Racism has been firmly embedded in medicine for centuries — so uprooting it is no small task. In this episode, author and journalist Linda Villarosa and Dr. Amaal Starling join Dr. Millstine for a conversation on the ways racism prevents Black and brown people from getting the care they need — and what can be done about it.
Read the transcript:
Dr. Denise Millstine: Welcome to the “Read.Talk.Grow.” podcast, where we explore women’s health topics through books. In the same way that books can transport us to a different time, place, or culture, “Read.Talk.Grow.” demonstrates how books can also give a new appreciation for health experiences and provide a platform from which women’s health can be discussed.
At “Read.Talk.Grow.” we use books to learn about health conditions in the hopes that we can all lead happier, healthier lives. I’m your host, Dr. Denise Millstine. I’m an assistant professor of medicine at Mayo Clinic in Arizona, where I practice women’s health, internal medicine, and integrative medicine. I am always reading and I love discussing books with my patients, my professional colleagues, and now with you.
I am so excited about today’s guests. My first guest is Linda Villarosa. She’s a journalist, an educator, and a contributing writer to the New York Times Magazine. She covers the intersection of health and medicine and social justice. She’s a journalist in residence and professor at the Craig Newmark School of Journalism at CUNY and teaches journalism, medicine and Black Studies at the City College of New York. Her book”Under the Skin” was published in June 2022. Linda, welcome to the show.
Linda Villarosa: Thank you. I like seeing the book with Post-its.
Dr. Denise Millstine: Lots of book tags. And this one, I hope we get to touch all of them. My second guest is Dr. Amaal Starling. Dr. Starling is an associate professor of Neurology at Mayo Clinic in Arizona. She’s a graduate of Drexel University College of Medicine and is residency and fellowship trained in headache neurology at Mayo Clinic. She is an expert in concussion and headache — particularly in women. She educates medical students, residents and faculty — including a grant supported program to eliminate racism by hosting Harriet Washington for Grand Rounds and directing a book club also focused on the book “Medical Apartheid.” Dr. Starling, welcome to the show.
Dr. Amaal Starling: Thank you so much for having me, it’s really a pleasure to be here with you, Linda.
Linda Villarosa: Same.
Dr. Denise Millstine: So, Amaal, let’s talk about “Medical Apartheid,” because we’ll probably spend the whole episode talking about”Under the Skin.” When we asked Linda for some recommended books, “Medical Apartheid” definitely came up on her list. Tell us about your project and how that went.
Dr. Amaal Starling: First of all, I know you mentioned that we’re content experts, but by no means would I ever say that I am a content expert in racism and topics of diversity, equity and inclusion. But what I am is a lifelong learner in this topic. And in thinking about it, what I learn I want to try to implement and enact change with that. With “Medical Apartheid,” it actually started with my colleague, Dr. Rashmi Halker Singh — she and I are part of a Facebook group of women’s neurologists across the nation. From that, a book club was initiated with “Medical Apartheid,” and it was such a rich experience. We wanted to bring it back to Mayo Clinic, so we applied for this grant to eliminate racism here at Mayo Clinic and were able to receive that.
Through social media, Dr. Halker Singh was able to communicate with Harriet Washington, and we were able to invite her to come to give Grand Rounds. It was just an amazing experience to have her here. What was also really important is that we were able to bring that back to our department and then larger out to Mayo Clinic, and do this bookclub where we were able to go through, especially in neurology, we actually split it up into three sessions — which worked perfectly with the book because it’s split up into thirds — and review it as a group. It exposed people to a lot of things that we should have known, but we didn’t know. We did not learn these things in medical school and we have not learned these things in continuing medical education highly relevant to what we do on a day-to-day basis.
It was really good to provide that education. But it was also a book club that had a lot of silence and a lot of reflection. I feel like it brought us together as a department, and even when we did the larger book club with people that we didn’t know, I felt the same way — that it just brought this sense of connection and this sense of “Let’s create a team of people sprinkled throughout Mayo Clinic to enact change.”
