NOTE: This post originally appeared as an Op-Ed on BlackDoctor.org and in La Vision Newspaper
Co-authored by
Gary H. Gibbons, M.D., Director National Heart, Lung, Blood Institute
Eliseo J. Pérez-Stable, M.D., Director National Institute on Minority Health and Health Disparities

COVID-19 has killed more than 230,000 people in the U.S., and the death toll continues to rise at a rate of about 1,000 per day [see recent data at CDC]. We know, however, that families and communities don’t count their losses in thousands or hundreds; they count them one-by-one – a father, a teacher, a sister, a friend, a nurse, a son, a Tribal elder, a church member. And these losses hurt.

But some communities feel the impact of COVID-19 more than others. Latinos, along with African Americans and American Indians, account for more than half of all COVID-related cases, even though they represent just a third of the population. According to the Centers for Disease Control and Prevention (CDC), these groups require hospitalization at a rate about five times higher than whites, due to the severity of their illnesses or lack of early access to health care. And the mortality outcomes reflect this as well: Latinos and American Indians die at 1.5 times the rate of whites, and African Americans, at 2.4 times the rate.

As scientists and NIH colleagues with more than 60 years of combined research experience in health disparities, we are not surprised by these discouraging statistics. But these awful numbers also feel deeply personal: they represent our friends, our family, our loved ones, too, as our roots are in these very communities—Philadelphia’s African American neighborhoods, Miami’s Cuban immigrant diaspora.

COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, has simply shone a spotlight on health disparities that have long affected underrepresented communities like ours. We know, for example, that obesity, diabetes, and heart disease are more prevalent among people of color. If you have any of these conditions and contract COVID-19 you run a much higher risk for severe complications and death.

But biology and behavior are just part of the picture. Where we work, whether we have access to quality health care, what we eat, and other socio-economic conditions also drive health disparities.

As we grapple with the effects of these health inequities on our daily lives, we can take simple public health measures to help prevent the immediate spread of this disease, starting with wearing a mask, washing our hands, and maintaining six feet of distance from others. But that won’t be enough to end the pandemic in communities of color.

As the leaders of two public health research agencies, we know we can’t just devise solutions from Washington, D.C. We must also work with those who are most trusted, respected, and closest to these hard-hit communities. Through joint local efforts, we believe we can ensure that the best, most accurate information reaches these communities, and that they are informed about, and included in, diverse research studies essential for developing safe, effective treatments, and vaccines for all. That is why the National Institutes of Health (NIH) has issued a $12 million award to support teams in 11 states to establish the Community Engagement Alliance (CEAL) Against COVID-19 Disparities.

This Alliance has already brought together community- and faith-based organizations, doctors, patients, researchers, community advocates and minority-serving educational institutions. For weeks, from Sacramento, California to Jackson, Mississippi, we have been listening carefully—to concerns, fears, very practical questions, and ideas. Our sincere hope is that, working together, we will find ways to overcome COVID-19 in a manner that takes into account the history, cultural differences, and unique input and needs of the people it affects most.

How do we do this? We start by offering reliable and easily understood information based on science, by dispelling myths, and by explaining the importance of research. CEAL is working with trusted members in communities like yours to ensure access to information that can be shared through virtual town halls, infographics, animated videos, and in many other ways – like social media posts.

Importantly, we also will be encouraging participation in research studies designed to stamp out COVID-19 in high-risk communities. That’s because clinical trials, the fundamental part of the scientific process, show whether new medicines and vaccines are effective at protecting you against disease. When a drug gets approved and your doctor prescribes it for you, you are not wrong to wonder whether it has been tested and shown to work — and especially shown to work for people like you.

This is why it is so important for research studies to include people from all races, genders, ages, socio-economic classes and more. We simply need to learn who is likely to benefit the most from any given treatment. In other words, we can’t develop effective drugs and vaccines to conquer COVID-19 in communities of color without the active participation of the people who live there.

We strongly believe that when done right, inclusive research leads to solutions that get us where we need to be. We already have safeguards in place to ensure historic wrongs are not repeated, and that safe and ethical standards are practiced consistently. The Food and Drug Administration, review boards, and expert panels at the NIH—indeed, each institution and company conducting medical research—rigorously review every phase of a clinical trial, from before it begins until after it ends. These review boards include not just scientists, doctors, and experts, but also community advocates who keep a watchful eye on the process.

While these factors are critical to ending this public health emergency, we must keep our eyes on an even bigger prize—a nation without the disturbing health inequities that compromise the health of our whole society. As clinicians who have cared for countless patients of color, as mentors who have supported underrepresented groups, and as members of communities where each one teaches one, we fully understand the power of community to make a difference in the long fight against this conquerable problem.

We firmly believe that by traveling this journey together—by sharing sound information, by squashing misinformation, by being responsible citizens and building trust in science—we can push this deadly pandemic into retreat. Hopefully when that happens, we can embark on a path of inclusion that gives everyone in America a fighting chance for a long and healthy life.

The coronavirus disease 2019 (COVID-19) pandemic has spotlighted the health inequities of Native Hawaiians and Pacific Islanders (NHPI) and provided the podium from which to amplify their voices.

Historically, the voices of NHPI were drowned out by other numerically larger health-disparate racial/ethnic groups in the U.S. Their unique health concerns are often overlooked because their data has been aggregated—grouped together—with those of Asian Americans, an arbitrary practice that has done a disservice to both groups.¹ NHPI know that resources follow the data, which is why they have been voicing their support for disaggregating—separating out—the data for NHPI and Asian Americans for decades, but to little avail.

Along comes COVID-19 to amplify their voices as to why data disaggregation is important.

NHPI have the highest number of COVID-19 confirmed cases of any racial/ethnic group in 14 of the 21 states that report disaggregated data, which include Arkansas, Colorado, Hawai‘i, Illinois, Oregon, Utah, and Washington.² In the other 7 states, including California and North Carolina, NHPI are among the groups with the highest case rates. In 11 of the 16 states reporting disaggregated death data, which include Alaska, Arkansas, Iowa, Louisiana, and Tennessee, NHPI have the highest COVID-19-related death rates of any racial/ethnic group. These inequities would have been concealed from the public had NHPI data been aggregated with other racial/ethnic groups.

