Yale Psychiatry Grand Rounds: June 18, 2021

June 18, 2021

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Yale Psychiatry Residency Program Commencement: "Bending the Arc: The Path to Social Justice in Mental Health"

Ruth Shim, MD, MPH, Luke & Grace Kim Professor in Cultural Psychiatry, Department of Psychiatry & Behavioral Sciences; Associate Dean of Diverse and Inclusive Education, University of California, Davis School of Medicine

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00:00Welcome everybody to the
00:022021 graduation address.
00:04This is one of the most special times in
00:07our year as we celebrate our wonderful
00:11graduating class of psychiatry,
00:13residents, fellows and psychology interns.
00:16We had two graduations already this week.
00:19The fellowship graduation will be this
00:23evening and we have seen that these are a
00:27really special group of people and we're so.
00:31Please, that that and proud of
00:34what they've accomplished during
00:35their time during residency,
00:37internship and fellowship.
00:40A few housekeeping.
00:43Notes there's no see me this
00:47week for the graduation address.
00:50We are since this is the.
00:52Graduation celebration we asked
00:55our graduating residents to have
00:58their videos on if they would like
01:01but the rest of us will be turning
01:04our our videos off. And our.
01:08Are we recording this presentation?
01:12Yes, yeah,
01:12so we will be recording so you know.
01:18We're absolutely thrilled to have our
01:21graduation speaker, Doctor Ruth Shim,
01:24and I'd like to now invite Doctor
01:27Barbara Bow to introduce her.
01:31Thanks so much John,
01:32and I'd like to also extend to welcome
01:35to this very special edition of our
01:38grand rounds honoring the 2021 graduates
01:40of our education programs and Happy
01:43Juneteenth as the inaugural celebration
01:46of our newest national holiday.
01:49I'd like to begin by acknowledging
01:51that indigenous peoples and nations,
01:54including the Mohegan Mashantucket
01:56Pequots eastern P Quad shadow Coat,
01:58Golden Hill, prakasit,
02:00Niantic and Quinnipiac, another,
02:01oh, Conklin speaking peoples,
02:03have stewarded through generations.
02:05The lands and waterways of what
02:08is now the state of Connecticut.
02:10We honor and respect the enduring
02:13relationship that exists between these
02:16peoples and nations and this land.
02:21Each year are residents nominated national
02:23figure to be their graduation speaker.
02:26The pastures witnessed COVID epidemics,
02:28uncovering of longstanding health
02:30disparities in terms of both infection
02:32rates and mortality in communities of
02:35color and the economic devastation in
02:38communities with concentrated poverty.
02:40We've witnessed murder of
02:42George Floyd and Brianna Taylor.
02:44But please send here in our own community,
02:47morbark Solomani.
02:49We began to play closer attention
02:51to racism's effects in our community
02:54in our department and institutions
02:57and international organizations.
02:58We endured the divisive politics before,
03:01during, and after the election season,
03:03including an insurrection to
03:05invalidate the election result.
03:08Given the context of this past year,
03:10the residents chose to invite a national
03:13scholar on racism and the economic,
03:15social and political determinants
03:17of mental health.
03:18I'm very pleased to have the opportunity
03:21to introduce Doctor Ruth Jim for
03:242021 graduation Grand Round Speaker.
03:27Doctor Shin graduated from College
03:29of William and Mary received her
03:31MD from Emory University School of
03:33Medicine and a Masters of Public Health
03:36from the Rollins School at Emory.
03:38She completed a residency at Emory,
03:41after which she joined the
03:43Morehouse School of Medicine.
03:44After work as Vice Chair of
03:47Education at Lenox Hill.
03:48Choose name that Luke and Grace Kim,
03:51professor in cultural psychiatry
03:53at the University of California,
03:55Davis,
03:55where she is also director of
03:58Cultural Psychiatry and professor
04:00of clinical psychiatry.
04:02Doctor Shim is a prolific scholar on the
04:05social determinants of mental health,
04:07cultural psychiatry and structural racism.
04:10Her book the Social Determinants
04:12of Mental Health is the definitive
04:14text on this topic.
04:16She is a sought after national
04:18speaker and served as a consultant
04:21on Diversity equity,
04:22inclusion at the medical School
04:24and academic program level.
04:26Lastly,
04:27Doctor Shin has been a leader in the
04:29American Psychiatric Association,
04:31becoming a distinguished Fellow
04:33of the organization and honorary
04:35Marshall of the AP,
04:36a convocation of Distinguished
04:38Fellows in 2019.
04:40Her decision to resign from that
04:43organization electrified the
04:44ongoing debate on racism in our
04:47national organization.
04:48And so it gives me great pleasure
04:50to welcome Doctor Ruth Jim as our
04:53graduation grand round speaker
04:54presentation is bending the arc.
04:56The path to social justice and mental health.
04:59Welcome Doctor Shim.
05:02Thank you so much, Doctor Robert,
05:04for that introduction.
05:05It's really so great to be
05:08here with all of you today.
05:10I just want to say congratulations
05:12to graduates of the program and
05:15also to wish everyone a happy,
05:17Juneteenth, Juneteenth as well.
05:19I am today talking about bending the arc,
05:22the path to social justice and
05:25mental health and and I really want
05:27us all to think about as as our
05:30residents are preparing to graduate.
05:33I want us to think about our own
05:35paths in our own career choices,
05:38and I hope to kind of share a
05:40little bit about some of my career
05:42choices in my path as we talk about
05:45the important issues related to
05:47social justice and mental health.
05:49So without further ado,
05:50I'd like to launch in the title of the talk.
05:54Is bending the arc and so that
05:56really comes from this quote
05:58that we're all familiar with from
06:00Martin Luther King Junior.
06:02He said that the arc.
06:03Of the moral universe is long,
06:05but it bends towards justice and I
06:08think that it's really important for
06:10us to think about that particular
06:13quote because to do this work
06:15and to spend time in this space,
06:17it requires a level of hope,
06:19an idea that justice is something that
06:22we can all achieve and work toward.
06:25So today we're going to spend
06:26some time talking about some key
06:29concepts associated with social
06:30justice and mental health.
06:32We're going to evaluate the evidence
06:34base of the impact of social injustice
06:37on behavioral health outcomes,
06:38and we're going to try to identify
06:41some solutions to dismantle
06:43structural racism and achieve social
06:45justice in psychiatry.
06:47So I don't have anything to disclose,
06:50but I always have to make a disclaimer
06:54before talking about these topics,
06:56because we're going to
06:58dive into some difficult,
06:59challenging things as it relates to racism,
07:03structural racism,
07:03social injustice in general,
07:05and these topics are difficult.
07:07They're uncomfortable as we
07:09talk about these things.
07:11Sometimes some complex feelings can emerge.
07:14These feelings include things like guilt,
07:16anger, resentment.
07:17Even defensiveness you may perceive me of
07:20accusing you of being racist or sexist,
07:22or any number of other negative things.
07:24You also may feel that as I'm
07:26talking about these issues,
07:27that I have some sort of specific
07:29political agenda that I am advancing.
07:31You may feel that I lack some
07:33sort of objectivity.
07:34I'm sharing that you might have these
07:37feelings because all of these things
07:38have been expressed to me at some
07:40point when I've talked about these topics,
07:43and sometimes even when I'm not
07:45talking about these topics.
07:46These feelings have been
07:47expressed towards me.
07:48So I just want to point out that
07:50if you have those feelings,
07:52it's OK.
07:53We're all mental health professionals,
07:54and the idea that is that we
07:56should be able to examine and look
07:58at these feelings that as they
08:00arise in our in ourselves.
08:02But as we think about that,
08:03I think it's also important
08:05to lean on the words
08:06of James Baldwin and he said,
08:08I'm not interested in anybody's guilt.
08:10Guilt is a luxury that we can no longer
08:13afford. I know you didn't do it,
08:15and I didn't do it either,
08:16but I am responsible for it because I
08:19am a man and a citizen of this country.
08:21And you are responsible for
08:23it for the very same reason.
08:25So with that I think we can kind
08:28of launch into our topic today.
08:30I'm having made having made my
08:32disclosures and disclaimers.
08:33Ann Ann.
08:33I want to say that it is again
08:35difficult to talk about these issues
08:37and particularly social injustice.
08:39We've been socialized in society to
08:41believe that it's not polite to talk
08:43about race or racism or oppression.
08:45We Start learning this very earliest
08:47children and it's not just in the
08:49United States that we learn this.
08:51If you were raised in another country,
08:53you've also probably been exposed to this.
08:55We don't.
08:56Particularly teach about these
08:57issues in child in our childhood
08:59and health professionals have not
09:01been taught about the connection
09:03between oppression and health.
09:05So much of our educational systems,
09:07including medical school,
09:08have had this tradition of teaching
09:11the concept of biological determinism.
09:13And I'll explain that concept
09:15and define it a little bit later.
09:18The other reason it's difficult
09:20to talk about these topics are
09:22because because of all of the events
09:25that took place last year.
09:27There has been such a focus.
