Covid,racism and Black Lives Matter: A deadly constellation

Underlying health conditions and ACE’s

It seems that a disproportionate number of people dying from COVID or having serious symptoms have what has euphemistically been called underlying health conditions. Those who seem particularly at risk are people who have well above average obesity levels, diabetes, heart and lung conditions and a range of metabolic syndrome disorders, as well as those who are immuno-suppressed (Jordan et al., 2020). For the under 60s for example, being obese seems to at least double the risk of hospital admission and indeed, mortality, and this has been seen in many countries (Lighter et al., 2020), including the USA, UK and France.

This is by no means just bad luck and can be linked to other findings about the effects of inequality, discrimination and particularly the long-term lifetime effects of Adverse Childhood Experiences (ACE’s). The data we have seen linking obesity and Covid-19 illness severity is crude, based primarily on Body Mass Index (BMI) measures, but we know that BMI is just one of many biomarkers linked with ACE’s (Huang et al., 2015). The higher the number of adverse life experiences, especially earlier on, is linked with worse health outcomes later, and to earlier death, and Covid-19 is not about to make an exception to this.

Multiple detailed studies show how, using basic measures of ACE’s, that the higher number of experienced, the increased likelihood of developing just about all physical as well as mental health outcomes (Huang et al., 2015; Su et al., 2015). While obesity is one marker, we see the same trajectory with, for example, hypertension, heart disease, strokes, cancer, diabetes, arthritis, lung disease, insulin resistance, inflammatory disorders, and many more. In addition, there is the host of psychological effects, from depression, anxiety disorders, eating disorders, correlated with high ACE’s (Felitti & Anda, 2010). Typically relevant for Covid-19 is the clear link between ACE’s and Chronic Obstructive Pulmonary Disease (COPD), a huge cause of death anyway in the western world, but much higher among those exposed to five or more ACE’s (Felitti, 2002).

It is important to note a few things here. While adverse experiences might increase the likelihood of behaviors which are risky (such as smoking, poor diet, and addictive behaviors), the pathways to such ill-health and the links between psychological and physiological states are multi-layered and structural. Epigenetically, gene pathways are turned on or off by adverse experiences. One example is the glucocorticoid receptor, which is linked to many serious psychiatric disorders (Yehuda et al., 2014). Being under stress and threat lowers our immune responses, and anyone’s immediate survival needs in the face of danger will trump the body’s desire to look after long-term immunity (Mehta et al., 2013). Indeed cortisol, often seen as the “stress hormone,” is a steroid with immune dampening effects (Buford & Willoughby, 2008).

Similarly, more Adverse Childhood Experiences equates with a range of effects on the nervous system, and the brain (McCrory et al., 2017b; Teicher et al., 2016) (eg on the hippocampus, amygdala, PFC and so much more). Constantly being on “red-alert” for danger or stress has powerful effects on immune functioning and the ability of the body to relax and recover, the healthy parasympathetic “rest-and-digest' system barely turning while we are under threat. This of course links with why we see such poor health outcomes in children who are maltreated.

People from BIPOC communities are grossly over-represented in the population struggling with poverty, economic stressors, scary neighborhoods, psychiatric problems and so much more. We are seeing the effects of structural inequality at a society-wide level. Of course, as scholars such as Wilkinson and Marmot have shown unequivocally, inequality itself in a society has profound health effects (Marmot, 2017; Wilkinson & Pickett, 2009). For example, more unequal societies have much worse health outcomes than more egalitarian ones.

Racial discrimination too has an effect at a biological and cellular level. Those from minority groups in areas of the US with more discrimination have been found to have higher levels of the stress hormone, cortisol (Lee et al., 2018), and also show faster biological aging, as measured by telomere length (Geronimus et al., 2015; Liu & Kawachi, 2017). This is mediated by oxidative stress and is linked, for example with type-2 diabetes and obesity.

Unconscious prejudice

Alongside the BAME mortality rates from COVID we are simultaneously grappling with the aftermath of the murder of George Floyd which has awoken a new generation to the extent of racism, prejudice and discrimination. Unconscious racial prejudice exists in most contemporary societies and causes huge emotional and physical pain, having repercussions on the minds, bodies spirits and hearts of multiple generations of people of color.

