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Illuminate the ways in which COVID-19 may have uniquely impacted minoritized and marginalized communities.
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Aletha Maybank, MD, MPH: My name is Dr Aletha Maybank, and I am chief health equity officer over the Center for Health Equity. The Center for Health Equity's mission is to ensure that we are helping to strengthen and really solidify and center AMA's work as it relates to health equity. And we started the series to really hear from physicians across the country and especially physicians who don't often have the space or get the space to talk and elevate their stories. And a lot of are minoritized and marginalized physicians, oftentimes, aren't heard from. So we really have valued the conversations that we've had over the last couple of months.
I just want to first recognize and honor the Indigenous folks in the land that we all kind of sit upon, and their thriving and surviving, as well as the historical context of those who are brought to this country who were enslaved for the production of our capitalist system and honor and recognize that their work and their sacrifice as well. And I'm very clear, this work of equity really stands on the shoulders of all of our folks and ancestors before us.
So I want to highlight also that we have a health equity resource center for COVID-19 on the AMA website. And we have, also on that site, some of the past episodes that you all can take a look at that we've had conversations around. So this conversation is going to center around mental health, which is very important for every single one of us. And I think COVID has definitely shed a light, not only on inequities, but also the inequities as it relates to access to services, as it relates to mental health, kind of this reality around not being connected to folks, and what does that do to mental health. Folks who have had deaths in their family, multiple deaths, what does that do, not only just to the individual's health, but also the family's mental health?
July was National Minority Health Month, Awareness Month. And, of course, there have been several public incidences and awareness of events that impact our mental health, the public murder of George Floyd, and this ongoing conversation. This is not whether or not you agree with Kanye West or in his running for presidency, but to me, it really elevates our challenge of being able to talk about mental health and the stigma that still surrounds it in our society and community. So today we have, and I'm honored to have, Dr Patrice Harris, who is our immediate past president, a psychiatrist, and she's the immediate past president of the American Medical Association and Dr Garcini, Luz Garcini, who is assistant professor at the Center for Research to Advance Community Health, which is a REACH program at the University of Texas Health Science Center in San Antonio. So welcome to both of you and thanks for being able to join.
So I just want to start off and how we start these conversations off, usually, just where are you at in this country, literally, and how are you doing? We're now, we're trying to figure this out earlier, we're now five months probably into the pandemic and it has flown by it's a lot, but still has flown by and just want to have a sense of how you all are doing.
Patrice A. Harris, MD, MA: Well, Aletha, as always, actually I will say this, Dr Maybank, because we always start with that, but, of course, we know one another and certainly feel free to call one another by our first names, but I am here in Atlanta. And today, at this very moment, I'm feeling pretty good because we are talking about mental health, but there is no question that over the past six months, there are days when I am more worried. There are days when I am down and quite concerned about where we are in this country on many levels.
So, but today it's a good thing at this moment, because we are talking about mental health. Just a couple of other things you mentioned that last month was a Minority Mental Health Month. It just has only been recently that we, from communities of color, are even comfortable talking about mental health above a whisper. And so I wanted to just acknowledge two people. I wanted to acknowledge Bebe Moore Campbell, the late Bebe Moore Campbell, who was very instrumental in getting July recognized as National Minority Mental Health Month. And she was talking about this before a lot of folks were talking about this. And I also want to recognize the previous Surgeon General, Dr David Satcher, who, in 2001, did a report focused on mental health, particularly around race and ethnicity.
So I'm having a good day. I will say, I know I said two things, but one more person, because I thought that it was important that Mrs Obama, former First Lady Mrs Obama talked about the fact that she's had difficult days and it had some days where she feels like she had a low-grade depression. So we are talking about it, and that's important.
Maybank: Absolutely. Thank you. Dr Garcini?
Luz M. Garcini, PhD, MPH: Yes. So I am in Texas. I am in, I fluctuate between San Antonio, Texas, and Houston. And as you know, the pandemic has hit us pretty hard recently. So at the moment, I feel very grateful, grateful to have a space like this to have an honor to share a space with two women, two other minority women like yourself, and put a voice to our communities and what is happening. So that's how I'm feeling. How I have felt over the past five months, I think, it's a mix between drive and motivation and sense of overwhelming. So I've been doing a lot of research and gathering data in our communities to see what is happening. What are the concerns? What are the barriers? How can we cross these barriers?
And there is a lot of distress. There is a lot of fear. There is a lot of panic and, sadly, there's a lot of distrust that is contributing to divisiveness among ourselves in more of our communities and contributing to further isolation. So it's a mix of feelings between feeling overwhelmed and sad for our communities and for what's happening in our country, but also it's a moment. A lot of our minority communities are communities that are very resilient and they find gifts in the midst of adversity to overcome and to come up flowed. So what are some of those lessons learned, that we can gather knowledge to keep moving forward?
