Vitamin D, false nostrums, and conspiracy theories: The world has enough real problems

Near the end of December, Tiffany Hsu, writing in the NY Times, discussed “Dubious COVID Cures”. She compared them to the similar nostrums popularly recommended for the 1918 influenza epidemic, when ‘a spate of ads promised dubious remedies in the form of lozenges, tonics, unguents, blood-builders and an antiseptic shield to be used while kissing.’ She quotes the head of research at MyHeritage, Roi Mandel as saying “So many things are exactly the same, even 102 years later, even after science has made such huge progress.”

Even after all this scientific progress and all the advances in health care, people are still fascinated by over the counter magic drugs, things that seem easy, and are often cheap (although usually very profitable), and somehow better than the treatments being offered by the medical community. This is, of course, even more so when that medical community does not have a whole lot to offer in terms of treatment, a particular issue for virus infection, and mostly talks about prevention, about such things as isolation and physical distancing. Wouldn’t it be better if you could just take something that would cure it or make it better or at least decrease the seriousness of an infection? And, you know, there are ‘studies’ that show it works (although of course I haven’t actually read them and would have no idea how to understand if the research was legit) and, you know, there are doctors who recommend it!  Like ‘Dr. Pierce’s Pleasant Pellets promised that the pills — made from “May-apple, leaves of aloe, jalap” — offered protection “against the deadly attack of the Spanish Influenza.”’ Oh, wait, that was from 1918 – but we have Dr. Oz!

This is not to say that some popular treatments do not have benefit, and this is especially good if they do not harm you, and if they are cheap. One such could be Vitamin D, which has been advocated (most recently for COVID-19, but for a lot of things) by many people, some of whom are actually experts. As with many “natural” remedies, most of the basis for this is in syllogism. You extrapolate from something that is known about a substance (commonly, as in the case of Vitamin D, that it “promotes immunity” – a pretty general, non-specific claim), but such claims are uncommonly backed up by rigorous testing to see if it actually does work. (Freeman’s Second Law: Something that makes sense is properly called a “research question”. You wouldn’t want to study something that didn’t make sense. However, to know whether it is actually true, you have to actually do the studies!)

Recently, The Guardian had an article titled “Does Vitamin D Combat COVID?”. It is very positive about the vitamin, citing many important people (unsurprisingly, being The Guardian, many from England), but does stop short of claiming that it will definitely work. The claims for benefit vary: it makes it less likely that you will get infected, that if you get infected you will get less sick, that if you get sick you are less likely to die. Not really quantified though. The reason is that there are studies that show both benefit and not, and none of them are definitive. There is also concern that people with more melanin in their skin, presumably a genetic adaptation to being from areas with more sunshine (and thus more vitamin D) can become vitamin D deficient when they live in areas in northern latitudes with less sun. Obviously, this is confounded by the existence of a variety of other social and medical health risks accruing to dark-skinned people in northern latitudes. Maybe it is an additional one, but it is unlikely that just taking Vitamin D will solve the problem of inequity.

The actual evidence is summarized in a recent piece in JAMA, “Sorting out whether vitamin D deficiency raises COVID-19 risk”. The first thing that you note here is that it is answering quite a different question – whether people who have low vitamin D levels have greater risk (and, thus, presumably, should take vitamin D supplementation), not whether everyone should be taking vitamin D. ‘Research findings about vitamin D and COVID-19 have been mixed and sparse,’ is the key finding, and the ‘Upshot’ of the pieceis a quote from Dr. Catherine Ross, a nutritionist at Penn State: ‘“Avoiding vitamin D deficiency is always a goal.”’

So you should take vitamin D supplements if you are deficient (Dr. Fauci says this also), although knowing if you are deficient would require both your having your level measured, something which is not recommended by the most reliable source, the US Preventive Services Task Force (USPSTF) for asymptomatic adults (although it is by many who are consultants to vitamin D advocating groups), as well as to know what the level below which you are deficient is: 20? 30? 50? You can find all of these in the “literature”. And it is concerning when advocates have industry ties. Nonetheless, vitamin D is available cheaply and generically, is safe if you don’t take too much (as a fat-soluble vitamin you CAN overdose on it), and Dr. Fauci takes it (same article). I took one this morning.

