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2020 American Public Health Association – Affiliate of the Year

RAC I S M HE A LT H #BlackHealthMatters

Delaware Journal of

Delaware Academy of Medicine

Board of Directors: OFFICERS Omar A. Khan, M.D., M.H.S. President S. John Swanson, M.D. President Elect

Public Health

Daniel J. Meara, M.D., D.M.D. Immediate Past President Timothy E. Gibbs, M.P.H. Executive Director, Ex-officio DIRECTORS Stephen C. Eppes, M.D. Eric T. Johnson, M.D. Joseph F. Kestner, Jr., M.D. Professor Rita Landgraf Brian W. Little, M.D., Ph.D. Arun V. Malhotra, M.D. John P. Piper, M.D. EMERITUS Robert B. Flinn, M.D. Barry S. Kayne, D.D.S.

Delaware Public Health Association

Advisory Council:

Omar Khan, M.D., M.H.S. President Timothy E. Gibbs, M.P.H. Executive Director Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.H.S. Richard E. Killingsworth, M.P.H. Erin K. Knight, Ph.D., M.P.H. Melissa K. Melby, Ph.D. Mia A. Papas, Ph.D. Karyl T. Rattay, M.D., M.S.

Volume 6 | Issue 5

A publication of the Delaware Academy of Medicine / Delaware Public Health Association

Lynn Jones Secretary David M. Bercaw, M.D. Treasurer

November 2020

www.djph.org 4 | In This Issue

28 | Addressing the Trauma of Racism from a Mental Health Perspective within the African American Community

Omar A. Khan, M.D., M.H.S. Timothy E. Gibbs, M.P.H.

5 | Press Release Timothy E. Gibbs, M.P.H.

Angela M. Grayson, Ph.D., L.P.C., B.C.-D.M.T., N.C.C.

6 | Guest Editor Marsha’ T. Horton, Ph.D.

8 | Guest Editor Jacqueline A. Washington, Ed.D., M.S.

10 | A prevailing problem of pretrial sentencing of DUI offenders: Impact on health & rehabilitation Hon. Nicole Alston-Jackson, M.Ed., B.A.

12 | Repeated, Ongoing, and Systemic Incidents of Racism and their Harmful Mental Health Effects: Addressing Trauma in the Lives of African Americans Kimeu W. Boynton, J.D.

16 | Red, White, and Bruised: How Systemic Racism Emotionally and Physically Bruises Black People in America. Andre Lamar

18 | Structural Racism as a Fundamental Cause of Health Inequities in Delaware and Beyond: What Does the Evidence Say?

Cassandra Codes-Johnson, M.P.A.

32 | To Be Seen and Heard: The BIPOC Experience in STEM Cecelia Harrison, M.P.H. Alexandra Mapp, M.P.H. Dominique Medaglio, Pharm.D., M.S.

34 | We Must Act Now: Building Trust and Increasing Minority Participation in COVID-19 Clinical Trials Marshala Lee, M.D., M.P.H.

36 | It Don’t Take Much to Piss Off a Cop: A Commentary on Systemic Racism in Policing Warren A. Rhodes, Ph.D.

40 | Connie’s Story: A View Inside Constance Malone

42 | “Enough Is Enough.” An Historical Perspective: Long Lasting Health Disparities in the African American Population in the Midst of the COVID-19 and the George Floyd Incident Marlene Saunders, D.S.W., M.S.W., L.M.S.W.

William J. Swiatek, M.A., A.I.C.P.

62 | The Impact of Racism and the Influence of Faith on the Mental Health of African Americans W. James Thomas, II, B.S., M.Div., D.Min.

66 | Racism as a Stressor Impacting the Health of African Americans Zollie Stevenson, Jr.

74 | Towards a More Healthy America: Reallocation of Health Care Resources in an Inequitable Health Care System Carole Guy, M.D., F.C.C.P.

77 | From the History and Archives Collection 78 | Advancing Racial Equity: Leading, Learning and Unlearning Tia Taylor Williams, M.P.H., C.N.S.

80 | The Traumatic Impact of Structural Racism on African Americans Gwendolyn Scott-Jones, Psy.D., M.S.W., C.A.A.D.C.

84 | Black Health Matters in the United States Timeline Dr. Lori Crawford, M.F.A.

86 | Global Health Matters Fogarty International Center

100 | Racism and Public Health - RESOURCES 102 | Racism and Public Health - LEXICON 103 | Index of Advertisers

Delaware Journal of Public Health Timothy E. Gibbs, M.P.H. Publisher Omar Khan, M.D., M.H.S. Editor-in-Chief Marsha’ T. Horton, Ph.D. Jacqueline A. Washington, Ed.D., M.S. Guest Editors Liz Healy, M.P.H. Managing Editor Kate Smith, M.D., M.P.H. Copy Editor Suzanne Fields Image Director ISSN 2639-6378

COVER Health indicators have improved for most Americans; however, Black/ African Americans and other minorities are not having that same experience. Couple that with systemic racism manifested in quality of care and you have a reality that’s hard to miss. Black/African American Health needs to matter. If Black/African Americans are not well, then the health of all Americans is compromised.

The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA).

only the opinions of the authors and do not necessarily reflect the official policy of the Delaware Public Health Association or the institution with which the author(s) is (are) affiliated, unless so specified.

Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Write ehealy@delamed.org or call Liz Healy at 302-733-3989.

Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages June not be photocopied, except in limited quantities, or posted online, without permission of the Academy/ DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to ehealy@delamed.org.

Advertising: Please write to ehealy@delamed.org or call 302-733-3989 for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products. Copyright © 2020 by the Delaware Academy of Medicine / Delaware Public Health Association. Opinions expressed by authors of articles summarized, quoted, or published in full in this journal represent

FEATURING: COVID-19: Immunity & Vaccine Potential

Join us for a virtual summit! Due to COVID-19 gathering restrictions, the 2020 Communicable Diseases Summit will be held virtually this year. Join us from the comfort of your own screen!

Marci Drees, MD ChristianaCare


WHEN Monday, November 9 8:20 am – 12:30 pm COSTS

- Healthcare Providers: $20 - Non-healthcare Attendees: $10 - State Employees: Free

Nemours/AI duPont Hospital for Children


Director, Division of Public Health Other Topics Including:



I N T H I S I S SU E Last summer, the editorial team concluded that we would elevate a frank discussion of Race and Health in the Journal. This decision was made long BEFORE George Floyd, Breonna Taylor and too many other names became a wake-up call and rallying cry about racism in America, and months before COVID-19 became a household term. We reached out to Guest Editors Marshá Horton, Ph.D. and Jaqueline Washington, Ed.D., both Black, to curate this issue, and we thank them for their leadership. We in public health have known for some time of the complex relationship between Race, the Social Determinants of Health, and health outcomes, and hope this issue is thought and action provoking. Turning to news of note about the Academy/DPHA (the parent organization and publisher of the Journal): we have been recognized as the 2020 Affiliate of the Year by the American Public Health Association. The press release from APHA about the recognition is on the following page. Introducing the award was Dr. Melissa Alperin, who highlighted the following as reasons for our selection: The DPHA is uniquely positioned as an Affiliate embedded within a state medical academy. With this relationship, the Academy/DPHA has provided a model for seamless partnership between traditional medical communities and public health. The Academy/DPHA draws together primary care providers along with public health workers including those at the state division of public health, local academic institutions and non-profits into one community focused on creating a healthier Delaware. The Academy/DPHA uniquely combines a hands-on approach to public health community building with a commitment to science and data. Several activities of note include: • Th  e Delaware Journal of Public Health serves as a model for data and information sharing. • Th  e Academy/DPHA strengthens the state approach to creating a healthier Delaware through its engagement with the Delaware State Health Improvement Plan; and their Delaware Immunization Coalition program. • Th  e Academy/DPHA is committed to providing professional education in the medical, dental, and public health realms. • Th  e Academy/DPHA is also strongly committed to providing quality learning opportunities to both young and old which increase awareness and health literacy. • Th  ey support students and young professionals through their student internship program which is focused on public health opportunities/projects. • Th  e work closely with the Pennsylvania and Maryland Affiliates though the Mid-Atlantic Public Health Partnership. • And many board and staff of the Academy/DPHA are active leaders within APHA. We have, in the pages of this Journal, through our columns, and through the very foundation of the Academy/DPHA, advocated for health equity and the advancement of the public’s health. We reaffirm this in the strongest terms now, by helping continue an important conversation in America about racism and health. It is our sincere hope that these efforts will help eliminate disparities and truly achieve the promise of health that all those in our country deserve.

Omar A. Khan, M.D., M.H.S. President

4 Delaware Journal of Public Health – November 2020

Timothy E. Gibbs, M.P.H. Executive Director

PRESS RELEASE Timothy E. Gibbs, Executive Director Delaware Academy of Medicine / Delaware Public Health Association 302-733-3919 tgibbs@delamed.org www.delamed.org

DELAWARE ACADEMY OF MEDICINE / DELAWARE PUBLIC HEALTH ASSOCIATION NATIONALLY RECOGNIZED The Academy/DPHA receives national recognition in the 90th Year of its operation. The American Public Health Association (APHA) has awarded the Delaware Academy of Medicine/Delaware Public Health Association (Academy/DPHA) with its 2020 Outstanding Affiliate of the Year award. The award was given at the APHA Annual Conference (held virtually this year) Council of Affiliates Reception Saturday evening. The CoA Outstanding Affiliate of the Year Award celebrates an APHA Affiliate that has made significant contributions through innovative programs and activities that impact the public’s health. The Affiliate of the Year Award is given to an APHA Affiliate that provides a model for other Affiliates for work or project(s) of high value to public health such as innovative workforce development programming or impactful advocacy for public health policy within its state. Tim Gibbs, M.P.H., executive director of the Academy/DPHA said “Just six years ago we became Delaware’s affiliate to APHA, and it has been an amazing experience which has led us to grow in ways few of us could have anticipated.” Mr. Gibbs was joined in accepting the award by President of the Board, Omar A. Khan, M.D., M.H.S. who stated “This means the world to our diverse membership of physicians, dentists, researchers, public health practitioners, community health workers, academics, and student interns. The Delaware Academy of Medicine was founded in 1930 and originally operated as Delaware’s medical library and conference center. In 2006, the Academy moved from its historic location in the City of Wilmington to Christiana Hospital in Newark, Delaware. Shortly after the move, Mr. Gibbs was promoted to the position of interim, then permanent executive director, and has overseen the transformation of the Academy into a public health, education, and research organization. In 2014, after three years of realignment work, the Academy applied to the American Public Health Association to become Delaware’s affiliate, and was accepted at the annual meeting held in Boston, MA that fall. Since then, programming and revenue streams to the Academy/DPHA have diversified to include funding from the CDC, and contracts with the Division of Public Health. In 2015, the Academy/DPHA started publishing the Delaware Journal of Public Health (www.djph.org), its signature, peer-reviewed publication. Other programs of the Academy/DPHA include the operation of the Immunization Coalition of Delaware, Student Financial Aid Programs, consumer health education programs, several clinical conferences, and student internship programs. Partners of the Academy/DPHA include the Delaware Health Science Alliance and its member institutions, the Delaware Chapter of the American Planning Association, the Delaware State Dental Society, the Medical Society of Delaware, and the Delaware Stroke Initiative. The Academy/DPHA is a founding member of the Midlantic Public Health Partnership (www.midlantic.org). The Academy/DPHA, a 501(c)3 tax-exempt membership organization is run by a board of directors, and supported by a public health advisory council, and investment advisory council. Membership in the Academy/DPHA is open to all healthcare provider degrees, public health degrees, researchers, academics, and students. The mission of the Academy/DPHA is “To enhance the well-being through education and the promotion of public health.” ###


Marsha’ T. Horton, Ph.D. Dean, College of Health and Behavioral Sciences, Delaware State University; Board Member, American Conference of Academic Deans

