As I write this in the long lockdown summer of 2020 in London, little seems more routine than scrolling through my social media feed. For months, my feed seemed to be all COVID-19, all the time—at first a jumble of frantically shared, haphazardly assessed epidemiological reports, interspersed with personal stories of friends’ struggles in lockdown and fears of getting sick or transmitting illness, and later increasingly expressions of mounting frustration at political leaders for their poor management of the crisis and talk of the U.S. elections ahead. Yet occasionally, events of a different tenor joined the feed: outrageous murders of Black people—the vigilante killing of jogger Ahmaud Arbery in Georgia in February, the video of which was released in May; the police killing of Breonna Taylor in her own Kentucky home as she slept in March; and especially the police murder of George Floyd in May, caught on video, a white police officer constraining him with a knee on his neck, other officers standing by, as Floyd pleaded, “I can’t breathe.”
The sharing of outrage over these specific events marked a return to and intensification of a pervasive element of social media before the novel coronavirus crisis: accounts of harassment and violence against racialized minorities, especially Black people. And the events keep coming—unexplained murders of Black trans women, white women calling the police on Black people for minor or nonexistent infractions, and killings of unarmed Black people by police and vigilantes. As Black Lives Matter activists have highlighted, these are examples of phenomena that are absolutely routine. These events should provoke our outrage precisely because they are all too ordinary.
These events deserve sustained attention. Unpacking their specificities can reveal a great deal about the particular interlocking structures that shape our unequal world. A fundamental contention of this book has been that our analysis should begin with the outrage at these events and their ubiquity; it should not end there. We need to go beyond holding such events up as fundamentally interchangeable examples of a world gone wrong.
There is value in sitting a little longer than a news cycle with the events that spur these moments of outrage. Stories of suffering can be so much cacophony in our social media feeds and in our collective consciousness. Amid the scrolling, poignant accounts of racism and other forms of oppression can and should spur outrage, and also insight. To be analytically meaningful, individual experiences cannot and should not be isolated from the social structure in which they emerge. A story isolated from its context is at best an anecdote. By itself, no small experience or event that I describe is convincing proof of the structure at work. An individual story can illustrate structural inequality, but broader social inquiry is necessary to demonstrate structural inequality. Moreover, what might seem like disparate events can and should be usefully read together. Deep engagement with past events can equip us analytically to confront current and future crises.
Each event described in this book has distinctive resonances with this time of COVID-19 and intensified anger over police violence. This book was largely written before the crisis of the novel coronavirus that causes COVID-19 and the contemporaneous global resurgence of the Black Lives Matter movement. Yet the book’s account can be helpful for beginning to grapple with both the racially disparate impact of the disease and the highly visible instances of police and vigilante violence that have spurred anger and activism. Here, I consider resonances between the cases that I have analyzed from the first two decades of the twenty-first century and the events of 2020 to offer an opportunity to reflect on events past, present, and future.
Sickening began with a chapter considering another moment of twinned crises in which Americans were initially figured as newly vulnerable and “all in this together” in the face of a global threat: the deaths of Black postal workers in the 2001 anthrax attacks very soon after the terrorist attacks of September 11. In a largely forgotten audio precursor to the viral videos that have been iconic of the Black Lives Matter era, one postal worker’s 911 call recorded shortly before he died provided an account of the structural and personally mediated racism that would lead to his death: a refusal by his governmental employers to acknowledge, address, or communicate about the dangers of (what we would now call) the “essential work” of sorting and delivering the mail, followed by inaction in the face of individual need by his health care provider, who failed to take his illness seriously. The sense that twenty-first-century terrorism was novel in terms of the scale with which it endangered Americans “at home” obscured the fact that it rendered particularly vulnerable those within the U.S. body politic who were never safe—not before 9/11, not after.