But the really big question is not vitamin D, even if the evidence is not absolutely clear. Overall, it is pretty safe and pretty cheap and has a conceptual justification and at least some studies show some benefit. The really big issue, as put forth early in this piece, is why do people continue to search for magic treatments that are not mainstream? Why do they often trust their friends and neighbors and strangers on the Internet more than doctors? I don’t know for sure, but in Hsu’s article comparing today to 1918 he quotes Jason P. Chambers, associate professor of advertising at the University of Illinois: “Human beings haven’t changed all that much. We’d like to believe we’re smarter, that we’d be able to spot the lies, but the ability of advertising to maintain its veneer of believability has only become more sophisticated over time.” Unfortunately, we’re probably not. That is why advertising is so successful.

This fear is related to not only mistrust of science (it is hard to understand) but to conspiracy theories in general; recently the “political” belief in a “deep state”, that “they” are lying to us and trying to keep important information and benefits from us. Of course, “they” may be; I certainly do not trust the leadership of our country (or any country) to necessarily work in the best interests of the people, except of the richest, most powerful and well-connected people. I absolutely believe that Big Pharma is only interested in making as much money as possible and selling us drugs which may not be any better than cheaper ones, or none at all. But the suspicion that science and medicine are working to harm us often segues into pretty odd stuff (I was recently sent this nonsense about the COVID vaccine being a plan to engender female sterilization!) (On the subject of conspiracy theories, Andy Borowitz’ recent satire – QAnon merging with the Elvis-is-Alive groups -- is, as usual, not far off the mark.)

I am sure that some of this is the fault of the arrogance of scientists and doctors. A good friend was recently diagnosed with breast cancer and was told by her doctors to “not go on the Internet, to not talk to anyone who has had it, because everyone’s cancer is different”. This is ridiculous, although I understand that they probably get frustrated by people coming up with silly or, worse, dangerous treatment ideas that they have heard from someone, or stories from their sister-in-law’s neighbor. This can of course be much better addressed, with something like “You’ll hear a lot from people who have had breast cancer; it is a common disease. You will certainly look things up on the Internet. Listen to them, but remember you are you, and your experience is not likely to be exactly the same as theirs. Please don’t take any treatments without discussing it with us, so we can make sure there is no danger. Welcome the support.” And, I would be wrong to omit, the big reason that doctors feel so pressured and don’t have enough time to talk to and discuss things with folks is in large part because the big corporations they work for (for-profit or “non-profit”) are about maximizing income, not health.

Still, people seem to find themselves drawn to “alternatives”. They like “natural”. OK, keep your mind open, but remember than “natural” is not necessarily better. Any substance that has any effect, positive, negative, or neutral is because of chemicals in it. That they occur naturally does not make them safer than those that are manufactured.

And watch the conspiracy theories and think about what is important. Life on earth could be extinguished by climate change. That is real. War which leads to nuclear war could do it first. People all over the world are starving, are without housing, without basic health care, subjected to natural disasters and man-made ones. They are being killed, often in genocides. In all countries, including ours, there is structural oppression of people based on race, religion, gender. Wealth is being transferred from regular and even poor folks to the richest at an astounding rate. Authoritarian leaders, and even fascists, are proliferating.

These are real problems, that need real concerted efforts to combat. Work on these. Don’t be distracted by non-issues.

Biden: Not Medicare for All, but leadership on COVID

The defeat of Donald Trump in the 2020 election was a wonderful thing, despite the less-good news: that the “blue wave” did not appear, that the Senate (barring two unlikely upsets in Georgia) will continue to be controlled by Mitch McConnell, that the GOP gained seats in the House, and especially that 70 million Americans voted to re-elect the worst president in American history, thus supporting racist, misogynist, anti-environment, anti-union, pro-corporate and pro-billionaire policies, and bellicose macho authoritarian bluster. The election of a Black (and Asian) woman as Vice-President is historic and great. While it is possible that Biden’s uninspiring “centrist” (read “center-right”) positions gained him votes, the division in America has never been more dramatic. Cities like, most highly featured in the days following the election, Philadelphia and Atlanta (as well as New York, Los Angeles, Chicago, etc.) went 70-80%+ for Biden, while rural counties went for Trump by the same margins.

