Kephart L. Structural racism as a determinant of Black mental health: looking back to move forward. Harvard Public Health Review. 2021; 30.
Black individuals in America are more likely to experience mental health problems, but less likely to receive treatment (American Psychiatric Association, 2017). In the United States, being mentally ill while Black can be a death sentence. Those who are Black and have a mental illness or a mental health condition are disproportionately represented in the criminal justice system and as victims of police killings (Agbafe et al., 2020). This crisis is amplified in the midst of the COVID-19 pandemic, a time of extreme economic and emotional stress, where Black and other people of color are overrepresented in COVID-19 deaths and underrepresented in COVID-19 vaccination (Ndugga et al., 2020). Structural racism is often defined as the codification of racism in laws, policies, institutions, practices, and societal norms—recreated and reinforced across time—that systematically disadvantage Black, Indigenous, and other people of color across societal systems and different levels of influence (Bailey et al., 2021; Williams, Lawrence & Davis, 2019). While structural racism itself can be thought to be a direct determinant of mental health, it also works indirectly through institutions and practices such as policing, mass incarceration, social control, segregation, scientific racism, medical racism, lack of access to culturally competent mental health care, stigma and discrimination (Davis, 2020). Importantly, this operationalization of racism above and beyond interpersonal discrimination requires interventions that disrupt, dismantle, and transform existing structures in the United States. In this paper, I will first describe how structural racism manifests through these pathways to lead to poor mental health outcomes for Black populations in the U.S. and briefly describe how interventions across different levels of influence can address this urgent public health issue.
Since the founding of colonial America, scientific racism has been used to justify the enslavement of Black people under false claims of mental inferiority and innate physical abilities that made them uniquely suited to bondage. In the mid-1800s, Dr. Samuel Cartwright, a prominent pro-slavery physician, published scientific literature asserting that enslaved individuals attempting to flee captivity (a diagnosis called “Drapetomania”) or who were insubordinate to their oppressors were suffering from mental illnesses that could only be “treated” with further subjugation (Cartwright, 1851; Krieger, 2011; Bassett & Graves, 2018). Flawed statistics demonstrating so-called higher insanity rates among Black individuals in free states versus slave states were used justify the continuation of slavery in the South and served as a common argument that was backed with “data” against abolition (Krieger, 2011). Scientific racism persisted well into the 20th century, perpetuating ideas of Black “inferiority” to justify continued dehumanization in the medical system and medical experimentation in Black communities (Washington, 2006; Bailey et al., 2021).
Leading up to the Civil Rights Movement, schizophrenia was increasingly reframed as a disease that mostly afflicted middle class white women to an aggressive disorder that primarily manifested in Black men (Metzl, 2010; Metzl & Roberts, 2014). Subsequently, Black men were viewed and treated as innately aggressive, prone to violence, and mentally ill – creating the grounds for institutionalization and intervention by medical institutions to treat, cure, or otherwise contain these individuals. Black Civil Rights activists were labeled as delusional, psychotic, and schizophrenic—symptoms and conditions that were seemingly triggered by their participation in the social and political movements at the time (Bromberg & Simon, 1968). This reframing of schizophrenia and the portrayal of Black men as mentally unwell created another pathway by which the medical system could exert social control over Black bodies who were seen as a threat to the existing white dominant order. This false narrative of Black men as inherently aggressive or criminal likewise provided justification for increased police presence and accompanying police violence to maintain “social order” in Black communities. A similar vilification of Black women occurred where, in the late 1980s, hospitals and law enforcement officials, urged on by the “crack epidemic” and the War on Drugs, began drug testing, arresting, and incarcerating pregnant women, most of whom were Black (Metzl & Roberts, 2014). Instead of receiving much needed treatment for their substance use, these women were vilified and criminalized – a practice that was a result of problematic racial stereotypes and federal policy that unequally criminalized substance use taking place in Black communities compared to white communities (Metzl & Roberts, 2014).
