US society’s acknowledgement of its legacy of slavery—what could be called the country’s original sin—is long overdue. Racism is still pernicious, pervasive and cutting short the lives of black Americans to this day.

This fact is inescapable in the midst of a pandemic which is killing black Americans at nearly three times the rate of white Americans. This disparity is not because of innate susceptibility to the disease; it is because of a wide range of inequalities that have plagued the black community since long before this health crisis began. 

There are the striking differences in access to covid-19 testing and treatment. There are the inequities that make black Americans less likely to be able to work remotely and more likely to take public transport, both of which put them at greater risk of exposure to the virus. And then there are the disparities in underlying chronic health conditions (such as cardiovascular disease and diabetes, to name just two) —perpetuated by four centuries of discrimination—that make this coronavirus more severe or even deadly for black Americans. 

The racial caste system of slavery that operated until the 1960s (known as Jim Crow) and 401 years of systemic racism and structural societal inequality still live on in every aspect of our daily lives. Nowhere is this more apparent than in health outcomes. It has taken a global pandemic—coupled with the visceral, horrifying deaths of George Floyd, Breonna Taylor and Ahmaud Arbery—for many Americans to acknowledge the truth: racism is deadly. 

As millions of people in the US and globally take to the streets, social media and online forums to declare that “Black Lives Matter” and demand real change there has never been a more urgent time to address the inequities that rarely make the headlines but nonetheless claim lives every single day. 

First, it’s time for US cities, health authorities, medical communities and wider society to demand nothing less than radical, large-scale investment in public health—something the US has never done. Currently, the vast majority of US healthcare funding goes toward treatment rather than prevention because that’s where the most tangible return on investment is found. But a growing body of research supports the notion that 80 to 90% of a person’s overall health is determined by factors outside of clinical medical care: social conditions play a decisive role. Everything from the air people breathe to the places they live and the work they do contributes to their health.

Economic stability is one of the greatest factors. Black families earn less compared with white families, but this disparity in income pales in comparison with the disparity in generational wealth. They hold far more student debt than white Americans and are more likely to default on their loans. They’re also less likely to own a home, to have savings or a retirement nest egg—which means the cycle of inequality builds with each generation. 

But economic investment alone is not enough. US society must also invest in efforts to dismantle racism itself. After all, racism is negatively correlated with factors such as employment, housing, education, income and access to healthcare. And it is shown to have a direct impact on health through the mental and physical “wear and tear” caused by the stress of experiencing discrimination day after day. 

There are a number of ways the public health community can embrace anti-racism efforts, including building more public health prevention into standard healthcare delivery and raising awareness of racial inequities. But this work cannot be executed in a vacuum. Public health authorities must create partnerships beyond their sector to make large-scale, tangible steps towards improving health outcomes for communities that have long been neglected by US systems. 

Bryan Stevenson of the Equal Justice Initiative once said that truth and reconciliation are sequential, not simultaneous. In other words, we cannot change what we do not first recognise and accept to be true. And the hard truth is that in America black lives haven’t mattered. It’s time we reconcile with that sin—and make changes that will save countless lives.