In her book Mediocre: The Dangerous Legacy of White Male America, Ijeoma Oluo describes a phrase that she and her fellow social justice advocates use whenever injustice occurs in society: “works according to design,” meaning that our unequal society didn’t come about by accident – it was designed to keep historically marginalized people on the margins. Oluo uses the example of the many unarmed Black people killed by the police, while the perpetrators consistently avoid criminal trials. We recently observed this system at work with the differential law enforcement response to the attack of mostly white insurrectionists on the Capitol building compared to the crackdown on Black Lives Matter protesters last year.
As two Black women psychiatrists, in a field in which just 2 percent of all psychiatrists are black, we are repeatedly confronted with a disturbing trend in how the mental health system in the United States works. A majority of Black and Latinx adults with mental health problems do not have access to treatment, and almost 90 percent of Black and Latinx adults who have substance use disorders in the U.S. do not have access to effective care. Indigenous populations have higher rates of alcohol use disorder than other populations, and Black people are more likely to be diagnosed with schizophrenia, labeled as hostile and loaded up on high doses of antipsychotic medication than white people. Transgender youth have higher rates of suicide than cisgender youth. The list of inequities in mental health goes on and on.
More disturbing are the traditional explanations for why these inequities exist in the first place. In medical school, training and ongoing clinical practice, there is an emphasis on biological determinism, the false belief that people of different racial and ethnic groups are biologically and genetically different, and cultural determinism, the false belief that differences in health outcomes are the result of people’s different cultural backgrounds and life choices. We (and our colleagues in medicine and other health professions) were taught to blame oppressed patients for their poor outcomes by implying inferiority (either biological or cultural) to the dominant white, straight, male culture, and that these poor outcomes were the result of incapability of oppressed and minoritized populations to conform to the standards of the dominant class and culture.
This type of argument persists today, with leading scholars advancing this argument as recently as July 2020. As members of groups most often oppressed—and members of the “untouchable” caste in the United States—we were faced with a cruel dilemma. To unpack what drives inequitable outcomes in health and mental health, either we must accept that we ourselves were members of a biologically and genetically inferior population—or come to a different conclusion, one in which we began to understand that the mental health system in the U.S. works according to design and is failing everyone in the process.
As we set out to review the evidence to support our hypothesis, data point after data point coalesced around a clear theme: the mental health of American society, particularly its marginalized members, is ravaged by the intentional, avoidable, inequitable distribution of resources, opportunities and basic protections. The most valuable framework for understanding the poor mental health outcomes and mental health inequities in this country is one of social injustice.
We also experienced the very personal manifestations of social injustice on mental health firsthand. While on a work retreat in San Miguel de Allende, Mexico (a city named in part after a prominent figure in Mexico’s War of Independence), we took a guided tacos and tequila tour during one of our breaks, led by a friendly Latinx male in his early twenties. Despite the city’s namesake, the young man defaulted to telling the city’s story from the colonizer’s perspective rather than that of the oppressed Indigenous people or the victorious revolutionaries.
Primed by the purpose of our trip and the work of the day, we asked the tour guide to give us the landmarks’ real stories. Perhaps we wore him down over time, because, to our surprise, not only did he educate us about historic injustices in San Miguel de Allende, but also about his personal story of contemporary injustice he experienced in our home country of the United States.
After his birth in Mexico, our amiable tour guide had been brought to the United States by his parents at a very young age. The U.S. was his home, where he learned with his classmates, played soccer with his neighbors and formed childhood memories with his family—until he was detained for lack of proof of citizenship following a routine traffic stop. Unsure of whether he qualified for the Development, Relief, and Education for Alien Minors (DREAM) Act, and without the money for an immigration attorney, he and his loved ones had never explored his eligibility. He was routed to a detention facility and eventually deported. While he had some extended family in Mexico, the grief of losing the only home he had ever known, coupled with the trauma of his incarceration, bred despair.
The result: self-medication with crystal methamphetamine—the use of which quickly shifted to a substance use disorder. His recovery, while difficult, ushered in a realization of how great the fear of deportation had impacted his and his family’s thoughts, feelings and behaviors—in essence, their mental health. He shared with us the relentless terror that was a way of life for himself and his family members and friends while living in the U.S.: fear of being stopped by the police, fear of being detained and deported—a constant level of anxiety that would meet all Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for generalized anxiety disorder.
Despite practicing as psychiatrists for many years in the U.S., neither of us had ever been taught to consider, or had ever seen, these patients who live in the shadows, living small, undetectable lives, in ceaseless terror of discovery. The shock of his story jolted us into a renewed desire to speak on behalf of these many never-to-be patients, who have been oppressed and marginalized by unjust and unfair policies in the U.S. that have impacted their mental health and increased the likelihood that they will develop substance use disorders as the only effective tool to cope with an unbearable burden of stress.
Six months later, we found ourselves submerged in the most dramatic manifestations of American injustice in our lifetimes. The COVID-19 pandemic took lives along the fault lines of chronic, intergenerational health, employment and socioeconomic racial inequities—killing people who looked like us, and like our siblings, our parents, and grandparents, at a rate of 3.6 times that for white people.
A few months into the pandemic, on a national holiday for those who died defending our nation and its freedoms, George Floyd died with a police officer’s knee on his neck. Though he was neither the first nor the last unarmed Black person in police custody to take his last breath on video, George Floyd’s final moments were broadcast to a nation slowed by COVID-19, and, perhaps, one also made acutely aware of the life and death implications of societal injustices.
After the extremely difficult year that was 2020, the evidence is compelling and overwhelming. The mental health system works according to design. As mental health professionals, we have failed in our most basic duties, and yet, many psychiatrists and other mental health professionals continue to display a disturbing lack of awareness of the role of social injustice in poor mental health and substance use disorder outcomes.
In a recent poll of members of the American Psychiatric Association (APA), when asked, “What are the top three ways that institutional racism is reflected in the APA as an organization, the second most common response was “none,” meaning that a significant number of psychiatrists do not “see” institutional racism at the APA. These very psychiatrists care for oppressed and marginalized patients who are the victims of structural racism as a way of life. Furthermore, the medical community as a whole has also recently demonstrated that many physicians have a long way to go in understanding the role of structural racism on health outcomes in the U.S.
Professional negligence as it relates to social injustice is unacceptable. Social injustice is far too pervasive. It is far too impactful. The lives—and the psyches—of those we claim to serve are shared by oppression and injustice, which create the underlying context that drives the social determinants of health. Thus far, we have not operated with an understanding of how social injustice sets this context. To begin to make progress, the mental health system must transform to dismantle the underlying structural forces of racism, sexism, oppression and discrimination, and must support the advancement of policies and practices that promote justice and equity in mental health access and care. This requires leaders who are committed to making decisions that emphasize equity over profits, guided by the expertise of local communities and members of oppressed and marginalized communities. We do not have time to waste. Recent events must spur us to action. As writer and activist Angela Davis once said, “I am no longer accepting the things I cannot change, I’m changing the things I cannot accept.”