Health Care Equity

Diversity equity and inclusion (DEI) in health care

Its impact on psychiatry

BY ASFIA QAADIR, DO

To better understand current barriers to equitable access and delivery of healthcare within BIPOC communities, we must understand the roots of racial trauma within the healthcare system as it evolved for hundreds of years in conjunction with the institutions of slavery and settler colonialism of indigenous tribes. Taking this closer look is a trend that is taking off across the nation, fueling renewed interest in placing modern healthcare practices in a broader social context. At PrairieCare, we too are taking a closer look at how psychiatric healthcare across the lifespan and within diverse communities can be transformed to truly meet the needs of our patients. This transformation begins with a deeper understanding of how racial trauma is embedded within the troubled history of psychiatric healthcare and ends with intentionally addressing systemic biases and limitations within the field that have impeded healing for so many patients. One bias I will maintain is that the field of psychiatry has an unparalleled capacity to ease suffering in a way many other areas of medicine cannot. It is time we honor this capacity by taking account of historical roots of harm and create new paradigms of patient care.

Looking back on history

While stigma is often cited as a barrier to accessing mental healthcare within BIPOC and immigrant communities, placing the sensibilities of a non-western culture as inherently limiting engagement in mental healthcare services distracts from learning about the roots of this stigma and the history that leads to such distrust within BIPOC and immigrant communities vis-á-vis psychiatric care. From the mid-nineteenth century up through the last 50 years, the seeds of this reticence to engage mental healthcare within BIPOC communities were planted through systematic policies that rendered mental healthcare facilities spaces of fear, powerlessness, harm and trauma.

 Issues of patient care inequities are rampant.

As the epidemic of youth suicide among indigenous youth grows, families struggle to manage crises without accessing hospitalization, residential services, or other intensive mental health care that could be life-saving. One of the most common fears encountered in mental healthcare settings is the fear of family separation. Whether via the complex involvement of Child Protective Services or consent for inpatient, residential, and day treatment settings of care, families often experience fear and trepidation of indefinite separation as well as a sense of powerlessness. These fears are rooted in historical legacies of harm and abuse within institutional settings. In particular, for indigenous youth, admission to inpatient and residential settings bears the weight of generations of abusive boarding schools and asylums to which they were relegated by powerful forces of settler colonialism. While the trauma of boarding schools continues to devastate survivors to this day, it behooves mental healthcare workers to understand the barriers to accessing mental healthcare within indigenous communities. 

The Indian Removal Act of 1830 heralded the era of forced assimilation of indigenous tribes to European settler culture. In practice, this was a systematic process of cultural genocide in which all traces of tribal beliefs, practices, and identity were federally outlawed and rendered illegal. Federal mandate forcibly removed generations of indigenous children from their homes and placed them hundreds of miles away from their tribes in boarding schools across the US and Canada. Recently hundreds of children’s remains in mass graves across Canadian boarding schools have been brought to light, and US Department of the Interior Secretary Haaland is proposing a federal initiative to investigate similar findings in the US. As history is brought to bear on today’s healthcare environments through myriad DEI efforts, the impact of this legacy of boarding schools has become intensified within mental healthcare. Survivors of boarding schools are survivors of complex early childhood trauma, and as adults, struggle with addiction, suicide, and complex PTSD. Transgenerational trauma is common among BIPOC families, with parents and caregivers retraumatized and struggling to maintain their own mental health.

Impediments to healing

Mental healthcare clinics, hospitals, and residential programs have the capacity to be spaces of healing and recovery. For many BIPOC patients and their families, however, the experience of going through mental healthcare services recreates scenarios of cultural erasure, family separation, and losses of autonomy and identity. With the lack of funding for child/adolescent inpatient beds, youth are often sent hundreds of miles away, sometimes out of state, to get emergent mental healthcare in a crisis. This structurally separates and disenfranchises parents who have to make the agonizing choice to consent to medical care and send their child away. For youth who are able to access inpatient and residential services closer to home, issues of patient care inequities are rampant within these spaces as care providers and patients struggle to bridge an invisible cultural divide when it comes to contextualizing mental distress, understanding the complex identity formation for BIPOC youth, the ramifications of psychiatric diagnoses, and limited treatment options that only include westernized models of healing. These inequities for indigenous youth, placed in context of the history of genocide and forced assimilation their families have survived, reinforce the notion of cultural erasure and harm to indigenous youth within mental healthcare settings.

