Hazards of Anti-Blackness in the United States

Abstract

On February 26, 2012, a Black child, Trayvon Martin, was executed in Sanford, Florida. Seventeen months later his killer was found not guilty. This is but one example of the state’s brazen disregard for Black life, rooted in the kidnapping and enslavement of Africans more than 400 years ago, and the ways in which they and their descendants were systematically tortured. Trayvon Martin’s murder catalyzed the Black Lives Matter (BLM) movement, which names and resists deeply entrenched state violence and inequities against Black people in the U.S. In this manuscript we: (1) summarize examples of structural disregard for Black lives in the U.S.; (2) describe how this disregard is reflected in differential patterns of social inequities, morbidity, and mortality; and (3) discuss how we can better employ the BLM perspective to frame a more historicized understanding of patterns in population health and to envision ways to resist health inequities.

Disregard for Black life in the US

There are a number of ways in which the structural disregard for Black life is visible in the United States. Virtually every aspect of Black life in the United States is impacted by centuries-old forms of White supremacy and mutating forms of anti-Black state violence. The purpose of this commentary is to document the ways in which disregard for Black life within U.S. social and criminal-legal systems harms the health of Black communities. By amassing and recording the suite of health hazards that accompany exposure to anti-Black racism in this country we take a critical first step toward holding the criminal-legal and public health communities accountable. We then offer recommendations grounded in a Black Lives Matter (BLM) perspective for next steps to resist these health inequalities.

BLM Epistemology

Our arguments are grounded in what we term BLM epistemology; one of the most influential interdisciplinary bodies of critical scholarship, which charts historical shifts in the expression of anti-Blackness in the United States. As scholars have noted, the U.S. was founded on white supremacist ideology and practice (Hannah-Jones, 2019; Muhammad, 2019). National wealth and power were built through the dehumanizing and savage oppression of enslaved Africans, who were treated as property and who were abused and killed through the forcible extraction of their labor. As many have argued before, the U.S. was founded on an ideal and a lie: that all should be created equal, while enslaved Africans and their descendants have been treated as far less than human (Baldwin, 1963). This has created a predicament in which Black people are perceived to be fundamentally problematic across time—to see Black people as fully human would require acknowledging and collectively grieving centuries of state violence. The acknowledgement of Black humanity and rejection of deeply held and influential anti-Black constructions of Black people as criminal, violent, unredeemable, undeserving, necessarily throws into relief the brutal ways in which Black people have been treated, and clarifies that “founding” ideals of equality and liberty have never been practiced (Hannah-Jones, 2019). And so, the “doctrine of black inferiority” (Hannah-Jones, 2019) is fiercely guarded and practiced, and its consequences are exponential, felt across health, social welfare, and criminal legal system policy.

Engagement with the Criminal Legal System

In the ten years since the killing of Trayvon Martin by George Zimmerman, at least 2,500 Black people were killed by police officers (Mapping Police Violence, 2021). Today, Black people are more than twice as likely as their White counterparts to be killed by a police officer (Mapping Police Violence, 2020), and police violence is the fifth leading cause of death for young Black men (Edwards et al., 2019). These statistics highlight the damage produced by Supreme Court interpretation of the Fourth Amendment—which protects people from unreasonable searches and seizures—legalizing racial profiling in police stops (Carbado, 2017).

Black people in the US are vastly overrepresented in each step of the criminal legal process, starting with surveillance, police stops, and arrests, and ending with lengthier jail and prison sentences (Brewer & Heitzeg, 2008; Mauer & King, 2007). Across the United States, Black motorists are 20% more likely to be stopped by police than their White counterparts. Furthermore, after sunset, when darkness may mask one’s race, Black drivers experience fewer stops, suggesting police bias in stop decisions (Pierson et al., 2020). When Black men are stopped by police, the interaction is more likely to involve abusive police behavior (Kramer & Remster, 2018). According to the National Association for the Advancement of Colored People (NAACP), 65% of Black adults report having felt targeted by police because of their race (NAACP, 2020). Such police-initiated encounters are shown to have detrimental impacts on health outcomes, including psychological and physical health (Sewell et al., 2016).

