Public Health Reconsidered From A Different Perspective

Jonathan Metzl is a doctor, psychiatrist, professor and author of several well-received books. Right before the pandemic he wrote Dying of Whiteness: How the Politics of Racial Resentment is Killing America’s Heartland. The work garnered a great deal of attention and significant praise. It is a powerful study, drawing from several disciplines, and made all the more engaging because of Metzl’s personal perspective and involvement. Dying of Whiteness remains all the more relevant because the issues it explores, the analysis it proposes, and the questions it raises, which are central to understanding many current public health debates.

At Vanderbilt University, Metzl heads the Center for Medicine, Health, and Society. The Center’s mission is for its students “investigate the cultural, economic, demographic, and biological factors that affect health, as well as learn to think critically about complex social issues that impact health care and health policy.” Appreciating that interdisciplinary approach helps to appreciate Dying of Whiteness. Metzl gives great attention to the hows and why of people’s actions – and how we think about their choices, their health, their lives. Necessarily the work pulls from different disciplines. While Dying of Whiteness is nominally a book about public health in rural America, it is valuable and pertinent for those in education, politics, economics, policy, and other areas. Driving Metzl’s investigation is an attempt to understand why people advocate for policies that are not, literally, in their best interest.

Metzl sketches the book’s argument up front. First drawing from history, he identifies strands of conservative political movements in the South and Midwest that call for certain actions. These ideas might have been considered fringe fifty years ago but have since moved into mainstream thinking. They include proposals such as increasing access to guns and cutting the social safety net to promote self-reliance. Propelling these strands are themes of white resentment, closely connected to a belief that these policies would secure, if not advance, white privilege. The initiatives, Metzl argues, tap into long-standing historical beliefs (or perhaps more accurately, myths) of American exceptionalism and whiteness. It is a thread well-known to students of American historiography. Pulling the argument together, Metzl stresses how these policies have turned out to harm those that are defending them. Literally, they are killing people – often the white people who call for them. The book opens with a dying man complaining about Obamacare even though accepting the care could save his life. He dies. Metzl does not belittle the man’s choice. Rather, he tries to understand how and why people, such as this dying man, would put their lives at risk for policies that hurt them.

Dying of Whiteness examines three big-ticket policy issues: firearm access with research in Missouri, the Affordable Care Act and possible expansion of Medicare in Tennessee, and cutting taxes (and services) in Kansas. Interviews, research and data inform each of these sections. Metzl grew up in Kansas and Missouri, and he currently lives in Tennessee. He makes sure to stress that he is not an outsider to these states. He knows many people and communities, and that connection informs the research. It is shaped by his own experience. At bottom, Metzl’s work sheds valuable light on how and why certain policies might be received and understood by segments of the population, groups of people often talked about but rarely listened to.

The section on gun access in Missouri is heartbreaking. Research consistently reveals that suicide rates increase substantially when guns are readily available. Moreover, many suicides are the result of sudden impulses, with suicidal action taking place within five minutes of the initial ideation. Metzl, who is nationally known as an expert on gun violence, goes deep into the changes in policy in Missouri and the tragic outcomes. He talks with many different people about their relationship with guns, their thinking about guns, and how guns have been woven into personal, family and cultural history. Many Missourians, especially white ones, think of guns as a right and sign of agency. The data, though, indicates the ready access to firearms leads to many more people dying or being injured. Suicides, especially those of white men, are high on the tables of data. Families torn apart by suicide have a great deal of difficulty with the loss and how to make sense of it, if it is even possible. Of key interest to the book’s premise, statistical analysis reveals that while many more Missourians were harmed with the removal of gun controls, whites were negatively affected at a much greater rate than other racial groups. This in large part stems from the higher prevalence of guns in the homes of white Missourians.

Tennessee’s distrust of the ACA (the Affordable Care Act or Obamacare) and rejection of Medicaid expansion was led by GOP officials and white voters. This next section of the book looks at high level policy and health choices and options of individuals. The connections and consequences are not clearly understood or appreciated. Different groupings of people, too, see these issues differently. Interestingly, voters of color thought that an extended health care safety net made sense at a much higher degree than white Tennesseans. Metzl looks at Tennessee’s earlier attempts to provide better and more affordable healthcare (TennCare), the difficulties in maintaining funding for it, and the ways that funding discussions tapped into many Tennesseans’ concerns about government priorities. The questions were rendered in partisan language. White men had the least support for the ACA. Unsurprisingly, they tended to assert that health was mostly the result of individual choice. This aligns and supports Metzl’s bigger argument, that whiteness informs individual and group identity, as well as policy. What that meant for many in Tennessee (as well as other parts of the US) is that supporting all through healthcare was socialist or communist. Many think of it as “un-American.”

Tennessee’s decision came with great costs. When the state opted out of expanded Medicaid, the results were clear and quantifiable. Many lives were shortened and many preventable diseases and conditions increased. The state’s mortality rates increased across all racial groups. While the methodology is complicated, Metzl is patient and transparent, walking the reader through the numbers. And poorer white citizens of Tennessee suffered significantly.

Kansas governor Sam Brownback’s draconian cuts in taxes and social services is the focus of the final section. Brownback and Kansas GOP leaders claimed that deep cuts in all services would create new opportunities and tremendous growth for the state. It was a much heralded “revolution” of limited government that many Republicans believed would provide a new model for America. Instead, the Kansas experiment resulted in increased inequities and bad outcomes for much of the state. It harmed all groups, though different racial groups were disadvantaged differently. While the policy changes had impacts across many different sectors, the focus here is on education. The results were significantly poorer outcomes for students throughout the state, profound drops in student learning and outcomes. Kansas schools, K-12, were a battleground for the budget cuts and new models. It is helpful to remember that the Supreme Court case that addressed discrimination in public education, Brown v. Board of Education, was about discrimination in Topeka, Kansas. In the decades since the 1950s, many in the state truly focused on strengthening school systems. That stopped under Governor Brownback. Metzl’s research covers both the development and implementation of the Kansas experiment as well as the resistance and eventually successful attempts to restore funding. While few view the experiment as successful, its legacy is casts a long shadow. Metzl rightly notes that reinvestment in public education takes many years to grab hold. It takes time to hire and develop good teachers, to find local education leaders who focus on school development, and to build the trust with parents and communities that allow for better schooling. Accordingly, students disadvantaged and school systems hurt by massive budget cuts do not snap back when funding levels are restored. The Brownback experiment has had long-term negative educational impacts for the state and its communities. Again, Metzl offers individual accounts and a great deal of data.

Dying of Whiteness is about racism and its intersection with policy. That noted, Metzl neither searched for nor found individuals voicing racist thoughts. He and his team conducted research for years and racism was not even a topic or concern in the many interviews and focus groups. It simply was not on the table. Rather – and this is the key point of Dying of Whiteness – racial resentments and anxieties shaped identities, politics, policies, and eventually, public health. Metzl’s insight is into how people, especially white people, think about themselves in 21st century America. Through the lens of public health, Metzl offers a very important way to gain better understanding of how identity and politics are formed and strengthened. I would assert, too, that this kind of deep interdisciplinary approach would be just as effective when applied to other groups, regions and topics.

In many ways, the book effectively anticipates how different groups of people would respond to a public health emergency, like the covid pandemic. Dying of Whiteness is very good, very much worthy of your time and reflection.

David Potash

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