Facing oppression like racism day in and day out can take a toll. Dr. Arline Geronimus realized this toll could have direct effects on health. She calls this “weathering” and defines it for us as “the way that oppression and marginalization physiologically erodes your body systems, your organs, and eventually you.” Mayo Clinic’s Dr. Sumedha Penheiter joins the discussion on what chronic stress can do to you — and what we can do about it.
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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, where I practice women’s health, internal medicine, and direct the section of integrative medicine in Arizona. I am always reading and I love discussing books with my patients, my professional colleagues, and now with you.
Our book today is “Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society,” by Arline Geronimus, through which we’ll be talking about the concept of weathering — especially the health effects associated with chronic stress among marginalized populations.
My first guest is Arline Geronimus, who is a professor at the University of Michigan with appointments in the school of Public Health and the Institute for Social Research, and is affiliated with the Center for Research on Ethnicity, Culture and Health. She’s an elected member of the National Academy of Medicine. Dr. Geronimus received her undergraduate degree in political theory from Princeton University, her doctorate in behavioral sciences from the Harvard School of Public Health and her postdoctoral training at Harvard Medical School. She’s the winner of many awards throughout her career and recently as the 2022 recipient of the James Jackson Distinguished Career Award for Diversity Scholarship from the National Center for Institutional Diversity.
Dr. Geronimus originated the biopsychosocial theory of weathering that we’ll be discussing today and is the author of the book, “Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society.” Dr. Geronimus, welcome to the show.
Dr. Arline Geronimus: Thank you very much. Thank you for having me.
Dr. Denise Millstine: Dr. Sumedha Penheiter has a doctoral degree in Biochemistry and Genetics from the University of Nebraska-Lincoln. Her postdoctoral work at Mayo Clinic was focused on Cancer Biology, where she researched signaling pathways in carcinogenesis. Subsequently she worked as a program manager within research administration at Mayo Clinic, with a focus on health disparities research. Currently she works as a manager and consultant within the Mayo Clinic Strategy Department, where she advises on strategies for optimization of systems and procedures using the agile and waterfall management methodologies. She’s also the President of the Board of Directors of the Rochester Diversity Council. Sumedha, welcome to the show.
Dr. Sumedha Penheiter: Thank you. Great to be here.
Dr. Denise Millstine: So once again, our book is the incredible Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society, and this book came onto our “Read.Talk.Grow” radar when we were talking with Linda Villarosa, whose 2022 book “Under the Skin” had a lot of accolades, as you know, Arline. You were featured in her book and she is featured in yours. We were so excited that she put us in contact with you and we got to read your book, and here we are. So Arline, let’s start with the definition of weathering, which is something that you actually created through your work and your research. Weathering posits that the health of African-Americans and other culturally oppressed, marginalized, or economically exploited populations — their health is subject to early deterioration as a consequence of social exclusion. You’ve worked on this for much of your career, but talk to us a little bit about weathering: how we can understand it, and what it looks like.
Dr. Arline Geronimus: Weathering is the way that oppression and marginalization physiologically erodes your body systems, your organs, and eventually you, leaving a weathered person vulnerable to infectious disease, to early onset of chronic diseases like hypertension or diabetes, or even obesity. It’s a function of the fact that people who weather are people who are facing structural barriers to making ends meet or to being seen or heard, or to being able to meet all their responsibilities, but who struggle tenaciously to do so anyway.
I named it weathering because of those two things — one, weathering like the erosion of your blood vessels in your body systems and the literal physiological damage that happens to your body if you’re a member of an oppressed population, and also because members of oppressed populations work resiliently to survive or overcome their oppression. And that can be weathering too – it’s shelter — it’s what allows them to keep working, to earn money, to go to school, to work several jobs if they have to, to work night shifts. But also they pay a physiological price for that as well, that contributes to having both shelter and storm.
Dr. Denise Millstine: I love this. I think it’s so powerful. When I think of weathering, I think of a tree at the edge of a cliff that has character, is gnarled, and it survived and it’s resilient. But that comes at a cost. So there’s both beauty and also a price in it. Sumedha, in your work, you have seen this concept, whether you’ve called it weathering or not, no doubt.
