In many parts of America, white people undermine their own health to death because they believe public policies that would help them are actually designed to benefit people of color at their expense, researcher Jonathan Metzl , MD, PhD, told an audience at Learn Serve Lead 2022: The AAMC Annual Meeting on November 12.
“There’s a disinformation machine coming” to turn people against certain proposals to expand government services and protections, as seen with the Affordable Care Act (ACA), Metzl said during of the session entitled “Dying of Whiteness: Politics, Politics and Racial Resentment”. This disinformation campaign included three messages: “This is a government intrusion into your life.” “It takes away privileges meant for you.” “Black will cut in front of you in line.”
Metzl saw the result of this message in focus group interviews several years ago with very sick men in Tennessee, who were asked, “Who benefits from health care reform?” While black men have always said that everyone in society benefits when everyone has access to good health care, white men have repeatedly said that health care reform takes resources away from white people to give more care for immigrants and people of color.
These views fundamentally influenced Metzl’s 2019 book, Dying of Whiteness: How the Politics of Racial Resentment is Killing America’s Heart. In it, the physician and sociologist explored how racial anxieties have dampened ACA enrollment in Tennessee, fueled the repeal of gun control laws in Missouri, and spurred education cuts. and social services in Kansas. As a result of these decisions, he argues, gun suicides and school dropouts among whites in these states increased and their life expectancies decreased.
Metzl, chair of the Department of Medicine, Health, and Society at Vanderbilt University in Tennessee, discussed his findings with AAMCNews several weeks ago. The interview has been edited and condensed for clarity.
What do you mean by “whiteness”?
I am not talking about White as a biological category or a genetic category. What I mean is the rise of a particular politics of whiteness that is anti-immigrant, anti-government, ardently pro-gun, steeped in a kind of nostalgia for a very often racialized imagined greatness.
There have always been many ways to be white in America. The question is how did this singular notion of whiteness as a category of resentment, this victimized notion of whiteness, become so powerful?
You wrote that the destruction of the health infrastructure contributes to worse outcomes for white people who share these views. How racial resentment contributes to the destruction of health infrastructure?
On an ideal planet, people would want to have as much access to a social safety net and doctors as possible. The way health insurance works and health infrastructure works, you want the most people involved in your network so you can democratize risk and cost.
When I was doing my research in Tennessee, the ACA was beginning to take shape. For the first two months, before it got politicized, people were like, “That sounds good. Someone is going to help me pay for my exams or pay for my prescription drugs. Everyone was for it. Their politics didn’t matter.
Then came this incessant message that this is going to put the government in your private life, it is going to take away privileges, it is a handout to minorities. After months of this message, we would see people who had been totally for the ACA rejecting the program for these reasons. I’ve met tons of people who actively and deliberately don’t buy coverage, even when they’re sick. The white replacement narrative was so powerful that it caused people to reject a basic human motivation for health and longevity.
You tell the story of one such person, Trevor, a sick man who said he’d rather die than be covered by the ACA. He is dead. What do health care workers take from a guy like Trevor?
Here is someone who was not willing to enroll in a program, even if we helped him, if it also benefited immigrants and minorities. He would tell me, “I don’t join a program if it benefits people I consider below me in the social hierarchy. This ideology of not sharing, of caring about other debaucheries, led him to make decisions against his own health.
He was part of a social/political team whose power and authority depended on someone like Trevor at the bottom of the social hierarchy denying something that would have been good for him. If someone like Trevor said, “I demand health care and I want leaders who are going to give me health care,” they couldn’t have afforded tax cuts. They needed people like Trevor to be martyrs.
When I read the stories of your interactions with people on ACA and gun violence, it seems like having a discussion with them based on data alone wouldn’t be productive for either party. People in medicine say, “I provide data. I can show you the maps. Why it does not work ?
We haven’t realized that the stories we tell about data really matter. Public health officials who study guns say gun reform is common sense, that we need background checks and red flag laws. A background check means that your information is recorded in a database when you purchase a firearm. And a red flag law means inviting the police and a judge to do an assessment on whether you can own it or not.
If you’re in New York, who cares? If you’re in a red state like Tennessee, the last thing you want is for the government to police your right to carry a gun. Things that are common sense in one locality are not common sense in the other. We failed to explain the data and adapt it to the ideology of others.
You have written several times that you do not accuse these people of being racist. Should we recognize that racism plays a role?
My research does not seek to discern individual racism. What I saw when I was talking to the poor is that part of the reason their racism, in quotes, was showing up was that they were part of a political party that was draining their resources and giving away money that would have gone to their education, their security, their health care, to tax cuts for the wealthy and corporations. Everything went out the window. There were so many structural factors.
If we just say people need more individual sensitivity or anti-racism training, without fixing the major structural drivers upstream of why their attitudes are what they are, then we’re just going to continue to be behind the eight ball.
You also wrote that you weren’t accusing them of being duped. But they support policies that harm them.
If your life goal is to ban abortion and have second amendment rights, then you are ready to do whatever it takes. I think health care is important, but many people I met thought banning abortion was much more important. My value system was not the same as theirs. It is important to see what their value system is.
Why is what we are talking about a matter of whiteness? Many people of color support the Republican Party and some of the policies and decisions you write about.
Many people who support Democratic policies have assumed that racial identity constitutes an ideology, and Democrats do so at their peril. There are many black Americans who are not African American. There are many Latin Americans who are Cuban. At our peril, we correlate skin color with ideology. Also, people have delivered fair critiques of Democratic finance, health and safety policies in a way that resonates.
If these political decisions about health care and gun safety are hurting some white people, aren’t they hurting people of color even more, given the health disparities between racial and ethnic groups in the United States? United ?
Minority and immigrant communities suffer enormously and unnecessarily from these policies. My data makes this painfully clear. But the data I follow reveals how the health and well-being of white Americans has also suffered from the health effects of these policies. Such effects have manifested themselves publicly, as when white spectators died in high-profile mass shootings linked to gun policies, or lack thereof, enacted by white conservative politicians. Other effects were much less obvious, such as the long-term implications of stalling health care reform or funding for schools and health infrastructure.
So I ask, why are white Americans putting up with this suffering? Why do they choose it, indeed? Writer Toni Morrison has bluntly stated the conflict inherent in this notion of American whiteness: to “restore whiteness to its former status as a marker of national identity, a number of white Americans are sacrificing themselves.”
This is not a book that ends with solution bullet points. But what should we do?
You need to replace structures that promote competition with structures where people can see the value of collaboration. When they first conceptualized the ACA, there was an idea that entire communities would get tax breaks if the community lowered their systolic blood pressure, lowered blood sugar, reduced ER visits, created more bike lanes, all these other health measures. . He rewarded people for working together across tribal lines. People might see the benefit of collaborating toward mutual health goals.
Of course, it was one of the first things to be thrown out the window.
Think about it: can we have people seeing and being rewarded for this kind of benefit? Consider ways structures can reward people for working together toward common health goals.
Trying to change people’s minds is exhausting and impossible. It is better to change the structures in a way that rewards cooperation.
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