There are two calamities killing Americans: COVID-19 and racism. One is novel, and the other is perennial.

It is not coincidental that black Americans have died of COVID-19 at almost three times the rate of white people. Both biological and socioeconomic factors contribute to this alarming statistic. However, as emergency physicians and public health practitioners who care for patients from diverse social and cultural backgrounds, we are keenly aware that biological factors are, in fact, biosocial in nature. We refer to the non-medical factors influencing health as the social determinants of health (SDOH). Racism and systemic injustice are driving forces of SDOH like education, employment, and housing, and are significant barriers to health equity.

For centuries, black Americans have faced not only physical violence as exemplified by the gruesome murder of George Floyd but also an invisible form of violence known as structural violence. First described by Johan Galtung in the article “Violence, Peace, and Peace Research” (1969) structural violence occurs when social structures prevent human beings from meeting their basic needs; when structures of political, legal, economic, psychological, and cultural thought impede individuals and communities from achieving their full human potential, elaborating dreams beyond their circumstances, and finding the resources to fulfill them. Racism, a flagrant example of structural violence, has pervaded American society since the nation’s beginnings.

According to Galtung, structural violence is an “avoidable impairment of fundamental human needs” and a contributing factor for premature death and unnecessary disability. Structural violence is inextricably tied to social injustice and the “social machinery of oppression.”

Here we are, facing a violent implosion between a life-threatening pandemic and the horrifying killings of black Americans. What can be done? What must be done?

As a starting place, we must look inward. No matter how anti-racist we are, we have unconscious biases and prejudices that cement internalized adaptations to structural violence. We are products of the cultures we are raised in, and group identity is a powerful magnet. I am ashamed to say that I began to grasp the meaning of white privilege only a few years ago, thanks to my college-aged daughter. She explained our inherent privileges and how the benefit of the doubt is subconsciously accorded to white versus black people. For instance, while my patients of color often find it difficult to access decent health care, white people of means and education living in areas with first-rate hospitals and holding jobs with adequate insurance are far more likely to obtain good preventive and acute care. They are far more likely to find physicians who will explain things to them, and they may even be positioned by education and wealth to absorb and easily apply what they are advised. In subtle ways that they might not even know to be white privilege, they are more likely to access the best specialists, organ transplants, and investigational drugs when they are seriously ill. It must be mentioned that factors external to medical access play a key role in unequal health outcomes: those who lack access to healthy food, clean air, or exercise time are much more prone to poor health and chronic diseases.

To be effective allies, we must acknowledge that racism is systemic and embedded in all institutions. We must have the humility to admit that our knowledge about racism is limited and superficial. Once informed about the history of oppression through slavery, the Civil War, and Jim Crow, we can then challenge ourselves to unlearn our perceptions of reality. We have to be willing to get uncomfortable and hear things we don’t necessarily want to hear.

Next, it’s time to act! Time to speak out against blatant injustices, time to reform our criminal justice system that discriminates against people of color, time to respectfully ask questions and listen, truly listen, to the lived experiences of people of color, time to promote education and work opportunities for black Americans, time to work toward health equity, time to march and peacefully protest hand in hand. Now is the time to speak to young kids about race and inclusivity. It’s time to condemn bigotry and white supremacy and to donate to anti-white supremacy organizations such as the NAACP, your local Black Lives Matter Chapter, Color of Change, The Sentencing Project, and Dream Defenders. It is time to condemn police brutality and abuse, demand nationwide de-escalation training, transparency, and accountability by law enforcement and bring justice to those responsible for the inhumane murder of George Floyd. There is no peace without justice.

Time to read books such as How To Be An Antiracist by Dr. Ibram X. Kendi, I Know Why the Caged Bird Sings by Maya Angelou, Just Mercy by Bryan Stevenson, Me and White Supremacy by Layla F. Saad, The Bluest Eye by Toni Morrison and The Fire Next Time by James Baldwin, watch films like Selma, Roots, 12 Years a Slave, The Hate U Give, and I am Not Your Negro or listen to the NYT 1619 Podcast by Nikole Hannah-Jones. When museums open again, visit the National Museum of African American History and Culture in Washington, DC. It will rock you to your core and open your eyes and heart.

Emergency physicians are not easily rattled, but when a patient says: “I can’t breathe,’ our heart rate goes up, and our pupils dilate. We know too well that the priorities when resuscitating a patient are ABC: airway, breathing, circulation. We can’t save a patient from death if we can’t secure their airway and facilitate breathing. A for Airway always comes first. George Floyd died in front of our eyes because his airway was forcibly obstructed for almost nine minutes. His final words, “I can’t breathe” — the same last words as Eric Garner and others unheard — are haunting and make me weep.

Bryan Stevenson writes in his book, Just Mercy: “We are all implicated when we allow other people to be mistreated. An absence of compassion can corrupt the decency of a community, a state, a nation. Fear and anger can make us vindictive and abusive, unjust and unfair, until we all suffer from the absence of mercy, and we condemn ourselves as much as we victimize others.”

Together we must take action to lift oppression off the necks of our black brethren. We are all born equal, with inherent dignity as children of God, the giver of the breath of life.

Josyann Abisaab is an emergency physician.

Image credit: Shutterstock.com