CHAPTER 3 Systemic Racism

The situation was desperate. People were dying at home for fear of going to the health centers, which were full of people sprawled on the floor, waiting for beds. “We saw entire families decimated by Covid,” Marcos Antônio dos Santos Junior told me, recalling how the first wave of Brazil’s Covid-19 epidemic in 2020 tore through his community in southeast Brazil.

Marcos lives in São João de Meriti, a city on the outskirts of Rio de Janeiro, which has earned the nickname “formigueiro das Américas” or “anthill of the Americas” because it has one of the highest population densities of any city in Latin America. Like most other cities of the Baixada Fluminensepart of the wider Rio de Janeiro metropolitan areait is also known as a dormitory city, according to Marcos, with many inhabitants commuting to the center of Rio de Janeiro to work during the day and then returning to São João de Meriti to sleep at night. He told me that although he loves his home city, he recognizes that it has “great needs,” particularly when it comes to health.

Brazil has a system of free, universal health care, but its public hospitals are badly underfunded. The situation is especially dire in low-income suburbs, favelas, and cities, including São João de Meriti, where populations are disproportionately “preto,” meaning Black, and “pardo,” meaning Brown or Mixed with African ancestry. According to Brazil’s 2010 census, its most recent one at the time of writing, about 63 percent of the population of São João de Meriti self-identified as Black or Mixed, in comparison to 48 percent in neighboring Rio de Janeiro. Black and Mixed Brazilians are also more likely than White Brazilians to rely exclusively on the public health care system, because of economic barriers in accessing private health insurance. Marcos, who identifies as Black, pointed to this as one of several examples of systemic racism, which he believes is the main driving force behind differences in health along racial lines in Brazil.93

“There are very poor neighborhoods in São João, people who are below the poverty line and have no help from the public authorities,” he explained. “Unfortunately, to have access to quality services, it is necessary to move from our city to the capital, and, even then, it is often necessary to have good financial conditions to achieve rights that should be offered by the public authorities,” he said. “When I look around, I am aware that being Black here in Brazil is very difficult.”

Marcos and I began corresponding in November 2021, with the help of online translation software (I don’t speak much Portuguese and he doesn’t speak much English). He told me about his family, before describing the pain and loss they endured when Covid-19 first reached their city the previous year. “I had the privilege of having a father who was a refrigeration mechanic, and the company that my father worked for provided health insurance, which contributed a lot to my health,” he said. “I trained as a mechanic and also managed to work in a company, which provided health insurance, even though it was not my dream job,” he added. But Marcos explained that being Black in Brazil feels like having the odds stacked against you. Even if a White person and a Black person are of equal social class, the Black person will certainly have more difficulty in achieving their goals, he told me. “With me and my family it was no different, we needed to fight a lot to have our basic needs met,” he said.

When Covid-19 hit São João de Meriti, Marcos felt he had little choice but to continue commuting to work each day in crowded public transportation, all the while praying to God to keep him and his family safe. After all, his job was what allowed him to take care of his and his family’s health. But a preexisting heart problem left his father, in his late sixties at the time, particularly vulnerable to the virus.94

“I lost my father to Covid,” said Marcos. “It was very difficult for us, because it was not even possible to say goodbye and have a dignified funeral,” he told me. At the same time, Covid-19 deaths in the wider community were mounting. “All the time we received news of death from neighbors and friends,” remembered Marcos. Hospitals and health centers in the city were overwhelmed with patients, forcing many people to travel to Rio de Janeiro in search of urgently needed care.

In May 2020, a report by nonprofit investigative news agency Pública revealed that neighborhoods of Rio de Janeiro and São Paulo with majority Black residents were experiencing more Covid-19 deaths in comparison with Whiter neighborhoods. Subsequent research has confirmed that Black and Mixed Brazilians who were admitted to the hospital with Covid-19 during the first months of Brazil’s epidemic lost their lives at a significantly higher rate than White Brazilians. “This pattern is explained by social inequalities and prejudice,” said Marcos. “I think there is a difference in health between racial groups, due to institutional racism here in Brazil.”95

Institutional racism, structural racism, and systemic racism are terms often used interchangeably to refer to the ways in which racism is deeply entrenched within the systems, structures, and institutions that underpin societies across the globe. More important than what we choose to label this form of oppression (I personally tend to call it systemic racism) are its devastating consequences on health.

Systemic racism is what is happening when Black Brazilians like Marcos encounter additional barriers to accessing quality health care that their White Brazilian counterparts don’t. It is also what is happening when, as we’ve seen, maternity wards are disproportionately closed in Black neighborhoods in the US, or when Māori women in New Zealand face additional barriers in accessing culturally safe cervical cancer screening. Importantly, though, it is also what is happening before people reach the point of even needing to access health care. It is the added challenges that many people belonging to marginalized racial and ethnic groups globally face in attempting to lead healthy day-to-day livesin accessing clean air to breathe, uncontaminated water to drink, nutritious foods to eat, and safe spaces in which to exercise.

To understand how systemic racism harms health, it is helpful to remind ourselves of its origins. In Brazil, as Marcos put it: “There is an almost unpayable debt from three hundred years of slavery.”

