8

Anti-Black Racism and the Mental Health of Black Men and Black Women in STEM

The session began with two vignettes that shed light on the effect of anti-Black racism on the psychological well-being of Black students and professionals. Cedric Bright, M.D. (East Carolina University), returned to an experience he had described earlier about the treatment of a Black trainee regularly ignored during rotations compared with his white peers (see Chapter 1). Vivian W. Pinn, M.D. (National Institutes of Health), recalled sitting on a review panel 35 years ago for government grants when she questioned why programs prioritized gaining cultural competency through training for majority residents rather than by expanding the number of residents of color. As the moderator of the session, she noted that the mental health of youth is affected by all the issues covered throughout the workshop, whether related to finances, treatment in the classroom, and elsewhere. Kevin Cokley, Ph.D. (University of Texas at Austin), described how racism manifests as trauma and outlined coping strategies to build resilience. Michellene Davis, J.D. (National Medical Fellowships [NMF]), highlighted the need for BIPOC medical students. Gabriel Felix, M.D. (Cambridge Health Alliance/Harvard Medical School) and Altha Stewart, M.D. (University of Tennessee Health Science Center), presented on two aspects of their profession of psychiatry: the challenges Blacks face as psychiatrists and the contributions they can make with their expertise.

RACISM AS TRAUMA

Dr. Cokley provided an overview of the psychological impact of racism. He noted the pain within families in dealing with racism, including the role of police brutality, and explained how racism is a form of trauma. He also suggested coping strategies.

Race has never been easy to talk about in public, as Dr. Cokley observed, recalling this was a message he learned growing up. The murders of Ahmaud Arbery, Breonna Taylor, and George Floyd have meant revisiting that assumption, which he reinforced with a video clip from the television show Black-ish. “Having these discussions in our families is not a theoretical abstraction,” he said. Dr. Cokley said he and his wife tried to shield their children from the horrific imagery of Floyd’s murder, but his 11-year-old saw it on social media. Dr. Cokley shared his son’s reaction and the painful conversation they had. Stepping back, he pointed out that the literature supports that images of police brutality hurt Black Americans’ mental health. Overlaying data on mental health with data on police killings shows

an additional 1.7 poor mental health days per Black individual each year or a collective 55 million additional poor mental health days annually (Bor et al., 2018). While the impact is especially acute within the first 2 months of an incident, Dr. Cokley said, media attention to courtroom trials and other events constantly serve to re-traumatize people.

Racism is trauma, Dr. Cokley stressed. People experience anxiety, powerlessness, depression, and other symptoms similar to those of trauma patients. About two decades ago, the U.S. surgeon general at the time recognized that members of ethnic and racial minority groups “face a social and economic environment of inequality that includes greater exposure to racism, discrimination, violence and poverty, all of which take a toll on mental health.”

Psychological and physical health are interlinked, Dr. Cokley said. Racism’s links to negative health outcomes and shortened lives have been documented. As one example, the daughter of Eric Garner, killed by police in New York in 2014, became an activist and died of a heart attack at just age 27. Other consequences of racism include substance use (Hunte and Barry, 2012), tobacco use (Purnell et al., 2012), acting out in violent ways (Estrada-Martínez et al., 2012), and emotional and health-related problems (Bratter and Gorman, 2011). Yet, as psychologist Janet Helms has argued, racism and ethno-violence are missing from the traditional psychological trauma literature (e.g., Helms et al., 2012).

Coping strategies can be maladaptive, such as remaining in denial, engaging in substance use, aggression, or self-blame, or in extreme cases, turn to suicide or terrorism. In contrast, adaptive coping strategies include seeking social support, limiting exposures to cues of racism (e.g., signing off of social media and television), utilizing religious or spiritual practices, seeking distractions from the cues of racism, participating in restful and relaxing activities, and engaging in peaceful activism.

BEHAVIORAL HEALTH SUPPORTS FOR BLACK MEDICAL STUDENTS

Ms. Davis said the purpose in her presentation is to raise awareness of the effects of racism on mental health with a focus on the need for behavioral health supports for Black medical students. She noted that the Centre for Community Organizations defines white supremacy culture as the idea that the thoughts, beliefs, and actions of white people are superior to those

of people of color.¹ She pointed out that this culture is expressed interpersonally and structurally through government, education, transportation, and other systems. Wealth disparities between white and Black households have resulted from long-standing inequities. “I want to make certain that we have this conversation through a lens of what we already know,” she stated. “Systemic racism is a lived experience of so many of our BIPOC medical students.”

Ms. Davis explained that the National Medical Fellowships has been advancing health equity at the intersection of the health-wealth gap for 75 years. “NMF has been ensuring the pipeline of BIPOC physicians,” she said. “Yet we know that our BIPOC medical scholars encounter racism in elementary, secondary, and higher education before they even get to medical school.” She stressed the need to look at disparities throughout the system, including the impacts of historic real estate practices on neighborhoods, school funding, disciplinary patterns, and access to gifted-and-talented, eighth-grade algebra, and advanced placement classes.