Pre-existing health disparities and inequities in the social determinants of health are driving the COVID-19 risk among NHPI.³ They make up a large number of the essential workforce, such as in the tourism and food industries.⁴ In the military, NHPI representation is 6 times higher than in the general U.S. population.⁵ NHPI are more likely to live in large multi-generational households and denser communities, which further increases their exposure risk. The high rates of asthma, obesity, diabetes, heart disease, smoking, and vaping among NHPI increase the risk for severe COVID-19 symptoms.⁶ COVID-19 containment and mitigation measures have led to an increase in economic hardships, behavioral health issues, and difficulties in managing chronic disease for many NHPI.

NHPI leaders and advocates have sprung into action to protect their communities.⁶ A National NHPI COVID-19 Response Team was formed, comprised of NHPI members from various states, each with county and state-specific groups. In Hawai‘i, the NHPI COVID-19 Response, Recovery, and Resilience Team was formed to join the national team’s efforts. These efforts have changed the policies and practices of county and state public health departments in the collection and reporting of NHPI-specific data. They have secured much-needed resources to ensure NHPI communities have personal protective equipment and food security; access to COVID-19 educational materials, testing, and places to self-quarantine; culturally-informed contact tracing; and financial assistance. NHPI communities took to social media and videoconferencing to stay connected with family and friends and to remain socially and culturally engaged during the COVID-19 containment and mitigation measures. These efforts have been independent of local, state, and federal governments.

NHPI are resilient and thriving communities in the U.S. Although they make up only 0.4% of the entire U.S. population, they are among the fastest-growing racial/ethnic groups.⁷ The Native Hawaiian population alone, for example, is expected to almost double in population size from 530,000 to nearly a million by 2040.⁸ As their population and dispersion across the U.S. grow, so does their influence.

The COVID-19 crisis has paved a path to health equity for NHPI. It has led to an unprecedented mobilization and the establishment of a strong national coalition. It has shown the efficacy of NHPI communities in responding to a public health crisis. NHPI communities are well organized and prepared to engage directly with county, state, and federal public health agencies to provide NHPI leadership, perspectives, and cultural assets in combating health inequities in NHPI communities.

As an ancient Hawaiian proverb proclaims, “Pūpūkahi i holomua!” (Unite to progress.) NHPI are doing just that.

References

1. Panapasa SV, Crabbe KM, Kaholokula JK. Efficacy of Federal Data: Revised Office of Management and Budget Standard for Native Hawaiian and Other Pacific Islanders Examined. AAPI Nexus. 2011;9(1-2):212-220.
2. NHPI COVID-19 Data Policy Lab Dashboard. UCLA Fielding School of Public Health; 2020. https://healthpolicy.ucla.edu/health-profiles/Pages/NHPI-COVID-19-Dashboard.aspx. Accessed November 16, 2020.
3. Kaholokula JK, Samoa RA, Miyamoto RES, Palafox N, Daniels SA. COVID-19 Special Column: COVID-19 Hits Native Hawaiian and Pacific Islander Communities the Hardest. Hawaii J Health Soc Welf. 2020;79(5):144-146.
4. Morey BN, Tulua A, Tanjasiri SP, et al. Structural Racism and Its Effects on Native Hawaiians and Pacific Islanders in the United States: Issues of Health Equity, Census Undercounting, and Voter Disenfranchisement. AAPI Nexus Journal: Asian Americans and Pacific Islanders Policy, Practice. 2020;17(1 & 2).
5. 2018 Demographics Report. U.S. Department of Defense;2018. https://download.militaryonesource.mil/12038/MOS/Reports/2018-demographics-report. Accessed November 16, 2020.
6. Samoa R, J.K. K, Penaia C, et al. COVID-19 and the State of Health of Pacific Islanders in the United States. AAPI Nexus: Policy, Practice and Community. 2020;17(1 & 2).
7. Hixson L, Hepler BB, Kim MO. The Native Hawaiian and Other Pacific Islander Population: 2010. U.S. Census Bureau;2012.
8. Goo S. After 200 Years, Native Hawaiians Make a Come Back. Pew Research Center. http://www.pewresearch.org/fact-tank/2015/04/06/native-hawaiian-population/. Published 2015. Accessed November 17, 2020, 2020.

By Saida Coreas, B.S.
Postbaccalaureate IRTA Fellow
Division of Intramural Research, National Heart, Lung, and Blood Institute

About a year and a half ago, I packed my bags and moved across the country from Los Angeles to begin my post-baccalaureate Intramural Research Training Award (Postbac IRTA) fellowship in Bethesda, Maryland. The NIH Postbac IRTA fellowship is a 1-to 2-year research opportunity for recent college graduates interested in applying to graduate or professional health school (e.g., medicine, dental, nursing, veterinary sciences).

I came into my fellowship with a desire to build upon my learned experiences, understand different aspects of research, and represent my community effectively. Having the privilege to be a part of Dr. Eliseo Pérez-Stable’s Minority Health and Health Disparities Population Lab at the National Heart, Lung, and Blood Institute (NHLBI) has allowed me to do just that and so much more. For example, I had the opportunity to be a lead collaborator in the development of a survey questionnaire for wave 3 of an NHLBI/NIMHD funded four-site Hispanic Community Health Study/Study of Latinos (a longitudinal cohort study of Hispanics/Latinos that began in 2008). To further support my growth, I have also had the opportunity to present our work at conferences, network with other NIH researchers, attend various workshops, enroll in graduate level classes, and work as lead and a co-author on peer-reviewed manuscripts.

As a first-generation Latina university graduate, it is important for me to work in the field of research and find a sense of community, especially in a prestigious agency such as the NIH. Seeing a friendly face who shares a similar background can create a sense of belonging and can make a world of a difference. As someone who is beginning to take steps toward a career in social and behavioral health, it reassures me that my goals are truly attainable. I am fortunate enough to be part of a diverse fellowship program and communities of support where other fellows share, understand, and empathize with my experiences and challenges, such as feeling prone to imposter syndrome.

