Dead on arrival is a term that most health care professionals would use to describe a patient who arrives at their facility too late for life-saving measures. Their heart is no longer beating. Gas exchange in the respiratory system has stopped. But what about patients who arrive at the emergency department, urgent care, primary care, etc. only to find that the barriers to receiving care almost certainly guarantee their untimely demise? Are they not also dead on arrival?
It may seem like a dramatic leap to make between a person who has been declared clinically deceased and the person whose social standing or ethnic identity results in substantial discrimination by our health care system. For some, it may be hard to fathom having to decide between paying rent or paying for insulin. For some, they may never have realized they belong to a group of people privileged with a lifespan a few decades longer than the people living 40 or even just five miles down the highway.
As a Lakota woman and psychiatric mental health nurse practitioner, I have spent my entire career in health care collaborating with patients facing those inequities and my entire life experiencing those same inequities. I have experienced the loss of both patients and loved ones to the systemic oppression that occupies our entire health care system in the United States.
The Impact of Systemic Oppression
Racial trauma and systemic oppression have long been recognized as detrimental to mental health and overall health outcomes (American Psychological Association, 2021; Comas-Diaz, Hall, & Neville, 2019). In the United States, non-Caucasian individuals have lower rates of health insurance coverage and typically have lower incomes than our White counterparts (National Center for Health Statistics, 2021). Even when we do have insurance coverage, we are less likely than White patients to receive timely care delivery of evidence-based care for conditions such as cancer, cardiovascular conditions, and stroke (National Center for Health Statistics, 2023; Yearby, Clark & Figueroa, 2022). This type of oppression also affects those with substance use disorders (SUDs). These individuals are often seen as being in control of their condition. They are also likely to be seen by others as being dangerous or unpredictable. In the media and entertainment industry, individuals with substance use disorders are often portrayed as violent. This results in continued stigmatization of substance use disorders. For example, we are more likely to report seeing individuals with substance use disorders as being unpredictable or dangerous when we have never experienced that behavior from an individual with substance use (National Academies Press, 2016).
Disregard for the well-being of non-White populations through unequal access to adequate housing, living wages, and appropriate health care for generations has created a state of chronic injustice resulting in a well-spring for health disparities. These forms of systemic oppression and others, including race-based medicine and race-based clinical decision models taught in medical schools and their continued use in practice, have been identified with a call for elimination (American Medical Association, 2021; Vyas, Eisenstein, & Jones, 2020).
Blind Spots for Health Care Providers
Surely health care professionals can separate what they might see on television and what is reflected in evidence, right? Maybe not. Individuals living with both substance use disorders and mental health conditions frequently have physical symptoms they report to their primary care provider (PCP) attributed to their SUD — rather than their PCP investigating those complaints in the same way that they would if the patient did not have any mental health conditions. These patients are also less likely to be referred for appropriate medical screenings that we know prolong life and improve care through early diagnosis, such as mammograms. If the discrimination experienced at health care facilities was not detrimental enough, funding for meaningful services to match the rates of substance use and mental health disorders continues to fall short of the mark, as it is rarely a priority at the state and federal levels (National Academies Press, 2016).
A Call to Action From the Frontlines
This past month, I was a panelist alongside other ethnic and racial minority health care providers to provide advice and mentorship to students of color hoping to enter the medical field. One student asked what I felt was the biggest challenge was for the health care system in the United States, and my advice for minority health care professionals as they enter the workforce. I shared that the lack of acknowledgement of systemic oppression is the single biggest issue in the health care system as I see it.
When I say we should “acknowledge this issue,” I do not mean that we publish a report and then continue to tolerate oppressive policies and practices. My advice is that we demand diversification of the health care workforce and accept nothing less than immediate action to implement a monitoring system that can identify and rectify instances of substandard care of patients from ethnic minorities, who are LGBTQ2S+, and/or who are living with mental health and substance use disorders. My advice is that we not only act on implementing anti-racist and anti-oppression policies that we know work (Hostetter & Klein, 2021) but that we also reduce funding to academic institutions (namely those with nursing programs and medical schools) that cannot demonstrate meaningful progress towards changing policies that are exclusionary of ethnic minorities, and that we should instead prioritize funding for all levels of care for people living with mental health and substance use conditions.
As a panelist, I advised all of the future health care professionals that they prepare to experience secondary traumatization due to being exposed to patients suffering in front of their eyes as a result of an oppressive system, and in ways they themselves have likely already experienced, either directly or through a loved one. I have lost count of how many times in my career I have thought, “Wow, we seriously do not matter, and this system has zero use for us outside of squeezing whatever labor it can out of us before we die 20 years earlier than White people. Not if your circumstances never change and not even if you manage to get a degree. There is no land of opportunity if you depressed, using drugs, or are the wrong color.”