This is an issue for us all. We all need to get to know and understand the attitudes, beliefs and prejudices we all carry. Only by owning up to these, and thinking about how they arose, can racist attitudes be challenged effectively. Condemning prejudice in others and denying it in ourselves is a classic but unhelpful unconscious ploy, as is self-hating and self-shaming.

The backdrop to all this is the overdetermined set of social forces that gives rise to discrimination, inequality, racist behavior, discourse, and actions. Such attitudes are kept in place via structural inequality and how systems around status and social rank play out in most societies. In many societies status and economic advantage is linked with subtle gradations of skin color, such as in many South American countries. Think of the economic gain in slavery and now in the US prison system, exploiting for profit many more Black people than ever were slaves. We need to remain alive to the bigger political questions, and remember that racism and prejudice are about more than individual blame.

In-groups and bias

We can all be shocked by having racist or discriminatory thoughts. The question is how to ensure that such unconscious attitudes do not persist, and not translate into actions. I recently again did the Implicit Association test (Rudman et al., 1999). This tests our biases, whether on race, gender and a host of other issues. It gets people to pair pictures (eg white or Black faces) with words (eg good bad, violent etc) and what it is measuring is our response time. If we are slower to pair a Black face with positive words, this suggests an unconscious bias. Our unconscious cannot lie. I have done a few of these and have not always liked the results, which are hard to argue with. Even seasoned political campaigners for racial equality and rights, irrespective of their ethnicity, often find they have unconscious biases they were not aware of and are somewhat ashamed of. People of any race can internalize racist attitudes and not know they have them. It suggests that we have internalized messages about race from history and wider society, and these become unconscious beliefs. If such beliefs are revealed we can challenge them, but we certainly cannot challenge them if we deny them.

Our evolutionary heritage handicaps moves toward a racially less discriminatory world. Predispositions that evolved for sensible evolutionary reasons might now undermine a more equal, less prejudiced world. We evolved in small hunter-gatherer communities where mutual trust, loyalty and identification with one’s in-group were necessary for our very survival. Facing mortal dangers from predators and rival groups meant that in-group loyalty and cohesion were vital. We evolved to distrust the “other.”

We see the legacy as early as in infancy. Even babies show preference for adults who look and talk like them and like the same things as them, and they even often like people who harm people who are dissimilar to them (Hamlin et al., 2013). Fifteen month infants like fairness but when the unfairness is to someone of another race, such preferences disappear (Burns & Sommerville, 2014). This is shocking and suggests that to combat racism we need to work against central aspects of our evolutionary heritage. We evolved to favor people who seem more “like us” (Van Leuween et al., 2016).

Humans from infancy adapt to survive and fit in, which requires learning cultural expectations and the nuances. Indeed babies from different cultures cry differently, with different prosody and gestures, from the first weeks of life (Mampe et al., 2009). Not fitting in is literally painful, similar pain circuits activating in the brain when ostracized as when feeling physical pain (Cacioppo & Cacioppo, 2014). We like and need to belong, and prefer people in a group we are in, even if the allocation into groups has no objective basis.

The chances of reaching out to those in other cultures and groups are further compromised as the feeling that one belongs, and group loyalty, increase self-esteem (Hewstone et al., 2002), so it is good for us to belong. Prejudice about ethnicity, class or nationality are extreme examples of a double-edged predisposition.

Our group biases can be extremely unsettling. In a typical experiment in America white subjects were shown both black and white faces for 30 milliseconds, too short a time for the conscious mind to register. When shown black faces, scans revealed heightened amygdala response, suggesting non-conscious fear. When the pictures were shown for long enough to register consciously, the scans showed activation in brain areas involved with conflict resolution, suggesting that the subjects were grappling with their own racism (Cunningham et al., 2004).

A clue as to how to manage our unconscious racism comes from how, when the black face was well known and highly thought of, such as Nelson Mandela or Barrack Obama, then the same prejudices were less present in white participants. There are active steps we can all take to challenge our unconscious prejudices but burying our prejudice or projecting it onto others is unhelpful. Mostly our biases are non-conscious and implicit, reflecting societal beliefs and prejudices, often developed early in childhood.

