Culture, Madness and Medicalisation: COVID, communities of colour and mental health

In our third year Culture, ‘Madness’ and Medicalisation module, students receive a critical introduction to today’s dominant psychological/clinical practices such as psychoanalysis, bio-psychiatry, psychotherapy, counselling and clinical psychology and the importance of anthropology in illuminating how psychological/clinical practices are dramatically shaping contemporary subjectivities and wider socio/cultural life. This year, our featured essay from the module is by KJ Davita.

KJ’s bio: I am KJ, I am a third-year anthropology student from Seattle, USA. My favourite areas of research and learning include social anthropology, political anthropology, and environmental and sustainability practices within indigenous communities around the world.

The COVID-19 pandemic has disproportionately affected communities of colour in America with high infection and death rates (Tai et al., 2020). This increased susceptibility may be due to both biomedical factors, such as increased risks, to certain health adversities that may affect their abilities to overcome the virus, as well as social impediments such as lowered access to health care services and lack of access to utilities such as the internet and social services. Mental health effects are exacerbated by these inequities and are further worsened when compounded with the stress of being targeted for systemic racism and racist attacks. These realities leave communities and individuals more vulnerable to adverse outcomes if they or someone in their family or care contract the novel coronavirus (Gray, 2020).

The coronavirus was first confirmed to have reached the United States on 31 January, 2020 in Washington State (The Guardian, 2020).  In the US, Black, Native and Latino people are more likely to be diagnosed and experience COVID-19 complications and related deaths, due to existing ‘social determinants in health’ (Ludon et al., 2020). The World Health Organisation defines these determinants as ‘the conditions in and under which individuals are born, grow, work, and live, and the broader set of forces and systems’ meaning political, social and economic structures and policies. Compounding these existing racial inequalities and social determinants, communities of colour have suffered higher morbidity and mortality rates under a government that ‘did not take proper precautions to mitigate the spread of the disease’ (Dorn et al., 2020).  Although it varies by pre-existing conditions and age, the average fatality rate of the disease is between 2-3%, but is much higher for communities of colour because of pre-existing conditions and the outlined social and economic factors above (Vidal-Alaball et al., 2020).

The COVID-19 pandemic has revealed racial disparities in America. Although making up only 13% of the population, African Americans are 20% more likely to experience mental health issues and crises (Ibrahami et al., 2020). Systemic racism causes racial health disparities and the COVID-19 pandemic has highlighted how the economic and social factors related to the pandemic have caused detrimental mental health symptoms in Black and Brown Americans. In Chicago, African Americans make up 30% of the population but have accounted for 50% of Covid cases and 70% of deaths (Ibrahami et al., 2020). Black Americans and Native Americans and those on low income are more likely to suffer from conditions that increase the risk of illness due to COVID-19 as opposed to white, higher income Americans (Raifman, 2020). The experience of systemic racism and its economic consequences can severely impact psychological and physical health and are associated with symptoms including depression, anxiety and overall ill health (Okazaki, 2009). Racialised encounters act as a stressor that produce responses in people of colour when the encounter is perceived as being racist or discriminatory (Okazaki, 2009) and these stress responses are known to lower the immune response, leading to adverse comorbidities that create heightened susceptibility to the coronavirus and negative long term health outcomes.

There has been a long history of inequities in the delivery of mental health services to minority groups in comparison to white Americans; collaterally, minority groups receiving the same kind of care as white Americans may be problematic as there is a lack of culturally relevant mental health services as the needs, symptoms and causes are vastly different between various cultural groups (Sue et al., 1978). Care programmes should be culturally relevant and need to take into account certain community and social factors that affect people of colour such as contemporary and historical exposure to racism and institutionalized practices and policies (Ibrahami et al., 2020). These factors, compounded by structural disparities such as ‘access to medical insurance wealth and income volatility’ (Raifman & Raifman, 2020) means that many people of colour are less likely to be able to access mental health resources due to economic factors.

When looking at the pandemic response in Native communities, certain socially relevant barriers specific to Native Americans must be considered. Native Americans are amongst the least educated (Olife, 2017), least employed (Austin, 2013), in American society and also face disproportionately high rates of violent crime and suicide; 1 in 2 Native women have been sexually assaulted (Indian Law Resource) and Native men are more likely than any other demographic to be killed by the police (Woodard, 2016; Koerth-Baker, 2016). Moreover, Native Americans between the ages of 15-24 make up the highest percentage of suicides (Echohawk, 2010), despite being one of the smallest demographics in the USA, making up only 2% of the population (U.S. Department of Health and Human Services Office, 2010). During the pandemic, Native Americans, specifically Southwest Natives, face ‘a much higher hospital rate, a much younger hospital rate, a much quicker go‐right‐to‐the‐vent(ilator) rate for the population, and a doubling every day…and could wipe out those tribal nations’ (Kakol et al., 2020). COVID-19 produces higher mortality among those with underlying health conditions and Native Americans have high comorbidities such as heart disease and diabetes that would put them further at risk (Dorn et al., 2020).

It is reported that 12% of deaths amongst Native Americans are due to direct or indirect misuse of alcohol (L. Tim, 2019) and those in treatment or suffering from substance abuse may experience considerable setbacks and relapses to cope with enforced social isolation.  Because treatment programmes such as Alcoholics Anonymous rely on participants using social support groups, these interactions may be interrupted during the pandemic. Similarly, support networks for those who live alone, such as elders with adult children or partners who have passed, may have relied on social gatherings such as powwow, ceremony or other social activities to ensure mental wellbeing. Again, those without access or those who are not computer literate may not be able to engage virtually in social meet ups that are available to those with internet access or computer literacy.

