggling, that seems to trigger this accelerated aging process. Um, the weathering process. And—

[00:24:54] Linda Villarosa:
That's right.

[00:24:55] Steven Johnson:
—it, it's, uh, and you, and you literally see it. I mean, you, you, there's a very powerful moment actually in one of the last chapters where you go to Appalachia and you're talking about the, the largely white poverty there. And you, you meet a, a homeless person named Scott, I think it is. And at one point you're asking about his life and uh, you ask him how old he is, and in your mind, you're like, “I think he's probably 70.” And he's like, “I'm 48.” You know, it's just, you see, there's just an extra 22 years of aging that's happened because of that problematic load.

[00:25:27] Linda Villarosa:
And it was Dr. Geronimus who encouraged me, not in so many words, to look beyond Black people. Weathering doesn't discriminately, um, affect Black people. It's just that we've been in this country longer, been treated worse for a longer amount of time.

So when I went to, um, Appalachia, I was very curious, because I knew it was a place where, um, you know, there was a really, the, the main industry was very difficult. Being a coal miner is hard. Then coal mining is kind of stripped away. Um, you know, the, the resources were taken away and then the jobs left.

But then they were a place where opioid drugs were poured in by pharmaceutical companies, then pulled back, and then heroin took its place. So I was initially interested because there was a HIV spike, so I was like, “Why would HIV be spiking in this day and age?” Except that people are using, um, injecting drugs.

And so when I went, I was also in the back of my head thinking about what Dr. Geronimus had said. It's not necessarily only Black people, but it's just that this is what we know, this is what we've seen, this is what we've studied. Right away at that Mr. Scotty, I was shocked at how old he was, ‘cause I was thinking, “Oh, he's got to be much older than me.” He didn't look well, and so many people were like that. I was surprised each time in West Virginia I got the ages wrong.

[00:26:55] Steven Johnson:
Another thing that is a shared property between places like West Virginia and places like that neighborhood in Chicago that you were talking about earlier is environmental conditions, particularly air pollution.

I mean, I think we're coming to realize that air pollution as a long-term health problem. It, you know, we're not even talking climate change here. We’re just talking about, you know, breathing in, um, small pollutants in the air is just a huge health burden, and it's one that, once again falls disproportionately on Black communities, even wealthier Black communities.

You read about a study in 2018 that was conducted by the EPA, that that showed that there was this disproportionate impact in terms of air pollution on Black communities. Talk a little bit about that.

[00:27:41] Linda Villarosa:
I got assigned a story for the New York Times magazine about asthma and children, and I was really interested in this and I had to decide where would I, you know, where would I center my reporting and where would the narrative take place.

And at first, I thought I would go to the South because I knew somewhere around Cancer Alley in the South by Louisiana and those Mississippi and those states that are long-term polluted, um, by refineries. And then I looked at Philly because asthma was really high there, especially among Black folks. And I went to a community called Grays Ferry, and I was following some community health workers. What they were doing was going into homes. They were, you know, had some experience with asthma in their children or their own families, and they were helping individual people to get rid of asthma triggers. So if you had a cat, if you had mold, um, if there was a lot of dust in the house, and they taught him how to use medication and it was really lovely.

But then every time I went to somebody's house, I'd look out the window and I'd see this gigantic refinery and no one was saying anything about it. And I started thinking, “Wait a minute, this is the giant trigger here.” And it was, you know, the largest refinery in the Eastern seaboard, and it was right in the middle of Philadelphia.

It has since… It exploded during the middle of my reporting and has since closed. So they're dealing with the cleanup now. But I just remember, what am I doing? I should not be reporting on individual people, trying really hard to get better when there's this other gigantic refinery that's causing so much air pollution in this city.

And I looked at how the people ended up in, you know, living near a, this giant refinery. First, there was public housing put up in that community because it had been redlined because of the refinery, which had been there since the 1800s. So you couldn't get a mortgage there anyway, so public housing came in.