My purpose here is not to be a political commentator, but to discuss what this might mean for health care under a Biden administration. Certainly not a supporter of any kind of single payer universal health insurance, including Medicare for All, Biden further has to contend with a (probably) Republican Senate and a newly strengthened rightist Supreme Court that even as this is being written is hearing another challenge to the ACA, President Obama’s signature domestic achievement, and the scaffold on which Biden hoped to build his own health care plan by adding a “public option”.

Assuming that, despite Senate and possible SCOTUS opposition, the ACA survives and even that the “public option” becomes law, it would be a great advance in the number of Americans who had access to decent health insurance (which, in itself, may doom its chances in those two “august” bodies!) Indeed, the arguments that many, including myself, have made for the savings that could be achieved by government single-payer program (extension of an improved Medicare to everyone) would likely be somewhat achieved by a well-designed public option, since better coverage would cost less money than it does under the private, for-profit, insurance sector. Not nearly as much as would be achieved by single-payer, but enough to have a good chance of eroding the base of those who hang on to excessively costly, poor-quality private insurance.

And yet, ”Medicare for All” continues to enjoy wide public support, certainly in those “blue” cities and counties, but also within the US as a whole, including some of the “reddest” areas. People know that their health insurance is costly and that the coverage is inadequate, and that not only their lives and health are at great risk, but so (to the extent that they have any) is their “treasure”. Democrats who supported M4A were all re-elected, while many opponents were defeated. Indeed, this illustrates the difference between those in power, members of the Senate and the House (and SCOTUS) who serve the wealthy and are mostly wealthy themselves, for whom tax cuts for their patrons and corporations (under the umbrella of the scandalous SCOTUS decision in Citizens United that declared money to be speech and corporations to be people!) are the main agenda, and their constituents. The latter have poor and costly health insurance, benefit little if at all from tax cuts, and are losing their jobs right and left as US companies push more and more money to the top. For the former, Medicare for All is a bugbear; for the latter it may be a lifeline.

The most important healthcare issue in which the election of Joe Biden is likely to make a big difference, however, is the most important healthcare issue currently facing America, and the world – the COVID-19 pandemic. This second (or maybe third) wave is breaking all kinds of records for new cases, new hospitalizations, and new deaths. In my state, Arizona, we have the highest rates since July. The nation has had well over 100,000 new cases a day recently, in some of the “reddest’ counties, with rates over 200/100,000 residents in some. The reason is that the virus does not care about what you want, and apparently what we have wanted is greater opening, an end to social isolation and not going out to restaurants and bars, not having parties and funerals and visits with our relatives. We want businesses to open, we want our jobs back, we want our personal economy (not just the stock market) to improve. We bristle at the “discomfort” of masks (like the “discomfort” of seatbelts). We want to rush, en masse, onto the football field to celebrate a huge victory for Notre Dame over Clemson (oh, wait, we did that!)

The problem, of course, is that each of those things spreads the virus, and the spread of the virus means more people will die. I have often said REOPENING=DEATH and it remains true, however much we want it not to be; there is nearly a linear relationship between the degree of reopening in any city or state and the increase in the rate of cases of “the rona”. Now, as we look toward all those college students, including those from Notre Dame, returning home for the holidays, we hold our breaths as we worry about how many of their parents and grandparents will become infected and die, putting a damper on the celebrations.

Masks and reasonable social distancing will not prevent this entirely, but will help a lot; masks really decrease transmission. Having a President who wears a mask, who encourages safer behaviors, who does not encourage total irresponsibility as has the current incumbent, is likely to make a big difference. Something has to, and certainly it needs to happen soon. Most encouraging, Biden is not only willing to, but enthusiastic about accepting science as the guiding principle of the response to the epidemic. He has already named members to his COVID “panel”. It could use some more epidemiologists, some nurses, but the intent and direction are good. The increase possibility of a vaccine, especially the recent news from Pfizer, is very encouraging. With a new administration committed to making a difference by using strategies that might actually make a difference, the trajectory of the virus might be turned around.