09:29Such an emphasis on addressing
09:31racial injustice on issues related
09:33to social injustice,
09:34that there are certain people
09:35that feel that this is probably a
09:38little bit too much now that maybe
09:40we're over emphasizing this issue.
09:42Maybe there's an over correction
09:44that is happening,
09:45and that also makes it hard for us to
09:48talk about these particular issues.
09:51So this picture here is an op Ed that
09:54was published in the Wall Street
09:57Journal a couple of years ago.
09:59It was by a physician by the name
10:02of Stanley Goldfarb,
10:04who was at the time who was previously
10:06the associate Dean of curriculum
10:08at the University of Pennsylvania
10:10School of Medicine,
10:12and he was in this article which he,
10:15he titled,
10:16Take two Aspirin and Call Me by my Pronouns.
10:19He was lamenting.
10:21The change that he had been observing
10:23as as associate Dean of curriculum
10:26that medical schools were focusing too
10:28much on this concept of social justice.
10:31So we know this is a controversial
10:34topic topic.
10:35This idea of social justice and
10:37where it belongs and what it is.
10:40But he was very concerned about how
10:43it's been kind of as he thought of
10:46seeping into medical education and
10:48he stated in his in his in his op.
10:51Add why have medical schools become a
10:54target for inculcating social policy
10:55when the stated purpose of medical
10:58education since Hippocrates has been
11:00to deliver to develop individuals
11:01who know how to cure patients and
11:04he also said that curricula will
11:06increasingly focus on climate change,
11:08social inequities, gun violence bias and
11:11other progressive causes only tangentially
11:13related to treating illness and so will
11:15many of your doctors in coming years.
11:17So he was really sounding the alarm sounding.
11:20The call saying that this
11:23is a pretty dangerous.
11:24Place that we were heading
11:26to in medical education.
11:27Of course there were a lot of people that
11:30have disagreements about this perspective.
11:32There is debate on both sides about the issue
11:35of the role of social justice in medicine,
11:38so several of his colleagues responded in a
11:41response in the in the Philadelphia Inquirer,
11:44and they said that social and health
11:46policies have always determined who gets
11:48sick and who gets care and where and how.
11:51Understanding the social drivers of health
11:53and illness is not peripheral or tangential.
11:56Delta health it is the key to diagnosing
11:58and meeting a patient's fundamental needs,
12:00and so again,
12:01I would submit to you that there is
12:04debate about this issue and there's debate
12:06about the role of social justice and
12:08whether it should be included or thought
12:10about when we think about medicine.
12:12When we think about health,
12:14and so I think if we're going
12:16to wade into this debate,
12:17we need to define what we're talking about.
12:20And so I think we should define
12:22the concept of social justice.
12:24It again, has been, I think,
12:25misinterpreted has lots of.
12:27Fox behind it,
12:28but it is at its core a philosophical
12:31concept in a philosophical term,
12:33and so the philosopher David Miller
12:35defined social justice as the
12:37distribution of good or advantages
12:39and bad and disadvantages in society,
12:41and more specifically,
12:43how these things should be distributed
12:45in society.
12:46So he mentioned that it was concerned with
12:49the ways that resources are allocated
12:51to people by social institutions.
12:54And then the philosopher John Rawls
12:56added to this definition and said
12:58that it was also about assuring the
13:00protection of equal access to liberties,
13:03rights and opportunities,
13:04as well as taking care of the least
13:06advantage members of society.
13:08When we think about mental illness,
13:10Anan,
13:10particularly people with serious
13:12mental illness and people with
13:13substance use disorders.
13:15These are often the least
13:16advantage members of our society.
13:18And so when we think about social
13:20justice as it relates to psychiatry
13:23and mental health.
13:24It becomes central to the work that
13:26we do and should be at the center
13:29of what we're thinking about.
13:31So as I mentioned,
13:33it's difficult to talk about these issues,
13:35but particularly when we talk about race,
13:37there are a couple of things that
13:40we need to kind of get on the same
13:43page about and one of those is
13:45this idea that race is a social
13:48and political construct.
13:49I know that we've all heard this.
13:51I've heard this concept stated many
13:53times in many different settings.
13:55What's interesting about hearing
13:56it is that it doesn't always.
13:58It's not always exactly clear
14:00what is meant by that.
14:02But what's really meant
14:03when you say that race is
14:06a social construct or a political
14:08construct is that the very concept of race.
14:12This idea that you can categorize people
14:14into different groups based on these
14:17characteristics was an idea that was
14:19constructed that was developed in society
14:22to advance so certain social goals and
14:25to advance certain political goals.
14:27For example, slavery, for example,
14:29the subjugation of one group
14:31over another group.
14:32So that is the idea behind that.
14:35The definition of race is a social
14:37construct and it really leads into a clear
14:41understanding that race cannot be accurately,
14:44biologically or genetically categorized.
14:45And it's funny because it seems
14:48very obvious to me of this.
14:50Of this point we can't draw somebody's
14:53blood an identify what their race is.
14:56We can't do a genetic test and
14:59determine what somebody is racist.
15:01We cannot accurately biologically categorize.
15:03Race, and yet a lot of.
15:07Really smart really.
15:08Until intelligent medical professionals,
15:10including physicians and researchers,
15:11really don't fully grasp
15:13this particular point,
15:14and so there is a lot of debate about this,
15:18and it stems back to that idea
15:21of biological determinism.
15:23So what we do know about race is
15:26that it is a rough and imprecise
15:28proxy for a number of other things,
15:32including culture and genetics
15:33and socioeconomic status.
15:35And yet we use this very.
15:37Rough and imprecise proxy to make
15:40a lot of different assumptions
15:42and biases and prejudices,
15:45and to confirm those assumptions
15:47and biases and prejudices.
15:49Prejudices about our patients.
15:51Which is very strange because and mess
15:54and we we pride ourselves on being
15:57precise and accurate and get these.
15:59These proxies are really quite imprecise
16:02and and in some ways very lazy ways
16:06to try and go about categorizing
16:08and understanding our patients.
16:11So I have this quote that I I'd like
16:14us to kind of spend a little bit
16:17of time contemplating right now.
16:19It says that African Americans
16:21have higher incarceration rates,
16:23higher unemployment, lower incomes,
16:24lower home and business ownership,
16:26less education, less health care,
16:28more disease and lower life
16:30expectancy than whites.
16:31If you believe blacks are
16:33naturally dumb sick criminal,
16:35you have your answer for these discrepancies.
16:37If however,
16:38you resist using stereotypes
16:40to make sense of your world.
16:42Institutional racism provides a
16:44very practical and very traceable
16:47explanation for the inferior societal
16:49position of African Americans.
16:51The reason why I want us to contemplate
16:55this quote is because it seems so obvious,
16:58right?
16:59I it seems really clear.
17:01Of course we don't believe that
17:03blacks are naturally dumb,
17:05sick or criminal,
17:06but yet we don't always default to
17:08thinking about how institutional
17:10racism explains the inferior societal
17:13position of African Americans.
17:15And I would submit that in medicine.
17:18A lot of times we don't necessarily seek out.
17:22The real the cause of the of
17:25the inequities that we see in
17:28particular racial and ethnic groups.
17:30We almost tend to default to that
17:33belief that maybe maybe there is some
17:36sort of natural intrinsic inherent
17:39difference as it relates to intelligence,
17:42health status, tendency to commit
17:44certain behaviors, or do certain things.
17:47And so I do want us to think
17:50about that as we as we consider.
17:54Moving through this,
17:56this discussion that we're having today.
17:59So the question is how did
18:01we get here and you know,
18:03we have to think about our history and many
18:06people are familiar with this painting.
18:08It is the signers of the
18:10Declaration of Independence.
18:11We know that the Declaration of
18:13Independence was one of the founding
18:15documents of of this country.
18:17We're also very familiar with this
18:19very important foundational quote.
18:20We hold these truths to be self
18:22evident that all men are created equal,
18:25that they are endowed by their creator
18:27with certain unalienable rights.
18:29That among these are life, liberty,
18:31and the pursuit of happiness.
18:33Such a beautiful sentiment and and you know,
18:36again, the thought by which
18:38this country was founded,
18:40that the values and the principles
18:42upon which this country was founded.
18:45But I think that we really have
18:47to acknowledge that when the when
18:49Jefferson was crafting these words,
18:52and when these signers came together
18:54to to bring this these words forth
18:57in the founding of this country.
19:00They really weren't talking about all people.
19:02Clearly they already said all men,
19:05but they also really weren't talking
19:07about a number of other groups of people.
19:10They were really only refering
19:12to the folks that looked like
19:14the gentleman in this room,
19:16and it was those people that
19:18were endowed by the creator with
19:20certain unalienable rights.
19:22And really the rest of society.
19:24All of the people that did not look like
19:28these men were not considered to be.
19:31People who had the same liberty
19:33the same independence,
19:35the same opportunity to pursue
19:37happiness in society.
19:38And it was that mindset that really
19:41led overtime to the development of
19:43the pseudoscience that we think about
19:46as it relates to mental illness.