“It is a natural progression for medical education to be far from immune from the pervasive decay caused by the same white supremacy culture that exists in all of society,” she said. She noted an article in JAMA Open reported that fewer than half of medical schools include teaching about health disparities in their curriculum (Fernandez, 2020), and the American Association of Medical Colleges Curriculum Inventory in 2018 and 2019 showed that only 87 of 131 schools required teaching about the social determinants of health at Academic Level 1, with far fewer at the higher levels.² A 2018 study showed Black patients have better health outcomes when paired with a Black physician, yet only 5 percent of doctors are Black (Alsan et al., 2018). She continued:

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¹ See https://coco-net.org/white-supremacy-culture-in-organizations/.

² See https://www.aamc.org/data-reports/curriculum-reports/interactive-data/social-determinants-health-academic-level.

Referring to research by Daniel Dawes, Ms. Davis stressed that the political determinants of health create the social drivers that affect health (Dawes, 2020). Systems and structures are erected as a result of policies, laws, and regulations. Black medical students deal with race-related stress day in and day out, Ms. Davis said, quoting from an article by Brown University M.D. candidate Kelsey Brown (2020). The article drew on research by psychologist Shelley Harrell that the options in achieving well-being are to eliminate the stressor or strengthen the resources to deal with the stressor (Harrell, 2000). Unlike other traumas when healing can begin when the trauma ends, race-related trauma will never be over or concluded, and anticipating the elimination of racism is unlikely. Medical schools can reflect on how they perpetuate these systems personally and institutionally, Ms. Davis said, and then make changes. They can also create environments that acknowledge the reality of racism, especially after a traumatic incident.

It is important to center student voice, Ms. Davis stressed. She noted Kelsey Brown called for steps to make medical schools actively antiracist institutions. Collective coping activities must be supported. The antiracism work must be time- and resource-intensive, Ms. Davis said, and involve far more than setting up a chief diversity officer with no budget or authority. She stressed the need for faculty and administrators to acknowledge medicine’s history, ensure accountability, and show up for students. As Kelsey Brown (2020) wrote, safe and protected spaces for students must be created and supported, along with a team of readily available diverse mental health professionals trained to work with diverse medical students.

Ms. Davis closed by telling participants, “You are the people who can rewrite the narrative going forward. When students complete their medical education, they enter a health-care system built on inequity, disproportionate allocation of resources, and explicit and implicit bias.” She stressed moving from a focus on recruitment of students to retention, matriculation, and success to ensure that new Black doctors thrive—not just survive—and turn the tide on health disparities, which she said has been and will be the mission of National Medical Fellowships. She urged ensuring that BIPOC physicians are not “standing alone” in their institutions and in society as they provide care while challenged by their own experiences of racial trauma. Behavioral health support is essential “not because they are ill prepared, not because we must readjust the way they are admitted to medical school, but because a more holistic lens is needed that sees all of them in all their glory and in the history in which they have experienced life in this country and abroad,” she concluded.

PSYCHIATRY IN THE BLACK COMMUNITY

Dr. Felix and Dr. Stewart presented as a team to reflect psychiatric perspectives as, respectively, a third-year resident and senior faculty member who are leaders in numerous organizations. Dr. Felix reflected on the earlier presentations that framed racism as a form of trauma. He shared a recent experience while on call in the emergency department, when a patient on the phone screamed racial epithets and said he wanted to kill Black people without knowing that Dr. Felix is himself a Black man. “That is an example of what our trainees can face, having the duality as a health-care professional and identity as part of being BIPOC,” said Dr. Felix. “This is important to highlight because many white people do not understand the impacts and trauma this kind of racism may have.” He recounted witnessing racist experiences as an undergraduate, going through cognitive restructuring while at Howard University College of Medicine, then adjusting to his current residency environment. For example, in talking about COVID-19 in its early days, he sensed that some supervisors and colleagues underplayed it because they did not lose family members and friends. Dr. Felix shared that he wrote a piece about the psychological effects of wearing a mask as a Black man, and that some white colleagues were surprised that he experienced such concerns (Felix, 2020).

In considering trainees and other student learners, Dr. Felix said it is important to identify both risk and protective factors that may affect them. “Learners have these experiences across different fields of STEM, and it is important for us to be very intentional about building trustworthy supports. By that I mean supports that do not minimize, but rather validate and are not skeptical. And when harm is implemented, as will inevitably happen, there is a conscious and sustained effort to ensure that it will not happen again,” he said.

