In early 2016 I met Trevor, a forty-one-year-old uninsured Tennessean who drove a cab for twenty years until worsening pain in the upper-right part of his abdomen forced him to see a physician. Trevor learned that the pain resulted from an inflamed liver, the consequence of “years of hard partying” and the damaging effects of hepatitis C. When I met him at a low-income housing facility outside Nashville, Trevor appeared yellow with jaundice and ambled with the help of an aluminum walker to alleviate the pain he felt in his stomach and legs.

Debates raged in Tennessee around the same time about the state’s participation in the Affordable Care Act and the related expansion of Medicaid coverage. Had Trevor lived a thirty-nine-minute drive away in neighboring Kentucky, he might have topped the list of candidates for expensive medications called polymerase inhibitors, a lifesaving liver transplant, or other forms of treatment and support. Kentucky adopted the ACA and began the expansion in 2013, while Tennessee’s legislature repeatedly blocked Obama-era health care reforms.

The white body that refuses treatment rather than supporting a system that might benefit everyone is a metaphor for the decline of the nation as a whole.

Even on death’s doorstep, Trevor was not angry. In fact, he staunchly supported the stance promoted by his elected officials. “Ain’t no way I would ever support Obamacare or sign up for it,” he told me. “I would rather die.” When I asked him why he felt this way even as he faced severe illness, he explained: “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.”

At the most basic level, Trevor died of the toxic effects of liver damage caused by hepatitis C. Yet Trevor’s deteriorating condition resulted also from the toxic effects of dogma. Dogma that told him that governmental assistance in any form was evil and not to be trusted, even when the assistance came in the form of federal contracts with private health insurance or pharmaceutical companies, or from expanded communal safety nets. Dogma that, as he made abundantly clear, aligned with beliefs about a racial hierarchy that overtly and implicitly aimed to keep white Americans hovering above Mexicans, welfare queens, and nonwhite others. Dogma suggesting to Trevor that minority groups received lavish benefits from the state, even though he himself lived and died on a low-income budget with state assistance. Trevor voiced a literal willingness to die for his place in this hierarchy, rather than participate in a system that might put him on the same plane as immigrants or racial minorities.

Trevor also died because the dogmas and hierarchies he supported reflected the agendas of politicians who clamored that health care reform and Medicaid expansion represented everything from government overreach to evil incarnate. Anti-ACA invective found particular champions in GOP lawmakers in Tennessee, a once centrist state that turned hard right. These politicians repeatedly made sure that Tennessee did not create its own Obamacare exchange, expand Medicaid, or embrace the health care law in any way.

Thus, routine screenings, filled prescriptions, visits to doctors’ offices, and many other factors linked to better health outcomes rose steadily in Kentucky in the four years after that state expanded Medicaid. Such trends lifted the overall well-being of many Kentuckians and particularly helped people who suffered from what are oddly called preexisting conditions such as hepatitis C—oddly, in my opinion, because “preexisting” assumes that a person’s existence begins at the consummation of health insurance coverage. Meanwhile, preventive care and proper treatment remained unattainable for many lower-income Tennessee citizens, in large part because of their state’s political choices.

As a physician, I had some sense of the complex medical and psychological explanations for Trevor’s symptoms. I worked in an intensive care unit during my internship, where I saw firsthand the devastating effects of organ failure. I then trained in psychiatry, where I came to appreciate how people’s deep defense mechanisms and projected insecurities can lead them to act in ways that seem at odds with their own longevity.

Yet the more I spoke with Trevor, the more I realized how his experience of illness, and indeed his particular form of white identity, resulted not just from his own thoughts and actions but from his politics. Local and national politics that claimed to make America great again—and, tacitly, white again—on the backs and organs of working-class people of all races and ethnicities, including white supporters. Politics that made vague mention of strategies for governance but ultimately shredded safety nets and provided massive tax cuts that benefited only the very wealthiest persons and corporations. Politics that, all too often, gained traction by playing to anxieties about white victimhood in relation to imagined threats posed by “Mexicans and welfare queens.”

‘Ain’t no way I would ever support Obamacare or sign up for it. No way I want my tax dollars paying for Mexicans or welfare queens.’