Then people were able to dig their way out of public housing, but they didn't wanna go far from where they grew up and where their, their family legacies were. So they ended up in communities not far from public housing, but still close to the refinery. And I, I just wanted to show that these people didn't do anything wrong.

The story was called “The Refinery Next Door”. It's not their fault, but it is a Black community. It is, still has a lot of public housing nearby. That is something that the government did and blaming individual people and even, you know, I, this community health project is important to show individual people how to lessen their asthma risk and asthma attacks, but it's not healing the overall problem.

[00:30:24] Steven Johnson:
In this last section, I'd like to turn to some of the solutions that you talk about. One of the key solutions that you talk about near the end of the book, um, is, is really a kind of an underappreciated figure in the United States, but, but maybe a little bit more familiar overseas, which is sometimes called a community health worker.

Sometimes overseas. It's it's, visitadors or village health guides or women group leaders. Latona Giwa, the doula in the story we talked about, is kind of an example of this. Uh, it's a really important role. Give us a description of what that role is and, and, and how as a society we can support that kind of person.

[00:31:09] Linda Villarosa:
I first saw them in Africa. I was in Ethiopia and Zambia, and I've hadn't heard the term before and I didn't realize that that was a thing until I got there. And I spent the day with, with a young woman who was one of two community health workers in a village. She had been, because she could read and write, she was taken, um, chosen by the people in the village to go get what's the equivalent of a, like a nursing degree.

She came back to the village and she was like, the, doctor of folks, and she wasn't doing everything, but she was doing the things that she could and might be educating people about how to take care of themselves. It might be giving shots, it might be doing, well, baby visits, might be doing gynecological exams.

Things just very simple. Might be being the connection to get someone, it might be delivering a baby, but it was also like a midwife. But then it also, she'd be the link between if the person had to go to the hospital, and you know, the person who didn't have a lot of experience, and there certainly was, is not the kind of healthcare in Ethiopia or Zambia like we have here.

So I started thinking about it. I started thinking, why don't we have more of that in the United States? And part of it is because we lean too heavily on technology and um, sort of the kind of best healthcare money can buy. And it's often medicine or something, you know, machines. Instead of looking at the link between like what happens before you get sick, these are the people who can help you stay well.

These are the people that early in whatever illness you have can make your connection to the healthcare system. And I was arguing with someone who was saying, “Why are you talking about community health workers? You're just saying…Um, why you're just giving a solution that costs more money?” And I'm like, “What costs money is people being sick.” And in, in stage especially, and a community health worker, whatever the name is, whether it's a doula or patient navigator, these are people who have some kind of training or experience with the problem but aren't, you know, con—connected to the technology. They’re the, sort of the care in the term healthcare for me.

And a lot of times when I'm doing stories, it is someone like Latona Giwa. It is someone like Mr. Cedric, who was the patient navigator in a story I did about HIV/AIDs. It's these people who come with kindness and support and care and attention, and they make the connection between the technology and the clinic and the hospital and the person.

And I think that what is missed and what is only gonna get worse in America is rural health and in rural areas that where Zambia and Ethiopia do not look that different from Mississippi and Alabama and parts of Louisiana. That is where community health workers really function the best.

[00:34:02] Steven Johnson:
I was thinking as I was reading Under the Skin yesterday that those properties that you associate with community health workers, that translating and explaining the complexity of the health situation or the medical institution and also motivating and inspiring the people they work with, um, that describes a lot of what you do and have done in your work.

Well, one of the things that's really striking about the, the book, I think, is that in the last couple of chapters, you talk a number of points about being optimistic right now in, in part because of the events of the last two years, despite all the tragedy that's that's been baked into the last two years. Tell us about that optimism.

[00:34:41] Linda Villarosa:
I feel as though there is so much that has happened in the last two years since the rest of the world discovered racism in America. And um, we had this pandemic which sickened so many people and also confirmed much of what we already knew about racial health disparities and about some of this stuff.

