Director’s Innovation Speaker Series: Changing Minds & Advancing Lines: Why We Must Keep Pushing for Mental Health Equity

Director’s Innovation Speaker Series: Changing Minds & Advancing Lines: Why We Must Keep Pushing for Mental Health Equity


Transcript

JOSHUA GORDON: Hello, everyone, and welcome to the NIMH Director’s Innovation Speaker Series. I’m Joshua Gordon, Director of the National Institute of Mental Health. It’s my pleasure to welcome you to today’s talk and discussion, which I think you will find fascinating.

Before we get started, I just want to go over a few logistical details. As you see, hopefully, at the bottom of your Zoom screen, you’ll see a Q&A box or a Q&A button. If you should have technical problems or if you want to ask a question of the speaker, please use the Q&A function. Do not use the chat function if you see it, just the Q&A. You can enter questions into the Q&A at any time during the talk, and at the end of the talk, I’ll moderate a discussion based upon those questions with our speaker today.

Just in case you don’t see it, you can enable closed captioning on the Zoom, and there’s also an ASL interpreter. Just make sure you find that person on your video feed and pin that person so you can see the ASL interpreter.

The other notice is that this, as are all Innovation Speaker Series lectures, will be recorded and made available on the NIMH.gov website within a few weeks. If you enjoyed today’s program and would like to make sure that your friends and relatives and countrymen who might have been unable to attend directly would like to see it, please let them know. Or if you want to see it again, you’ll be able to do so in a few weeks.

With that, it’s really my pleasure to welcome Daniel Dawes, Senior Vice President for Global Health and the Founding Dean of the School of Global Health at Meharry Medical College, to give today’s Innovation Speaker Series lecture. Dr. Dawes is a jurist doctor, but a doctor nonetheless, is a widely respected healthcare and public health leader, health policy expert, educator, and researcher, who serves, of course, as I mentioned, as the Founding Dean of the School of Global Health and Senior Vice President of Global Health at Meharry Medical College in Nashville, Tennessee. Before this, he had served as Executive Director of the Satcher Health Leadership Institute and a Professor of Health Law, Policy, and Management at Morehouse School of Medicine.

He is the author of two groundbreaking health policy books, 150 Years of Obamacare, and The Political Determinants of Health, both published by Johns Hopkins University Press. Among his many achievements, Daniel was an instrumental figure in developing and negotiating the Mental Health Parity Act, the Genetic Information Non-Discrimination Act, the Americans with Disability Act amendments, and the Affordable Care Act’s health equity-focused provisions.

These and other landmark federal policies have changed the game for healthcare and mental health care in the United States. And they are built off his many years as a principal investigator on numerous grants in the area of health equity, including establishing the nation’s first health equity tracker, founding the Health Equity Leadership and Exchange Network, and being a principal investigator of the HHS National COVID-19 Resiliency Network. Professor Dawes is an elected member of the National Academy of Medicine, an elected fellow of the New York Academy of Medicine. He serves as an advisor to the White House COVID-19 Health Equity Task Force, an appointed member of the CDC’s Advisory Committee to the Director, where he co-chairs the CDC’s health equity work, and the NIH’s National Advisory Council for Nursing Research. Professor Dawes, welcome. Thank you for joining us today, and the floor is yours.

DANIEL DAWES: Well, thank you so much, Dr. Gordon. It is a true honor to be with you and to be with all of you today, especially during Black History Month as we celebrate this important month, and we talk about an issue that is near and dear to my heart, one that is impacting our fight to advance health equity in the United States and beyond, and of course, I speak about mental health equity.

So, I’m going to pull up my slides, see if we can get that up here, and begin. You know, when we think about the hierarchy of chronic disease value in America, for too long, mental illness has been relegated to the lower end of that hierarchy, and when you couple this with the hierarchy of human value in this country, you can begin to see and understand the striking inequities in mental health and substance use disorders.

Now, I know for many of us who have been in the trenches advocating for mental health reforms, it has been a frustrating endeavor trying to overcome the stigma, discrimination, and unfair barriers to advance mental health, and develop the kind of strong partnerships needed to move the needle of mental health equity to a meaningful degree in the right direction.

So, I want to commend all of you on your 75th anniversary at NIMH, and of course to you, Dr. Gordon, for leading from the front, not the sidelines on this important issue. The work that you all have been doing has been instrumental in our success in changing minds, and advancing the lines over the last 75 years, relative to mental health equity in America. Dr. Satcher, renowned leader in his own right, someone who I’m honored to call a dear friend and mentor, about 25 years ago said it best, when he issued his Surgeon General Report on mental health, there can be no health without mental health. And we know that there can be no health equity without mental health equity.

Diseases of the brain absolutely impact our systemic health, which is impacted by the wider set of forces and systems shaping the conditions of daily life. So, I want to take a moment now for all of us to look at how this has played out for some people by watching a short video which examines the political drivers of mental health.