The continued criminalization of Black men and women experiencing mental health issues has created a perpetual cycle wherein these individuals are perceived as inherently aggressive or threatening and are responded to with violence. In just the past few years, the use of police as first responders to mental health crises led to the needless deaths of Black Americans such as Marcus-David Peters, Natasha McKenna, Daniel Prude, and perhaps unnamed others (Boyd et al., 2016; Jordan et al., 2021). A study by Thomas, Jewell, and Allen (2018) indicates that police are more likely to fatally kill unarmed, older Black, mentally ill men compared to their white counterparts. Black individuals in need of mental health treatment may be racially profiled, experience police violence, be taken into police custody, and experience subsequent incarceration. Incarceration itself is associated with several poor health outcomes, infectious disease risk, psychological distress, and further victimization for experiencing mental health symptoms instead of receiving treatment (e.g., solitary confinement) (Nowotny & Kuptsevych‐Timmer, 2018). Those with mental health conditions are overrepresented in the incarcerated population. One study from Los Angeles county indicated that 40% of Black inmates were receiving mental health services although only representing 30% of the incarcerated population (Appel, 2020). Police violence and mass incarceration have a negative impact on the mental health of entire communities. Bor, Venkataramani, Williams, and Tsai (2018) provide evidence that the occurrence of police killings damages the mental health of Black individuals, even if they are not directly related or involved with these incidents. The use of police as first responders to mental health crises is one mechanism that continues to traumatize whole communities and maintain the disproportionate incarceration of Black individuals.
The funneling of Black individuals with mental illness into the prison pipeline is also a consequence of the many failures of the U.S. healthcare system to provide access to adequate and appropriate mental health treatment. Lack of guaranteed access to health insurance in the U.S. can make it difficult for these individuals to enter the health care system in the first place. Once in the healthcare setting, provider bias and unconscious internalization of harmful stereotypes may mean that Black individuals in need of treatment are not asked about their symptoms, do not receive treatment, and if they do receive treatment – it is divorced from their social and environmental contexts. Today, doctors are still more likely to overdiagnosis Black men with schizophrenia, prescribe higher dosages of antipsychotic medication, and describe these patients as hostile or violent (Metzl, 2010; Metzl & Roberts, 2014). Black patients are far more likely to be diagnosed with schizophrenia and less likely to be diagnosed with mood disorders, despite exhibiting the same symptoms as white patients (Gara et al., 2012; Schwartz & Blankenship, 2014). Doctors are also less likely to prescribe medication or offer treatment to Black patients (McGuire & Miranda, 2008).
Current mental health supports are likely not meeting the needs of Black individuals with mental health conditions. In addition to provider bias, lack of culturally-appropriate care and the absence of a systematic trauma-informed approach that acknowledges the unique stressors and generational trauma experienced in Black communities remain substantial barriers to treatment (Novacek et al., 2020). In 2015, data from the American Community Survey indicated that only 4% of psychologists were Black compared to the 86% who identified as white (Lin et al., 2018), and in 2017, only 2% of the members of the American Psychological Association identified as Black (American Psychological Association, 2017). These systemic issues in the health care setting are compounded by generational distrust of the medical system due to historical exploitation and experimentation in Black communities (Washington, 2006).
Underscoring the issues posed by scientific racism, mass incarceration, and healthcare fragmentation are the settings in which these systemic barriers play out. Racial residential segregation and racial redlining are mechanisms that have concentrated poverty in communities of color for generations and many urban communities continue to be racially segregated today (Osypuk & Acevedo-Garcia, 2010; Rothstein, 2017). Racial residential segregation led to the deliberate disinvestment of resources from neighborhoods where Black people were forced to reside (Fullilove, 2001). Segregation systematically structures racialized access to education, employment, safe living conditions, food, tobacco, alcohol, and medical care – all of which are important determinants of mental health (Williams & Collins, 2001; Fullilove, 2001; Maguire et al., 2016;). Redlining is independently associated with higher preterm birth, lower life expectancy and greater prevalence of chronic diseases (McClure et al., 2019; Krieger et al., 2020; Nardone et al., 2020). The stressful conditions created by segregation such as poverty, violence, and crime can all work together to create mental harm among the residents who reside in these segregated neighborhoods (Fowler et al., 2009). Furthermore, crime and violence in these communities is often used to justify and maintain a high police presence and perpetuates the practice of police as first responders to mental health crises. Descriptions of Black, segregated communities as “inherently more violent or criminal” typically fail to mention the historical policies that created these conditions such as the 1970s “War on Drugs” and various criminal justice reforms in the 1980s and 1990s that triggered mass incarceration, disproportionately criminalized the actions of Black people, widely expanded police funding and presence, and facilitated the ease by formerly incarcerated individuals could and would be reincarcerated (Moore & Elkavich, 2008; Schoenfeld, 2012). Indefinite police presence also serves as a way to maintain the racial boundaries of communities created by segregation.
On the interpersonal level, stigma – in the form of negative attitudes to those with mental health conditions – may prevent individuals from seeking treatment. If mental illness is framed as a personal failing, people may feel shame, fear about opening up with others in their support network, and fear provider bias (Brown et al., 2010). There is evidence to suggest that stigma may be a more important barrier in seeking mental health treatment among Black individuals compared to other racial or ethnic groups and that mental health stigma may be stronger in Black communities. A qualitative study by Campbell and Mowbray (2016) found that Black American participants perceived that those with depression are seen as “crazy” or “weak” and thus either hid their symptoms or did not seek treatment at all to avoid being seen or treated differently. Among some participants, depression was racialized and gendered as being something that primarily affected white women and not something prevalent in their community (Campbell & Mowbray, 2016). While the stigma of mental illness serves as a deterrent for seeking treatment for anyone, this effect may be especially pronounced in Black communities.