One in every three Black men in the US will be incarcerated during their lifetime (Wildeman & Wang, 2017). Although substance use patterns are similar, Black people are nearly six times more likely than their White counterparts to be arrested and incarcerated for a drug-related offense (NAACP, 2020). Additionally, when they are convicted, Black people receive harsher sentences compared to White Americans (Rehavi & Starr, 2014). Prosecutors are twice as likely to pursue a mandatory minimum sentence for a Black defendant than for a White defendant charged with the same offense. This is significant as those with mandatory minimum sentences spend five times longer in prison on average (U.S. Sentencing Commission, 2017). At the end of 2018, the Black incarceration rate was more than five times the rate among Whites and nearly twice the rate among Hispanics.

Among certain age groups, the Black incarceration rate is even higher. For instance, one in twenty Black men ages 35 to 39 were in federal or state prison in 2016 (Carson, 2018). This disparity is particularly problematic because Black men are often incarcerated during periods of their lives when they are expected to be productive members of the workforce, and incarceration reduces subsequent income earning by as much as 50 percent (Craigie et al., 2020). Incarceration also shapes and is shaped by income inequalities. Black men from low-income families are at an elevated risk of legal system involvement (Bertram, 2018). According to a recent report by the Brookings Institute, boys born into families in the bottom 10 percent of the income distribution (those earning about $14,000 per year) are about 20 times more likely to be in prison in their 30s, compared to boys born into families in the top 10 percent (Looney et al., 2018). Racism in the carceral system also undoes economic progress within Black communities; a 2018 Prison Policy Institute report found that Black men raised in the top one percent (average income 1.7 million) are as likely to be incarcerated as White men raised in households earning $36,000 (Bertram, 2018). Social theorists have charted the ways in which White supremacy, or the belief that White people should have dominance over or are superior to others (ALD, 2021) has adapted through historical time, calling the current era of mass incarceration the New Jim Crow (Alexander, 2012).

The criminal legal system also profoundly shapes political voice and power, via the systematic disenfranchisement of people convicted of felonies (Uggen et al., 2016). It is estimated that 1 in 16 Black people in the United States were barred from voting in the 2020 presidential election, a rate nearly four times higher than that of other races (Uggen et al. 2020). In four states, Florida, Kentucky, Tennessee, and Virginia, more than 1 in 5 Black Americans are barred from voting (Uggen et al., 2016).

White supremacy is a profoundly entrenched ideology that also shapes how Black people are treated by individuals, as well as by systems, and its role in the disparate treatment of Black people’s involvement with the legal system is well-documented (Alexander, 2012). However, its impact is realized in other aspects of Black lives as well. Recent research suggests that over the last 25 years, there has been no change in the high level of discrimination against US Blacks seeking employment (Quillian et al., 2017). Merely existing and engaging in day-to-day responsibilities are acts that Black people are punished for, through discrimination. For example, Black people in the U.S. face discrimination when attempting to secure a mortgage for property purchases (Hanson et al., 2016), shopping for necessities (Zenk et al., 2014), bird watching (Bellafante, 2020), existing on university campuses across the U.S. (Bauer-Wolf, 2019), and reading (Haile, 2020).

Social scientists and economists have quantified the financial toll of discriminatory policies and practices on Black Americans. Approximately $70 trillion in wealth has been extracted from Black Americans over the course of several generations, largely due to ripple effects of slavery and their inability to build wealth using government-sponsored programs that almost exclusively benefited White Americans (Rochester, 2017). Although the brunt of racism and discrimination is primarily borne by Black people, all Americans pay a price. While the true cost of racism may be incalculable, economists estimate that inequities have cost the U.S. economy approximately $16 trillion over the past 20 years (Peterson et al., 2020). Creating more equitable social conditions in the U.S. may require a redistribution of wealth and a substantial commitment to taking bold steps to prevent future reinforcements of inequitable patterns, and to redress past injustices inflicted on Black Americans (Hannah-Jones, 2020).