Dr. Denise Millstine: I participated in the larger book club, and with every section of the book, I thought, “How did I not know this? How have I been so ignorant to this?”
Linda, you’ve brought”Under the Skin” to really shine light on what we don’t know about health care and the racism that still exists within it.
Linda Villarosa: Well, first, I’m really impressed with what you’re doing. I consider Harriet Washington a mentor. She is a forerunner to the work that I do. When I was at Essence Magazine, she was one of my writers, so I really appreciate that and all that she has to offer you.
Dr. Denise Millstine: I was at a conference earlier this year — I’m fellowship trained in integrative medicine — so it was the National Integrative Medicine Congress. Our first kickoff speaker was Dr. Michelle Morse, who’s the chief health officer for New York City. She was talking about the correction for Black patients with GFR, which is the kidney function — glomerular filtration rates — and how that came to pass, and how it’s been applied for decades to the effect of delaying diagnosis of kidney disease in Black patients such that when they are diagnosed, they’re diagnosed so late that they are much more likely to go on dialysis.
Linda, this is just one example and you bring the same example up later in your book, but I was floored that I never stopped to think about why that correction factor is there.
Linda Villarosa: I was telling my editor at the New York Times Magazine about that, and she was like, “Wait, that still exists?” And I had had a kidney function test maybe three weeks before, and I held it up to her and I said, ‘See, there’s a Black calculation and a white calculation.’ And you see the Black calculation is circled on my sheet.
If you look into it, it goes by the false idea that Black people have more muscle mass as a group, as a race, have more muscle mass so that we secrete more creatinine. Then it changes the way that our reading happens for kidney function. I’m like, wait a minute, I am the tiniest person ever. I definitely do not have more muscle mass than the average person. So it’s strange that it’s stuck around this long. You can see there’s debates about it in medical societies and medical schools, but it’s still there. It’s important for us to be aware of it and to understand that it is something that really is not effective. I’m teaching pre-med this semester and I had my pre-medical students analyze that as a group and it was really interesting what they came up with. Most of them said, “Wait, this is how it came about? This seems strange. Why is this still here?” But I doubt they would have questioned it if I hadn’t brought it up.
Dr. Amaal Starling: I think what’s great in that section is how you mentioned that it was questioned by a trainee. I forget if it was a student or a resident, but I think it was a medical student that questioned it and then enacted change. I agree with you. We’ve seen that here at Mayo Clinic as well, that our medical students are the ones that have actually participated in a lot of changes in the curriculum. The beauty is that we’ve been able to take that and not just apply it to the medical school, but then elevate that to graduate medical education that then actually requires training of the program director — so the faculty, so we can provide that. But you’re right, a lot of this is coming from the trainees rather than coming from a top-down approach.
Linda Villarosa: I think that’s super interesting. A lot of medical students, interns, and residents came through the educational system, during that time, the Black Lives Matter movement. So they were sort of radicalized. They became active as young activists and then they took that same energy into medical school. Even though it feels unfair (I know you all know how hard medical school is), to be trying to enact change and push against your administration and your professors and it’s difficult, but I’m excited that it’s happening.
Dr. Amaal Starling: Yeah, I honestly feel like that passion that they bring is a part of their wellness. I think that if you’re only doing medicine, that can really break you down — but if you’re passionate about something, it really brings in a piece of meaning. A lot of the medical students have really taken that on as their mission, which is nice to see, although I recognize that it’s then important for us to take that baton and move it forward.
Dr. Denise Millstine: Let’s start at the beginning. So let’s talk about maternal and fetal health, which is so important. Here is a fact from your book that I’ll read directly. “College-educated Black mothers are more likely to die, almost die, or lose their babies than white mothers who haven’t finished high school.” Your book talks a lot about how many people want to equate race with socioeconomic status, but that is not accurate — that this is an independent risk for mothers.
Linda Villarosa: And I knew that already. I knew that as far as many racial health disparities, but when I saw that statistic — and the one I saw was even more dramatic, it was simply about maternal mortality and it was simply about severe maternal morbidity. And it said that a Black woman with a master’s degree, a Ph.D., an M.D., or a J.D. is more likely to almost die during pregnancy and childbirth than a white woman with an eighth grade education.
