Mental Health Disparities in Latinx (Flores, 7/29/2020)

A big thanks to CEDAWG and Dr. Yvette Flores, clinical psychologist and professor of Chicano/a studies at UC Davis, who gave a powerful and heartfelt Grand Rounds presentation this week on how to consider and approach the mental health of marginalized groups, particularly Latinx , in this time of COVID. Again, it is hard for me to give her words justice in summary, but the following is my attempt.

Dr. Flores started with "stating the obvious": 1) That racism, sexism, homophobia and other forms of discrimination affect the mental health of those who experience them, 2) That stress affects well-being and 3) That yes, in fact, we are all in this together.

If I don't wear a mask, I affect you.

If my grandchildren don't wear a mask, it affects me.
We are all a little anxious, depressed, and experiencing past traumas as we live this pandemic.

We all need to be in this together, including in mental health.

Dr. Flores spent some time reviewing the important effects of stress on mental health.

Social stress: stress is produced not only by personal events but also by the social conditions that surround us-- and for all our patients, their intersectional identities (gender, class, nativity, immigration status, length of residence in the US). 

Minority stress: high levels of stress faced by members of stigmatized minority groups (race, gender, sexuality, linguistic ability, physical/mental abilities), including:

• lacking proper social supports
• socioeconomic status (SES)
• interpersonal discrimination

Marginalized status affects physical and mental health.

Good stress vs. bad stress: a little stress has been found to improve performance, but a lot of stress can become problematic. In what ways is minority stress a risk factor? And how may minority stress also be a protective factor?

I love considering the possibility that the very minority stress our patients are experiencing may make them simultaneously vulnerable and resilient. 

What has COVID-19 Revealed?

1) Health disparities have been made more visible

2) Xenophobia and hate crimes against Asian Americans

3) Disregard for these disparities from politicians at the highest levels

4) People of color disproportionately work in front line jobs

5) Disproportionate unemployment rates for Latinx and African Americans

6) Ageism (are old people important enough?)

How can we translate scientific data in a way that people can understand?

How do we frame the message?

"There is no one to blame here, but we all have responsibility."

Role of Gender: For the working class, life and work are often synonymous. How does unemployment affect men? How does unemployment impact women who are single parents and have to work? People of  color will often go to work despite the risk because of their gender or cultural mandate that it is their obligation to provide. But this is also a class issue (always need to think intersectionally).

What are the protective factors in communities of color that might mitigate the crisis?

1. Resilience: Immigrants are tremendously resilient. It takes incredible courage to make the journey that many immigrants (particularly undocumented immigrants) make.
2. Stoicism:  coping, "it's alright, I am fine", challenging for healthcare professionals to care for someone who says they are fine (when they clearly aren't). Dr. Flores' rec: Bring in partner if there is one/
3. Religious faith: "Si Dios quiere" God willing. Can be frustrating because seems fatalistic but is also protective. How can we leverage this?
4. Networks of support:  Overcrowded and/or Multi-generational households, which make them more vulnerable are also the very support structures that allow people to survive. How do we mobilize the 
5. Positive ethnic, racial and gender identity: reaffirm their identification (whatever they may be). Call them what they want us to call them. 

Remember that mediational factors may ADD to minority stress

• Internalized racism
• Controlling images (often propagated in the media-- more serious and perverse than stereotypes), many are gender specific (angry black woman, loud Latino, Latino male as criminal or rapist). How does this affect internalized perception of people of color?  How are people in power speaking about these controlling images?
• We must uphold the identities of the people with whom we work: we need to counter these controlling images (mental health workers)

And finally, on coping: how to potentiate coping, so we can be better healthcare providers and caretakers. 

Dr. Flores called this digging into our ancestral well: we have all learned lessons from our family that can help us to serve our patients. In times of crises, we can draw from the stories/legacies that the elders and ancestors have shared with us (and with each of our patients), which can help transform our fears into opportunities

Where do you draw your strength to continue to care for your patients?

Self care is essential during COVID-19:

It is important for us to promote self-care and resilience as we do this work.

Gendered expectations (nurture ourselves in order to refill the well)

Remember to check out and disconnect in order to connect to ourselves 

Cultural traditions can offer balancing and healing: including prayers, smudging, meditation, mindfulness, exercise, baking, cooking

Health Equity (Muodeme, 7/23/2020)

Special thanks to Dr. Ada Muodeme for her thoughtful and thought-provoking Grand Rounds this week on Health Equity. 

A friend and healthcare provider asked me this week, "Why are you hosting  so many Grand Rounds on race, racism, equity, and inequity?" My response is the following: "We bring you these topics because we-- the Sonoma County medical community-- need formal education on these topics. We need race discussions in our academic centers, in our hospitals, in our clinics, in our classrooms, break rooms and beyond. Grand Rounds is a natural place to start these conversations."  

And I am so grateful to our brave residents for being the leaders of this education!