Differential Patterns of Morbidity and Mortality

Experiencing this level of structural racism and racialized bias on a regular basis impacts the health of Black people, resulting in elevated blood pressure, cortisol levels, and inflammation (Simons et al., 2018), and structural disregard for Black life in the US is also reflected in Black Americans’ systematic exposure to discrimination within the healthcare system. Anti-Black discrimination within the health care system is well established, with examples such as differences in the pain management given to Black Americans compared to others experiencing the same conditions (Hoffman et al., 2016) and racial bias in the algorithms used to guide healthcare spending (Obermeyer et al., 2019). Black Americans are less likely to receive referrals for diagnostic tests to detect breast (Chu et al., 2003), ovarian (Armstrong et al., 2005), and colorectal cancer (Berry et al., 2009), and are more likely to undergo more serious medical procedures that are not necessarily warranted for chronic conditions, such as amputations among diabetics (Goldberg et al., 2012). While rates of cardiovascular disease are disproportionately high among Black people in the U.S., they are also less likely to receive clinically indicated cardiovascular procedures (Epstein et al., 2003; Fincher et al., 2004).

Even crossing the street may be a hazardous activity for Black people in the United States. A Las Vegas, Nevada study demonstrated that fewer drivers yielded to Black pedestrians (as compared to Whites) while they were crossing the street at a high-income neighborhood crosswalk, contributing to higher rates of pedestrian crashes among people of color (Coughenour et al., 2017). Similarly, a study commissioned by the Oregon State Department of Transportation reported that, on average, Black pedestrians in Portland waited 32% longer to cross the street than White pedestrians because drivers were less likely to yield to Black pedestrians (Goddard et al., 2015). These behaviors may help explain the higher rates of adult pedestrian deaths among Black Americans (1.4 per 100,000) than White Americans (0.9) (Kaufman & Wiebe, 2017).

The systematic and ubiquitous devaluation of Black life is ultimately expressed in profound inequities in population health. Black people in the US are more likely than Whites to experience hypertension, diabetes, and stroke (CDC, 2017). Black women experience high rates of poor maternal health outcomes, including a pregnancy-related death rate four times that of White women (Berg et al., 2010) and an infant mortality rate 2.3 times that of Non-Hispanic White women (CDC, 2019). HIV infection rates are disproportionately elevated among Black Americans, particularly among Black men who have sex with men (MSM) (CDC, 2020b). In 2018, Black Americans comprised 13% of the US population but 42% of new HIV infections (CDC, 2020b). These patterns are also expressed in inequities in measures of mortality and longevity; Black people on average live 3.5 fewer years than Whites and there are annually well over 80,000 deaths among Black people in the US that could be prevented if the Black-White mortality gap were eliminated (Satcher et al., 2005). Yet more glaring differences in mortality emerge when you examine life expectancy according to zip codes (Geronimus et al., 2001). For example, data from the Baltimore City Health Department revealed a 16-year gap in life expectancy between the wealthiest zip code in Baltimore, where 16% of residents are Black, and the poorest zip code, where 95% of residents are Black (Baltimore City Health Department, 2017). Likewise, children born five miles apart in racially divided communities in Philadelphia face up to a 20-year difference in life expectancy while those in Chicago three subway stops apart face a 16-year life expectancy difference (Center on Society and Health, 2020).

A number of scholars have provided frameworks for understanding social and health disparities and how structural factors contribute to health inequities. For instance, Dr. Camara Jones (2000) describes levels of racism – institutionalized (differential access to goods services, and opportunities based on race), personally mediated (prejudice and discrimination), and internalized (acceptance of inferior status of members of stigmatized races) – illustrating how each level works and how its impact can be mitigated. The health consequences of these various forms of racism have stubbornly persisted across generations (Bailey et al., 2017).