That’s what got me interested in this topic, and to write my 2018 cover story, “Why America’s Black Mothers and Babies Are in a Life or Death Crisis.” Without a doubt, that statistic tells you, “Wait. You cannot just blame women for their own issues that happened during pregnancy and childbirth, and you cannot blame Black culture.”
Dr. Amaal Starling: I was really struck by that — as you can probably already tell, I’m a very solution-oriented person — so I was like, okay, here is all of this data, but are there groups of people who have been able to make change? I think there was a group that was in Louisiana, and in California, that put in all of these different sets of awareness and education — and there was a change in the numbers, but that it unfortunately continued to have that racial divide.
It was one of those things where you were like building it up, and I was like, “Yes, this is great. This is awesome. We can upscale this.” And then I was like, “Oh no, we still didn’t get to the root of the matter.”
Linda Villarosa: Well, it was interesting because that story started out simply as a solution story. It was about how doulas can really help women during pregnancy and birth. My editor said, “Well, no, you have to go back and figure out why this is happening in the first place. Why are we the only wealthy country where the number of birthing people who die or almost die, related to pregnancy and childbirth, is going up?” That doesn’t make sense in our country where we spend so much money on healthcare. And then I remember that somebody that I interviewed said, “We can’t doctor our way out of this.” And that stuck with me. In California, they did try to doctor their way out — and it made a difference. It made a difference to change what happens to birthing people in the hospital setting, but it mostly affected white women and to some extent Latinx women.
So then I was impressed by the state of California, a Black-led legislation, that said now you have to — if you are working with a pregnant person and birthing person — you have to go through some kind of anti-racism training. That happened pretty recently and it was right before COVID, so we don’t know how well it’s worked yet. Then the state took a step further and said as part of continuing medical education for all health care providers, you have to go through some kind of training.
The question is, what is the training? How involved is it? How valuable and beneficial is it? But I’m impressed with the state that it made movement. It looked for a solution and it didn’t just look for a solution that was about technology, spending more money, or sort of doctoring our way out of this situation.
Dr. Denise Millstine: Or simply telling women to just take better care of themselves. The answer is not as simple as eat better and exercise more. While those things are very important, that is not the solution either. Can you talk about weathering?
Linda Villarosa: Well, first, I want to say that Dr. Arline Geronimus is someone who I really respect as a mentor. I just finished her book “Weathering,” which is coming out in March. You have to have her back on when her book comes out. Weathering is a concept that Dr. Geronimus has been looking at for 40 years since she was an undergrad at Princeton.
I looked at that because that was a reason to help explain why women across class lines, Black women across class lines, would have these poor birth outcomes. The concept is quite simple. It’s that hard coping against discrimination harms your body, because when there’s an insult or there’s something traumatic happens to you, your body goes right into fight or flight — and the systems become kind of on fire. Your heart rate goes up, your blood pressure goes up, your cortisol hormones are increased — and that makes a lot of sense in isolation. But when it happens over and over and that’s happening too often to your body, it creates a kind of accelerated aging, which Dr. Geronimus (she’s at the University of Michigan), called “weathering.”
I like the word because it has a twofold meaning. It talks about weathering on the body the way a storm might weather a house. It knocks off the shingles. It breaks the windows; it chips the paint — the dual purpose of weathering is that we weather this storm. We’re still here. We have family, we have kinship, we have community, and we have love. That makes it so that we can weather the storm of the lived experience of being a person of color, and especially a Black person in America.
Dr. Geronimus takes it a step further because I asked her, “Is this like this a Black thing?” And she said, “No, this is anyone who’s harmed that it can happen to.” She suggested, “Why don’t you look into what’s happening to people in Appalachia, where it’s mostly white folks who have had a really hard time there and have very poor health outcomes?”