There are, and will continue to be, great obstacles. The most vulnerable populations will continue to be the most vulnerable – including people in prison, and those immigrants in federal detention, whose rates of infection are staggering. The Pfizer vaccine requires shipping and storing at temperatures of -80 degrees, which is very difficult in many places, particularly in less developed countries where the pandemic is raging.

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But leadership from the US President can go a long way. Whatever else we might wish from him that we are unlikely to get, we can hope that Biden will provide this.

How the left is losing the COVID “war”

Guest post by Edgar Blaustein.  Originally posted at Medium.com

Can the left already be losing the political war regarding the COVID pandemic?

A look at the political impact of the current coronavirus crisis in the United States, the United Kingdom and France, and what it might portend for the left.

Hail to the chief! Pandemic as legitimization

Donald Trump’s, Boris Johnson’s and Emmanuel Macron’s rise to power share key similarities: lack of legitimacy, and, for Trump and Johnson, appeal to nationalist sentiments (MAGA, Brexit). Trump through lies, luck, and electoral math won the Presidency with less than a majority of voters. Johnson won through lies on Brexit (no hard borders, more money for health services). Macron won with less than a quarter of votes in the first electoral round. Nevertheless, the winner takes all systems in all three countries gave the victor complete control of the legislative and executive branches of their respective governments. Though lacking legitimacy, all three wanted to think of themselves, as great war leaders such as Churchill, Roosevelt or De Gaulle.

Unlike the World War II leaders, our modern day chiefs have had the leisure over the last several years to choose their wars. Trump’s initial attempts failed, as he was outmanoeuvred by Xi Jinping and Kim Jong-un. Trump and Pompeo sounded the drums of war with Iran, but Iran, notably through attacks on oil tankers and a Saudi refinery, stopped US escalation.

Johnson’s chosen enemy was the European Union, framed as a faceless foreign oppressor, trying to grind down the plucky English. But “getting Brexit done” ran up against barriers: no hard frontier” between the Ireland and Northern Ireland, and the impossibility of assuring economically vital free trade with Europe without membership in the European Union.

Macron’s struggle was against “recalcitrant” sectors that opposed his vision of the “modernisation” of France, clinging to “outdated” notions such as progressive taxation, unions, worker’s rights, public services, or a public retirement system. Macron had won most battles, but the ceaseless conflict — with the gilets jaunes, trade unions, students — had taken its toll, and at the end of 2019, Macron’s government was visibly suffering from wear and tear.

At the end of 2019, all three leaders were in difficulty. And then came the coronavirus.

The birth of the war against a virus.

German President Frank-Walter Steinmeier said “This pandemic is not a war. It does not pit nations against nations, or soldiers against soldiers. Rather, it is a test of our humanity.”

And yet, the three leaders wound up framing their reaction to a health emergency as a war. But the path that led them to the war paradigm was far from direct. Indeed, in a first phase, all three initially downplayed the risk of the pandemic. In a second phase, they for a short while followed the “herd immunity” strategy, letting the infection run its course. And then in a third phase, all declared war on the coronavirus.

The three leaders hesitated, contradicted themselves, changed discourse, lied about the lack of personnel protective equipment, were contradictory on the subject of tests, all in frantic efforts to avoid assuming responsibility for massive unemployment and tens of thousands of unnecessary deaths. Trump’s “I take no responsibility” will certainly go down in history.

The three tried to frame their failures as responsible action to find balance between the health and economic impacts. As the double health and economic crisis deepened, they pivoted to “communicating”, a difficult task, since several countries — South Korea, Taiwan, New Zealand, Germany, Viet Nam, the Kerala state in India, among others — have demonstrated that rapid effective action on health, combined with a strong safety net for workers, leads to optimal economic as well as health results.

There appears to be no simple left/right divide that explains which countries have been most successful in meeting the crisis. Some rightist or extreme right governments — Poland, Germany, Austria, Australia or Japan — have done better in dealing with COVID, than the Social Democratic governments of Spain or Sweden. It does seem that women leaders, whatever their politics — New Zealand, Taiwan, Germany, Iceland, Finland — do better than men.