Dr. Sumedha Penheiter: Sure. Just out of personal experience, if I may add — I was born and raised in India and I moved to a small town — well, in Lincoln, Nebraska — from where I was Delhi. You feel so othered in the sense that there is a dominant culture, and having been in a culture where there was more of a caste system rather than a dominant culture versus a non-dominant culture, you just feel like a fish out of water and you’re always putting your A-game on and your best foot forward.
I’ve spoken to other colleagues, people of color, and they feel very uncomfortable stepping even out to the grocery store without having a proper suit, perfect hairdo, perfect makeup on, because they feel that they’re judged all the time. My husband, who’s white — when he has to go for an early morning blood draw, feels very comfortable just walking in in his sweatshirt pants and just drawing his blood. I feel that I will not get that respect or I just have that inside of me, that consciousness that I need to look good to be respected. So this ever vigilance that you feel because you are not part of the dominant culture is so exhausting and it’s always on. That really wears you down. I notice that a lot with other cultures, especially people of color, that feel that they’re constantly being judged and they’re always walking on eggshells, it feels like, when they are out in public. That has an anesthetic load, as you pointed out earlier. It raises your blood pressure. You’re constantly in a fight or flight mode and that really wears you down or weathers you down, as you said.
Dr. Arline Geronimus: It’s the physiological consequence of being vigilant all the time or what we also call ‘managing your social identity’ or code-switching: various ways you try to put on your A-game and do what you need for the people around you to respect you and not to fear you. In some cases, for a professional woman, maybe it’s that you want some respect and for your voice to be taken seriously. If you’re a young black male like Tyre Nichols or George Floyd, it can be a matter of life and death, whether you’re viewed as a threat or fitting any negative, racist stereotype. In either case, you do suffer physiological arousal. It may be greater or less great depending on if you’re literally fearing for your life or just trying to be respected and seen. But that chronic, being what you called in fight or flight, for example, wears down your immune system, your neuroendocrine system, your metabolic system, your cardiovascular system. It’s that constant wearing down of those things that can lead to early onset of hypertension and diabetes, or to be more susceptible to COVID, or to dying from COVID at a younger age when members of the dominant group don’t die from COVID as much if they’re under 65.
But it happens to much younger people in oppressed and economically exploited groups. It’s constant vigilance. Again, if you’re a young, black male, or you’re in certain settings where you actually could be viewed as threatening, it’s not just vigilance 1.0, it’s like vigilance 10.0, as in having your head on a swivel all the time, and being acutely sensitive, as well as having to code-switch or look unthreatening.
It also can be added to by other kinds of stressors. We think about having to work night shifts, having to work two or three jobs to make ends meet, or never having a break — it’s also having to stand outside waiting for the bus in frigid weather, then to stand on the bus packed like a sardine, and then to get to your job, which might be physically taxing or emotionally taxing and where you also have to be managing your social identity and being sure you’re being polite and looking respectable.
One last point I’ll add is, if you’re exposed to environmental toxins, they can be physiologically stressful. The idea of weathering is that for people who face those stressors chronically, they experience fight or flight akin to the very brief period before being attacked by a cheetah. After that period, we either flee and escape or we’re killed. Either way, within a few minutes, we no longer need to have our heart rate up so that we can get oxygenated blood to our large muscles — so we can run or fight better or faster or stronger — and we can just go back to our normal state of physiological being. But if you have fists in your face at every turn, and if you’re not able to have any time to recover because you’re always managing your social identity or because you’re having to work three jobs because your wages are so low, then that’s where the erosion comes, because the stress hormones that regulate your fight or flight response just never recede the way they were meant to after about 3 minutes or so, if you survived the ordeal.
Dr. Sumedha Penheiter: May I just jump on to that? Regarding the safety part of things, I agree with that completely. When I was a graduate student, the World Trade Center was bombed. Middle Eastern women and Indian women, to a person who’s never really traveled, look the same. We were so scared after that happened because someone of Indian origin was thought to be Middle Eastern and was shot in Kansas, which wasn’t too far away from Nebraska. We were very, very careful and really avoided going out and grocery stores during daylight hours — and these were all Ph.D. students that were getting their degree. After 9/11, there was a study that came out where they saw that Arab women after the 9/11 event had a lot of premature babies or babies that had low birth weight as a consequence of this chronic stress. So, yes, I’ve felt a little bit of life being threatened, too, and that is definitely eons above the constant worry of what you’ve perceived.