Edna Maria de Araújo, a public health researcher at the State University of Feira de Santana in Brazil and a member of the Racism and Health Working Group from the Brazilian Association of Collective Health, agrees with Marcos and argues that to understand racial and ethnic inequalities in Brazil today, we need to consider the legacy left on the country by European colonization and transatlantic slavery. A 2020 research article by de Araújo and Kia Lilly Caldwell, a researcher in African, African American, and Diaspora studies at the University of North Carolina at Chapel Hill, among other academics, examined data showing vast racial and ethnic disparities in Covid-19 outcomes in both researchers’ base countriesBrazil and the USand pointed toward commonalities between the two nations that could explain these patterns of inequality. The researchers highlighted the fact that Black (and, in Brazil, Brown or Mixed) people in particular, the majority of whom are the descendants of enslaved Africans in both Brazil and the US, were also disproportionately impacted by the pandemic in both countries. Indeed, this chapter in human history contributed significantly to the systemic racism and health inequities that persist in many countries globally to this day.96

Of the estimated eleven million enslaved Africans transported to the Americas between the sixteenth and nineteenth centuries, it is thought that about five million were brought to Brazil: more than any other single country. The Portuguese were the first to make the transatlantic journey in the late 1400s, transporting enslaved humans bought from slave traders in West Africa across the ocean to Brazil. I remember learning about this history as a child during a visit to Ghana, where my maternal and paternal grandmothers were from and where my father grew up. My parents had taken my sister and me to visit Elmina Castle, a formidable structure erected on the Ghanaian coast by the Portuguese in the late fifteenth century, which became a major location for holding enslaved people captured from different parts of West Africa during the transatlantic trade. Our tour guide told us about the horrendous conditions in which people were kept there and the inhumane ways in which they were treated, before being packed into ships as cargo and destined to either die a horrific death at sea or to continue life in the Americas as someone’s property. We learned also how Elmina Castle was taken over by the Dutch in the 1600s and then ceded to the British in the 1800s, both also major slave trading nations.

My sister and I could feel that we were the product of all of these histories: our parents are both half Ghanaian, we grew up in the Netherlands, we have British nationality, and we are both the descendants of enslaved Africans through our paternal grandfather, who was from Dominica, a small Caribbean island nation south of Guadeloupe. Our surname, Liverpool, suggests that our enslaved ancestor was transported from Africa to the Americas by the British via the port of Liverpool, which was a major slave trading port in the UK. It would take both of us a lot longer to fully appreciate the continuing legacy of these histories in our modern world.

As de Araújo and Caldwell illustrate in their research article, this legacy is very much connected to the disproportionate impact of Covid-19 on Black people observed in both Brazil and the US. Brazil became the last country in the western Hemisphere to abolish slavery in 1888, and although the country never had a legalized system of racism directly equivalent to the Jim Crow laws that enforced racial segregation in the US, employment discrimination and residential segregation have consistently limited opportunities for Black and Mixed Brazilians. This systemic racism continues to impact people today; the average income of Black and Mixed Brazilians remains about half that of White Brazilians, not entirely dissimilar from the picture in the US, where in 2019, Black men and women earned about 78 and 66 cents, respectively, for every dollar in average hourly wages earned by White men.97

Economic inequality like this also exists in many other countries around the world, including the UK, where people from British colonies and former colonies in Africa, the Caribbean, and Asia were encouraged by the government to immigrate in the mid-twentieth century to help boost the workforce in the aftermath of the Second World War. On arrival, these immigrants, among whom were my paternal grandparents, faced considerable racial discrimination, which was only made illegal in the UK in 1965a year after my father was born in London. This made it more difficult for “colored” people to get jobs and to find accommodation, contributing to economic inequality: in 1964, a Conservative MP was elected in the constituency of Smethwick in England after endorsing the (uncensored) slogan “If you want a n***** for a neighbour, vote Labour.” As in other countries, the legacy of this systemic racism can be felt in the UK to this day.

A report that examined rates of poverty in the UK prior to the Covid-19 pandemic found that 43 percent of Black households were in persistent poverty, compared with 19 percent of White households, for instance. And whether in the UK, the US, or Brazil, there is no doubt that being on low income is associated with worse health, including a higher prevalence of chronic health conditions that have been linked to poorer outcomes with Covid-19, such as cardiovascular disease and diabetes. Being on low income is also associated with reduced access to quality health care, particularly in the US, which is exceptional within the OECDan association of mostly wealthy countriesin not having a system of universal health care. But as the experiences of Marcos and so many others show, even in Brazil, which has a universal health care system, similar inequities in access to care are present.98

“Those with low socioeconomic status are those who have limited access to the public health system and are unable to pay for private health care,” de Araújo pointed out, recapitulating what Marcos told me. And in Brazil these people are disproportionately Black, she added. “We live in a country where racism is structural,” said de Araújo. “I think it is necessary to deconstruct racism through the implementation of public policies that aim to repair iniquities committed against the Black population, not only in the area of health, but in all areas,” she added.