Importantly, we must consider the occurrence of everyday discrimination that may wear and tear on a Black individual’s mental health. Both interpersonal discrimination and wider systemic inequities lead to poorer mental health outcomes among Black and African-American individuals in the U.S. (Williams, 2018; Williams, Lawrence, Davis, & Vu, 2019). There are several mechanisms by which discrimination can induce stressful conditions that uniquely impact people of color and harm mental health. Experiences of interpersonal discrimination can prompt feelings of “self-defilement” wherein discriminated individuals feel misunderstood, disrespected, over-scrutinized and feel distressed over the contradictory nature of these experiences to larger U.S. societal messages and expectations of equality and fairness for all (Fleming et al., 2012; Williams, 2018). Past experiences with interpersonal discrimination as well as the perceived threat of discrimination can trigger a state of “heightened vigilance,” by which people of color navigate through life in a constant state of psychological arousal in order to better anticipate and protect themselves from potential threats of discrimination from people and environments (Himmelstein et al., 2015; Williams, 2018). Exposure to persistent negative stereotypes in the media and microaggressions in interpersonal encounters (broadly, cultural racism) can cause acute feelings of distress, and the accumulation of these experiences over time can impact mental health and wellbeing (Nadal et al., 2014; Williams, 2018). Repeated experiences of interpersonal discrimination may also contribute to feelings of internalized racism or internalized stigma. Internalized racism is characterized by acceptance of one’s marginalized status in society, negative feelings toward same race and other nonwhite racial groups, endorsement of white superiority, acceptance of negative stereotypes, and feelings of low self-esteem and worthlessness (Kwate & Meyer 2011; Williams, 2018). Studies measuring internalized racism have found associations between higher feelings of internalized racism and lower levels of self-esteem, greater levels of depressive symptoms and more psychological distress (Brown et al., 2002; Hughes et al. 2015; Mouzon & McLean, 2017; Williams, 2018).
Today, we are in the midst of COVID-19 crisis and a systemic racism crisis where widespread police violence, social isolation, essential or frontline work, unemployment, as well as personal loss and grief are likely creating and compounding mental health issues in the community (Egede & Walker, 2020). While this crisis begets immediate attention, the various ways racism manifests through law, policy, institutional practices, and interpersonal encounters requires a variety of solutions that take place across all levels of influence and that are co-created or designed by those most impacted. In 2020, the American Public Health Association (APHA) declared structural racism a public health crisis. States and local city governments across the United States—in response to the killing of George Floyd and spurred on by subsequent #BlackLivesMatters protests—have followed suit. These declarations represent an important step that can meaningfully shift public health priorities to address root causes of racial inequities, indicates that concrete steps will be taken toward action and accountability, and can encourage other states and localities to do the same to confront racism directly (Nembhard & White, 2020; Krisberg, 2021). Reparations for Black Americans by the federal government could ease economic and emotional stress, help close racial wealth gaps, and facilitate access to resources, such as mental health treatment (Bassett & Galea, 2020). Interventions that take place in early childhood, such as strengthening parental capacity, increasing access to resources, and building child resilience, may be a mechanism by which to disrupt the school to prison pipeline and reduce childhood trauma that leads to poorer mental health outcomes in adult life (Dobbie & Fryer, 2011; Williams & Mohammed, 2013). Programs such as the Harlem Children’s Zone or the Open Society Institute in Baltimore aim to explicitly counter and address the disinvestment of resources caused by racial redlining and segregation by supporting early childhood development, the provision of or strengthening of educational supports, and the operation of community health and wellness centers – with the explicit goal of disrupting the intergenerational effects of systemic racism. This type of systematic investment can improve the physical, mental, and social health of the community, reduce exposure to harmful stressors, and increase access to much needed resources like local and culturally relevant healthcare providers and healthcare settings (Spielman et al., 2007; Chang & Jordan, 2011; Dobbie & Fryer, 2011; Theodos et al., 2020).