Dr. Arline Geronimus: And the study you’re referring to was of women in California. So it wasn’t even anyone near where 9/11 occurred. It was just through learning about it and understanding through the media how unsafe it was at that moment to be perceived as Muslim — whether you were or weren’t or self-identified that way. Now we see that with some Asians, for people who have started to feel Asian hate because our last president referred to COVID as the China virus, as if China had somehow given us this horrible pandemic.
People don’t make distinctions based on knowing your history or deciphering if you’re literally of Chinese heritage or from any one of the so many other Asian groups. That’s a key point, too, because it’s your social identity. It’s not necessarily what you feel is your identity, but it’s how people see you or might see you. And that’s what you were talking about with the Indian women after 9/11. You, first of all, probably knew that no one should have just lumped all Muslims or Arabs together as threatening — that made that social identity very unsafe. But people went even further, and just anyone who had a physiognomy that they would interpret as possibly Muslim was also under threat, literal threat, as well as psychosocial threat.
I think weathering is that piece that explains how we link systemic and structural racism to inequities in health, because it’s through that fluency on the one hand of the dominant culture, either erasing other cultural ways of being or misrecognizing them and stereotyping them, devaluing them, and it’s through that people in the more marginalized groups being fluent in knowing that that’s how they’re seen in this culture that they’re in or the culture they were born in if they are immigrants. That’s what makes you vigilant — it’s your knowledge of how you think the dominant group sees you and others you. That triggers the vigilance that then can mean your survival in some circumstances or advancement in some professional circumstances, but also means that your body is constantly under the impact of cascades of stress hormones that wear down your health.
Dr. Denise Millstine: I want to jump in here and put a plug in for the book, because the two of you have used so many phrases that can be confusing to people or even new to people who are exploring the topic of weathering and related topics. I think you do an amazing job, Arline, in “Weathering,” talking about othering. You call this chronic awareness being a chronic vigilante. You give names to these situations that I really appreciate allow for the ability to then discuss them and move them forward in as much as recognizing them and hopefully creating awareness so that there is change. A couple of the other terms that we saw in the book are age washing. Can you talk about that?
Dr. Arline Geronimus: Not only do I think weathering is important to think about in terms of population health, because it’s a new concept that I think contributes some new insight, but I believe part of what dominant culture has done and part of what creates systemic othering of certain groups, is it points to all the wrong things when people are trying sincerely to come up with policies or programs to reduce the health disadvantages that oppressed groups suffer. They come up with the wrong ideas, and that’s because we’re living under a variety of dominant ideologies. One of them is what I call age-washing. Age-washing is this idea that the only thing that leads to poor health, early aging, or disability is not taking care of yourself — that we’re all capable of just going through a developmental set of stages from fetal life, infancy, childhood, adolescence, then your prime adult ages, and then we deteriorate more and experience senescence and aging. That’s what we’ve been age-washed to believe — certainly there are developmental processes, and you especially see that in kids who are growing. It’s quite clear in the old — but they are not the only thing that contributes to your health. In an age-washed world, when we see that some groups of people or individual people have worse health or die young or get what we call “preexisting conditions” or become obese, we think it’s something they did as an individual because we’ve been age-washed that your body would just naturally go through these stages and you’d have this several decades-long period in your twenties, thirties, forties and fifties where you’re in your prime of life. So when you see populations who are dying in their twenties, 30s, 40s, or 50s, or who become disabled or who develop hypertension or diabetes in their 20s or 30s, we think as individuals they must be doing something wrong.
Now, if we’re generous about it, we might say they don’t know better, or we could give them health education, or maybe it’s that there’s not enough grocery stores with fresh vegetables in their community. All of that is part of it — but the less generous way age-washing gets used is that you must be from an immoral group or a lesser group, who aren’t personally responsible. What weathering highlights is what makes certain groups of people more likely to have shorter life expectancies or shorter healthy life expectancies — the way society treats them, not how they as individuals treat themselves. In fact, to the extent they try to overcome, as I mentioned before, all the barriers in their way and are actually acting what we might recognize if we looked at it as very responsible, self-sufficient, or caring for their families is part of that storm of weathering. So I feel like the idea is very limited at best and just wrong — and actually 180 degrees wrong at worst.
Dr. Denise Millstine: Sumedha, I can imagine in your work at Mayo Clinic and looking at health disparities, this is a concept you’re very familiar with.