And I did that. I went back to her and I said, “Well, I went there and you’re right.” What I noticed was that anyone I interviewed looked much older than their age that they eventually shared with me. I just thought, I’m not a physician or a scientist, I’m a journalist. Observation is my best skill and I just kept looking at the people thinking, “Why do they have these kinds of diseases that hit people much later?” One, they have opioid problems. There is an epidemic there. But what I noticed was people having strokes and heart disease and diabetes when they were in their forties and fifties. That struck me and it sort of confirmed for me that idea of weathering.
Dr. Amaal Starling: I have sticky notes and highlighting all over that part because it really spoke to me as a headache medicine specialist, where the vast majority of my patients have chronic migraine. I always talk to patients — I’ve never known this term of weathering; I might actually work that into my conversations with patients — but I always talk to patients about how they have so many different things going on that make their body feel like they’re being chased by a bear and their “fight or flight” is on. That is really hard on the body and it’s really hard on the chronic pain systems in the body because if you were actually being chased by a bear, you want to be sensitive to light, sounds, smell, pain, because that would help survival — but for you to do that 24/7, day after day, after day, that really affects the brain.
This is a conversation I literally have every day, multiple times a day, with my patients, so I loved that intersection that I found and it also, again, made me think this is a more nuanced conversation that I will need to have with my patients who are people of color, who are immigrants, or who are marginalized in some way, maybe from LGBT population because some marginalized populations will obviously have that higher weathering and risk of chronic pain conditions.
Linda Villarosa: That’s super interesting and I’m really glad you’re putting that into practice. Dr. Geronimus’s new book has a lot of solutions to it. Many of them are highly political, but also some of them are personal. It’s just to lean into those networks and systems of support, which I think is super important to all of us, especially when you’re talking to patients.
Dr. Denise Millstine: Somewhat related is mental health and what an important topic that is, and how systemic racism has really affected how Black people have been treated — higher diagnoses of schizophrenia, for example, being criminalized versus being treated medically, and then one that is probably under-recognized and very pertinent to our listeners is eating disorders, and how under-recognized they are in Black women.
Linda Villarosa: In my book, I chose the narrative of Audrey Brianne. She and I went to college together, but I didn’t know the story until later that she had an undiagnosed eating disorder. She, like me, grew up in Denver, in a predominantly white community. Because she was Black, no one thought she could have an eating disorder, so it was really under-recognized. Finally, she did get diagnosed. She ended up going to college. Later, she had bipolar disorder. She had a build-up of mental health concerns that went underdiagnosed and underrecognized that she was able to hide because her job was as a Hollywood stylist. She was one of the few Black women in this business at that level. She was hiding all of her emotional pain. She was also drinking. She ended up at the point of suicide. Luckily, that didn’t happen and she got treatment.
I was very struck by how much she was trying to be a so-called superwoman or a strong Black woman. That was something that we covered back in the day when I was at Essence, and we did a story about that — how it feels like pain is just part of your existence, and you try to hide it because of the image of Black women being always strong.
I was very interested in this story and it really struck me. I sort of gendered that chapter, and on the male side, I talked about the intersection of policing and criminalization and Black men and mental illness. I focused on Mark McMullen, who was a family friend of mine, until after years and years and years of struggle with mental illness and substance abuse that were connected. He was murdered by the police in Boston. I talked to his mother yesterday and she said, “Thank you so much for talking about Mark’s story, because it always just looks like he was a ‘thug’ or a criminal, but he was really suffering and he wasn’t treated well.” And she said, “I am still in too much grief to read the chapter, but I’m glad you wrote about him.”
Dr. Amaal Starling: I was just at a conference this weekend that’s to inspire neurology residents to enter the field of headache medicine. One of the talks that I gave was about headache diagnosis, and it really centered around listening to the patient, listening to their journey, listening to their story, hearing them and believing what they say. An interesting question came up: “Where I work, we have a lot of patients that are coming from the prison. How do you believe them?