Income inequality isn’t the only way that systemic racism manifests in today’s world, according to Darrick Hamilton, an economist at the New School in New York City. Hamilton is a prominent US policy adviser and a leading scholar in the field of stratification economics, which recognizes the importance of social hierarchies and structures in shaping people’s economic outcomes. He told me: “A lot of our conversations around economic security and well-being have focused on income. But over the last decade or so, there’s been a greater emphasis with regards to understanding perhaps a more paramount indicator of economic security: wealth.”

As with income, wealthwhich Hamilton defines succinctly as “the difference between what you own versus what you owe”is a strong predictor of overall health and well-being. “If you’re faced with some calamity that you didn’t anticipateyou lose your job, there’s a pandemicit is that nest egg of wealth that allows you to endure,” he said. Meanwhile, debtthe opposite of wealthhas been linked to higher perceived stress and depression, as well as poorer self-reported general health and higher blood pressure.99

Wealth, to an even greater extent than income, is unevenly distributed along racial and ethnic lines. In the US, for instance, the median Black or Latinx household has 10 or 12 cents in wealth, respectively, for every dollar owned by the median White household. This racial wealth gap, as Hamilton calls it, is a significant contributor to racial and ethnic disparities in health and may partly explain why racial health disparities often persist even after controlling for income.

“The racial wealth gap is an implicit indicator in economic terms of a long racist history in the United States that has really important contemporary implications,” he told me. “If we go back to the beginnings of the nation, it was a period in which Black people served literally as an asset for a White, land-owning plantation class,” he said. In the nation’s more recent past, racist practices since outlawedincluding redlining, a policy under which the Federal Housing Administration denied loans for housing in and near predominantly Black neighborhoods, and racial covenants, preventing non-White people from buying homes in certain neighborhoodshave deprived Black families of generational wealth.100

Hamilton suspects that this long-standing economic inequality contributes to worse health outcomes for Black people as well as other people of color, not only by fostering gaps in access to quality health care, but also by taking a direct toll on mind and body. “When we ask Black people to work twice as hard to overcome obstacles, that manifests in negative health. And what is pernicious and ironic, is that those who are perhaps social climbers in a relative sense, compared to White people, are predisposed to even greater health risks,” he said. As an example, he pointed to the Black-White gap in the rate of infant mortality, which is present among infants with mothers at all levels of educational attainment, and which is even wider among those whose mothers are educated to master’s degree level or higher. “When you find that a college-educated Black woman is more likely to suffer an infant death, if she’s expecting, than a White woman who dropped out of high school,” Hamilton continued, “then that’s not only suggestive of a disparity across race, but one where, as Black people move up in socioeconomic status, the comparative disparities across race actually rise,” he said.101

Writing this book forced me to rethink my understanding of how systemic racism harms health. Hamilton’s argument and the evidence he cited made me realize that the relationship between economic inequality and health is far more complicated than it might first appear. Like many people, I had previously always assumed that if a person could overcome the odds and improve their economic situation in spite of all the barriers that exist within our unequal worldincluding those resulting from systemic racismthen that person would reap all the benefits in the form of better health. After all, higher socioeconomic status is clearly associated with improvements in health within all racial and ethnic groups. But this assumption ignores the fact that overcoming the oddsparticularly overcoming systemic racismcan itself come at a cost to health.

“When we tell people to work twice as hard to get by, you’re asking somebody to be above average. You’re asking somebody to be supersomething that is above a norm,” said Hamilton. “Well, with any system, there’s costs to that.” This may partly explain why the health gains associated with increasing socioeconomic statusmeasured in Hamilton’s earlier example as the level of educational attainment among Black or White mothers in the UStend to be shallower for those most likely to be disadvantaged by systemic racism compared to those most likely to benefit from it.

There is another issue with my previous assumption: it accepts the premise that a person’s health should depend on their economic situation and puts the onus on the individual to improve their situation and their health. This might work if we lived in a world where everyone had equal access to opportunities and resources, but that clearly isn’t the case. And I think part of the reason I didn’t fully appreciate this earlier is because of my own privileged position.

I am fortunate to have had a very privileged upbringing. My parents immigrated to Europe in the 1980smy father from Ghana to the Netherlands, and my mother from Lebanon to the UK (my father was actually born in the UK, but his family moved back to Ghana when he was a baby and he grew up there). Both my parents went to university, and they worked hard to ensure that my sister and I had everything we needed and more so that we could achieve good grades in school and have access to more opportunities than they had. We were one of the only Black families in our neighborhood in the Hague, where I was born and raised, and my sister and I were one of few Black children at the elite, international school my parents forked out to send us to.

I think my parents both have what my sister and I now often jokingly refer to as “good immigrant syndrome.” They faced considerable racism in their lives, and they were desperate for themselvesand usto fit in, be accepted, and even thrive within the predominantly White environment we were living in. There was a sense that we had to be “above average,” as Hamilton put itwe had to be twice as good and work twice as hard, as if to compensate for our Blackness. I think this had a big influence on me. I took school extremely seriously as a teenager and achieved top grades in all my subjects. I was extremely motivated to go to university in the UK, like my mother had, and I received offers from four of the five universities I applied to there to study biomedical science.

