Racial capitalism is the root cause of disease and unequal health outcomes.

Abstract In the influential 1995 article “Social Conditions as Fundamental Causes of Disease,” Bruce Link and Jo Phelan described social and political factors as “fundamental causes” of death and disease. Whitney Pirtle has recently declared racial capitalism another such fundamental cause. Using the case of the water crisis in Flint, Michigan, she has argued that racial capitalism's role in that situation meets each of the criteria Link and Phelan's article outlines: racial capitalism influenced multiple disease outcomes, affected disease outcomes through multiple risk factors, involved access to flexible resources that can be used to minimize both risks and the consequences of disease, and was reproduced over time through the continual replacement of intervening mechanisms. We argue for Pirtle's conclusion using the extensive literature on racial capitalism and case studies concerning housing in the United States and Brazil and what Naomi Klein has termed “corona capitalism” in India. If races correspond to hierarchies of material security, as suggested by Ruth Wilson Gilmore, then these hierarchies and their causal effects are fundamental determinants of public health. Essays In the oft-cited 1995 article “Social Conditions as Fundamental Causes of Disease,” Bruce Link and Jo Phelan describe social and political factors as “fundamental causes” of death and disease. Part of the inspiration for the authors’ claim was the intractability of poor health outcomes in impoverished communities, even of particular diseases. “[E]ven if one effectively modifies intervening mechanisms or eradicates some diseases,” the authors argue, “an association between a fundamental cause and disease will re-emerge. … [F]undamental causes can defy efforts to eliminate their effects when attempts to do so focus solely on the mechanisms that happen to link them to disease in a particular situation.”1 Link and Phelan's analysis presents an important question: how to diagnose the social conditions themselves. Recently, sociologist Whitney Pirtle suggested a provocative answer when she asserted that racial capitalism should be considered a “fundamental cause” of death and disease.2 Using the case of the water crisis in Flint, Michigan, she has argued that racial capitalism's role in the crisis there meets each of the criteria Link and Phelan's article outlines: racial capitalism influenced multiple disease outcomes, affected disease outcomes through multiple risk factors, involved access to flexible resources that can be used to minimize both risks and the consequences of disease, and was reproduced over time through the continual replacement of intervening mechanisms. In this essay, we will argue for Pirtle's conclusion by supplementing it with tools identified by Arlene Bierman and James Dunn. Bierman and Dunn provocatively claim that “social class dwarfs healthcare as a determinant of health.” Bierman and Dunn take it that class is linked to health outcomes through its influence on populations’ abilities to reliably access “basic necessities”: housing and food. Poverty is the “leading cause of avoidable mortality” in part because of the “forced choice” that impoverishment presents to low-income people: whether to pay rent, buy food, or seek medical care.3 No matter how a person in this predicament chooses, something will go missing, undersupplied, or come by erratically, which will become a vector for negative health outcomes. But decades of social science have also linked race with these same outcomes. Moreover, authors in the literature on racial capitalism tie race and class together with the broader system of capitalism that determines how income, wealth, and social advantages are produced and distributed. Racial capitalism's effects on public health can thus be understood as a fundamental cause of health outcomes using the same approach that Bierman and Dunn used to link health outcomes to class. For public health research, what is key is perhaps less whether we use the terms “race” or “class” but the system of hierarchies that both these terms help to categorize: different strata of material security and insecurity, or the degree of security with respect to “basic necessities.” Racial Capitalism The term “racial capitalism” is used by people expressing a set of intellectual positions about our global social structure that developed over the twentieth century. The sociologist Oliver C. Cox developed some of the key building blocks of what became racial capitalism theory in Class, Caste, and Race (1948) and The Foundations of Capitalism (1959). He concluded that “racial antagonism … developed within the capitalist system as one of its fundamental traits” and, furthermore, that “racial feeling developed concomitantly with the development of our modern social system.”4 The term “racial capitalism” originates from African theorists like Neville Alexander and Harold Wolpe, and it was popularized in the United States by theorists including Cedric Robinson.5 Theorists of racial capitalism hold that racism is a functional part of capitalism—that is, that