Race and Public Health

With coronavirus still at large, we are witness to the further fortification of an edifice I thought was already invincible: the Standard Approach to medicine and public health. In the Standard Approach, poor African-American (and increasingly, Hispanic) lives are left in jeopardy so that affluent lives, usually white, can be extended. After all, when we talk about “health” in the United States, what we mean is the extension and improvement of white lives. We see this now in the grave disparities in the coronavirus death rate between patients of limited means who are treated in publicly supported hospitals and the ones with private insurance who are treated in better-staffed and better-equipped private hospitals. We see this in the more than twofold-higher death rate from coronavirus for Black Americans compared with whites. We see it in the data showing that two-thirds of coronavirus deaths in the nation’s largest concentrated outbreak—that is, New York City’s—occurred in neighborhoods where median income was below the city average.

In the Standard Approach, all illness is a matter of risk, and all risk a matter of personal choice. This formulation is a double sleight of hand. First, we’re schooled to think of illness as a discrete, well-defined, unwanted alteration of our normal state. Illness is the thing that keeps us from going to work or school, doing well in the job interview, or taking good care of the kids (the sociologist Talcott Parsons aptly dubbed this “the sick role”: it’s our social performance that changes).

Yet it’s obvious that the realm of human suffering is boundlessly greater than just diagnosed illness. The down-defining of illness to mean only this sort of disease experience reduces a vast landscape of suffering to just a few points, ones that have names and putative causes: diabetes, HIV/AIDS, scarlet fever. We do add to this illness geography when something culturally prominent offers itself: obesity, depression, erectile dysfunction. That’s of little consequence. The important point, all-too-thoroughly hidden, is that were it not for the conventional reductionism, America’s health concerns would be: heartbreak, angst, loss (of a loved one, of a job, of faith), homelessness, lonesomeness, poverty. America’s health approach would include building and strengthening community bonds, supplementing incomes to eliminate want, making decent housing available universally, reforming the industrial food system so that everyone can eat real food, reforming the labor system so that everyone has time for a private life, and so forth.

That our medical and public health system—our “health” system—doesn’t relieve suffering, instead focusing only on the rarer conditions that can be named as diseases, is neither misguided nor pointless. How devastating smallpox was! And cholera, tuberculosis, black lung, HIV/AIDS, and more. It’s wonderful that we have a system today that can alleviate some aspects of malaise and prolong meaningful life for many people. Still, the system isn’t in any sense aimed at real health—not when you think of health as a diminution of suffering. It’s disease management.

With the Standard Approach, a disease has a cause. Notably, the cause is a failure. Your HIV infection is a result of your reckless sexual behavior, your chronic back pain shows you had neglected to keep fit, your diabetes has arisen from unwise dietary choices, your stroke from your failure to take statins. Now, with coronavirus, the failure was your not engaging in “social distancing” or not wearing personal protective equipment. Or the failure was the state or federal government’s, for failing to make the PPE available, failing to require masks, failing to decontaminate the buses.

Here is how the race aspect works: Black Americans, as many scholars have noted, have been held back by longstanding government policies in housing, finance, education, employment, and voting rights; subjected to discrimination both overt and hidden; and stripped of wealth by a century-and-a-half of Black codes and judicially sanctioned schemes. These included President Andrew Johnson’s rescission of the Freedmen’s Bureau policy that had provided formerly enslaved persons in Georgia and South Carolina with 40 acres of land; laws requiring Black citizens freed from official slavery to work, but preventing them from moving to find better jobs, virtually sentencing them to continued subsistence servitude; official dispossession of land inherited by Black landowners, based on the absence of legally recognized deeds; federally endorsed redlining and the accompanying wholesale denial of mortgage loans; the issuing of other-than-honorable discharges to Black WWII servicemen, denying them housing and education benefits through the GI Bill; U.S. Supreme Court decisions in Village of Arlington Heights (1977), finding no violation of the equal protection clause in de facto racial discrimination absent clear evidence of discriminatory racial intent, and in Schuette (2014), allowing state legislatures to ban affirmative action at public universities; and more. All legal and official.

Black Americans are thereby subjected to the miseries of crowded and inadequate housing, exposure to toxins, violence, and low-paying work. Because the Standard Approach holds the individual and the community accountable for their own ills, the high prevalence of obesity, diabetes, hypertension, heart disease, poor school performance, HIV/AIDS, or addiction is always understood to demonstrate a fault of the Black individual or the Black community. The specific failures, according to the health system, are sexual license, poor eating habits, out-of-wedlock births, low impulse control, affinity for getting high. Well-heeled white children might “experiment” with drugs, consume fast food, and yet remain of “normal” body mass index, and avoid being shot in a neighborhood beef—and that is somehow evidence not of the benefits accruing to whiteness but of the failure of Black (again, increasingly also Hispanic) Americans to embrace what it is supposed to mean to be American. Which is to author a healthful life for themselves, constraints (see above) notwithstanding.

Coronavirus also reveals that equating healthfulness with whiteness is not primarily a matter of “implicit bias” on the part of white doctors, police officers, loan officers, and the rest.  It is not solely a matter of discrimination against individuals, overt or covert. It is built into the system. You cannot readily escape airborne contagion such as coronavirus if you live in a crowded household in a densely populated neighborhood. You cannot hope to get adequate nursing care in an ICU if you don’t have medical insurance and, when sick, must go to a public hospital where the nurse-to-patient ratio is 1:15 or 1:20, rather than the recommended 1:4, and where equipment for patients with respiratory failure has to be shared or rationed. If you are in one of the groups documented to be more likely to die if infected with SARS-CoV-2 (diabetic, hypertensive, older, male), you still can’t protect yourself if you are required to work in a meatpacking plant or a morgue because your job is considered essential.