My fellowship has challenged me in many ways and molded me into a better researcher and critical thinker. I have grown so much professionally and personally. I am both humbled and grateful to have found great mentors and to be working in a supportive environment that has enabled me to succeed in my fellowship while preparing for my next step—graduate school and beyond. If there is one thing I learned from my training and mentors that might inspire other immigrant ethnic minority students who often feel inadequate, it is to take a risk! You have something to bring to the table. There are people out there who want to help navigate your path and amplify your voice.

Jennifer Alvidrez, Ph.D.
Rick Berzon, Dr.P.H., P.A.
Dorothy Castille, Ph.D.
Nancy L. Jones, Ph.D., M.A.
CDR Nadra Tyus, Dr.P.H., M.P.H.
Division of Scientific Programs

The impact of the COVID-19 outbreak has strained daily life for people living in the United States, affecting nearly every sector including biomedical research. The disruption has also disproportionally affected the lives and livelihoods of populations that experience health disparities, which are also the populations that NIMHD’s research addresses.

To provide an opportunity to better understand the impact of COVID-19 on researchers and research funded by the institute, NIMHD hosted four COVID-19 NIMHD Investigator Forums this summer. NIMHD staff who hosted the events were Drs. Jennifer Alvidrez, Rick Berzon, Dorothy Castille, Nancy Jones and Nadra Tyus. We knew that the COVID-19 pandemic created many challenges for our research community and learned of the creative strategies they developed to navigate these challenges using their extensive connections with health disparity communities. We structured the forum to hear directly from NIMHD Principal Investigators (PIs) about their observations and thoughts in three areas:

1) Impact of COVID-19 on the communities where research is conducted
2) Strategies to modify recruitment, data collection, and/or intervention protocols
3) Understanding and addressing the impact of the pandemic on study outcomes.

First, the NIMHD research community expressed gratitude to be able to share their views on the impact of COVID-19 on their communities and their research teams, as well as to learn from their colleagues, and in some cases, form new collaborations. Although there were nuanced differences in experience and outcomes among the different health disparity communities, the researchers noted that these communities shared many similarities.

Addressing the impact of the pandemic on the communities where the research is conducted.

Nearly all research activities involving in-person contact had been stopped due to the pandemic. These decisions were made both out of concern for the burden imposed on these communities by COVID-19, and with caution to keep them and the research staff safe. Direct impact on these communities was seen with respect to COVID-19 cases, hospitalizations, and deaths, but they were also indirectly impacted, with multiple-sector disruptions effecting the community members’ wellbeing. On request by their community partners, many NIMHD investigators helped provide COVID-19 health information and linkages to resources and services. NIMHD PIs developed new partnerships to mitigate COVID-19 risks and enhance access to preventive measures in these communities; and at the request of their communities, they have increased their involvement in providing direct care and in helping navigate the available resources.

Strategies to modify recruitment, data collection, and/or intervention protocols.

Many investigators worked with their research staff and communities to modify their recruitment, data collection and intervention protocols. Investigators observed a general willingness of research participants to engage in online or virtual data collection and interventions. Some noted an increased enthusiasm to participate among individuals with more free time due to work or school closures. Investigators also shared suggestions on how they overcame connectivity barriers that made virtual participation challenging in some geographic areas or within some populations. Many surveys and behavioral interventions were modified for online, virtual or telephone collection. Although generally feasible and acceptable, these remote strategies were not always possible for participants with limited internet access, connectivity issues, or smart phones with limited data plans. Interestingly, several PIs noted that some participants preferred telephone contact over web meeting platforms like Zoom, to preserve confidentiality in more crowded living arrangements.

Many investigators reported specific challenges regarding biological specimen collection. Often, the laboratories had limited capabilities, and some areas encountered long delays in workflow because the laboratories were shipping biospecimens to other facilities for processing and analysis. Some investigators piloted mail-in biological specimen collections and one even mentioned considering a physical pick-up service. However, samples that required blood draws could not be collected remotely.

For studies that depended on recruitment in clinical settings, PIs were acutely sensitive to the increased demands of their clinical colleagues. Re-starting these studies required modifications to assure that they could work in the new paradigms of clinical care during a pandemic. Some projects, including those done in clinical settings or in schools, remained in a holding patterns, with investigators waiting to see how long the interruption would last before deciding whether to move to virtual participation or end enrollment early.

Understanding and addressing the impact of the pandemic on study outcomes.

The research community was especially aware of the fact that the pandemic would affect many of the key pathways and outcomes for their projects. Most investigators who had resumed data collection were collecting COVID-19-related data from participants to be able to tease out COVID-19-related effects on study outcomes. However, for some projects, the outcomes of interest were impacted so dramatically that controlling for COVID-19 related factors would not be sufficient. For example, school bullying does not occur in the same way when children are not in the school.

Investigators reflected that reporting study findings that occurred during the pandemic would need to explain issues such as missing data, lower enrollment, and the lack of definitive conclusions for research during this period. They hoped that scientific journals and NIH would provide guidance on how research is presented and interpreted to account for the impact of the pandemic on study outcomes.

Overall, it was clear from these investigator forums that the NIMHD research community is passionate about making a difference to the communities with which they are involved. Many of the investigators, research staff, and community collaborators are personally experiencing higher levels of stress due to the pandemic. Not surprisingly, the NIMHD research community continues to face these unprecedented challenges with creativity, flexibility, and tremendous resilience.

Dr. Harold W. Neighbors

When I started graduate school in the mid-1970s, I had just one seemingly simple research question. I wanted to know: “Who had the higher rate of mental illness, Black or White Americans?” I remember the puzzled looks from fellow students, as most of them already knew the answer – “Blacks of course!” Their reasoning made good sense – life was harder for Blacks in the United States, and a life spent fighting against racial discrimination can lead to emotional damage.