Dr. Sumedha Penheiter: I completely agree. I have seen this in a lot of research studies where sleep deprivation, especially in the black community, is a big factor that affects how fast people age or get sick. In general, I can just share from my personal experiences really quick, if that’s okay. During the pandemic, there was talk of furlough at Mayo Clinic and all the health decisions were in the middle of not knowing what comes next. My daughter, who was a 2020 graduate at the time, developed an eating disorder. My parents living in India, who I could not reach out to when the pandemic was at its worst. I exercise, I eat well, I do everything right — and lo and behold, I didn’t even realize the chronic stress I was under. I was not able to sleep at night because we were constantly worried about how this virus is going to affect us and our futures. I developed Grave’s Disease and that just came out of the blue. Since then it’s been a cascade of health issues. It’s the same for a lot of people who are overweight or obese — and you just assume. In a lot of work, the fat stigma that was there in the research that I have overseen or supported through projects, people are blamed for their own doings because they are not taking care of themselves and they’re bigger. That was a big thing — that fat shaming or stigma or bias around people that are overweight kind of. It’s a vicious cycle that leads to people feeling alienated from the health systems because they always felt judged by the medical providers, as well as their peers. I know people who work out and do everything right, and for some reason their biochemistry or metabolism is just not conducive to being this super skinny, athletic body type. I’ve definitely seen a lot of that, and it’s causing overweight people not to be part of the health system or wanting to use the health system because they always felt judged, which then in turn, has a negative effect.
Dr. Denise Millstine: I think it’s important to look at that. And for our listeners who might not be familiar, Grave’s disease is an autoimmune thyroid condition and you might think of it as just being random or mysterious, but you can see that in a state of chronic stress, you’re going to be more susceptible to these chronic illnesses. They’re not necessarily the ones that we in the health care community tie directly to lifestyle factors.
In your book, Arline, there are super impressive statistics about the number of chronic diseases in women. In your book, you say “Women of color have an average of four or more chronic health conditions by the time they reach age 50. In Black women, 60% of them have hypertension by the age of 45.” These are not older women — I guess from my age-washed perspective — but really, this is a very young age point to see more of them are hypertensive than not. The impact of this is just enormous.
Dr. Arline Geronimus: Yes. And if they’re hypertensive, they’re likely to have other morbidities or develop them. Instead of thinking of hypertension as its own unique disease — to some extent, you need to, in terms of treatment — but if you think of it as a reflection of being weathered, it means that other body systems have also probably been dysregulated. Autoimmune disease is a perfect example — it is very weathering related because the dysregulation of your immune system that happens with the accelerated aging that is triggered by weathering leaves you very susceptible to either not surviving infections or surviving them, but then going into overdrive as your immune system tries to do its job in the face of its being dysregulated and weakened.
That is a source of autoimmune disease. I often thought — and I mentioned this in the book — that one reason that you saw so many more COVID deaths among black women, indigenous, or Latina immigrants, for example, was that most people weren’t seeing that if they got COVID, they either might have had weathered immune systems that led them not to be able to rally, or they had dysregulated immune systems that led them to rally too much, which would cause those cytokine storms that often precede a COVID death. There are many other reasons they were more exposed to COVID, because of working front-facing essential jobs, taking public transportation with others who were also susceptible, living in overcrowded housing, doing jobs that Latinx women and men, often in the Midwest at least —
Dr. Denise Millstine: Work in crowded facilities.
Dr. Arline Geronimus: Right, that are not ventilated well, where people are standing very close to each other and handling everything as it goes down the line. Certainly those are very clear structural ways that our segmentation of the labor market puts people of color, more often, not just in low wage jobs, but ones that are actually very stressful or unhealthy or toxic — but it’s also that if those things happen on top of being already weathered to some degree, then you’re susceptible to a worse infection or to cytokine storm as you try to deal with the infection.
Before COVID, weathering could also explain the earlier ages and the much greater prevalence of autoimmune diseases among oppressed populations.
Dr. Denise Millstine: And in the book, another layer — not that there needs to be more layers to make this so challenging — but another layer is this issue of being slow to treat oppressed communities. We would really love to believe that the health care approach is equal for whatever patient is in front of us, but you provide very distinct examples of women who are famous, of women who are resourced and educated, who have outcomes that are frankly shameful.