I said, “We’re in the business of believing people.” We treat pain conditions. We don’t see it. There’s nothing we see — This is an invisible disease of abnormal brain function. It doesn’t matter if someone is coming as a CEO of Wal-Mart, the CEO of Mayo Clinic, or coming from the prison, we should have no biases about this journey that they’re telling us. It really speaks to those biases and assumptions and how that’s going to impact this individual’s migraine care, because there’s already people thinking, “They’re not going to tell me the truth because they’re in jail.”
Linda Villarosa: That is so deep. That’s really good that you’re saying that to providers and future providers. It’s really important that people are listened to, regardless of where they come from. That’s the job, so that’s so great what you’re doing.
Dr. Denise Millstine: We see that through the book too — this concept of medical neglect. The woman who had triplets and was hemorrhaging and was nearly passing out when the emergency services arrived and treated her as if she had taken a substance — without respect and without really recognizing the severity of what was going on there.
Linda Villarosa: What’s mostly sad about that, too — though everything is sad — but also, what if she was taking the substance? She should still be treated with dignity and respect. I think that sometimes in these discussions, we forget about the different levels of issues that can come up. It’s not just in the hospital or in a clinic. It also is in E.M.S., which is part of the healthcare system.
I was very moved — I got two really good reviews on”Under the Skin.” One was in the New York Times Book Review, and it was by a woman who I don’t know, but I know of her. She’s a very wonderful writer. In the middle of the review, she shared her own traumatic experience, giving birth, and at the end, she said that even though she felt like she had done everything right, including reading my previous articles — she still felt like it was her fault that her birth didn’t go as expected.
The second review was in the Washington Post, and it was again a really high-level writer reviewing the book. In the middle, he told the story about his wife, who was treated so badly by the E.M.T.s, and she had a stillbirth. A stillbirth is always a tragedy — but then on top of it, to be treated as though you’re faking, drug seeking, something like that, is doubly bad.
I was very moved by that. I think I’m a very evidence-driven writer. That’s what I care about. I care about research, but I also care about narratives. At some point, this pile-up of people’s narratives, storytelling, and sharing becomes a second form of evidence.
Dr. Amaal Starling: I talk a lot about stigma in migraine and chronic pain — and about how when you’re exposed to that external stigma (and it’s also a genetic disease, so often people that I treat with migraine had a mother who had migraine), they grow up in this world of externalized stigma that they see that their mother may have faced, and then they naturally internalize that stigma, which is why in our disease stay, 80% of people with migraine don’t even talk to a doctor about their symptoms. That really correlates with the fact that it’s not about blaming people of color and Black people about not seeking health care, but it’s that internalized stigma of “They’re just going to blame me” or “They’re just going to say it’s not a problem” or “My kidney function is fine,” or whatever it might be.
They’ve internalized that, but that really still is as a result of all the racism that they have experienced generationally, and that’s been passed down from the moment they’re newborns, or even the moment of conception.
Linda Villarosa: I was in this conversation yesterday about respectability, how as Black people, we often go into the health care system dressed up or trying to look professional and sound professional — code switching when we’re talking to health care providers. Part of that is you don’t want to seem too hysterical because then it’s like, oh, that’s just a hysterical person, perhaps drug-seeking, or out of control. But when you’re trying so hard to be respectable, you may be minimizing your actual pain and feeling, which is what my mother does. I just let her tease me. She said, “You have such low pain tolerance.” I said, “Oh yeah Mom, I get that you think that, but actually, if you’re more like me — maybe you’re telling the truth about what’s going on with your body so you can get the kind of treatment that you’re trying to seek here.” It’s an interesting balance being a Black person in the health care system — of how you are supposed to behave in order to just get care.
Dr. Amaal Starling: And that adds to the weathering. Right?
Linda Villarosa: Exactly.
Dr. Denise Millstine: You tell the story really beautifully about when your father was ill and your mother was dressed like the CEO of the hospital. She had actually been in hospital leadership. You came dressed as a career woman and literally showed your father’s advanced degrees and said this man, withering in front of you, deserves your respect and can understand what you’re saying to him — so please speak to him in a way that is respectful and honors that he has that background.
