The administration of former U.S. President Donald Trump deliberately harnessed racism and class animosity to push policies that caused hundreds of thousands of American deaths, according to a scathing new report in the British medical journal The Lancet.

After undertaking a comprehensive assessment of the health and environmental impacts of Trump’s presidency, the 33 scientists who co-authored the article estimated that rollbacks of environmental and workplace protections led to 22,000 excess deaths in 2019 alone. They also found that 40% of U.S. deaths during 2020 from COVID-19 would have been avoided if the country’s death rate had been closer to that of its G7 peers, and blamed Trump for eschewing the advice of public health agencies and politicizing common sense responses to the pandemic such as mask-wearing.

The findings rely on comparisons with previous U.S. norms and those in other countries to make statistical assumptions about what mortality rates might have been if Trump hadn’t swerved away from the global scientific consensus. Philip Landrigan, a pediatrician and epidemiologist at Boston College who was one of the report’s co-authors, argued that it was fair to make the linkage.