Whiteness and Health and Dying in America

Dying of Whiteness: How the Politics of Racial Resentment Is Killing America’s Heartland By Jonathan M. Metzl

New York, NY: Basic Books, Hatchette Book Group; 2019

352 pp; $22.99

ISBN: 1541644980

ISBN-13: 9781541644960

It is the rare book that has the potential to transform thinking so thoroughly that it offers to change a paradigm. Jonathan Metzl has written such a book with Dying of Whiteness. The conventional understanding of health disparities must take a different shape because of this groundbreaking work.

WHEN POLICIES BECOME IDENTITIES

The key insight in Dying of Whiteness is that, in the United States, certain policies have become so intertwined with White identity that the policies themselves serve as racial identities. And White people are willing to die to uphold them.

For decades, the overall trend in the United States has been toward longer life spans while there have been persistent racial disparities in life expectancy between White people (78.9 years) and African American people (75.5 years) according to 2017 data from the Centers for Disease Control and Prevention (http://bit.ly/2JafteN). However, life expectancy for White Americans is shortening. This decline stands in contrast to the continuing upward trend for other groups, and it is nearly unprecedented in US history. The last time there was a decline in life expectancy was between 1915 and 1918, during a global influenza pandemic and the First World War. This public health mystery is at the heart of Dying of Whiteness.

The book is divided into three case studies that focus on political issues with a core of support among White voters: expansion of gun rights in Missouri after the #BlackLivesMatter uprising in Ferguson, Tennessee’s decision to opt out of the Affordable Care Act (ACA), and the GOP “experiment” in Kansas that implemented extreme tax cuts to a host of public goods, including education. Each state provides a case study for investigating why White people are so enthralled by a particular ideology that they are willing, even eager, to embrace policies that ensure their ill health and early death.

Trained as a psychiatrist and a sociologist, Metzl has a personal connection to each state he studies. He grew up in Kansas City, which straddles Missouri and Kansas, and now lives in Tennessee, where he is the director of the Vanderbilt Center for Medicine, Health, and Society. Throughout, he weaves his personal narrative into the larger story about the puzzling fact of shortened White life spans.

To find answers, Metzl analyzes population health statistics from a number of databases as well as evidence from secondary data analysis and news reports. Most compelling for this reader were the in-depth interviews he conducted in each state from 2013 to 2018. During these interviews, he spoke with middle-class, working-class, and working-poor people about what he calls the “urgent and contested political issues facing the American electorate, including health care, guns, taxes, education, and the scope of government”(p.106). The mixed-method analysis pays off when Metzl juxtaposes the public health data with insights from the interviews.

MISSOURI HANDGUN LAW REPEAL

In the Missouri case, Metzl considers the state’s repeal of the permit-to-purchase handgun law, making guns easier to buy and legal to openly carry. Metzl used the Web-based Injury Statistics Query and Reporting System (WISQARS) database to analyze gun suicide rates by race and gender. He found that White men in Missouri were seven times more likely to turn their firearms on themselves than to be fatally shot by someone else. Yet, Metzl finds little support for regulating guns in Missouri, even in suicide support groups. When he asks a Missourian who has lost a loved one to suicide what guns mean to them, the reply is swift, “Freedom. Liberty. Patriotism. That’s why we just voted for Trump. No way we were going to let ‘Crooked Hillary’ take those things away from us” (p.29). In further analysis of the resulting impact on “potential years of lives lost,” he found that, “loosening gun policies in Missouri went hand in hand with the loss of over 10,500 years of productive white male life in the state” (p.106). Metzl connects the allure of “armed white maleness” (p.108) with a system of rights, privileges, and power that eases the pain of social dislocation that many Whites feel.

TENNESSEE BLOCKED AFFORDABLE CARE ACT

Perhaps the most telling example comes from the Tennessee data. Here, we meet a man Metzl calls Trevor, described as a 41-year-old cab driver who is chronically ill with hepatitis C and has no health insurance. If Trevor had lived one state over, in Kentucky, which adopted the ACA, he would have had access to expensive medications called polymerase inhibitors or been eligible for a lifesaving liver transplant. But, because he lives in Tennessee, a state that has repeatedly blocked the Obama-era health care reform, Trevor faces an early and painful death. When Metzl interviews Trevor at his home, he offers this takeaway quote from the book: “Ain’t no way I would ever support Obamacare or sign up for it. I would rather die” (p.3).

Metzl follows up with a question to Trevor about why he feels this way, and he says, “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens” (p.3).

It is this sentiment, expressed over and over again by Metzl’s respondents, that is the answer to the mystery about White death. It is an illustration of what, a century ago, scholar W.E.B. Du Bois first identified as the “mental wage of whiteness,” and that many African American scholars have since documented.^1(p28) In the contemporary milieu, the wages of Whiteness have been combined with what historian Timothy Snyder has called “sadopopulism,”^2(p274) in which political leaders win support from already subjugated citizens only to implement policies that are designed to hurt them further.

OPIOIDS AND TRANSLOCAL WHITENESS

No one book can do everything, and while Dying of Whiteness does a great deal, there are some missed opportunities here. For those who have been following the news of Whiteness and health, it may come as a surprise that there is little mention of opioid deaths here. This is understandable given the methodological framework Metzl deploys, and one can envision another study that replicates his work examining policies about opioids and White overdose deaths in states such as West Virginia or Oklahoma.

By design, the book has an exclusive US focus. This is not necessarily a shortcoming, but readers concerned with global public health and translocal Whiteness (e.g., identifying as White across national boundaries) will need to look elsewhere. To augment their understanding of Whiteness and health globally, readers would do well to consult the literature on colonialism and “tropical medicine” in national contexts outside the United States.³

WHITENESS AS HEALTH RISK

Metzl’s work challenges the conventional approach to the study of racial disparities in public health, which has largely been framed as a comparison of minoritized groups to the White population and suggests a deficit model.⁴ The assumption guiding much of this work is that Whiteness confers a health advantage.⁵ But if, as Metzl clearly shows, Whiteness is also a health risk, then how are we to understand health disparities?

Rethinking health disparities in light of Metzl’s work will require taking a new look at the unquestioned advantage ceded to Whiteness and require a recalibration toward a more nuanced view, as some researchers have begun to do.⁶ Rather than relying on the outdated assumption that minoritized groups carry the source of disparities, perhaps we should begin to take seriously what James Baldwin called “the lie”⁷ of being White and that the lie is killing us all.