Many of my well-meaning colleagues in the medical and public health establishment have been good lately about paying lip service to the social determinants of this form of health. But often they mean only that capitalism isn’t fair; corporations aren’t nice; some people are badly harmed by the economic system and then they develop illnesses. Such people, described with distancing formulations like minorities, or the faux-intimate those folks, are usually Black or Hispanic. Medical and public health professionals conclude that they themselves must work harder to alleviate the diseases of the poor, targeting “those folks” (as if America’s Black poor haven’t been targeted often enough) with comprehensive sex education, dietary advice, counseling, or fitness programs. They can do better. Our job is to help them.

These social-justice views of health have something in them of pity, and also of superiority. I can’t go for that. Where is the ardor for a system that is earnest about relieving suffering? Such a system would have social health at its base. That would require a reckoning with race, not just a targeting. It would also require reforming all the policies that have conveniently—conveniently for the privileged classes, I mean—made social circumstances such as wealth inequality and underfunding of public schools resistant to change. Maybe the United States is there already—with the pulling down of Confederate monuments, the renaming of Princeton’s Woodrow Wilson School, agitation to restrain the police from beating or killing Black people. But cultural change is a long road. Even if we are beginning to walk it, the journey’s end is far off.

A system that is earnest about relieving Americans’ suffering would not only be social, though. It would have medical components. Specifically, it would provide medical care universally for those conditions that do qualify as diseases. Coronavirus reminds us that the persistent absence of such a system in the United States both defies the moral bases of human rights and works out badly in practical terms. If you can’t get medical treatment for a contagious disease because you live in Florida, Alabama, or one of the 11 other states that do not offer publicly funded medical insurance (i.e., Medicaid) to nondisabled adults under the age of 65 and you can’t isolate yourself because you work and sleep in close quarters with other people, you are going to spread the contagion. If you can get medical treatment, but only in a public hospital because that is where ambulances take people who look like you, your care providers are likely to contract the disease simply because there aren’t enough of them to attend to everyone and to disinfect the surroundings. The paranoid misrepresentations by the president and his sycophants are not the main reason why the United States can’t contain coronavirus; the main reason is that we have not mustered the political will to create a health system for everyone.

Why is the Standard Approach so mighty a fortress? The reason certainly isn’t cost containment: the estimated $3.6 trillion spent per year on health by Americans is by far the highest in the world as a proportion of GDP. The approach doesn’t work particularly well, either, even by the overly simplistic metric of longevity. Americans’ life expectancy of 79.1 years is about the same as Lebanon’s and Panama’s, and well behind that of the citizens of most other wealthy countries (85 years in Japan, 84 in Spain). It has no moral appeal. The Standard Approach has left us, we are learning now, with the deadliest outbreak of coronavirus anywhere in the world.

As a clue to why the Standard Approach remains impregnable, let me venture two observations. First, to reduce the alleviation of suffering to a matter of risk management creates a kind of total system. In such systems, the sociologist Erving Goffman observed, “each official goal lets loose a doctrine, with its own inquisitors and its own martyrs, and … there seems to be no natural check on the license of easy interpretation that results.” When our nation’s leaders say the United States has the coronavirus outbreak under control, some officials will be inclined to traduce their obligations to the public in order to go along with the doctrine, others will resign in dudgeon, and many people who are badly served by the official goal will die. But all of those who care will interpret the ensuing drama in their own way. This sounds bad as a public health scheme, and it is. But it serves certain administrative narratives—the machinery of government at work, the freedom to take one’s own view—that are reassuring in their own way.

Second, managing disease as if it were the fault of individuals or communities is helpful to the perpetuating of privilege. John Stuart Mill, fierce advocate of liberalism, knew that the status of the privileged would be threatened by any true witness to the suffering of the masses. He wrote in 1836,

To most people in easy circumstances, any pain, except that inflicted upon the body by accident or disease, and upon the mind by the inevitable sorrows of life, is rather a thing known of than actually experienced. This is much more emphatically true in the more refined classes, and as refinement advances: for it is in avoiding the presence not only of actual pain, but of whatever suggests offensive or disagreeable ideas, that a great part of refinement consists.

Through the lens of this year’s events, Mill’s assertion looks awfully apt. Health, meaning freedom from pain and other suggestions of disagreeable ideas, is the easy breath of privilege. It is the breath of all of us whose status exempts us from being called on to carry out essential occupations without adequate protection from a dangerous virus; of the person whose breath will never be choked off by a policeman’s arm or knee; of those people who will never be shot in their own home by police because, to use Claudia Rankine’s phrase, “you are not the guy and still you fit the description because there is only one guy who is always the guy fitting the description.”

What will it take to bring the Standard Approach down? That’s a question for this moment, when coronavirus and Black Lives Matter together have our attention. What will it take for a country with a GDP of $20 trillion to attend to the alleviation of human suffering? What will it take for health to be for everyone? Americans should have known long ago how to name our college dorms, football teams, and military bases. We should have known (arguably, did know) how to stop contagion. Simple problems with easy solutions, and yet so hard to act on. My questions here go much deeper. There’s work to be done.