The focus of the second chapter was another crisis of American identity and unity: the racially disparate impact of Hurricane Katrina, in which the fissures in the body politic have been more widely recognized than they were in the wake of 9/11. The largely poor and Black population of New Orleans had been made acutely vulnerable by the governmental expectation that people would pursue safety on their own. The orders to evacuate the city in advance of the storm were impossible to follow for many who did not have access to either private cars or any other form of transportation, in a way that is evocative of the impossibility of following the COVID-era orders to “shelter in place” for those who must leave home to support their household’s basic needs. Criminalization of those who were either going about their lives or seeking help—gathering food from shuttered supermarkets, or those seeking shelter in the Superdome—resonates with police and vigilante violence that is so pervasive today. At the same time, media preoccupation with “looters” obscures structural violence. As in the current crisis, long-standing structurally induced heightened burdens of chronic diseases, such as cardiovascular disease and diabetes, made African Americans more vulnerable still to acute illness. Now, as then, the fragmented and inadequate U.S. health care system compounds the harms of baseline exclusions.
Mass incarceration was the focus of the third chapter, on the suspended sentences of the Scott sisters. Mass incarceration has been foregrounded in both of the twinned crises of the current moment as well: excessive imprisonment enacted through a structurally racist criminal justice system goes hand in hand with harms to the bodies of prisoners themselves. The racially disparate harm to health that mass incarceration instantiates is not new to this extraordinary time, and yet attention to the extraordinary can meaningfully illuminate the routine violence of prisons as institutions that contribute to the constitution of contemporary racialization and the denial of full citizenship. Prisons and jails have been sites of some of the largest coronavirus outbreaks, rendering people who are awaiting trial or who have been convicted of crimes, whether serious or trivial, particularly vulnerable to exposure. In a way that is similar to “essential workers” but even more heightened, prisoners are treated as disposable. Even when the illnesses and deaths are technically due to a disease, the source of the suffering should be located as the system. Calls for prison abolition have become increasingly urgent.
The fourth chapter highlights the stratification of environmental and infrastructural risk in the preferential treatment of General Motors’ machines over the population of Flint in that city’s infamous water crisis. This, too, is relevant in the current moment. For example, an extraordinary number of households in nearby Detroit have lacked access to running water because their services had been shut off for being behind on onerous water bill payments—and this human rights violation has extra impact in a pandemic, by making it impossible for people to follow hygiene guidance.1 More broadly, the austerity-induced scarcity of infrastructural capacity in particular places is too often taken for granted. Decades of disinvestment in public health infrastructure have created a terrain in which bodies are differentially vulnerable to heightened precarity. The Flint water crisis took place in the context of the imposition of emergency financial management, prioritizing bond holders over residents, which was bad for health generally and particularly bad for African Americans. As in postcolonial contexts in which structural adjustment policies have been imposed, prioritization of the financial sector over the survivability of people exemplifies biopolitical inequalities.
A primary focus of the fifth chapter, on the McKinney pool party incident, is police brutality as a mechanism by which segregation is enforced. The violent control of access to leisure has been a foregrounded element of this moment, in which we have been urged to “stay home” in unequal homes and socially distanced outdoor space has not been available to all. Another focus was the role of professional media in the civil rights movement and amateur social media today. The McKinney pool party case was a relatively early example of the kinds of viral videos that have catalyzed Black Lives Matter and have gained in importance since then. In a way that is both continuous and discontinuous with the way that images were created and distributed in the twentieth-century civil rights movement, amateur videographers and artists have generated and distributed images of police violence in their demands for justice.
The sixth chapter, on Serena Williams’s birth story, returns to the fundamental issue of denial of care that was highlighted in the first chapter. Black communities and individuals are hypersurveilled but inadequately cared for. The concept of “weathering,” invoked to understand the premature aging caused by living in a racist society that has impact on maternal health and birth outcomes, might also be evocative for understanding heightened Black vulnerability to COVID at younger ages. Self-advocacy is important but is also not enough, as health care providers all too often do not listen to or trust Black patients. In the mobilization of Williams’s story for reproductive justice advocacy, as in the mobilization of stories of COVID-19 and of police violence for Black Lives Matter, we can also see community strength and resilience in the contestation of oppression.
