Special Report: Racism and Inequities in Health Care for Black Americans
Abstract
Black Americans have long suffered from the negative health consequences of racism and encountered numerous barriers to receiving the health and mental health care they need. These inequities have intensified during the COVID-19 pandemic. What is the role of psychiatry in addressing these problems and working toward the eradication of racism?
Organized medicine and health care systems have consistently described their desire to achieve health equity. The coronavirus pandemic and its impact on Black communities shine a light on the pervasiveness of what has so far been an unattained goal—accessible, high-quality, and evidence-based care for all groups regardless of race, class, gender, or sexual identity. In the midst of the current public health crisis, psychiatrists and mental health professionals are challenged to take a closer look at their role in meeting the needs of communities that have been made vulnerable by systemic forces and social factors. The disproportionate number of Black Americans who have been infected by SARS-CoV-2 and died from COVID-19 is a call to action for all institutions and individuals that provide treatment, services, and care to engage with these communities in impactful ways. Our Association, its members, and its allies have the capacity to target local and national responses to the anxiety, loss, grief, and collective traumatic reactions of Black Americans.
The health of Black Americans has been synonymous with inequity since our country’s inception. While the word “inequity” is a useful descriptor in measuring outcomes, it fails to define the core reasons for health disparities. The substance of inequity is racism. Medical and institutional racism have driven disparate outcomes from Black Americans since the Colonial period. During the times of enslavement of people of African descent, they were considered inferior and inhuman. As property and possessions, the primary function of those enslaved was free labor to support the national economy.
The health and safety of Blacks at that time were of no concern. Physicians and medical scientists of the 19th century perpetuated white supremacy. Blacks’ desire for freedom or escape from captivity had been described in medical literature as a form of insanity, drapetomania. Enslavement was purported to be necessary to prevent insanity, and whipping was described as an effective treatment for this condition. Propaganda before and after the Civil War erroneously described excessive numbers of Blacks as residents of asylums in free states to dissuade abolitionist movements.
Although the enslavement of Black people effectively ended with the Emancipation Proclamation, little changed. Separate but equal policies could not quell the racist laws of the Jim Crow era. Hospitals and asylums for Blacks were absent, few, or poorer in quality. Segregation dominated at the start of the 20th century and limited Black Americans’ ability to own land and property, develop independent wealth and resources, sustain financial stability, and access health care. Even Black soldiers in World Wars I and II faced discrimination and were unable to access equal services through what became the Department of Veterans Affairs. Federal laws did not grant protections regarding access to health care for Black Americans until the 1960s. In 1965, through amendments to the Social Security Act, Medicare and Medicaid finally desegregated hospitals and health care systems.
Today, discussions of the mistrust of Black Americans solely focus on historical scientific and medical racism (for example, the Tuskegee Study of Untreated Syphilis in the Negro Male). Rarely do these discussions unearth what garnered present-day mistrust. Additionally, there is minimal emphasis on the steps that science and medicine have taken and should take to rebuild trust and connect with Black communities in ways that are culturally informed.
The field of psychiatry has struggled in a similar regard. As patient care shifted in the 1950s and 1960s from institutions and hospital settings into community settings, community mental health programs failed to meet the needs of Black communities. Black psychiatrists and activists led efforts to promote reform in mental health research, education, training, and workforce development; however, there continued to be a disconnect when it came to psychiatric and organizational leadership. Black physicians have traditionally propelled effective changes in organized medicine and health care. In fact, in 2008, the AMA issued an apology to the National Medical Association (founded in 1895 by disenfranchised Black physicians to be a collective voice for its members and communities) for racial discrimination in its organization’s policies and practices.
The National Academy of Medicine (previously the Institute of Medicine) published a landmark report in 2002, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” that examined racism in health care. It outlined the societal impact of racism and its effect on health care outcomes for Blacks and discussed professional biases. The document also discussed the inequities in service delivery. For example, Black patients were often undertreated for their depressive symptoms and white patients were more likely than Black patients to receive antidepressant medications for symptom management. Other major studies show racial differences in the diagnosis of psychotic disorders. Black people are more likely to be overdiagnosed with schizophrenia spectrum disorders, are more likely to be prescribed antipsychotic medications, and are more likely to be prescribed higher dosage strengths of neuroleptics than white people, despite similar symptom presentations.
