The Public Health Consequences of Hate
During the past two weeks, I found myself riveted by the media accounts of the Charlie Hebdo massacre in Paris, where three men, purportedly motivated by a desire to avenge satirical cartoons demeaning the Prophet Muhammad, killed 12 people and injured 11 others. A total of 20 people were killed between January 7 and 9, as the Charlie Hebdo shootings were followed by police involvement and subsequent shoot-outs on the outskirts of Paris. The events, understandably enough, galvanized France, and resulted in astonishing, large-scale demonstrations in Paris against extremism and violence. Much has been written, some it very good, about the role that satirical humor has historically played in democratic societies, and about how the Charlie Hebdo massacre represents the perversion, by a few, of religious ideals that aspire to elevate us. Insofar as this helps us to make sense of this tragedy, it is performing an invaluable public service, moving us beyond mourning to a place where reason and rationality prevails, making tomorrow easier to face.
Yet, the events in Paris also cast into bold relief the public health consequences of hate crimes—acts of hatred that are much more prosaic, much more mundane, and that touch the lives of millions, daily.
Population health scholarship over the past two decades has illuminated how prejudice, discrimination, and segregation, linked to inter-personal hatred and antagonism, have a pernicious and pervasive effect on the health of populations. Duncan and Hatzenbuehler, for example, linked lesbian, gay, bisexual, and transgender (LGBT) youth suicide in Boston with neighborhood-level LGBT hate crimes involving assaults, and found that sexual minority high school students who lived in neighborhoods with higher rates of assault were significantly more likely to report suicidal ideation or attempts. They also found evidence of a higher prevalence of marijuana use among these same LGBT students in higher hate crime neighborhoods. Another study found that “structural stigma,” defined as anti-gay prejudice at the community level using the General Social Survey, was associated with higher all-cause mortality among sexual minorities. Ilan Meyer put forward a conceptual framework that links stigma and prejudice to mental health disorders among LGBT people through hostile social environments.
On the individual level, Kessler and colleagues found that respondents to the MIDUS national survey who personally perceived any kind of major lifetime discrimination were more likely to have major depression. Discrimination following a specific, collective event also has been studied. Arab Americans living in the U.S. who perceived abuse after the 9/11 attacks were more likely to report high levels of psychological distress and lower levels of happiness.
The literature extends well beyond the negative health effects among the minorities who are targeted by specific discrimination. One study found that racial resentment, which also can be referred to as symbolic racism, was associated with smoking among non-Hispanic whites, suggesting that the consequences of hate reach out-groups and those in majority groups. The link between smoking and a host of physical health problems is, in turn, inarguable. Additionally, there is a robust literature about the relationship between segregation, often a proxy for racial tension in a community, and health outcomes. One systematic review found that isolation segregation was associated with poor pregnancy outcomes and mortality. A paper from our research group a few years ago estimated that about 176,000 deaths annually may be attributed to racial segregation.
Witnessing the extreme expression of hatred—the murder of dozens of people by a few—has galvanized the world’s attention, casting a harsh light on the currents of intolerance and showing us all too brutally how hatred, in its ugliest manifestations, can tear at the fabric of civilization. But, perhaps, the most sobering reflection emerging from this terrible event is not that this was an isolated incident, but rather that hatred and intolerance pervade our daily lives, with real and substantial impacts on the health of populations. At core, this sheds light on the fundamental causes of population health, on the social processes and structures that influence our day-to-day lives and that form the conditions that produce health. This suggests, to my mind, that a concern with the health of the public is inextricable from a concern with issues of social justice that influence the conditions that make people healthy.
There are many reasons, beyond health, why hatred and intolerance should have no place in a pluralistic, enlightened society. But health is a shared and universal aspiration. A desire to maximize the health of populations should galvanize us. It should push us to engage with the social fractures that threaten our potential to become healthier people. This argues strongly for the centrality of a social justice agenda to an activist public health approach—one that is concerned with understanding and creating the conditions that promote health in populations.
I hope everyone has a terrific week. Until next week.
Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health