My experience attending an elite, predominantly White school turned out to be ideal training for my life at university, where I was often one of the only Black students at the lectures I attended. I graduated with a First Class bachelor’s in Immunology and Infection from University College London, before moving to the University of Oxford, where I had been accepted into a highly competitive PhD program funded by the Wellcome Trust charitable foundation.

In order to fit into these various White, elite worlds, in both the Netherlands and the UK, I was forced to internalize negative ideas and stereotypes about Black people (I have since learned that this is a common experience among minoritized people in that positionjournalist Linda Villarosa describes going through something similar in her book Under the Skin). To make sense of these racist notions I had absorbed, I had to believe that my family and I were somehow exceptions. We “weren’t like other Black people,” as many of the White people around us frequently reassured us. Even when I experienced racism myself or when I was directly faced with the products of systemic racismsuch as the fact that just 1 percent of university professors in the UK are BlackI convinced myself that these were individual failures rather than systemic ones.102

The same faulty logic is often applied to racial and ethnic disparities in health, for instance with my earlier assumption that climbing the economic ladder against the odds would be sufficient to rescue Black people and other systemically marginalized people from poor health. This fails to recognize that our societies are fundamentally unequal in so many ways.

Covid-19 forced a greater reckoning with this inequality because it exposed the systemic nature of it so brutally. Consider Marcos in Brazil. At the height of the pandemic, Black and Mixed Brazilians like him were more exposed to the virus because they were less likely to be employed in jobs that could be done remotely and more likely to be commuting to work by public transport, like he was. The situation was similar in other countries including the US and UK, where Black people and other people of color were more likely to be working in jobs that were deemed essential during the pandemic and that couldn’t be done from home. Ironically, many of these so-called essential jobs were poorly compensated: a 2021 analysis in the US found that essential workers constituted almost half of all workers in lower-paid occupations. Being on a lower income is associated with poorer health and increased vulnerability to diseases like Covid-19, so this is a vicious circle. Andas we are about to discovereconomic inequality isn’t the only way in which systemic racism manifests and harms health.103


The first time Rosamund Kissi-Debrah noticed something was wrong with her daughter, Ella, was in October of 2010. Ella was seven at the time and it was half term, a school holiday. “We were doing the Great Fire of London at school and we went to see the Monument,” Rosamund told the BBC during an interview about a decade later. “Ella had a cold and she was climbing up the stairs. I remember her voice saying to me, ‘I can no longer climb,’ and me saying, as mothers do, ‘You’ve only got a cold, what’s stopping you?’ I still feel really bad about that,” she said. Ella managed to make it to the top, but she was exhausted during the train ride home and, uncharacteristically, fell into a deep sleep. Soon afterward she developed a strange-sounding cough, like that of a smoker, and within several weeks she had become so unwell that she had to be put into a medically induced coma.104

Over the next three years, Ella would be hospitalized almost thirty times after experiencing severe attacks of what was eventually diagnosed as a rare and complex form of asthma. “You know she was always fighting to breathe and it’s something I will never get over. Seeing your child chokethat’s how I call itconstantly, she used to collapse and stop breathing and then I’d have to resuscitate her and then she’d come back,” Rosamund recalled, during an interview in a 2020 BBC documentary. “She said to me, ‘I think I’m going to die,’ and my insides, literally, you know it’s like a vomiting feeling.” In February 2013, Ella did die, following a severe asthma attack. “I can’t believe how much she battled, but she suffered horrendously,” Rosamund said. “She was nine.”

In December 2020, following years of campaigning by Rosamund and others, a London court ruled that polluted air made a material contribution to Ella’s death, making her the first person in the UK to have air pollution listed as part of their cause of death. Ella and her family lived very close to the South Circular Road, one of the busiest highways in London. Her school was about a thirty-minute walk away, mostly along a pavement beside traffic. Crucial evidence in Ella’s case was a 2018 report by asthma and air pollution expert Stephen Holgate at the University of Southampton, which concluded that exposure to illegal levels of air pollution was a key driver of her asthma. Holgate had examined tissue samples taken from Ella’s body, as well as data from pollution sensors located close to her home near the South Circular Road. The official cause of Ella’s death was ruled as “died of asthma contributed to by exposure to excessive air pollution.” Coroner Philip Barlow added that inaction by authorities to reduce levels of nitrogen dioxide and a lack of information given to Ella’s mother both “possibly contributed to her death.”105

Following the verdict, Rosamund told my former colleague and mentor, journalist Adam Vaughan at New Scientist: “This is my daughter, this is what happened to her, and we have proved it.” During one of several conversations we had a year or so later, I asked Rosamund what she had been feeling in that moment. “I think relief, yes, sadness, probably sadness first. Also, the fact that she wasn’t here, because she always wanted to know what was wrong with her,” she trailed off. “It wasn’t going to bring her back,” said Rosamund. “But, for me, it gave me a sense of peace.”106

Rosamund is a remarkable human beingI have been in awe of her since the first time we spoke. Beyond the ruling on the cause of Ella’s death, she remains a tireless campaigner for clean air in London and beyond. She is extremely kind and patient, and she is absolutely determined to make the world a better place for her childrenElla’s twin siblingsand for future generations. “You need to strive for change, you need to strive for things being better. That’s why I do what I do,” she told me. “I do hope that it does impact the next generation of young people coming up, that my children who are in their teens will be able to have better air one day.” She is also extremely resilient. “You’ve caught me on a good day. I am ever hopeful,” she told me. “There are parents who’ve lost children, and they die very soon afterwards. It changes your whole life,” she said. “I am blessed. I have twins. And, yes, I have difficult days. But I do want to be here for them as long as possible.”