VIDEO: To best grasp the political determinants of health, let’s examine another hypothetical example that combines experiences of real people in urban and rural communities. Over time, we’ve gotten to know and appreciate Jessica, a young woman raised in a low-income housing environment, a community often overlooked and neglected by elected officials.

For example, her living situations have often been dictated by predatory landlords. Their political pull in her district has allowed these landlords to trample tenant rights that would have prevented substandard housing situations. Jessica’s personal salvation can be found in her three children, Wilson, 17, Francine, 11, and Jasmine, who has just celebrated her second birthday. In every way, they are fiercely committed to each other, just as Jessica has worked so hard to maintain.

There are, however, overwhelming obstacles for each of them, and Jessica has had to navigate the choppy waters of her worst nightmare, a contemplated suicide attempt by her child. Pressures can mount at any age and influence the way we see the world. It’s so tough when these thoughts overwhelm teenagers. It’s even worse when they threaten our younger children.

How do political determinants of health affect our emotional well-being? Francine wants to attend her school’s suicide prevention support group, though she is younger than most of its participants. Because funding has been drastically cut this year, fewer administrative personnel are available to maintain after-school programs. Her only option is an all-ages group that meets on Tuesday afternoons. Francine knows that her mom does everything she can to provide for her family, but their lives have always been financially strained.

Jessica’s minimum-wage job at the neighborhood convenience store doesn’t provide the necessities her family needs. As a result, Francine has only two wardrobe choices to wear to school. Kids in her class have noticed the redundancy, prompting many of them to ridicule her on a daily basis. With the state’s free meal program significantly slashed, Francine starts most days with no breakfast and is embarrassed by the meager lunches from mom Passover. And budget cuts have displaced the number of school counselors from three last spring to one this fall.

With virtually no attention being provided to Francine’s mental health, her feelings of loneliness and isolation have increased. Each day is an emotional obstacle course that she can barely navigate. Since she was nine years old, Brianna has been abusing multiple forms of alcohol. In fourth grade, due to production costs and labor competition overseas, her parents lost their jobs at the shirt manufacturing plant.

Witnessing her father’s heavy drinking as he rotated in and out of jobs, Brianna echoed his behavior. It’s taken her these past two years to realize that she’s likely an alcoholic. Jose is the senior and most prominent member of the support group. As an only child raised by two mothers, most of his life has been filled with affection and loving doses of attention.

Recently, however, new state laws have made Jose feel like having two moms has made him an outcast. Frustration with his mothers has grown at the same rate as the national spotlight has expanded on the subject. The more newsworthy these stories became, the less often his friends wanted to get together. Though initially difficult to manage, Jose has learned to better handle these pressures and admits to finding the support group a healthy release overall. But where is Viola?

No one has seen her at school the past two days. Was her fear of her family’s reduced housing choice voucher finally realized, forcing them to relocate to another city? Or were her family’s disputes and instabilities too much for Viola to bear? It’s Byron, the school’s favorite algebra teacher and moderator of the support group, who inspires the kids’ discussion.

To do so today, he’s brought Danny to the conversation. As everybody knows, Danny is a professional baseball player and former student within these hallways. When his sister was caught in the crossfire of a gun battle between neighborhood rival gangs, Danny started experiencing depression at age 15. Given his school’s location and lack of prominence within the city, Danny received little social or psychological support. His baseball coach, however, could personally relate to Danny’s difficulties and provided the guidance he needed to focus on both school and athletics.

Danny steered his life back on track and excelled at his most personal pursuits to win the attention of colleges around the country. Majoring in American History, Danny realized that his college scholarship was a product of more than 60 years of federal acts and laws enabling kids of all backgrounds to pursue academic and professional success. It’s never easy to measure how political determinants sway our personal health, especially on an emotional level, but being aware of their influence can serve to improve our well-being. What does this mean for all of us? What can we do to improve and mend our community’s most damaged systems?

DANIEL DAWES: Well, there’s certainly a lot that we can do, and as we think of how to proceed on this quest to advance health equity, we need to understand that the road to health equity must be intentionally paved with the determinants of health, because the inequalities seen and experienced in our society were not by accident.

Thomas Piketty, a world-renowned economist, has recently concluded in his work that inequality did not simply emerge from economic reality, from technological change, or the organization of production, nor from inherent disparities in individual talent, ability, or effort. Rather, he argues, inequality is determined through struggles that take place in the political sphere.

Now, this raises an important point. If the resources and advantages attained through the political sphere are not equally distributed among population groups, then it shouldn’t surprise any of us that health outcomes and premature deaths are not equally experienced among certain population groups. Recent research has actually concluded that downstream interventions, which focus on change at the individual level, are more likely to increase health inequality than are upstream interventions, which focus on the social change or policy change.

Many of you have seen these statistics in one form or another. I’d love for you to just let them wash over you for a moment. Many of these have been published in the over 7,000 peer-reviewed journal articles that are published each year, looking at health inequalities in America.