The countries that did not act rapidly have had to impose lockdowns, a blunt medieval pandemic control instrument that dates back to the time when humanity knew very little about the science of disease. Lockdowns are in no way progressive, although progressives must respect them when there is no better alternative, as in the case of our 3 countries.

The combined health and economic crisis in these three countries represents a severe threat to the legitimacy of their leaders. The depth of the crisis and the loss of legitimacy of the governments has led many leftists to imagine that we are on the brink of radical change, even the end of capitalism. The remainder of this article will argue that this is not the case, and that whatever our long term goals are, in the short term we should focus on more immediate achievable victories.

COVID is worse for the left than the subprime crash.

The 2007–2010 financial crisis was triggered by the collapse of Bear Stearns and Lehman Brothers, in the very heart of the capitalist financial system. The “shadow bankers”, who engineered the 1999 repeal of the Glass-Steagall Act walked away with hundreds of billions in profits made during the decade of the expanding bubble, while the general public paid for the crisis when the bubble burst. At the time of the subprime crisis, many people (author included) thought that the bankruptcy of the capitalist system had been made evident to the majority, and that the way was open for radical change. The crisis gave rise to the occupy movements, their European variants such as “indignados”, and in part to the Arab Spring and “Nuit debout”.

The actual results over the last decade were the opposite of radical progressive change. Economic inequality increased, the hold of bankers on public policy expanded, the influence of the right wing press increased. Authoritarian regimes have come to power over half the globe. Democracy, trade unions, free press … all declined. As Naomi Klein has argued (“The Shock Doctrine: The Rise of Disaster Capitalism”), capitalists are generally better equipped than progressive forces to take advantage of a major shock. Furthermore, the specific nature of the COVID crisis makes a radical change even less likely than was the case in 2008.

• Capitalism did not cause COVID. Indeed, the modern capitalist system has contributed to the coronavirus pandemic, through globalisation-driven increases in travel, through accelerated exploitation of natural resources that increase interactions between wild animal populations and human activity, and through the neo-liberal sabotage of public health systems. Nevertheless, it is false, and harmful for progressive forces, to argue that capitalism caused COVID. Viruses, animal to human transmission, and long range trade all existed long before the emergence of capitalism.
• COVID weakens intergenerational solidarity. The lockdowns strike most heavily on the finances of the youngest, whose professional and economic situation is often fragile. In contrast, older people, a majority of whom have a stable retirement income, suffer most from the health risk of the double crisis. This divide in material interests, coupled with the lack of close links between generations, has led to a political divide.
• Weaken class solidarity. COVID divides workers by race, by class, and by type of work. The most obvious cleavage is between white collar workers who can telecommute, and essential blue collar workers who are exposed to sickness. Furthermore, since many of the essential workers are from minorities, this distinction is also of a racial nature: Black people are 4 times more likely to die than the general population in the UK, and 3 times more likely in the US.
• Increase oppression of women. In normal times, many two income families “outsource” the principal domestic tasks: childcare, cooking, cleaning. This has ended under lockdown. Furthermore, with schools closed, home schooling is a new domestic task. It is no surprise that women have assumed a major share of this increased workload.
• Physical distancing degrades the tissue of society. Staying 1 or 2 meters away from other people is a physical measure to prevent the spread of the corona virus. Breaking down social links is an unfortunate, and perhaps partially unavoidable, consequence. This frazzling of the tissue of society is harmful for progressives, since our main tools for collective action — demonstrations, public meetings, civil disobedience, strikes — are difficult or impossible for the moment. The rise of telecommuting will most likely make it even harder for unions to penetrate into tech related industries. Naomi Klein, in “How big tech plans to profit from the pandemic”, shows how the “tech bros” plans to make use of the crisis.
• Justify the permanent surveillance State. “Test, trace, isolate”, while essential to fight COVID, nevertheless involve public intervention into the private lives of citizens. Successful programs in China, South Korea, Taiwan and Hong Kong all involved massive privacy intrusions. China, in particular, has woven the COVID tools into already existing, widespread programmes of surveillance of citizens lives. We can expect that these surveillance tools and powers will be used against progressives.
• War on truth. Rightists have made a scale change in their war on truth. The chloroquine controversy, built on the basis of nothing, is just one example. Rightists no longer attempt to counter the truth, they simply bury it under a constantly growing pile of rumours, factoids and lies. Hannah Arendt, in “Lying in Politics: Reflections on The Pentagon Papers”, explains that the fog of lies aims to make both thinking and action impossible.
• Democracy, pollution, climate. It is clear that different strands of progressive movements will have lost ground and lost momentum during the pandemic. For instance, President Donald Trump signed an executive order to ease up on businesses that make so called “good-faith” attempts to follow regulations during the coronavirus pandemic. This text will not detail the many other cases of using the crisis to weaken democracy, and to sabotage regulations on the environment.