racism is not merely part of the explanation of how capitalism got here in the first place but also an active part of the reason capitalism persists.6 Geographer and abolitionist Ruth Wilson Gilmore, one of today's leading theorists of racial capitalism, introduces useful specificity about how racism functions in a capitalist world, defining it as “the state-sanctioned or extralegal production and exploitation of group-differentiated vulnerability to premature death.”7 Vulnerability to premature death comes, of course, in many forms: at least as many forms as there are ways to die prematurely. But here it is instructive to recall Bierman and Dunn's reasoning for classifying social class as a prime driver of health outcomes. First, they point out the what: that poverty is the “leading cause of avoidable mortality.”8 Second, they point out the why: that impoverishment presents low-income people with a “forced choice” between paying rent, buying food, or seeking medical care, thus ensuring that something essential will be shortchanged. It is not poverty in and of itself, then, that causes death but what poverty reliably does: it causes insecurities or precarities that have an understood and deleterious effect on health outcomes. Race, theorists of racial capitalism point out, has this same effect on populations. Food insecurity is an important determinant of public health. Undernutrition, particularly of children, is a primary cause of ill health and premature mortality in the Global South.9 Famines represent an extreme case of food insecurity. Groundbreaking work by philosopher and economist Amartya Sen highlighted a surprising fact about this extreme case that is politically informative about the structure of our society: famines often are unrelated to food availability. This point is counterintuitive. Before Sen wrote, the traditional approach to explaining famines appealed to food scarcity: famine involves starvation, and starvation is lack of food. This “food availability approach” was assumed in classic works of economics and philosophy (most famously by Thomas Malthus). If you wanted to explain a famine, you appealed to activity in or of the natural world that would interact with the food supply: pests, droughts, heat waves.10 In “Famines,” Sen appeals to two cases. The first is a famine in Ireland following a potato crop failure in 1822. There, people starved to death even though there was plenty of corn to eat. The second concerns the Bengal famine of 1943, in which three million people starved to death even though food production had actually increased relative to 1941, when there was no famine at all. The food availability approach does not offer a satisfying explanation to these famines. In both cases, Sen argues, the failures were sociopolitical: the reluctance of the British Empire to defend its colonized subjects rather than particular elites’ financial interests.11 The reason that people starved in Bengal and Ireland is explicable in terms of the framework offered by racial capitalism, especially as explained by Robinson and Gilmore. Robinson notes that the social structure enabled by splitting the ruled into separate populations arranged into a sharp, vertically organized hierarchy was developed in Europe (to the disadvantage of groups like the Irish and the Slavs) and came to operate on a world scale (incorporating Africans and Indigenous peoples) because of European colonization and subsequent capitalism.12 These distinctions in hierarchy, Gilmore's definition tells us, become differences in group-level vulnerability, with groups further down the racial hierarchy systematically experiencing more vulnerability than groups farther up. This stratification is exploitable by the political powers that be: in Ireland, to defend profits and colonial control by largely English elites (higher up the racial hierarchy than the Irish) and, in Bengal, to defend the strategic interests of the British military (which feared Japanese invasion in rural Bengal). The theory of ecologically unequal exchange allows us to tell this same kind of story on a global scale, and with a wider reference to ecological phenomena than with the narrow focus on agricultural systems. This theory holds that our world economic system moves energy and biophysical resources from poorer to richer countries. This scheme in turn distributes ecological risks perversely, tending to concentrate them in the Global South.13 With the Global South carved into planetary politics by the same forces that colonized Bengal and Ireland, richer countries like those in Europe are “draining ecological capacity from extractive regions by importing resource-intensive products and shifting environmental burdens to the South through the export of waste.”14 Similarly, environmental economists and geographers have advanced the “pollution haven hypothesis,” which predicts that companies faced with stringent and costly environmental regulations in one country or region will move production to places with less-stringent regulation. The relationship is causal: higher-income countries (disproportionately yesterday's colonizers) have more economic leverage against