key: cord-0853824-d6l0fnb8
authors: Farquharson, Wilfred H.; Thornton, Carmen J.
title: Debate: Exposing the most serious infirmity–racism’s impact on health in the era of COVID‐19
date: 2020-07-19
journal: Child Adolesc Ment Health
DOI: 10.1111/camh.12407
sha: bf1c57a4089cd9a0787be7e21fb70bb4aae232dc
doc_id: 853824
cord_uid: d6l0fnb8

The COVID‐19 pandemic retells a story that other diseases like HIV, diabetes, and cancer have clearly internationally illustrated. Minorities in developed countries across the globe – especially those of African, Hispanic, and Native American descent – suffer a greater burden of disease than whites. The evidence of the cause and effect relationship of racism on mental and minority health outcomes is staggering. Racism and its influence on policy and important structural systems allow health inequities across racial and ethnic groups to persist. What’s more troubling is how systemic racism impacts children from all races and has been perpetuated across many generations dating back hundreds of years. The impact of racial oppression is seen through intergenerational trauma which impacts youth in varying ways. For this article, we offer three areas in which racism causes healthcare disparities, intergenerational trauma, social determinants, and cultural mistrust. Effective policy change and a greater level of accountability must be placed on major systems including health care, to most fully counter racism’s varied role in sustaining mental health inequities.

During his 1966 address to the Medical Committee on Human Rights, Rev. Martin Luther King, Jr. included in his speech the quote, 'of all the forms of inequality, injustice in healthcare is the most shocking and inhumane' (Zabel, 2006) . While racial segregation in public institutions has ended and voting rights extended to communities of color, many societal inequities in place during the US Civil Rights Movement continue to thrive. More than fifty years after Dr. King's address grave disparities in healthcare outcomes among racial and ethnic populations remain. However, differences in health outcomes among racial and ethnic groups are not a problem exclusive to the United States. The COVID-19 pandemic retells a story that other diseases like HIV, diabetes, and cancer have clearly illustrated internationally. Minorities in developed countries across the globeespecially those of African, Latin, and Native American descentsuffer a greater burden of disease than whites. The evidence of the cause and effect relationship of racism on mental and minority health outcomes is staggering. Racism and its influence on policy and important structural systems allow health inequities across racial and ethnic groups to persist (Gee & Ford, 2011) . The greatest question and our most important work surrounds how can we terminate systemic racism and offer healthy and safe environments where all children can thrive. For this article, we offer three areas in which racism deepens challenges and drives a broader need to address health disparities among communities of color during the era of COVID-19.

Intergenerational trauma defines how the experience of a traumatic event that began years before the current generation is transferred and impacts how individuals within a family or community understand, cope with, and heal from trauma (ACAMH). Racism's impact on mental health is obvious. A family's or community's exposure to racism over multiple generations has had lasting and reprehensible effects on many socioeconomic levels. The transference of trauma across generations is also known to result in increased emotional dysregulation in children (Powers et al., 2020) . The long-term psychological impact and trauma of COVID-19 has yet to be observed, but the social isolation, fear, and grief resulting from the pandemic will likely impact the children. Specifically children who live in poverty that may only be afforded adequate social engagement through school and other community programs that have been closed due to the virus. Some children may have experienced higher levels of abuse as lengthy stays at home prolongs time spent with a caregiver who may also abuse or neglect children.

The disenfranchisement of people of color from a global perspective has roots dating back to slavery as can be evidenced by where some descendants of slaves currently live. One of the greatest social determinants impacting health is housing. Living in a safe environment with access to healthy options for nutrition and good air and water quality is not guaranteed for many living below the poverty line.

Government officials took serious measures to stop the spread of COVID-19, and the term 'Social Distancing' became the slogan that required people to both stay at home and remain 6 ft. or more away from one another. In cities like London, New York, New Orleans, and Chicago, that order was impractical for most. It is no secret that those cities are largely inhabited by people of color for a number of historical reasons such as affordability and employment. Social distancing and the ability to work from home are not an option for many. In the UK, it was noted that nearly 1/3 of the Black Africans and ¼ of Black Caribbean people were considered key workers or essential (Siddique, 2020) . This would reflect the fact that 35% of patients in ICU in England, Wales, and Northern Ireland were members of the BAME (Black, Asian, and Minority Ethnic) community and hospital deaths for Blacks in the UK were twice as high compared to their white counterparts.

