The coming fall months are an excellent time to reflect about past events and about the opportunities that can arise in the future. Since most of the work we do each day in behavioral health centers on redressing social injustice, I would like focus on the topic of social justice. Where do we stand? Where do we need to go? The quest for social justice is perhaps the most fundamental human problem of our present time in history.
First, we require a few concepts. Social justice is based on the notions of disparity and equity. Disparities occur when those who are more advantaged fare better in health status, access to healthcare, or achieving successful health outcomes. Clearly, these are issues of social injustice. Such problems do demand efforts to promote equity. When the least advantaged are provided the greatest assistance and support, equity can follow. Thus, equity is not synonymous with equality. Social justice can prevail if equity can be achieved.
It is well known that the mental health and substance use fields suffer from numerous disparities. Those who are poor and minorities are more likely to be exposed to poor-quality social determinants of health, to suffer various traumas, and to subsequently experience a broad range of behavioral health conditions. They also are less likely to have access to any care at all. When they do have such access, the care is more likely to suffer from quality problems.
So, where do we stand on these disparities in the fall of 2020? I think that the data show that the disparities experienced by persons with behavioral health conditions are not diminishing and, in fact, may be becoming more severe.
With the exception of a very recent uptick, length of life for Americans has decreased in the past several years, due primarily to the diseases of despair: suicide, opioid overdose and alcohol cirrhosis of the liver. Suicide rates have increased and are dangerously high, and opioid misuse and deaths are extremely high. National health insurance coverage rates have decreased for the first time in the past five years. Such changes are known to disproportionately affect persons with behavioral health conditions. Rural areas have exceptional difficulty in offering any behavioral health services.
On the positive side, progress is being made, albeit slowly. Parity protections are being extended to more persons with behavioral health conditions, thus promoting better equity. Medicaid is being expanded, primarily through waivers, to cover additional persons with better services. Evidence-based practices are being implemented, and peer support and peer-operated services are becoming available more broadly. Also, technology is being used quite effectively to extend virtual services in both urban and rural communities.
Going forward, we have a very clear task for 2021 and beyond. We must undertake a careful assessment of social justice issues across our entire behavioral health landscape, a task that has been made even more urgent by the current coronavirus crisis.
Some of the key questions we will want to address are the following:
- Which specific population groups have the most glaring problems of behavioral health disparities in health insurance, health status, access to care and achieving recovery?
- Which providers serve these very disparate population groups? How can we enhance their efforts?
- Which specific providers have problems of disparities in use of evidence-based practices, peer support, staff skills, and use of technology?
- Which states and counties serve populations with the greatest behavioral health disparities?
For each question, we also must ask how we can redress these observed behavioral health inequities and then take action to do so.
This important work should focus not only on service delivery to those who already are ill, but also on disparities that are woven into the fabric of our very communities. Some additional key questions might include:
- What major disparities exist in specific communities with regard to housing, jobs, social support and the factors that generate them? What impact do these disparities have on the emergence of behavioral health conditions?
- How do the racial, ethnic, age, and sexual orientation composition of a community influence the disparities that specific groups actually experience there?
- How does the physical arrangement of a community promote disparities or equity?
- What resources, expertise and collaborations are needed to address the disparities that exist there?
At the community level, we also must ask how we can partner with other local, county and state organizations and groups to make progress on these issues.
If we are to continue to succeed as a society, it is essential that we make every effort to address the disparities and inequities that we see around us every day. The coming year offers not only the possibilities of new insights because of the coronavirus crisis, but also the continuing opportunity to undertake this very important quest in earnest.
Let’s make the most of this opportunity of necessity.