More broadly, each chapter highlights the vitality of biopolitical questions of racism and health disparities that are so urgent in the current moment—within the body politic, whose lives are fostered, and whose are not? Importantly, the ethical scope of this question must not be limited to the intensive care unit. Rationing of health care resources is not new to COVID times. If many people have become newly afraid of rationing, that is because they had scant prior awareness that there were already segments of the population who had routinely been left out of the allocation of care. I hope that this book also points to the need to move beyond “lifeboat ethics” in the coronavirus context and more generally.2 In coronavirus times, there has been more interest in discussing the allocation of mechanical ventilators than in questioning the conditions that made some bodies more vulnerable than others in the first place. We can and should decry the unequal provision of medical care, in crisis times and in ordinary times, and we should also illuminate how wide-ranging elements of the social world beyond health care settings contribute to the stratification of health and well-being.
There are many compelling cases of racism and health disparities beyond what I have been able to analyze here, and there will undoubtedly be more in the future. How might readers carry out a similar form of analysis in the face of social injustices that occur in different times and places? Here, I outline an activity along the lines of assignments that I have developed for my own undergraduate classrooms.3 This four-step template can be adapted for use in wide-ranging classroom contexts or engaged by readers to guide them in writing their own analyses.
Find a Micro Scale: Sometimes the intimate scale is already present in a case as it is disseminated in the media—there is an event that happened to a specific, named person, in a particular encounter at a particular moment in time. Thus, the micro scale might be a very specific first-person account, as here with the postal worker’s 911 call. Other times, however, the analyst will have to be creative to pick out and highlight a small element within a larger event—for example, the ability of General Motors to protect its engine plant during the Flint water crisis. In this scale, you might find a combination of institutionalized racism, personally mediated racism, and internalized racism.4
Find a Meso Scale: Attend to the surroundings of the event. What is the near context in which this event occurs, chronologically and socially? In what kind of space—neighborhood/city/region—does the event occur, and how does that matter? Who else is around, whether as participant or bystander? The meso scale might be a city or a suburb, an organization or a social sphere, each associated with particular health care systems and systems of social control. This scale will often reveal institutionalized racism.
Find a Macro Scale: Attend to the broader social and historical context of the event. How does it emerge out of trends in history and society in the United States (or other national context)? How does it participate in the political economy of the contemporary health care system and the entrenched biopolitical priorities that render some lives differentially disposable? How does it reflect major drivers of racial inequality, such as the structures of segregation, access to care, and exposure to harms? This scale is vital for attending to institutionalized racism.
Read Media Closely: Newspapers, magazines, and social media posts do more than present an account of an event; they shape stories and provide broader narratives. Attend not only to what they are saying but also to how they are saying it. What is assumed about the readers of the story, including their background assumptions, default sympathies, and emotional responses? Who is presented as the protagonist of the story, who is in the background, and who is rendered invisible? Whose interests are treated as urgent sites of concern? Whose conditions of privilege or deprivation are taken for granted and treated as the normal state of affairs? How are the people involved articulated as full members of the “American public” (or not)?
Read Materials from Activist Organizations: This overlaps with reading media broadly, since both mainstream and activist accounts are often featured in social media, blogs, and online magazines. But it is important to be intentional about finding sources that are explicitly engaged in advocating for justice. How are those who are mobilizing around the case framing what has happened, and to what ends?
Read Relevant Scholarship: Scholarly writing is invaluable for grappling in a rigorous way with history and broader social context. Scholarly writing is easy to identify: broadly, it is written by people who have academic affiliations—that is, their bylines will say their title (such as PhD student or professor) and institution (such as a university or research organization) rather than merely “writer”—and it cites its sources, including referring to what other scholars have said. Note: make sure that your reading includes work by Black scholars (this will come up again below).
Pay Attention to History: Look beyond the flash of the news cycle and search for ways in which the contemporary event emerges out of a history.5
Pay Attention to Infrastructure: How is the built environment contributing to the situation in which the event transpires? What about systems of distribution of goods and services?
