ELEANOR BREEN O’BYRNE
Dear Sajid Javid,
I am writing to you regarding
the fact that black people are four times more likely to be detained under the Mental Health Act than their white counterparts (NHS Digital, 2021).
I was dismayed at the release of the Sewell report in March 2021 which denied that there was any institutional racism within the UK, and specifically “there is no overwhelming evidence of racism in the treatment and diagnosis of mental health conditions” (Commission on Race and Ethnic Disparities, 2021:200). This not only contradicts the position of the Royal College of Psychiatrists (RCPsych, 2021), it ignores statistics which demonstrate racial inequalities and gaslights communities of colour, denying their lived experience. Government data shows that as well as being more likely to be detained, black people are more likely to present to services via the criminal justice system, are more likely to be restrained and are less likely to be offered psychological therapies (NHS Digital, 2021; RCPsych, 2021). The Sewell report claims that these disparities are explained by differing rates of mental illness in different ethnic groups. This is a dangerous assertion. Historically scientific theories of biological difference between races have been used to justify the subjugation of particular ethnic groups (Littlewood & Lipsedge, 1982:37). The idea that black people are inherently, or genetically, predisposed to conditions like schizophrenia is pervasive but it is false. Anthropologists have deconstructed the theory that genetic variation between races can explain inequalities in health outcomes, showing that there is more genetic variance within racial groups than between them (Goodman, 2016; Kuwaza & Gravlee, 2016). Racial categories are socially constructed but the impact of race and racism is real (Mullard, 2021), as Davis argues “disparities are a biological expression of race relations” (2019:562).
Dismissing the role of racism and explaining these disparities through differing rates of mental illness also misunderstands a central tenet within the practice of psychiatry. Diagnosis within psychiatry is a subjective practice, with no blood tests or imaging able to confirm a diagnosis. This means that psychiatric diagnoses are especially vulnerable to the influence of prejudice. Littlewood & Lipsedge show how a psychiatrist’s diagnosis can be influenced by preconceived ideas about particular ethnic groups (1982:105). They discuss the case of Calvin Johnson, a Rastafari man who migrated to the UK from Jamaica. Upon seeing him, a man with locs being restrained by police, but without any further assessment, a doctor had written that Calvin was “probably a relapsed schizophrenic” (1982:4). Research has shown that when psychiatrists are given the same clinical history but different demographic information, they are more likely to give a diagnosis of schizophrenia if the patient described is black (DelVecchio Good et al., 2003:413). We should not accept that this data reflects purely biological, and immutable, difference in illness prevalence
, the picture is far more complex. [JT1]
The Sewell report also claims that health disparities between ethnic groups can be explained by socio-economic inequalities. While evidence shows that poverty can increase one’s risk of developing a mental illness (Marmot, 2020), relying on this argument to explain the racialised disparities is problematic and requires deeper enquiry. Firstly, data shows that racialised health disparities are not explained by socio-economic differences alone. When socio-economic disparities are controlled for, people of colour still have worse health outcomes than their white counterparts (Davis, 2019; Kuzawa & Gravlee, 2016; Mullard, 2021). That is not to say that poverty and class don’t matter. Structural violence describes how certain groups within society are particularly vulnerable, being both at increased risk of ill health and less able to deal with crises when they occur. This violence is not overt but is built into the structures and systems within society (Farmer, 2004). Within this framework we would not accept that higher rates of poverty among certain ethnic groups explain higher rates of serious mental illness, we would be asking why are certain groups more likely to live in poverty? [JT2] How do poverty and race interact to create particular vulnerability in these groups? These are the questions your government should be asking.
Finally, I’m going to talk about Olaseni Lewis, a name that I hope stays with you. He was 23 when he was admitted voluntarily to Bethlem Hospital due to a deterioration in his mental health. He became agitated when nurses refused to let him leave and the police were called. They restrained Olaseni face down for 30 minutes, when he became unconscious the police decided he was feigning
it and initially took no action. He never recovered consciousness and died three days later from cerebral hypoxia (Gayle, 2017). This tragic case is sadly not unique. I bring up Olaseni’s case for two reasons; firstly, to ask why this man in need of support was met with violence, and secondly to dispute the idea that black communities have unfounded fears of mental health systems. Racism does not need to be overt for it to have deadly consequences.
‘Aversive racism’ describes how negative racialised stereotypes, for example that black people are violent, can inform the care that black people receive, even when these beliefs are unconscious (DelVecchio Good et al., 2003:414). I have already discussed the ways in which this kind of bias can affect diagnosis. I would argue that this kind of racism is also at play when we see that black patients are more likely to receive coercive treatment. The Sewell report argues that certain communities do not access care for mental illness because of a ‘mistrust’ of the mental health system and ‘fear’ that they will be discriminated against (Commission on Race and Ethnic Disparities, 2021). This insinuates that people from these communities are more likely to present to services in state of crisis because they did not seek care earlier on. This framing places the blame on people from ethnic minority communities while dismissing legitimate fears. Olaseni Lewis sought help for his mental illness, and he died at the hands of the police. Fear of a system which has used lethal force against a young man in distress is a legitimate fear.
The Sewell report suggests that education and outreach are needed to address the racial disparities in mental health outcomes. I would argue that this is not only insufficient but fails to address the complex underlying causes. Instead, I am advocating for the following:
- The government must take action to address the underlying structural racism which exists in the UK. This will require investment to reduce economic inequality and break the cycle of intergenerational poverty which disproportionately impacts black communities (Bailey et al., 2013).
- Teaching on structural racism needs to be integrated into medical school curriculums and post-graduate training to address diagnostic bias, to raise awareness of structural and aversive racism, and to destabilise the concept that race is a purely biological risk factor for many diseases (Bailey et al., 2013; Sobo et al., 2020).
- Transdisciplinary work between clinicians, social scientists, policy makers, and, most importantly, communities with lived experience is needed. Anthropologists have been actively involved in researching low vaccine uptake amongst certain ethnic groups
, similar work can be done within mental health settings (Sobo et al., 2020).This work is the first step in building trust with communities and could help create new systems of care which are actively anti-racist.
I hope that this letter convinces you that racial disparities within Mental Health Care need to be taken seriously. I know that I am one voice amongst many calling for change. For too long people of colour have suffered discrimination, both personal and structural, which increases their risk of mental illness while reducing the chance that they will receive compassionate care. This needs to change. The change I am calling for is not one of cultural competency, or of increased outreach. We need to address, not simply acknowledge, underlying inequality and structural violence. We need psychiatrists and other mental health professionals to engage critically and reflexively. We need interventions which are actively anti-racist. We need to build trust within communities who for too long have been discriminated against and then blamed for the harm they suffer.
A concerned doctor
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Gayle, D. (2017). Man who died after police restraint was ‘gentle giant’, court told. The Guardian. Retrieved from https://www.theguardian.com/uk-news/2017/feb/07/man-died-olaseni-lewis-police-restraint-gentle-giant
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NHS Digital (2021). Detentions under the Mental Health Act. Retrieved 1 March 2022, from https://www.ethnicity-facts-figures.service.gov.uk/health/mental-health/detentions-under-the-mental-health-act/latest
RCPsych (2021). Equality Action Plan. Retrieved 1 March 2022, from https://www.rcpsych.ac.uk/docs/default-source/about-us/equality-diversity-and-inclusivity/equality-action-plan—january-2021.pdf
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