It is obvious that Rosamund loves her children dearly and her face lights up whenever she shares memories about Ella. During one of our conversations, I asked her how she thinks Ella would want to be remembered. “That’s really easy,” she replied. “She would want people to know how kind she was, how much she loved her friends and her family,” Rosamund told me. Ella was an “all-rounder,” she said. She was very good in school and continued with schoolwork sent by her teachers even while she was in the hospital. She was also talented at sports, said Rosamund. “Not being able to breathe was the biggest challenge for her. But most things she found quite easy,” she explained. “She was very good at cycling, she was very good at swimming, she was very good at football,” said Rosamund. “But definitely, she considered all the other things she was doing as passing timeher ultimate ambition was to be a pilot.” Rosamund’s eyes brightened as she recalled taking Ella and her siblings on a trip to Bournemouth to see the Red Arrowsthe UK’s Royal Air Force aerobatics display teama few years before Ella passed away. “At the time I thought, oh Lord, we’re from Lewisham, in Bournemouth, and we were like practically the only Black family there on the beach, as you can imagine,” she said, and we both laughed.

“Because of her obsession, we’d left home really early to come to Bournemouth, so she can watch the Red Arrows for bloody ten minutes,” Rosamund said with a chuckle. “It became an annual thing, to go and see the Red Arrows.” Ella absolutely loved it; she was determined to get her asthma under control so that her health wouldn’t interfere with her dream of one day becoming a pilot. “They’ve dedicated an airfield and a plane to herand it’s to encourage children from backgrounds like her to become things like pilots,” Rosamund told me proudly. “If she was here, she would really like that.”

Ella isn’t here, thoughand her tragic experience is unfortunately part of a much wider problem. One UK analysis found that Black children and adults were about twice as likely to be admitted to the hospital for asthma as their White counterparts, while the risk among South Asian children and adults was almost three times higher. In London, where Ella lived, a 2016 study for the mayor found that people from Black ethnic groups accounted for 15 percent of all Londoners exposed to nitrogen dioxide levels that breach European Union limits, despite making up just 13 percent of the city’s population at the time. Ella’s mother, Rosamund, and I spoke about these inequalities during a conversation the day after what would have been Ella’s eighteenth birthday.107

“Lewisham has one of the highest asthma rates in London,” said Rosamund. She and Ella’s siblings still live in the same house in Lewisham in south-east London. “That is one of the criticisms of me, that why don’t I move?” she told me. “Number one, I can’t afford itbut that’s not even the point,” said Rosamund. “Also, when you move to these more exclusive areas to do with clean air, the [ethnic] diversity is less,” she pointed out. “Look, if I want to go and buy plantain and yam, I just go down the road. I take it for granted. If I want to go and buy kenkey [a West African dish] or anything, I just go down to Catford. I don’t think people get that, but anyway. And also, my friends are heremy friends who have supported me through this whole thing, they are here,” she said. I could very much relate, especially as a child of Ghanaian immigrant parents and as a general plantain lover, but alsomore importantlysimply as a human being: the suggestion that people should leave their homes and communities to escape from dirty air is not only nonsensical (where will we all go, once we’ve polluted all the air?), it is also racist.

Black people and other people of color are disproportionately exposed to air pollution, not just in London, but across England. A 2022 analysis by Friends of the Earth, an international environmental campaigning network, found that people of color in England are three times more likely to live in a very highly polluted area than White people. Very highly polluted areas are also more likely to be deprived, suggesting that those who are the most likely to be exposed to the highest levels of pollutants are also the least likely to be able to afford to move elsewhere.108

“In order to be able to pick and choose where you live, you need to be earning and how many of us are in that situation?” Rosamund pointed out during our discussion. “There is a [less polluted] area near-ish, if we had money, I’d like to move to. It’s way above our budgetway, way, way abovebut it’s not too far from here. But we are not in that income bracket. God, hell no, we’re not,” she said.

The inequities in air pollution exposure that cost Rosamund and her family so dearly in the UK are mirrored on the other side of the Atlantic, as well as in many other countries around the world. “Environmental racism isn’t something that has been linked to the UK much, but it is here,” said Rosamund. “When I looked into environmental racism in the States, oh my god, it’s even worse,” she told me.