Linda Villarosa: It was so sad. My dad was a very dignified person. He is mild mannered. He’s kind of quiet. So to see him — he was very angry. He was really upset. He had restraints on his body. It was only because he was also trained as a scientist, so he could understand, he was scared. If he was spoken to with kindness and respect, he would not have been behaving that way.
Even if he was, he shouldn’t have been treated that way — there’s certainly another way to talk to him. I don’t like to pull out the middle-class respectability card, which my mother and I had to do — but it was the only thing that we felt we had. And to fast forward, I went to speak at the University of Colorado School of Medicine a few weeks ago, and I noticed that the people were really kind to me. They were like, “Are you okay?” One of the women was holding my hand — and I’m thinking, “What’s going on here?” Then I looked around and there were army barracks. I realized that the veterans’ hospital where my father had been had been transformed into this medical campus where I was — and I didn’t realize it until they told me.
I had a little bit of a reaction to say, “Oh, my God, this was the site of what happened to my father and mother and me.” But it was also really fulfilling to go back, tell the story, and see the interest in this topic that happened at this medical school, which was not a good place for my father years ago.
Dr. Denise Millstine: Maybe an area of how racism affects health that is under-recognized, but comes out so strongly in your book, is environmental racism — the impact of where we live on how healthy we are. Can you talk about that?
Linda Villarosa: The first story I ever did on that topic was at Essence. I went to a town in Louisiana where the people were sending me photos of themselves. They all had rashes. Almost 100% of the children had asthma. They had all these problems. I remember that they were always told that they weren’t taking good care of themselves.
I went there and it was a huge refinery that they were living near. There was no chance of anything happening to change that. The suggestion to them was just move away. This was a town that was founded by enslaved people and the people had been there for generations.
Then fast forward, I did a story for The New York Times Magazine years later, just a few years ago, on a similar town in a similar neighborhood in Philadelphia that was up against the largest refinery on the East Coast — It was right in the middle of the city. And again, so many kids had asthma. I went to the nearest elementary school, and the nurse was saying, “Oh, there’s so many children with asthma.” And I said, “Oh, how do you take care of them?”
And she opened a cabinet that was alphabetized with all the asthma inhalers of the children. It was so interesting because when there was a protest, people were screaming, “If you don’t like this place, move away.” The refinery was there first. The city, because it was a redlined area and because of the refinery, the city put public housing there.
People moved into public housing and then they dug their way out of public housing by working, getting jobs, and pooling their money together. They bought houses, but of course, they wanted to buy homes that were in the area where all their friends and family were — so they were still near this refinery that was taking no responsibility for the poisoning that was happening.
It was also extremely hard to prove. That was the hard part when I was working on that story and also the chapter in my book that’s on environmental racism and environmental justice — it’s very hard to prove a cause and effect between the pollution that comes from the facility and the poisoning of the people. I did my best, and certainly there’s a lot of people who are on the ground working, including at Drexel, where you went. Sharrelle Barber is at Drexel, and her father is Reverend Barber of the Poor People’s Campaign. They are doing very interesting work around environmental justice and figuring out how to prove the cause and effect.
Dr. Amaal Starling: I think it’s so important for us as physicians and clinicians to consider the environment that people are living in and the social determinants of health before we give our plethora of advice as to what they should do. That was something else that we’ve been bringing up in conversations that we’re having with trainees. We always talk about the lifestyle changes that can be helpful for migraine or for other neurologic diseases — but don’t just start with that. Start with learning about the person, learning about their access to green spaces before you tell them to go take a walk every day — learning about their access to grocery stores before you tell them to have a whole food diet.
All these kinds of things are so important and providing those recommendations without knowing where someone is coming from, breaks the trust that we have with that patient, because the patient walks out of that appointment thinking, “They don’t know me, they don’t really care about me. They’re not even trying to get to know me.” They give up on care and don’t come back for that follow up visit.
It worries me. I have a pit in my stomach to know, perhaps without my growing awareness, but without that awareness that I may not have had, five, ten years ago, how many patients for whom did I break trust because of those missteps that I made.