19:49And so physician by the name of
19:52Samuel Cartwright,
19:53about 50 years after the signing of
19:55the ratification of the Constitution,
19:58he really defined certain conditions
20:00that he described as psychiatric.
20:02Illness among enslaved black people and
20:04one of them was this concept of drapetomania.
20:07He said that this was a condition
20:10in which slaves had a mental
20:12illness of this desire to run away
20:14from slavery to escape captivity.
20:17So that was the mental illness
20:19that they were suffering from,
20:21and he spoke about this illness.
20:23He said,
20:24if anyone or more of them at anytime
20:26are inclined to raise their heads to a
20:29level with their master or overseer.
20:32Humanity in their own good,
20:34requires that they should be punished
20:35until they fall into that submissive state,
20:38which was intended for them to occupy.
20:40They have only to be kept in that
20:42state and treated like children to
20:44prevent and cure them from running away.
20:47And the other thing that he said,
20:50the other condition that he
20:52described was this condition called
20:54dysaesthesia ethiopica.
20:55He said that this particular
20:57condition was the illness within
20:59enslaved black people of rascality or
21:02or the natural tendency to be lazy,
21:04to not want to work hard.
21:07And he said of this condition.
21:09This is this disease is the
21:12natural offspring of liberty,
21:13the liberty to be idle to wallow in filth.
21:17And to indulge in improper food and drinks
21:20after the prescribed course of treatment,
21:23the slave will look grateful and thankful
21:26to the white man whose compulsory power
21:29has restored his sensation and dispel
21:32the mist that clouded his intellect.
21:34So what we're seeing with this origin of
21:38psychiatric pseudoscience is this idea,
21:40where without any sort of context
21:42without understanding the context of the
21:45condition that enslaved Africans were.
21:47Experiencing the perspective of
21:49Doctor Cartwright in looking at
21:52this at these at these folks,
21:54without that context led to him
21:57pathologizing very very normal behaviors.
22:00And so when he talked about
22:02this decision ethiopica,
22:04there was no context about the idea that
22:07slaves were often working far above the
22:11natural level of productivity for any human,
22:14and they were often working at
22:17that level of productivity.
22:20In a,
22:21in cases in which they were
22:23severely malnourished,
22:24oftentimes because slave owners were
22:27not giving slaves adequate nutrition,
22:29and so they were operating at extreme
22:32levels of productivity in a state
22:35of extreme nutritional deficiency.
22:37And yet that when when an enslaved
22:40African and slave black person
22:43was not working to the standard,
22:46that Doctor Cartwright felt
22:48that they should have.
22:50He felt that that was some
22:51type of mental health problems,
22:53so that lack of context really is
22:55is the beginning of when we start
22:58to think about how these concepts
23:00become kind of ingrained in the way
23:02that we practice psychiatry even to
23:04this day and the other thing that
23:06I think is particularly disturbing
23:08that we need to think about and and
23:10the description of these conditions
23:12is that Cartwright had a particular
23:14idea about how both of these
23:16conditions should be treated,
23:17and he felt like the proper treatment.
23:20Or both of these conditions was whipping?
23:24So I want to take this time
23:27to define two concepts.
23:29An really contrast the idea of health
23:32disparities with health inequities.
23:34So health disparities are defined as
23:36differences in health status among
23:38distinct segments of the population,
23:41including differences that occur by gender,
23:43race or ethnicity,
23:44education or income or disability,
23:46or where you live.
23:50This is different from this
23:51concept of health and equities,
23:53which are disparities in health
23:55that are the result of systemic,
23:57avoidable,
23:57and unjust social and economic
23:59policies and practices that
24:01create barriers to opportunity.
24:02I think it's really important
24:04for us to contrast these,
24:06because here in the United States we
24:08talk a lot about health disparities.
24:10The problem with using that particular
24:12definition is that it's not precise enough.
24:15It doesn't speak to the origin
24:17of the difference,
24:18and because it just defines the difference,
24:21and it doesn't say why that difference.
24:24Exist in the 1st place.
24:25We have the tendency to air on
24:27the side of saying that maybe
24:29the driver of that difference
24:31is some sort of intrinsic.
24:35Some sort of intrinsic quality of
24:37of the group or the individuals
24:39that have those differences?
24:41Maybe there's some sort of intrinsic
24:44biological difference that's driving it.
24:46Maybe there's some sort of cultural belief
24:48systems or choices that people make
24:51that's really driving that difference.
24:53And again, we tend to say that perhaps
24:56it's the problem of that person rather
24:59than recognizing that the majority of the
25:02differences in health that we see, the.
25:04Overwhelming majority in fact,
25:06almost all of the differences in health that
25:09we see are really the result of systemic,
25:11avoidable, and unjust social
25:13economic policies and practices.
25:14So it's really important that we get to
25:17the place where we're really thinking
25:19very hard about what is driving.
25:21What is creating this particular
25:23difference in health,
25:24and so it's much more precise to
25:26use the term health inequities when
25:29we talk about these differences.
25:32And then it's important for us to
25:34define this concept of the social
25:36determinants of mental health.
25:38So we see the social determinants
25:39as the social and environmental and
25:41economic conditions that impact
25:43and affect mental health outcomes
25:45across various populations.
25:47We know that these conditions are
25:49shaped by the distribution of money
25:51and power and resources at global,
25:53national and local levels,
25:54which themselves influenced are
25:56influenced by policy choices.
25:57And we also understand,
25:59I think most importantly that the.
26:01The social determinants of health
26:03and mental health are prominently
26:06responsible for the health disparities
26:08in inequities that we see both
26:10within and among populations.
26:12And so this issue of disparities and
26:15inequities is very personal to me
26:18because I attended medical school,
26:20residency and Community psychiatry
26:22fellowship all in Atlanta at
26:24Emory University.
26:25Emory University is not unlike
26:28most academic medical centers in
26:30which there are multiple locations,
26:32multiple sites and so I I had the
26:35pleasure of being able to train both at
26:39Emory University Hospital which was located.
26:43In probably the richest part
26:45of the suburbs of Atlanta.
26:47Probably one of the most affluent
26:50places in all of Atlanta.
26:52I had the ability to contrast
26:55that educational experience with
26:57working at Grady Memorial Hospital,
26:59which was located in the poorest
27:02section of Atlanta and located in
27:06the part of the city in which.
27:09Incomes were lowest and outcomes or poorest,
27:12and what was interesting about that
27:14experience and this idea of health
27:16disparities versus health inequities
27:18is that when I was a medical student,
27:21but then particularly as a resident
27:23in psychiatry, I would,
27:25I would rotate at Emory University
27:27Hospital in the inpatient unit,
27:29and then I would rotate a Grady Memorial
27:32Hospital in the inpatient unit and
27:35we would have the same process we would.
27:38We would identify people
27:40we would hospitalise them.
27:41We would admit them to the hospital
27:43and we would take time to provide
27:46them with the appropriate therapies
27:48which included medication therapies,
27:50group therapy, individual therapy,
27:52and treatment with the mill.
27:54You, which was very helpful and wonderful,
27:56and what I would see is that
27:59those patients at
28:00Emory University Hospital would
28:01take some time and they would get
28:04better and we would discharge them
28:07and they would go back to their
28:09lives and then a Grady we would.
28:12Admit people to the hospital.
28:14We would treat them with medication.
28:16We would treat them with therapy
28:18group and individual therapy.
28:19We would treat them with the
28:22millou and they did not get better.
28:24And so we would still discharge them,
28:27but they would not improve in the
28:29same way that I would see patients
28:31improve at at Emory. And again, why?
28:34What was going on there?
28:36And so that really sparked for me
28:38the start of my questioning of what
28:40was going on because I was the same
28:43position I was providing the same care.
28:45I wasn't doing anything differently and
28:47how it was interacting with the patients
28:50at Grady and the patients at Emory.
28:52It made me wonder I could have.
28:54Kind of defaulted to explaining.
28:56Maybe there's some sort of intrinsic
28:59difference between the patients that
29:01I was treating at Grady and the
29:03patients that I was treating at Emory,
29:05but it really started me on a path to
29:08discovery of what is really driving
29:11what's really at the foundation for
29:13why I'm seeing these differences
29:15in real time and also it it it
29:18was really it sparked in me.
29:20A desire to do something because
29:22I felt quite helpless.
29:24If I'm doing the same.
29:26Work,
29:26and if I went into psychiatry to help people
29:29and I'm not able to affectively do that,
29:32what is that saying about about me
29:34and so I felt that I needed to try
29:36and reach out and and discover some
29:39solutions I needed to explain what
29:41was happening in a way that that
29:43allowed me to feel like I was making
29:46some sort of progress in this space
29:48and so that led to work with Michael
29:51Compton at Emory at the time on the
29:53social determinants of mental health.
29:55And it was really an understanding
29:57that it was the social.
29:58Economic and social and economic
30:00factors that were leading to the
30:03development of these differences
30:04and outcomes that we saw.
30:06And so we really did gather the
30:09best available evidence on how all
30:11of these different social factors
30:14impact mental health.
30:15That work has led overtime,
30:17to my understanding of the
30:18foundations of what creates the
30:20social determinants of mental health.
