S1 Episode 1: Equity Explained, Systemic Racism and Suicide

In Season 1 of the Addiction Medicine Podcast, Victor Armstrong, Chief Health Equity Officer at the North Carolina Department of Health and Human Services, discusses equity as it relates to substance use disorder and mental health.

In Episode 1, Victor discusses what equity means to him, how he understands systemic racism and where his views may veer from popular consensus. Victor untangles suicide rates among young African-American men and offers thoughts on where our focus as healthcare professionals and society ought to be going forward.

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Transcript

"Hi. I am Victor Armstrong. I am Director of the North Carolina Division of Mental Health,  Developmental Disabilities and Substance Abuse Services. I am by training a social worker, I am a mental health advocate, and I share all those things because I think we’re all kind of a total sum of all those parts, everything that brought us to this place where we are now. So a lot of my focus is not just on mental health treatment and providing access to mental health services, but it’s about raising awareness around mental health issues. It’s about reducing stigma around mental health. Because I think at the end of the day, in my role, it is about creating resources and access to behavioral health services for all North Carolinians. While our focus is primarily on the underserved, those who receive Medicaid or are uninsured, in many ways, we chart the path and set the stage for how mental health is viewed throughout the state. That includes areas of equity and inclusion where traditionally those may not have been things that we have really focused on or dialed in on.

A lot of our focus, particularly over the last year or so has been around equity and particularly racial equity. For me, whether you think of issues in terms of race, ethnicity and culture, or whether you’re thinking about socio-economic challenges, equity really comes down to allowing any group of people, any historically- marginalized community to live up to it’s full potential. And I think, where the merge is between race and ethnicity and socio-economic status is, when you look at who are predominantly uninsured in this country, it is black and brown people. When you look at people who are living at the lower end of the socio-economic spectrum, it is black and brown people. So, at the end of the day, it’s hard to separate the two. Now, I think the other question - the challenge we often have is that we think in terms of we think of racism, systemic racism. We think of it in terms of a good and bad binary. That you’re either not racist and a good person or you’re racist and a bad person. I look at it very differently. I look at systemic racism not as something you assign to an individual. Systemic racism to me is a power differential. 

Consider the fact that Black people report psychological stressors at a 20 percent higher rate than white people. But at the same time, black people are less likely to initiate mental health services and more likely to terminate mental health services prematurely, they’re more likely to enter the mental health system in the back of a police car, or in a hospital emergency room. Neither of which are conducive to good outcomes or building a good relationships with the mental health system. When you consider all those things and you consider the reasons why, one of the reasons is, services, outpatient services, community resources, traditionally have not been located in communities where black and brown people live. And if you’ve gotta take a bus, three busses to get to your initial appointment, you’re less likely to make an appointment, you’re more likely to terminate that appointment prematurely. Consider also that when you think about why there are more stresses on black and brown people, obviously socio-economic challenges do impact mental wellness. People who are impoverished, people who are incarcerated, people who are experiencing domestic violence are much more likely to have psychological stressors than those who are not. And then when you come back to that power differential, you think about who has access to resources, who has access to services. Now looking at it from the perspective of someone in my position who is looking at from an aggregate system, from a state system.” //

"And consider also that throughout my career I’ve worked in community behavioral health, I’ve worked on the payer side, I’ve worked on the private side. And one of the things I’ve learned, we think in terms of aggregate numbers. We can create resources that may be accessible to 75 or 85 percent of the population. And that makes us feel like you’ve done a really good thing. But you can have resources accessible to 75% of the aggregate population and still miss 75% of the black population or 75% of the LatinX population or 75% of the Native American population. That’s where that socio-economic construct, that power differential comes into play.

If we look at where suicide rates are trending, one of the highest rising rates is among African-American males, young African-American males. When we ask ourselves the question why, we have to think about first of all, what suicide is. When we think of suicide, we tend to think of suicide as the ultimate disease. Suicide itself is not a disease. Suicide is the worst possible outcome of a culmination of a lot of very complex things, often including mental health challenges, which goes back to some of the socio-economic factors. So, when you think about why suicide is increasing in black and brown communities, you can’t separate that from historic racism, which has included race-based exclusions from education, from jobs, from housing, and those things tend to take a toll on a community. And then you look at, even over the past year, when we think in terms of what’s occurred during the pandemic. I also tend to think of the pandemic not just as the coronavirus itself.. I think of it as the total sum of both what the pandemic has caused and some of the health disparities it’s highlighted, but I also think of it as a span of time. So, when I look at this coronavirus pandemic era that we’ve been in, I think about the past 13 months, which have included the deaths of George Floyd, Ahmaud Arbery, Brianna Taylor, all these things that we have experienced and all of these things culminate. It’s very difficult for us, as part of human nature to really separate out things, to separate out stretches of time, so as we look back over this past year, even as we may think about the coronavirus pandemic, our collective feeling about this past year is going to include all of those things. And so for Black and brown people, when you look at all of the stressors, when you look at black and brown people dying disproportionately at the hands of law enforcement, when you look at the health disparities, when you look at the poverty issues, when you look at some of the political rhetoric that has occurred over the last several years. All of those things culminate into more stressors on black and brown people. Now, again, when you think about access to care. When you think about that suicide is not the disease, but is a culmination of all these different things, then where our focus has to be is on prevention. Our focus has to be on how do we get upstream. If you don’t have access to those upstream resources in your community, you are ultimately going to be more susceptible to the worst possible outcome, which is suicide. "