Indeed, a 2019 study in the US found that Black and Hispanic people were on average more exposed to air polluted with PM2.5particulate matter less than 0.0025 millimeters acrosscompared to White people, despite generally contributing less to air pollution. The prevalence of asthma is also higher among Black people in the US compared to White people. According to the US Office of Minority Health, non-Hispanic Black people died from asthma-related causes at nearly three times the rate of non-Hispanic White people in 2020. The disparity is larger for children, among whom asthma is generally more common than among adults: non-Hispanic Black children were about five times more likely to be admitted to the hospital for asthma compared to non-Hispanic White children in 2019, for instance.109

Climate change is exacerbating these sorts of racial and ethnic health gaps, according to Yoshira Ornelas Van Horne, an environmental health researcher and justice advocate who was previously based at the University of Southern California but has since moved to Columbia University. Ornelas Van Horne’s research is focused on addressing unequal exposures to harmful contaminants that affect structurally marginalized communitiessomething she understands intimately. “I grew up in a community, you know, Phoenix [Arizona], west side Phoenix, and it’s kind of one of those communities that is labeled by academia as being an environmental justice community. So, one that lacks access to trees, green spaces. It’s now divided by a freeway, which, in terms of asthma, living near freeways is one of those things that contributes to worse respiratory health outcomes,” she told me. “For me, I think just seeing that community and other ones that I could relate to having to bear the brunt of environmental contamination is what really drove me to pursue this research,” she said.

I reached out to Ornelas Van Horne after hearing her speak about her wide-ranging research on a podcast produced by Agents for Change in Environmental Justice, an organization at which she serves as assistant director for curriculum development. She told me about research she had been involved in, examining the health effects of “playa dust”wind-blown particulate matterin an area of southern California. The area, Imperial Valley, has a majority Hispanic and predominantly Mexican American population, and is located near a salt lake called the Salton Sea. The lake was formed in 1905, when heavy rain and snowmelt caused the nearby Colorado River to swell and flood the area. It has since been sustained by runoff from farms close by. But this source of sustenance is shrinking due to growing water scarcityand so is the Salton Sea.110

“What we’ve seen is that this lake has been drying upand that’s led to the uncovering of what we call the playa dust,” Ornelas Van Horne told me. “Playa is the Spanish word for beach,” she clarified. “There’s a lot of dust that occurs in this area, because it’s also a very desert-prone area, so what we’ve seen is that there’s been a lot of community anecdotes that they’re not able to go outside when these high winds are going on, because it’s affecting the health of them and their children,” she said.

To examine these health effects more closely, Ornelas Van Horne and her colleagues surveyed 456 parents of elementary school children in the area about their children’s symptoms and compared this with the children’s estimated exposure to particulate matter air pollution using data from regional environmental monitors. “We’ve actually found that in this community, they have about 22 percent prevalence of asthma, which is extremely high,” she said. “It’s one of the highest in California.” These findings are consistent with earlier research, which has shown that rates of asthma-related emergency visits among children in Imperial Valley are double the state average. In their preliminary study, Ornelas Van Horne and her colleagues also found an association between increases in particulate matter air pollution in the environment and increases in reports of respiratory symptoms, such as wheezing, as well as use of asthma medication among the children. “Really our hunch is that there’s something in the immediate environment that’s contributing to their symptoms,” she told me. “And so, we’re really trying to investigate, what is it about this dust? I’m particularly looking at pesticides,” she said.111

Replenishment of the Salton Sea over the years with runoff from nearby farms means the lake bed contains lots of pesticides, in addition to other potentially toxic substances in the sediment, including metals such as lead and arsenicall of which can become mobilized as dust when wind blows over dried-up areas of the lake bed. Globally, environmental injustices like this are likely to become more pronounced as the planet warms, warned Ornelas Van Horne.112

As climate change drives changes in land use and diminishes water resources, the production of wind-blown dust and dust storms is expected to accelerate. India, which experiences regular dust storms, is already seeing rises in the severity and frequency of these extreme weather events. In 2018, northern India was hit by three severe dust storms in a row, which were found to be associated with increases in particulate matter concentrations. Air pollution levels in India are already among the highest in the world and there are also vast inequalities in exposure within the country. Districts with higher percentages of people belonging to traditionally marginalized caste groups have been found to have higher average PM2.5 concentrations, for instance.113

Environmental racism is everywhereanother insidious manifestation of the systemic racism that harms the health of people belonging to marginalized racial and ethnic groups around the world. This is not a new phenomenon. In fact the term “environmental racism” originated in the US in the late twentieth century, coined by civil rights leader Benjamin Chavis. A landmark report published in 1987 by the United Church of Christ Commission for Racial Justice revealed that race was the most significant predictor of a person living near hazardous waste, and in 1990, sociologist Robert Bullard’s book Dumping in Dixie linked the siting of hazardous waste facilities with historical patterns of segregation in the southern US. The report and Bullard’s book are often cited as part of the beginning of the country’s environmental justice movement and, unfortunately, their findings are just as relevant today as they were when they were first published; more recent analyses have identified similar associations between race and the location of hazardous waste sites in the US.114

In addition to pollutants in the air people breathe, there are also racial and ethnic inequities when it comes to exposure to other environmental pollutants and contaminants. A 2019 report showed that communities of color in the US experience higher than average rates of drinking water violations, where drinking water fails to meet legal safety standards. This disparity is exemplified by severe water crises in Flint, Michigan, and Jackson, Mississippi, two cities with majority Black populations.115

