In his book Violence: Reflections on a National Epidemic, psychiatrist James Gilligan describes structural violence as “the increased rates of death and disability suffered by those who occupy the bottom rungs of society, as contrasted with the relatively lower death rates experienced by those who are above them.” By that definition, the Republican repeal and replace of Obamacare in the House of Representatives on Thursday was an act of violence. The victors’ gloating made the spectacle all the more hideous.

The House bill sets in motion the gutting of Medicaid, on which 74 million poor, disabled and elderly people depend, the demise of guaranteed coverage for those with pre-existing conditions, and the retrenchment of insurance subsidies for needy individuals and families. It allows states to ditch the requirement that insurers cover essential services such as maternity care. In a further attack on poor women, it defunds Planned Parenthood for a year. The bill was rushed to a vote before the Congressional Budget Office could assess its impact, but it has been widely reported that at least 24 million Americans would lose their health insurance because of it.

While the Senate is likely to water down its worst provisions, the House bill sends a clear message: in the eyes of Congressional Republicans, the lives of the poor, old, and disabled are worth less than those of the healthy, wealthy white men who rule the country. This harkens back to the sordid days of eugenics in the early 20th century when such prejudices were enshrined in social policies like the compulsory sterilizations of people thought to be “defective” because of their poverty, ethnicity, race, or disability. If Trump and his acolytes have a pre-existing condition, it is loathing for those on the bottom rungs of society, a loathing so deep that they are literally prepared to see them suffer and die.

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In his inaugural address Trump invoked the “carnage” in our inner cities. It’s time to focus on the carnage caused by his administration. Preparing for the day when he is finally held accountable, we need to create an index of lives lost or harmed by his policies. A broad definition of violence should guide this project. The victims of the assault on health care belong high on the list, but so do the civilian casualties of American bombings in Iraq, Syria and Afghanistan. We also need a carnage index for the toll on the environment, as the Trump regime turns over more public lands to private resource extraction, eliminates pollution regulations, allows oil drilling in the Arctic and Atlantic, and turns back the clock on combatting climate change.

Too often, Americans let their leaders off the hook for the violence they perpetrate. George W. Bush is now being lauded for his paintings of American war veterans. But what about all the Iraqis killed in the war he started? By 2015, at least 165,000 Iraqi civilians had died from direct war-related violence, and perhaps twice as many from the war’s indirect effects on the availability of food, clean water, and health care. Many Americans are simply not aware of these shocking statistics.

Let’s start counting Trump’s casualties now and widely disseminate the results. The hard numbers of a carnage index provide an important antidote to impunity.