It thus appears that the specific nature of the COVID crisis will leave the left in a weaker position than was the case after the subprime crisis.

We are not in a pre-revolutionary period

Six months ago, the UK, France and the United States were led by men who, even if they were stumbling, were strongly supported by at least a substantial minority that was enthused by their nationalistic, racist, xenophobic fear mongering. Certainly — as shown by Bernie Sanders, Jeremy Corbyn or Jean-Luc Mélanchon — there were also substantial minorities of mostly young people that give enthusiastic support to reformist candidates critical of capitalism. Nevertheless, the three radical reformists have all lost elections to more conservative politicians: Sanders lost to Biden, Corbyn to Johnson and then Keir Starmer, and Mélanchon to Macron and Le Pen. From these results, we conclude that the support for substantial reforms stems from perhaps 20% of the population, far from the overwhelming large majority that could be the basis for a mass movement for radical, post capitalist change.

The COVID crisis paradoxically weakened the political support for the three Presidents, while at the same time — for reasons outlined above — weakening the tactical capacity for action by the anti-capitalist left. In this context, the killing of George Floyd and the BLM and related movements swept across all three countries. From the point of view of the author, the BLM movements are radical in character, but reformist in their demands, mostly seeking limited reforms of a democratic nature: the right for people of color to live without fear of being harassed, beaten or killed by police. The achievements of the ’60s civil rights movement shows that this and related BLM demands are hugely important, and nevertheless achievable within the current political and economic system.

Since the end of decolonisation and the wars in South East Asia almost half a century ago, the left, with the exception of victories on women’s and LGBTQ rights, has lost more struggles than it has won. Today, over half of our planet’s inhabitants live in countries controlled by different types of authoritarian, xenophobic and racist regimes.

The left desperately needs short term victories to reverse the drift towards authoritarianism. While the current situation is not in general favourable for progressives, the specific nature of the COVID crisis in the three countries could lead to victories on specific objectives, such as the following.

• Rebuild public health systems, and public hospitals.
• Universal health care. Millions of Americans lost their health care when they lost their jobs. The spread of the virus in poor communities shows that health care must include undocumented workers and families.
• Vastly increase international cooperation on preventive health issues. We cannot avoid a future pandemic unless all countries, even the poorest, have the capacity to rapidly identify and isolate new diseases. We need a strengthened WHO. Even the most closed minded of capitalists can understand that spending a few tens of billions per year to build up world health systems would cost much less than the next pandemic.
• Increase protection of workers in times of unemployment, both through financial support, and effective retraining to allow workers to adjust to inevitable economic change. Again, a portion of capitalists would support such action.

The BLM movements show support exists for another category of actions, focusing on policing, and more broadly on systemic racism. Two types of measures should be within our reach:

• Measures to limit police violence in poor communities, such as always-on body cams, new rules for use of firearms, end of choke holds, effective surveillance of deaths of people in police custody, some kind of control on abusive stop and frisk, or transferring some police functions to unarmed civilians. These measures broadly correspond to the slogan “defund police”.
• Measures to reduce discrimination against minorities in employment and in the media. The actions of several large enterprises (for instance in the Facebook boycott) show that large parts of the capitalist class will support some measures.

Three other measures might be within reach.