30:22And that's actually social injustice,
30:24and so this is work that I did
30:26with Sarah Benson and in the book
30:29that was just published this this
30:31year and I really want to kind of
30:34walk you through my thinking and
30:36how it's evolved and how it's been
30:39expressed in in in this work.
30:41So this figure is a conceptualisation
30:44of the social determinants of mental
30:46health and at the very top you see
30:48this idea of adverse mental health
30:50outcomes and mental health in equities.
30:53And if you move down this figure,
30:55you're moving further upstream.
30:57So one step down and you
30:59get to a number of risk factors
31:01and we understand that risk factors
31:03are things that precede an illness
31:05an increase the likelihood that
31:07one will develop that illness.
31:09In psychiatry we spend a lot of time.
31:12Thinking about risk factors we we
31:14work to identify risk factors so
31:16that we can intervene and hopefully
31:18prevent poor mental health outcomes.
31:20But what I've started to understand and
31:22what I began understanding as I was
31:25doing this work as I was exploring these
31:27areas around social determinants of
31:29mental health is if you were interviewed.
31:42And of that, risk factor happened long
31:45before the risk factor came into play.
31:48So if you're trying to address this issue,
31:50but you haven't moved further upstream,
31:52if you haven't gotten to what Sir
31:54Michael Marmot and and Jeffrey Rose
31:56called that causes of the causes.
31:58If you haven't gotten there then you,
32:00then you're really missing what's driving
32:02the development of the risk factors,
32:04so you have to move further upstream
32:06and further upstream gets us to these
32:08social determinants of mental health,
32:10and you can see there are a
32:12number of them in the boxes.
32:14It may be a little bit difficult to see,
32:16but it's it's certainly not.
32:18All of the social determinants
32:20of mental health,
32:21but it's many of the social determinants
32:24of mental health and it includes things
32:26like adverse childhood experiences,
32:28discrimination,
32:29exposure to violence and conflict,
32:30interactions with the
32:32criminal justice system,
32:33low education and unemployment,
32:34or underemployment,
32:35poverty and income inequality,
32:37homelessness, and housing instability,
32:38food insecurity, transportation and security,
32:40and poor access to health care.
32:42And then things like adverse features of the
32:45built environment and neighborhood disorder,
32:47and pollution.
32:48Exposure in climate change.
32:50So all those things are the social
32:52determinants of mental health.
32:54They are the foundation that drives
32:56the development of these risk factors,
32:58which leads to these adverse mental health
33:00outcomes in these mental health inequities.
33:02But again, as I spent time
33:04thinking about these concepts,
33:05it's it's become very clear to me.
33:08I've started to understand that if
33:10you're intervening at the level of the
33:12social determinant of mental health,
33:14you are still intervening too late
33:16because there are number of things
33:18that set the context that set the
33:20foundation for the development of the
33:22social determinants of mental health.
33:24And what is really driving all of that
33:26is social injustice or the unfair and
33:29unjust distribution of opportunity.
33:31And the thing that creates that
33:34unfair and unjust distribution of our
33:36of opportunity or our social norms,
33:38the beliefs, the mindsets,
33:40the attitudes we have about certain
33:42people in certain populations,
33:44including who is worthy in our
33:46in our population,
33:48of certain advantages and who
33:50is worthy of disadvantage.
33:51Who should be elevated in our
33:54society and who should not.
33:56And then those social norms are
33:58complemented by public policy's
34:00the laws that we passed to reflect
34:02those values in our in our society.
34:04So,
34:04based on our beliefs about certain people,
34:07we pass laws.
34:08Those laws create unfair and unjust
34:10distribution of opportunity,
34:11which then drive the development of
34:13the social determinants of mental health,
34:15which then lead to the risk factors
34:17which then lead to the adverse mental
34:19health outcomes in mental health inequities.
34:22So that's a lot.
34:23And I'm going to use an example
34:25to really kind of clarify what
34:28I'm talking about.
34:29So if we're thinking about social norms,
34:32let's think about crack cocaine and crack.
34:34Use disorder,
34:35so all of us,
34:37I think from a social norm perspective,
34:39have a mental image of
34:41what a crack user looks
34:43like, and this may be seared in
34:46our brains from the early 1980s,
34:48or even thoughts about that if you
34:51weren't even born during the early 1980s.
34:54You can still have thoughts about about
34:56what it what a crack user looks like.
34:59What are social norms? Are we?
35:01We tend to think about black people.
35:04If it's a black man,
35:06we we tend to associate them with criminal
35:08behavior with being violent and dangerous
35:11as a result of a desire to get drugs.
35:13If it's a black woman,
35:15we tend to think of a woman who
35:17is so hell bent on getting more
35:20crack cocaine that she's willing
35:22to put her children at risk.
35:24She doesn't really care about her children,
35:27and because of the moral panic that
35:29developed in the 1980s and this belief.
35:31That we have because of these social
35:34norms about what type of people use crack
35:37cocaine and what their value is in society.
35:40We passed a number of laws that reflect
35:43that that belief system and one of them
35:47was the anti Drug Abuse Act in 1986
35:50which created this 100 to one jail.
35:52Sentancing disparity between
35:54crack cocaine and powder cocaine
35:56and what it said there was.
35:58If you had one gram of crack
36:01you would have the same.
36:03Jail sentence as somebody who had in their
36:06possession 100 grams of of powder cocaine,
36:09which really makes no sense because
36:12these are the same chemical compounds.
36:15These drugs.
36:16The difference really is that crack
36:19cocaine is a drug that is much
36:22much more less less expensive.
36:24It's a drug that is mostly used by
36:27people that are low income and many
36:31people that are low income because of.
36:34Inequities in our society happened to
36:36be black people and so because of that
36:40disparity and because of that powder
36:42cocaine is more likely to be used by
36:45people who are affluent who have money.
36:48And because many people in our
36:50society who are affluent happened
36:52to more likely be white people.
36:54You saw this difference in how these
36:57particular drugs were sentence and
36:59so that 100 to one jail sentancing
37:01disparity which is an extreme difference
37:04persisted for many years until 2010.
37:06Where that jail sentencing disparity
37:09was changed to 18 to one again,
37:11it really makes no sense that
37:14there should be any jail disparity
37:16as these are the same drugs but
37:19yet still this disparity exists.
37:22There's legislation right now trying
37:24to eliminate the disparity altogether,
37:26but it still exists in some form,
37:29and so this is how our laws reflect
37:32our beliefs about certain populations.
37:34As a result that created an.
37:37Unfair and unjust distribution of
37:39opportunity which led to a cascade
37:42effect of a number of social
37:44determinants of mental health,
37:46being incarcerated in and of itself is
37:49a social determinant of mental health.
37:52It also creates generational effects
37:54because children who have parents
37:57who go to jail that is actually
37:59an adverse childhood experience,
38:01so so you're creating problems
38:03across generations.
38:04But but also once somebody
38:06gets out of jail or prison.
38:09It's very difficult for them
38:11to find employment. It's there.
38:12They're entered into a cycle of poverty.
38:15It is very difficult to get education
38:17to to kind of address multiple
38:19social determinants of mental health.
38:21It's difficult to find housing so so,
38:24so this activates a number of social
38:27determinants and I will just point out
38:29again that one of the things around
38:32our social norms of crack cocaine is
38:34that we have really associated crack
38:36cocaine use with the criminal justice system.
38:39So Ernest Drucker,
38:40in a plague of prison, said.
38:42The fundamental clinical accountability
38:44of drug treatment professionals
38:46to individual patients has been
38:49subordinated to the goals of
38:50the criminal justice system.
38:52And I'd just like us to take
38:55a minute to contrast that with
38:57how we think about the opioid,
38:59use epidemic and the fact that
39:02we don't necessarily have.
39:03We have a very different image
39:05in our minds when we think about
39:07people who use opioids and our
39:10social norms are different,
39:11we don't consider the opioid use
39:13epidemic to be a drug problem that
39:16should be addressed through the
39:18criminal justice system we consider
39:20it to be a public health problem,
39:22and we don't necessarily consider mothers.
39:25Who use opioids to be these horrible people.
39:27The way that we think about mothers who
39:30use crack cocaine and so part of that.
39:33Again we see the difference in the
39:35laws that we pass and much of that
39:38relates to our social norms an and
39:40the public policy that we passed
39:42to reflect those social norms.
39:45So I want to take a little bit
39:47of time to go over a couple of
39:50important key concepts.
39:51I want to talk about.
39:53I mentioned that we don't spend a lot
39:55of time thinking about the connection
39:57between oppression and health,
39:59and so I want to spend some time
40:01defining certain types of oppression.
40:03And this is work by Iris Marion Young in
40:05what she calls the five faces of oppression.
40:08So we have exploitation,
40:09which is the unequal exchange
40:11of one groups labor and energies
40:13for another groups advantage.
40:14An advancement.
40:15Clearly, when we think about exploitation,
40:17we think about slavery.
40:19But I think that much exploitation
40:21happens in our society today.
40:24Human trafficking is a very
40:26clear example of exploitation.
