An opportunity for hope?
By William B. Lawson MD, PhD, DLFAPA
I am old enough and fortunate enough to see and appreciate the changes that have occurred over the past half century in the health care system, especially regarding mental health. I still vividly remember visiting a state mental hospital where a great uncle spent much of his life. The building had all of the negative aspects of an institution including limited resources and communal showers. But then chlorpromazine (thorazine), a drug used for treating certain mood disorders, was invented and he was able to spend the rest of his days at home with his family. Fast-forward several decades, when I began my career as a psychiatrist, I was part of a team that completed a study with clozapine, the first antipsychotic that was demonstrably superior to others. Again, I saw the wonders of medical technology as people with severe mental illness once relegated to back wards in chronic institutions were able to engage in meaningful relationships and live productive lives. Relative to the rest of medicine, treatment of the mentally ill is relatively young and the wonders of new advances and treatment long seen in antibiotic therapy and cancer treatment are still emerging in psychiatry.
But there is a dark side. I remember the first studies that showed major discrepancies between racial and ethnic groups in outcomes for most physical disorders. African Americans and Latinos consistently showed a greater illness burden, more mortality throughout life, and shorter life expectancies. A surgeon general’s report confirmed with regard to mental disorders what was already known for most physical disorders: greater disease burden and less access to treatment for racial and ethnic minorities. Various explanations such as greater genetic vulnerability or less efficacy for standard treatment simply did not hold water. The socioeconomic differences in ethnic groups certainly play a role, but these differences persist despite controlling for class or only comparing those on Medicaid rolls. Clearly attitudinal factors and political factors trumped medical technology despite improved delivery systems.
In mental health, substantial progress was made in diagnostic techniques despite the absence of biomarkers as is the case for most disease states. Missed diagnosis and overdiagnosis became less common through the years , making treatments more reliable and predictable. Yet African Americans continued to have missed diagnoses or received the wrong treatments for the condition. Disorders with more pessimistic outcomes such as schizophrenia were overly diagnosed and often newer more effective medications were not prescribed. Often aberrant behavior was considered a basis for incarceration rather than diagnosis and treatment. The diagnostic problem has persisted despite improved diagnostic techniques and focused efforts to address ethnicity and culture. Lack of access to newer more effective treatments have continued despite efforts to expand their use.
Austin in many ways reflects this contrast in medical technology and ethnic disparities. It has been regarded as among the healthiest cities in the country. Yet it also has among the worst ethnic disparities in disease outcome in the country, parallel to geographical disparities. African Americans and Latinos are heavily concentrated in the East side of the city, which also has the worst health outcome statistics. Mental health is no exception, with minorities reporting more mental distress and less access to treatment. Austin offers clues as to how such disparities develop and persist. In 1928, a decision was made to force African and Mexican Americans to the East side of the city. That area was designated as the “bad side” of town and hospitals and clinics simply were not developed there, nor were many physician practices encouraged there. Route 35 later provided a physical barrier that emphasized the racial and ethnic dichotomy.
Today there is some hope. A world-class medical school is being built based on the newest concepts in health delivery and a focus on patient needs rather than income. A partnership with a Huston-Tillotson, an Historically Black University, and the development of a health and wellness center is bridging that gap.
The Dell Medical School is partnering with Integral Care, which is the primary provider of mental health and substance abuse services for low income individuals, to improve access to new advances in mental health treatment. The opportunity for clinical trials that include ethnic minorities should improve access to new treatments. The development of early intervention programs such as Recovery After an Initial Schizophrenic Episode (RAISE), which educates the community that the severely mentally ill can recover, the integration of mental and physical health services, and links to improved access to services in the correctional system are ongoing initiatives that may be the answer to some of these disparities.
The Humanities Institute, in partnership with the Austin Public Library, will be screening the award-winning Code Black, a 2013 documentary follows the story of a dedicated team of charismatic, young doctors-in-training as they wrestle openly with both their ideals and with the realities of saving lives in a complex and overburdened system, on Thursday, May 4, 2017 at 6:30pm at the Terrazas Branch of the Austin Public Library. Dr. Ted Held, Director of Reproductive Health at People’s Community Clinic, an FQHC based in Austin, and Faculty at the Dell Medical School will be present to host a brief community discussion following the film. This event is free and open to the public.
Dr. William B. Lawson is Associate Dean for Health Disparities at the Dell Medical School and Director of Community Health Programs and Professor at Huston-Tillotson University, where he leads the Sandra Joy Anderson Community Health and Wellness Center. He is also UT Austin’s institutional representative for the Health Disparities Education, Awareness, Research and Training (HDEART) Consortium.