Race, the Pandemic, and Psychiatry

Influence of the pandemic and Black Lives Matter on academic medical centers.

Posted Aug 24, 2020

The combined influence of the Black Lives Matter (BLM) movement and the COVID-19 pandemic has led those working at academic medical centers to become more acutely aware of the consequences of racism on mental, physical, and public health. The harsh realities of growing up Black in America became vividly evident with the tragic killing of George Floyd and the societal reactions that followed. As health care workers responded to the pandemic, the deadly consequences of growing up poor and Black have been evident in hospitals every day. 

Increased awareness of societal issues raised by the BLM movement is leading many people to investigate new ways to achieve equality for all. The BLM movement and COVID-19 pandemic have triggered substantial responses at many medical centers. True change will only come from consistent, long-term efforts and not from short-term, emotionally driven, knee-jerk responses. Long-term efforts depend, in large part, on the leadership of those responsible for directing universities and medical schools. At our home institution (Washington University in St. Louis), the Dean of the Medical School and the Chancellor of the University along with leadership at our hospital partners in BJC Healthcare have made powerful statements in support of the BLM movement, and these statements have been accompanied with tangible actions. 

Medical centers, including our own, are enhancing anti-racism education programs in the curriculum of medical students and residents. Formal and informal diversity programs for faculty and staff are being actively revised and augmented. There is a strong, dedicated desire to increase the diversity of students, residents, and faculty. Faculty with the background and skill set to lead diversity programs at medical schools are in high demand.

Regarding mental health, the pandemic has resulted in marked increases in anxiety disorders, depression, and substance use. This is especially true in high-risk groups, including health care workers. Black Americans in particular are at high risk from the pandemic. Many are essential workers and, therefore, at increased risk for exposure to COVID-19. Many take public transportation, thus increasing exposure. Many live with multiple family members in crowded neighborhoods, thus limiting the ability to socially distance and increasing exposure to others. Those who are unemployed or underemployed may not have health insurance and may be living with untreated or inadequately treated co-morbid health conditions, including diabetes, hypertension, and renal disease, which increase the risk of serious consequences and death from COVID-19. The societal shutdown during the pandemic has cost numerous jobs, particularly among the most economically challenged members of our society. All of these stressors greatly enhance the risk of mental distress and psychiatric disorders.

The pandemic and the BLM movement have increased awareness of the inadequacy of our current health care system, including mental health care, in being able to provide services to those most in need. We believe that there will be a surge of interest in public health policy to deal with these problems, but policy changes will be slow to implement. New approaches for delivering mental health care are desperately needed. The rapid transition of health care and psychiatric services to telemedicine has been a positive outcome of the pandemic, but this transition has again left the most economically disadvantaged of our society underserved.

One of the biggest impediments in addressing inequities in our health care system is the fact that the survival of medical schools and hospitals depends on financial reimbursement for health care services. The current reimbursement system provides generous funding for medical specialties that are procedure-based (for example, surgery and radiology, among others) and more limited reimbursement for fields like family medicine, pediatrics, and psychiatry in which care requires significant time spent with patients. Medical centers and hospitals are incentivized to emphasize technology-oriented fields to generate the cash flow needed to continue their various missions, including clinical care and, in the case of academic medical centers, research and education. Unfortunately, these incentives do not provide sufficient support to address the complex health needs of those with inadequate insurance and limited financial resources.

Perhaps the inequities made visible by the intersection of the BLM movement and the pandemic will lead to serious consideration of better funding mechanisms for our health care system that would address the broader health care needs of all members of our society. Addressing the complex issues regarding diversity in medical centers is critical. However, true progress will require improved community outreach, diversity programs, and much-needed financial reform of our health care system.

This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD

References

Evans, M.K., Rosenbaum, L., Malina, D., Morrissey, S., & Rubin, E.J. (2020 Jul 16). Diagnosing and treating systemic racism. N Engl J Med. 383(3): 274-276.

Pfefferbaum, B., & North, C.S. (2020 Aug 6). Mental health and the Covid-19 pandemic. N Engl J Med. 383(6): 510-512.