The Underutilization of Mental Health Services Among Minority Groups

Poor mental health and mental illness have become increasingly prevalent in the United States. In 2019, about 20% of adults reported experiencing mental illness, representing over 50 million individuals.. This mental health crisis was further exacerbated by the COVID-19 pandemic, when many experienced social isolation, stress, grief, and financial struggles. WHO (World Health Organization) reported that the pandemic triggered a 25% increase in the prevalence of anxiety and depression worldwide. Among those affected, the mental health of certain racial/ethnic minority groups worsened relative to that of non-Hispanic white individuals. Specifically, there was a greater increase in mental illness reported for Black, Hispanic, and Asian adults. Furthermore, these groups are less likely to seek out mental health treatments and care. This underutilization of mental health services, especially among people of color, is a persistent and important issue in healthcare.

A potential reason for this underutilization is an individual’s perception or experience of acts of discrimination. A recent study published in Journal of Health Care for the Poor and Underserved found that discomfort in asking questions to a health care provider was associated with lower likelihood of underutilization of mental health care, indicating that positive encounters with the health care system contribute to a willingness to seek out care. In addition, researchers found that “everyday discrimination from non-health care sources, major discrimination events, and discrimination from health care sources each independently contributed to lower utilization of needed medical care after adjustment for measures of structural discrimination.” Another study published in PLOS One found that perceived discrimination in medical settings was “significantly associated with report of not having enough time with the physician and not being as involved in decision-making as desired.” Thus, it becomes clear that perceived discrimination contributes to an individual’s lack of trust in health care, leading to a underutilization of its services.

Cultural factors may also contribute to this under-utilization. One major factor is stigma against mental health. For example, mental illness is still considered taboo in many Asian cultures. As a result, many Asian Americans tend to dismiss, deny, or neglect their mental health concerns. Even further, many Asian Americans face parental pressures and pressure to live up to the “Model Minority” myth. Another factor could be language. Many Hispanic and Asian Americans do not speak English as their first language and, as a result, may experience language barriers within the healthcare system when translators or interpreter technologies are not readily available.

So how do we combat this underutilization of mental health services? First, it’s imperative that we combat provider bias. This can be done through cultural competence training, teaching effective cross-cultural communication skills and awareness. It’s also important for policymakers to take into account the cumulative effect of discrimination outside the health care system. Thus, communities can begin to change norms that sanction chronic and everyday discrimination. In terms of combating cultural influences, we can first employ more bilingual services to ensure that everyone can effectively communicate their needs. While the stigma against mental health found in many cultures is a very complex issue, we can take steps against it. As community members, we can take the time to remind our loved ones that mental care is health care and that there is nothing wrong with experiencing mental health struggles.

While the underutilization of mental health services among minority groups is a pervasive issue, it is not one without hope for improvement. By providing more culturally-sensitive information and working to ensure accessible care to all, we can help to eliminate this harmful trend.

Edited by: Elissa Gorman

Graphic Designed by: Sofia DiFulvio

References

1. https://mhanational.org/issues/state-mental-health-america

2. https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide

3. https://muse.jhu.edu/article/242580

4. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0215976

5. https://www.apa.org/pi/oema/resources/ethnicity-health/asian-american/article-mental-health

Prioritizing Profit over People

A health crisis is not urgent until privileged populations become casualties. Oftentimes, during these crises, privileged populations are helped at the expense of minority populations. For instance, the HIV/AIDS epidemic became a national calamity because heterosexual individuals, which composed the majority of the U.S. population at the time, feared that they would contract HIV/AIDS. Thus, because HIV/AIDS was believed to originate from homosexual individuals, homophobia spread in an attempt to protect heterosexual individuals, leaving homosexual individuals behind in the dust. For instance, healthcare workers like Dr. Hunter Handsfield promoted homophobia in order to protect heterosexual individuals like himself from the potential “threat” of homosexuals. Dr. Handsfield emphasized that because heterosexuals are at such a low risk, no matter how promiscuous they are, there must be “something special about gay sexuality with respect to disease transmission.1” Even when faced with evidence that heterosexual infections more than doubled in 1985,2 he and other health authorities did not believe the surge warranted a warning to heterosexual individuals that they, too, could sexually transmit HIV/AIDS.1

The same trend of disregarding minority populations persists 50 years later. But, unlike the HIV/AIDS epidemic, the health crisis at hand has an undeniable culprit to blame: Chemours– a chemical plant. Chemours produce a specific toxin called Perfluoroalkyl and polyfluoroalkyl substances (PFAS) that decompose over thousands of years.4 These toxins get expelled into drinking water used for North Carolina’s poorer communities, disproportionately harming poor and non-white residents.3 Because these communities primarily consist of impoverished and non-White individuals, there is considerable debate whether removing Chemours from drinking water is a worthwhile problem to solve, despite the fact that it causes irreversible damage to the bodies of these underserved individuals.