What is this anger and profound sadness I feel? What is this confusion and pain I feel? What is this rage, sense of injustice and futility I feel? It is the aftermath of sustained, repeated trauma. Trauma that touches my heart, my soul, my mind and my body. It doesn’t matter if it’s trauma I have personally experienced or witnessed. It doesn’t matter if it’s a story told by my father or by a friend. It doesn’t matter if it’s portrayed in a movie or seen in actual news coverage. The response is the same. There are tears that reflect the pain in my gut and anger in my mind. I can try to be calm, try to be dispassionate but that does not help. I can participate in weighty discussions or loud debates about what we should do, what should have been done, who should be fired and who should be hired. But we all know that there are no easy fixes. This is not an issue that sprung up out of nowhere; it represents a long history, a pattern of systemic racism inflicted upon a people that were not viewed as people. How many times must we watch men, women, boys and girls be terrorized by those vested with power by our society? That power is supposed to keep order, to help us feel protected; but that power is used to intimidate, to clearly communicate that you are not something to be protected, you are something the rest of us are to be protected from. How many times must we watch the double, no, the triple and quadruple standard be applied? Colin Kapernick kneeled on a football field as a sign of protest. It was peaceful, it was powerful, it was impactful; yet, he was vilified; fans screamed out that he was unpatriotic, that he hated this country; and he was marginalized by the NFL. Ben Kesling applied his knee to the neck of George Floyd while he was handcuffed and face down on pavement for 8 minutes and 46 seconds (520 seconds). Most people can hold their breath for 30 seconds. Navy Seals, the best of the best, can hold their breaths for 120 – 180 seconds. But no one can hold their breath for 520 seconds. Mr. Floyd was nonresponsive for the final 2 minutes and 53 seconds. A fellow officer stood by with his hands in his pockets. What is the impact of this trauma? What is the impact of systemic racism? There are long-term and short-term effects. One of the long-term impacts is multi-generational trauma, and these impacts are felt by the victims, the perpetuators, and their respective communities. One impact is desensitization. I remember a telling scene from the movie “A Time to Kill,” in which a Black man was being prosecuted for killing the men who abducted, raped, and beat his 10year old daughter. There are ups and downs during the trial but towards the end, it appears as if an acquittal is unlikely. During closing arguments, the father’s attorney tells the jury to close their eyes and listen to a story. He describes, 6 Delaware Journal of Public Health – November 2020

in slow and painful detail, the entire ordeal of the 10-year old little girl. At the conclusion of the story, the attorney then asks the jury, “now imagine she’s White.” Oftentimes, when I consider how people’s behavior are viewed, I ask myself, “How would this be different if he/she was White?” Consider the Charleston church shooting in 2015 where nine people were murdered during Bible Study. When Dylan Roof was arrested, he complained of being hungry, so officers treated him to a free meal from Burger King. In May – June 2020, peaceful protestors were shot with rubber bullets, sprayed with tear gas, and tackled and thrown to the ground. This double standard is not just applied in the criminal justice system. Every day we are confronted with political leaders and policy makers who lie, twist facts, and then deny all wrong-doing. Every day I wonder, how would this behavior be perceived and received if the perpetrators were people of color? The entire history of our country was and continues to be intertwined with a double standard based on race and economics. Consider “The Trail of Tears,” Jim Crow laws, Japanese Internment Camps during World War II, and immigrant detention centers today. Who gave American settlers the right to claim someone else’s land? Who gave southern politicians the right to segregate public facilities funded by un-segregated tax dollars? During World War II, we fought against the Germans and the Japanese. Why weren’t German-Americans sequestered in Internment Camps? Immigrants to the United States come from around the world. Why is it that recent Executive Orders restricted immigration from Africa, the Middle East, Central America, and Latin America? “Four score and seven years ago, our fathers brought forth on this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.”1 But have we, as African American people, ever really been free in this country? If freedom means not having to worry about being treated differently when you shop in a high-end store, then no, we’re not free. If freedom means seeing an officer roll up beside you or behind you and not having to wonder if an encounter will be civil or lead to death, then no, we’re not free. If freedom means there are no longer laws, regulations and/or policies in place that are flagrantly biased, then no, we’re not free. If freedom means that outspoken, intelligent African American men and women are not marginalized, dismissed or ignored, then no, we’re not free. If freedom means that a diverse workforce is not considered “politically correct” instead of necessary for vital productivity, then, no, we’re not free. And finally, if freedom means that when I walk into the office of a healthcare provider, I am assured that I will receive the same level of respect, courtesy

and quality of service that Caucasian clients receive, then no, we’re not free. So again, I ask, “What is the impact of this trauma? What is the impact of systemic racism? Specifically, what is the impact of this trauma contextualized within systemic racism on the health of African Americans?” This edition of the Delaware Journal of Public Health is dedicated to Racism and Health. What does it look like, what does it feel like, how is it operationalized through the lens of physicians, attorneys, educators, social workers and health advocates? These are critical voices that need to be heard; but we must be mindful that cultural, societal and individuallyexperienced trauma is a constant overlay, the proverbial, ever-present watermark on the lives of African Americans. It is an honor and a privilege for me to serve as one of the Guest Editors. My only hope is that, as you read, you will listen with your head and with your heart. This must stop, but it’s only by working together can we effect change.

REFERENCES 1. Lincoln, A. (1863). The Gettysburg Address. Gettysburg, PA.


Jacqueline A. Washington, Ed.D., M.S. Program Manager, Harrington Value Institute Community Partnership

Every day when you look in the mirror, what do you see? Do you notice attractive features? Or do you acknowledge flaws and imperfections? Many of us recognize what we choose to see in our reflection, or that we identify something that does not exist depending on our mood, or that we wish our reflection reveals something even if it is not reality. With the help of COVID-19, America has been forced to look in the mirror and recognize that its flaws and imperfections associated with recurring injustices has deeply soiled the moral fabric of this country. We have a serious dilemma in this current climate: being aware of what is directly in front of our faces for so long, yet we choose to ignore it. The recent events of police murder and brutality coupled with a pandemic and correlated economic fallout that disproportionately affects African Americans has forced America to revisit its reflection – a history that has been ignored. The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) have described the Coronavirus (COVID-19) as a highly contagious illness caused by a virus that can spread from person to person. If contracted, this virus may spiral into a critical illness for some and result in death for many others, with or without pre-existing conditions. From my perspective, racism is its own pandemic (COVID-R) because it behaves as a viral illness of hatred, brutality, lies, double standards, hypocrisy, abuse and murder causing health disparities, social economic inequity and death among African Americans and other communities of color. COVID-R has been spreading viciously since the foundation of this country. For two hundred and forty-six years (1619-1865), Black people were considered collateral and wealth via enslavement. From 1865-1968, the birth and foundation of legal discrimination policies and laws caused inhumane treatment and suffering endured by Blacks. Similar to the scientific clinical context of COVID-19, racism has its own viral characteristics that are contagious and infectious, using a host (people) to reproduce and cause communal spread and death with the potential to exist for years. African Americans comprise of 13% of the US total population, and yet, to-date, have the highest infection and mortality rates from COVID-19 than any other racial group.1 One reason for this daunting statistic is the growing evidence around pre-existing chronic medical conditions such as type II diabetes and hypertension increasing the risk for severe complications and mortality when contracting COVID-19. African Americans are disproportionately burdened with a high prevalence of these co-morbidities and other health 8 Delaware Journal of Public Health – November 2020

disparities, thus making the growing disparity of the impact of COVID-19 more apparent.1 While the data around the medical perspective is undisputed, it is imperative to understand the connections between the societal racial infrastructure, health and the severe impact structural racism has on public health. In the United States, long standing ideals and societal factors associated with white supremacy have shaped and laid the foundation for structural racism. Since the arrival of the first 20+ Africans in this country, racial segregation has been the spoke in the wheel of structural racism. In its simplicity, structural racism can be defined as the ways of which white supremacy ideas are choregraphed and shaped as a part of our lives. Dr. Tricia Rose, a professor at Brown University who leads a current study called the How Structural Racism Works Project defines structural racism in the United States as, “the normalization and legitimization of an array of dynamics – historical, cultural, institutional, and interpersonal – that routinely advantage whites while producing cumulative and chronic adverse outcomes for people of color.”2 Residential segregation, also known as housing discrimination, is a clear example of this type of a legitimized system strategically designed to routinely advantage whites while producing disadvantage circumstances for Blacks. Overtime, this system has resulted in a cascade effect; crystalizing the link between structural racism and public health. Prior to COVID-19, the poverty rate for African Americans was 22% compared to only 9% in whites.1 Poverty, and poor quality housing and neighborhoods often lead to higher exposure and access to unhealthy commodities such as tobacco and alcohol, and less access to fresh foods and exercise outlets (gyms and safe parks). As such, underserved communities of color lack access to quality schools and healthcare, and are therefore more prone to working in essential industries earning lower wages and develop chronic illnesses such as obesity, cardiovascular disease and diabetes.1 COVID-19 and COVID-R combined have exacerbated these health disparities and social inequities among African Americans. According to a study at Northwestern University, Black men are three times more likely to be killed by police within their lifespan compared to White men.3 More formidable is that death by lethal force committed by an onduty police officer is 2.5 more times likely to occur with Black people than whites.3 It is more apparent now than before that COVID-R is a public health issue. An article recently published in Neurology Today explains how structural racism

is detrimental to the neurologic health of African Americans. The publication further points out several ongoing studies revealing direct correlation between racism to several chronic diseases such as hypertension and dementia, as well as acute illnesses such as stroke.4 If Social Determinants of Health as we know it are the conditions in which people are born, grow, live, work and age,5 then the evidence is unequivocally clear that COVID-R has brutally impacted every condition and component of well-being and the overall health of African Americans. America, look in the mirror and ask yourself “what does all this mean?” Consider your reflection and acknowledge that, if truth be told, the COVID-R pandemic and its mutated offspring, systemic-structural racism, is so enflaming and traumatizing that the premise for naming racism as a public health issue is further emphasized in an editorial published in the New England Journal of Medicine stating that “Discrimination and racism as social determinants of health act through biologic transduction pathways to promote subclinical cerebrovascular disease, accelerate aging, and impede vascular and renal function, producing disproportionate burdens of disease on Black Americans and other minority populations.”4,5 It is no longer simply the case that which zip code you live in determines your life expectancy. It is now an atrocious absurdity to know that the reality of being a Black African American in this country means that you may lose your life while • Receiving medical treatment (#Tuskegee Experiment) • Being handcuffed (#GeorgeFloyd) • Going jogging (#AmaudArbery) • Relaxing or sleeping at home (#BriannaTaylor, #AtatianaJefferson) • Asking for help after being in a car accident (#JonathanFerrell, #RenishaMcBride) • Using your cellphone (#StephonClark) • Leaving a party (#JordanEdwards) • Playing a childhood game of cops and robbers in a public park (#TamirRice) • Walking home from the store with a bag of candy (#TrayvonMartin) • Receiving a normal traffic ticket (#SandraBland) • Reading a book in your own car (#KeithScott) • Walking with your 10-year old grandchild (#CliffordGlover) • Shopping at Walmart (#JohnCrawford) • Attending weekly bible study at church (#Charleston9) It is ridiculous to know that the amount of melanin in your skin or simply living while being Black has become the new variable that determines mortality rates.

The conversation on race/racism is uncomfortable, and it should be. This country is methodically unequal and crafted to favor one group over others. In this issue of the Delaware Journal of Public Health, you will read and hear from a wide range of perspectives and authentic viewpoints on Racism and Health. The leaders of this journal have taken a bold approach in creating space to have a difficult conversation on this topic, and I am honored to serve as one of the Guest Editors. This edition provides a platform for authors who otherwise may not have an opportunity to use their voice and contribute in an unconventional way to tell their stories, share traumatic experiences, and shine a florescent light on current data associated with America’s history on this topic. So, let’s get comfortable with being uncomfortable, and have a consistent conversation about racism (COVID-R) as a public health crisis. Education, awareness, funding, training and legislation are all essential to addressing this 400+ year old pandemic, but somehow it is not enough. What is the secret sauce? If we do not face reality and acknowledge our individual contributions to communal spread of COVID-R, then how can we fundamentally change this public health crisis? Take a second look in the mirror America. What do you see?

REFERENCES 1. Tai, D. B. G., Shah, A., Doubeni, C. A., Sia, I. G., & Wieland, M. L. (2020, June 20). The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States. Clin Infect Dis, ciaa815. https://doi.org/10.1093/cid/ciaa815 2. Rose, T. (2014, Dec 14). How structural racism works [Video]. Brown University. YouTube. Retrieved from: https://youtube.com/watch?v=KTvsOJctMk&t=995s 3. Edwards, F., Lee, H., & Esposito, M. (2019, August 20). Risk of being killed by police use of force in the United States by age, race-ethnicity, and sex. Proceedings of the National Academy of Sciences of the United States of America, 116(34), 16793–16798. https://doi.org/10.1073/pnas.1821204116 4. Shaw, G. (2020). It’s a public health crisis: How systemic racism can be neurotoxic for Black Americans. Neurology Today, (13): 24–25. Retrieved from https://journals.lww.com/neurotodayonline/fulltext/2020/07090/ it_s_a_public_health_crisis__how_systemic_racism.4.aspx 5. Evans, M. K., Rosenbaum, L., Malina, D., Morrissey, S., & Rubin, E. J. (2020, July 16). Diagnosing and treating systemic racism. The New England Journal of Medicine, 383(3), 274–276. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMe2021693 https://doi.org/10.1056/NEJMe2021693


A Prevailing Problem of Pretrial Sentencing of DUI offenders: Impact on Health & Rehabilitation Hon. Nicole Alston-Jackson, M.Ed., B.A. Magistrate Judge – Kent County Justice of the Peace Court