40:28But also we see exploitation in treatment
40:31of workers across a variety of setting,
40:34treatment of migrant farm workers,
40:37for example,
40:38and many other groups in which
40:41labor is exploited.
40:43Coastal imperialism is when we established
40:45the ruling class culture as the norm
40:48and we other those groups that are
40:50not part of the dominant culture.
40:52I really clear example of cultural
40:54imperialism has to do with the
40:57ways that we think about research
40:59when we're conducting and looking
41:01at odds ratios and risk ratios,
41:03we often pick a reference group and
41:05I find that whenever I'm reviewing
41:08or looking at any sort of article in
41:11which we are examining race or ethnicity.
41:14The reference group, no matter how many
41:16people are in that particular study
41:18of whatever group we're talking about,
41:20the reference group is always white people,
41:22an it just seems very strange that we
41:25would kind of kind of naturally accept
41:27this as the norm without questioning.
41:29Why are we saying that this is this
41:32particular group is considered to
41:34be the thing that we are using as
41:37the reference for our research.
41:39Powerlessness is when oppressed
41:40groups lack power or they are blocked
41:43from routes to gaining power.
41:45I think there are examples of
41:48this all over the place,
41:50but clearly right now we're seeing
41:52a lot of that as it relates
41:55to voter suppression laws,
41:57ways to prevent certain people
41:59from representing themselves in
42:00in elected positions in preventing
42:03certain communities from from
42:04representing their own interests.
42:06Marginalization is when we expel
42:08specific groups from meaningful
42:10participation in society.
42:11I think the clearest historical example
42:14of this is treatment of indigenous
42:17populations here in the United States,
42:20but we've seen many examples
42:22throughout history,
42:23including Japanese internment,
42:24and we also see it currently in
42:28mass incarceration.
42:29And then violence is pretty straightforward.
42:31It's threats and experiences of
42:33physical and structural violence.
42:34I just wanted to find structural
42:36violence as harm that is done when
42:39someone in power does harm to someone
42:41that has less power or groups in power
42:44harm groups that have less power.
42:45It does not have to be physical violence,
42:48it just has to be some form of harm.
42:53So a couple of other principles
42:55is important for us to go over.
42:58One is this concept of essentialism.
43:00This is the belief that there are distinct,
43:03unchanging and natural characteristics
43:04that define social groups and
43:06facilitate their categorization.
43:07This this is our tendency to want to
43:10put people into discrete boxes and say
43:12that certain people in certain groups
43:15really fall into these boxes very easily.
43:18The problem of course,
43:19with this is that human beings
43:22are never this.
43:23Simplistic and cannot be categorized
43:25with such accuracy as as we believe
43:28in with the concept of essentialism.
43:31Erasure of context,
43:32which I've already touched on,
43:34is this failure to consider social
43:36historical context when seeking to
43:38understand the etiology of inequities.
43:40So clear example with Doctor
43:42Cartwright's theories about
43:44about certain mental illnesses.
43:45But we also saw this well defined by
43:49Jonathan Metzl in the protest psychosis
43:51when he talks about how schizophrenia.
43:54Became associated with the civil
43:57rights movement without a lot of
44:01context around the desire for people
44:04to fight for their civil rights.
44:07And biological determinism is the
44:09false belief that racial groups are
44:11biologically and genetically different.
44:13Again,
44:14I always kind of get stuck on
44:16this because it seems like such
44:18a basic concept an yet there are
44:21people who really still strongly
44:24believe in biological determinism.
44:26Anan a perfect example of that is
44:28that recent study where they looked
44:31at medical students and asked and
44:33found that a significant number
44:36of medical students still believe.
44:38On these concepts, like black people
44:40have thicker skin than white people,
44:43black people have fewer nerve
44:44endings than white people.
44:46That these beliefs continue to
44:48persist in our medical education
44:50system and then cultural determinism
44:52is the false belief that differences
44:54in racial group are racial groups
44:56are the result of cultural factors,
44:58and this is of course not trying to
45:01imply that culture is not important,
45:03but it doesn't necessarily drive
45:05the differences in outcomes that
45:08we often tend to.
45:09I think that that it does,
45:11or we maybe put too much emphasis.
45:14We may say that certain groups have
45:16poor outcomes as it relates to diabetes
45:18and hypertension because of their
45:20dietary choices based on cultural
45:23beliefs around their dietary dietary choices,
45:25but yet we're not looking at all
45:28around the structural design of of
45:30how those dietary choices came to be.
45:33We're not looking at the structural
45:35drivers of how certain groups
45:37have different access to certain.
45:39Foods so so it's just this tendency
45:41that kind of overemphasize certain
45:44factors without really getting
45:46to the structural causes.
45:49There are multiple types of discrimination.
45:51There is legal and illegal discrimination.
45:54Of course legal discrimination
45:56is best exemplified by the Jim
45:59Crow laws of the South.
46:01But illegal discrimination is what
46:03we tend to think of as it relates to
46:06employment opportunities and the idea
46:09that you cannot discriminate against
46:11certain protected classes in our society,
46:14and so illegal discrimination
46:16applies to those protected classes
46:18specifically for employment.
46:20Based on the Civil Rights Act,
46:23and it was just recently expanded
46:25to include LGBTQ populations,
46:27but only very specifically and
46:29work in workplace settings.
46:31Then we have overt and covert discrimination.
46:34Overt is really common,
46:36clear examples when you're
46:37being discriminated against.
46:39Covert is more the implicit
46:41types of discrimination.
46:42We often talk about microaggressions.
46:44It's when you're kind of left
46:47scratching your head, wondering if
46:49you were discriminated against or not,
46:52and not being entirely.
46:53We are about that and then there are
46:56multiple levels of discrimination.
46:58There's interpersonal,
46:59institutional, and structural.
47:01Interpersonal is the one we spend a
47:03lot of time talking about focusing on.
47:06It's it's this idea of the the one on
47:09one interactions that we have with people.
47:12It's the things that get the most news.
47:14Get the most media attention.
47:16Get the most focus and when again
47:18what's really driving the inequities
47:20in our society are those structural
47:22and institutional levels of
47:24discrimination that we experience
47:25and so to define structural racism.
47:27It is a system in which public
47:29policy's institutional practices.
47:31Cultural representations,
47:31another norms work in various,
47:34often reinforcing ways to perpetuate
47:36racial group in equities.
47:37This system identifies dimensions of
47:39our history and culture that have
47:42allowed privileges associated with
47:44whiteness and disadvantages associated
47:47with color to endure an adapt overtime.
47:50It is not something that a few people
47:52or institutions choose to practice.
47:54Instead, it's been a feature of the social,
47:56economic and political systems
47:57in which we all exist.
47:59It does not require the actions
48:01or intentions of others,
48:02so we can all be very good people
48:05and structural racism can still
48:06blossom and flourish in our society
48:08and just to drive that point home.
48:10If we got rid of all of the
48:13interpersonal discrimination
48:14that exists in our society today,
48:15we would still see racial and
48:17ethnic inequities due to the
48:19persistence of structural racism.
48:21So in the time that I have left,
48:24I want to spend some time
48:26giving some examples of social
48:28injustice and mental health.
48:29We've already talked about the war on drugs,
48:32so I'm not going to cover that again,
48:35but I will mention very briefly
48:37around residential segregation.
48:38We we were most of us are familiar
48:41with this concept of redlining,
48:43how certain neighborhoods were invested
48:44in and certain communities of color.
48:47Those neighborhoods were
48:48divested in or disinvested in,
48:49and so those communities.
48:51Then had a withdrawal of resources,
48:54including clinics,
48:55hospitals,
48:55those types of settings,
48:57but I think one of the best examples
49:00of residential segregation has
49:02to do with COVID vaccinations,
49:05and so we saw a recent study that
49:07showed that people who live in
49:10predominantly black communities have
49:12to travel significantly farther to
49:15get to the closest COVID vaccination
49:18site than people who live in
49:21predominantly white communities.
49:23And so it's interesting because
49:25we've spent a lot of time thinking
49:28about the COVID vaccine,
49:30talking about vaccine hesitancy,
49:31talking about cultural beliefs that are
49:34preventing people from getting the vaccine.
49:37But we haven't focused as much
49:39on the structural barriers.
49:41The barriers associated directly from
49:44residential segregation that are
49:46really driving some of the differences
49:48that we see in access to vaccinations
49:51an and people cannot get vaccinated.
49:53If they can't get to a vaccination site,
49:56so instead of spending as much time
49:58as we are trying to convince people,
50:00I think we have to think about
50:02how how these structural issues
50:03are really driving some of these
50:05differences that we're seeing.
50:07Some of these inequities.
50:09Immigration policy this is a particular
50:12issue as it relates to the fact that
50:15we have certain quotas about who people,
50:18which countries.
50:18It's OK for people to come into
50:21this country from and so we have
50:24certain places that we have
50:26identified as as desirable places
50:28for people to immigrate from,
50:30and then we have certain countries
50:33that are less than desirable and
50:35therefore we are much more restrictive
50:38about who comes into the country from.