Now, these under-resourced groups have struggled to live in a society that has erected barrier after barrier to weaken their bodies and hasten their deaths, leading to the striking inequities in health status, in healthcare, and life expectancy that we see across the board. Now, how have these arrived? Well, we all know that they have an economic burden on the United States. If the mental and the behavioral health system became more equitable in America, how many lives and how many dollars could be saved moving forward?

Well, in a study that I conducted with the Robert Graham Center at the American Academy of Family Physicians and the Eugene Farley Center for Health Policy at the University of Colorado, we analyzed the data and attempted to answer those questions. From our limited data sets, what we found was that almost 117,000 lives could have been saved from 2016 to 2020, and almost $278 billion linked to those lives could have been saved.

And to clarify this, these lives are considered deaths in excess of premature deaths, meaning that these are beyond what we already expected the number of premature deaths to be for a given population group in America. Understanding then that this number operates from a baseline of an already larger number of deaths for the United States, it is critical that these deaths are looked at with a magnifying glass to uncover the real reasons, not only for their deaths, but for prevention moving forward.

As scientists and researchers, we are used to acknowledging limitations to a study, but this same acknowledgement needs to be applied in real life, especially when we’re dealing with real people, not made-up figures in literature. Our research acknowledged some more limitations embedded within the data that we used, which did not account for the entire population. These included individuals who are incarcerated, those who are nursing home residents, residents of assisted living facilities, the unhoused, active military, and those who are institutionalized in psychiatric facilities.

In summation, a total of about 5.8 million people, by our estimates, had been excluded from the national sampling pools in these federal surveys. So, we went back to crunch some more numbers, only to discover that our initial figures worsened by a whole lot, with $23 billion in excess cost burden among the unhoused alone, and a range of about $40 to $69 billion of excess cost burden among those who are incarcerated. We also found an additional $63 to $92 billion could have been saved among these population groups. With each death and each group that is overlooked or excluded, the cost grows even more astronomical.

So, this begs another question. What if we became equitable and provided adequate treatment for these populations? What would our future look like then? From this report, we know what the costs are, we know what it would lead to in terms of the future, how much would be saved each year if that were to happen.

So, what’s driving these results? Well, many of us have seen the recent headlines highlighting the everyday impact of the political determinants of health, the effects of which can be observed in many areas of health and healthcare, including young children growing up without mothers, owing to high maternal mortality rates, poor and minoritized families being funneled into substandard housing by inequitable systems, and people with depression, anxiety, PTSD, bipolar disorder, drug or alcohol use disorder, or ADHD reporting over twice the odds of accessing transportation.

We have seen over the last several years the struggle to advance health equity in America and the levers of politics and policy that have been used at all levels and by all branches of government, which have affected the health outcomes of every population group in one way or another. Political determinants of health are evidenced in the data. Research has shown us that high obesity rates, maternal mortality, infant mortality, gun violence, depression, opioid addiction, substance use disorders, diabetes, heart disease, cancer, HIV AIDS, and many other health problems can be firmly linked back to policy action or inaction.

On your screen, we’ve highlighted a few of those that are directly correlated to mental health. An increase in voter restriction barriers correlated with a 25% higher probability of not having health insurance. Living further from roadways was significantly associated with decreases in depression and anxiety symptoms among older adults and mediated partially by loneliness and air pollution.

Structurally racist redlining policies from the 1930s were associated with decreased current behavioral health clinician availability in redlined communities. Black infant deaths in the United States Voting Rights Act exposed counties decreased by an average of 11.4 additional deaths beyond the decrease experienced by unexposed counties between the pre-VRA period and the post-VRA period. Of course, the list goes on.

In the United States, our community’s health is not an organic outcome. It is not a coincidence that certain groups of people in our community experience higher premature death rates than others. And it’s not a fluke that certain groups of people experience poverty for generations locked out from attaining the American dream.

Our system or systems have not always valued each group equally or realized the long-term implications that policies have on the health of its people. Why is this happening? Well, today we recognize that a variety of forces collectively impact our health and they determine the quality and the extent of our lives on this earth, including the social, environmental, economic, behavioral health, healthcare, and genetic factors. And of course, we know key among these determinants, it is argued, are the social determinants of health, the structural conditions in which all of us are born into, we live in, and we die in, that affect all aspects of our health and well-being.

Well, of course, from research, we know that they do play an outsized role in these human-made preexisting inequities, but underlying each one is a political determinant that we can no longer ignore. You see, too often we’ve been stopping at the social drivers of inequities, failing to look back and just dig down a little bit deeper to see the depths of the problem and understand its root causes and distribution.

And as a result, we have been missing the link between the social and the environmental and other determinants of health with their policy roots. For every social determinant of health, there was a preceding legislative, regulatory, ordinance, legal, or other policy decision that resulted in the structural conditions that we all find ourselves in today.

So, how did we actually get here? How did we get to these striking inequities in health status and health care? How is it that inequality gets under our skins, leading to accelerated aging or biological weathering, as Dr. Arlene Geronimus has taught us? Or how is it that it leads to the earlier onset of chronic diseases in these groups, as Dr. Williams, David Williams, Dr. Lisa Cooper, and others have highlighted in their work?