So, I began my investigation, uncovering layer after layer of complexity surrounding what I thought was a simple question. My motivations were both professional and personal. Personally, like many families, Black and White, mine had revealed a few semi-private stories about “bad nerves” (the preferred language of emotional distress used to describe mental health problems) that were offered for consumption in the smallest of morsels. And even though my curiosity was never quite satisfied, I instinctively knew not to push for too many details. Professionally, there was my first “big” assignment as a graduate research assistant on a new, innovative study, the “National Survey of Black Americans”¹. I wrote my dissertation on one aspect of the subject: help-seeking behavior for mental health problems, using data from the National Survey of Black Americans. My dissertation research told me that Black Americans need to stop, look, listen, and most importantly, tell the truth about our feelings. The key to sound mental health is what people of color decide to do about profound sadness, feelings of helplessness resulting from attacks on our self-esteem, and hopelessness due to unjust institutional impediments that erode aspirations for achieving one’s best life². My investigation revealed that when feelings become unbearably painful, they are symptoms. Once you are symptomatic, you need to get help. It is just that simple; and difficult; and complicated.

Access to Mental Health Care
Gaining access to mental health therapy is too hard for too many, especially for people of color. I know this to be true from my own help-seeking experiences. One of the lessons I learned was that getting help meant overcoming the fear of what others will think should it ever become public knowledge that you were in therapy. I was fortunate. My work history eliminated the financial barriers and I was, eventually, able to overcome my fear of being thought less of, because I decided to exercise my right to professional therapy³. Mine is but one story. Sadly, national statistics show that we still have a long way to go to eliminate racial and ethnic inequities in mental health services⁴.

Speak Up: Say Something to Somebody
If you feel something, say something, to somebody. Cutting ourselves off from a potential confidant, or our natural support networks, increases social isolation precisely when we need other people the most. Even worse, social isolation can lead to feelings of loneliness, which is bad for our mental health⁵. When we step back to view the larger social context surrounding what often feels like an exclusively private choice, we see that we do not need to face these problems alone; to do so is a choice we make. The first step is to reach out to just one person. But please hear me on this – we must go public!

Be Your Own Mental Health First Responder
In short, we are our own mental health “first responders.” We must act upon our symptoms in a manner that starts to alleviate the distress we feel. People of color must push back against stigmatization by telling our stories, because that is one way to erase the idea that mental health is something qualitatively different and apart from health. To me, Minority Mental Health Awareness Month, now known as Black, Indigenous, and People of Color (BIPOC) Mental Health Month, is about quality of life. Sadly, compared to Whites, Black Americans remain less happy with our lives. Racial and ethnic population group comparisons have limitations and are not always subject to thoughtful explanations. But a commitment to health equity demands the accountability that comes from regularly monitoring comparative data for changes over time⁶.

My Recommendations
July 2020 is the best month for everyone, regardless of skin color, age, gender identity, sexual orientation, religious background, or disability status, to start a new year of working on mental health.

Here are five ways to work on your mental health:

• Listen to your heart and vow to take better care of yourself.
• Cross your heart and promise to tell the truth.
• Summon the courage to talk with just one person about your true feelings.
• Try to question, or at least process, all racial micro-aggressions regardless of when the aggression occurred. Micro-aggressions, no matter how unintentional or accidental, are never “innocent,” and they certainly are not small. And because they often appear quickly, seemingly “out of nowhere,” the opportunity to respond in “real-time” also disappears quickly. A note of caution here; it is not always possible to respond directly, and it can be especially challenging to do so in the workplace.
• Connect with people who are committed to advocating for policies that are beneficial to the mental health of all people of color. Collective action, based on a shared identity and a sense of common fate, is good for mental health.

Acting on these recommendations will not be easy. I struggle with all of them. It is not easy precisely because our situation is so complicated. I have been around long enough to remember the family stories my elders used to tell us about what life was like when they were “coming along.” Because of them, my life has been different, less difficult, and better in many ways. They put in the hard work and made the sacrifices; now it is our turn to build upon that foundation and make it better for others.

References

1. Jackson, J. S. (1979-80). Program for Research on Black Americans. National Survey of Black Americans Series.
2. Neighbors, W., Sellers, S. L., Zhang, R., & Jackson, J. S. (2011). Goal-Striving Stress and Racial Differences in Mental Health. Race and Social Problems, 3(1), 51-62. https://doi.org/10.1007/s12552-011-9042-6
3. Neighbors, H. W. (2019). AAMC. “Manning up” can often bring men down.
4. Substance Abuse and Mental Health Services Administration. (2015). Racial/Ethnic Differences in Mental Health Service Use Among Adults.
5. Taylor, H. O., Taylor, R. J., Nguyen, A. W., & Chatters, L. (2018). Social Isolation, Depression, and Psychological Distress Among Older Adults. Journal of Aging and Health, 30(2), 229-246. https://doi.org/10.1177/0898264316673511
6. Iceland, J., & Ludwig-Dehm, S. (2019). Black-White Differences in Happiness, 1972 – 2014. Social Science Research, 77, 16-29. https://doi.org/ 10.1016/j.ssresearch.2018.10.004

By Victoria M. O’Keefe, Ph.D. (Cherokee/Seminole Nations of Oklahoma)
Mathuram Santosham Endowed Chair in Native American Health, Assistant Professor, Licensed Clinical Psychologist
Associate Director, Center for American Indian Health
Department of International Health, Social & Behavioral Interventions
Johns Hopkins Bloomberg School of Public Health

Dr. Victoria M. O’Keefe My late grandma, Virginia Feather Revas, was a Cherokee Nation citizen, a fluent speaker of ᏣᎳᎩ ᎦᏬᏂᎯᏍᏗ (Cherokee language), and a Community Health Representative (CHR) for our tribe. CHRs are embedded within their tribe and serve important roles in health promotion for their communities.¹ My grandmother served our tribe proudly and instilled in me the importance of working on behalf of our people. My favorite memories with her, from visits to Oklahoma, were going to our family’s creek to catch ᏥᏍᏛᎾ (crawfish) for dinner, attending stomp dances and pow wows, and admiring her talent for beadwork and quilt making. These memories are important teachings that I value now more than ever.