Specifically, the hearing on House Bill 1095, which sought to regulate PFAS contamination, was a battleground between the interests of corporations and NC residents.5 For these underserved NC residents, without any interventions, PFAS would still remain in their drinking water, as the toxin will still have half of its original concentration after nearly 4 years.6 However, despite this, leaders still opposed the bill in favor of supporting corporations, citing that regulation already exists.5 This battle between corporations and NC residents on PFAS regulation extends beyond this hearing, but as always, corporations still win. For example, while the Environmental Protection Agency (EPA) acknowledges that PFAS promotes an abundance of health risks, the agency refuses to ban the entire PFAS chemical class without further research.4 Instead, environmental agencies across the nation recommend inadequate and inconsistent limits for different types of PFAS compounds rather than the banning or restricting the whole class of toxins.4

In yet another example of government negligence, the Department of Environmental Quality, which is responsible for monitoring Chemours,6 has faced over $500,000 in total for their poor compliance in assessing levels of PFAS contamination.7, 8 Like other NC entities promising to serve public health, DEQ promises to implement policies that address issues like PFAS, but instead creates policies that benefit wealthier corporations. In the words of the North Carolina Black Alliance, this is “violence in the form of policy.”3 Yet, despite reprimands from the North Carolina Black Alliance, time and time again, federal and NC state governments continue to choose policies that promote economic development, harming their most vulnerable constituents. Policymakers, who benefit economically themselves from prioritizing corporations, make excuses for these policies, claiming that affected residents should fend for themselves amidst a clean water crisis.

In an attempt to offer insight into the real dangers of negligent PFAS regulation, Emily Donovan, an advocate for underserved populations, cried “as she listed friends who have died of or developed rare cancers,” while living along rivers contaminated with PFAS.5 As the issue on PFAS regulation remains unresolved, people of color and low-income residents continue to face the brunt of the consequences, subject to the power of corporations who care little of their interests.

This disparity between people of color and low-income residents and more privileged populations is not limited to the PFAS regulation battle. Poor, black, indigenous, and people of color (BIPOC) are not only more likely to depend on polluted water sources, but are

“also more likely to eat fast food meals that come in PFAS packaging, live in rental units with PFAS-laden carpeting.” 3

Hopefully, this trend of prioritizing corporations over underserved populations will not endure. Eventually, victims of profit-driven policies will reach a breaking point, pushing legislators to create policies that protect their interests and their long-awaited human rights.

Edited by: Anne Sacks

Graphic Designed by: Ariha Mehta

References

1. Altman, L. K. (1985, January 22). Heterosexuals and AIDS: New data examined. The New York Times. Retrieved November 3, 2022, from https://www.nytimes.com/1985/01/22/science/heterosexuals-and-aids-new-data-examined.html

2. Rensberger, B. (1986, January 17). AIDS cases in 1985 exceed total of all previous years. The Washington Post. Retrieved November 3, 2022, from https://www.washingtonpost.com/archive/politics/1986/01/17/aids-cases-in-1985-exceed-total-of-all-previous-years/38c933d7-260c-414b-80f7-0dd282415cc6/

3. NC Black Alliance. (2021, August 3). Violence in the form of Policy. North Carolina Black Alliance. Retrieved November 3, 2022, from https://ncblackalliance.org/violence-in-the-form-of-policy/

4. Sorg, L. (2020, July 6). New research confirms presence of toxic 'forever chemicals' in scores of NC water supplies. NC Policy Watch. Retrieved September 20, 2022, from https://ncpolicywatch.com/2020/07/01/ new-research-confirms-presence-of-toxic-forever-chemicals-in-scores-of-nc-water-supplies/

5. Sorg, L., Sorg, L., About the author Lisa SorgLisa Sorg, & Sorg, L. S. L. (2022, June 6). At Emotional Committee hearing over Pfas Bill, lawmakers and concerned citizens confront Chemours, business interests. NC Policy Watch. Retrieved November 3, 2022, from https://ncpolicywatch.com/2022/06/03/at-emotional-committee-hearing-over-pfas-bill-lawmakers-and-concerned-citizens-confront-chemours-business-interests/