50:41From those populations,
50:42but the other thing we do is that we
50:44scream people in our immigration policy,
50:47and so if you have a serious
50:49mental illness or if you have
50:51a substance use disorder,
50:52you're not going to be admitted
50:54as an immigrant to this country.
50:56You will be screened out from from
50:58consideration the thing that's
51:00interesting about that is is it's the
51:02direct result of this immigration policy.
51:04Why we see this healthy immigrant effect?
51:07Why we see that when people
51:08come to this particular
51:10country, they as immigrants
51:11they are often healthier.
51:13Then the people that live here,
51:16the residents of this country and and
51:19what's fascinating about that is again, we.
51:22We tend to air on the side of
51:24making cultural explanations.
51:27For this. We say that oh,
51:29this immigrants have different values.
51:32They have different dietze.
51:33They have different cultural beliefs and
51:36that is really what's driving the better
51:39outcomes for these immigrants without
51:41again looking at the structural barriers.
51:44That we have created in which we have
51:47screened out and and particularly
51:49selected a particularly healthy population.
51:51And then that is really what's driving the
51:55the differences in outcomes that we see.
51:57The Social Security Act of 1935,
52:00of course,
52:00created retirement benefits.
52:02A wonderful act that allowed older
52:04people to be able to retire in
52:07comfort and be able to not have a
52:09lot of financial anxiety or stress.
52:12Not have a lot of poverty associated
52:14with their with older adulthood.
52:16And they could also pass their wealth onto
52:19their children and their grandchildren,
52:21building wealth building generational wealth.
52:23The reason that the Social Security
52:25Act is an example of structural racism.
52:28It's because in order to get that past
52:31Southern senators required that it
52:33excludes domestic and agricultural workers,
52:36and so domestic and agricultural workers at
52:39that time were the were predominantly black.
52:43And so despite having worked
52:45your entire life,
52:46if you were a domestic
52:48run agricultural worker,
52:49you could not retire and get these Social
52:52Security benefits in your retirement.
52:54So you couldn't then have less anxiety
52:57and Peace of Mind in older adulthood.
53:00And you also couldn't pass that
53:02wealth onto your children.
53:04So you really saw this this huge
53:07widening of the wealth gap in
53:09this country as a result of the
53:12passage of the Social Security Act.
53:15And then let's take a little bit of time
53:17to talk about the mental health care.
53:19This is data from Samsung showing that
53:22in 2018 about 69% of black adults and
53:2567% of Latin X adults with any mental
53:28illness received no treatment whatsoever.
53:30About 42% of black adults and 44% of
53:33Latin X adults with serious mental
53:36illness received no treatment.
53:38When we talk about substance use disorders,
53:41these numbers get terrifyingly large.
53:4389% of Latin X adults with substance
53:46use disorders and 88% of black adults
53:49with substance use disorders reported
53:51receiving no treatment whatsoever.
53:53So I have to pause and say what
53:56is the cause of these this.
53:59This extremely high rates of people not
54:02accessing health care and particularly
54:04not accessing mental health and
54:06substance use services and and the
54:09reason I pause is because think
54:11about the explanations that you have
54:13often had for these these reasons,
54:16I think we might say particularly
54:18around Black and Latinx populations.
54:20They have a lot of stigma towards
54:23mental illness. They they they tend to.
54:26Not want to seek treatment and
54:28we might even say oh they,
54:30they're not particularly well educated
54:32about mental health problems or
54:33substance use disorder problems,
54:35and so they may be less likely to
54:38seek out treatment 'cause they may
54:40not think that they have a problem.
54:43But really, when we asked people
54:45about why they weren't seeking mental
54:47health treatment or substance use,
54:49treatment cost was the most commonly
54:51cited reason why people said they didn't
54:54seek care and it was twice as often.
54:56As a minimisation of symptoms and
54:59nearly five times as often as stigma,
55:02so again we have the tendency to
55:04air to this idea that it's some
55:06sort of intrinsic issue rather than
55:09looking at the structural causes.
55:11The fact that we have created an
55:14inequitable mental healthcare system in
55:17this country that makes it very difficult
55:19if you are poor to access quality,
55:22mental health and substance use,
55:24disorder services and so cost
55:26is really the driving force.
55:28These structural explanations
55:29are the driving.
55:30Course we talked behind why we see such
55:33high rates of lack of accessing treatment?
55:37So.
55:37The question is where do we need to go,
55:41and I think that we need to start
55:44off by understanding where we are,
55:47so we're currently in the state
55:49of inequality.
55:50This is where we have unequal access
55:53to opportunities within society and
55:55many people will think that the best
55:57way to address this is to focus on
55:59equality and a lot of people talk
56:01about the importance of equality.
56:03Equality is when we're thinking about
56:05fairness and we're thinking about
56:06making sure we're evenly distributing
56:08tools and assistance to everybody
56:10that everybody gets the same thing,
56:11and so if we're making any sort
56:14of intervention,
56:14the most important priority is to make
56:16sure that that intervention is fair
56:18and that everybody gets the same thing,
56:21but.
56:21As you can see,
56:22a quality cannot be the goal because it
56:24doesn't address the underlying factors.
56:26So one of the goals has to be equity.
56:29It has to be identifying custom
56:31tools that identify an address,
56:33the inequality and it is
56:35really unchanging you're.
56:36You're thinking the interventions
56:38aren't focused on being fair.
56:39The interventions are making sure everybody
56:42gets what they need to have a healthy up.
56:45An opportunity to have mental health and
56:47and and and to promote good mental health.
56:50But equity actually cannot be the goal alone,
56:53because as you can see,
56:55while it does help a little bit,
56:57we still have an issue here.
57:00And so we have to combine our work
57:03inequity with thinking about justice,
57:05which is when we are fixing the
57:07system to offer equal access to
57:10both tools and opportunities.
57:12So it really is about coming up with
57:15structural solutions to the problems
57:17that we have within our within our system.
57:21And so,
57:22how do we go about doing that?
57:24There are a number of things that
57:26we need to think about,
57:28and I'll go through each of them really,
57:31really quickly.
57:32So the first relates to education
57:34and self reflection,
57:35and I have to say that
57:37because we didn't learn
57:38any of this in our health professional
57:41schools in our grade school,
57:43in high schools or in college,
57:45it means that we have to
57:47do this work on our own.
57:49And I think that what's great
57:51about our graduating residents.
57:53And many of our younger generations
57:55is that there are a lot of people
57:58that did learn some of this when
58:00they were in college because they
58:02were able to major in and focus on
58:05issues like critical race theory and
58:07certain types of studies in which they
58:09learned a lot of this information.
58:12But for the rest of us,
58:14we have to play catch up and so
58:16here are a list of many books
58:19that will get us started if you
58:21if you just read these books.
58:24The level of your understanding of
58:26these concepts will will multiply.
58:27I promise it it did for me because
58:30I did not learn any of this stuff
58:33in any in any school settings.
58:35I will also just say that those
58:38books are dense and hard,
58:39and so if you want to try and
58:41do some easier reading,
58:43I've listed some books here that
58:45are much easier to kind of be
58:47an introduction to this concept,
58:48but also if you're just too tired of reading,
58:51there are a number of podcasts that
58:53really very affectively address these issues,
58:55including the 1619 project and seeing white,
58:57and there are a number of
58:59documentaries that can introduce
59:01you to these topics as well,
59:02and so I am not your is is a
59:05perfect example of that so.
59:07There's many, many,
59:08many ways.
59:09There's really no excuse for not in
59:11educating yourself on these topics,
59:13but of course education is not enough.
59:15We have to practice this concept
59:17of cultural humility.
59:18Cultural humility is when we
59:20commit to a lifelong process of
59:22self evaluation and self critique.
59:24We understand that we can't take one class.
59:27We can't go to 1 grand rounds.
59:29We can't read one book and all of a
59:32sudden be an expert or even be competent,
59:35or even have competence in an area.
59:38We have to be willing to do this
59:40work for the rest of our lives
59:43and we have to commit to that.
59:45And then we have to commit to
59:47this process of self exploration,
59:49which is very hard.
59:50We also have to have a desire to fix
59:53power imbalances between providers
59:55and clients because we have many
59:57power imbalances that are really set
59:59up to make it clear that there is a
01:00:01group that is in power over a group
01:00:04that has less power and it's not
01:00:06really there serving any other purpose.
01:00:09But just to to create that
01:00:11understanding and make it clear for
01:00:13the people in power to feel more
01:00:15powerful and so we have to desire
01:00:17to fix those power imbalances.
01:00:18And we have to work on developing
01:00:21community partnerships to advocate
01:00:22within the larger organizations
01:00:24that we participate in.
01:00:25And then we need to practice
01:00:27structural competence or even
01:00:29structural humility,
01:00:30which is defined by Jonathan Metzl
01:00:33and Helena Hansen as the trained
01:00:35ability to discern how a host of
01:00:37issues defined as symptoms or other
01:00:40diseases are influenced by upstream
01:00:42social determinants of health.
01:00:44So we really need to get skilled at
01:00:47seeing how these social determinants
01:00:50of health show up in the presentation
01:00:53of the problems that our patients.