During this time of government-enforced social isolation, mental health and psychiatric care are being delivered via telemedicine, and it is important to note that many people lack adequate utilities such as internet connections that will impede their ability to access these services. The rapid spread of the disease and the burden on health care professionals has meant that because it is now fundamental that social distancing measures are enforced and followed, healthcare professionals are providing telemedicine appointments to mitigate the risks (Vidal-Alaball et al., 2020). Around 628,000 tribal households lack adequate or any internet connection (Schapiro, 2020) and nearly half of all Americans without internet access are people of colour or those on low income (Floberg, 2018), so delivery of these interventions is not available to large groups of people of colour during a global pandemic where it is paramount to adhere to social distancing practices. Many mental health care providers are navigating delivery of telemedical care for the first time, so patients may not be receiving the best quality care. The delivery of telemedicine mitigates the risks of disease spread and helps individuals and hospitals save money on antiseptic materials such as gloves, hand sanitizers and soap.  This further heightens the risk to people of colour who lack the adequate resources to engage with these telemedicine programmes and does not allow them to adhere to social distancing rules and stay at home orders.

Minority groups make up a disproportionately large percentage of essential workers such as retail and grocery workers, transportation employees, healthcare workers and custodial staff (Dorn et al., 2020). These essential workers don’t have the option of adhering to the stay-at-home orders and therefore are most at risk of contracting coronavirus. Black and Brown communities live in more underserved and densely populated areas and face racism, discrimination and systemic oppression at school, and work and lack access to equitable mental health care, social resources and healthy food options in comparison to their white counterparts (Ibrahami et al., 2020).  Minorities make up the majority of essential workers and  in New York City, one of the epicentres of the disease worldwide, 75% of essential workers are people of colour.  This accounts for another cause of the increased susceptibility to contracting the virus amongst people of colour, because essential workers in food production, retail, healthcare and sanitation workers are not able to work from home like so many others (Thorbecke, 2020). Economic factors may not allow these workers to stay home despite high risk and outbreaks in their communities; people of colour make up large percentages of low-income families and are more likely to live in overcrowded homes and overpopulated community conditions that elevate exposure and reduce the ability to safely quarantine or self isolate (Raifman, 2020).

Through the pandemic, there has been in a rise in anti-Chinese sentiment and attacks spurred on by misinformation from racist media outlets as well as from President Trump himself, who has called the virus both the ‘Chinese virus’ and ‘Kung Flu’ at rallies and in press conferences (The Guardian, 2020). This covert hate speech ‘inspires racism and violence’  (The Guardian, 2020) against Asian Americans and The ACLU has said that blaming China ‘leads to dangerous scapegoating and widespread ignorance, just when accurate public health information is critically needed’ (The Guardian, 2020). Racist tropes about Chinese people ‘eating strange foods and being disease ridden’ (Cheah et al., 2020) are a form of collective racism that can lead to individual racist attacks and abuse against Chinese and Asian individuals and families and in turn harms the mental health of those experiencing this. Many Chinese Americans have reported that racial discrimination has caused psychological distress and anxiety during the pandemic and nearly 2,000 reports of discrimination against Asian Americans have been made since the beginning of the pandemic (Cheah et al., 2020).

Because of the delayed response and inadequate infrastructure to deal with a health epidemic, the pandemic has caused social insecurity due to factors such as emotional and social isolation, food, housing and income insecurity, and a lack of properly funded and adequate nets and programmes for people to rely on during uncertain times. Because of this lack of security, there are many emotional outcomes that people may exhibit including increased ‘stress, depression, irritability, insomnia, fear, confusion, anger, frustration, boredom, and stigma associated with quarantine’ (Pfefferbaum et al., 2020). Healthcare providers can play an important role in addressing the emotional responses and helping patients manage their own responses to these social problems. Because people of colour bear the brunt of morbidity and mortality due to COVID-19, these mental health concerns are heightened in communities of colour and further highlights the need for culturally competent and socially relevant forms of care to help people of colour navigate these emotions.

The stigma of seeking help from a psychiatrist or receiving other forms of counselling may cause increased distress in people facing mental health crisis during the pandemic; destigmatising and normalising stress responses by talking about our mental health with our loved ones and encouraging conversation around this may help people access the help they may need in the future (Pfefferbaum et al., 2020). Social quarantine is known to cause psychosocial distresses and longer times in quarantine and isolation have recently been associated with increased symptoms of PTSD, which indicates that the act of self isolation and quarantine is perceived as a time that may cause trauma itself (Hawryluck, 2020). The instability of the pandemic, not knowing what will happen next or who will get sick or if you’re already sick keeps our bodies in a perpetual state of fight or flight. This mechanism is designed for our bodies to either prepare ourselves to deal with a problematic encounter or to run away (Cherry, 2019) and this is engaged almost constantly during this pandemic due to intense media coverage and not knowing what to plan for next.

Pfefferbaum (2020) argues that the ‘Covid-19 pandemic has alarming implications for individual and collective health and emotional and social functioning’, but with the increased conversation and media attention around the impact on people’s mental health and fear during isolation and a worldwide pandemic, we may move to destigmatising and normalising seeking help when we are facing unprecedented and distressing situations. Addressing the historical and deeply embedded structural and institutionalised racism that exists in America’s history and policies that has been further unveiled during the pandemic will help alleviate the burden on people and communities of colour and provide them with access to social programmes that can deliver culturally competent forms of health care.

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