The lower court, as the conduit for judicial engagement in criminal offenses, is tasked with the day to day responsibility of balancing fair and impartial court outcomes with individual system decision-making; while weighing the independent needs of offenders, such as with Driving Under the Influence (DUI) offenders, in the pretrial phase of adjudication. Presently, within the Justice of the Peace Court, DUI offenders present to the Court in the county of jurisdiction by local police agencies and endure a hearing of the initial presentment of charges, prior to the setting of bail. Unfortunately, in the pretrial phase, mechanisms that potentially affect the sociological and mental health of DUI offenders is often a road untraveled. This speaks to the notion of necessary prison reform and perhaps the need to introduce evidenced-based sentencing as a pretrial alternative. Based on statistics collectively provided by the National Institute of Justice (1984) and Carson and Sabol (2012), between 1980 and 2011 the national incarceration rate has increased 397%.1 Absent the obvious reasons for incarceration, there are many factors that contribute to the colossal increase of incarcerated individuals, but according to Brinkley-Rubenstein, they are challenging to identify. This commentary will focus on DUI offenders and how the pretrial sentencing process potentially impacts health. Newly written and adopted prison reform in Delaware has birthed a framework for rendering bail decisions for most criminal offenses, including DUI charges. The matrix utilized, The DELPAT (Delaware Pretrial Assessment Tool) is a guideline tool used to set bail based on history of failure to appear for court and expected future recidivism. Use of the bail decision model is intended to reduce the “unnecessary pretrial incarceration of defendants who do not have sufficient means to pay money bail”. The model further “reduces potential loss of employment, the pressure to plead guilty, the economic toll on non-affluent defendants and their families, and other substantial harm that results from excessive use of money bail” (Chief Justice C. Seitz on Bail Reform Act - adopted by DE General Assembly on the 13th of December 2018).2 Public safety remains a weighted factor. Often, DUI offenders are ordered to pay a secured money bail, which means detainment within a correctional institution in the absence of posting bail for release. In many cases, pretrial incarceration causes a snowball effect. The DUI offender will experience loss of employment and pay, which can create a potential hardship for the offender’s family, in addition to them bearing future court costs. Using a heuristic lens, the economic position of the offender is potentially disturbed, perpetuating a downward spiral in their mental health status, and eventually triggering relapses of overindulgence and/or irresponsible consumption of alcohol, while awaiting an arraignment or preliminary hearing. The likelihood of DUI offenders living with 10 Delaware Journal of Public Health – November 2020

psychosocial issues and co-occurring disorders that exacerbate use is not uncommon and is particularly prevalent amongst military veteran offenders. The State of Delaware houses the first statewide veterans’ treatment program in the country. The program firmly stands on the following premise: “Stressful combat duty in Iraq and Afghanistan do not necessarily end for veterans after they return home. Many return with post-traumatic stress syndrome or other mental health issues. In addition, there may be drug or alcohol abuse caused or exacerbated by their military service. Now home, they may have difficulty with readjustment to civilian life and become involved in criminal activity. The U.S. Department of Justice estimates that approximately 10% of adults arrested have served in the military”.3 Presently in the lower court, the judicial system inherently overlooks the causally related factors impacting recidivism for DUI offenders. The responsibility of the Magistrate Judge is to fairly and impartially make pretrial decisions in the interest of public safety, and to minimize the risk of re-offending. The root cause of the addiction is not addressed at this level and substance abuse interventions are not imposed during pretrial, unless ‘clear and convincing’ evidence of the need for treatment/intervention is a valid claim proffered by the sitting judge. The prison walls, while unmoved in expansion, are forced to house non-convicted offenders awaiting adjudication, substantially adding weight to the systemic issue of overcrowded prisons as described by Brinkley-Rubenstein.1 According to Brinkley-Rubenstein’s article “Incarceration as a catalyst for worsening health”, research over time demonstrates the seismic increase in federal prisons due to stricter and mandatory sentencing for drug offenders compared to a rise in criminal offenses committed.4,5 In other words, an increase in the number of federal prisons is not tied to an increase in criminal behavior; rather, it is more directly tied to changes in sentencing guidelines. Often, following adjudication of DUI cases in the higher court, sentence orders might include treatment, such as in-prison programs like Reflections, to be completed during the sentence term. The Reflections program is a direct result of 2011 legislation, developed to strengthen consequences of DUI entanglement. At its core, the program fosters the belief that DUI offenders should realize that responsible use of alcohol trumps driving a vehicle under the influence. Further, participants are forced to face individual personal stimuli or factors that affect overindulgence, such as existing mental health issues.6 What remains problematic and counterproductive is that, depending on staffing and space, inmates are waitlisted indefinitely, and

possibly untreated prior to a release date. Unsurprisingly, the mental health issue(s) is simply not addressed. This ultimately decreases the likelihood of successful community reintegration for the DUI offender. The construct of the pretrial sentencing phase is critical to tangible court outcomes and offender success. A prevailing problem that undermines sound judicial decision-making is the element that causes systemic contradictions…implicit bias. When use of boiler plate orders for secured bail are made in DUI cases, without viable pretrial possibilities for intervention and due to predisposition of DUI offenders, the system overtly crafts a re-cycle of systemic bias. Shaking a finger at “the deviant,” metaphorically speaking, is for naught, if the deviant behavior is not causally and effectively addressed. Overall, nonspecialty court judges reasonably would not be armed with the technical knowledge to evaluate addiction, relapses, and appropriate intervention, as would other specialty court settings. A possible solution to this problem is DUI Court, a form of Community Court. Community courts or problem-solving courts around the country are court venues driven to address “quality of life or nuisance cases, and to take a more proactive approach to public safety.”7 Problem-solving courts further seek to address the underlying problems of criminal offenses and deviant behavior, by casting a net to involve community stakeholders, public health officials, law enforcement, social service agencies, and faith-based organizations to realize offender success and reduce recidivism. Shaping of this court concept through funding and community/ stakeholder involvement is necessary to advance transformation of court outcomes for offenders with underlying issues that attribute to criminal behavior. The subjective thought behind the creation of this DUI Court model is to form a problemsolving court, to handle and manage DUI cases at the pretrial sentencing phase, and to provide intervention upon arrest rather than immediate imposition of money bail/non-money bail and detention in a correctional facility. The overall intent of the DUI Court as described by the California Judicial Branch website is “to provide individualized treatment and supervision to defendants with repeat DUI or DWI charges.”8 DUI courts are designed to provide an alternative to a traditional method of incarceration through a system of supervision, accountability, and rehabilitative treatment. Studies on incarceration and health show incongruent results of rehabilitation caused by the stress prison culture, environment, and/or conditions offer. DUI-related incarceration is, formidably, a catalyst to decline in health. In conjunction, adding courtordered treatment to the pallet of an existing chaotic penal structure, coupled with existing issues of offender mental health conditions, such as PTSD or anxiety, is highly problematic; and offering zero pretrial intervention to a DUI offender, who may lose basic life necessities due to incarceration and further intensify symptoms of his or her addiction and may possibly be subject to homelessness upon release, for example, is equally questionable. The prison system, in many cases, is not an institution of rehabilitation, but an agent of socialization that precipitates further dysfunction (e.g. when an inmate is ordered

in-prison intervention, and upon completion of a sentence, has not received treatment). The result upon release and reintegration is not rehabilitation, but either an existing thirst for what is familiar or fear of reincarceration; perhaps unaddressed psychosocial issues, untreated physical conditions, and/or newly developed physical health problems, socially ineptness, and diminished financial health. Amidst the opioid epidemic, alcoholism and drug addiction are pervasive problems in the U.S. The prison facilities are overwhelmingly crowded with offenders of every kind, including felony DUI offenders serving mandatory sentences, and DUI offenders serving pretrial sentences because they are not equipped financially to post bail. Fiscal planning, appropriation of funds, stakeholder involvement, and grant funding are core to the development of an effective DUI Court model. The National Center for DWI Courts (NCDC)9 provides a framework for the development of these types of courts and is aligned with the success of Drug Treatment courts (NADCP) National Association of Drug Court Professionals. Confronting addiction at the onset of identification, in the pretrial phase, is critical to achieving positive health outcomes for the offender. The idea is to implement least restrictive pretrial sentencing in order to promote treatment while awaiting adjudication, as well as alignment with higher court convictions and evidence-based sentencing. Correspondence: The Honorable Nicole Alston-Jackson, Nicole.jackson@delaware.gov

REFERENCES 1. Brinkley-Rubinstein, L. (2013). Incarceration as a catalyst for worsening health. Health & Justice, 1, 3. https://doi. org/10.1186/2194-7899-1-3 2. Code, D. (2018). Title 11, Chapter 21: Bail Reform Act. Retrieved from: https://delcode.delaware.gov/title11/c021/index.shtml 3. Courts, D. (n.d.). Veterans Treatment Court. Retrieved from: https://courts.delaware.gov/superior/veteranscourt/ 4. Mauer, M., & Chesney-Lind, M. (Eds.). (2002, Jan). Invisible punishment: The collateral consequences of mass imprisonment. The New Press. 5. Wacquant, L. (2010, May). Crafting the neoliberal state: Workfare, prisonfare, and social insecurity. Sociological Forum, 25(2), 197–220. https://doi.org/10.1111/j.1573-7861.2010.01173.x 6. Parra, E. (2014, May). DUI program teaches coping for alcoholics. The News Journal. Retrieved from: https://www. delawareonline.com/story/news/local/2014/05/10/dui-programteaches-coping-alcoholics/8957087/ 7. National Center for State Courts. (n.d.) Community Courts. Retrieved from: https://www.ncsc.org/topics/alternative-dockets/ problem-solving-courts/community-courts/resource-guide 8. Courts, C. (n.d.). What is a DUI/DWI court? Retrieved from: https://www.courts.ca.gov/5980.htm 9. National Center for DWI Courts. (n.d.). About. Retrieved from: https://www.dwicourts.org/ 11

Repeated, Ongoing, and Systemic Incidents of Racism and their Harmful Mental Health Effects: Addressing Trauma in the Lives of African Americans Kimeu W. Boynton, J.D. Assistant Professor, Sociology and Criminal Justice, Delaware State University

INTRODUCTION Trauma is any event or experience which threatens one’s physical or psychological well-being, including the ability to cope.1 Defining trauma has typically involved studying war veterans, holocaust survivors, and victims of sexual and domestic violence.2 While this definition is important and sheds light on issues related to traumatic events, it does not necessarily include repeated and ongoing incidents involving racism and disparate treatment faced by African Americans in their daily lives. The definition itself is too vague and lacks the cultural factors and nuances needed to account for generational trauma that has resulted from centuries of racialized social and legal practices, like slavery and segregation. These nuances show themselves in the daily lives of African Americans and are passed down over generations to ensure survival and safety. As scholars have written of the generational trauma experienced by descendants of Native Americans and Holocaust survivors, it follows that African Americans would fit the same paradigm: displacement, involuntary social disruption, family separation and substandard living conditions.1 Academic and clinical studies involving the mental health effects of disparate treatment and racial trauma are an emerging, but highly necessary, discipline. Traumatic events can be both real and perceived and do not necessarily have to involve direct affect.3

HISTORICAL ANALYSIS Discrimination has historically been defined as some form of disparate treatment of similarly situated individuals, especially where race, gender or class may offer distinctions between individuals. Racial discrimination has played an enduring and often insurmountable role in conflicts throughout American history. Since colonists and enslaved persons landed in Jamestown, Virginia in 1619, racism and disparate treatment of African Americans has been both a de jure and de facto part of American society. Racial discrimination has been recognized by psychological professionals as having a traumatic effect on members of minority groups.3 In particular, African Americans have been the focus of hundreds of years of brutal chattel slavery, discriminatory legal practices and socioeconomic marginalization. Racial trauma associated with discrimination in general is detrimental to the psyche of African Americans and perhaps may have damaging effects on their White counterparts as well. It should be noted that Dr. Martin Luther King, Jr. gave a speech at the American Psychological Association’s annual convention in 1967, outlining the role psychologists could play in addressing the ills of racial discrimination.4 He spoke of the need to have 12 Delaware Journal of Public Health – November 2020

social scientists and psychologists address racial discrimination, specifically invoking the riots of the 1960s as examples of African American responses to conditions that impacted their everyday lives in American society. He further went on to discuss maladjustment, a psychological term, as one’s inability to adjust to racial segregation and discrimination. With King’s foresight in mind and the continued law enforcement incidents that have garnered national media attention and sparked protest movements throughout the country, the overwhelming feelings by some is that little, if any progress has been made for many African Americans. Addressing trauma and post-traumatic stress disorder (PTSD) symptoms experienced by African Americans must be an integral part of any proposed policy solutions. Moreover, recommendations and legal remedies must address what has been and should be considered an ongoing public health issue. According to Alsan, Wanamaker, and Hardeman, peripheral trauma can result from racially charged events.5 Their study of the Tuskegee Syphilis experiments, an act of targeted racial injustice, shows potential health implications for individuals not directly affected by the event. This peripheral trauma can occur in African Americans, as they are likely to be familiar with events by which they may not be directly affected. The authors studied all-cause mortality rates for African American men between 1968 and 1987. They found that the all-cause mortality rates increased after the Tuskegee study ended in 1972. Moreover, the all-cause mortality rates were higher for African American men living closer to Tuskegee. Similarly, they found a marked decrease in outpatient visits for African American men between 1973 and 1977; impacting higher geographically closer to Tuskegee, AL. Other examples of peripheral trauma may include seeing historical images of brutal tactics used by Whites during the civil rights movement or learning about the cruel and inhumane conditions of the southern plantation system during slavery. One need not have been directly affected to absorb the trauma associated with such events. Transmission of trauma across generations is one example of how peripheral trauma affects individuals.6 Survivors of traumatic events, such as the Holocaust, may develop PTSD and affect the mental health of their offspring.7 The terror attacks of September 11, 2001 and their aftermath are an analogous example of how peripheral trauma can occur. While the vast majority of Americans were not directly affected by the attacks, there was a clear nationwide reaction both on the day of the attacks and for many months after. Palpable fear and a lack of feeling safe were present in communities far removed from New York, Virginia, and Pennsylvania. Police interaction in disadvantaged and minority communities have long been fraught with racial animus and have created the

perfect petri dishes for trauma to be experienced by African Americans. The 1968 Kerner Commission Report8 on Civil Disorders found that riots during the 1960s took place in the aftermath of confrontations between police and community members and were not the result of African American anger, but the natural response to White racism that led to frustrations on the part of African Americans. The report made broad policy and legal recommendations to improve police and community relations, including the curtailing of indiscriminate stops and searches, physical and verbal abuse, and reassigning officers who had bad reputations with community residents. Interestingly enough, the report also made recommendations that addressed housing, education, and employment. It seems that the authors of the report were right on the cusp of recognizing the factors that lead to disadvantaged people creating survival tactics to deal with the everyday traumas of a racialized caste system, sanctioned by governmental authority. Unfortunately, the recommendations made in the Kerner Commission Report have been largely ignored over the past 50 plus years. This willful ignorance has perpetuated extrajudicial law enforcement interactions with African Americans, albeit captured on cameras for public viewing. But more importantly, it has exacerbated the tensions, distrust and attitudes held by African Americans toward the police. The contemporaneous issues of police killings and brutality toward African American bodies is the re-traumatizing of events the report hoped to address.