In Flint, for example, residents were exposed to lead and other contaminants in drinking water after the city switched its water supply from Detroit-supplied Lake Huron water to drawing water from the Flint River in 2014. The effect on residents’ health was visible in a study conducted around the same time; it found that within the Flint area, the incidence of elevated blood lead levels among children under five increased following the switch. It is worth pointing out here that there is no safe level of lead exposure and that young children are particularly vulnerable to lead poisoning, which can cause permanent damage to the brain and central nervous system. Poor Black children are especially at risk; one study found that across the US, Black children living below the poverty line were four times as likely to have elevated levels of lead in their blood compared to White children living in poverty.116

But all this just begins to scrape the surface of the relationship between race, environment, and health. More than six hundred miles south of Flint there is a region along the Mississippi River in Louisiana that houses more than a hundred oil refineries, plastics plants, and chemical facilities; it has earned the nickname “Cancer Alley” as a result of the health issues experienced by its mainly Black residents. In 2021, a team of independent UN human rights experts described the situation as “environmental racism” and called for plans to further industrialize the region to be called off.117

To take another example: historical hard-rock mining in the western part of the US left a legacy of more than 160,000 abandoned mines, which are, for the most part, on the lands of Indigenous peoplesand there is evidence that Native American populations living near abandoned uranium mines experience elevated risks of kidney disease and hypertension. Ornelas Van Horne was part of a team of researchers who investigated the health impacts associated with the accidental discharge in 2015 of three million gallons of acid mine drainage from the Gold King Mine near Silverton, Colorado, into Cement Creek, a tributary to the Animas and San Juan rivers. The nasty-looking, yellowish-brown liquid began spilling out on August 5 when a crew contracted by the Environmental Protection Agency to inspect the mine inadvertently disturbed a layer of rock and dirt that had been sealing its opening. A risk assessment conducted by the EPA, which considered a recreational scenario for hikers, concluded that continuous exposure to sediments through a daily water intake of a half gallon per day from the river would be unlikely to cause adverse effects over an extended time period. But according to Ornelas Van Horne, this risk assessment failed to consider the intimate interaction that local Indigenous populations, including the Diné or Navajo people, have with the San Juan River.118

“The community were really the ones that helped us formulate our research, because they were like, ‘Well, I use this river for way more things than just hiking, like, my children, we pray with this water, we irrigate with this water,’ ” Ornelas Van Horne told me. To address this oversight, in the summer of 2016 she teamed up with local community members and researchers at the Diné Environmental Institute, the Navajo Nation Department of Health, and the University of Arizona to conduct several focus groups, as well as a survey of 63 adults and 27 children living in three Navajo communities along the river. Together they identified 43 unique activities between the Diné and San Juan River and demonstrated that since the Gold King Mine Spill, the average number of activities each person in the survey reported engaging in had fallen by 56 percent. This was associated with considerable trauma for community members.

“A lot of them brought up these themes of historical traumathis isn’t the first time that something like this has happened; there had been a previous river spill decades before that nobody came to help them with, their community has been impacted by the mining industry for decades. Not to mention, they consider really the first trauma to be that of colonization,” said Ornelas Van Horne. “They perceive the spill to be extremely detrimental to their health and to cause a lot of anxiety and worries about the future, because a lot of them didn’t know how they were going to explain this to their children, or if they were going to be able to go back to doing their cultural activities, which they consider to be protective factors toward their health,” she added.

Taking into account all of the activities between the Diné and San Juan River, Ornelas Van Horne and her colleagues worked with the affected communities to develop a community-based risk assessment and to implement an environmental sampling protocol. “Overall, we did see that the levels of at least two contaminants that we were mainly concerned with, which were arsenic and lead, were below the [limits] that the Navajo Nation had for some of these activities,” Ornelas Van Horne told me. “This brings up a really good point of having communities set their own standards and be in charge of their own data,” she said. “What we advocate for the community is really building infrastructure, not just for the Navajo Nation, but other communities, to be able to do and have continued environmental monitoring.” This is important, as long-term uncertainties remain about the accumulation of contaminants in the San Juan Riveras well as about contamination from the thousands of other abandoned mines in the region and in other parts of the country. “There’s over ten thousand abandoned mines in that area alone,” Ornelas Van Horne pointed out. “We’re not really able to know the status of the other ones or how much contamination they may be polluting into that river or other ones, unless we’re actively monitoring for contaminants,” she said.