Between 2013 and 2018, I traveled extensively in the South and Midwest—in Sarah Palin’s words, the “real America.” I wanted to learn how people balanced anti-government and pro-gun attitudes while at the same time navigating lives impacted by poor health care, widening gun-related morbidity, and underfunded public infrastructures and institutions. During my travels, I met many people who, like Trevor, were dying in various overt or invisible ways as a result of political beliefs or systems linked to the defense of white “ways of life” or concerns about minorities or poor people hoarding resources. The stories these people told me became jumping-off points for a more sustained investigation of how particular U.S. notions of whiteness—notions shaped by politics and policies as well as by institutions, history, media, economics, and personal identities—threaten white well-being.

I found that Trump supporters were often willing to put their own lives on the line in support of their political beliefs. As a result, when viewed more broadly, actions that may have seemed from the outside to be crazy, uninformed, or self-defeating served larger political aims. Had southerners, including Trevor, embraced the Affordable Care Act and come to depend on its many benefits, it would have been much harder for politicians such as Trump to block or overturn health care reform. By design, vulnerable immigrant and minority populations suffered the consequences in the most dire and urgent ways. Yet the tradeoffs made by people like Trevor frequently and materially benefitted people and corporations far higher up the socioeconomic food chain—whose agendas and capital gains depended on the invisible sacrifices of low-income whites.

The white body that refuses treatment rather than supporting a system that might benefit everyone then becomes a metaphor for, and parable of, the threatened decline of the larger nation. Rather than landing a man on the moon, curing polio, inventing the Internet, or promoting structures of world peace, a dominant strain of the electorate voted in politicians whose platforms of American greatness were built on embodied forms of demise.

• • •

My book Dying of Whiteness, which came out of this research project, explores the effects of what became central GOP policy issues—loosening gun laws, repealing the Affordable Care Act, or enacting massive tax cuts that largely benefited the wealthy and corporations—on white population-level health. I also track the health effects of what various authors have called anti-government, anti-tax, pro-gun, and oft-Republican forms of “white backlash conservatism”—a dynamic illustrated by Trevor’s rejection of the ACA because of concerns about nonwhite minorities taking away his resources.

My research enabled me to assemble a narrative about how, in five steps, the embrace of white identity politics by U.S. voters produced catastrophic health outcomes for those same voters.

Rather than landing a man on the moon, curing polio, inventing the Internet, or promoting structures of world peace, our era’s vision of American greatness is built on embodied forms of demise.

First, a host of conservative political movements emerged (or reemerged) in southern and midwestern states over the latter twentieth and early twenty-first centuries that brought into mainstream U.S. politics once-fringe agendas, such as starving government of funding, dismantling social programs, or allowing free flow of most types of firearms. These movements—ranging from the Tea Party to iterations of libertarianism funded by the Koch brothers, to the Freedom Caucus, to the so-called alt-right given voice through outlets such as Breitbart—arose from vastly different agendas and points of origin. However, their interests grew ever-more aligned as they came to power in southern and midwestern states in ways that shaped state agendas, national GOP platforms, and, ultimately, policies of the Trump administration. As this played out, theories of backlash conservatism gave way to something even more powerful: practices of backlash governance.

Second, these increasingly unified forms of conservatism advanced politically through overt or implicit appeals to what has been called white racial resentment. In other words, these agendas gained support by trumpeting connections to unspoken or overt claims that particular policies, issues, or decisions served also to defend or restore white privilege or quell threats to idealized notions of white authority represented by demographic or cultural shifts. This was both a top-down process (politicians used racial resentment as a tool for class exploitation) and a bottom-up one (the language of white resentment became an increasingly accepted way of talking about whiteness more broadly).

To be sure, groups such as the Tea Party rose to prominence for a wide array of cultural, economic, and religious reasons, many of which had relatively little to do with whiteness or race. Lower-income communities left behind by globalizing economies, disenchantment with Democrats, and the growing influence of corporate lobbies and megarich donors on party politics unquestionably played major roles. A number of people with whom I spoke, when I explained my thesis, told me that positions that appeared to reflect racism instead reflected a larger, color-blind “hatred of the poor.”