My grandma’s words to work on behalf of our people always stuck with me. As a first-generation college student and undergraduate psychology major, I quickly realized I wanted to focus my career path on mental health research with and for Native people. The urgency I felt in this decision was due to a few reasons. First, there was hardly any representation of Indigenous people or content in my education from kindergarten through my undergraduate training. Invisibility of American Indians/Alaska Natives (AI/ANs) from public discourse is a modern form of discrimination and impacts numerous areas of Native life, including mental health.² It wasn’t until I was in a clinical psychology doctoral program that I saw and had Native role models as professors, and learned about mental health research and clinical work with Native communities. Second, I searched the empirical literature and found that the majority of published articles about AI/AN communities and mental health reflected deficit-based and Westernized narratives/methods. Tribal values and teachings, like the ones my grandma passed on to me, weren’t represented in research. Finally, I remember reading an article by Dr. Joseph Gone (Aaniiih) illuminating “the sad reality [is] that the mental health needs of this nation’s Native American citizens remain largely overlooked and ignored” (p. 10) due to the federal government’s lack of fulfilling its trust responsibility to tribes.³ These factors motivated me to use my education as a pathway to increase and improve Native representation in academia, encourage strengths-based and alternative approaches to mental health that are responsive to AI/AN community needs, and engage Indigenous knowledge and cultural strengths that promote mental health and wellness.

Though my grandma didn’t get to see me accept my first job at Johns Hopkins Bloomberg School of Public Health at the Johns Hopkins Center for American Indian Health (JHUCAIH) in 2017, I’m constantly reminded of her teachings and her own work as a CHR. The innovative suicide prevention work developed by the White Mountain Apache Tribe and JHUCAIH, is carried out by community mental health workers (CMHWs).⁴ CMHWs serve their own communities, reduce barriers to, and stigma associated with, mental health care services, and provide culturally effective brief interventions and psychoeducation.⁵ This capacity building within tribes promotes self-determination over community mental health and overall wellness. The expansion of local mental health care by CMHWs can also promote tribal languages, values, and traditions that directly and indirectly help reduce mental health inequities.⁵

To promote AI/AN mental health, we need to rely on our community strengths and traditional teachings – teachings that connect mental health with physical and spiritual health. We also need to create culturally safe spaces for AI/AN youth and scholars to lead the next generation of wellness practice with tribal communities. I hope every day that I’m making my grandma proud and that I’m passing on a bit of her legacy as a beadworker, novice Cherokee language speaker, and promoter of tribal communities’ health and wellness.

The Center for American Indian Health is providing information on COVID-19 for Native Communities. Visit https://caih.jhu.edu/programs/category/covid-19-response.

References

1. Indian Health Service. (2020). Community Health Representative. https://www.ihs.gov/chr/
2. (2018). Reclaiming Native Truth. https://illuminatives.org/reclaiming-native-truth/
3. Gone, J. P. (2004). Mental health services for Native Americans in the 21st century United States. Professional Psychology: Research and Practice, 35(1), 10-18. doi: 10.1037/07357028.35.1.10
4. Cwik, M. F., Barlow, A., Goklish, N., Larzelere-Hinton, F., Tingey, L., Craig, M., Lupe, R., & Walkup, J. (2014). Community-based surveillance and case management for suicide prevention: An American Indian tribally initiated system. American Journal of Public Health, 104(Suppl 3), e18–e23. https://pubmed.ncbi.nlm.nih.gov/24754618/
5. O’Keefe, V. M., Cwik, M. F., Haroz, E. E., & Barlow, A. (Epub 2019). Increasing culturally responsive care and mental health equity with Indigenous community mental health workers. Psychological Services. https://pubmed.ncbi.nlm.nih.gov/31045405/

Margarita Alegría, Ph.D.
Chief, Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Mongan Institute
Professor, Departments of Medicine & Psychiatry, Harvard Medical School

There has been tremendous attention brought to mental health as part of the coronavirus pandemic. The good news is that there is now almost universal recognition that when our mental health is precarious, costs are immeasurable. What has become more apparent is how this cost is much higher for people of color. But why is their burden of mental illness so much greater? What can help shed light on how mental illness impacts racial and ethnic minorities so adversely and profoundly, even when they have lower or similar prevalence rates of mental health disorders when compared to White people¹?

Let me offer some things to consider, some food for thought. First, we need to pivot from attributing these differences in mental health burden to the individual and recognize how they can be best understood by structural inequities attributed to policy, law, governance, and culture. They include, for example, U.S. immigration policies, voting ID laws, housing segregation regulations, drug sentencing laws, among others. They steer people of color to a plethora of unfair experiences, differences in opportunity and limitations toward accessing the beneficial social determinants of health. Together, structural inequities negatively influence the ability to recover from health problems, including mental health issues.

There is strong evidence that chronic exposures to early stressors influence brain development. For example, the harmful impact of structural inequities can be represented by differential exposure to traumatic and chronic stressors impacting child development². Clearly, the environmental context matters, as we see from national surveys that show 61% of Black children have experienced at least one adverse childhood event compared with 40% of White non-Hispanic children. And although we have paid attention to the role of families in these negative outcomes, we have been ignoring the influence of institutions, including schools, criminal justice systems, and governments, along with their decision-makers. These are the prominent factors that influence (or determine) whether people live in socioeconomic advantage versus disadvantage, threat versus nurturance and support, or opportunity versus hopelessness.

Structural inequities are insufficiently addressed by academic researchers and in policy discussions of mental health among populations of color. Yet, they are the root causes of disparities in mental health. Take for example employment in the food and retailer industry, where women of color have the highest rates of work schedule unpredictability³; even higher than others within the same company, at the same rank. Daniel Schneider, Ph.D., assistant professor at the Department of Sociology, University of California, Berkeley, and Kristen Harknett, Ph.D., associate professor of Social Behavioral Sciences at the University of California, San Francisco, have shown how work unpredictability and instability, both in terms of hours and schedules, impact these women in their ability to make child-care arrangements⁴, and how it generates work-life conflicts in the family life⁵. All this instability translates to greater risk for behavioral problems in their children⁶, and anxiety and depression in themselves.

