Racism and Mental Health Research: Steps Toward Equity
In 1997, I was a medical intern at Presbyterian Hospital in New York City, working on an AIDS (acquired immunodeficiency syndrome) unit. By then, fewer and fewer people were dying of human immunodeficiency virus (HIV)-related diseases. Effective antiretroviral therapy had brought the virus under control for most people, effectively turning a deadly infectious disease into a manageable chronic condition. But not for everyone. It was too late for my patient, a Black man with AIDS in his mid-30s. He had developed a terrible lymphoma that had infiltrated his lungs. Over the week that I cared for him, each breath was shallower and more painful than the last, each dose of morphine we gave him to control the pain lasted for a shorter period of time. Eventually, all I could do was sit next to his bed and comfort him. I watched him struggle to take his last breath.
A few weeks ago, I watched another Black man die. Like many of you, I watched the video of George Floyd’s killing. I watched the police charged with ensuring public safety ignore his cries for help. I watched them ignore the bystanders imploring them to release him, or at least to check his pulse. Ultimately, I watched as he also struggled to take his last breath.
My patient died from AIDS, a disease that in 1997 was seven times more likely to kill Black Americans than Whites. Mr. Floyd died from police brutality, which also disproportionately impacts Black people who are nearly three times more likely to die at the hands of the police than White people. But both of these men actually died of systemic racism, in different guises. Systemic racism involves policies and practices that propagate throughout our society, resulting not only in interpersonal injustices but also in inequalities in access to care, quality of care, and health outcomes. Mr. Floyd’s death and the events that have followed have forced me, as a White male, to reckon with my own role in perpetuating these injustices and inequalities.
As the Director of the NIMH, I am charged with striving to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure. I cannot ignore the fact that this mission is not achievable without taking into account the inequalities that lead to worse mental health outcomes in underserved and minority communities. Indeed, the trauma of racism and police violence can themselves exacerbate mental health outcomes. While the recent events have put that trauma into the national spotlight, these traumas have been occurring for generations. I recently charged NIMH staff with developing a research plan that focuses on identifying mechanisms associated with mental health disparities and testing interventions aimed at promoting equity and improving outcomes. A draft of this plan is nearing completion and will be released within the coming months. One of our first efforts, prompted by community input and building on a virtual roundtable, will be to strengthen research into the alarming rise in suicide rates in Black youth. We will also expand our efforts to listen to key stakeholders to ensure that our research is squarely focused on the needs of Black communities.
I am also charged with ensuring an effective and inclusive workforce for mental health research. Here, I cannot honestly look my friends, colleagues, and co-workers in the eye and say that I am already doing everything I can to ensure that Black communities are treated fairly by the institution that I am privileged to lead. Many of you know success rates for Black applicants for NIH funding are dramatically lower than for White applicants, even controlling for factors such as educational background, publications and citations, research awards, seniority, etc., and the NIH has implemented several programs to address this gap. Much to my chagrin, our own similar analyses confirmed that such disparities persist for Black applicants for NIMH funding, as I presented at the National Advisory Mental Health Council in February 2020. The reasons for this disparity are not entirely clear, but our response cannot wait for clarity. To address these issues, I am immediately embarking on steps which include (1) working closely with NIH and Center for Scientific Review leadership in their efforts to identify and eliminate bias and disparities in grant scores through policy revision, reviewer training, and procedural change, in a manner consistent with the recommendation of the Advisory Council to the Director Working Group on Diversity ; (2) working to ensure NIMH post-review decision making is fair and focused on promoting inclusivity; (3) engaging Black NIMH applicants and grantees in a series of conversations to understand their perspectives on the factors impeding and facilitating success; and, (4) based on these conversations; providing solutions to meet the needs of Black applicants and grantees and others facing funding rate disparities. It is my hope that these actions will begin to reduce the success rate disparity in the next year and eliminate it within five years.
These efforts represent deliberate steps toward ensuring that NIMH extramural processes are appropriately and equitably responsive to the needs of all Americans. We will simultaneously be redoubling our internal efforts to ensure a diverse and inclusive NIMH workplace, starting with a series of intentional conversations with employees to learn more about the experience of being Black at NIMH. We will also be examining our employee demographics and increasing our outreach during recruiting with the aim of ensuring we are doing all we can to diversify the NIMH workforce.
Systemic racism is a complex issue that affects all facets of our society; institutions and individuals can unknowingly promote or support racist practices. The events of the past weeks make it painfully obvious to me that we cannot use this complexity as an excuse for inaction. Watching is not enough. We each have a role to play in taking concrete actions to address the mental health toll of racism on our communities and the systemic racist practices that impede the success of Black employees. We at NIMH will do our part, and we invite you to join us in this effort.
Allgood KL, Hunt B, Rucker MG. African American: White Disparities in HIV Mortality in the United States: 1990-2009 . Journal of Racial Ethnic Health Disparities. 2016;3(1):168‐175. doi:10.1007/s40615-015-0141-8.
Bor J, Venkataramani AS, Williams DR, & Tsai AC. Police killings and their spillover effects on the mental health of African American Americans: a population-based, quasi-experimental study . Lancet. 2018;392(10144):302‐310. doi:10.1016/S0140-6736(18)31130-9.
DeGue, S, Fowler, KA., & Calkins, C. Deaths Due to Use of Lethal Force by Law Enforcement: Findings from the National Violent Death Reporting System , 17 U.S. States, 2009-2012. American Journal of Preventive Medicine. 2016; 51(5 Suppl 3), S173–S187. https://doi.org/10.1016/j.amepre.2016.08.027
Erosheva, EA, Grant, S, Chen, M, Lindner, MD, Nakamura, RK, & Lee, CL. NIH peer review: Criterion scores completely account for racial disparities in overall impact scores . Science Advances. 2020; 6(23). eaaz4868. 10.1126/sciadv.aaz4868.
Ginther DK, Schaffer WT, Schnell J, et al. Race, ethnicity, and NIH research awards . Science. 2011;333(6045):1015‐1019. doi:10.1016/science.1196783
Hoppe TA, Litovitz A, Willis KA, et al. Topic choice contributes to the lower rate of NIH awards to African-American/African American scientists . Science Advances. 2019;5(10): eaaw7238. Published 2019 Oct 9. doi:10.1126/sciadv.aaw7238
Williams, DR. Stress and the Mental Health of Populations of Color: Advancing Our Understanding of Race-Related Stressors . Journal of Health and Social Behavior, 59(4): 466-485, 2018.