aamc.org does not support this web browser.
  • AAMCNews

    Racial resentment hurts White people too, physician tells colleagues

    Many White people in America’s heartland have been convinced that health care reform takes their resources to benefit people of color, says sociologist Jonathan Metzl, MD, PhD.

    Jonathan Metzl, MD, PhD, author of "Dying of Whiteness," takes questions from the audience at Learn Serve Lead 2022 on Nov. 12 in Nashville.
    Jonathan Metzl, MD, PhD, author of "Dying of Whiteness," takes questions from the audience at Learn Serve Lead 2022 on Nov. 12 in Nashville.
    Credit: Richard Greenhouse

    White people in many parts of America are undercutting their own health to the point of death because they’ve been convinced that public policies that would help them are actually designed to benefit people of color at their expense, sociologist Jonathan Metzl, MD, PhD, told an audience at Learn Serve Lead 2022: The AAMC Annual Meeting on Nov. 12 in Nashville, Tennessee.

    “There’s a disinformation machine that comes” to turn people against some proposals to expand government services and protections, as was seen with the Affordable Care Act (ACA), Metzl said at the session entitled “Dying of Whiteness: Politics, Policy, and Racial Resentment.” That disinformation campaign included three messages: “This is government intrusion into your life.” “This is taking away privileges that are meant for you.” “Black people are going to cut in front of you in line.”

    Metzl saw the result of that messaging during focus group interviews several years ago with very ill men in Tennessee, who were asked, “Who benefits from health care reform?” While Black men consistently said everyone in society benefits when all have access to good health care, White men repeatedly said that health care reform takes resources from White people to give more care to immigrants and people of color.

    Those views fundamentally influenced Metzl’s 2019 book, Dying of Whiteness: How the Politics of Racial Resentment Is Killing America’s Heartland. In it, the physician and sociologist explored how racial anxieties dampened enrollments in the ACA in Tennessee, fueled the repeal of gun control laws in Missouri, and spurred education and social services cuts in Kansas. As a result of these decisions, he contends, gun suicides and school dropouts among White people in those states rose, and their life expectancies fell.

    Metzl, director of the Department of Medicine, Health, and Society at Vanderbilt University in Tennessee, discussed his observations with AAMCNews several weeks ago. The interview has been edited and condensed for clarity.

    What do you mean by “Whiteness”?

    I don’t mean 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, bathed in a kind of nostalgia for imagined greatness that is very often racialized.

    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, get so powerful?

    You wrote that the destruction of the health infrastructure contributes to worse outcomes for White people who hold these views. How does racial resentment contribute to the destruction of the health infrastructure?

    On an ideal planet, people would want as much access as possible to a social safety net and to physicians. The way health insurance works and health infrastructure works, you want the most people involved in your network so that you can democratize risk and cost.

    When I was doing my research in Tennessee, the ACA was starting to take shape. In the first couple of months, before it became politicized, people would say, “This sounds great. Someone’s going to help me pay for my checkups or pay for my prescription drugs.” Everybody was for it. It didn’t matter what their politics were.

    Then came this relentless messaging that this is going to put the government in your private life, it’s going to take away privileges for you, it’s a handout to minorities. After months of that messaging, we would see people who had been totally for the ACA rejecting the program for these reasons. I met tons of people who actively, purposefully did not sign up for coverage, even when they were ill. The narrative about White replacement was so powerful that it caused people to reject a core human drive of health and longevity.

    You tell a story about one of those people, Trevor, an ill man who said he’d rather die than get ACA coverage. He died. What do health care workers take from a guy like Trevor?

    Here’s somebody who wasn’t willing to sign up for a program, even if we would help him, if it would also benefit immigrants and minorities. He was telling me, “I’m not signing up for a program if it will benefit people who I see as beneath me on the social hierarchy.” That ideology of not sharing, of worrying about profligate others, caused him to make decisions against his own health.

    He was on a social/political team whose power and authority depended on somebody like Trevor at the bottom of the social hierarchy denying something that would have been good for him. If somebody 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 the ACA and gun violence, it seems that having a discussion with them based on data alone wouldn’t be productive for either side. People in medicine say, “I provide data. I can show you the charts.” Why doesn’t that work?

    We’ve not realized that the narratives we tell about data really matter. Public health people who study guns say gun reform is common sense, that we need background checks and red flag laws. A background check means having your information tracked in a database when you buy a gun. And a red flag law means inviting the police and a judge to do an assessment about whether you can own it or not.

    If you’re in New York City, who cares? If you’re in a red state like Tennessee, the last thing you want is to have the government tracking your right to carry a weapon. Things that are common sense in one locality are not in the other. We haven’t done a good job of explaining data and molding it to the ideology of other people.

    Several times, you wrote that you weren’t accusing these people of being racist. Should we acknowledge that racism plays a role?

    My research does not aim to discern individual racism. What I saw when I was talking to poor people was that part of the reason that their racism, quote-unquote, was coming out was that they were part of a political party that was draining their resources and giving the money that would have gone toward their education, their safety, their health care, toward tax cuts for wealthy people and corporations. It was all going out the window. There were so many structural drivers.

    If we just say people need more individual sensitivity or anti-racism training, without fixing the bigger upstream structural drivers 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’re not accusing them of being duped. But they are supporting policies that hurt them.

    If your life goal is to outlaw abortion and have Second Amendment rights, then you’re willing to do whatever it takes. I think health care is important, but a lot of people I met thought that outlawing abortion was much more important. My value system wasn’t the same as theirs. It’s important to see what their value system is.

    Why is what we’re talking about a Whiteness thing? A lot of people of color support the Republican party and some of the polices and decisions you write about.

    Many people who support Democratic policies made an assumption that racial identity casts ideology, and that’s to the peril of the Democrats. There are a lot of Black Americans who are not African American. There are a lot of Latino Americans who are Cuban. To our peril, we correlate skin color with ideology. Also, people have leveled fair critiques of Democratic policies about finance, health, and safety in ways that resonate.

    If these policy decisions about health care and gun safety are hurting some White people, aren’t they hurting people of color even more, considering the health disparities between racial and ethnic groups in the United States?

    Minority and immigrant communities suffer greatly and needlessly from these policies. My data makes this painfully clear. But the data I track reveals the shocking extent to which the health and well-being of White Americans suffered from the health effects of these policies as well. Such effects played out in public ways, such as when White concertgoers died in high-profile mass shootings linked to gun policies — or lack thereof — enacted by conservative White politicians. Other effects were far less obvious, such as the long-term implications of blocking health care reform or defunding schools and health infrastructure.

    So I ask, why do White Americans support this suffering? Why do they, in effect, choose it? Writer Toni Morrison stated the inherent conflict of this notion of American Whiteness bluntly: 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 bullet points of solutions. 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 were first conceptualizing the ACA, there was an idea that they would have whole communities get tax breaks if the community would lower their systolic blood pressure, lower blood sugar, lower emergency room visits, create more bike lanes, all these other health metrics. It rewarded people for working together across tribal lines. People would be able to see the benefit of collaborating toward mutual health goals.

    Of course, that was one of the first things that got thrown out the window.

    Think about it: Can we have people seeing and being rewarded for that kind of benefit? Think about ways that structures can reward people for working together toward common health goals.

    Trying to change people’s minds is exhausting and impossible. It’s much better to change structures in ways that reward cooperation.

    Keep the conversation going

    Discuss this session and more while networking with your peers in academic medicine during, and long after, Learn Serve Lead, by joining the AAMC’s virtual community. More than 3,000 of your peers are already there!