Or take for example, bail setting, sentencing laws, and racial profiling for people of color, which disregard a person’s available resources to defend oneself, and create rampant distrust and perpetual anxiety⁷. For Black youth, feelings of constant discrimination and a sense of unfairness, in combination with a lack of mental health treatment, may lead to losing hope that may even lead to suicide^8,9.

We need to change the narrative to focus on how our institutions magnify the harms from mental illness rather than minimize them and promote well-being. It’s time to act on these structural inequities!

References

1. Alvarez, K., Fillbrunn, M., Green, J. G., Jackson, J. S., Kessler, R. C., McLaughlin, K. A., Sadikova, E., Sampson, N. A., & Alegría, M. (2019). Race/ethnicity, nativity, and lifetime risk of mental disorders in US adults.Social psychiatry and psychiatric epidemiology, 54(5): 553-565. https://doi.org/10.1007/s00127-018-1644-5
2. Sacks, V., Murphey, D. (2018). The prevalence of adverse childhood experiences, nationally, by state, and by race or ethnicityChild Trends.
   
3. Storer, A., Schneider, D., & Harknett, K. (2019). What Explains Race/Ethnic Inequality in Job Quality in the Service Sector?Washington Center for Equitable Growth.
4. Schneider, D., & Harknett, K. (2019). It’s About Time: How Work Schedule Instability Matters for Workers, Families, and Racial Inequality. The Shift Project.
5. Schneider, D., & Harknett, K. (2019) Consequences of Routine Work-Schedule Instability for Worker Health and Well-Being. American Sociological Review, 84(1): 82-114. https://doi.org/10.1177/0003122418823184
6. Schneider, D., & Harknett, K. (2019). Parental Exposure to Routine Work Schedule Uncertainty and Child Behavior. Washington Center for Equitable Growth.
   
7. Davis, R. A., Savannah, S., Yañez, E., Fields-Johnson, D., Nelson, B., Parks, L. F., Do, R., Macaysa, A., & Rivas, R. (2016). Countering the Production of Health Inequities. Prevention Institute.
8. Dennis, K. N. (2019). The complexities of black youth suicide. Scholars Strategy Network
9. Lindsey, M. A.; Sheftall, A. H; Xiao, Y., & Joe, S. (Epub, 2019). Trends of suicidal behaviors among high school students in the United States, 1991-2017.Pediatrics, 144(5). https://doi.org/0.1542/peds.2019-1187

By Rada Dagher, Ph.D., M.P.H.
Program Director
Division of Scientific Programs
Clinical and Health Services Research
National Institute on Minority Health and Health Disparities

Maternal mortality rates in the United States have reached an all-time high. While these rates have dropped globally in the last few decades¹, in the United States, they have more than doubled between 1987 and 2015². The picture is even grimmer for racial and ethnic minority communities, where African American and American Indian/Alaska Native women have the highest maternal mortality rates of all racial/ethnic groups².

While most of the discussions about the maternal mortality crisis focus on the physical causes of death, the relationship between maternal mental health and mortality rates is largely ignored. For example, postpartum depression leads the list of mental health conditions affecting new mothers, and women experiencing this disorder may have suicidal thoughts and thoughts of harming the baby³. The novel coronavirus (SARS-CoV-2) pandemic that is causing COVID-19 disease outbreaks is another factor to consider. Due to social distancing, women have much lower access to the usual support systems (e.g. family, doulas) that promote their mental health during the vulnerable period of transitioning into motherhood. Recently published data from China on the impact of the COVID-19 pandemic suggests increased rates of postpartum depression⁴ among Chinese women. Moreover, a recent report from a convenience sample of U.S. mothers of children of ages 0-18 months, shows elevated depression (34.1%) and anxiety (34.6%) rates⁵. Yet, the currently proposed interventions to address maternal mortality do not consider approaches to prevent and/or treat postpartum depression. One such approach is providing paid leave for new mothers.

Research has consistently shown that access to paid leave is associated with better maternal mental health⁶. For example, my research on Minnesota mothers has shown that taking up to six months of leave after childbirth is associated with decreased postpartum depressive symptoms, and an employer’s paid leave policy predicted longer leaves⁷. Notably, the U.S. is one of two countries in the world (the other is Papua New Guinea) that do not have a national paid leave law⁸. Thus, women’s access to paid leave is contingent on their employer’s policy or the state they reside in. Only eight U.S. states and the District of Columbia have some form of paid leave policy, but none provide full wage replacement⁹. Without mandated federal policies, only about 15% of workers have paid maternity leave.

This lack of a national paid leave law lends itself to racial and ethnic disparities in access to leave benefits, especially given the occupational segregation and workplace discrimination in the United States. For example, African American and Hispanic mothers are more likely than their White counterparts to report being fired by an employer for taking leave after childbirth or quitting their jobs after childbirth¹⁰. Three out of 10 discrimination claims were filed by African American women between 2011 and 2015¹¹. These claims ranged from being fired for taking maternity leave, being denied a promotion or raise due to pregnancy, having inadequate maternity leave allowance, and having to endure physically taxing work conditions or extreme manual labor during pregnancy¹¹. California’s Paid Leave Program is an example of how paid leave can have a positive impact. Prior to this law, African American women took an average of a week of leave after childbirth compared to four weeks for White women¹². After the program was implemented, the average maternity leave taken by both African American and White women increased to seven weeks¹².

Another example is a study that evaluated leave policy reform in Norway, which provided four months of paid maternity leave for women¹³. The reform was associated with a range of better outcomes for Norwegian mothers. This included lower body mass index, obesity, blood pressure and pain, improved mental health and better self-reported health. The reform also lowered the likelihood of smoking and increased engagement in vigorous exercise¹³. It is notable that countries where maternal mortality rates have significantly dropped (~ -50%) in the past few decades (e.g., France, Germany, Sweden), have generous paid leave laws.