Pay Attention to Technology: Some of the technologies that I have discussed are obviously medical—pharmaceuticals, especially. Yet many technologies that matter are not medical, ranging from pipes to swimming pools to cell phone cameras.
Pay Attention to Economic Context: Who is working, and how are they paid? Who is paying for things, how are they doing so, and who benefits? How does capitalism matter?
Pay Attention to Citizenship Claims: Who is in a position to make demands of the state and of other powerful institutions, including but not limited to medical institutions? How do they make those demands, and in the face of what resistance?
Pay Attention to Intersections: Race is not the only category of identity at stake in any particular experience or event. Pay attention to how race intersects with class, gender, age, disability, sexuality, and other systems of power.
Pay Attention to Voice: Whose stories are being represented in the dominant account? How might you seek out additional, less prominent perspectives?
Pay Attention to Knowledge: Start local: how have you come to know about the event? But also pay attention to the ways that knowledge matters in the event: whose knowledge is valued, whose is discounted, who is treated as an expert, who is believed at all, and how does it matter?
Pay Attention to Power: Who has it, and how is it used? Who doesn’t have it, and how does it matter?
Remember the Humanity: Sometimes the people whose stories are invoked become lost behind a slogan. Be sure to recount the stories with compassion. The system is brutal, but your treatment of the subjects should not be.
Remember Social Justice: Sometimes the story of the individual is so compelling that it makes it hard to see the terrain. Attending to individual human experiences of suffering is not an alternative to attending to structural oppression but a necessary complement to it. Moreover, analysis of racism should not simply be an intellectual exercise but should always be oriented toward justice.6
Cite Black Women: “Cite Black Women” is a hashtag and a website (http://www.citeblackwomen.org/), and it is also a call to practice.7 No matter what your own identity is, it is absolutely vital to read Black women’s media production and scholarship. If the event at the center of your analysis is about the experiences of another racialized group, such as Indigenous people or non-Black immigrants, also seek out scholarly and activist accounts by people who are members of that group. This does not mean that you must exclusively cite Black women and other scholars of color.8 But any account—especially but not only about topics like racism and health—will be hopelessly empty without engaging with what Black women have already written. Moreover, give credit to those Black women writers in your own account.
Although these steps are numbered 1–4, they are necessarily iterative. Reading will help to articulate scales for analysis, curiosity about additional layers of analysis will spur additional research, and the writing process is itself inextricable from the analysis. Working through the components once might get an analysis started, but creating a compelling account will require working through the stories and analytical frames multiple times over.
I have elaborated this analytical template with attention to racism and health in the contemporary United States in mind, but readers may also find it useful for analysis of other topics, times, and places. I have endeavored to make the components concrete enough to be feasibly realized as described, even as I offer them with the understanding and expectation that teachers and readers will make modifications for their own contexts, circumstances, and focal concerns.
The chapters of this book have provided examples of this template in action. My approach has involved attending to wide-ranging contexts and analyzing cases across scales. This book has looked at harms to health that have occurred across different domains: workplaces, communities, prisons, environments, leisure spaces, health care settings. Those harms have been diverse: infectious disease, chronic disease, kidney failure, lead poisoning, bodily constraint, maternal mortality. Their impacts have been borne on different scales as well: by individuals, their workplaces, communities, families, cities. I hope that my accounts of each event, and how the range of events work together, provide analytical insight into each of the particular instances and into the broader patterns of personally mediated and especially institutionalized racism. Different cases will spur distinctive lines of inquiry, and I hope that the diversity of my own examples is generative.
Analysis is important—it helps us to make sense of human experience and to understand the social world in which we live. Other forms of action matter too. It is beyond the scope of this book to describe precisely what actions readers should take to address the injustices analyzed here, but I hope that this book spurs curiosity to explore opportunities to get involved with such efforts. Moreover, I hope that the diversity of stories has helped to highlight the wide-ranging domains in which readers might take additional action.