This is my lived experience; this reality for me and others like me every single day, and who look at our kids knowing that it is their reality, too. If this is not your reality, you can help fix it. If this is not the reality of your kids, you can teach them to strive for something better than indifference.
Upcoming Webinar: Vulnerable or Oppressed?
Wednesday, September 27, 2023
Presented by Whitney Fear, RN, MSN, PMHNP-BC, PMH-C
NPD practitioners are change agents, creating influence through their practice adoptions. Understanding factors contributing to poor health outcomes in certain populations and how nomenclature contributes to health disparities are key to initiate changes that improve population health. In this session, you’ll learn how leveraging the impact of social capital provides tangible steps to address social inequities and answer the question: Are these populations vulnerable, or are they oppressed?
Learn more and register.
Interested in hearing more from Fear?
Stay tuned for Fear’s conversation with NPD Forecast hosts Naomi Fox, MSN, RN, NPD-BC, CCRN, and Stephanie Zidek, MSN, RN, AGCNS-BC, NEA-BC, NPD-BC, in an upcoming podcast episode.
References
American Medical Association. (2021). Organizational strategic plan to embed racial justice and advance health equity. https://www.ama-assn.org/system/files/ama-equity-strategic-plan.pdf.
American Psychological Association. (2021). Role of psychology and the American Psychological Association in dismantling systemic racism against people of color in the United States. https://www.apa.org/about/policy/dismantling-systemic-racism
National Center for Health Statistics. Health, United States. (2021). Delay or nonreceipt of needed medical care, nonreceipt of needed prescription drugs, and nonreceipt of needed dental care during the past 12 months due to cost, by selected characteristics: United States, selected years 1997–2019. https://www.cdc.gov/nchs/hus/data-finder.htm.
National Center for Health Statistics. (2023). Health, United States, 2020–2021: Annual Perspective.
DOI: https://dx.doi.org/10.15620/cdc:122044.
Comas-Diaz, L., Hall, G. N., & Neville, H. A. (2019). Racial trauma: Theory, research, and healing: Introduction to the special issue. American Psychologist, 74(1), 1-5. http://dx.doi.org/10.1037/amp0000442
Committee on the Science of Changing Behavioral Health Social Norms; Board on Behavioral, Cognitive, and Sensory Sciences; Division of Behavioral and Social Sciences and Education; National Academies of Sciences, Engineering, and Medicine. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington (DC): National Academies Press (US); 2016 Aug 3. 2, Understanding Stigma of Mental and Substance Use Disorders. Available from: https://www.ncbi.nlm.nih.gov/books/NBK384923/
Hotstetter, M., & Klein, S. (2021). Confronting racism in healthcare: Moving from proclamations to new practices. The Commonwealth Fund. https://www.commonwealthfund.org/publications/2021/oct/confronting-racism-health-care
Vyas, D. A., Eisenstein, M. D., & Jones, D. S. (2020). Hidden in plain sight - Reconsidering the use of race correction in clinical algorithms. New England Journal of Medicine, 383(9), 874-882. DOI: 10.1056/NEJMms2004740
Yearby, R., Clark, B., & Figueroa, J. F. (2022). Structural racism in historical and modern US health care policy. Health Affairs, 41(2), 187–194. https://doi.org/10.1377/hlthaff.2021.01466
Vyas, D. A., Eisenstein, M. D., & Jones, D. S. (2020). Hidden in plain sight - Reconsidering the use of race correction in clinical algorithms. New England Journal of Medicine, 383(9), 874-882. DOI: 10.1056/NEJMms2004740
Yearby, R., Clark, B., & Figueroa, J. F. (2022). Structural racism in historical and modern US health care policy. Health Affairs, 41(2), 187–194. https://doi.org/10.1377/hlthaff.2021.01466
Whitney Fear, RN, MSN, PMHNP-BC, PMH-C
Psychiatric Mental Health Nurse Practitioner, Family HealthCare
Whitney Fear is an ANCC board-certified psychiatric mental health nurse practitioner currently working at Family HealthCare in Fargo, North Dakota. Prior to becoming a nurse practitioner, she worked primarily in the fields of emergency medicine, substance use, community health, and mental health. Her clinical specialties are trauma-related disorders, substance use disorders, medication-assisted treatment, perinatal psychiatry, harm reduction, and LGBTQ2S emotional health.
She feels that an integral part of fulfilling the responsibilities of a nurse should include advocacy for issues such as health equity and social justice. Fear serves as a board member for Indigenous Association. She is the current chairwoman for the Fargo Native American Commission. In her free time, Whitney enjoys spending time with her partner, children—twins Isabella and Remy—and bonus sons Brian and Oliver, painting, creating traditional beadwork/quillwork, and being outdoors.