Similar instances of environmental racism can be found across the border in Canada. After a 2020 study found an association between long-term mercury exposure and premature mortality among people of the Grassy Narrows First Nation community, lawmakers voted to collect more data on the impact of environmental contaminants on racial and ethnic minority communities. The mercury was released into the community’s aquatic ecosystem from a chemical plant in the 1960s in what has been described as one of the worst environmental disasters in Canadian history. Meanwhile, in Ecuador, thousands of Indigenous peoples are still living with the health effects of contamination from an oil spill in April 2020, which contaminated the Coca and Napo riverskey sources of water and food for local communities.119

Environmental racism and inequity are also evident on a global scale. According to the WHO, outdoor air pollution caused an estimated three million premature deaths worldwide in 2012, with 88 percent of these deaths occurring in low- and middle-income countries, and the greatest number in the WHO Western Pacific and South-East Asia regions. And it is no secret that countries in the global south, including large populations of color, are more likely to experience the impacts of climate changeincluding health effects.120

The environments we live in have an enormous impact on our ability to live healthy lives. This fact was glaringly obvious to Marcos, when he reflected again on the challenges facing his and other communities on the periphery of Rio de Janeiro in Brazil. “We need basic sanitation,” he told me. “Many communities and peripheral neighborhoods do not have access to this.” Poor sanitation is linked to poor health through increased transmission of infections. A 2021 study in Brazil suggested a possible relationship between poor basic sanitation and Covid-19 cases, for instance. That study didn’t include analysis of data on race or ethnicity but research from other countries strongly suggests that inequalities in people’s living environments contributed to racial and ethnic disparities in disease and death during the pandemic. In the UK, household overcrowding was associated with increased Covid-19 risk among ethnic minority groups, for example. And studies in the UK and US have pointed to increased air pollution exposure as a contributor to more severe Covid-19 and more deaths from the disease among marginalized racial and ethnic groups.121


The more we unravel the economic and environmental impacts of systemic racism across societies, the less surprising racial and ethnic health gaps become. We have already examined racial and ethnic disparities associated with several illnesses, including the world’s biggest killercardiovascular diseasea person’s risk of which is strongly influenced by their diet and physical activity level. But overlapping economic and environmental inequalities influenced by systemic racism mean that not everyone has equal access to an environment with affordable, healthy food, or to safe, green space with clean air in which they can exercise.

In several countries, including the UK, the US, and Brazil, there’s evidence that people belonging to marginalized racial and ethnic groups and people on low incomes are more likely to live in so-called food deserts, areas with little or no access to healthy food, or in food swamps, where unhealthy food options dominate over healthy ones. Living in unhealthy food environments has been linked to obesity, which is a major risk factor for cardiovascular disease among other health conditionsand there’s evidence that rates of obesity are higher than average among Black and Hispanic people in the US and among Black people in the UK, for instance.122

There are similar inequalities when it comes to access to green spaces, which provide places for people to exercise or to just spend time in nature, with vast physical and mental health benefits. I have been an avid jogger since living in Oxford, in southeast England, where I was lucky to have access to lots of beautiful running routes in my immediate surroundings. Yet across England, there’s evidence that areas with high proportions of Black and other ethnic minority residents tend to have fewer green spaces, compared with Whiter areas. According to a 2010 report by the UK’s Commission for Architecture and the Built Environment, since merged into the Design Council, areas where fewer than 2 percent of residents are “Black and minority ethnic” have six times as many parks on average than areas where ethnic minority groups account for more than 40 percent of residents.123

In countries, including the UK, the US, and Brazil, where Black people (and Black men in particular) are often overly policed and more likely to be the victims of violent crime, concern about safety is another factor that can discourage people from exercising outdoors. The murder of Ahmaud Arbery, a twenty-five-year-old Black jogger, in a racially motivated hate crime in 2020 illustrates why. Ahmaud was followed by three White menfather and son, Gregory and Travis McMichael, and their neighbor, William Bryanbefore being cornered and fatally shot, as he jogged through a predominantly White neighborhood in Georgia. A 2017 study in the US found that middle-class Black men living in majority White neighborhoods tend to exercise at lower rates than those who live in majority Black or racially diverse neighborhoods. This is despite the fact that majority White neighborhoods tend to have more facilities for leisure-time physical activity and more green and walkable spaces in comparison with Black neighborhoods, the study notes. Marcos highlighted similar concerns around safety in his neighborhood in São João de Meriti, Brazil, during our correspondence. He mentioned that children in his neighborhood don’t feel completely free when they play soccer outside, because of fears about violence. Research in Brazil has found that Black people are more likely to be the victims of homicide, in comparison with people belonging to other racial and ethnic groups.124

Marcos and his wife, Élida, have taken an active role in supporting members of their community to participate in sports and eat healthy diets. In 2014, they launched “Projeto Inclusão”’ or the Inclusion Project, to provide educational support to local teenagers having difficulties in school; during the pandemic, they expanded the project’s outputs, for instance, helping to provide food to struggling families in their community. The project has since grown even further. “Today in the project we conduct sports activities, education, arts, vocational courses and encourage preventive medicine through healthy eating, because we know our reality, so we encourage the population that taking care of health is better than taking care of disease,” Marcos told me. While efforts like the Inclusion Project are extremely commendable, on their own they cannot undo the centuries of systemic racism and inequality that have contributed to worse health for Black people and other people of color in many parts of the world. Governments globally must do more to ensure everyone has access to the resources needed to live a healthy life, by addressing systemic racism in all its forms.

The story doesn’t end here though, because in addition to the systemic forms of racism in societies we discussed so far, other forms of racismfrom chronic daily discrimination to acute racial traumaalso contribute to racial and ethnic inequities in health and well-being. So I decided to delve into the latest research examining the health harms of these more interpersonal forms of racismand ask whether and how these harms might be transmitted intergenerationally.