Racism and Public Health
By Anthony L. Schlaff, MD, MPH
Director, Public Health Program
Professor, Department of Public Health and Community Medicine
Tufts University School of Medicine
As I reflect on the horrific murder of George Floyd, and on the hopeful signs of a white awakening to the depth, power, and horror of racism in the United States, I think we in public health must stay mindful of two critical things.
First, that racism causes massive amounts of suffering and death, and is responsible for a large proportion of the health disparities we have in our world today.
Second, that our ability to put good public health measures into practice and prevent future public health catastrophes depends on our dismantling racism.
To the first point, students in public health and health professions are taught that almost every health problem they study takes a greater toll on communities of color, particularly African American communities, than on white ones. This is true for infant mortality, maternal mortality, asthma, diabetes, hypertension, stroke, cancer, and many other of our most common and most serious health problems. Not surprisingly, it is also true of COVID-19, with disease and death rates in communities of color three times or more those in white communities. Students are not always taught, however, that the causes of these higher rates lie not in biology but in the vastly different economic, social, and environments in which people of color, on average, live. And even if they are taught about these “social determinants,” they are rarely taught how most of the differences in these determinants are created by and maintained by racism.
The differences in these social determinants between African Americans and whites are neither just vestiges of slavery 160 years ago nor just of discrimination today. Rather, they are a consequence of a 400-year history that started with slavery but continued through Jim Crow, lynching and terror, forced segregation through restrictive covenants and contract loans, exclusion from the full benefits of the New Deal, Social Security, and the GI Bill, exclusion from unions and union jobs, the war on drugs, and the 21st century practices of mass incarceration and subprime mortgage lending. All this - essentially organized, sustained, society-wide theft from people of color - results in the 92% wealth gap that explains much of the health inequities we see today.
Health students and professionals should carry with them a 3-pronged framework to analyze health differences by race when they see them.
- Biology plays no meaningful role in these differences, which are largely explained by differences in socio-economic status (SES) (most importantly the 92% wealth gap) that leads to great differences in the social and physical environment.
- SES does not fully explain all the differences in health, as there are other, unmeasured harms caused by daily exposure to racism.
- SES differences do not arise by chance, but because of racism now and in the past.
We need to undo structures of racism, but we also need to address the wealth gap, if we are to improve our population’s health.
To the second point, we must as a nation understand how racism has poisoned our entire politics and left us with the weakest social policies and social insurance systems in the industrialized world. Our fear of “the other” has resulted in us denying support to all who have need. Our educational, unemployment, anti-poverty, social insurance, and safety net systems are all chronically underfunded. We police and imprison but do not provide support. Our health care system generates procedures and profits but provides too little prevention and care and robs dollars from social services that provide far more health benefit. We spend so much political energy fighting to keep resources from people of color that we have chosen policies that have created some of the greatest inequities and lowest amounts of social mobility in the industrialized world. Racism thus robs us twice: first by denying opportunity to people of color who might otherwise be able to offer so much more to society; and second by denying to all of us the caring and support systems that almost every other industrialized nation on earth provides its citizens.
And as 2020 is showing us, the divisions among us are now so deep that we cannot even mobilize the political will to protect ourselves from a deadly virus. Unless we heal these divisions – and that has to start with healing the racism that divides us – how will we cope with climate change and the other existential threats we face?