Of high priority is the healthcare reform needed to address the multitude of gaps in coverage for individuals with mental health conditions, as well as the persistence of harmful, discriminatory, and racist practices in healthcare settings. First, access to health insurance must be increased for Black individuals, whether through Medicaid expansion policies or ideally universally guaranteed health insurance for everyone. Studies suggest that Medicaid expansion is associated with an increase in access to primary care and preventive services, reduced racial/ethnic disparities in having healthcare insurance, and an increase in Black patients reporting they had a usual source of care (McMorrow et al., 2015; Buchmueller et al., 2016; Yue et al., 2016; Kominski et al., 2016). However, having health insurance does not guarantee access to treatment as mental health services may not be covered by health insurance plans, and when they are covered, there may be significant gaps in coverage. Laws that necessitate insurance coverage of comprehensive mental health services are likely needed to address this gap. Even then, access to free mental health treatment is likely not enough on its own to end racial and ethnic disparities. Black individuals in the U.S. experiencing poor mental health systematically lack access to mental health providers that look like them and understand their contexts (Ayalon & Alvidrez, 2009). While strengthening the capacity of current providers to provide culturally-competent care may improve patient health outcomes (Lie et al., 2011), more efforts are needed to recruit individuals from Black communities into the mental health field through community outreach, worthwhile and resonant incentives, and the creation of a mental health treatment environment where both patients and providers of color can thrive by dismantling structural barriers that limit their meaningful participation in the healthcare system (Williams et al., 2013; Blackstock, 2019; Prasad, 2020).
Finally, social movements can raise awareness and prompt large-scale advocacy efforts in response to many of the structural determinants of health described before. The #BlackLivesMatter movement has raised awareness and outrage around extrajudicial police killings, prompting widescale protests and more explicit acknowledgement in the mainstream of how structural racism persists in nearly all aspects of American society (Bassett, 2015; Jee-Lyn García & Sharif, 2015; Baig, 2017; Krieger, 2020). The #DefundthePolice movement, while triggering emotional responses with its “provocative” name and radical premise, has likewise raised awareness of systemic issues in the institution of policing and provides concrete policy solutions, like redirection of police funds to strengthening social services, education, mental health treatment, among other health-promoting streams (Deivanayagam et al., 2020; Watson et al., 2021). The centrality of Black health in these social movements are reminiscent of the Black Panther Party’s engagement in health activism during the Civil Rights Movement to counter the continued exclusion of, or harm done to Black and other oppressed people in the dominant medical system (Morabia, 2016; Nelson, 2016; Bassett, 2016). Part of this healthcare work included free health clinics located in several urban cities in the U.S., and the provision of “patient advocates” or “community health workers” – members from the community who helped patients meet their most basic needs like food, housing, schooling, or legal advice (Morabia, 2016; Nelson, 2016; Bassett, 2016; Waxman, 2021). By tying health with social justice, the Black Panther Party influenced official health policy in the 1960-1970’s and has ensured that health equity remains a central tenet in social movements today (Bassett, 2016). Large social movements such as #BLM can also be leveraged to raise awareness around poorer mental health outcomes experienced by Black individuals, in order reduce stigma around mental illness and mental health treatment in Black communities (Watson et al., 2021). The publicization of recent police killings of Black individuals who were in the midst of mental health crises has already begun to spur these conversations (Pazzanese, 2021; Watson et al., 2021; Rafla-Yuan et al., 2021).
The pathways by which environmental, social, and individual factors affect the mental health of Black individuals in the U.S. are complex, numerous, mutually reinforcing, and while this paper offers a broad overview of how structural racism operates through several levels and institutions to harm mental health, it is not comprehensive. Although every single mechanism and pathway is not yet identified, there is ample evidence available today to suggest that existing structures and policies – the “status quo” – systematically harm Black mental health. Explicitly antiracist interventions on several of the pathways covered here could not only improve the mental health of Black individuals in the U.S., but also their physical health and emotional wellbeing. A comprehensive approach is needed, one which acknowledges the legacy of explicitly racist practices that are embedded in U.S. institutions, refutes white supremacy, and seeks to completely dismantle and transform existing power structures. The collection of interventions briefly described here each contribute to this effort across a variety of domains and disciplines beyond public health. While not a small or easy undertaking, the work has already begun, and we all have the opportunity to participate.
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Lindsay Kephart is a first-year doctoral student in the Department of Social and Behavioral Sciences at HSPH. Prior to entering the Population Health Sciences program, she was an epidemiologist for the Massachusetts Department of Public Health, supporting the Tobacco Cessation and Prevention Program with surveillance, evaluation, and evidence-based research. Her work has focused on integrating a justice perspective in programmatic work, changing the tobacco landscape through policies that modify the built environment, and examining the impact of institutional inequities on health risk behaviors. Her current research interests broadly include neighborhood effects on health and incorporating equity in policy implementation. Lindsay received her Master of Public Health from the Tufts School of Medicine with a concentration in Epidemiology and Biostatistics.