Dr. Stewart thanked the previous speakers during the workshop who set the stage for discussion of mental health. Mental health is the “necessary sauce,” as Dr. Emdin said (see Chapter 5). “This is where we must focus on the integration of who we are authentically with who we are trying to be as health-care professionals and not let one or the other override or overwhelm,” she said.

She shared that she has been reflecting on the fact that “words matter” as she has been immersed in a number of relevant conversations with Black medical students, residents, and faculty. In a co-authored commentary in Academic Psychiatry, she and Donna Sudak, M.D., wrote how diversity

of the psychiatric workforce is affected by unwelcoming environments, including choice of language and messaging (Sudak and Stewart, 2021). For example, the term “underprivileged” is an inaccurate assessment of reality because “we were never privileged to begin with, but we have managed to be successful.” Similarly, she noted the phrase “minority tax,” but suggested instead the concept of a “majority subsidy” that goes along with a notion of privilege. She said:

She also referred to the term “pipeline programs.” To Dr. Stewart, “Pipeline implies a direct route to get into STEM for young people. What we really want is to create the pathway to success and thriving as health-care professionals. I am shifting my language to a ‘pathway’ that starts with a pipeline as a point of entry but then goes all the way through to my senior level in a faculty position, where I still sometimes find myself the only Black person in the room,” Dr. Stewart stated. Related to Dr. Felix’s reporting of the surprised reaction among white colleagues that he was subjected to racism as a Black physician, she shared the term “hallucinatory whitening.”

Dr. Stewart said these terms reinforce the responsibility to younger professionals focused on the social justice aspects of health care and want to see change in their lifetimes. She said she has made three commitments for the rest of her career to reframe the culture and dismantle structural racism: explore with communities of color, especially Black communities, how to form circles of support around Black medical students when they are in communities; provide authentic safe spaces; and give cover when young colleagues speak out.

DISCUSSION

Dr. Pinn, Shirley Malcom, Ph.D. (American Association for the Advancement of Science), and Evelynn M. Hammonds, Ph.D. (Harvard University) engaged in a brief discussion following the presentations. Dr. Pinn asked how the field of psychiatry can play a role in overcoming the

pressures of racism. Dr. Stewart recognized the dual stigmas related to mental illness and Blackness as perpetual enemies. While structural racism must be eliminated, “within our community, we have to make headway to understand the importance of mental health as a health issue—no health without mental health is the mantra I use—and to engage with the stigma associated with it.” To help medical students, she urged working with the families and support systems to help them understand that when the students are under pressure, they need to have access to the necessary mental health supports. When they do not, they begin to question whether they are worthy, and it becomes a self-fulfilling prophecy, Dr. Stewart observed.

Dr. Malcom commented STEM presents additional challenges because it has been considered an inherently elitist space. She related that in the Supreme Court case Fisher v. University of Texas (570 U.S. 297 (2013)), Justice John Roberts asked, “What unique perspective does a minority student bring to a physics class?” She noted physicist Sylvester James Gates effectively challenged this comment with examples (see Conover, 2016). She also recounted a fearful experience when she was stopped by a policeman at night. When she told a white friend, he was shocked by her fear, not realizing that her advanced degrees and awards would not protect her in that situation as a Black woman. She noted her isolation in graduate school and the helpful assistance she received from a psychiatrist to deal with the “constant drip, drip, drip of racism, especially when we are ‘the only.’” Referring to Dr. Cokley’s coping strategies (see above), she said she engages with peaceful activism, such as in her work on institutional transformation through her work with SEA Change.³

Dr. Hammonds shared recent pushback from a white male involved in a faculty search process, which reflects the “majority subsidy” described by Dr. Stewart. He could not understand that the finalists for a faculty position did not include a white male while not questioning the years of search processes in which all candidates were white males. She noted her own multiple identities as a Black woman, mother, professor, and the need to help students navigate their multiple identities and seek mental health support, especially during the pandemic. “We have more pressure than ever before to speak out and provide cover for students so they have a different future. Our silence does not protect us,” Dr. Hammonds said.

It is difficult to find trusted mental health advisors, a participant noted. Dr. Stewart suggested dialogues with the Black Psychiatrists of America,

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³ For more information on AAAS SEA Change, see https://seachange.aaas.org/.

the Psychiatry and Behavioral Sciences section of the National Medical Association, and the Black Caucus of the American Psychiatric Association. She offered to connect the Roundtable with these people and groups. She said there is no directory of Black mental health professionals or a reference point for students who may want to consult with a professional in a different location than where they live.

In final thoughts, Dr. Cokley pointed out that Black children have “the talk” about racism as part of their lived experience and not as an abstraction. Dr. Pinn returned to the point about the harms facing Black men and women, no matter their academic degrees and professional titles. Dr. Felix reiterated being intentional about connecting resources. Dr. Malcom said, “The systems are working exactly as they were designed to. We must disrupt and transform them.”

REFERENCES