Vast COVID-19-related concerns have impacted children and adolescents of color at greater levels including, one or both parents/caregivers becoming ill or dying, one or both parents/caregivers becoming unemployed due to layoffs, no or limited home access to WiFi or electronic devices to consult for medical care or continue school work, and isolation along with losing access to support services or safe places as home may be an abusive environment. Without question, socioeconomic factors caused these COVD-19-related disparities. However, we cannot deny nor overlook that the healthcare system is ill-advised on how to incorporate best practices in caring for people of color. Suggestions and recommendations abound on the need to include the voice of communities of color in decision making when handling healthcare issues and in conducting research.

Further examination of social determinants highlights a healthcare system that has remained deficient in providing unbiased coverage, is shaped by barriers in provider linguistic and cultural competency, and riddled with obstacles in creating adequate access. Insurance status has been identified as a significant contributor to ambulatory care for blacks (Kirby et al., 2006) . With regard to insurance-based healthcare systems like the United States., there was a message of 'no-copay' for COVID-19

testing, but what about people with no insurance? And what about the message that hospitals and testing sites were sanctuary sites? If the primary goal is population health and saving lives, these barriers cannot persist among a global pandemic.

The idea of seeking treatment and getting tested for COVID-19 can be frightening for many people. The current political climate in the United States has been cruel to both documented and undocumented immigrantsparticularly those from countries in the Caribbean and Central and South America. This undoubtedly creates a barrier to care as people have been unable to get insurance and are less likely to seek medical care despite their conditions out of fear of being detained or deported by US Immigration and Customs Enforcement (ICE). When it comes to the consideration of clinical trials for a COVID-19 vaccine, issues of cultural mistrust arise within African American communities as the US Public Health Service Syphilis Study at Tuskegee, gynecological experiments in slave women, and the use of Henrietta Lacks' HeLa cells are remembered (Washington, 2006) .

Failure to achieve health equity across communities of color reflects the clear racial divides that run across the United States, the UK, Europe, and most of the world. To most fully counter racism's varied role in sustaining health inequities, effective policy change and a greater level of accountability must be placed on major systems including health care, housing, education, employment, and criminal justice.

The charge as we continue to move through the COVID-19 pandemic and prepare for recovery is to shift the focus to population mental health, as that will be the true second wave in managing the trauma of a global pandemic. Practitioners should focus on targeting the children of the most impacted communities in order to disrupt the pattern of intergenerational trauma. Be prepared to address the disproportionate impact on people of color when providing treatment and aid children and their parents to regulate emotion. Ensuring measures for adequate and accessible telemedicine should be considered a high priority. Additionally, we must not cease efforts toward community outreach and patient care because of fear of infection. People of color with limited health literacywhich is a contributing factor to health disparitiesneed outreach to close the gap (Orr et al., 2013) .

Every public official and practitioner should consider the tenets of 'Herd Immunity' and apply it as a means to promote mental health awareness and end racism. With a growing population of people who embrace the cultural norms of other groups and prioritize mental health treatmentchange is subsequent.

Should mental health professionals understand

Structural racism and health inequities

Explaining racial and ethnic disparities in health care

Racial/ethnic differences in medicare experiences and immunization

Intergenerational transmission of risk for PTSD symptoms in African American children: The roles of maternal and child emotion dysregulation. Psychological Trauma: Theory, Research, Practice, and Policy

British BAME Covid-19 death rate 'more than twice that of whites

Medical apartheid the dark history of medical experimentation on Black Americans from colonial times to the present

What happens to health care quality when the patient pays? Quality and Safety in Health Care

Accepted for publication

The authors have declared that they have no competing or potential conflicts of interest.

No ethical approval was required for this article.