• a guaranteed of a job or of a basic income. This would be cheaper than the current hodgepodge of measures, and would be a more effective countercyclical Keynesian economic shock absorber. Unfortunately, opposition might come as much from some workers as from capitalists.
• deepening of democracy, or at the least limiting of corruption.
• perhaps a more progressive tax system. Possibly a one time special COVID wealth tax on multi-billionaires, to repay the public borrowing during COVID. Spain may create such a a wealth tax. Perhaps some kind of reparations for slavery.

We should use the opportunity of the weakness of our rulers to fight for significant and achievable short term goals. We need victories to strengthen progressive movements, to improve our capacity to win future battles. We must at the same time keep in mind our long term goals, and use the experience we gain in short term struggles to develop common ideas on our vision for the future, our strategies, our alliances, our tools and modes of action.

This text benefited from the generous help of Robert van Buskirk and Jérôme Santolini, who kindly contributed, even though they disagree with major portions of the text.

Institutionalized racism and violence and the impact on people's health

I recently wrote about the confluence of the COVID-19 pandemic and its greatly disproportionate impact upon poor and minority communities, and the increasing awareness of the overall oppression of minority communities that has come to a head in the aftermath of the murder of George Floyd by the police in Minneapolis, along with the huge protests (and police repression of those protests) around the country (‘Structural racism, structural violence and COVID-19: We must fight both epidemics’). This incredibly important and deserves not only further discussion here but ceaseless discussion in all venues until the US really changes.

Minority communities in the US (and for the rest of this piece, “in the US” will be implicit) have always suffered a much great burden of chronic disease, much more limited treatment options, and worse health outcomes. It is not new with COVID-19. In addition, minorities have always suffered more police brutality, more incarceration and involvement in the criminal “justice” system, and more violent death. We live in a nation and a society that was built upon and perpetuates not just racist bias but a structure in which repression of minority people, especially people of color, and most especially African-Americans, is an intrinsic component. Police violence against Black people is not (solely) a result of the individual racism of the police officers inflicting it; it is the purposeful enforcement mechanism of institutional racism, which has always existed in the US: slavery, Jim Crow, mass incarceration. The White-run police state in apartheid South Africa was odious and obvious, and most Americans correctly identified its purpose, but our own similar structures seem to have been harder for many to see. This is partly because they have been less clearly stated in law (for at least a few decades), and in part because in South Africa, Whites are a small minority whereas here they are the majority (so far). But, if perhaps less obvious and to some degree less severely violent, our own society has always had racism built into its fabric.

Facts that must be acknowledged: Black people are victims of police violence, and are killed by police way out of proportion to their percentage of the population. Black men are involved in the “criminal justice” system at, at least, 3x the rate of White men. Black families have a net wealth of about 10% of White families. For years, decades, centuries, official policies, laws and de facto practices have relegated Black people to the back of the line, kept them from good jobs, housing, and education. Black men, even if they have money, or are doctors, or are off-duty police officers, are more likely to be stopped, harassed, arrested, injured or killed.[1]

Racism can take many forms; Dr. Camara Jones, a professor at the Morehouse School of Medicine and former President of the American Public Health Association (APHA), describes three broad types: institutionalized (which is what I am mainly discussing here), personalized (that expressed by individuals toward others), and internalized (the “self-hate” that victims of racism may begin to believe about themselves, in part at least)[2]. They are all important, and all affect the health of the victims, and all need to be addressed. We have increasingly seen campaigns aimed at raising (White) people’s awareness of unconscious (as well as conscious) bias.  This is good, and important, but our analysis needs to go far beyond the idea of individual bias, and understand WHY people have grown up with and maintain such bias.

The US was built upon the free labor provided by chattel slavery of African-Americans. Many of our “Founding Fathers” (e.g., Washington, Jefferson, Madison) were not only slaveholders, but plantation owners with huge numbers of slaves. Thomas Jefferson’s “agrarian ideal”, that our nation would be best off if its people were farmers, was either ironic or hypocritical; it was not Jefferson but his slaves who did the farming at Monticello. Compromises with slaveowners led to a Constitution whose flaws are now obvious; that each state has two senators, regardless of population, was intended to help the South. Thus today small states are overrepresented in the Electoral College (e.g., Wyoming has one congressional district and thus 3 electors, 5.5% of California’s 55, but its entire population is less than any of California’s 53 congressional districts). Indeed, the South wanted to count each slave as a person for the sake of the census, although they had no intention of letting them vote; the ‘3/5’ rule was a compromise. Of course, today it is the “conservatives”(really, racists) who say no to counting everyone, especially undocumented immigrants (a category that did not exist at the time of the Constitution).