Based on these treatment differences, it would appear that health care systems and mental health professionals misinterpret or ignore the experiences of Black patients. Expressions of Black distress are often policed (in both figurative and literal senses). Blacks are disproportionately represented in justice system involvement—particularly true for Blacks with severe mental illness—and are more likely to receive harsher sentences than their white counterparts. Experts agree that the mental health services provided in jails and prisons are inadequate.
Even with the dynamic interplay of racism and health, these topics are avoided in both undergraduate and postgraduate medical education. Professional standards and licensure requirements offer no emphasis on dismantling medical racism. When topics that superficially cover race are reviewed in additional settings, it is often within the domain of medical ethics. Relaying the stories of the Tuskegee study and Henrietta Lacks and her illustrious immortal cells—tissue taken without her knowledge that gave rise to innovations in medical research like vaccines, gene mapping, in vitro fertilization, and others—and their implications on medical experimental and informed consent are highly important in the history of Black health, yet these examples only scratch the surface regarding the relationship between racism and American health care. When health care systems, academic medical centers, and professionals sidestep deep dives into abuse, terror, discrimination, and biases, poorer health for Black Americans persists.
COVID-19 and the Experience of Collective Trauma for Black Americans
In light of the pandemic presented by the SARS-CoV-2, data have emerged regarding the effects of the virus and its pathology on global life and the global economy. For Black Americans, the alarming rates of infection and disproportionate number of deaths reinforce their feelings of abandonment by American health care and expose their unenviable positions in the social order. The CDC characterized COVID-19 data from 14 states for the month of March. While Blacks accounted for only 18% of the catchment area, they had a disproportionate hospitalization rate for infection (33%). Hospitalization was likely a proxy for both infection rate and disease severity.
While disease burden impacts rates of death, other factors that prevent access to care might be at play for Black Americans. Rana Mungin, a 30-year-old New York City schoolteacher and resident of Brooklyn, needed three visits to a local hospital before she was admitted for symptoms associated with COVID-19. Her sister recounted that during her second visit, the ambulance attendant didn’t seem to take her complaints very seriously. The attendant instead insisted that her shortness of breath was due to a panic attack. During her subsequent hospitalization, Rana required ventilator support and later died from disease complications in April.
In Michigan, the city of Detroit with its large Black population offers an example of the racial and economic factors that contribute to community spread of the disease. Detroit has received little economic support from the state government and federal aid in the wake of COVID-19. Historically, many communities are in medically underserved areas. Detroit is the major contributor to the state’s disproportional death rate of Blacks (33% to 40%) from COVID-19 despite the fact that this group comprises only 14% of state residents. In Chicago, 70% of COVID-19 deaths occurred in Black communities, most notably its South Side neighborhood. New York City shows comparable findings, and Southern cities like Albany, Ga., and New Orleans have faced similar challenges in Black communities. Racial data collection for COVID-19 isn’t ubiquitous; less than half of the data obtained through the CDC contain racial estimates.
American racism and adversity play a role in the higher psychiatric disease burden and trauma for Blacks. They not only face traumatic events common to modern society, they also experience the impact of racism, which starts early in their developmental processes. Overall, Black children are more often exposed to adverse childhood experiences than white children. Prior studies have shown that Black people have higher rates of posttraumatic stress disorder than white people. For Black Americans, the statistics associated with the coronavirus pandemic add to this serial or repeated trauma.
COVID-19 and Stigma
While the press coverage of COVID-19 in the Black community helps to expose inequities, this reporting also poses the risk of stigmatizing these populations. There have been multiple opinions circulating that Black Americans are more predisposed to COVID-19 because of their biology, physiology, or genetics. These distortions point to medical racism (for example. lung capacity and spirometry; kidney function and estimated glomerular filtration rate). Some politicians and medical professionals have misled the public by giving misinformation to news outlets. They frame their statements in ways that overlook factors that contribute to preexisting medical conditions such as obesity, diabetes, hypertension, and heart disease. Preexisting social conditions such as poverty, food and housing insecurity, and racism are the primary factors that impede access to quality health care. Our communities face real challenges. Among them:
The paramedics/emergency medical technicians who refuse to transport patients from Black neighborhoods.
Clinicians who send patients home because they didn’t articulate symptoms in a certain way.
States that decline to extend access to medical insurance to eligible groups.