Dr. Nancy Krieger’s ecosocial framework provides a conceptual understanding of the ways in which health inequities become embodied, or incorporated into our biology (Kreiger, 2012). The framework considers pathways to embodiment in relation to types and levels of exposure to risks, such as economic and social deprivation, environmental hazards, socially inflicted trauma including discrimination, targeted marketing of harmful commodities, inadequate or degrading healthcare, and degradation of ecosystems. It also considers individual and societal reasons that one might be more susceptible or resistant to an exposure. At the core of this model is the understanding that lived realities of discrimination and oppression become embodied, biologically, and operate through multiple levels and pathways across a person’s life course and historical generations. More recently, this framework has been used to better understand COVID-19 related disparities (Krieger, 2020).

Disparate Effects of COVID-19

The emergence of COVID-19 has had a devastating impact on Black communities in the U.S. As of May 28, 2020, Black people were at least 2.5 times more likely to be infected with COVID-19 than White Americans (Oppel et al., 2020). In some states, these disparities are even greater. For instance, in Wisconsin, a state where just 6% of the population is Black, Black Americans account for 27% of all COVID-19 deaths (Goody & Wood, 2020). Some evidence suggests that Black people may have had less access to COVID-19 testing, particularly early in the pandemic when tests were scarce, thus delaying diagnosis and treatment (Farmer, 2020). When they do receive a diagnosis, they are also more likely to be hospitalized and to be placed on a ventilator (a sign of more severe disease progression), and to experience mortality (Hsu et al., 2020). However, the full extent of racial disparities in COVID-19 cases and deaths is unknown, as data on race and ethnicity are missing for hundreds of thousands of documented cases.

These systematic inequalities are rooted in state violence and the ways—both stark and subtle—in which White supremacy is upheld. Discriminatory practices such as unequal access to healthcare and healthcare providers’ implicit biases may increase the risk of contracting COVID-19. Compared to Non-Hispanic White and Asian Americans, Black Americans are up to 60% more likely to be underinsured or uninsured (Berchick et al., 2018; Gould & Wilson, 2020), which is associated with delays in receiving preventive care and poorer health outcomes (Hadley, 2003).

Delays in preventive care can increase vulnerability to COVID-19 by reducing the likelihood that comorbidities linked to severe COVID-19 response, such as diabetes, cardiovascular conditions, and asthma, are actively managed (Alam et al., 2021). Other significant contributors to COVID-19 vulnerability among Black Americans include concentration in residential communities with high population density and more multigenerational households, making social distancing and isolating sick family members a greater challenge (Gould & Wilson, 2020), and higher air pollution – 54% above average according to a 2018 U.S. Environmental Protection Agency report (Mikati et al., 2018). Air pollution has long been known to increase the risk of asthma, heart attacks, bronchitis, and lung cancer (Paulin & Hansel, 2016), each of which is believed to independently increase the risk of death from COVID-19 (CDC, 2020a). Racism embedded within historical and contemporary policies and practices have led Black Americans to occupy a greater share of substandard housing in neighborhoods with adverse health attributes linked to greater risk of COVID-19 (Swope & Hernández, 2019). A study evaluating COVID-19 vulnerability estimated that 30% of Americans live in counties at the greatest risk of health and economic disruption due to COVID-19, while a larger share – 43% of Black Americans live in those same counties (Fitzhugh et al., 2020).

In addition, Black Americans are over-represented in essential work settings such as grocery stores, factories, postal service, public transportation, and healthcare services where work cannot be conducted from home (McClure et al., 2020; Rho et al., 2020). While Black workers make up one in nine workers overall (11.9% of the workforce), they make up one in six of all front-line-industry workers (Gould & Wilson, 2020). These positions may require close contact that make it difficult to follow CDC guidelines for physical distancing.