Maybank: Absolutely. Thank you. And so let's move into during this COVID time, and you both kind of hinted at some so far, but what have been your biggest concerns as it relates to mental health during this time of COVID and everything else? What is really on top of mind in terms of your concerns? And we'll get to opportunities and all of those things as well, but I kind of just want to, for the audience to kind of tease out, what have been the major concerns? So Dr Harris, you go ahead.
Harris: Yeah, I'll start. Also, I think we should also mention sort of where we were pre-COVID. I think that's always important, and as regards of mental health, we had seen actually overall increase in the number of suicides, but our particular increase in the number of suicides among our youth, and even our very young youth. I think some people don't even want to consider or think about those, five to 11, even thinking about ending their own lives, and so that was pre-COVID.
Now we are in COVID, where we have increased stressors, with anxiety and loss of job and more financial insecurity. A parent's not able to pay for the things perhaps they pay for before. Children's lives have been disrupted, and all of these things were sort of a part of what, I would say, many of these things were a part of what we needed to do for COVID, but they are the very issues that cause increased risk for mental disorders.
That's been my biggest concern. Here, we already we're in a crisis mode, if you will, and now we have a situation where that just increases. On top of that, more barriers to getting treatment, which was already inequitably available among Black and brown communities. I think that's been a couple of my biggest worries.
Garcini: Yes, I work—
Maybank: I have it on mute. Dr Garcini, go ahead. Thank you.
Garcini: Absolutely. I would definitely echo Dr Harris that we know that they were huge health inequities and disparities existing prior to COVID, and this is just widening the gap. In the midst of a sociopolitical environment that is creating a lot of distrust and fear, and I think that is going to become a huge barrier, is a huge barrier, but it's going to be even wider as people even think about accessing confidential services or health services, because they're wondering how is my information going to be used?
If I start disclosing any sense of threat, will my children be taken away from me? Will my immigration legal status serve as a case for the deportation? We are seeing this even on people who are citizens and residents, so it's creating a lot of mistrust that is leading people to become more isolated and alienating themselves. Which along with that, we have the pressure and anxiety, the increase in suicides that Dr Harris mentioned. I think that's at the forefront of my mind. How do we start rebuilding trust in an environment that every day seems to go backward rather than forward?
Maybank: Yes, and we'll come back to trust because trust impacts so many. We think about the vaccine treatments, all these things that are about to come forward and the underlying, especially for Black and brown communities, the underlying concern or reality is a lack of trust for potentially what's coming forward. That has implications.
Can we talk specifically about mental health in the health care providers? We've heard many stories, and Dr Harris's AMA, you've heard many stories directly as well from physicians and their challenges of working and not having the resources that they need and the stress of that. Then having to go home and work to take care of their families and the stress of wanting to protect their families as well, and not feeling like they're able to, but there were so many other things. Can you speak some to that?
Harris: Absolutely, and such an important topic on a lot of issues. As physicians, and really all health care professionals, I think we've been trained to take care of a crisis, but I think the way we've been trained and the way we've thought about crises and disasters is they would be time limited. This particular public health crisis has been unrelenting, nonstop, for many physicians. Of course, those in the hardest hit areas.
There's been no opportunity for any downtime, again, speaking of those. We are just not prepared for that, not just physicians and not individually, but our system is not prepared for that. Then on top of that, and again, physicians, nurses, psychologists, health professionals, we are willing to enter the breach, but we also expect to have the supplies that we need.
Here we are with this unrelenting COVID-19 crisis. We don't have the supplies that we need. Don't always have the support that we need. People are speaking out and are being disciplined, and so there's that fear. Let's just also admit that, as a community, this is a generalization, there's not always an incentive to even ask for help. That's a whole other conversation around licensure and so forth and so on. I'm really concerned again about the mental health of our profession and all the health care professionals.
Now, fortunately, some systems are putting in place supports, and these are just in time supports and not that the next day or the next week, but right now, when you need it. We are putting in some systems of support. That is not universal, but there are systems that are doing that.
Aletha, I am worried, and again, I'm not predicting this, but I'm worried about this. I think the good news about that is that we can prepare, but I think we should be thinking about the long term impact on everyone. Again, particularly health professionals we're talking about in this question, and be prepared to have an infrastructure to deal with longer term impacts as they come up.
Maybank: We can come back to that as well, and what does that look like? What does it mean to say the infrastructure and re-imagining an infrastructure, I think is important? Dr Garcini, can you reflect on health care providers in your interaction with them as well?
