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?
[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