DISCUSSION The Diagnostic and Statistical Manual of Mental Disorders (DSM)9 addresses various traumas that may lead to healthy and unhealthy recovery and in many cases negative recovery and PTSD. Negative recovery can include the inability to control emotions in stressful situations, use of drugs or alcohol to suppress emotions and memories, and engaging in risky or promiscuous behavior. Equally troubling however is the fact that negative recovery may result in an individual becoming numb to situations of repeated stress and trauma. The DSM does not address racial discrimination as a trauma, nor does it outline how racial discrimination plays a role in creating conditions that could lead to PTSD. Systemic discrimination and incidents of racism faced by African Americans has historically been viewed as too trivial or not catastrophic enough to justify a PTSD diagnosis.10 Similarly, the most recent editions of the DSM offer some insight into the way culture may affect experiences of trauma, but it still does not specifically address trauma faced by specific members of minority groups.11 In order to understand the farreaching traumatic impact of racism on African Americans, the conversation must include the historical wrongs visited against them, the impact of peripheral trauma, and how the impact of these phenomena should probably be viewed as ongoing and systemic. Historical examples of disparate treatment can have far reaching traumatic effects from a peripheral viewpoint as previously mentioned. African American fathers and mothers have had “the talk” with their children as a primer on how to conduct oneself when interacting with the world outside of one’s home, and especially when interacting with law enforcement. The talk is a reaction to previous trauma and though not real to the child, can thereby be perceived trauma that can be adopted by the child. African American parents resort to racial socialization to

communicate racial experiences to their children, thereby hoping to pass on coping mechanisms to African American children who are likely to face discriminatory racial encounters.12 Additionally, research done by Jackson et al. showed an association between racial and gendered stressors and antenatal depressive symptoms in expectant African American mothers in the Atlanta area.13 The publicized violent police interactions between African Americans and police directly affected the mothers’ need to protect their children from anticipated negative police interactions. This type of anticipated interaction is a clear example of reaction to trauma. Geller et al., suggest a causal link between aggressive police practices and subsequent effects on the mental health of young men in New York City.14 The authors’ results show a disturbing pattern that is all too evident in disadvantaged communities. Young men who were frequently the target of stop and frisk and other aggressive practices displayed higher levels of anxiety and trauma after such contacts. These aggressive police practices were implemented to target high crime areas, but lead to compromised mental health outcomes for young men who had intrusive police contacts.14 The stop and frisk tactics, given legal weight by the Supreme Court decision in Terry v. Ohio,15 have become common place in many cities and neighborhoods heavily populated by people of color. These tactics have also lead to serious tension between police and community stakeholders. Media representations and sensationalization of these activities, combined with racism and underlying biases, contributed to perceptions by Whites that African Americans must be policed in a fashion akin to wartime occupation and, like societies at war, trauma and PTSD are natural manifestations. As previously mentioned, trauma can be both real and perceived. According to Smith, racial trauma takes three forms for African Americans: directly experiencing racist events that lead to physical, psychological or emotional injury (violence, social profiling, false allegations of crime, etc.) that have a traumatic effect, witnessing events that have racial overtones, and living in or under difficult conditions as a result of race or poverty.3 The traumas associated with such experiences may not always fit the classic definition outlined in the DSM, but they have all of the elements that lead to compromised mental health outcomes. Furthermore, one’s ability to cope after experiencing traumatic events is directly related to the status of one’s mental health and their ability to cope. However, the coping mechanisms may be stifled by repeated and systemic traumas related to race and discriminatory encounters. Henderson found that African American youth in Washington, DC had a hard time conceptualizing trauma, even though their shared experiences fit all of the elements defined in the DSM.11 The author of the study purports that cultural beliefs helped form the perspectives that African American youth use to define trauma. Because the DSM lacked any real analysis of cultural factors, specifically those related to African Americans, assessment of trauma is extremely limited from a traditional westernized viewpoint. Much of their trauma related to experiences, real and perceived, that were tied to feelings of being stuck in socioeconomically bad conditions, living in violent and disadvantaged neighborhoods, death, and harassment by law enforcement.11 Lack of effective coping mechanisms or the prolonged hyper vigilance involved in living under racist conditions can have a detrimental effect on one’s health outcomes.16 13

Other studies have shown how police killings of and violent encounters with African Americans can detrimentally affect the health of adolescents. Specifically, Staggers-Hakim tied national police brutality cases and extrajudicial killings to the social and mental well-being of African American boys.17 Though African Americans account for 13.4% of the U.S. population, they are proportionately over-represented in cases involving deadly force by law enforcement. For example, African Americans are three times more likely to be killed by police than other ethnic groups and are more likely to be unarmed during these deadly encounters.17,18 The suggestion that racism can play a major role in the mental health outcomes is bolstered by the fact that feelings of hopelessness occur when there is a belief that “it could happen to me.” Moreover, these feelings may become aggravated by the fact that many of the nationally televised police brutality cases rarely result in accountability for the officers or departments that commit them. Law enforcement agencies in the state of Delaware are not immune from the current crises affecting African Americans in other parts of the country. A recent report from the U.S. Commission on Civil Rights highlights some of the issues related to implicit bias, aggressive police tactics and unfair treatment of African Americans by Wilmington, DE Police.19 While the City of Wilmington mirrors many urban areas that contend with issues of poverty, crime, unemployment and other socioeconomic ills, its African American citizens have routinely complained of aggressive tactics and mistrust of the police. Crime control strategies -- vestiges of the War on Drugs -- were routinely employed by Wilmington Police officers. Residents routinely complained of being stopped and searched for no reason other than “walking while Black.” Residents also described police as militarized and lacking in cultural awareness. These strategies and attitudes are the breeding ground for distrust and can lead to trauma development. A glaring example of this type of policing strategy involved local police in Kent County, Delaware arresting 22 individuals, “The Camden 22,” on June 9, 2020 for protesting the killing of George Floyd in Minneapolis, Minnesota.20 An African American photojournalist working for a local newspaper, well known in the community for covering news events and displaying full press credentials, was arrested along with those protesting. He stated that he was with the press multiple times, but his statements were ignored. Did local law enforcement simply see an African American male and not a journalist exercising his first amendment right to cover a newsworthy event? Notably, all charges were dropped against the protesters and the journalist and Governor Carney tweeted that journalists should not be arrested for doing their jobs. Implicit biases create situations that foment racial tensions. These tensions quickly turn into trauma for residents who must navigate their surroundings, knowing that racial issues are always just below the surface of their everyday lives.

RECOMMENDATIONS Racial trauma is real and should be treated like any other trauma that can lead to PTSD. Continual reminders of traumatic racial events from the media, real and perceived racial events in the lives of individuals, and living conditions that promote racial caste systems are the key indicators that trauma can and will 14 Delaware Journal of Public Health – November 2020

occur. Mental health practitioners must understand that racism is the pathology of a system that affects the lives of minority members of society on an almost daily basis. With that in mind, practitioners can employ many of the same practices used to treat individuals who have developed PTSD as a result of combat, through family or sexual violence, or other forms of traumatic life events. It is important to note that in assisting individuals with PTSD, one must not bring one’s own biases into treatment. Because of past historical events, African Americans may be skeptical of clinical treatment practices. Alternative treatments must include culturally sensitive approaches such as utilizing therapists who have a clear understanding of institutionalized racism, ethnoviolence and microagressions. Perhaps engagement with African American therapists could aid in the sharing of experiences and breakdown the mistrust that some clients may harbor toward psychological treatment. Lastly, alternative treatments may include yoga, meditation or other physical practices, as they have been successful in reducing stress and tension.21 In responding to individuals with traumatic racial experiences in their backgrounds, seek out ways to help them with healthy recovery and coping development. Ensure that they do not become numb to their experiences or develop a sense of hopelessness and despair. The literature has shown that many individuals that experience traumatic events can and do recover in healthy ways. For example, many individuals learn from traumatic experiences and become better at managing themselves when confronted with similar threats in the future. They also develop coping skills that assist them in responding to future events. However, if we consider the abovementioned issues of repeated and systemic racial trauma experienced by African Americans, the odds of good recovery go down exponentially. The recovery phase is likely to include increased vigilance, aggression, PTSD, physiological symptoms, and abuse of intoxicants,3 all of which result in an increased likelihood that the individual will be revictimized. The key to successful recovery is improved function for the affected individual. Since African Americans are more likely to experience PTSD as a result of ongoing traumatic events, multiple stakeholders need to address the treatment factors for members of this group. Institutions (schools, state and local government, etc.), law enforcement, health systems and community members can act holistically to intervene and prevent ongoing trauma.22 Lastly and perhaps most importantly, law enforcement agencies, with the assistance of the federal government, need to revamp policing practices and build trust with the communities they are tasked with “protecting and serving.” Simply holding rogue officers accountable for bad acts would ease years of tension and trauma built up in African American communities. Employing training methods that emphasize de-escalation and crisis intervention would serve police and communities well. Combatting implicit bias, recruiting officers from within urban communities, and removing the stigma of police as militarized occupying forces would do much to build trust in minority communities as well.

CONCLUSION No single approach to combatting racial trauma will work effectively. Institutions must begin by recognizing the facets

of their practices which adversely affect African Americans and other people of color. Once a thorough recognition and acknowledgement is made, healing for individuals dealing with ongoing trauma can begin. They will no longer see themselves as outsiders or the lowest members of a racial caste system. Above all, as this issue has the immediate effect of creating deadly consequences, law enforcement agencies must begin to rethink how their personnel police communities of color. Implicit bias creates trauma and though existent in all individuals, must be curtailed in law enforcement personnel. Racial trauma must be viewed as a legitimate form of mental health ailment and should be dealt with using valid and proven treatment mechanisms.

REFERENCES 1. Williams-Washington, K. N., & Mills, C. P. (2018). African American historical trauma: Creating an inclusive measure. Journal of Multicultural Counseling and Development, 46(4), 246–263. https://doi.org/10.1002/jmcd.12113 2. Herman, J. L. (1997). Trauma and recovery. Basic Books. 3. Smith, W. (2010). The Impact of Racial Trauma on African Americans. Retrieved from: https://www.heinz.org/userfiles/impactofracialtraumaonafricanamericans.pdf 4. Farley, F. (2013). M. L. King Jr.’s Visit with Psychology. Psychology Today. Retrieved from: https://www.psychologytoday.com/us/blog/the-peoplesprofessor/201301/mlking-jrs-visit-psychology-1 5. Alsan, M., Wanamaker, M., & Hardeman, R. R. (2020, January). The Tuskegee study of untreated syphilis: A case study in peripheral trauma with implications for health professionals. Journal of General Internal Medicine, 35(1), 322–325. https://doi.org/10.1007/s11606-019-05309-8 6. Fonagy, P. (1999, April). The transgenerational transmission of holocaust trauma. Lessons learned from the analysis of an adolescent with obsessive-compulsive disorder. Attachment & Human Development, 1(1), 92–114. https://doi.org/10.1080/14616739900134041 7. Dashorst, P., Mooren, T. M., Kleber, R. J., de Jong, P. J., & Huntjens, R. J. C. (2019, August 30). Intergenerational consequences of the Holocaust on offspring mental health: A systematic review of associated factors and mechanisms. European Journal of Psychotraumatology, 10(1), 1654065. https://doi.org/10.1080/20008198.2019.1654065 8. U.S. National Advisory Commission on Civil Disorders. (1968). Report of the National Advisory Commission on Civil Disorders. https://belonging.berkeley.edu/1968-kerner-commission-report 9. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 10. Butts, H. F. (2002). The black mask of humanity: Racial/ ethnic discrimination and post-traumatic stress disorder. The Journal of the American Academy of Psychiatry and the Law, 30(3), 336–339.

11. Henderson, Z. (2019, June 30). In their own words: How Black teens define trauma. Journal of Child & Adolescent Trauma, 12(1), 141–151. https://doi.org/10.1007/s40653-017-0168-6 12. Anderson, R. E., & Stevenson, H. C. (2019, January). RECASTing racial stress and trauma: Theorizing the healing potential of racial socialization in families. The American Psychologist, 74(1), 63–75. https://doi.org/10.1037/amp0000392 13. Jackson, F. M., James, S. A., Owens, T. C., & Bryan, A. F. (2017, April). Anticipated negative police-youth encounters and depressive symptoms among pregnant African American women: A brief report. J Urban Health, 94(2), 259–265. https://doi.org/10.1007/s11524-017-0136-3 14. Geller, A., Fagan, J., Tyler, T., & Link, B. G. (2014, December). Aggressive policing and the mental health of young urban men. American Journal of Public Health, 104(12), 2321–2327. https://doi.org/10.2105/AJPH.2014.302046 15. Terry v. Ohio, 392 U.S. 1 (1968) Retrieved from: https://www.law.cornell.edu/supremecourt/text/392/1 16. Sewell, A. A., & Jefferson, K. A. (2016, April). Collateral damage: The health effects of invasive police encounters in New York City. J Urban Health, 93(1, S1), 42–67. Retrieved from: https://doi-org.desu.idm.oclc.org/10.1007/s11524-015-0016-7 https://doi.org/10.1007/s11524-015-0016-7 17. Staggers-Hakim, R. (2016). The nation’s unprotected children and the ghost of mike brown, or the impact of national police killings on the health and social development of African American boys. Journal of Human Behavior in the Social Environment, 26(3-4), 390–399. https://doi.org/10.1080/10911359.2015.1132864 18. Johnson, K., Hoyer, M., & Heath, B. (2014, August 15). Local police involved in 400 killings per year. USA Today News. Retrieved from: http://www.usatoday.com/story/news/nation/2014/08/14/policekillings-data/14060357/ 19. U.S. Commission on Civil Rights. (2020). Implicit Bias and Policing in Communities of Color in Delaware. Retrieved from: https://www.usccr.gov/pubs/2020/01-22-DE-Implicit-Bias-PolicingReport.pdf 20. Update on charges: Dover Post reporter released after what police describe as a disorderly protest led to 22 arrests. (2020, June 9). Delaware Business Now. Retrieved from: https://delawarebusinessnow.com/2020/06/reporter-photographerarrested-by-state-police-in-camden-area/ 21. Parekh, P. N. (2011, September) From Murder to Meditation. Khabar. Retrieved from: http://www.khabar.com/magazine/cover-story/from_murder_to_ meditation 22. Graham, P. W., Yaros, A., Lowe, A., & McDaniel, M. S. (2017, June). Nurturing environments for boys and men of color with trauma exposure. Clinical Child and Family Psychology Review, 20(2), 105–116. https://doi.org/10.1007/s10567-017-0241-6 15

Red, White, and Bruised: How Systemic Racism Emotionally and Physically Bruises Black People in America. In the wake of George Floyd’s death by Minnesota cop Derek Chauvin on May 25, activists rallied against racial inequality.