There has also been stigma associated with public health measures to prevent the spread of disease. The effects of discrimination may make it more difficult for Black individuals to wear a facial mask in public since they may be perceived as threatening or violent or involved in criminal activity. Viral and antibody testing may have a connotation tied to negative experiences of family members and past generations who underwent medical experimentation for institutional gain (rather than personal or community fulfillment). Contact tracing and being monitored by public health departments (that is, forced authority) may be distressing and amplify the natural and typical hypervigilance of Black Americans. Leaders in medical, policy, and public health should alter their approach in ways that are sensitive to the needs of the Black community.
COVID-19 and Black Mental Health
Preexisting social conditions and stressors are particularly problematic for Black Americans suffering from mental and substance use disorders. As psychiatrists, we are responsible for dealing with the next wave of this pandemic—the traumatic response of COVID-19. The effects of isolation, unemployment, and grief place already vulnerable populations at risk for greater loss. The Census Bureau’s Household Pulse Survey shows that anxiety and depressive symptoms may be more prevalent during the pandemic. While a rise in measures that screen for anxiety and depressive symptoms may not predict the development of illness or a mental disorder, one can assume that groups suffering from the greater burdens of morbidity and mortality will also carry the weight of its psychological sequelae.
Blacks may be more burdened by anxiety associated with COVID-19 given the economic impacts. They have historically had higher rates of unemployment, are more likely to work blue-collar jobs, and are less likely to have employer-sponsored insurance. Blacks are more likely to use public transportation and more likely to fit into the category of essential worker. Socioeconomic status may factor into disparate health outcomes; however, access to mental health services even lags for Black Americans who have access to insurance benefits and the financial resources to support treatment engagement.
The Path Forward: A Strategy for Health Equity
The plight to eradicate the disparity is not the sole responsibility of the Black community, Black psychiatrists, or Black leaders. Psychiatrists and leaders of any background should address these issues directly and forcibly. The experience of Blacks and other marginalized groups in America is one of constant invisibility. Black people often wonder whether anyone notices their pain. Black patients repeatedly feel unseen and unheard in clinical settings. (One recent example is the coverage of maternal mortality rates in this group and the horrifying stories recounted by prominent celebrities of their antepartum and postpartum experiences.) The perpetual feeling that Black lives are less than or disposable, even in the beneficent environments of health care, is one that cannot be taken lightly.
Compounding Black Americans’ fear of the COVID-19 pandemic are the many and continual experiences of collective trauma through witnessed violence and the maltreatment of people who look like them and their family members. For people who have been victimized throughout history, images in the media of Black people and other racial/ethnic minorities being ripped from buses or thrown to the ground off subways simply because they are not wearing masks trigger negative emotions and physical distress. In addition to these images, Blacks are frequently exposed to recordings of Black men and women being violently assaulted or killed by their neighbors, community members, and those in authority. Psychiatrists must acknowledge and validate their patients’ feelings and experiences and serve their immediate needs. Through rapport building, patients may truly share how COVID-19 data and distressing images impact their lives and the sense of safety and security for themselves and their loves ones.
The generational trauma and enduring pain of Black individuals weigh heavily on their mental health. The disparate effects of these illnesses and deaths are not new phenomena for Black individuals; they’ve lived it for centuries. In the 1960s, racism was recognized as a public health issue, and that fact remains the same today. These disparities cannot be removed without intentional action and effort. To fully engage communities that have been overlooked and marginalized, we can’t simply offer prescribed treatments, services, or care. The medical profession infrequently builds partnerships with these groups to target the social drivers of health. Little is done in the way of anti-racist educational training or in advocacy for policies that produce the needed resources for Blacks to thrive and flourish. Wealth, power, and prestige—major social determinants of good health—are hoarded by the elite. Health equity can be accomplished only with a redistribution of wealth and resources and meaningful reforms that remove barriers for social programs and economic prosperity.
Black Americans represent approximately 13% of the U.S. population. Black physicians account for only 5% of the physician workforce and are even less represented in the psychiatric workforce. Black psychiatrists cannot go it alone in achieving equity.
The events of the past weeks highlight the imperative that leaders in psychiatry must acknowledge their role in community engagement. The national outrage over the deaths of Breonna Taylor, Ahmaud Arbery, and George Floyd should herald a call to action for leadership to promote the sanctity of Black lives and the well-being of Black patients.
Your steadfast responsibility as a staff physician, as medical director, as chief medical or executive officer, as board member, as program director, as attending, and as department chair is to collaborate with Black communities to serve their interests and connect with their values and goals. Finding ways to incentivize organizations and health care systems to support education, research, and culturally informed workforce development should be the mainstay of any strategy to accomplish health equity. ■