6. NC Department of Environmental Quality. (n.d.). Chemours consent order. Retrieved September 20, 2022, from https://deq.nc.gov/news/key-issues/genx-investigation/chemours-consent-order

7. DEQ assesses penalties of nearly $200,000 for Chemours violations. NC Department of Environmental Quality. (2021, March 31). Retrieved September 20, 2022, from https://deq.nc.gov/news/press-releases/2021/03/31/deq-assesses-penalties-nearly-200000-chemours-violations

8. [1] Release: DAQ Assesses Penalty of Over $300,000 for Chemours Violations. NC DEQ. (2021, October 4). Retrieved September 20, 2022, from https://deq.nc.gov/news/press-releases/2021/10/04/release-daq-assesses-penalty-over-300000-chemours-violations

Ethics of Medical Resource Allocation

Should scarce medical resources be provided to those who have waited the longest for them or require it the most? Should a 20-year-old be prioritized over an 80-year-old for a life-saving cure? Let’s say we have one hospital bed for every 1000 citizens or only 57,000 ventilators in a country of over 1.3 billion people [1]. Who gets precedence? Unfortunately, this is the very challenge that plagues many developing countries every day.

How do we fairly allocate medical resources, especially when there is a critical shortage for them? This brings us to the conversation on the ethics of healthcare rationing, which has never been more imperative than today as we strive to recover from a global pandemic. A pandemic that has exposed the poor healthcare systems around the world, especially in my home country of India where systemic inequities are highly prevalent – whether this be the lack of primary care providers, low medical supplies, inadequate hospital infrastructure, or shortages of medical devices. Those who can least afford these limited resources are disadvantaged the most, while, the private healthcare sector continues to grow, providing for the urban rich. However, rationing simply based on socioeconomic status is evidently unfair, so here are some alternative approaches of distribution:

· Aged-based approach: Most experts believe that a country should distribute their strained resources such that it simultaneously saves the most live and maximizes the benefits received, either by prioritizing patients more likely to recover or have a longer post-treatment life. This is supported by the fair innings approach developed by Alan Williams, which contends that the lives of the young are of higher value as compared to patients who have lived a long life (i.e., already had a “fair inning”). [2]

· Providers of the family: The policies of the World Bank contest that those of working age, who provide for a household, should be given more importance, as they often work to financially sustain not just themselves but also their family. [3]

· Economic approach: This approach claims that those less well-off, particularly in developing countries, deserve a higher priority as they are often more susceptible to poor health and possibly live in more vulnerable environments, wherein spreading of infections is more likely. Thus, treatment of these patients could contain the transmission of potential diseases. [4]

Despite all these considerations, no perfect solutions to rationing healthcare exist and medical professionals, policy makers and the public are stuck with tough choices. However, greater regulation, public and private partnerships, and standardization of healthcare across a country are essential and urgent to move forward. Along with this, an increase of awareness about bioethics, especially in developing countries, is imperative to gain collective understanding about how to adequately respond to considerations of rationing and allocation.

If you would like to know more about the ethics of healthcare rationing, feel free to checkout this episode of my podcast where I spoke with Dr Saumil Kapadia about allocating medical resources in a developing country like India, especially in a pandemic:

https://spotifyanchor-web.app.link/e/7KAr0aAhuub

Edited by: Caroline Palmer

Graphic Designed by: Eugene Cho

References

1. Singh P, Ravi S, Chakraborty S. COVID-19: Is India’s health infrastructure equipped to handle an epidemic? Brookings.edu.blog. 2020 Mar 24[cited 2020 Apr 8]. Available from: https://www.brookings.edu/blog/up- front/2020/03/24/is-indias-health-infrastructure-equipped-to-handle- an-epidemic/

2. Williams A. Intergenerational equity: An exploration of the ‘fair innings’ argument. Health Economics. 1997 Mar-Apr;.6(2), 117–32

3. Wagstaff A. QALYs and the equity-efficiency trade-off. J Health Econ. 1991 May; 10(1), 21–41. doi: 10.1016/0167-6296(91)90015-f.

4. Mahurkar, A. (2020). Ethics in the COVID-19 emergency: Examining rationing decisions. Indian Journal of Medical Ethics, 05(02), 168–169. https://doi.org/10.20529/ijme.2020.049