An activist holds a Black Lives Matter sign in the middle of Route 13, while a protester behind her is car surfing.

A trio of Black and White protesters march on the highway with their fists raised in solidarity.

16 Delaware Journal of Public Health – November 2020

In Dover on May 31, hordes of protesters completely took over Route 13, marching with signs and heavy hearts in our Capital City.

Dover Police Station became a destination for a demonstration on May 31, where passionate activists filled the precinct’s steps, raising their voices against police brutality.

With traffic stalled, some protesters briefly marched against on-coming vehicles to spread their message of racial equality. Police eventually re-directed motorists in order to make it safe for protestors to continue marching on the opposite side of the highway.

Images provided by Andre Lamar.

Marching toward the highway, young women stand in the street against racial injustice in downtown Dover. 17

Structural Racism as a Fundamental Cause of Health Inequities in Delaware and Beyond: What does the Evidence Say? Cassandra Codes-Johnson, M.P.A. Associate Deputy Director, Division of Public Health, Delaware Department of Health and Social Services

INTRODUCTION Health inequities are described as differences in health among different groups of people. These are well documented, persistent, and even increasing for some health conditions across the U.S., including in Delaware (DE). Health inequities may be viewed in the context of race, gender, sexual orientation, income, education level, disability status, or geographic location, among others. Further, when it comes to health, the oppressions associated with each of these statuses can yield compounding negative health effects based on their identity or class (e.g., “female” and “immigrant”). Because these are socially constructed categories related to social hierarchy, and related differences in health do not derive from biology or genetics, experts consider such health differences to be socially produced. As such, we can conclude that “health inequities are not only unnecessary and avoidable, but in addition, are considered unfair and unjust.”1 People of color in the U.S. experience some of the most pervasive and persistent heath inequities in our country. While it is important to recognize, examine and address health inequities that exist across various racial and ethnic groups, including Native people, Latinxs, and others, the historical context of slavery and persistent oppression among Black individuals in the U.S. warrants particular focus. This paper highlights the magnitude of health inequities experienced by Blacks in the U.S. and in Delaware. It defines structural racism, and provides an overview of the scientific literature regarding the role of structural racism in creating and perpetuating racial health inequities, with a particular focus on residential segregation, mass incarceration and implicit bias within the healthcare system. Much of its content is drawn from a policy brief, titled Structural Racism as a Fundamental Cause of Health Inequities2 produced jointly by the Division of Public Health, Delaware Department of Health and Social Services (DHSS) and the University of Delaware, Partnership for Healthy Communities; and the Health Equity Guide for Public Health Practitioners and Partners3 published by the Division of Public Health, DHSS.


18 Delaware Journal of Public Health – November 2020

MAGNITUDE OF RACIAL HEALTH INEQUITIES Life expectancy and infant mortality are two of the biggest indicators considered in evaluating the overall health of a population. Using those two factors as a snapshot, one can get a sense of the magnitude of health inequities experienced by Black individuals in the U.S. Figure 1 highlights that while infant mortality rates have fallen among all racial and ethnic groups since 2000, the gap between groups persists, with Black, nonHispanic women experiencing an infant mortality rate of 10.9 deaths per 1000 live births in 2014, compared with a rate of 4.9 per 1000 among White, non-Hispanic women. Another way to look at the inequity in infant mortality is to examine the ratio of infant deaths across racial groups. Figure 2 highlights how this ratio (i.e. Black infant mortality divided by White infant mortality) has changed over the past 80 years. As seen in this figure, the Black-White infant mortality ratio reached a low of approximately 1.5 in 1948 and stayed below 2.0 prior to the mid-1980s, when it began to climb steadily until reaching a peak over 2.5 in 2000. This Black-White ratio has remained well above 2.0 in recent years and the most recent data from the Centers for Disease Control and Prevention indicate that the infant mortality rate for Black mothers is 2.3 times that of White mothers in the U.S. Health inequities experienced by Black individuals in the U.S. can also be seen in terms of life expectancy. Despite recent progress, especially among Black males, the gap in life expectancy between Blacks and Whites was still 3.4 years in 2015.4 Further, a recent analysis of health status and outcome measures across different racial and ethnic groups found that Blacks fared worse than Whites on 24

Figure 2. Infant mortality rate by race, US, 1935-2015

out of 29 indicators, including rates of asthma, diabetes, heart disease, HIV, and cancer.5 Among these findings is evidence that Black children also have higher rates of asthma, teen pregnancy, and obesity. Growing data and evidence are pointing to structural racism as being a root cause for persistent health inequities experienced by Black individuals in the U.S.

Figure 3. Social Determinants of Health

STRUCTURAL RACISM Racism is a complex social phenomenon that can be defined in many ways and is expressed on different levels. It involves individual and collective attitudes, actions, processes and unequal power relations.6 On an individual level, racism can be expressed as intentional or unintentional acts of commission or omission, based on assumptions that one race is superior to another. For example, a restaurant owner who refuses to serve a Black patron is committing an intentional act of racism, while a doctor who neglects to recommend the same surgery for a Black patient that is recommended for a White patient with identical symptoms may be unintentionally committing an act of omission. On an individual level, racism may also be internalized, such that members of a stigmatized race accept negative messages about their own abilities and intrinsic worth.7 Internal racism may be expressed by Black individuals dropping out of school or referring to themselves using negative stereotypes. Institutional or systemic racism can be defined as differential access to the goods, services and opportunities of society by race, which is often codified in our institutions as customary practice or even law.7 The historic practice of redlining, such that Blacks were systematically denied mortgages in certain neighborhoods, or charged higher insurance premiums, are expressions of institutional racism. A subtler, but potentially just as serious, form of institutional racism may be seen in the content of public school curricula, or images in the media, that are biased towards the culture and experiences of the majority population. Institutional racism in one area or sector may reinforce or interact with racism in another, such as the ways in which discrimination in housing perpetuates problems with underfunded schools and limited educational opportunities for Black children living in segregated neighborhoods.8 Institutional racism is interconnected with individual forms of racism and often serves to reinforce discriminatory beliefs and values. For this reason, the concept of structural racism has been suggested as a way to reflect the “totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, healthcare and criminal justice”.9 Structural racism can be described as: “A system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity. It identifies dimensions of our history and culture that have allowed privileges associated with ‘whiteness’ and disadvantages associated with ‘color’ to endure and adapt over time.”10 Conceptually, we can think about this definition of structural racism in the context of the determinants of health model presented in Figure 3. This “rainbow” figure is frequently used to describe the social determinants of health. The model highlights levels of influence, with the most distal factor -- the prevailing socioeconomic and cultural conditions -- as the very structure of society in which

each of the other levels function. The model puts living and working conditions, such as housing and education, within the context of these societal structures, suggesting that they are not naturally occurring conditions. Rather, living and working conditions come about as a result of overall societal structure, culture, and both historic and current public policies. Data suggest that living and working conditions are not inevitable; they are amenable to change. The model also highlights the fact that individual behavior and lifestyle choices are made within the context of one’s social and community networks as well as the broader environment. In thinking about health inequities, we can see how negative aspects of living and working conditions in Black communities are largely the result of structural racism, where historical and contemporary policies, practices, beliefs, and attitudes have resulted in an unequal distribution of resources across communities. More specifically, structural racism has led to many Black neighborhoods being characterized by a lack of employment opportunities, underfunded public schools, substandard housing, inadequate access to health insurance and health care, and lack of greenspace and recreational opportunities, as well as high concentrations of poverty, pollution, and violence — all of which threaten health directly and indirectly.11 While social networks may be strong and promote health and well-being in communities of color, policies and practices in our criminal justice system disproportionately incarcerate Black men, women and children, with direct health impacts on those who are incarcerated and potentially dismantling what would have otherwise been strong social support and community networks.12,13 In addition, the stress of racial discrimination is associated with coping behaviors that are detrimental to health, such as smoking, alcohol, and drug use.11 Ongoing stress associated with racism can also have direct physiological impacts on the body (i.e. allostatic load) and is associated with mental health problems such as anxiety and depression.11 Black Americans are more likely to die from cancer and heart disease than White Americans, and are at greater risk for the onset of diabetes.14 These negative influences and exposures can accumulate over time and across generations.9 An understanding of how structural racism shapes the determinants of health for Black communities leads us to conclude that structural racism is a fundamental cause of health inequities for these populations.7,15 19

RESIDENTIAL SEGREGATION “Residential segregation is a foundation of structural racism.”9 Residential segregation is the physical or spatial separation of two or more social groups within a geographic area. It is a fact of history in the U.S. and is long identified as the root of many social and racial inequities in American cities. While different racial and ethnic groups and immigrants have experienced segregation in the U.S., Blacks have been victims of an unparalleled level of deliberate segregation that is perpetuated through individual actions, institutional practices, and public policy.16 Patterns of segregation among Blacks in the U.S. remain the highest across all racial/ethnic groups.17 According to Dr. David Williams, a leading scholar on racism and health, “the single most important policy that continues to have pervasive adverse effects on the socioeconomic status and the health of African Americans is residential segregation.”18 Further, residents of segregated neighborhoods continue to be politically alienated and lack power such that conditions often remain entrenched.19 Segregation is a contemporary problem that persists in the U.S., despite the myth of integration.20 While the latter half of the 20th century saw an end to explicit policies aimed at keeping Blacks from White neighborhoods (e.g. the Fair Housing Act of 1968),

“such practices continue to be realized by purportedly colorblind policies that do not explicitly mention ‘race’ but bear racist intent.”9, For a detailed historical analysis of segregation, including its roots in law, public policy, and public and private institutions, and its contemporary manifestations and enduring impacts see A Century of Segregation: Race, Class and Disadvantage by Leland Ware.8 An estimated 176,000 deaths were attributable to racial segregation in the U.S. in 200021 and there is a growing evidence base linking segregation to a range of indicators of the poor health status of Blacks living in segregated communities. Health inequities are “largely a function of the separate and unequal neighborhoods in which most Blacks and Whites reside.”16 Research demonstrates that racial health inequities grounded in segregation are more than a function of diminished socioeconomic status of individuals living in segregated communities, and that health inequities remain even after accounting for income and education levels. Rather, the places themselves and the nature of the social, political, built and physical environments affect health directly and indirectly in myriad ways.9,11,12,22 Figure 4 provides an overview of the pathways through which residential segregation impacts health outcomes with strong supporting evidence.

Figure 4. Pathways and outcomes through which residential segregation harms health.

20 Delaware Journal of Public Health – November 2020

MASS INCARCERATION The rate of incarceration among Blacks is higher than any other sub-population in the U.S.23 Indeed, the incarceration rate among Black men is 3.8 to 10.5 times greater than among White men, depending on the age group. The greatest gap occurs among 1819 year old Black males in this age group. Data showed that this population were more than 10 times more likely to be incarcerated than their White counterparts in 2014.22 These rates translate into nearly one in three Black men being imprisoned in their lifetime.13 Such high rates can be considered mass incarceration, which is defined as historically and comparatively extreme levels of imprisonment that are so heavily concentrated among some groups that incarceration has become a normal stage in the life course.13,24 Mass incarceration obviously affects individuals who are imprisoned, but also has a ripple effect on families and entire communities; nearly half of Black women have a family member who is imprisoned, and a Black child is much more likely to have a father in prison compared with a White child.13 There is strong evidence that the disproportionate rates of incarceration among Black communities are the result of discriminatory policies and practices in the criminal justice system, such as the “War on Drugs” era policies of the 1970s and 1980s.9,25 Further, upon release from jail or prison, existing policies, such as denial of voting rights among those convicted of a felony crime, create barriers for individuals to become fully integrated back into society. Similar to the impacts of historical and persistent segregation, these “ostensibly color-blind policies have criminalized communities of color” and left a lasting legacy of cumulative disadvantage on individuals, families and communities with long-term impacts related to unemployment, low educational attainment, poverty, and violence.9,13,26 Not surprisingly, the high rates of incarceration in Black communities have negative health effects on incarcerated individuals, families, and entire communities. Given the magnitude of those affected by mass incarceration, it is believed to be a contributor to racial health inequities in the U.S. and may even help to explain inequities in health between the U.S. and other developed countries.13 The United States has the highest incarceration rate in the world as of 2018, at 698 prisoners per 100,000 population. Other stable democracies such as United Kingdom, Portugal and Canada all have an incarceration rate less than 150 prisoners per 100,000 population.27 Although there are a number of challenges in researching this topic and drawing conclusions about the nature of causality between incarceration and poor health, there is general consensus among experts that incarceration has strong negative effects on the health of inmates over their lifetime.13 In a comprehensive review of the literature, researchers Wildeman and Wang summarize the evidence: • Ironically, imprisonment may be protective in the short-term, as it provides reduced exposure to some forms of violence, alcohol, and drugs, and improved access to health care; but physical and psychological well-being worsens over time. • Incarcerated individuals have higher rates of many infectious diseases and chronic conditions compared with nonincarcerated individuals. • Family members of incarcerated individuals are negatively affected by impacts of incarceration, including financial hardships (i.e. decreased family earnings), relationship challenges from separation, and reduced social support, stress, and behavioral and mental health problems in children.