Well, we all know that the impact of slavery and colonialism has been associated with contemporary mortality, poverty, heart disease, intergenerational trauma, infant and maternal mortality, etc. And so, as we’re thinking about the structural conditions that generate higher mental illness and substance use disorders, as we think about the healthcare cognitive assessment tools, we need to think about how they came to be in the first place. So, I’m going to look back at big P policy and little p policy, both governmental and non-governmental policy, and I’m going to start 400 years ago.

I won’t start at 1619, although I do believe that is a fair starting point, but I’m going to start at 1641, because this was the time when the health equity champions, if you will, tried in vain to abolish slavery. But the commercial interests, recognizing that these abolitionists were gaining headway in their advocacy to abolish their business model said, wait a second, we’ve got to do whatever we can to preserve the status quo, to sustain our business model of slavery.

And so, in 1641, the commercial interests worked with the policymakers, starting in Massachusetts, developing their first and landmark legislation to authorize slavery or to at least legalize slavery, the body of liberties law. That body of liberties law was then used by Connecticut, New York, Maryland, and the other colonies, again, to justify enslaving other human beings. Well, as if that weren’t enough, when the health equity champions pushed back and said, wait a second, upon reading this law, we believe that it is silent. It did not mean to include the offspring of these black enslaved individuals.

And the commercial interests went back to work with the policymakers a few years after that to amend the law to ensure the inclusion of the offspring of these black enslaved folks. Around the same time as that was being developed, policymakers then went even further, designing policies that would directly impact not only black enslaved individuals, but indigenous population groups across the country. They developed laws that prohibited these individuals from being able to raise their own food.

We know that food, food security, access to nutritious foods is a critical social determinant of health. They also continue to develop, pass, implement, and enforce policies that would prohibit these groups from earning their own money. We know employment is a critical determinant of health. They also passed additional policies that prohibited folks from being educated, from being able to learn to read and write.

Again, we know that education is a critical social determinant of health. Beyond that, we know that there were also, depending on the jurisdiction that you live, laws that were developed to prohibit black and indigenous groups from being able to move around freely, right?

They were required to walk at night with a pass or with lanterns, depending on the jurisdiction. They were prohibited from congregating in large numbers, et cetera. We know that these laws were recycled from one generation to the next, from the 1600s into the 1700s and into the 1800s when Jim Crow reared its ugly head with a vengeance.

We saw the proliferation of laws at local, state, and federal levels, again, designed to make it very difficult for these minoritized groups from being able to realize their full health potential and address their social determinants of health needs. From the time of slavery, epigenetic research has shown a direct link to intergenerational trauma. From the Jim Crow era, we’ve seen a direct link to aggressive breast cancer prevalence among African American women who tend to have the most deadly form of breast cancer, triple negative breast cancer.

We’ve also seen how creative racists can be in our society. There was an attempt after the 1800s, as we got into the early 1900s, when the health equity and civil rights champions said, wait a second, these explicitly racist policies that are denying one or two or three groups of people access to social and economic benefits, they’re unconstitutional. They violate our equal protection clause, oh, Supreme Court.

Well, at that point, the Supreme Court could no longer ignore the truth and, quite frankly, stopped to pretend that there was explicitly racist policies and said, fine, you’re right, you cannot implement policies or pass policies that are explicitly racist. Well, what did they do? Instead, they pivoted to what we call facially neutral policies, policies that are on their face. They don’t exclude a group, but they were designed in such a way that they would have the same effect.

The Social Security Act is one such law, a law that included provisions that would prevent those in agricultural and in the domestic workforce from being able to pay into Social Security. These were largely operating against women, African Americans, and immigrant population groups at the time. In fact, 78% of African Americans fell into one of those two buckets and were prevented from being able to realize the benefit of that law.

Dr. Perrin was one of the architects of that, and he was also the architect of the syphilis study in Tuskegee, as well as the Guatemalan prisoner syphilis experiment that occurred. You can imagine why that was developed in such a way to ensure that once it was implemented, it would exclude these groups.

We also saw, after World War I, the Homeowners’ Loan Corporation Act under the Franklin D. Roosevelt administration designed and implemented to again target certain communities from being able to realize the economic benefits of policy. In this case, the country needed to be stimulated. The FDR administration said, what can we do to stimulate the economy?

Well, they recognized that there was a great need to understand which communities, which neighborhoods were having issues with their mortgages. They went out into 200 cities, in the neighborhoods of these cities, working in tandem with local and state policymakers to grade these neighborhoods from an A, B, C, or D, and then to align them with a certain color.

Of course, your A communities were your affluent communities, your B communities were your middle-class white communities, your C communities were your, quote-unquote, undesirable immigrant communities, and your D communities were your largely African American, or in some cases, Asian American communities, and they were deemed hazardous communities.

Well, interestingly, once these reports were aggregated and sent back to the federal government, they used those reports to create additional policies, right? Policies that would then determine who would get access to VA and FHA home mortgage loans.