The “race” (pardon the pun) is fixed; we do not all start from the same place; Blacks start with one hand tied behind their back (or one leg shackled?). It is not just in health or in police violence; the story of government-sponsored racism in housing is amazing and scary (as portrayed in this video). What is amazing is how persistent this has been.  On the death of John Lewis, a true American hero, some have discussed the role that the violence perpetrated by police on nonviolent protestors in Selma, AL, had on helping push the Voting Rights Act of 1965 into law. Signing it, President Johnson noted that it had been over a century since the Emancipation Proclamation, but that in the South many Blacks still could not vote. Today, in 2020, it is more than half again as long and in the US – not only in the South – strategies continue to be implemented to keep minorities from voting.

The negative impact of our racist infrastructure on the health of minority people is tremendous. Woolf and colleagues estimated that in the decade 1991-2000, all medical advances averted 176,000 death, but if African-Americans had the same death rate as Whites, over 686,000 deaths would have been averted![3] Park and colleagues demonstrated that Leukocyte Telomere Length, a marker of cellular aging indicating cumulative biologic stress, which equates to shorter lives, is indeed shorter in those who perceive the neighborhood they live in as poor quality, compared to those who perceived their neighborhoods as good quality.[4]

Our medical schools, on the front lines of training new physicians, rarely overtly address the pervasive, not occasional or individually-mediated, racism of our health care system. We still train students to start presentations including race (and gender) -- “A 53-year old Black male” – although in the US “race” is a social construct and the genetic variation within any “racial group” is far greater than that between different groups. A recent article in the New England Journal of Medicine by medical student LaShrya Nolen uses the metaphor of the bulls-eye lesion of erythema migrans that characterizes early Lyme disease – in people with white skin. Because it is not as obvious in people with dark skin, the diagnosis is made later and complications are more common. She observes that we are “missing the bulls-eye” in addressing systemic racism in medical education.[5] In a New York Times Op-Ed, “Medical Schools Have Historically Been Wrong on Race” Dr. Damon Tweedy comments on the pervasive racism in patient care and education of physicians that is current as well as historical.

If we are to approach a system where there is truly health equity, we need to work simultaneously on many fronts. The health care delivery system, and its educational components, need to restructure from the ground up. Much more significantly, we need to address the Social Determinants of Health: access to safe housing, enough food, good jobs? Opportunity for a good education, not tied to the income of one’s parents through local school funding; all the things that make health worse and telomeres and lives shorter. We need to dismantle the police state that addresses protests against police brutality with more police brutality; to recognize that the police do not protect everyone equally, but primarily have the role of repression in some of our communities, and stop incarcerating such a high percent of Black males.

We are in a war for the soul of our nation. Will the racism of our history continue to dominate the reality of our lives, and continue to create and maintain inequity and poor health and death, or will we, finally, more than 150 years after the Emancipation Proclamation, really begin to address structural racism and its impact upon our health?

 

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[1] Derrick CB, “Sirens: 4 decades of harassment by the police”, Guernica, July 27, 2020

[2] Jones CP, “Levels of Racism: A Theoretic Framework and a Gardener’s Tale”, Am J Public Health. 2000;90:1212–1215.

[3] Woolf SH, Johnson RE,Fryer GE, Rust G, Satcher D, ‘The Health Impact of Resolving Racial Disparities: An Analysis

of US Mortality Data’,  American Journal of Public Health | December 2004, Vol 94, No. 12,2078-81.

[4] Park M, Verhoeven JE, Culjpers P, et al., “Where you live may make you old : The Association between Perceived Poor Neighborhood Quality and Leukocyte Telomere Length”, PLOS One, June, 17, 2015.

[5] Nolen, L, “How medical education is missing the bulls-eye”, N Engl J Med 382;26 nejm.org June 25, 2020