Again, this is all unconscious, and we all can interpret the same sensation differently. I work with children and adults who have been traumatized and they often interpret something is dangerous or a threat that most of us see as ordinary. Their brains have developed to expect and protect them from danger (McCrory et al., 2017a). However, unlike many of these children, often black people are not wrongly seeing disdain, contempt, suspicion or fear, but are picking up real signals. It is hard to imagine what it feels like to be consistently on the receiving end of contempt or suspicion, let alone hatred. I remember 40 years ago reading “Black Like Me,” a shocking account by a journalist who darkened his skin and then traveled to areas he thought he knew. The reactions and experiences he had were as if he was in another planet, attack, revulsion, ostracism, hatred and more, despite being the same person, with the same genes, mind, posture, eye color, gait and everything else. It is little surprise that even young children can internalize such attitudes, seen when black kids heartbreakingly think that white dolls are better or more good than black dolls (Bergner, 2009) (video here).

When shown pictures of people in pain, if the other person is of one’s own ethnic or cultural group, such as African-American or Caucasian American, distinct parts of the brain, those involved in empathy, are active, but less so if the person suffering is from another group (Mathur et al., 2010). Such dehumanization, of “some lives not mattering,” seems to be at the heart of many atrocities based on prejudice such as race crimes.

It is chillingly easy to diminish, dehumanize or “other.” In one study an ethnically and socially mixed group were shown images of a range of people, such as a female college student, a male American fire-fighter, a businesswoman and wealthy man, a disabled woman, a female homeless person and male drug addict. They were asked to imagine a day in the life of each of these people, an exercise that generally induces empathy. Strikingly, while the empathy circuits in the volunteers’ brains lit up for all the others, for both the homeless person and the drug addict areas dominant for disgust, such as the insula, were most active (Harris & Fiske, 2011). Indeed, very worryingly given the current social trend toward inequality and social divisions, in many the brain areas linked with disgust lit up in response to poor people generally. Again, we need to be careful not to condemn too much. We evolved to have suspicion of the “other” who in our evolutionary past could be dangerous or, relevant to Covid, carry pathogens.

When we do imagine the lives of BAME people who receive non-conscious signals of distrust, fear, contempt and dislike day-in day-out it is hard not to feel compassion. It can be no coincidence that black people living in racist areas in the US have higher levels of nearly all worrying health related biomarkers, from shorter telomeres to higher allostatic load. (Liu & Kawachi, 2017). Racism is internalized not just in minds, but becomes embodied (Gravlee, 2009) in a way the leads to the very health issues that have predisposed to Covid mortality, such as obesity, diabetes and other metabolic issues (Paradies et al., 2015).

Groupness is a mixed blessing. Belonging makes us feel better, and is one of the roots of genuine mutual care and cooperation. However, it can also lead to dehumanization of others and inhibit cooperating with those we deem different. Surprisingly oxytocin, a hormone central to bonding, mutual trust and cooperation, increases empathy. Yet the same neurochemical has a darker side. When people are in close-knit and bonded groups, such as the huddles of sportsmen before or close families, oxytocin levels rise. Yet people given oxytocin intra-nasally become more likely to help those in their own ethnic group, and less likely to aid those from other groups (De Dreu et al., 2011), a finding found in Belgium between Walloons and Flemish citizens, and in another study, in Israel between Hassidic orthodox and non-religious Jews (Fershtman & Gneezy, 2011).

Defences against feeling bad and prejudice

We also know that when times are tough, group identification can be an unconscious way of bolstering a fragile sense of self by identifying with an in-group, hence gang membership and the increase in racism and xenophobia witnessed so often with economic crises, another of which we might be about to face. People showing a hubristic over-blown pride have higher levels of prejudice than those with ordinary self-confidence (Ashton-James & Tracy, 2011). “Authentic pride,” which might derive from hard work and a genuine sense of achievement, is more likely to lead to a compassionate and empathic attitude to others. Pride based on hubris, geared to bolstering fragile self-esteem, is a more arrogant and less genuinely self-confident kind, and suggests attempting to feel better by diminishing others. Such studies back up the psychoanalytic idea that we can cope with bad feelings about ourselves by projecting them onto others. In the aforementioned study, those with more authentic pride were not only more empathic but they harbored less prejudice. This of course might also make sense of why we see such a rise in far-right and racist groups when there is an economic downturn and economically challenged groups, like some white working class men, can be tempted to more racist attitudes.