Well, after that, we also saw other facially neutral policies, the Housing Act, the Housing Act, which displaced over half a million Black and Brown members of their communities across the United States, where these homes were taken from them, the properties were raised, and then they were sold very cheaply to real estate developers, who then created housing for more affluent communities. We saw the 41,000-mile interstate highway developed under the Eisenhower administration.

Many of you who work in very lower socioeconomic status communities have noticed these highways that cut right through these communities, and again, what has research shown, that there is a direct link to higher rates of depression, anxiety, diabetes, asthma, owing to these infrastructure.

But the one thing we need to think about as we are moving forward and we’re looking at the structural conditions is to think about how they came to be in the first place. How did these railroads, these highways, these infrastructures, the factories, and so forth, come to be in the first place? If you connect the dots, you will see there was a direct link to a policy decision. Moving forward, for the sake of time, we know that today, many of these communities, same communities, struggle with a poverty tax that has essentially been laid on them through the form of higher payments for auto insurance, home mortgage loans, lower property appraisals.

We’ve also seen this idea of food, pharmacy, and hospital deserts, making it very difficult for these communities, these neighborhoods, to access resources to improve health or maintain their health. Where the big P policy had been driving a lot of these now over the past several decades, we’ve now seen little p policy, these commercial interests, saying, well, my goodness, if the government isn’t going to invest in these communities, why would we ever take a risk on this? This would be a poor return on our investment, they have argued, that we wonder why the structural conditions are what they are.

Lastly, let me move us into another existential threat that we are facing here in the United States and across the world, this idea of climate change and what it’s causing through climate gentrification, where ironically, many black and brown and poor white communities were pushed further inland, owing to these racist covenants, and preventing them from owning property closer to the seashore.

Now, as the sea levels are rising, we see many of these communities that have been on the higher elevated lands being pushed out of their homes, displacing them, and it does have a lot of health impacts currently as well as in the future. Well, all told, we can see the impact that these political determinants of health have on lower socioeconomic status communities as well as communities of color.

Professor Michael Marmot, who has been a pioneer of the social determinants of health, has stated that life expectancy as a measure of health tells us a great deal about how we are doing as a society. But, he argues, the inequalities in health tell us even more about a society. Where you live absolutely matters.

And as you can see, the neighborhoods that were redlined, that were starved of resources by laws and policy are now today the very communities that have the lowest life expectancies and the worst health outcomes. Notice the 20 plus year differences in life expectancy. Notice the generations that are lost depending on where you live. Well, we know that policy is a driving force for many of the health inequities that we have seen or experienced ourselves. But it can also be a driving force for achieving health equity because only policy can fix what policy created or has broken in the first place.

So, permit me to take us back one more time in the past because as William Faulkner, the great Southern writer, has stated, the past is never dead. It’s not even past. Well, throughout our history, you can see the constant struggle, a tug of war, if you will, between those advancing the political determinants of health inequities and those who have been trying to counter the negative effects of policies by leveraging the political determinants of health. Going back in time, and I’m going to start at 1789 because I know I’ve had several folks who have said, well, Daniel, it’s not fair.

You started at 1641. We weren’t even a constitutional republic then. That’s not a fair starting point. Fine, I say, let’s start at 1789. At this time, you had the abolitionists, you had mental health reformers, you had advocates for homeless populations and others coming together trying to strategize about how best to get the federal government to provide for the general welfare of the least among us.

Well, if you think we’re having a very contentious debate over health equity, over advancing healthcare access, advancing health equity for vulnerable and marginalized population groups, it seems to me from the record that it was equally contentious. At that time, as they were strategized, they thought about who they could approach as a major policy influencer to push that agenda forward.

They landed on, of course, Benjamin Franklin. Although Benjamin Franklin had been a lifelong slave owner, as he grew older and as he came closer to his deathbed, he recognized what an evil institution it was, and he wanted to lend his name to the cause.

These groups got together and said, Benjamin, would you please sign this petition that we have created calling for the federal government to stop the separation of children from their mothers, to stop the breakup of these enslaved families, to abolish slavery once and for all? Would you join us, Benjamin, in getting the federal government to provide necessities for these population groups, food and clothing, shelter that they so desperately need? Would you join us, Benjamin, in helping us to get the federal government to provide educational opportunities, true employment opportunities, as well as health services to these vulnerable population groups?

Well, he said, yes, I’ll do it. Signs the petition, it gets to Congress, and my gosh, it stirs up this heated debate. The House, the Senate said, how dare you, Benjamin? How dare you, health equity champions, bring up this issue when you know that we’re just getting settled as a government?

Now is not the time to be talking about these issues. Isn’t that a refrain that we have heard over the last 230 plus years of our constitutional republic? Now is not the time to be addressing health inequalities in America. Well, the Senate said, we’re not even going to dignify Benjamin Franklin’s petition with an answer.

But the House said, wait a second, we can’t let Benjamin get away with this. We’re going to address it. And in bullet-by-bullet form, they actually, by the records, decided to push back on his arguments, essentially raising a confederalism argument, stating that it is not the responsibility of the federal government to provide for the general welfare of these folks.

