The appalling events in Charlottesville, Virginia, this month bring into arresting focus the devastating effects of racism and hatred. On Saturday Aug 12, a group of politically right-wing protestors, which included white supremacists, neo-Nazis, and Ku Klux Klan members, rallied against the removal of a pro-Confederate statue, and clashed with counter protestors. Heather Heyer, a civil rights activist, was run down and killed by a speeding car driven by a Nazi sympathiser; many more were injured in what is being called an act of domestic terrorism. The harrowing images of swastikas, lit torches, and bigotry shouted by angry marchers evoked a repugnant past, an anachronism. They also left many observers expressing despair and disbelief that such extremism could still exist in America today. In fact, the Southern Poverty Law Center, which monitors hate crimes, says that far-right views, including white supremacy, are increasing in the USA. Similarly, Australia, Canada, and countries across Europe are seeing a rise of right-wing populism.

The Charlottesville horrors, and the subsequent lack of adequate censure of extreme-right supporters by President Trump, have been widely condemned, and rightly so. There are no “very fine people” among the fanatics of Charlottesville. But condemnation will only go so far. Calling Trump morally blank, inept, and destructive is right, but it is also useless. Liberal outrage, self-satisfying in left-wing echo chambers, amounts effectively to pity, not remedy. And it can embolden supporters who see criticism as an attack on their politics and culture.

Public health teaches us that the only cure is to treat the causes. Behind the fanatics, whose behaviour can never be excused, are causes of the causes of hatred. And these lie at least to some degree in the feelings of disenfranchisement and perceptions of social inequality held by some white Americans. In a globalising world in which the USA's demographics are shifting—to be younger, less white, more urban—changes toward a more equal society can feel like a threat. As The New York Times recently noted , some white working class Americans voted for Trump, in “an attempt to rebalance the inequity they saw holding them back—economically, politically and culturally”. For some communities, extreme feelings of unfairness coalesce with grievances that white history and heritage are being lost. While many commentators disparage the racial anxiety of these communities about their loss of white privilege, no remedy for such a sense of social fracture will come from further denigration and division. So while racial intolerance against any group is absolutely inexcusable, the reasons for communities feeling threatened and isolated must be better understood.

As we wrote in December, 2016 , health can be a unifying power in moments of despair. A health lens sees the surge in opioid addiction and rising mortality rates among white Americans (including by suicide) as signalling a community in painful crisis. It views disintegrating social cohesion in low-income communities as central to diminished well-being and insecurity . In recognising the social and political determinants of health, a health lens shows how poor job prospects, lack of educational opportunities, and social isolation can fuel fear, resentment, and disempowerment. Racial intolerance, then, can be partly understood as rooted in feelings of lack of agency—no control over one's life and blaming others for poor prospects. When describing what he would most like to change among the white American working class, J D Vance writes in his powerful Hillbilly Elegy: A Memoir of a Family and Culture in Crisis, “The feeling that our choices don't matter”.

American health professional associations responded to the Charlottesville events by reaffirming hate crimes as a public health issue. The American College of Physicians , American Medical Association, and American Public Health Association have issued policy statements citing evidence that abuse, harassment, prejudice, and stigma are associated with poor health outcomes and they urged the implementation of anti-discrimination and hate crimes laws. But they must do more. Health leaders in America and beyond must support bipartisan efforts to ensure affordable health care for Americans, especially for those most vulnerable socially and economically. Ensuring expansion of Medicaid coverage to poor Southern states and providing access to medication-assisted treatment for drug addiction are clear, straightforward ways to help heal obvious wounds.

Hate, racism, and anti-Semitism are always unacceptable. But as uncomfortable as it can feel, we must work to illuminate the causes of the causes of the feelings of disenfranchisement among disadvantaged white Americans. Universal access to high-quality health care can be one important means to strengthen these frayed social bonds.

Copyright © 2017 Getty Chip Somodevilla/Staff #: 831158848

Article Info Publication History Identification DOI: https://doi.org/10.1016/S0140-6736(17)32285-7 Copyright © 2017 Elsevier Ltd. All rights reserved. ScienceDirect Access this article on ScienceDirect