• Neighborhoods with high levels of incarceration are associated with poor health indicators at the community level, including high rates of asthma, sexually transmitted diseases, and poor mental health.13 Ultimately, mass incarceration is associated with a range of poor health indicators among those who are imprisoned as well as among their family and community members. The disproportionate incarceration of Black individuals, coupled with the poor health outcomes associated with incarceration, contributes to racial health inequities at the community, state, and national levels. Wildeman and Wang conclude that “the criminal justice system has become an institution — like the education system — that both reflects systematic and institutionalized racism and exacerbates existing inequities.”13

RACISM IN HEALTHCARE In 1999, the U.S. Congress asked the Institute of Medicine (IOM) (now the National Academy of Medicine) to conduct an analysis of potential disparities in the types of care and quality of care received by racial and ethnic minorities within the U.S. health care system. Three years later, the IOM published their findings in the report, Unequal treatment: Confronting racial and ethnic disparities in health care, which was widely considered to be one of the most comprehensive analyses of the topic to date.28 Over the course of nearly 800 pages, the report documents strong evidence from over 100 studies of “remarkably consistent” patterns of racial and ethnic disparities in care for a range of health conditions and types of treatment, which remain even after socioeconomic factors are controlled (e.g. income and insurance status) and even when patients present with the same symptoms, diagnoses, and comorbidities. Various studies within the IOM report highlighted the existence of “implicit” or “unconscious” stereotypes or biases among potentially well-meaning providers that can have significant influence on interactions with patients and contribute to negative outcomes. The report also documents discrimination across systemic or institutional factors, such as the ways in which care is organized and financed that negatively impact access to quality care among racial and ethnic minorities. The authors argued that disparities in care “occur in the context of broader historic and contemporary social and economic inequality, and present evidence of persistent racial and ethnic discrimination in many sectors of American life.” In effect, the report documented structural racism as it relates to the health care system. Over the past 15 years, the federal government has continued to study and document trends in health care disparities in the National Healthcare Quality and Disparities Report that is mandated by Congress. The annual report is produced with the help of an inter-agency workgroup led by the Agency on Health Care Research and Quality (ARHQ) and can be found at https:// www.ahrq.gov/research/findings/nhqrdr/nhqdr17/index.html. The most recent report finds that Blacks experience worse access to care compared with Whites for more than half of the measures used in the analysis.29 While the report concludes that some progress has been made in relation to the quality of care provided to Black patients, disparities remain for approximately 40% of the quality measures. For example, in 2015 the rate of adults with potentially avoidable hospital admissions for hypertension was 170.3 per 100,000 for Blacks, a rate more than five times as high as the rate of 33.9 per 21

100,000 for Whites. The report also reveals that approximately 20% of the quality measures show worsening disparities between Blacks and Whites, including children who visited the emergency department for asthma and a measure of exclusive breastfeeding through three months.27 Numerous studies in the academic literature also document inequities in access and quality of health care grounded in unconscious bias and other discriminatory practices. In a systematic review by Hall and colleagues, the authors conclude that “most health care providers appear to have implicit bias in terms of positive attitudes toward Whites and negative attitudes toward people of color.”30 Although the authors argued for more research to better understand the ways in which such bias contribute to poor outcomes, “there is widespread consensus that health care providers themselves contribute to racial health care inequalities.”28,31

WHITE PRIVILEGE One reason that unconscious or implicit bias may persist in even such a helping profession as health care is due to white privilege. White privilege is defined as “a system of benefits, advantages, and opportunities experienced by White persons in our society simply because of their skin color.”32 It involves greater access to power and resources among White people that are not earned, are unseen, and are often taken for granted. As Collins explains, subtle versions of White privilege can be seen as everyday conveniences that White people do not have to think about.33 For instance, it is difficult to find children’s books written by or about people of color; or when cashing a check, a person of color may worry that their financial credibility could be questioned. Collins explains that these everyday conveniences are privileges associated with the “power of normal,” where White people are more likely to live their daily lives without thinking about their skin color. While these everyday examples may seem benign to some, they reflect larger structural issues related to racism. Further, White privilege extends to other, potentially more impactful areas of everyday life, such as White people portrayed in positive roles on television and in movies; whereas Black people are often portrayed using negative stereo-types.34 This contributes to things like racial profiling and its negative consequences. A sales associate may follow a Black person around a store in suspicion of possible misdeeds, whereas White people do not have to worry that their skin color may influence others’ perceptions of their credibility, honesty, or innocence.35 According to Collins, “This privilege is invisible to many White people because it seems reasonable that a person should be extended compassion as they move through the world. It seems logical that a person should have the chance to prove themselves individually before they are judged. It’s supposedly an American ideal. But it’s a privilege often not granted to people of color.”31 The implications of white privilege are readily seen when it comes to our criminal justice system. White people are less likely to be stopped by police because they looked suspicious, and people of color who are unarmed are still more likely to be killed by police than armed White people.36 White privilege can also help explain why Blacks are treated differently (with negative consequences) in our health care 22 Delaware Journal of Public Health – November 2020

system. In his essay White Privilege in a White Coat, Dr. Max Romano, explains many of the ways in which medical education privileges those with White skin, such as being taught from an early age that White people can become doctors; the ease with which he could find mentors and role models who shared his race; and learning about medical discoveries made by White people, without acknowledging how “many of those discoveries were made through inhumane and non-consensual experimentation on people of color.”37 Such privileges have led to an entire system that is structured to favor White physicians and White patients. According to Romano, “most White doctors do not think race affects them or their clinical decisions… however, multiple studies reinforce the existence of racial bias among physicians and its negative implications for patient care.” Whether it is in relation to everyday conveniences, housing, education, criminal justice, or health care, these myriad privileges are ubiquitous and yet largely unseen. McIntosh likens White privilege to “an invisible weightless knapsack of special provisions, assurances, tools, maps, guides, codebooks, passports, visas, clothes, compasses, emergency gear and blank checks.”38 These privileges accumulate over time and space contributing to the large and persistent gaps in resources and status across racial and ethnic groups in the U.S. And while white privilege is not the same as racism, it exists because of historic and enduring racism. As McIntosh further explains, “white privilege is an invisible package of unearned assets that I can count on cashing in each day, but about which I was ‘meant’ to remain oblivious.” Collins also argues that white privilege is unconsciously enjoyed but consciously perpetuated.31 Acknowledging white privilege does not devalue or ignore individual accomplishments or hard work; but rather draws attention to unearned privileges simply granted due to the color of one’s skin. Acknowledging white privilege calls on public health practitioners, health care providers, and policymakers to be more explicit and purposeful in addressing racism in order to advance health equity.

STRUCTURAL RACISM AND HEALTH INEQUITIES IN DELAWARE Structural racism is believed to underlie many of the health inequities experienced by Black communities in our state. For instance, Blacks have an infant mortality rate that is approximately two and half times that of Whites; the homicide rate for Black men increased 116% between 2012 and 2016, and is seven times higher than for White men; although the death rate for HIV/ AIDS has decreased in recent years, it is still 11 times higher for Blacks than Whites in Delaware.39

Table 1. Dissimilarity index by geographic area in Delaware Geographic Area

Dissimilarity Index*

New Castle County


Kent County


Sussex County


City of Wilmington


*Calculated using 5-year population estimates, 2013-2017, US Census

Delaware’s history of residential segregation and its lasting impact on health is apparent in the ways in which health inequities can be viewed geographically. Table 1 provides estimates of segregation across Delaware counties and the City of Wilmington according to the dissimilarity index, which is a commonly used measure of residential segregation. Values of the index between 0 and 30 are considered low segregation; 30-60 are considered moderate; and >60 are considered highly segregated.15 Wilmington has the highest level of segregation, and if we look across neighborhoods in the city, we can see how health varies dramatically by place and race. In figure 5 of Wilmington, the darker shaded areas have the highest percentage of Black residents. Life expectancy varies by approximately 16 years across Wilmington neighborhoods with Black communities generally experiencing the lowest life expectancy. Although not as dramatic, Dover sees approximately an 8-year gap in life expectancy across neighborhoods.

CONCLUSION The impact of health inequities can be seen most recently in national data available regarding who is dying from, COVID-19. The mortality rate for African Americans is 2.4 times higher than whites. For Asians and Latinxs, the mortality rate is 2.2 times higher than Whites. In addition, although African Americans represent 13 percent of the U.S. population, they represent 25 percent of the deaths. This health disparity is also becoming more prevalent among Latinxs, particularly in states and localities where a predominant number of “essential workers” are Latinxs. As it pertains to the Native American population, the effect on those communities is also troubling because local tribes suspended the services—like casinos and other private enterprises—that often fund vital community programs.40 In Delaware, while Blacks make up 21.9% of the population, they make up 27% of COVID-19 positive individuals, and 26% of deaths. While Latinxs

Figure 5. Estimated percent of all people who are Black residing in Wilmington neighborhoods and life expectancy


ethnically make up just 9% of the population, they make up 29% of those testing positive for COVID-19 but have a lower rate of deaths (6%) from the disease. According to the Centers for Disease Control and Prevention, “health equity is achieved when every person has the opportunity to attain his or her full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances.”41 Given the review of literature presented above, it is evident that achieving health equity requires action on multiple fronts to dismantle structural racism. First, addressing social conditions through policy change has long been recognized by experts as the best way to improve health and advance health equity. Place-based and cross-sector policy strategies are recommended to address the multitude of ways in which the housing market, education system, job market, and the built and physical environments interact to produce health. Investments in communities can have direct benefits that reduce health threats (such as crime and pollution) and indirect benefits that promote healthy behaviors (such as sidewalks, green space, and healthy food establishments). High quality, equitable education and safe, affordable housing are fundamental to health improvement, as are promoting living wage jobs and access to quality health and social services. However, improving neighborhood conditions is insufficient if the underlying structures and processes that determine the distribution of resources are not fundamentally changed. The evidence cited above suggests that conditions in Black communities have roots in historical and contemporary racism. Therefore, we must confront structural racism if we are to have a meaningful impact on health inequities. This means, among other things, a fundamental shift in power and decision-making with respect to public policy and distribution of resources from the local level to the federal level. Further, while improving conditions in Black neighborhoods is critical for health improvement, we must also address the issue of “separation that remains so pervasive and endemic to the American way of life that we rarely even question it.”19 We must debunk the myth that integration has been achieved and continue the unfinished work of the civil rights agenda. Training and education continue to be important. It has been argued that training for health professionals should more systematically include content related to social determinants of health and specifically racism and health.9 However, the need to work across sectors to address underlying neighborhood conditions to improve health calls for broadening the scope of such training to other sectors and disciplines. Just as there can be an accumulation of burdens and risks when racist policies and practices are perpetuated, dismantling such policies and practices in one sector can have a positive ripple effect in other areas. Finally, there is much we can still learn through research about the ways in which racism impacts health, including for instance, the ways in which racism can be mediated, how racism interacts with other forms of oppression, or for understanding the generational health impacts of racism. There is also a need for improving the ways in which both racism and health are measured, and for using multilevel analyses to capture the complexity of factors in the racism and health equation. These and other research activities can improve our understanding of this complex issue and may be particularly important for addressing criticisms and skeptics. However, it seems evident 24 Delaware Journal of Public Health – November 2020

that we know enough about racism as a determinant of health inequities to act. Further, where research may be most useful is in evaluating policy and practice changes meant to address racism and its consequences. For example, “The Equity Solution,” a paper published in 2014 from the progressive think tank PolicyLink and co-authored with The University of Southern California (USC) Program for Environmental and Regional Equity (PERE), argues that racism isn’t just morally abhorrent — it’s economically destructive. The paper outlines that if the pay gap among racial groups was eliminated, the US might be 14% richer annually.42 Similarly, research is needed on the most effective strategies for building public and political will for change, such as research on framing and social movements. Findings from these applied studies can help to further our collective efforts to advance equity in health. Correspondence: Cassandra Codes-Johnson, Cassandra.codes-johnson@delaware.gov

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27. Wagner, P., & Sawyer, W. (2018) States of Incarceration: The Global Context 2018. Retrieved from: https://www.prisonpolicy.org/global/2018.html 28. Institute of Medicine. (2002). Unequal treatment: Confront racial and ethnic disparities in health care. Washington, DC: National Academies Press. 29. Agency on Healthcare Research and Quality [AHRQ]. (2018). National healthcare quality disparities report. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://www.ahrq.gov/research/findings/nhqrdr/nhqdr17/index.html 30. Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., . . . Coyne-Beasley, T. (2015, December). Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systemic review. American Journal of Public Health, 105(12), e60–e76. https://doi.org/10.2105/AJPH.2015.302903

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19. Yang, T. C., Zhao, Y., & Song, Q. (2017, January). Residential segregation and racial disparities in self-rated health: How do dimensions of residential segregation matter? Social Science Research, 61, 29–42. https://doi.org/10.1016/j.ssresearch.2016.06.011

34. Wang, Y. N. (2016). Reel inequality: Hollywood actors and racism. United States: Rutgers University Press.

20. Cashin, (2004). The failures of integration: How race and class are undermining the American Dream. United States: Public Affairs. 21. Galea, S., Tracy, M., Hoggatt, K. J., Dimaggio, C., & Karpati, A. (2011, August). Estimated deaths attributable to social factors in the United States. American Journal of Public Health, 101(8), 1456–1465. https://doi.org/10.2105/AJPH.2010.300086 22. Williams, D. R., & Mohammed, S. A. (2013, August 1). Racism and health I: Pathways and scientific evidence. The American Behavioral Scientist, 57(8), 1152–1173. https://doi.org/10.1177/0002764213487340 23. Carson, A. (2015). Prisoners in 2014. Bureau of Justice Statistics, U.S. Department of Justice. 24. Garland, D. (Ed.). (2001). Mass imprisonment: Social causes and consequences. London: SAGE Publications. 25. Hinton, E. (2016). From the war on poverty to the war on crime: The making of mass incarceration in America. Cambridge, MA: Harvard University Press. 26. Jensen, E. L., Gerber, J., & Mosher, C. (2004). Social consequences of the war on drugs: The legacy of failed policy. Criminal Justice Policy Review, 15(1), 100–121. https://doi.org/10.1177/0887403403255315

