There is a trait other than skin pigment that we humans do seem to share all but universally: a rather short attention span.
A veritable “moment” before the COVID19 pandemic began rewriting the modern history of public health practice, fixating our attention, and propagating our miscellaneous anxieties, we had declared another epidemic here in the United States a national emergency, after considerable debate and dithering. The opioid epidemic, from which we are far from fully recovered even now, was so bad that it had actually caused average life expectancy in the United Stated to decline, a departure from trends for all developed countries in the modern era. As bad as it is- it is far from clear that COVID will have such an effect.
When I first braved the proposition of “total harm minimization” as the right response to COVID, I had this in mind. Haphazard interdiction of the SARS-Cov-2 threat by shutting society down too hard, too indiscriminately, seemed just the kind of jolt that would disrupt the progress related to opioid abuse and propagate addiction in the context of desperation, destitution, and despair. And so, alas, it has been.
The advent of the opioid epidemic was itself incubated by other epidemic, or better yet “hyperendemic” states. In epidemiology, an epidemic is when some factor impacts the public health at a surprising, new, or unprecedented scale. Since we expect no measles in the modern era, and certainly no smallpox- any few cases of either would be “epidemic.” But when the high rates of a condition become long known and accommodated with apathy; when, in other words, familiarity has bred contemptuous neglect- the condition is hyperendemic. An epidemic is a sharp peak; hyperendemic is the high plateau of adverse normalcy. Obesity is a salient example.
So, too, are the many contributors to the opioid crisis- and to a wide spectrum of related woe. These include a tolerance of predatory profiteering here, something far beyond the requirements of healthy capitalism - a willingness to mortgage the health of even children for the sake of gratified shareholders, and a rosy glow on quarterly profit statements. This extends from the pharmaceutical industry, now indicted in its most peccant parts for propagating the addiction crisis that compensated them with profit; to the vast expanse of willfully addictive ingestibles that masquerade as our food.
They include massive and growing disparities of every conception, from income, to education, to location, to safety. They include differentials in access to medical care, the very care that might- if compassionate and devoted and determined and readily available- ameliorate the toll of addiction, and infection for that matter, one victim at a time. Decent medical care in times of urgent need can never be a hand out, for it is a human right; it ought to be a reliable hand up. But that hand reaches out selectively, and with…bias.
Which brings us to the convulsions of now, born of bias and a stunning human capacity for myopia. Both the epidemic that so recently was- the opioid crisis- and the epidemic that still very much is- COVID19- “see” the colossal and disgraceful folly of racism far more clearly than we.
The opioid epidemic fed on poverty and despair, and so, of course- like other forms of addiction- preyed upon disadvantaged communities of color. But skin color per se is of no true consequence to any aspect of the human condition, character, spirit, or potential. Skin color is simply a proxy for relative disadvantage. And so, where the predation of addiction found victims available, it preyed upon them- undeterred if they happened to suffer from relative pallor. As told in Hillbilly Elegy, and by many others, the opioid crisis wreaked havoc in places of communal poverty- however white.
The view from the spike protein of SARS-Cov-2 is much the same, if not more so. The primitive construct of this RNA virus lacks eyes, of course, but sees us clearly just the same, and sees: we are the same. We are- whatever our favored conceits on the topic- one species, biologically indivisible; one kind of animal.
The skin pigment that invites the contemptible, reptile-brain apprehensions of racism- is inconsequential to most of what matters about being human. But, to be fair, the pigment- melanin- and its production by cells called melanocytes- is not entirely inconsequential. A relatively high concentration of melanin by busy melanocytes protects the vulnerable skin of us “naked apes” from the relentless tropical sun of our common origins.
This same density of skin pigment, however, reduces the efficiency with which we manufacture vitamin D in our skin with sunlight exposure. When sun is abundant, the balance is just right. But when the human diaspora took us out of Africa and ever further north in Europe, vitamin D deficiency became an ancient threat. Our ancestors navigated this threat, as they did the threat of starvation compounded by a native lactose intolerance- with the aid of natural selection. Early Europeans spread genetic mutations that favored their own survival across the generations of themselves. Such mutations included the ability to digest lactose; and skin pallor.
To be clear, being white is the mutation- in three genes, apparently. Being white is the departure from the native, common, human condition. Being white means making vitamin D more efficiently when sun exposure is limited, and tolerating the onslaught of tropical sun less well- a trade-off engineered in the mindless service to survival under varying circumstances. Being black, or brown, means more melanin, means the native human state, means less efficient production of vitamin D, and means better tolerance of intense sun.
It all means nothing else, until we – blind, or seeing; thinking, or reflexively reptilian- decide it means something else, and make it so by acts of discrimination.
To be clear- we all have exactly the same melanin and melanocytes that paint the concentration of our skin pigment across a spectrum. Some of us have a pallor born of 8000-year-old or so northern European mutations. When we, as we often do, seek the bronzing of the sun (when not actually paying for the same through a contrivance such as a “tanning salon”)- we are activating our melanocytes. We are recruiting the cells we have in common with every human, of every hue- to paint our skin a bit darker. Each time they do, they quietly cry from within: you are all the same. This superficial difference is of degree, not kind, and that degree is reduced by…daylight. If ever there was a case of “illumination” meaning many things at once, let this be it.
The dreadful costs of human presumption, entitlement, and rapacity to all other species is measured in the tragic loss of this planet’s magnificent biodiversity for which we are directly responsible. Racism is the toxic extension of such abuse to ourselves, misperceiving what is truly only “us” - as us and them, and feeling justified that “us” should benefit at the expense of “them.”
Exploitation would not be justified if there were a “them,” but there is none; there is only us. For clarity on it, ask COVID. Ask the drugs. Ask all the ravages of epidemic and hyperendemic misfortunes - from addiction to infection, poverty to institutionalized violence, obesity to diabetes, the toll of COVID19 to the parallel toll of its interdiction - that will prey on the vulnerable among us, wherever they are found.
That they are preferentially found in communities of color has nothing meaningful to do with human skin pigment, and everything to do with the standards we tolerate as representative of our collective character.
No one I know personally is sanctioning violence. Just as I have friends and family with different skin pigment than my own, I have friends and family who wear uniforms of differing color, too- and some of those are blue. This is not about using one act of violence to justify another. It is ultimately Newtonian, a tale of actions- and inevitable reactions. The actions of racism call out for our common, impassioned, devoted, human reactions in the service of constructive relief. In a vacuum where construction ought to be- destruction is sure to prevail. We invite it by abdicating.
How jarring, how ironic, and what a profound indictment of the flaws in human character that racism would ignite civil strife, and ominous intimations of worse, before ever the COVID pandemic, highlighting our common vulnerability, had wound down. How disquieting that the very transition back from social distancing is being disrupted by the physical proximities of mass protest, born in turn of a misguided divisiveness. How revealing of our myopia, and willing submission to the most primitive impulses of our wary brains, that a virus sees our sameness where we do not.
The superficial hue of human skin varies; the color of our blood, the workings within- are common to us all. We were, allegedly, all in this together. That remains to be seen, and much depends on how deeply we choose to look.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and current President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.