01:00:55Come to us to address.
01:00:57And then we have to address this
01:00:59issue of acting on social norms
01:01:01and acting on public policy's.
01:01:03And so we must promote social
01:01:05norms of inclusion, equity,
01:01:06and respect in all situations,
01:01:08in all places.
01:01:09And I have to make a disclaimer when
01:01:11we talk about promoting social norms.
01:01:13We can have a healthy dialogue on this,
01:01:16but but I must again quote James
01:01:18Baldwin and say we can disagree
01:01:20and still love each other.
01:01:21Unless your disagreement is rooted
01:01:23in my oppression and denial of
01:01:25my humanity and right to exist.
01:01:27And so it's.
01:01:28It's fine to debate some of these issues,
01:01:31but there are actually some things around.
01:01:34Oppression and denial of humanity.
01:01:36They're actually not debatable,
01:01:37and so if we're going to promote
01:01:40social inclusion and social norms of
01:01:43of inclusion and equity and respect,
01:01:45we have to enforce these social
01:01:47norms of inclusion and equity.
01:01:49We need to enforce them everywhere
01:01:52in our families, in our communities,
01:01:54in our work settings.
01:01:56And we also have to educate or
01:01:59legislate to change social norms.
01:02:01So a number of people harbor these
01:02:03beliefs about different populations.
01:02:05These negative beliefs are
01:02:06negative social norms.
01:02:07Just because they don't know any better.
01:02:09Many of them have not had a lot
01:02:11of experience or interaction with
01:02:13certain groups or certain populations,
01:02:15and so in those cases,
01:02:17education can be very important
01:02:19and to helping change social norms.
01:02:21But I I recognize that there is
01:02:23a subset of the population that
01:02:25no amount of education is going
01:02:27to reach them because they have
01:02:29hateful views about different people
01:02:31or people that are different from
01:02:33themselves and in those cases.
01:02:35That's when the legislation
01:02:36becomes important.
01:02:37That's when we use the laws that are
01:02:40established in our society in our policies,
01:02:42in our educational settings to prevent
01:02:45those people from doing harm in society.
01:02:48And it may include,
01:02:50you know,
01:02:50using our policy is to remove
01:02:53certain learners.
01:02:54I'm certain educators from interacting
01:02:56with learners or other situations
01:02:58like that we must observe and
01:03:00challenge our own implicit biases.
01:03:02This is really hard work.
01:03:04The better you become at
01:03:06identifying your biases,
01:03:07the more frustrating the work becomes
01:03:10because it in intrinsically challenging
01:03:13your implicit biases means that
01:03:15you were going to come up against.
01:03:18Values that your biases have that
01:03:20are different from your personal
01:03:22values and it becomes hard to
01:03:24constantly reflect on the fact that
01:03:26you have thoughts that are against
01:03:27your own personal value system,
01:03:29but it's still important to do this
01:03:32work and it I would just say that you
01:03:34have to do this work,
01:03:36but then offer yourself some grace as
01:03:38you as you become better or skilled at
01:03:40identifying your own implicit biases.
01:03:42And then, as I said before,
01:03:44we have to evaluate and breakdown any
01:03:47unnecessary hierarchies that exist with.
01:03:48In our society within
01:03:50our clinical structures,
01:03:51within our interactions with our patients,
01:03:53we have to do that work because a many
01:03:57hierarchies that we have in our society
01:03:59are not there to do anything but to
01:04:02make people in power feel more powerful.
01:04:07And then we have to advocate for
01:04:09effective and equitable public policy's,
01:04:11and that really means thinking about the
01:04:13fact that all policies are health policies,
01:04:16and therefore all health policy czar.
01:04:18Are mental health policies.
01:04:19And so we must take action beyond
01:04:22the walls of our clinics or
01:04:24hospitals or treatment centers.
01:04:26And we must advocate for those
01:04:28policies that address the social
01:04:29determinants of mental health.
01:04:31This work involves us all communicating
01:04:34with our elected officials at
01:04:36all levels at the local state.
01:04:38And national levels and it
01:04:40requires us to promote equitable,
01:04:42equitable representation to make sure
01:04:44that whenever we're forming any committee,
01:04:47whenever we were creating any system
01:04:50in which people are going to make
01:04:53decisions about anything that we have,
01:04:56the right representation that reflects
01:04:58the people by which the issue or
01:05:01the policy is going to be made.
01:05:04And and it also involves forming
01:05:07cross sector collaborations and
01:05:09community coalitions and working.
01:05:11And equating working equitable
01:05:13equitably with our community,
01:05:15coalitions and collaborators.
01:05:17Making sure we're compensating them
01:05:20appropriately for their time and their
01:05:23energy. So you know to to wrap up.
01:05:26I would just say that for myself
01:05:29this this desire back when I was
01:05:32at Emory in Atlanta to really think
01:05:34hard about why I was seeing these
01:05:37differences really led to my career
01:05:39and focusing on how to how structural
01:05:42racism and social determinants of
01:05:44health had led to these poor outcomes.
01:05:47And so I've found that the last
01:05:50thing that we all have to do is
01:05:53think about how to speak up.
01:05:55And use our voice and for me
01:05:58it has been writing articles.
01:06:02Making statements within within
01:06:03academic settings to really advance
01:06:05these issues on a larger scale,
01:06:07and I think that it's all incumbent upon
01:06:11all of us to speak up when we can whenever,
01:06:14because politically political stances
01:06:16and policy interventions are required if
01:06:19we are to remain apolitical or neutral,
01:06:21that is and of itself a political stance,
01:06:24it is a tacit acceptance of the status quo,
01:06:28so it's not enough to say that
01:06:30we're not waiting until.
01:06:32Political issues this is work that
01:06:34we all have to do and so I call
01:06:36on the words of Audre Lorde.
01:06:38She said when we speak we are afraid our
01:06:40words will not be heard nor welcomed.
01:06:43But when we are silent,
01:06:44we are still afraid.
01:06:45So it is better to speak so we
01:06:47all need to work on speaking up an
01:06:49I really want to challenge our graduates
01:06:51to find your voice and to speak even
01:06:54when you're afraid because it is.
01:06:55It is always better to speak.
01:06:58And so to the end,
01:07:00I just want to say that we've had this
01:07:03great experience in the last year or so,
01:07:07in which we've seen a lot of progress
01:07:10being made and progress is made
01:07:12through the passage of legislation,
01:07:15court rulings, and other formal mechanisms
01:07:17that aim to promote racial equality.
01:07:20And it's been great,
01:07:21but I think that we have to remember
01:07:24that always with progress always
01:07:26comes inevitable retrenchment.
01:07:28And retrenchment refers to the many ways in
01:07:31which progress is very often challenged,
01:07:34neutralized or undermined
01:07:35in key policy arenas.
01:07:37If we're not ready for the retrenchment,
01:07:40we can get very.
01:07:43We can despair.
01:07:44We can get very overwhelmed and
01:07:47frustrated and demoralised because
01:07:48when we feel like progress is being
01:07:51made when we're faced again with
01:07:53retrenchment as we see happening
01:07:55so much in our society right now,
01:07:58it's overwhelming and and I will just
01:08:01point out that a recent study showed
01:08:04that support for Black Lives Matter
01:08:07is actually less now than it was.
01:08:10Prior to George Floyd's murder,
01:08:11so this is just another example
01:08:13of how we can see retrenchment
01:08:15showing up in our society.
01:08:17So I want to leave.
01:08:19I want to leave you with some hope
01:08:21and with the idea that of how to get
01:08:24past this feeling of retrenchment.
01:08:26And so I will leave you with the
01:08:28words of Congressman John Lewis.
01:08:30He said, do not get lost in a sea of despair.
01:08:33Be hopeful, be optimistic.
01:08:35Our struggle is not the struggle of a day,
01:08:38a week, a month, or a year.
01:08:40It is a struggle of a lifetime.
01:08:42Never ever be afraid to make some noise
01:08:45and get in good trouble, necessary trouble.
01:08:47Thank you.
01:08:55Thanks so much Doctor Shim
01:08:56for it really terrific talk.
01:09:00We're able to have questions in
01:09:02the chat and now we're we're
01:09:04usually at the end of our session,
01:09:06but I'd like to extend.
01:09:08For those of you who are able to extend,
01:09:11and if you'll put your questions in the chat,
01:09:14will provide them to Doctor Shim.
01:09:21Fortunately, Bob Diana. Unfortunately,
01:09:23the chat is disabled, so we can only go to
01:09:28the. Co hosts for.
01:09:30I don't know why but.
01:09:33You can't put your. Questions,
01:09:36but I just have a question
01:09:38for you Ruth. It's always good
01:09:40to see you and thank you.
01:09:43Your slider impeccable really just amazing
01:09:45and so grateful to have you as our speaker.
01:09:49I've been thinking a lot about how to move
01:09:52forward and I want to remain optimistic,
01:09:55especially for our graduates.
01:09:57But how to remain optimistic in
01:09:59the context of legislation that.
01:10:02Is trying to silence the voices.
01:10:05In particular,
01:10:06I gave a talk about social racism.