The constitution doesn’t allow us to do that. We are not to be the great almoner for these various population groups. And so, they stated that the states which are closer to these people, remember, black and slave folks, people with mental illness, substance use disorders, homeless individuals, the states are closest to those folks. Therefore, they know what’s in their best interest.

They are the ones who need to tackle those issues. Hmm. Well, unfortunately, by the time that response was sent to Benjamin Franklin, he had died three weeks later. And that was the first time in US history that the light of health equity had dimmed in terms of advancing of equity focused policies in America.

It would take us 75 years later, during 1863, during a major war, the Civil War, for health equity champions to get together again and say, wait a second, we are going to be winning the Civil War. We are going to have all of these newly freed people and poor whites and other population groups that will be displaced as a result of the Civil War. What are we going to do to provide health services to them, to provide these necessities that human beings need to not only survive, but thrive in society?

And so, they started working on the Freedmen’s Bureau Act, America’s first and most comprehensive health policy, most reticulated health policy and health reform policy addressing the social determinants of health needs of these population groups, primarily African American and poor whites. Through that law, they argued for everything that those back in the late 1700s have been arguing.

But there was one provision that was so contentious that even President Lincoln couldn’t get his supporters to embrace. And that was the provision to provide health services to newly freed people. And so, President Lincoln, in the spirit of compromise, said, listen, strike that provision, pass the rest of the bill, get it to my desk, and I will sign it into law. And that’s exactly what they did. They started, they ended negotiation, they got it, he signs it.

What happens four weeks later? He’s assassinated. And his supporters, not wanting to squander the opportunity, the crisis presented, said, wait a second, we believe that upon rereading the statute, that it does authorize us to provide health services in addition to all of these other things that were called out in the bill.

And so, they went about recruiting clinicians from the North into the South and Midwest. They started building sanitariums, hospitals, and clinics throughout the South and Midwest to provide health services. But as this program was being implemented, what happens? As we have seen time and time again, racism doesn’t sleep in this country and hate has never taken a break in our country, unfortunately.

And that’s exactly what happened. After seven years, the opponents of ill will, as Dr. Martin Luther King called them, were successful in dismantling America’s first major health reform law intended to address these inequities. It would then take us 150 years later under the Obama administration to create another more comprehensive and reticulated health reform law that included 62 health equity-focused provisions to tackle these inequities.

Unfortunately, we have seen, as I mentioned, the tug of war with opportunities for folks, opponents, if you will, of health equity to come in and prevent the implementation of the majority of those provisions.

I’ve been talking a lot about the executive and the legislative branches of government, but we all know there’s been this other sleepy branch of government that has been wreaking havoc and undermining our efforts to advance health equity. Throughout the Supreme Court’s tenure, they, of course, refused to acknowledge, as I mentioned, that there were structural and institutional forms of discrimination until the early 1900s when the Civil Rights Movement was taking off.

But in recent dicta, we have seen in recent case law that they continue to recycle this language, that vestiges of past segregation by state decree do remain in our society. Past wrongs committed by the state and in its name are a stubborn fact of history, and stubborn facts of history linger and persist. But, they argue, though we cannot escape our history, neither must we overstate its consequences in fixing legal responsibilities.

Think about what that means for a moment. This declaration from the highest court in the land is alarming for at least three reasons that I could come up with, and I’m sure many of you could come up with many, many more.

First, the court fails to take into account the evidence from a broad spectrum of research in public health, in nursing, in medicine, in psychology, sociology, social work, etc., demonstrating the lasting impact that these vestiges of slavery, segregation, and subsequent unjustified discrimination have on population groups. Second, it has a rippling effect, setting a precedent for other policies commissioned by the other bodies in our government. And third, the court has been arbitrarily determining the point at which these vestiges of legally sanctioned discrimination cease to significantly impact certain communities, essentially arguing that after a certain amount of time, it doesn’t matter anymore.

Get over it, they argue, but here’s why we cannot get over it, and why as health equity scholars, researchers, and champions, we must connect the social determinants of health to their policy roots in the United States.

The Supreme Court would rather view inequities as products of what we call private choices or products of the social determinants, so they do not have constitutional implications or legally enforceable remedies. Health equity champions who continue to make the case that inequities are solely socially derived and fail to show the policy or the political connection will only bolster the Supreme Court’s viewpoint, thus weakening any legal protections to check these structural and institutional forms of discrimination, as well as, of course, denying legal remedies to those who have been impacted by health inequities.

So let me, in the last few minutes that I have left, talk about how we can leverage the political determinants of health. We’ve seen how the hierarchy of human value has evolved over time, and how inequities were structured or concretized in our policies or processes over the last several hundred years.

But fortunately, here’s the good news, before folks leave this talk today thinking, my gosh, this is such a depressing time, it really isn’t, because we have witnessed the incredible impact that equity-focused policies, such as the Civil Rights Act, the Voting Rights Act, and others had immediately following their passage or implementation and enforcement.