companies and more politically empowered populations, which correlates with tougher environmental regulations. Some empirical work has lent support to this hypothesis.15 The locating of manufacturing in countries with weaker environmental regulations redistributes environmental risk along the same lines as the ecologically unequal exchange theory predicts and can be viewed as one causal mechanism within that theory's larger story.16 Inequitable distribution of environmental risk doesn't happen only at the global scale. Within countries, there are “green crime havens”—areas of unlawfully elevated environmental risk. As with the pollution haven hypothesis, this concept represents the geographical distribution of pollutants and environmental vulnerability in ways that track power relations.17 And, as with the other theories, the relationship described is a causal one: researchers at Auburn University and the University of Florida explain that the havens arise “as part of power differences and corresponding zoning decisions,” not simply as a result of the havens’ proximity to natural resources that companies want access to for production.18 Whether one relies on the globally scoping ecologically unequal exchange theory, the transnational pollution haven hypothesis, or the idea of subnational green crime havens, the balance of evidence suggests that the geographical distribution of pollutants and environmental risk reflects social power dynamics. Moreover, the evidence suggests that the relationship between the political power of a population and its susceptibility to environmental vulnerability is a causal one, not simply a set of unhappy coincidences. This fits squarely into Gilmore's definition of racism: “the state-sanctioned or extralegal production and exploitation of group-differentiated vulnerability to premature death.” Racial capitalism, then, links racial power and security disparities themselves to environmental exposures and health outcomes. Housing Racial capitalism also explains stable, long-term, structural stratifications in housing. Consider the examples of the United States and Brazil. In the United States, a variety of systems secure the investments of landlords by shifting the financial and social risks of housing toward the most vulnerable residents.19 Working-class and affluent renters pay similar amounts of rent but live in housing of vastly different levels of quality because working-class renters are often confined to dilapidated housing stock.20 Low-income renters are identified via complex surveillance systems that function much like a criminal record: appearances in housing court, credit problems, and run-ins with the law can all mar a low-income tenant's record and prevent them from accessing safe housing.21 Racial stratifications show up in the same pattern: Black renters are disproportionately targeted for eviction, by predatory lending, and by the police, all circumstances that serve to increase these renters’ vulnerability to housing insecurity.22 Urban informal settlements are characterized by a combination of concentrated poverty, insecure and poor-quality housing, political disenfranchisement, and a lack of access to essential life-supporting services such as clean water, sanitation, and health care. In Rio de Janeiro, Brazil's second largest city, 1.39 million people (22 percent of the total population) live in informal settlements.23 Morro da Providência, Brazil's oldest favela, was first settled by veterans of the War of Canudos in 1897. Following the war, soldiers settled on the morro (“hill”), and later, opportunities for unskilled laborers also attracted formerly enslaved people (who had been freed in 1888). At this time, the government had given little thought or support to how newly liberated people would survive; hundreds of thousands of formerly enslaved people came to Rio seeking employment provided by Rio's wealthy families. In Morro da Providência, these newly freed people had nowhere to live, but they had access to free land in the morros. Many of these dynamics are still in place in Morro da Providência. The population is largely Black and mixed race; by contrast, Rio's wealthy southern zone is 80 percent White.24 Land in Rio is incredibly valuable, and proximity to the capital city is a necessity for many who rely on the opportunities there for survival. While the government of Brazil has worked with favelas to improve infrastructure and expand access to sanitation, residents of Morro da Providência live in a state of constant precarity given Brazil's history of policies that result in the displacement and destruction of these informal settlements. India's “Corona Capitalism” Racial capitalism does not apply only to long-term, structural phenomena like housing and ecological exchange. As we saw in Sen's example of famines, it also applies to short-run crises of material insecurity. In this final section, we consider another short-run example: the ramifications of stratification under racial capitalism in the crisis of the Covid-19 pandemic. India's pandemic response has demonstrated the symbiotic relationship between racial capitalism and disaster capitalism