Stress, including poverty, inequality and danger wire our brains for distrust. When the chips are down and danger looms, we can’t afford to be open and trusting. Very anxious fearful children, as well as abused and traumatized ones, are much more anxious, and suspicious of difference (Williams et al., 2015), and the parts of their brain involved in fear, such as the amygdala, are highly active (Ohashi et al., 2014). People with more social fear tend to be more anti-difference, ant-immigration and, pro-segregation (Hatemi et al., 2013). Some research has suggested that people on the political right have higher activation in fear related brain areas while those on the left have more activity in areas involved in curiosity, self-reflection and empathy (Kanai et al., 2011).

What much research is suggesting is that when people are suspicious, fearful and experience threat, they tend to have more activation in areas of the brain such as the insula, central to disgust, and fear, and less activation in brain areas to do with empathy, curiosity, trust or openness to novelty. Generally, brain areas that are dominant in fear, anxiety, threat or anger work against those that are central to cooperation, empathy or caring for others.

Thus the potential for racism and a fear of difference seems to be engrained in human nature, but is exacerbated in the face of fear and uncertainty, which is when most of us tend to cling to the known. When our backs are against the wall, we tend to see threat everywhere and resort to flight/flight responses rather than empathy and care for others. Fear tends to make us more suspicious and wary of others (Renshon et al., 2013). This might explain a recent research finding that those who felt most threatened and less “safe” in response to covid were the ones more likely to hoard toilet paper (Garbe et al., 2020), a kind of “look after number 1” threat response.

When stressed or more anxious we seem to become more suspicious of the “other.” In one study 138 men from Cambridge, Massachusetts watched films and then answered questions. Some watched relaxing images such as of beaches and palm trees, or heard soothing music. Others had to watch Sylvester Stallone’s rather terrifying film, “Cliffhanger.” The latter group not surprisingly had heightened physiological reactivity after watching 2 min of rope dangling peril. Maybe more worryingly, this led them to have stronger anti-immigration and prejudiced attitudes. A message from this might be that if we make people feel safe, valued, secure and cared for they are less likely to develop such racist attitudes.

Conclusion

To conclude, many, if not most, of us, harbor racist and other discriminatory attitudes, unconsciously. These attitudes, often imbibed via the media, perpetuate divisions in our society and suffering in the discriminated against. Such attitudes and experiences, being on the receiving end of contempt or prejudice, has a knock-on effect right down the cellular level., leading to the increased predisposition of BAME groups to be suffering the kinds of health issues associated with poor COVID outcomes. In increasingly unequal societies we see poor physiological and psychological health issues (Marmot & Bell, 2016; Wilkinson & Pickett, 2009, 2018), and of course psychological issues, as well as poverty, is linked to struggles to parent and the likely increase in ACE’s (Metzler et al., 2017).

As well as needing to look long and hard at our own prejudices, and work to shift these, we also need to be aware of deeper societal and systemic issues. Racism has been central to the maintenance of contemporary consumerist capitalist society, and the increased inequality within them. This includes mass incarceration of Black Americans who become effectively slave labor, ghettoization and cheap labor, and disproportionate numbers of minority groups on the lowest social rungs, suffering poverty and great psychological and health adversity.

Much resistance to the Black Lives Matter movement has come from those that would be arguing that all lives matter. But if we dehumanize any other their lives and lifeblood do not matter to us. The Black Lives Matter movement does not of course suggest that only Black Lives Matter, but rather that Black Lives Matter equally. We can work against our tendency for prejudice and dehumanization, which means first owning up to it and not being self-hating. One of my heroes James Baldwin stood up with courage against racism and also knew and said “not everything that is faced can be changed but nothing can be changed unless it is faced.” This applies equally to “whitewashing” structural racism and atrocities but also to facing, with some self-compassion, our own internal prejudices.

Thus, racism and its effects run deep and wide, in attitudes, overt discrimination, unconscious prejudice, and having effects right down to a cellular level. Metabolic issues such as obesity and COVID morbidity can be linked with racism and discrimination but also to structural inequalities. These are serious issues, literally deadly serious, and as often the poorest and most discriminated against are suffering most and bearing the brunt. This issue of who is ill and dying and why, goes to the root of how we have organized society, and the effects of this are showing up at a socio-economic, biological and cellular level as well as psychological levels.