In one study that was published in 2006 by Dr. Nancy Krieger and her colleagues, where they examined the effect of the 1960s civil rights laws on infant mortality rates, they found that the concurrence of the timing, the abruptness of the rate changes following 1964, the sharp decline in infant death from infant conditions that are treatable in hospital settings, and the contrast with minimal changes among whites suggests the Civil Rights Act was the cause of these trends.

They estimated that between 1965 and 2002, approximately 38,600 Black infant deaths were prevented by implementation of Title VI of the Civil Rights Act alone. And other scholars have immediately found, following the passage of the Voting Rights Act, Medicare and Medicaid legislation, the Fair Housing Act, we saw declines in premature deaths of racial and ethnic minorities in the U.S. across the board.

But then what happens? We started to see an increase in premature deaths among these groups in the early 1980s, and then a widening of the life expectancy gaps between population groups after attempts were made to limit implementation of these egalitarian or equity-focused policies, like the Community Mental Health Systems Act that President Carter and his wife had struggled, the most comprehensive health reform law at the time, as a result.

Now, in our country, the principal roots of current and historical health inequities are found in the political determinants of health, which inequitably distribute social, healthcare, and other determinants, and they’ve created the structural barriers to equity for population groups who lacked power and privilege. All political determinants affect every single one of us because they encompass the systematic process of structuring relationships, distributing resources, and administering power. However, there are stark differences in how negatively or how positively they affect certain individuals and communities.

Let’s take a look at this. Let’s look at how we can leverage this, right? Whenever I’m analyzing a health outcome, whether it’s a mental health outcome or not, whether it’s an inequitable health outcome or not, I think about them in terms of how they came to be in the first place. What was the policy that created it or has been perpetuating or exacerbating it over time? How did the policy or political action or inaction structure relationships in the community? How have health-protective and health-sustaining resources been distributed in the community? How has power been administered in the community throughout their tenure? Once that analysis is done, I then create an action plan based on the political determinants of health framework. Here you can see the tri-part definition.

Of course, many of these health policies are cross-cutting. They’re not just in one bucket, but they can be cross-cutting underpinning on, of course, your analysis. This was my best attempt looking at the evidence from a political science, legal, public health, and historical lens to think about the levers that have been pushed and pulled over time to advance or hinder health equity.

The idea here, in a nutshell, is that once a perceived health inequity is identified, you have to conduct your due diligence to ascertain whether the health outcome is systemic, avoidable, and unjust, as Dr. Paula Braveman has instructed us. How far can you venture to understand whether it is an institutional or structural barrier that created or has been perpetuating that inequity? What is the policy change desired, and can you demonstrate the value of investing in change? Why is that?

Because in the United States, health equity champions have to understand the disquieting and harsh truth that the political determinants of health inequities have rarely, rarely been addressed unless their reduction or elimination served other purposes. You see, the success of any advocacy effort has depended on how palatable they are to commercial interests and whether there is an investment value to the government.

I want to use as an example to really bring this home what happened in the 1940s. As many of you are aware, we were going through the Second World War. During the 1940s, there was a great recognition, after trying for 150 years in this country, of getting comprehensive mental health reform passed.

Finally, the country was on its knees from a mental health crisis. Here, you had the military generals, admirals, coming together with the business leaders, recognizing that, my gosh, we have a problem. At the time, 20% of young people were unfit to serve in the military, and 40% ended up leaving prematurely, according to Dr. Felix, who was head of the Division of Mental Hygiene in the 1940s at the Public Health Service.

At that time, they also brought in others, General Hershey, who came in, and others, who found that 50% of their hospital beds were being occupied by people with mental illness. All of a sudden now, we had a problem. Even though mental health equity champions have been arguing, we’ve always had a problem, but we waited until it got exacerbated to the point where it was in crisis mode, and we now were reacting.

Well, at that point, after mental health champions learned that the moral argument was insufficient and had been insufficient for 150 years, they tied their arguments to an economic and a national security argument, arguing that, how in the world, if you do not invest, oh, federal government in our young people, how in the world can you expect them to outcompete our global competitors? How in the world can you expect them to defend our nation from external threats?

Finally, Congress wakes up, the federal government wakes up, and we got the first piecemeal bill that actually led to the establishment of the National Institute on Mental Health passed, the National Mental Health Act in 1946. That helped us to finally move the needle in the right direction because we leveraged the economic and national security arguments.

Now, as I close, where do we go from here? For many folks, we are in a very serious time in our nation’s history. Ken Burns, the documentarian, has stated that we’re in the fourth period of a very dark period in U.S. history. I don’t push back on that. I actually agree that it is a very dark time.

However, I’m also optimistic because by my count and the way that we slice and dice history from an equity lens, we are in the fourth period of a remarkable period for health equity. The first period, as you heard me mention, occurred during President Lincoln’s tenure, where he created the first policy to address the social determinants of health needs and provide health care to newly freed Black and poor white people.