Maternity leave provides new mothers with the time to adapt to multiple physical, social, and psychological changes:

• Time to heal from childbirth
• Ability to breastfeed
• More time to care for newborns
• Adherence to postpartum care visits
• Receipt of postpartum depression screening

Yet, in the United States, one quarter of mothers are back to work two weeks after childbirth ¹⁴. In light of the COVID-19 pandemic and lack of necessary support systems for new mothers, paid leave seems even more pressing. On December 20, 2019, the President signed the Federal Employee Paid Leave Act, which provides 2.1 million federal workers with up to 12 weeks paid leave following childbirth, adoption or fostering. This is an important first step to increase the population of workers with access to paid leave which would perhaps reduce maternal mortality rates. As U.S. researchers delve deeper into the causes of racial disparities in maternal mortality, they would be remiss not to investigate the relationship between uneven access to paid leave policies in minority populations and the disparities in maternal deaths.

Note: For more information on work policies and disparities in maternal mental health, check out Dr. Dagher’s presentation at the Institute for Women’s Policy Research webinar.

References

1. WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. (2015). Trends in Maternal Mortality: 1990 to 2015. https://www.unfpa.org/publications/trends-maternal-mortality-1990-2015.
2. Sieber, R.A., (2019). Rising Maternal Mortality: Key Concepts and Opportunities for Intervention. The Journal of Lancaster General Hospital. http://www.jlgh.org/Past-Issues/Volume-14-Issue-4/Sieber_Maternal-Mortality.aspx.
3. Stewart, D.E., & Vigod, S.N. (2019). Postpartum Depression: Pathophysiology, Treatment, and Emerging Therapeutics. Annual Review of Medicine, 70: 183-196. https://doi.org/10.1146/annurev-med-041217-011106.
4. Sun, G., Wang, F., & Cheng, Y. (Preprint with the Lancet, 2020). Perinatal Depression During the COVID-19 Epidemic in Wuhan, China. http://dx.doi.org/10.2139/ssrn.3576929.
5. Cameron, E., Joyce, K., & Delaquis, C., et al. (2020). Maternal Psychological Distress & Mental Health Services Use During the COVID-19 Pandemic.
6. Aitken, Z., Garrett, C.C., Hewitt, B., Keogh, L., Hocking, J.S., & Kavanagh, A.M. (2015). The Maternal Health Outcomes of Paid Maternity Leave: A Systematic Review. Social Science & Medicine, 130: 32-41. https://doi.org/10.1016/j.socscimed.2015.02.001.
7. Dagher, R.K., McGovern, P.M., & Dowd, B.E. (2014). Maternity Leave Duration and Postpartum Mental and Physical Health: Implications for Leave Policies. Journal of Health Politics, Policy and Law, 39(2): 369–416. https://doi.org/10.1215/03616878-2416247.
8. The International Labour Organization. (2014). Maternity and Paternity at Work: Law and Practice Across the World. https://www.ilo.org/global/publications/ilo-bookstore/order-online/books/WCMS_242615/lang–en/index.htm.
9. National Partnership for Womean and Famililes. (2019). State Paid Family and Medical Leave Insurance Laws. https://www.nationalpartnership.org/our-work/resources/economic-justice/paid-leave/state-paid-family-leave-laws.pdf.
10. Donovan, S.A. (2019). Paid Family Leave in the United States. Congressional Research Service Report. https://fas.org/sgp/crs/misc/R44835.pdf.
11. National Partnership for Women and Families (2018). Black Women’s Maternal Health: A Multifaceted Approach to Addressing Persistent and Dire Health Disparities. https://www.nationalpartnership.org/our-work/resources/health-care/maternity/black-womens-maternal-health-issue-brief.pdf.
12. Rossin‐Slater, M., Ruhm, C.J., & Waldfogel, J. (2013). The effects of California’s Paid Family Leave Program on Mothers’ Leave‐Taking and Subsequent Labor Market Outcomes. Journal of Policy Analysis and Management, 32(2): 224-45. https://doi.org/10.1002/pam.21676.
13. Butikofer, A., Riise, J., & Skira, M. (2018). The Impact of Paid Maternity Leave on Maternal Health. http://dx.doi.org/10.2139/ssrn.3139823.
14. Abt Associates Inc. (2012). Family and Medical leave in 2012: Technical report. https://www.dol.gov/sites/dolgov/files/OASP/legacy/files/FMLA-2012-Technical-Report.pdf.

By Eliseo J. Pérez-Stable, M.D.
Director, National Institute on Minority Health and Health Disparities

The past few weeks have been an extremely difficult time in the United States. George Floyd’s death was so painful to witness. Even more painful is the knowledge that he was only one in a long, long line of African American men and women who have been killed by police in America. It is a relentless, terrible history, and his death was yet another reminder of injustice in our lives. It is the same injustice that American Indians suffered in colonial times and the 19th century, losing their lands and being victimized by war. It is the same injustice that led to mass deportation of Mexican Americans—people born in the United States—in the 1930s. It is the same injustice that led to the internment of Japanese Americans during World War II. This is our history.

I have watched the protests—at times coupled with violence but mostly peaceful—and been heartened by the Americans of all races who have continued to show up, day after day, to say that Black lives matter and structural racism must end. This is a society that is proud to say that all are created equal, with liberty and justice for all, but the history of injustice is clear. People are not standing for it anymore.

Here at the National Institute on Minority Health and Health Disparities, we spend a lot of time thinking about inequality. In our 10 years as an institute and our 10 years as a center before that, we have funded countless studies on minority health and on the health disparities that exist in our country.

Race and ethnicity are social constructs defined by self-identity and encompass culture, tradition, history, and biology all at once. But the effects of these social constructs are real and influenced by appearance, skin color, and social class. Racial and ethnic minorities in the United States face a disproportionate burden of many conditions, including heart disease, diabetes, obesity, and asthma.

We have funded many studies on the reasons for these problems and how to help. Social conditions are responsible for many of the health disparities affecting African Americans. African Americans are more likely to live in places with no full-service grocery stores—and with very easy access to cheap foods that raise the risk of diabetes, obesity, and other metabolic disorders. Low-quality housing and exposure to air pollution in their neighborhoods make asthma worse. A lack of educational opportunity and employment discrimination mean African Americans are more likely to work low-wage jobs without health insurance.