Yet a major part of these movements’ appeals lay in rallying cries that tapped into emotionally and historically charged notions that white Americans should remain atop other racial or ethnic groups in the U.S. social hierarchy, or that white “status” was at risk. This is not to say that any one specific person was expressly racist. Rather, frameworks of white racial resentment shaped debates about, and attitudes toward, various public policies and acts of legislation. Sometimes, the racial agendas of these calls to arms were overt and obvious. For instance, posters of then president Barack Obama photoshopped with a feather headdress and a bone through his nose began to appear at anti-ACA Tea Party rallies. In 2016 former Missouri Republican Party director Ed Martin told a cheering Tea Party for Trump rally in Festus, Missouri: “Donald Trump is for Americans first. You’re not racist if you don’t like Mexicans.” (That same year, the Tea Party Patriots funded Asia-bashing advertisements featuring fictional Chinese executives in suits speaking Mandarin and laughing about how they were able to buy thousands of acres of Missouri farmland.) At other times, the racial underpinnings of the agendas appeared all but invisible to people on the ground, as with decisions to rally around issues such as guns, health insurance, or public schools—issues whose racially charged histories had been obscured by the passage of time.

Third, the policies that took shape when these once fringe forms of conservatism entered the mainstream GOP and assumed legislative power often negatively affected the health of middle- and lower-income populations. While some of these policies and actions directly affected health care, others not expressly linked to health, such as the proliferation of civilian-owned firearms, nonetheless carried profound medical implications. White backlash politics gave certain white populations the sensation of winning, particularly by upending the gains of minorities and liberals; yet the victories came at a steep cost. When white backlash policies became laws, as in cutting away health care programs and infrastructure spending, blocking expansion of health care delivery systems, defunding opiate-addiction centers, spewing toxins into the air, or enabling guns in public spaces, the result was increasing rates of death.

White America’s investment in maintaining an imagined place atop a racial hierarchy harms the aggregate well-being of U.S. whites as a demographic group, thereby making whiteness itself a negative health indicator.

Fourth, a wide array of middle- and lower-income people experienced negative health consequences from these policy decisions—again, largely because the policies involved elaborate strategies for tearing down community structures for middle- and lower-income Americans but hardly any blueprints for building them back up. Minority and immigrant communities, often the targets of backlash’s ire, suffered greatly and needlessly. But the health and well-being of white Americans suffered from the health effects of these policies as well. Such effects played out in public ways—such as when white concertgoers died in high-profile mass shootings linked to gun policies (or lack thereof) enacted by conservative white politicians. Other effects were far less obvious, such as the long-term implications of blocking health care reform or defunding schools and infrastructure.

Finally, as with Trevor, many lower- and middle-income white Americans continued to support these policies and ideologies—with their inherent links to narratives of imagined victimhood and domination—even after their negative effects became apparent and promises made by politicians such as Trump unraveled. Indeed, for a variety of reasons, white Americans in parts of the United States saw drops in life expectancy. But instead of scrapping these state-level policies as examples of historically bad governance, they became the foundations for legislation at the national level, in the form of Trump-era tax bills, gun policies, health care strategies, and other ill-fated initiatives. All the while, the issues themselves—such as guns, health care, or taxes—accrued larger symbolic or moral meanings in ways that rendered conversations about the effects of specific policies ever-more difficult.

The confluence of these trajectories has led to a perilous state of affairs: a host of complex anxieties has prompted increasing numbers of white Americans such as Trevor to support right-wing politicians and policies, even when these policies actually harm white Americans at growing rates. As these policy agendas spread from southern and midwestern legislatures into the halls of Congress and the White House, ever-more white Americans are then, literally, dying of whiteness. This is because white America’s investment in maintaining an imagined place atop a racial hierarchy—that is, an investment in a sense of whiteness—ironically harms the aggregate well-being of U.S.      whites as a demographic group, thereby making whiteness itself a negative health indicator.

• • •

We make a wrong turn when we try to address racism mainly as a disorder of people’s brains or attitudes. Instead, racism matters most to health when it shapes politics and policies that then affect public health.

My focus on the health effects of U.S. backlash politics for white Americans is in no way meant to minimize the larger effects of racism in the United States. It should be taken as a matter of fact, but all too often is not, that systems in which race correlates with privilege have devastating consequences for minority and immigrant populations. Cuts to health delivery networks, communal safety nets, schools, and social services, alongside policies that enable the proliferation of guns, often impact minority populations first and most severely. Racism itself can also have profoundly negative health consequences. Epidemiologist Yvette Cozier and her colleagues have uncovered associations between frequent experiences of racism—such as receiving poor service in restaurants and stores or feeling unfairly treated on the job or by the police—and higher risks of illness and obesity among African American women. Sleep researcher Michael Grandner has found links between perceived racism and sleep disturbances. And public health scholar Mario Sims found that lifetime discrimination was associated with greater rates of hypertension among adult African Americans.