Furthermore, Black Americans are also disproportionately incarcerated, putting them at increased risk of COVID-19 infection both during their sentences and after release. Early research indicates that the number of COVID-19 cases in prisons and jails is rising rapidly, and that outbreak clusters are often associated with correctional facilities (McCarthy, 2020; Saloner et al., 2020). In addition, in the months following release, formerly incarcerated individuals are more likely to live in congregate settings such as homeless shelters, where the risk of COVID-19 infection may be high (Tobolowsky et al., 2020).

Summary

In summary, as noted by others, racism is an epidemic that devalues and extinguishes Black life (APHA, 2020; Marcus & Gonsalves, 2020). It manifests itself in numerous ways that jeopardize the health of Black people. This occurs in daily experiences and interactions with others, but also with structures of oppression and social institutions that routinely prevent them from reaching their full potential. Historically, opportunities for economic advancement and upward mobility have been jeopardized by structural barriers that are detrimental to the health of Black people. Although the relationship between racism and negative health outcomes is increasingly being recognized by community leaders throughout the U.S., sustainable solutions to address discriminatory practices and policies that have resulted in decades-long suffering and trauma among Black people have yet to be widely implemented. To the contrary, despite the supposed growth in social consciousness among Americans (Beinart, 2016), there have been limited improvements in the relative social position of Black people over the past several decades. Rather, disparities in incarceration rates, educational attainment, wealth accumulation, and other measures of economic success and integration have all increased (Parker et al., 2016).

After the brutal police killing of George Floyd and ensuing BLM human rights uprisings of 2020—which on June 5, 2020 were attended by half a million people in 550 U.S. cities—institutions across the country clamored to develop anti-racism policies and workshops (Buchanan et al., 2020). It is unclear how successful these initiatives will be, as a prior systematic review of implicit bias trainings found that less than half produced any long-term positive change in outcomes (FitzGerald et al., 2019). However, the energy driving these initiatives has the potential to drive systemic change. Conversations informed by racial and social justice are emerging in city councils, state legislature, and Congress regarding plans to shift funding from militarized policing to community investment (Krieger, 2020). While we are hopeful that these changes will produce positive outcomes, concerted and historicized efforts are needed to address the deeply embedded ways in which racism and White supremacy degrade population health.

Recommendations

We suggest four ways in which future strategies could help mitigate this burden. First, declarations of racism as a public health problem have enabled cities in the United States to address health disparities and dedicate resources to addressing historical trauma experienced by Black Americans. For instance, Milwaukee County, Wisconsin followed its declaration of racism as a public health problem with an ordinance outlining steps to address racial biases in its government, including the creation of a “racial budgeting tool” to assess the impacts of local budget cuts and investments on communities of color (Kaur & Mitchell, 2020). While the declaration alone is does not sufficiently address negative health outcomes associated with racism, with increased awareness and resources dedicated to addressing health inequities, localities will be establishing their priorities and intent to deliver services that reduce/remove structural barriers to optimal health.

Second, as argued by others (Bassett & Galea, 2020), granting meaningful reparations for enslavement may help mitigate the long-term, deeply entrenched intergenerational socioeconomic impacts created by slavery and the ensuing policies and practices. These practices, including redlining, refusal to enforce fair housing laws, and school segregation, have and continue to reliably reproduce health-related inequities across generations. Reparations may be granted in various forms, including investments in under-resourced communities to help address health inequities by improving the social conditions in which many Black communities are situated. Increasingly, US cities are either introducing or implementing polices aimed at redressing historical injustices, including the consequences of systemic racism (Human Rights Watch, 2021; Treisman, 2021).

Although it may be too soon to evaluate their impact, several states have started to mobilize resources to finance reparations proposals. In March 2021, Evanston, Illinois approved the nation’s first reparations program for Black people to address ongoing harm caused by historical housing discrimination and promote home ownership and wealth building among Black residents (Treisman, 2021). Reparations efforts have also been initiated in California and cities including Providence, Rhode Island, Asheville, North Carolina, Burlington, Vermont, and Amherst, Massachusetts (Human Rights Watch, 2021). On April 19^th, a House of Representatives committee voted to advance the H.R. 40 Bill, the Commission to Study and Develop Reparation Proposals for African Americans Act; however, its future in the evenly divided senate is uncertain (Behramann, 2021). President Biden has expressed support for the bill and has allocated significant resources to address racism in US cities, including directing an additional $20 billion in federal funding to schools in high-poverty majority Black and Hispanic areas (Saksa, 2021).