I hate that this is how we had to learn it. But I think that this is a turning point right now. This is a turning point where we can change the way we've done things for centuries, and I'm really hopeful because I am on the ground. When my book came out, it felt like it came out at a really good time because people wanted to know more information about what I was writing about to explain racial health disparities. To look, because we've been trying so hard to get rid of this stuff, to equalize things, but looking through a poverty lens that hasn't worked, and I get really excited when there’s, like whether it's a city, a state, a government, a hospital, a medical school looks and says, “Wait, we have to do things differently.”

Sometimes it means anti-racism and explicit bias training. I was on the phone with Mary Bassett. Mary Bassett was the New York City Health Commissioner. And when she was there, she mandated all 7,000 employees go through some kind of, it was an undoing racism training. And I asked her, I said, “How did that go?”

And she said it was pretty good, but a lot of people resisted and it was hard. But the other thing that was important in that was that she mandated, looking at, um, changing policy. So it couldn't just be training individuals or retraining or undoing. It had to also be looking at where the problems in New York City were the worst and attacking them and looking beyond poverty to race as a risk factor, and I was really impressed with that. I'm impressed at many medical schools around the country where there have been medical students who have looked at the way they are educated and saying, “Wait a minute. Some of the same myths and fallacies that began during enslavement are still embedded in our medical training in our medical education, even in medical textbooks, and we don't want to go into medicine in the, in that way, doing things wrong, harming people, even if it's not, you know, if it's not on purpose.” And I'm really impressed with them.

[00:37:09] Steven Johnson:
There, there’s some basic facts here now about the relationship between race and, and health inequality that we, we're no longer debating. We're debating now, you know, what we can do about it, what we should do about it, but the, the fight to establish that connection, I think we've started to win finally after 20 or 30 years.

[00:37:28] Linda Villarosa:
I really agree with you and I used to get invited to hospitals or to medical schools to a grand rounds just to be debated. To say, “Well, actually…” and then people would, you know, the physicians or the medical instructors would be arguing with me and saying, “Well, actually in this, this isn't, you're not exactly right in this.” And now I don't get that anymore. I get this hunger to have discussions about these topics, to think, “How can we be better?”

I'm really excited by, you know, we talked about, at the beginning of this conversation, we talked about how exciting it is when someone's thinking changes, and I think this is really an exciting time to see people's thinking change, to see things shifting, to see that it's too late to turn back. You can't unsee this reality and this truth, and I find that really exciting.

It's also wonderful to see change and to see hope, and to see passion, and I really appreciate many of the people we've mentioned, including Dr. Geronimus and Dr. Yancy and others who have taught me so much about this and you know, I'm excited. My next big thing, I'm going to the APHA, the American Public Health Association Conference in Boston in November, and I'm just checking off the days until I go because I just realize how much there is to learn still.

[00:38:46] Steven Johnson:
We're very grateful both for all the work you've done over the year, this book in particular, and for you joining us today on the TED interview, it's been a wonderful conversation.

[00:38:54] Linda Villarosa:
Well, thank you. And I accept the, um, mantle of being a journalism doula, and I'm proud of that. So thank you. I appreciate it, and I always love talking to you.

[00:39:05] Steven Johnson:
You can put that on the CV going forward.

That's it for the show today. The TED interview is part of the TED Audio Collective. This episode was produced by Constanza Gallardo and mixed by Erica Huang. Sammy Case is our story editor and fact-checking by Meerie Jesuthasan. Farrah Desgranges is our project manager. Wilson Sayre is our managing producer, and Gretta Cohn is our executive producer.

Special thanks to Dan O'Donnell, Michelle Quint, and Anna Phelan. I'm your host, Steven Johnson. For more info on my other projects, including my latest book, Extra Life, you can follow me on Twitter at @stevenbjohnson or sign up for my Substack newsletter, Adjacent Possible.