Garcini: Absolutely. I think the here is where we see another disparity and another gap, right, in that, do we know that there is not enough providers of minority backgrounds? A lot of the time the caseloads and the nature of the cases that minority providers see is going to be very different.
They might have to take more cases, particularly, for example, for Spanish speaking, because there's not that many at the forefront. They'd become overwhelmed with so many patients that they have to see. Or, for example, the complexity of the cases in terms of maybe seeking care of the advanced stages of the disease, whether it's physical or mental and not having the resources. When you provide your recommendations to treatment, to provide your families with what they need, it bears a bigger burden on the providers, I would say.
Then on the other hand, we also have providers across all different cultures. When you face people from minority communities to reflect on your own biases, do I have the tools and the resources to be able to effectively, culturally and competently treat these patients? It creates a lot of anxiety for providers across color lines, skin color.
Unfortunately, we haven't figured out how do we disseminate cultural and contextually sensitive treatments for our providers to best meet the needs of our communities? So that's definitely another thing that increases tension and stress among our health care workers.
Maybank: Absolutely. And that's what—oh, go ahead.
Harris: Yeah. And just add to that, really, when we talk about Black and brown health professionals, I believe there is an increased burden. I don't have children, but a lot of my female women physician colleagues were talking about the George Floyd videotape and how they could not bear, many people could not bear to watch it. But it was even more traumatic for them as mothers. And they just could not bear it because, again, they were just worried. That even increased their worry about their sons and their daughters, again, with Breonna Taylor. So I think, as we talk about the mental health of the health care workforce, in general, and we need to also talk about the particular concerns and worries and issues that impact Black and brown health professionals, in the midst of seeing COVID and police violence disproportionately impact Black and brown individuals, and racism and structurally which is playing out in all of these issues.
Maybank: Absolutely. And the other thing about the professional of color, the physician of color, health care provider of color, is that they have to go back to their workplaces that oftentimes, as has already been highlighted, that are not diverse, right? And oftentimes have to explain or stomach or tolerate comments. And it can be exhausting, as well, and how to deal with that context at the organization or your institution also can feel very burdensome, from what I'm hearing.
One of the opportunities that we are going through at AMA is that we are doing a survey of marginalized and minoritized physicians, during this COVID time, to better understand their experience. I think the data, those are things that aren't often asked of providers and physicians of color. So we need the data. And we talk a lot about the data and the importance of data. And I would imagine, and you both could reflect on this, there's a lack of data as it relates to mental health. And without having to even say the specifics of it, but there's a lack of data in terms of understanding Black and brown communities and what they're going through. Any thoughts and comments about that?
Harris: Well clearly, we start with the data, and there's a gap, but Aletha, you and I talked about this early on in this pandemic that the good news is, if you can glean any good news, is that we did ask for, and some data did come out early on. Because you and I were talking about typically what happens is oh, after we get through the crisis, someone says, "Oh, I think this may have impacted Black and brown communities. Let's try to gather the data," and then it's not there. So even though we are nowhere near where we need to be, but when you talk about mental health, there's even more of a challenge, sometimes, with getting the data regarding the impact on Black and brown communities. You might be getting to this, and I can wait if you want to, but you mentioned trust.
Harris: And as those of us in the workforce in mental health, trust is important at any time. But candidly, our patients tell us things that they don't even tell their spouses and partners and significant others. And so trust is required for us to really develop a relationship and to even help out, as best we can. And so, some folks don't want to disclose then and then they're not counted in the numbers and then we don't have the accurate data to then determine what services. It's perpetuating further issues around lack of services and the data that is required.
Maybank: Absolutely. Thanks for that.
Garcini: And if I may add to that. I think also, because we attend minority communities, we need to step out of our comfort zones and be embedded in the communities that we serve. And a lot of that would require us to collaborate with faith-based organizations, who see the front lines of what's happening. And we want data, we need to go out there, rather than waiting for our people to come and get it. We need to use our community health workers, who are a fantastic support for the communities that traditionally don't have access, our safety net providers. I think it is time to think outside the box. The complex issue is the funding part that we often have to do a lot with very little. But if our people required it, I think it's time to put those as a priority in the forefront to gather the data that we need to best meet the needs and to shorten the gaps that have become so big with this current pandemic.
Maybank: Absolutely. So getting to advocacy, per se, and AMA being a very strong advocate for health and the well-being of folks across the country, as well as the physician community and health provider community. Dr Harris, are you able to speak a little bit to what—over the last year in your presidency, you've been very busy and I know you're still busy—what have been those key areas that you've been able to kind of advocate and speak to, as it relates to mental health, and use the AMA as kind of the power and voice in that space?