While social justice was definitely integrated into my own medical training, race and racism in medicine were definitely not a part of any training. I did not get taught about how race and racism are structurally a part of medicine. I was not trained on allyship, anti-racism or white privilege. These are topics most white people (myself included) need to hear, read about, grapple with, and consider both personally and professionally. While many of our current residents come to us now with formal training in race and medicine, their teachers have little to none. 

And so we do this work.

This is another GR presentation by a BIPOC better listened-to than summarized by a white gal like me, but here are a few key points:

• Dr. Muodeme reminded us that healthcare comprises only 10% of an individual's health and well-being-- the remaining 90% includes behaviors, environment, societal factors, etc. She grounded her talk in the historical perspective of the African American citizenship status and health experience from 1616 to 2020-- slavery, Jim Crow, and Civil Rights. 

• Dr. Muodeme also shared with us a definition of health equity: "The attainment of the highest level of health for all people". Health equity-- she continued-- requires valuing everyone equally, societal efforts to address avoidable inequities and injustices, and the elimination of health and healthcare disparities.

• But what I appreciated most about Dr. Muodeme's presentation was her focus on the concept of unconscious bias, and the process of self-reflection and self work we all need to do to help mitigate those biases. "I don't know a doctor who comes to work thinking I don't want to right by my patients today," she said. "I don't know a doctor who thinks I am going to treat my black patients differently". And yet, we know we do. The system does. And we do. 

And so, pay attention, watch your thoughts, all. And see you next week!

Allies and Accomplices: How Health Care Providers Can Cultivate Equity (Washington 7/15/2020)

Well, Dr. Sharon Washington did it again. And this time on Zoom (which is no easy task). She pushed us. And moved us. To think differently. To act. To do better. To question the insidiousness of race and racism embedded in our society and in medicine. To not be not racist, but rather to be ANTI-racist. She is such a tremendous speaker and incredible teacher, and we at the Santa Rosa Family Medicine Residency are so lucky to have had her with us this last year and a half. 

A summary cannot really do Dr. Washington's work and words justice. I highly recommend you watch the Grand Rounds if you did not attend live, but nevertheless, here are some highlights. . .

Racism is not merely one individual's negative thoughts about another person of a different race. Racism is more layered and complex. It includes:

• internalized: the devaluing of one's own identity and culture according to societal norms
• interpersonal: the way in which we perpetuate racism on an individual basis
• institutionalized: the way in which institutions perpetuate racism
• structural: system of public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways, to perpetuate racial group inequity

Dr. Washington highlighted the legacy of inequity for African Americans in the US dating back 401 years (see image)

Dr. Washington reminded us that:

• There is racial bias built into almost every aspect of healthcare.
• Significant health disparities exist for people of color in chronic disease (diabetes, cancer, heart and kidney disease), infant and maternal mortality, stroke, addiction and mental illness.
• People of color receive fewer/less breast cancer screenings, kidney transplants, vaccinations, eye exams cardiac care, cancer pain meds, revascularization procedures, and mental health treatment.

In order to not be part of the problem, health care providers have a responsibility to be ANTI-racist: the active process of identifying and eliminating racism by changing systems, organizational structures, policies and practices, and attitudes so that power is redistributed and shared equitably.

What is allyship? 

Allyship is a person of one identity group standing in support of another identity group 

• allyship is not a noun, it's an action
• allyship is about listening
• allyship is not a proclaimed identity--> trust is earned
• allies don't take breaks
• allies educate themselves (and don't expect marginalized people should teach you)
• allies don't need the spotlight
• allies focus on those who share their identity
• when criticized or called out, allies listen, apologize, act accountable, and act differently going forward

What is an accomplice? 

"While an ally will mostly engage in activism by standing with an individual in a marginalized community. An accomplice will focus on dismantling the structures that oppress that individual or group-- and such work will be directed by the stakeholders in the marginalized group" (Teaching Tolerance)

• accomplices assess an organization for inequities in hiring, promotion, pay, evaluation, termination, etc
• accomplices encourage major institutions benefiting from inequities to invest in marginalized communities
• accomplices engage in anti-racist assessment of laws, policies, institutions, and systems
• accomplices divest institutions from (private) prisons, detention centers, and institutions engaged in systems harmful to BIPOC
• accomplices promote self care for BIPOC
• accomplices create systems of accountability for supporting hate speech and behavior

Examples of what allies and accomplices can do in medicine:

• Petition the laboratory you use to stop reporting GFR differentiated by race
• Hold a fellow physician accountable if they send a racist email or make a racist comment
• Interrupt micro-aggressions when they are happening
• Don't vote to appoint someone to the board unless they divest from investments that perpetuate racist structures
• Pass the microphone to the marginalized person next to you whose voice is not often heard

Questions to ask yourself:

• In what ways can you be an ally?
• In what ways can you be an accomplice?
• In which institutions do you have agency to create structural change?
• What is holding you back from taking action?
• What commitment can you make to move you toward meaningful action?