The chapters have included many examples of people taking action against racism in health in wide-ranging ways. Some of the actions have taken place on an intimate, interpersonal scale of advocating and caring for family members and patients. Others have taken place in broader social spheres, raising awareness about injustice and demanding change. This has sometimes been undertaken by people acting individually and then amplifying their stories through social media: a teen with a cell phone camera recording police violence at a pool party, a celebrity recounting the barriers she faced accessing urgently needed medical care for complications of childbirth. Important work has also been done by groups of people in many kinds of organizations—the Association of Black Cardiologists advocating for victims of Hurricane Katrina; the Malcolm X Grassroots Movement and Black church groups mobilizing against the unjust incarceration of the Scott sisters; SisterSong Women of Color Reproductive Justice Collective working to empower Black women “to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”9
If you aren’t already involved, it can be hard to know where to begin, but if you start looking, you can find a point of entry. Get involved where you find yourself. If you are a student or an educator, look for groups working on these issues at your school, college, or university. Whether you are academically affiliated or not, look for groups in your neighborhood, city, and region as well. Reading and perhaps further reflection on your own experiences have, hopefully, equipped you with some baseline understanding, but as you get involved wherever you are, start by listening and learning from what is already going on, rather than just charging in. You likely will have something to contribute, but you won’t be able to know what that might be until you’ve listened to the ongoing conversations and seen the initiatives already under way.
There are many places to find these already existing endeavors. You might start with direct action groups, such as a Black Lives Matter chapter if you happen to have one in your city, or another group working for racial justice.10 Another good place to start is with local governance—start following local news, keeping an eye out for relevant issues on the docket of the city council or similar body, and show up when people are speaking at a hearing. Those speakers can alert you to organizations and initiatives with which you might connect. Other institutions, such as libraries and especially independent Black and feminist bookstores, also often provide entrees—look for events and meetings there, and attend them. Artistic and cultural events with political content, too, can be excellent starting points.
The opportunities for involvement will be different in each locality, but my experience in Atlanta might be illustrative. I started to find my political community there when meeting organizers at a workshop held at the MondoHomo queer music and arts festival. That led to participating in mobilization against a particular proposed law that would have intensified criminalization of street-level sex workers, which led to contributing to the development of the transformative organization Solutions Not Punishment.11 I also found and contributed to intersectional feminist community by serving on the board of the feminist bookstore Charis Books & More.12 Along the way, I worked with other faculty in support of antiracist and other social justice advocacy on my university campus. As this list illustrates, my preference is for the local—if you are more drawn to national politics, you can start by getting involved in national campaigns for candidates you believe in; if you are more drawn to global social movements, you can start by connecting with those. Many people find like-minded community with which to organize through social media—find out who to follow, and start to get involved.
There is also scope for action against racism in health within health care. Those who currently work in health fields—or are in the process of training to work in health fields—can challenge themselves to work against the medical system’s deeply ingrained biases against trusting Black patients in need. They can also work for transformation from within, such as physicians practicing “structural competency”13 or doulas supporting Black women in childbirth.14 Those working in medical fields also have a special role in advocacy against the structural inequalities in health care delivery—they can advocate for authentically universal access to care, both in theory and in practice—and for the diminishment of structural inequalities more broadly.15 Medical practitioners, including those in training, can also put their esteemed standing to use by taking part in direct action, through organizations such as White Coats for Black Lives.16
As each of the chapters of this book and the COVID-19 crisis have demonstrated, medical systems are one urgent site of change. Martin Luther King Jr.’s famous 1966 clarion call against segregation in health care remains resonant today: “of all the forms of inequality, injustice in health is the most shocking and inhuman.”17 King was talking about the harms of segregated hospitals, but throughout his life of advocacy, he highlighted the need for much broader transformation. All citizens, and indeed all residents, can also work for change in diverse domains.
The racially disparate impact of the coronavirus and the intensified mobilization against police and vigilante violence of 2020 have underscored the urgent need for transformation in and beyond health care. Health care institutions are urgent targets for action, but they are not the only ones. Health is more than a medical matter.18 Legal structures that privilege profit over people can be changed. Housing policies and structures that reinforce segregation can be redesigned. Police and prison systems can be made more accountable to public concern—or abolished. Another world is possible.