01:10:09Basically in an addiction and in Iowa,
01:10:12and they just passed a bill
01:10:14that would be effective July,
01:10:16one that basically the majority of
01:10:19the context of what I share would
01:10:22not be allowed to be discussed,
01:10:24and the grand rounds format so.
01:10:28You know what do you do?
01:10:30A lot of people are out, you know,
01:10:32trying to make it illegal to
01:10:33talk about critical race theory.
01:10:35There are those amongst us who will continue,
01:10:37but people need their jobs
01:10:39for their survival.
01:10:39So I'm thinking about maybe how
01:10:41have you contemplated this butter?
01:10:42What are some creative
01:10:44ways to make sure that?
01:10:47We're able to discuss these
01:10:48issues and this is such a great
01:10:50question and thank you so much.
01:10:52I Anna,
01:10:53you know,
01:10:53I rely on you as as one of my
01:10:56close collaborators and and one
01:10:58of the people that is in in the
01:11:01fray doing this work with me.
01:11:03So I so appreciate you.
01:11:06So it is challenging and similarly to you,
01:11:09I'm giving a talk to next week in
01:11:11Texas an I was told as I was putting
01:11:14the talk together that I cannot
01:11:16have social injustice in the title
01:11:19and that that is a that is a while.
01:11:22While this speakers are very
01:11:24happy for me to talk about it,
01:11:26that that is a policy that was
01:11:29created by the governor and I'm
01:11:31not allowed to use that that term.
01:11:33So so there is an extreme.
01:11:36Push this is the retrenchment that
01:11:39we are seeing right now and it is.
01:11:42It is clear that we are seeing this
01:11:46retrenchment because progress is
01:11:48being made an and people that have
01:11:51power that have have been successful
01:11:54at holding and maintaining power
01:11:56to advance their needs are very
01:11:59effective at holding on to that power.
01:12:02They're very effective as at
01:12:04identifying what threats might.
01:12:07'cause their power to come into question.
01:12:10And so these these things are in
01:12:13fact clear examples of people trying
01:12:16to make sure that they maintain
01:12:18their power and that any threats to
01:12:21disrupt that power be neutralized.
01:12:24And so then the work becomes.
01:12:28The work becomes it's incumbent
01:12:31on all of us who have.
01:12:34Some measure of power to push back,
01:12:37and so I would say you know,
01:12:40you know we're doing this work
01:12:42and it's it's our responsibility
01:12:44to speak up and speak out and
01:12:47continue to speak on these things.
01:12:49But I actually think it's even
01:12:52more incumbent on people that
01:12:54don't look like us to do that work.
01:12:56It's more incumbent on all
01:12:58of the members of of
01:13:00this institution.
01:13:01It's all of you in here in this room.
01:13:05This is the work that you have to do.
01:13:07You have to. This is when I say
01:13:10speak out and and take a stand.
01:13:12This is the work you have to be
01:13:13willing to advance these concepts.
01:13:15You have to be willing to say no.
01:13:17We are going to talk about these things.
01:13:20We're going to.
01:13:20We're going to face risk and you
01:13:22have to be willing to take that
01:13:24risk as people that have greater
01:13:26power than than people that are kind
01:13:28of on the ground in the trenches.
01:13:30You have to be willing to
01:13:32absorb some of that risk,
01:13:33so it involves us all being braver.
01:13:36And recognizing that we have
01:13:37privilege and we have power in
01:13:39using that privilege and power
01:13:41to advance these concepts.
01:13:44It appears that if you send a question
01:13:47directly to John or me that that we are
01:13:49able to use the chat and one person
01:13:52has figured that out and question is.
01:13:54Great talk. Do you think that
01:13:56will be will ever rejoin the AP A?
01:13:59If So what would it take to
01:14:01get this question a lot?
01:14:04Uh, what will it take? You know,
01:14:06I'm I'm I'm so I I I have no desire
01:14:10or plans to rejoin the EPA right now,
01:14:14and one of the reasons why is
01:14:16because I have been fortunate enough
01:14:19to be involved in organizations
01:14:21where I see what real attention
01:14:24to these issues looks like,
01:14:26what real commitment to to looking
01:14:29at yourselves to looking at
01:14:31yourself as an organization to
01:14:33dismantling structural racism.
01:14:34What a real commitment looks like.
01:14:38And and the EPA has not demonstrated any
01:14:41interest in making that level of commitment.
01:14:44And so if at some point.
01:14:48That level of commitment is made up.
01:14:50Then I would be happy to
01:14:52rejoin the organization.
01:14:53I will tell you that that level of
01:14:55commitment in the organizations that I'm
01:14:57in where I'm seeing that work happened,
01:15:00I I think I'll just very clearly
01:15:02say to you that I'm a member of
01:15:04the Board of the Robert Wood
01:15:06Johnson Foundation that I'm seeing.
01:15:08I'm seeing that work play out.
01:15:11I've seen what a commitment of
01:15:13an organization to advancing
01:15:15racial injustice looks like,
01:15:17and that comes from leadership that
01:15:19comes from the top of the organization,
01:15:22and it has to be a an intrinsic
01:15:24value at the very top,
01:15:27and so if that is not a value of
01:15:29the leadership and then that leader
01:15:32has to be really brave to then be
01:15:35willing to push forward and take
01:15:38the organization in a direction
01:15:40in which there is risk.
01:15:42Severe risk involved,
01:15:42and again I I'm fortunate to
01:15:44be able to witness that happen,
01:15:46and I know what that looks like.
01:15:48I'm fortunate to be in an
01:15:50organization that does that,
01:15:51and so I don't really need to align
01:15:53myself with organizations that aren't there.
01:16:00Thank you other questions.
01:16:13Well, I guess I have.
01:16:15I'll take the prog ative of
01:16:17asking a question.
01:16:19We've we've tried to work on
01:16:22a curriculum that's that will
01:16:24help ensure our residents.
01:16:26We hope will ensure our residents
01:16:28don't go out and and promulgate was
01:16:30going to say health disparities.
01:16:32But now I'm going to say health inequities.
01:16:35Thank you. Well done and I
01:16:37was you know what were.
01:16:40I think one of the things that
01:16:41we need to work on is how do we?
01:16:44Evaluate or assess our presence
01:16:46abilities to to do that,
01:16:48and I was wondering if you had any
01:16:51ideas about about that process. Hello.
01:16:55Yeah, that's a challenging question.
01:16:58That's a really challenging question.
01:17:01How do we? How do we know that
01:17:04we are graduating residents
01:17:06who are structurally competent?
01:17:09Anne have structural humility
01:17:12and cultural humility.
01:17:14And that's again, it's really hard.
01:17:17You know we don't have like a.
01:17:19We don't have a a a set.
01:17:22A set of like metrics you know
01:17:25we have these milestones and we
01:17:28we we think about those things,
01:17:30but we don't have kind of a clear
01:17:34set of metrics around this.
01:17:37I will say that.
01:17:40What it would look like to me?
01:17:43Would be that you would know.
01:17:46Based on the work that people
01:17:49choose to go into.
01:17:51You would know based on if we started to see.
01:17:55Some small changes in in equities
01:17:58in in the local environment
01:18:00in New Haven for example I.
01:18:02I think that's how you would
01:18:05start to see that's how you
01:18:07would start to know and I would.
01:18:10I will just say that a lot of places
01:18:12are starting to think about how
01:18:15the ways that we've traditionally
01:18:17evaluated what is considered competent,
01:18:20whether that be in psychiatry or in
01:18:23other things is is maybe not accurate.
01:18:27And so I've even written about
01:18:29how the US news and World Report
01:18:31rankings for medical schools
01:18:33doesn't really get at any sort of
01:18:36clear understanding of what would
01:18:38make for a good provider or what
01:18:41makes a good hospital or what
01:18:44makes a good medical school.
01:18:47But yet we see that white coats
01:18:49for black lives has created a
01:18:52racial justice report card.
01:18:54Really thinks about how do you?
01:18:56How do you take a different set of
01:18:58metrics by which you're evaluating how
01:19:01effective the work that you're doing.
01:19:04So so I think that it's kind of on us.
01:19:08I think Bob that we have to think
01:19:11about creating the metrics or or
01:19:13borrowing the metrics that have already
01:19:16been in use that really are metrics
01:19:18that are looking at how competent
01:19:21or how skilled is the learner.
01:19:24Is the trainee on addressing
01:19:25issues of racial equity addressing
01:19:27issues of social injustice,
01:19:29so maybe this is a this is a competency,
01:19:32some sort of milestone
01:19:33work that we need to do.
01:19:35I do know that the AC Jimmy is
01:19:38very interested in this and is
01:19:40thinking about how to do this work.
01:19:44Thank you.
01:19:47Alright.
01:19:50John, any questions in your chest.
01:19:53None, none in mind. Alright,
01:19:58I think we're going to wrap up.
01:20:00It's really been a pleasure to
01:20:02have you Doctor Sherman and thanks
01:20:04so much for joining us for as our
01:20:07graduation speaker. Thank you and
01:20:08congratulations again, graduates.