Linda Villarosa: More and more physicians are like you, really trying to ask the full load of questions about the person and not just making those kinds of assumptions. In my book, I shared the story of my mother’s community, which is Inglewood in Chicago, where people lived to age 60, and nine miles north, they lived to age 90.
When we went to that community, I understood why. My grandparents came from Mississippi to Chicago. So growing up for my mother and me for part of my life, it was a place of sparkle. It was a place of success and achievement and grit. And then when I went back, it was a place of erasure.
It looked more like rural Mississippi in parts than it did the city of Chicago. I interviewed a couple of physicians, one of whom had started a Black men’s health clinic in the same community because of such poor health outcomes. I said, “What happened to your clinic? It ran for a while.”
He said, “I realized that providing health care to people wasn’t as helpful as I thought it would be.” He switched to raising wealth and figuring out how to build wealth in the community. Even before they got to the clinic, that’s when the problem happened. Because of a lack of healthy air, food safety, education — all of those social determinants of health that make people healthy were missing in that community. So providing health care, it turned out, at the men’s clinic — women were seeking health care from that clinic — and it wasn’t doing what was expected.
I never forgot that because I thought when you have a physician who is saying the connection between health and wealth is so important, but let’s focus on the wealth part — that was kind of mind blowing for me.
Dr. Amaal Starling: It gets back to that root cause of that systemic racism. That is what perpetuates the disparity and wealth disparity in health. It’s the racism that we need to address, except besides all these Band-Aids that we’re putting on, which is hard. I can’t imagine how to do that except for increasing awareness, at least to start with. And then the next generation that’s coming, that really seems to have a lot of people that are activists and really have high hopes of what they would like to see the world change to.
Linda Villarosa: I agree with you. Some of the reason that I do the work is that I’m learning. I’m like you, a lifelong learner — and what struck me about that story of my mom’s community in Chicago was I knew it had been redlined, but I didn’t understand that it’s also been subject to contract buying. About the time that the bulk of people were coming up from Mississippi and Alabama to Chicago and Cleveland and Detroit, in Chicago specifically, contract buying was in place. A Black person couldn’t get a mortgage and buy a house outright. You had to buy on a contract. I ran that by my mother — I said, “How did grandfather buy that building that he got?” And she said, “I don’t know. It was on some kind of contract. He was always terrified that he would lose it.”
If you can’t invest in the community, you can’t buy a home outright, and a home is usually the biggest part. That’s what you leave your children. That’s what you sell to make money. That’s the bulk of how most Americans make their wealth. If you can’t have that, then it makes the community less healthy — because of the lack of wealth.
I just really put those pieces together. I know I wrote a book on this topic and I’m really proud of it, but I feel like I keep learning things that surprise me.
Dr. Denise Millstine: I really love how you finish the book with hope — You also have to talk about COVID because we’ve just lived through COVID — but in both of your work in education, one of the concepts is that who treats us matters — that promoting awareness and anti-racism learning among all medical health professional learners is important, but it’s also really important to promote and support people of color and people from a variety of different backgrounds coming into medical education.
Linda Villarosa: I’m really, really psyched that this semester at the City University of New York, I’m teaching at the medical school, so my students are pre-med. I realize many of them are first generation or immigrants, so they don’t know everything about the history. They have the basics, but I took them all the way back. I started at 1619, because I was part of the 1619 project, and then I took them all the way through and we went through enslavement, reconstruction, all through history. And they were really surprised. They knew the basics, but to hear the background, to hear the details of that — they were startled. Then the next thing I said was, “Tell me about someone in your family or one of your loved ones who has gone through some kind of discrimination in the health care system.”
And 100% of them had something that someone had gone through, if not themselves, and sometimes their very close relatives. I had a hard talk with them because I’m super optimistic and hopeful and I don’t like to erode their optimism. But I said “I cannot leave this class without warning you about some of the racism and discrimination you yourselves might encounter. It might be because you have Black or brown skin. It might be because you’re Muslim. It might be because you speak with an accent — but people are going to question your medical credentials and you have to be ready. You have to find out how to support yourselves.”