33. Collins, C. (2018). What is white privilege, really? Teaching Tolerance, 60, 39–41. Retrieved from https://www.tolerance.org/ magazine/fall-2018/what-is-white-privilege-really

35. Amico, R. (2017). Exploring white privilege. New York, NY: Taylor & Francis. 36. Bhopal, K. (2018). White privilege: The myth of a post-racial society. Chicago, IL: Policy Press. 37. Romano, M. J. (2018, May). White privilege in a white coat: How racism shaped my medical education. Annals of Family Medicine, 16(3), 261–263. https://doi.org/10.1370/afm.2231 38. McIntosh, P. (1989). White privilege: Unpacking the invisible knapsack. Peace and Free- dom. July/August: 10-12. 39. Delaware Health & Social Services, Division of Public Health. (2016). Delaware Vital Statistics Annual Report. https://www.dhss.delaware.gov/dhss/dph/hp/files/ar2016_net.pdf 40. APM Research Lab. (2020). The Color of Coronavirus: COVID-19 deaths by race and ethnicity in the U.S. Retrieved from: https://www.apmresearchlab.org/covid/deaths-by-race 41. Centers for Disease Control and Prevention. (n.d.). Health Equity. Retrieved from https://www.cdc.gov/chronicdisease/healthequity/index.htm 42. Treuhaft, S., Scoggins, J., & Tran, J. (2014). the equity solution: racial inclusion is key to growing a strong economy https://policylink.app.box.com/v/equity-brief 25

The DPH Bulletin

From the Delaware Division of Public Health

October 2020

Health Systems Protection Section helps keep consumers safe during COVID-19

Diabetes Wellness Expo goes virtual in November

To reduce the transmission of COVID-19, food establishments must adhere to strict measures that are updated in the 27th modification of the State of Emergency, including: Other than when eating or drinking, staff and customers must wear a face covering at all times. ● Customers must have a reservation at establishments that provide table service, unless the establishment has a system for ensuring that customers without a reservation do not gather while waiting to be seated. Takeout may continue under pre-Phase 1 guidelines as long as patrons do not enter the dining facility when picking up an order. ● For food and drink establishments that do not provide table service, signage and floor markings must designate appropriate spacing for patrons waiting in line. ● Customers seated at one table or booth must be at least six feet apart from seated customers at another table or booth. ● Ketchup and other condiments must be provided directly to diners in single-use, disposable containers, or re-usable containers that are cleaned between uses by new parties. ●

Between June 2 and September 15, DPH’s Health Systems Protection Section (HSP) completed 1,004 inspections of businesses and food establishments in response to 2,350 complaints regarding violations of the Governor’s executive orders. Non-compliance can result in fines, closures, and reduced capacity. Customers who observe food establishment workers not wearing their masks or other violations should send a complaint to HSPcontact@delaware.gov. Dining establishments that need HSP’s advice can send floor plans and questions to the same address. For information about preventing foodborne illness at home or when eating out, visit www.cdc.gov/foodsafety/foodborne-germs.html.

26 Delaware Journal of Public Health – November 2020

The Annual Diabetes Wellness Expo is moving online in 2020 due to the COVID-19 pandemic. The Delaware Diabetes Coalition (DDC) is sponsoring six virtual education sessions that promote self-management and a healthier lifestyle for people with diabetes and prediabetes, their families, and their caregivers. The free 2020 sessions are on November 12 and 19 at 12:00 p.m., 2:00 p.m., and 4:00 p.m. The agenda and registration will be released in the coming weeks. Self-management prevents complications such as kidney failure, adult blindness, lower-limb amputations, heart disease, and stroke. More than 91,000 Delawareans have diabetes and an additional 78,000 people have been diagnosed with prediabetes, according to the Division of Public Health (DPH). Being overweight or being obese are major contributing factors for developing diabetes. People with prediabetes can significantly reduce their risk for developing type 2 diabetes by being more physically active and eating a healthier diet. For more information about the Virtual Diabetes Wellness Expo Education Sessions, visit the DDC at https://www.dediabetescoalition.org/, send an email to director@dediabetescoalition.org, or call 302-5196767. Sponsors can register online at http://bit.ly/DDCVirtual. For programs and resources, contact DPH’s Diabetes and Heart Disease Prevention and Control Program at 302-744-1020 or http://www.dhss.delaware.gov/dhss/dph/dpc/diabetes.html. 

Proper household drug disposal Use a medication drop box to safely dispose of unused medications. Find 28 locations at HelpIsHereDE.com.


Annual Delaware Healthcare Forum will be held virtually on October 29 The Delaware Healthcare Association’s 24th Annual Delaware Healthcare Forum will be held virtually on October 29, 2020. The educational conference is designed for Delaware’s hospitals and health systems, from chief executive officers to managers and nurses. The day-long event is sponsored by the Delaware Healthcare Association, in a joint providership with the Healthcare Leadership Network of the Delaware Valley, and Bayhealth. Click here to register. For more information, visit www.deha.org/ or contact Yasmine Chinoy at Yasmine@Deha.org or call 302-674-2853.

Virtual Communicable Diseases Summit scheduled for November 9

The popular “Health Summit: Communicable Diseases” will be held virtually and a month earlier. The virtual summit will be held on November 9, 2020 from 8:30 a.m. to 12:30 p.m. The annual event is sponsored by the Delaware Academy of Medicine/Delaware Public Health Association and the Division of Public Health. Attendees represent health care professionals including physicians, nurses, public health professionals, and allied staff. Click here to register. For more information, visit www.delamed.org/CD2020 or contact Kate Smith, MD, MPH at ksmith@delamed.org or 302-733-5571.

State launches COVID-19 mobile app

Delawareans can download a new mobile app, COVID Alert DE, to get notifications whenever they were in close contact with someone who tested positive for COVID-19. Close contact is less than six feet for 15 min. or more. Residents age 18 and older who live, work, or attend college in Delaware can download the free app to receive secure and anonymous notifications. The Delaware Department of Health and Social Services (DHSS), Division of Public Health (DPH) and the Delaware Department of Technology and Information created the COVID Alert DE app with NearForm, a software developer. Its purpose is to supplement the work of DPH contact tracers by identifying close contacts sooner, as well as identifying contacts for which positive persons may not have information. The app sends an exposure alert to those who are running the app on their phones when their phone is near other phones also running the app. It works across state lines in states such as New Jersey, Pennsylvania, and New York that use the same app technology. COVID Alert DE is available in the App Store or Google Play. For more information, visit https://coronavirus.delaware.gov/covidalert/.

Overdose prevention training events scheduled statewide Naloxone (Narcan®) is a lifesaving medication that usually can reverse an opioid overdose by restoring someone’s breathing, giving people time to call 911. If you use opioids or you have friends or family who use opioids, you should consider getting naloxone and having a plan of action. Tell people where you store the naloxone kit. Make sure to keep naloxone in the home, as that is where the majority of overdoses occur. Free naloxone distribution and training events are scheduled statewide. Participants receive naloxone kits and on-the-spot training on how to administer it. Trainers share overdose rescue information and assist in downloading the OpiRescue app. Click here for upcoming overdose prevention training events. Find more resources on HelpIsHereDE.com or the HelpIsHere Facebook page.

The DPH Bulletin – October 2020

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Addressing the Trauma of Racism from a Mental Health Perspective within the African American Community Angela M. Grayson, Ph.D., L.P.C., B.C.-D.M.T., N.C.C. Good Fruit Expressive Arts Counseling & Psychotherapy LLC; National President-Elect, American Dance Therapy Association

ABSTRACT The combined impact of police enforced fatalities and racially charged viral videos, specifically those targeting African American youth and adults, has sparked a global outcry concerning the mental health and traumatic effects of racism within the African American community. While racism in America has been considered dormant or nonexistent in the 21st century, it has impacted the everyday lives of African Americans since the early 1500s. This article will provide an overview of how racism creates and instigates long term traumatic effects on the mental health of African Americans with some concrete recommendations for mental well-being.

HISTORICAL PERSPECTIVE OF TRAUMA To those looking from afar, the mental and emotional survival of African Americans looks like perseverance. The determination, tenacity and sheer fortitude of people who have been enslaved, oppressed and denied basic human rights looks like strength, willpower and grit. However, if we dare to take a closer look, we will see the pain, scars and anguish of generations of trauma. According to the Merriam-Webster dictionary, trauma is defined as a) an injury (such as a wound) to living tissue caused by an extrinsic agent and b) a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury.1 When most people think about trauma, the initial tendency is to think about those who have been exposed to war, combat, natural disasters, physical or sexual abuse, acts of terror, and catastrophic accidents. While these are surely some of the most profound forms of trauma, a person does not have to personally undergo an overtly distressing event for it to significantly affect them. The experience of African Americans in America historically has and continues to be characterized by trauma and violence more often than for their White counterparts and impacts emotional and mental health of both youth and adults.2 When I was child, there was a nonviolent retaliatory song that was used to taunt bullies, “sticks and stones may break my bones, but words will never hurt me!” As a psychologist, I can definitively inform you that “sticks and stones” and “words” are both detrimental when incessantly repeated over an extended period. The first can be deemed as physical assault or abuse while the second is clearly mental abuse. Both harmful in their own ways and both leaving emotional scars that turn into negative thoughts about one’s being and/or value. This can be akin to how the trauma of slavery and racism leaves long lasting effects on the mental health of African Americans. Racist comments and aggressive and often violent racist actions such as the murder of a multitude of unarmed African Americans by White people have a cumulative negative effect on African Americans both directly and indirectly.3 When addressing the vileness of slavery and racism, African Americans are often told by White people to 28 Delaware Journal of Public Health – November 2020

simply “get over it” or “that was in the past, let it go” or “go back to Africa if you don’t like it here.” Subsequently, research across all helping professions have shown that derogatory comments and discriminatory actions like these often result in higher instances of depression and anxiety in the African American community, in addition to contributing to the racial trauma.4–8 Structural, institutional, and individual racism born from historical dehumanization, oppression, and violence against African American people has cultivated a healthy mistrust and less affluent community experience concerning the delivery of care in the health system.2 African Americans living in the United States have unknowingly been trying to cope with the long standing effects of mental and emotional trauma due to slavery and racism since the early 1500s. For centuries African people were enslaved, tortured and abused by White people through slavery, sharecropping, Jim Crow laws, white supremacy culture, police brutality and exclusion to services beneficial to White people. The relentless mistreatment and disdain for the African American body and mind has caused reluctance to seek both physical and mental health care which can often be attributed to a general distrust of the medical establishment. This distrust is not without merit: historically, African Americans have been misdiagnosed at higher rates than White patients and experience higher rates of mortality. In addition, Black communities have been exploited by the U.S. government and medical community (Tuskegee Experiment, Henrietta Lacks, et al.) in the name of medical advancement.9 Finally, African Americans tend to have worse underlying health conditions in large part because they are regularly more exposed to health hazards than their White counterparts. These health disparities and inequities are neither a reflection of genetic nor behavioral differences, but of policies that harm African American communities.3 Research has revealed that rates of mental illnesses in African Americans are similar to those of the general population; however, much like access to good medical care, disparities exist regarding mental health care services resulting in African Americans receiving poorer quality of care and lack of access to culturally competent care.10

RESULTS OF RACISM ON MENTAL HEALTH Recent headlines have declared that the U.S. is facing two pandemics: COVID-19 and Racism. It is true that both have devastating effects on human welfare and family structures, as well as sociopolitical economic structures. However, there is one glaring difference between the two. COVID-19 with its sweeping unknown origins is relatively new, while Racism has been maliciously seething in every aspect of American culture for centuries, disproportionately eating away at the psyche of African Americans. This intersection of events has forced them to process and deal with layers of individual trauma on top of new mass traumas from COVID-19 (heightened anxiety, isolation, depression, uncertainty, and grief from financial or human losses), police brutality, and divisive political commentary which has resulted in compounded layers of complexity for individuals to responsibly manage.2 Dr. Joy DeGruy, author of Post Traumatic Slave Syndrome, developed a theory that explains the etiology of many of the adaptive survival behaviors in African American communities throughout the United States.9 She explains that it is a condition that exists as a consequence of multigenerational oppression of Africans and their descendants resulting from centuries of chattel slavery, a form of slavery which was predicated on the belief that Africans were inherently genetically and biologically inferior to White people. As such, Africans were dehumanized as being without spirit, emotions, soul, desires and rights. However, once chattel slavery was abolished and dismantled, African Americans became the targets of institutionalized racism which continues to perpetuate injury today. DeGruy’s research lead her to the acronym M.A.P. which concludes that 1) Multigenerational trauma together with continued oppression leads to 2) Absence of opportunity to heal or access the benefits available in the society which ultimately leads to 3) Post Traumatic Slave Syndrome or PTSS. She also proposed that the ability to identify a shared cultural experience and have a descriptive term—Post Traumatic Slave Syndrome—allows for individuals to identify the experience, articulate it, and express it without guilt, fear, blame, or anger and is a source of healing and strengthening within the African American Community. Inadvertently due to living in a constant state of survival, many African Americans with mental disorders are unaware that they have a diagnosable illness at all. They have convinced themselves that life in general has many struggles and the only solution is to make do with the hand one has been dealt. As a result, they are even less aware that effective psychological treatments exist for their specific problem. Within the African American community, talking about mental health issues is considered “taboo” as it is believed that “what goes on in this house, stays in this house!” and “we don’t need White folks thinking we’re all crazy.” Because of the taboo surrounding open discussion about mental illness, African Americans often have little knowledge of mental health problems and their treatments.11 Consequently, as a result of how mental illness is portrayed in movies, TV and the media, most people have an image of the typical psychologist as an older, begrudged White male with a notepad. This contributes

to the perception of African Americans that psychologists would be insensitive to the social and economic realities of their lives. As a result of their views on talking about mental health issues and psychologists in general, African Americans are grossly underrepresented as mental health service providers within institutions as well as in private practice. Despite the slow consistent progress made over the years, racism continues to have an impact on the mental health of African American people. Stigma and judgment prevent many African Americans from seeking treatment for their mental illnesses despite the severity of the symptoms of the illness. Unfortunately, African American people with mental health conditions, particularly schizophrenia, bipolar disorder, and other psychoses are more likely to be incarcerated, misdiagnosed and over medicated than people of other races. Research indicates that African Americans believe that mild depression or anxiety would be considered “crazy” in their social circles. Furthermore, many believe that discussions about mental illness would not be appropriate even among family.12 Likewise, African Americans may be resistant to seek treatment because they fear it may reflect badly on their families—an outward admission of the family’s failure to handle problems internally.11 It is important to note that reservations against treatment may be rooted in actual experiences of racism and encounters with medical professionals lacking cultural awareness.11 When considering treatment, African Americans look for subtle cues to determine if a therapist holds racist attitudes, as many are afraid of being mistreated due to their race or ethnicity.