The second one opened about 100 years after that, where health equity champions recognized that Dr. Martin Luther King Jr. was right. Of all the forms of inequality, injustice in health is most shocking and inhuman. Two years into that movement, folks started working on policies to desegregate our hospitals, leading, of course, to Medicare, Medicaid legislation, the Civil Rights Act, and others to address the overt forms of discrimination.

The second one opened up after that, where we had an opportunity to address the more subtle forms of discrimination in our society. Then today, we are in the current moment, which for the first time, the U.S. government has been harnessing the powerful levers with a whole of government approach to advancing health equity and addressing the upstream determinants of health inequities. Yes, every time we’ve had these awakenings, we’ve had terrible backlash and retrenchment. We are undergoing some of that too today.

We see that before our very eyes, but it is up to us to keep pushing forward, pushing for mental health equity and not to give up because we are even closer to realizing this vision than any other generation before. As Dr. David Satcher has reminded me, especially now, he argues, we need mental health leaders, scholars, researchers who care enough, know enough, have the courage to do enough, and who will persevere until the job is done.

First, you have to care about these communities, but as you have heard today, caring is simply not enough. You have to know enough. You have to avail yourselves of the knowledge of the political determinants of health. As you’ve also heard, this movement to advance health equity is not for the faint of heart. You have to have tremendous courage to do enough and persevere until the job is done. I hope that we have such leaders today.

I want to thank you all again for the privilege of your time. Thank you all so very much for the incredible work that you have been doing, which has been enabling us to continue to drive policy in the right direction.

JOSHUA GORDON: Thank you very much, Professor Dawes, for that wonderful and inspiring talk. We have just a couple of minutes left, so I want to ask a question that’s a bit of a hybrid of many. We have a bunch of questions in here, and I want to give you a chance to describe.

You talked about your optimism, but also how multiple things have accumulated over the years, multiple chances at equity leaving us in our current state. What is the role of further policy changes versus other societal efforts, for example, philanthropy, religious organizations, et cetera, in helping advance the cause of health equity at the current point in time?

DANIEL DAWES: Oh, my gosh. Dr. Gordon, that is such a powerful question. I love it because you have hit on something as I was listening to your question, thinking about how there were times when you had philanthropy not aligning with the role or the efforts by our policymakers at all levels. It does take a whole approach to this, right? A whole of government, philanthropy.

This is why I do applaud the work that folks like Grant Makers in Health have made when they worked with David Satcher when he was Surgeon General, and he was pushing this mental health report and trying to get folks to come together and address them 25 years ago. It took philanthropy. It took government to build awareness, to raise awareness. I do think there are folks who are nervous because they hear the word political.

It is not partisan. We’re not talking about partisan, but we do have to accept, and we have to understand that policy impacts all of life, quite frankly. There are forces out there that have been working to maintain the status quo, one, to create these inequities, and then, of course, to maintain those. It is going to take all of us at all levels to really harness the power of transdisciplinary collaboration to move the needle even further. I think it is a whole approach and an alignment between philanthropy, between government, between the private sector, and, of course, other systems.

JOSHUA GORDON: All right. I can’t resist one more, although I know that means we’ll go over a couple minutes in time. I hope you can answer this one. How might the average American do something to support this work? What can be done in any workplace, for example, to improve health equity? Are there types of policies you would recommend folks take a second look at? What can we do?

DANIEL DAWES: Oh, my gosh. Well, I think it doesn’t matter what level you are or what comfort level you might have. There’s something we all can do at the interpersonal, the institutional, the structural level. I want to argue that voting – I didn’t get a touch up on voting too much today – but simply going out and voting. Of course, fighting those forces that are trying to prevent groups from being able to exercise their constitutional right to vote is an act that could help us tremendously.

Voting can mean the difference between life and death for our communities, as we are now seeing. As the research is coming out through legal epidemiology research, we can connect those dots better than ever before. And so, if we do not appreciate, we do not build awareness to how voting, the implications of voting on our health and how long we will live on this earth, my goodness, guess what? Then folks will continue to not understand why it is serious and be apathetic.

I think I have noticed in the communities that I’ve worked with around the country, in the South, in the Midwest, and beyond, whenever we’ve connected those dots for community members, not even academic audiences, they say, ah, my gosh, I didn’t know that before, and I didn’t realize that this highway that cut through my community when I was a little girl was actually created by an act of law. I said, yes, ding, ding, ding, ding. This is why voting matters, and this is why there are always opportunities for folks to continue to undermine the vote. But voting, voting, voting is so critical, especially in this election.

JOSHUA GORDON: Well, thank you very much for a wonderful talk. I’ll just add that there are a whole bunch of comments in the Q&As saying what a wonderful, insightful, inspiring talk it was. So, thank you so much.

Thank you to everyone who attended. And again, if you want to share this with your friends, family, and others, just send them to our website in a few weeks’ time where you’ll be able to see a recording. Sorry we didn’t get to many other questions. I tried to merge a few of them in these two questions I was able to ask. Bye-bye for now. Thanks for coming.

DANIEL DAWES: Thanks, everyone.



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