Harris: Well, Aletha, as you recall, on June 19 when I was inaugurated and, of course, in addition to our three strategic priorities and priority arcs at the AMA, I said that I also wanted to, again, building on AMA policy, I wanted to amplify three things during my year as president. I wanted to amplify the importance of mental health and how it needs to be integrated or embedded, centered in overall health. I talked about the diversity of the physician workforce, but not as an endpoint, but diverse physician workforce in the service of equity. And I've talked about trauma, specifically, childhood trauma. And, as I've said over and over during this last year, of course I would not have wished this pandemic on our world, but certainly those are three areas that have been amplified. And I have been able to amplify and connect the dots over this past year.
So it is my hope, but I say it's a pragmatic hope, I'm pragmatically optimistic, because it will require the AMA and other organizations and physicians, in general, everyone to continue to advocate that mental health is centered, equity is centered and that trauma is a part of the conversation as we move forward with a brand new system. And you started out at the very beginning, talking about envisioning a brand new system, where these things are embedded and intertwined in all systems. Not just what people consider the traditional health care sectors.
As I say, now, every sector is a health care sector because every sector contributes to the health care or lack thereof. And so we have to work together to envision that. And of course the AMA will be partnering with the American Psychiatric Association, I'm sure others. I do want to say one quick example. It's something that you say a lot about the Center for Health Equity is we want to voice and model commitment to this. And so I think the modeling is important. You know, that at the AMA, we are looking at internally. And I just want to say that the American Psychiatric Association is doing the same thing. Jeff Geller, the current president, just appointed a task force to look at racism. One quick point, I know we're short on time, is that in the past, those who were enslaved, who ran away, they were characterized as having a mental disorder.
Harris: Exactly. So we have to look, all of us, look at our past as we build and envision that future.
Maybank: Absolutely. Dr Garcini?
Garcini: Yes. I could not echo more on the comments of Dr Harris. I think in terms of, how do we get out of where we are right now? And I think that the beginning is going back to the trust. How do we build trust? And I think there's a need to change the rhetoric that is taking place in our country. We need to be a more tolerant environment, more empathetic community, and less divisiveness among our people. We need to equip our communities and empower them to disseminate valid and reliable sources of information that are contributing to so much fear among them. So that's definitely another one. And the other one is it's time to move to interdisciplinary workforces with mental health providers at the forefront along with primary care providers to best meet the needs of our communities.
We need better assessments. We need to devise cultural context practices. I know a lot of the times we put a lot of emphasis on evidence-based practices, but a lot of those evidence-based practices haven't been tested in our people. A lot of the diagnosis that we have, trauma might not present with the same symptoms that it might present in our communities. So how do we start paying attention to those things in better tailoring our services, our assessments and our treatments to the people that needs it the most?
Maybank: Absolutely. In the last 3 minutes, this goes by really quickly. This is the first time we have done a half hour. So I'm realizing this is really fast. I definitely thank you both for providing your voice at this time. What is one last piece of advice that you want to give? I could say the physician and provider community, but I'm going to say we're all a part of a community that has to go back to their homes and their families and engage. And so what is your key advice? I know as AMA we just released our campaign of Mask Up. So Mask Up, that's one. I got it. But even in the context of mental health, what's your one piece of advice?
Harris: Well, I think, again, get your information from a reputable source. There's a lot of physicians who, not a lot of physicians, there are a lot of people who are obtaining a medical degree from social media. And of course, no. So make sure you're getting accurate, reputable—there's even more misinformation out there around COVID, but also mental disorders. And sometimes people conflate normal feelings of stress and emotions with mental disorders. So we have to have these conversations. But get your information from a reputable source and ask for help when you need it.
Maybank: Thank you. And AMA website does have some sources, I know, for providers. There's a whole site that's there for providers and their family in terms of mental health resources so anybody's able to go to that. Dr Garcini?
Garcini: Yeah, certainly it's a question that I've always get asked, "Well, how can I help? I don't even know where to start." And I always tell people, "Look at the platforms that you have." We all have a platform regardless of the size of it. It can be at your family. It can be as a leader in your community. It can be at our academic institutions that are medical institutions as a provider. Whatever platform you have you set to set an example. Set an example as to how we interact with other people, how we destigmatize existing stereotypes that have caused so much damage in our communities, how we start spreading kindness among people. How can we help each other navigate the current crisis without going into conflict? Facilitating the opportunities for dialogue without being offended and showing respect for people. I think if we can all start small with that and start spreading some of that, there might be healing because where we are right now is just contributing to make things much worse.
Maybank: Thank you. Well, we've reached the time. I want to thank you both for your leadership, for your work and for your voice and for sharing and spending this time with us and the audience today. So thanks a lot. Take care and be well, everyone.
Harris: Thank you.
Garcini: Thank you very much.
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Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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