I showed them the hashtag #ThisIsWhataDoctorLooksLike, and told them why that exists — because there was a Black woman physician several years ago who tried to treat a patient who was having a medical crisis on a plane and she was pushed away because of the disbelief that a Black woman could be a doctor. I warned them of that. I said, “I want you to make sure you go into this profession because I know you. I hear you. I hear that you want to practice — Stay in the communities that you’re from and practice — and make sure that you’re working with marginalized and oppressed people. But I also want you to go in with your eyes open and with your heart ready for a time when you may not be treated as well as expected, given how hard you’re going to work to get through medical school.”
Dr. Amaal Starling: First of all, I wish I could be a learner in one of your classes. I would love that and I think it would be just so enlightening. The other story I wanted to share is that my mom, who’s doing quite well right now, had breast cancer and was treated here at Mayo Clinic in Arizona. I remember when she had her mastectomy and we were in the hospital, and she and I were walking around the halls at Mayo Clinic to get a little bit of walking in post-op.
She was walking and looking at the pictures around. All of the pictures were about the Mayo Brothers and the nuns, and they were all white. I’ve been here since 2008. I was a trainee here. I’ve been practicing here since then. I know it’s the history of Mayo Clinic, but my mom turns to me and she goes, “I am so lucky and blessed that you work here, because otherwise I would have never received care here.” — and I was like, “Why would you say that? That’s not true. Mayo Clinic serves everyone,” and she’s like, “No, they don’t. Look at all the pictures.”
I got choked up and immediately ended up writing an email to the CEO and saying, “We need to change the pictures on the walls.” It may not seem like a big thing, and I know it’s the history of Mayo Clinic and history is important — but it’s making people not feel included. The patients don’t feel included. They don’t feel like they belong, and I shared the story of my mom. We have seen a lot of change in the images that we have on our websites and that we have on our walls, but it makes such a big difference to have that representation.
Along those lines, like you said, Denise, about representation in the workforce, I just have to plug my dear friend, colleague, and inspirational role model Dr. Alyx Porter. She and her husband have a foundation, ElevateMeD, and are doing the amazing work of providing scholarships — because again, it’s the wealth that impacts the minimal number of people of color who are in medicine, especially Black people and Black men, particularly, who are in medicine. She’s providing scholarships and opportunities for people of color, specifically Black people, to enter the medical workforce and really provide that representation.
Our colleague, Dr. Poole, who now is at Mayo Rochester, has done some work looking at the race and ethnicity of the physician and the race and ethnicity of the patient, and how when there is a match, especially in those marginalized populations between that race and ethnicity, that the care and the medical outcomes are better — and also providing so much evidence and inspirational ways that we can definitely support diversifying the healthcare workforce. As a program director, that’s the main thing that we’re talking about. How can we diversify our next residency class so that we can play our role, not only for that trainee, but for the patients that we serve?
Linda Villarosa: So important. Thank you for sharing that.
Dr. Denise Millstine: I really feel like the world is a brighter place because of the two of you and all of the work that you do to bring this to light, and also provide hope and ways that hopefully healthcare will be aware of that will change in the future. This has been an amazing conversation. I just want to thank you both for being here, for just being such amazing women, doing amazing work and sharing it with the world.
Linda Villarosa: Thank you. I took notes during this because I learned a lot — so thank you. I really love sharing space with you, both of you. So thank you.
Dr. Amaal Starling: Thank you very much. I also took notes.
Dr. Denise Millstine: Thank you for joining us to talk books and health today on “Read.Talk.Grow.” To continue the conversation and send comments, visit the show notes or email us at readtalkgrow@mayo.edu.
“Read.Talk.Grow.” is a production of Mayo Clinic Press. Our producer is Lisa Speckhard-Pasque and our recording engineer is Rick Andresen. The podcast is for informational purposes only and is not designed to replace a physician’s medical assessment and judgment.
Information presented is not intended as medical advice. Please contact a healthcare professional for medical assistance with specific questions pertaining to your own health if needed. Keep reading everyone.
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