To understand how the medical system reinforced, supported, and benefited from the institution of slavery, it is necessary to reframe our fundamental understanding of the institution of slavery as a multifaceted system that was itself dependent upon, and provided support to, other systems. Slavery was a social, economic, and political institution. To maintain slavery took tremendous collaboration between multiple systems, and that collaboration included the medical system. During the 1800s, it was standard practice for medical colleges to use slaves from plantations and to advertise the wide availability of slaves in order to attract medical students and faculty. Physicians accepted slaves as payment for services. Physician-scientists entered into agreements with plantation owners and were either gifted or bought slaves to use in experimental procedures. 

state funded asylums were racially segregated, and poorly funded; it was prevalent to have overcrowding, as well as a lack of clothes, food, and beds. Sexual exploitation and abuse were rampant. Sterilizations were performed per policy on patients who became pregnant multiple times. Patients were leased out for work and routinely rerouted between asylums, jails, and poorhouses. Psychiatric literature published just prior to the Emancipation Proclamation formalized specific diagnoses of clinical insanity of freed slaves which subsequently led to the institutionalization and incarceration of freed Black men. Clinical descriptions were also formalized in the published literature that outlined racial tropes and planted the seeds for implicit biases which impair equitable healthcare delivery to BIPOC patients today.

Care providers and patients struggle to bridge an invisible cultural divide.

To understand the significance of the Tuskegee experimentation on African American men is to begin to understand the legacy of abuse of BIPOC communities within the medical and research sectors. From lack of consent, false diagnoses, false treatments, and systematically preventing access to life-saving treatment, the “Tuskegee Study of Untreated Syphilis in the African American Male” is perhaps the most prominent example of medical abuse which every healthcare provider should know about; it spanned 40 years until it ended in 1972. Our canonized medical ethics (e.g., respect for patients, “Do No Harm,” informed consent), as well as protections for research subjects via Institutional Review Boards (IRBs) for all research conducted in the US, all developed in the wake of Tuskegee. HeLa cells that are used today across the world to support cutting edge research and life-altering treatments were obtained via biopsy without the consent of Mrs. Henrietta Lacks or her family in the 1950s.   

Perhaps the lesson, at this point in the broad arc of healthcare justice is one of humility. A humility among those of us with a calling to heal and ease suffering which propels us to take account of the historical frame in which healthcare exists today. Indeed, most healthcare professions do not teach these historical roots of racial trauma, and as a result, clinicians systematically do not recognize, diagnose, or engage it. When we see our patients, the individual stories they carry, and also the systemic histories they bear, we will begin to create spaces of healing that can truly transform our communities. As we look to the future with renewed intention for inclusivity and improving patient care, mental health systems in particular have a unique opportunity to contribute to this effort, because mental healthcare inherently relies upon the integration of multiple professions and skillsets. From social workers, nurses, and psychiatric technicians to physicians, psychotherapists, and advocates for community-based services for families and youth, the work of mental healthcare is far-reaching. There is a need for increased representation among mental health workers to reflect the experiences and cultural nuances of our patients. For many families in need, that first step to seeking care is often facilitated by someone they trust and with whom they identify culturally.

As we increase our collective awareness through DEI initiatives, we must also dedicate ourselves to mentoring, recruiting, and supporting mental healthcare workers who represent the diversity within our communities. Weaving a path between vulnerability and resilience, BIPOC healthcare workers are pioneers within mental healthcare settings, and while their efforts may be lauded, this also means grappling with issues of professional microaggressions, lack of culturally responsive supervision, limited opportunities for professional growth in the absence of mentoring relationships, and disproportionately higher rates of burnout among BIPOC mental healthcare workers. The work of mentoring and recruiting BIPOC healthcare workers and training culturally responsive clinicians must focus on graduate programs that train our future physicians, social workers, nurses, and psychotherapists alike. From an educational perspective, children who have opportunities for better schools and higher education have a much higher likelihood of succeeding, whereas children without comparable opportunities–disproportionately BIPOC students–will struggle to compete academically despite their best efforts. The result is a lack of representation in our clinical settings, and this lack of representation affects patient care. In a state that has the largest racial gap in homeownership in the US, Minnesota also has the largest racial gap in student achievement scores in the nation. The call for equity in educational opportunities in Minnesota is indeed a call for equity in representation at all levels of society, most earnestly within mental health systems.

ASFIA QAADIR, DO, is the clinical director at PrairieCare Maplewood and Clinical Consultant to Diversity, Equity and Inclusion  across all PrairieCare locations.