Third, because of intensive over-investment in criminalization, police surveillance, mass incarceration, and the simultaneous disinvestment in the social determinants of health within Black communities, the overall health of Black communities continues to suffer disproportionately. Carceral systems are inextricably linked to the dehumanizing construction of Black people as property during enslavement, and their tools of punishment and abuse continue into the present moment (Spruill, 2016). The health consequences of direct and indirect exposure to the criminal legal system are vast and harmful, particularly within Black communities (Acker et al., 2019). Research suggests that each year spent within a prison results in a 2-year decline in life expectancy (Patterson, 2013). The economic consequences associated with disproportionate imprisonment have also been well-documented (Craigie et al., 2020). Rather than continuing to disproportionately invest in criminalization, surveillance, and incarceration, novel approaches would shift investments into addressing the social determinants of health in these communities, including widespread public and private investment in the creation of and access to quality jobs, housing, education, and health care.

Finally, investments should also be made in training opportunities and programs for Black and other underrepresented populations to promote the pursuit of public health and clinical careers. Diversity, inclusion, and anti-racist frameworks within these professions is essential to improve the health and economic outcomes of marginalized populations. For instance, there is substantial evidence that an increase in the percentage of physicians of color improves the mental and physical health outcomes of Black Americans (Alsan et al., 2019; Malhotra et al., 2017). Physician-patient racial concordance is associated with improved communication and trust, infant survival, and use of preventative cancer, diabetes, and cholesterol screenings (Greenwood et al., 2020). Black physicians are desperately needed given the reductions in Black men pursuing medical degrees over the past 10 years (Talamantes et al., 2019). COVID-19 contributed to a 30% spike in the number of Black and Hispanic applicants to medical schools during the 2021 cycle, but this increase may be temporary if systems are not adapted to promote minority recruitment and retention in physician training programs. Similarly, schools of public health and social work have made limited progress to increase minority representation. For instance, over the past 20 years, Black student enrollment in public health graduate programs increased by less than 5 percentage points and the proportion of Black tenured public health faculty rose by less than 3 percentage points (Goodman et al., 2020).

Given substantial (and growing) gaps in income equality and social capital of many Black communities, implementation of pipeline programs that include financial assistance, role modeling, standardized test support, and pathways from community college to advanced degrees in these fields are a useful starting point (Talamantes et al., 2019). These efforts should capitalize on the CARES Act, which reauthorized diversity workforce programs, freeing up funding for pipeline programs focused on physician workforce diversity (Moss et al., 2020). In addition, policy actions could increase opportunities for incentivizing and increasing accessibility to medical, public health, and social work training for populations at a consistent risk for experiencing health inequities. For instance, the Centers for Medicare and Medicaid Services (CMS), which subsidizes residency programs, could allocate funds according to minority representation or alignment with community diversity.

While efforts are made to build workforce diversity, focus should be placed on transforming these settings to be anti-racist environments, spaces of respite within which workers have the space to imagine, create and scale up more equitable systems. Programming components should include understanding the reverberating consequences of Black enslavement and its consequences, addressing white privilege, and recognizing and removing barriers to care, and can incorporate key insights from structural competency models (Metzl & Hansen, 2014).

Implications

In this commentary we have described the ways in which the routine disregard for Black lives in the U.S. has resulted in persistent health and social inequities among Black Americans. We have put forth four recommendations that we believe will help mitigate these inequities, including declarations of racism as a public health problem, granting reparations to the descendants of enslaved Africans, alternatives to the current carceral system, and increased workforce diversity within professions that work to improve population health and wellbeing. We believe that these actions represent a necessary step toward eliminating racial health disparities in the U.S. context.