Increasingly, we now hear that people with racist attitudes fare poorly as well. Racist views make people “sick” and “unhealthy,” neuroscientists claim, because the psychological effort of discrimination can raise blood pressure or cortisol levels and heighten risk for heart attacks or strokes. “Harboring prejudice may be bad for your health,” neuropsychologist Elizabeth Page-Gould writes, because racially prejudiced people experience such “bodily reactions even during benign social interactions with people of different races.”

But my findings suggest that we make a wrong turn when we try to address racism mainly as a disorder of people’s brains or attitudes, or try to “fix” the problem simply by attempting to sensitize people or change their minds. On an aggregate level, people’s individual racial attitudes have relatively little correlation to their health. Yes, in extreme cases like that of Trevor, racial animus can lead to medical disaster. Yet this correlation rarely holds true at the level of population health. Racial animosity rarely makes a person sick in and of itself—otherwise, there would be many more sick people of all backgrounds in the world.

Instead, racism matters most to health when its underlying resentments and anxieties shape larger politics and policies and then affect public health. I say this in part because many of the middle- and lower-income white Americans I met in my research were not expressly or even implicitly racist. Race did not even come up in many of our conversations. Yet racism remained an issue, not because of their attitudes but because they lived in states whose elected officials passed overly permissive gun policies, rejected health care reform, undercut social safety net programs, and a host of other actions. In these and other instances, racism and racial resentment functioned at structural levels and in ways that had far broader effects than the kinds of racism that functions in people’s minds.

Understanding why conservative white Americans vote in ways that negatively affect their own lives involves far more than pointing out ways that these voters may have been conned or deceived.

Addressing racism structurally allows me to raise what became the most troubling findings of my research: I found that, when tracked over time, racially driven policies functioned as mortal risk factors for all people living in states that had adopted them. This is because illness and death patterns that followed actions such as expanding gun proliferation or massive tax cuts mimicked those once seen in relation to other man-made pathogens, such as water pollution, secondhand smoke, or not wearing seat belts in cars, or during certain disease outbreaks. Society mobilized to reduce risk and improve health when toxins dumped into the water, cigarettes, or faulty automobiles led to declining health. But when the pathogens were policies and ideologies, they instead laid the foundations for politics furthered at the national level by the GOP, the NRA, and the Trump administration. In these ways, stories such as Trevor’s come to embody larger problems of an electorate that, in its worst moments, votes to sink the whole ship (except for a few privileged passengers who get lifeboats) even when they are on it, rather than investing in communal systems that might lift all boats. Anti-blackness, in a biological sense, then produces its own anti-whiteness. An illness of the mind, weaponized onto the body of the nation.

Understanding why conservative white Americans vote in ways that negatively affect their own lives involves far more than pointing out ways that these voters may have been conned or deceived. The particular issues about which Trump supporters appear to have been “duped” also tap into larger histories, myths, and ideologies. These histories, myths, and ideologies go a long way toward explaining the complex tension between promises of restored “greatness” on one hand and practices of self-sabotage on the other. Better awareness of this paradoxical tension might allow us to better promote an alternative investment in collaboration and equality—in many instances, by addressing ideologies of whiteness head-on rather than by proxy.

However, the electorate has chosen a regime whose policies come cloaked in the promise of restored privilege, enacted through mechanisms of polarization and divisiveness. As a result, we talk about eliminating financial safety nets and social support programs, allowing ever-more guns, and defunding roads and bridges while at the same time enacting tariffs and building walls. Such talk, and the policies that flow from it, often signify protection, preservation, or continued supremacy. But in many instances, they ultimately serve to hemorrhage our collective abilities to solve problems or help people in times of need. Ultimately, when white voters are asked to defend whiteness, whiteness often fails to defend, honor, or restore them.

From the book Dying of Whiteness by Jonathan M. Metzl. Copyright © 2019 by Jonathan Metzl. Reprinted by permission of Basic Books, New York, NY. All rights reserved.