Serena Williams is one of the people that you talk about with her complications around her peripartum period, which she has been public about. But, obviously she has more money than the vast majority of Americans and is a strong woman, who is very smart — and yet her diagnosis was delayed. So this being slow to care, I think is an important layer for us to be honest about.
Dr. Arline Geronimus: And she was slow to be diagnosed of the blood clots that had gotten to her lungs, even though she had had blood clots before. Pregnant women are at higher risk of having blood clots, even if they didn’t have blood clots before — so it seems like everything should have been screaming to her caregivers that this was a risk and if she’s having these symptoms that she recalls from when she had her blood clots before, they should take that seriously.
But it took all the tenacity she had and just refusal to give up and probably her resources in the end, being in a very good hospital that finally, in effect, saved her life. If she had been anybody else, she probably would have died.
Dr. Denise Millstine: So clearly, there’s a problem. Clearly, there is an effect that we’re under-recognizing at best or not recognizing at all, with the idea of chronic stress and how we can manage it and develop systems and support structures that recognize the realities of this — and try to rework our approach and the chronic stress that we’re putting people under as a society.
Sumedha, a lot of your work with professional organizations and within Mayo Clinic really looks at restructuring these systems and what we can do. Can you talk a little bit about the hope on the horizon?
Dr. Sumedha Penheiter: I think the first thing that we’ve all done is to recognize that there is a situation — that is definitely what we’ve done within strategy. We’ve developed a resource guide that I have actually led, where we really have the consultants look through this equity, inclusion, and diversity lens when consulting on projects, be it facilities, be it digital health, and be it health literacy.
That’s just the small steps in the right direction. But it’s understanding that one size fits all is not the answer. The greatest good for the greatest amount is not always helpful. It’s thinking of those that have slipped through the cracks or the underdogs, and how you can specifically — by just a few modifications — be more inclusive in your consultation of designs of facility: medical care, telehealth, just a lot of things that don’t require a lot of tweaking, but are very inclusive. We then implement that and then take that over to policy, especially where access to care is the biggest problem, and there’s a simple fix. There’s hospitals and health care systems that have partnered with Uber so they can bring patients in when they don’t have transportation, rather than having to go through four bus changes that a lot of people in big cities have to do all through chemo, and fighting with insurance companies to cover that transportation cost. It’s also having daycares in areas where you have stay-at-home moms that have to come in for their healthcare but can’t because they have to care for their children. So, again, lobbying to make sure that these social determinants of health are addressed. That’s the first step in the right direction. I’m also working with the Minnesota Cancer Alliance. I’m their vice chair. Right now, we’re lobbying at the Capitol to make sure that certain amounts of biomarkers that are standard for a lot of insurance companies’ coverage, if you have private insurance, are also covered by Medicare and Medicaid. Improving access and lobbying, and showing that it’ not a handout has been the big policy approach that’s been used.
Dr. Denise Millstine: Arline, I think you finished the book with that push for equity, which I think is a lot of what Sumedha’s talking about. Can you comment on that?
Dr. Arline Geronimus: One of the things that I think weathering lays bare as we’re watching George Floyd be murdered or Tyee Nichols, or any of the ways that racism either kills you stealthily by weathering you or through actual violence and immediate death — it happens because we’re not putting as a prime value in figuring out policy, (whether it’s policies in schools, policies in hospitals, or national policies) how important it is to be equitable and realize who is suffering the worst and needs the most help. Instead, we have ideas about profit or efficiency. One of the lessons of weathering is that if we don’t take equity into account, (and realize that it’s not just a kumbaya moment) in terms of really seeing what people need and what they’re dealing with, and how hard they’re working to deal with those things every day, people will continue to weather and we’ll continue to lose a lot of our human resources, cause major injustices, and have a healthcare system that’s sustainable for anybody.
For our healthcare system to get out of the trouble it’s in economically and stop costing so much, we have to have fewer people be sick. Weathering is a very big part of that sickness, and so we have to take equity into account and it should be front and center.
Dr. Denise Millstine: I love that as a place to wrap up. We need to have fewer people be sick. I really appreciate both of you for your work in raising awareness and connecting the dots — helping all of us to understand how chronic disease happens among various populations, and that we can hopefully change our systems to make the world healthier and better moving forward. Thank you for being on the “Read.Talk.Grow” podcast. It was fantastic to talk with both of you.
Dr. Sumedha Penheiter: Thank you. It was a pleasure being here.
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.