Over the last few months, my colleagues and I have watched, heartbroken, as health disparities have been made clear yet again through the coronavirus pandemic. African Americans, Latinos, American Indians, and Pacific Islanders are more likely to get seriously ill with COVID-19 and more likely to die from the disease. One reason for the disparity is the higher rates of underlying diseases such as diabetes that make COVID-19 worse. The other reason is the risk of getting infected in the first place. These groups are disproportionately the bus drivers, the supermarket cashiers, the frontline workers in pharmacies, the delivery drivers. They are less likely to have paid sick leave than White people are and less likely to be able to wait out the pandemic while working from home. People from these groups are more likely to live in dense housing with many family members, possibly several generations in a small space. Physical distancing, teleworking, and the option to self-isolate at home are novel markers of social privilege.

The underlying reason for these disadvantages is racism. Racism keeps minorities from being hired in many white-collar jobs and from feeling comfortable if they are hired. For decades, racism has kept African Americans and Latinos out of neighborhoods with strong schools—and poverty still does that today. Minority families have not had the chance to accumulate the generational wealth and security that many White families enjoy; racial discrimination in housing was banned only a little more than 50 years ago. And an African American man going for a run—getting the exercise that he knows he needs for his health—also has to wonder whether someone will murder him like someone murdered Ahmaud Arbery.

Racism degrades the health of African Americans and other minorities not only by limiting opportunity and sustaining poverty but also by increasing stress. We know from years of rigorous biological research that having high levels of stress hormones in the long term contributes to the development of chronic disease. We also know that getting suspicious looks, being followed in stores, and hearing racist remarks increase stress, as does poverty. Racism and the overpolicing of poor neighborhoods also increase the risk of dying from police brutality—yet another epidemic that has disproportionately affected African Americans for far too long.

We are all feeling roiled by a profound sense of unfairness, especially after months of watching the unequal consequences of the pandemic.

But I am an optimist, and I hope that these protests indicate the beginning of a change in our nation. As a teenager in Miami, I watched the news of the 1968 riots on our black-and-white television. Real change for the better has taken place since then. Now, in 2020, there is more for us to do. Real action to address systemic racism will not only reduce deaths from overpolicing, it will also improve the health of all Americans and move us toward a future in which all populations will have an equal opportunity to live long, healthy, and productive lives.

By Eliseo J. Pérez-Stable, M.D.
Director, National Institute on Minority Health and Health Disparities

The year 2020 will be remembered in history as one that changed the way we live as a result of a new global pandemic and the unequal effects on specific communities. The novel SARS-Cov-2 virus that has caused the COVID-19 global pandemic, has caused a societal awakening to the issues of existing health disparities and inequities in health care. The data we have for race and ethnicity present a stark reality: African American, Latino, American Indian and Pacific Islander populations are bearing a disproportionate burden of the disease.

As the NIMHD Director, I have had multiple opportunities to discuss the impact of COVID-19 on disparity and other vulnerable populations and share my thoughts on what the biomedical community can do and is doing in response to the COVID-19 pandemic. In this blog post, I will highlight two recent examples of these opportunities to place a spotlight on mitigating the COVID-19 burden on minority health and health disparities.

On May 4, 2020, I taped a Zoom interview with the NIH Director Francis S. Collins, M.D., Ph.D., for his newest blog endeavor called Francis Collins at Home. In Episode 9, you get to see our candid discussion about the challenges and opportunities we hope to see for improving health, especially for minorities and underserved populations, during this pandemic. Reports from multiple cities and states show that African Americans are disproportionately dying from COVID-19. In Washington, D.C., the highest rate of COVID-19 infections are in the wards east of the Anacostia river, that have more than 90% Blacks in the population. New York City, which has been the epicenter for this pandemic in the U.S., has had an increased rate of mortality among Latino populations as well.

It could have been predictable that we were going to face this dilemma with disparities. If you go back in history, similar things happened in the 80s, with the HIV/AIDS pandemic. With the COVID-19 pandemic, the outcomes have been observed on an accelerated timeline. The initial and most likely explanation for higher mortality in minority populations relates to two factors.

First, racial and ethnic minorities have a disproportionate burden of known comorbidities, such as cardiovascular disease, diabetes, obesity, asthma and many immune system disorders. These underlying comorbidities, along with advanced age, and being male, are the known demographic and medical vulnerabilities for a severe COVID-19 outcome.

The second factor relates to the risk of getting exposed to the virus, of which we have fewer clear data points. By neighborhood and household assessments, racial and ethnic minorities and the urban poor communities live in more crowded conditions that don’t offer effective physical distancing. A significant number of disparity populations work in service jobs where they are in the frontlines facing the public. They are the restaurant servers and people in the kitchen. They’re still the bus and Uber drivers, and those who are working in the pharmacies and supermarkets. These people are also the breadwinners of their household and need to work to feed their families and pay their bills.

I am also pleased to share a recent JAMA Network article that was written by NIMHD Deputy Director Monica Webb Hooper, Ph.D., NIMHD Scientific Director Anna Maria Nápoles, Ph.D., M.P.H., and myself. This Viewpoint was released on May 11, 2020. We share data about the most pervasive disparities from COVID-19, hypothesize why some pandemic prevention efforts may be hard to implement in racial and ethnic populations, and report on the current limited data on disease rates by race and ethnicity that is expanding. I encourage you to read the article and offer your comments here in the comment section of the blog.

At NIMHD, we are acutely aware of the many challenges that COVID-19 presents to our stakeholder communities. The pandemic has placed a spotlight on a health system that generates inequities. As states begin to relax risk-mitigation policies, an unfortunate opportunity to observe the etiology of health disparities presented by COVID-19 will be on display. Rigorous research is needed to identify the root causes of inequities, beyond individual behavior and biology. They must include the physical and social environment, policy, healthcare systems and social determinants. The pandemic presents a window of opportunity for achieving greater equity in healthcare of all vulnerable populations.