SUMMARY AND RECOMMENDATIONS Just as racism has been and continues to be consciously and subconsciously woven into the tapestry of American history and culture for centuries, it must be acknowledged that there is no quick fix and there are no “cures” for racial trauma. This is particularly true within the African American community where racially charged trauma occurs on a continual basis. In the absence of a “cure” for racial trauma, it would be in good interest for African Americans to adopt a mindset and attitude of healing these ancestral wounds through unified community efforts. The healing process must include every aspect of African American life but particularly mental health and well-being. Additionally, any effort or plan to eradicate the effects of racism and the trauma that has been inflicted on the mental health of African Americans will do well to include spirituality and religion, education and family support. In her work on Post Traumatic Slave Syndrome (PTSS), DeGruy recommends finding God, spirituality and religion as healthy tools to promote healing.9 Studies by the Pew Research Center reveal that African Americans are among the most religious of any racial or ethnic group in the United States, with 87 percent reporting a formal religious affiliation. As such, prayer and faith are often seen as a salve for mental health woes and may be favored over clinical medical and mental health treatment.13 Additionally, religion and spirituality played a crucial role in the mental and emotional survival of enslaved Africans and their descendants and it can be deemed that spiritual connectedness 29

continues to be practiced as a way for African Americans to try to heal by reverting to African traditions of kinship and community to cope with the mental and emotional confounds of racism and trauma.9 In addition to spirituality and religion, education about mental illness, diagnosable disorders, effects of psychotropic medication and the treatment process is critical to reducing barriers to treatment within the African American community. White established suggestions for overcoming this barrier by recommending public education campaigns (e.g., mass media), educational presentations at community venues (e.g., Black churches), and open information sessions at local mental health clinics.12 Implementation of these campaigns will not only provide much needed education but also provide opportunities to lessen the stigma and taboo of discussing, acknowledging and accepting mental health concerns within the African American community especially as it relates to the symptoms and effects of racial trauma. It is also important to note that the facilitators of these educational campaigns must come from the African American community in order to build trust in the mental health system. Moreover, incorporating the family into the mental health treatment is another crucial aspect in overcoming barriers to treatment. By gaining familial support, such as acceptance and acknowledgment of mental health diagnoses, open discussion about mental health treatment and symptoms, and participation in family therapy, there is a greater possibility that treatment will be consistent providing peace of mind as well as diminished fear of being outcast or stigmatized. Additionally, individual family members would be more forthcoming concerning experiences of racial trauma and injustice that occurred outside of the home providing a safe haven of support and empathy. In conclusion, DeGruy suggests that the work to alleviate PTSS will require a collaborative approach from those within and outside of the African American community.9 According to White, “It’s crucial that we tell stories that prove that people can overcome mental illness and lead rich, fulfilling, successful lives. This requires a shift in the way we portray mental illness in film, TV shows and the media as a whole.”13 Regardless, when trauma is on the table, avoidance of addressing the traumatic impact of racism on the mental health of African American people does not work in terms of providing the necessary support, education and avenues of healing and strengthening the community. Rather, the best way out of the matrix of racism perpetuated against African Americans is always by incorporating spirituality and religion, education and family support. DeGruy provides a distinction between healing, health, and well-being by stating that “healing will take us part of the way, working towards health and wellbeing will take us to our goal.“9 Nevertheless, there is much work to be done in order to address the trauma of racism from a mental health perspective within the African American community.

Many hands make light work ~ African Proverb Correspondence: Dr. Angela Grayson, angela@goodfruitexpressivearts.com 30 Delaware Journal of Public Health – November 2020

REFERENCES 1. Merriam-Webster Dictionary. (2020). Retrieved from https://www.merriam-webster.com/dictionary/trauma 2. Mental Health America. (n.d.). Black and African American communities and mental health. Retrieved from https://www.mhanational.org/issues/black-and-african-americancommunities-and-mental-health 3. Weller, C. (2020). Systemic racism makes COVID-19 much more deadly for African Americans. Retrieved from https://www.forbes.com/sites/christianweller/2020/06/18/ systemic-racism-makes-covid-19-much-more-deadly-for-africanamericans/#5de1e6647feb 4. Hope, E. C., Hoggard, L. S., & Thomas, A. (2015). Emerging into adulthood in the face of racial discrimination: Physiological, psychological and sociopolitical consequences for African American youth. Translational Issues in Psychological Science, 1(4), 342–351. https://doi.org/10.1037/tps0000041 5. Caulley, L. (2020). Sticks and stones: confronting the full spectrum of racism. The New England Journal of Medicine. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMp2021216 6. Utsey, S. O., Giesbrecht, N., Hook, J., & Stanard, P. M. (2008). Cultural, sociofamilial, and psychological resources that inhibit psychological distress in African Americans exposed to stressful life events and race-related stress. Journal of Counseling Psychology, 55(1), 49–62. https://doi.org/10.1037/0022-0167.55.1.49 7. Broman, C. L., Mavaddat, R., & Hsu, S. (2000). The experience and consequences of perceived racial discrimination: A study of African Americans. The Journal of Black Psychology, 26(2), 165–180. https://doi.org/10.1177/0095798400026002003 8. Landrine, H., & Klonoff, E. A. (1996). the schedule of racists of events: A measure of racial discrimination and a study of its negative physical and mental health consequences. The Journal of Black Psychology, 22(2), 144–168. https://doi.org/10.1177/00957984960222002 9. DeGruy, J. (2017). Post traumatic slave syndrome: Americas legacy of enduring injury and healing (2nd ed.). Portland: Joy DeGruy Publications. 10. American Psychiatric Association. (2017). Mental health disparities: African Americans. Retrieved from https://www.psychiatry.org/File%20Library/Psychiatrists/CulturalCompetency/Mental-Health-Disparities/Mental-Health-Facts-forAfrican-Americans.pdf 11. Williams, M. T. (2011). Why African Americans avoid psychotherapy. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/culturallyspeaking/201111/why-african-americans-avoid-psychotherapy 12. White, R. C. (2011). The color of mental illness: can racism make us mentally ill? Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/culture-in-mind/201110/ the-color-mental-illness?collection=81432 13. White, R. C. (2019). Why mental health care is stigmatized in Black communities. University of Southern California Suzanne Dworak-Peck School of Social Work. Retrieved from https://dworakpeck.usc.edu/news/why-mental-health-carestigmatized-black-communities




November / December 2020 Highlights from the Nation’s Health Online-only news from The Nation’s Health newspaper US withdrawal from global climate accord endangers human health: Nov. 4 marks end When the U.S. leaves the Paris climate agreement this November, it will be another major blow to progress on addressing climate change. ___________________________________________________________________________________________ CDC: One-third of people with a disability experience mental distress Over 17.4 million U.S. adults with disabilities experience mental distress, up to five times more often than the rest of the U.S. population, CDC says. ___________________________________________________________________________________________ Report: Improving sickle cell care means addressing racism A new report is calling on NIH to designate sickle cell disease a health disparity to help accelerate research. ___________________________________________________________________________________________ Amplify public health messages by sending an APHA action alert APHA infographic shows how easy it is to speak out on crucial public health issues. ___________________________________________________________________________________________ Americans urged to get flu vaccinations to prevent ‘twindemic’ Influenza and COVID-19 cases this fall and winter could cause a dramatic rise in illnesses and deaths ___________________________________________________________________________________________ HHS greenlights US pharmacists to administer COVID-19 vaccinations Pharmacists and supervised pharmacy interns will be able to provide COVID-19 vaccinations to people ages 3 or older under new federal guidance. ___________________________________________________________________________________________ More... CHECK OUT MORE PUBLIC HEALTH NEWS IN THIS MONTH’S FULL ISSUE. TOP 10 PUBLIC HEALTH NEWS STORIES FROM THE NATION’S HEALTH: 2019 READ AND SHARE


To Be Seen and Heard: The BIPOC Experience in STEM Cecelia Harrison, M.P.H.; Alexandra Mapp, M.P.H.; Dominique Medaglio, Pharm.D., M.S. The Value Institute, ChristianaCare

INTRODUCTION Over the course of several decades, there has been an overall improvement in health outcomes and access to healthcare for Black Americans and yet, they still face major disparities relative to their White counterparts. From life expectancy to chronic disease burden to maternal mortality, the disparities that Black, Indigenous, and people of color (BIPOC) face are disturbing. However, such stark contrasts do not stop with healthcare and health outcomes. BIPOC are exceedingly underrepresented in most academic disciplines, most notably science, technology, engineering, and mathematics (STEM). Unsurprisingly, disproportionate representation becomes more prominent among higher levels of leadership. As women of color who are engaged in public health and health outcomes research, we have firsthand knowledge of why representation matters, not only as researchers but as healthcare consumers as well. The issue of racial disparities in health outcomes and research is built upon an archaic foundation steeped in systemic racism. We all have a duty and responsibility to be a part of dismantling systemically unjust structures and policies, and rebuilding a new construct. As healthcare researchers and scientists, it is our duty to address systemic racism and subsequent impact on BIPOC communities. Furthermore, it is critical for us to engage in transparent conversations about implicit bias and representation at all levels of leadership.

THE IMPACT OF BIAS Bias is inherent to our existence as humans. It is created and shaped by life experiences and our daily living environment. Implicit bias can be conceptualized as reflecting mental processes that occur unintentionally and outside of conscious awareness. In contrast, explicit bias reflects deliberate mental processes that are available through conscious introspection.1 Everyone has implicit biases; those in STEM fields are not immune, despite the idea that such fields are thought to be objective and impartial.2 Without an acknowledgment and correction of these biases, it can unduly influence the diagnosis of disease, medical and treatment decisions, and patient interactions or bedside manner. However, it is not just present within the healthcare workforce but also in how the system measures healthcare quality, access, and utilization. For example, commercial prediction algorithms that use common clinical and financial inputs to predict healthcare utilization and cost have been found to have negative bias towards Black patients.3 If the inevitable goal of the healthcare system is to address racial and social disparities and their effect on health outcomes, shifting and correcting implicit bias is imperative. Interactions between BIPOC as healthcare consumers and the healthcare system are further complicated by historical distrust. The perpetual cycle of marginalization, inefficient systems of care, and mistrust create a 32 Delaware Journal of Public Health – November 2020

complicated feedback loop. Inequitable experiences with medical providers and the healthcare system only serve to drive away patients who have the highest need and who are most at-risk. Where does the medical community begin to address implicit bias, in order to best repair these fractured relationships and ensure an equitable experience for all? Some have suggested that the change begins with offering training in implicit bias to providers.4 By training providers and all who work within healthcare, biases can not only be identified but also addressed.4

A SEAT AT THE TABLE Implicit bias not only has affected how the healthcare community relates to BIPOC, but it has also impacted the racial composition of our healthcare researchers and scientists. Bias impacts which job applications are seriously considered and which perspectives we take seriously when making decisions. Unfortunately, it is not until sobering reports and statistics are released that we see the implications of those day-to-day decisions over time. One such report was “Women and Men in STEM Often at Odds Over Workplace Equity,” a Pew Research Center report published in 2018. This report found that one of the many reasons for the under representation of Black individuals in STEM roles is discrimination in recruitment and promotions.5 An upcoming publication in Social Psychological and Personality Science by researchers from Duke University’s Fuqua School of Business provides results that support this form of implicit discrimination. The experiment found that Black women with natural hairstyles (afros, locs, twists, braids) were perceived as less professional than Black women with straightened hair or White women with straight or curly hair.6 We, the authors, have experienced direct pressures, both in our personal and professional lives, to change the appearance of our natural hair to better assimilate with the majority culture. In addition to implicit discrimination at the application level, there are also barriers the BIPOC face upon entering the STEM workforce. The Pew Research Center reports that of those surveyed, 57% of Black STEM employees say that too little attention is given to increasing workplace racial and ethnic diversity compared to 15% of their White counterparts. The report also shows that 40% of Black STEM employees felt that their race or ethnicity made finding success at their jobs harder compared to just 5% of White STEM employees.5 Many provided qualitative data to support their survey answers: “As a Black woman I get looked over for promotions or advancement because of stereotypes. It is believed that Black people are lazy and unqualified which is totally the opposite. Sometimes I feel that people are threatened by me because they know I am capable, qualified and competent to do the job.” - Black woman, nurse, 345

“There are not many people of my race in my industry. It requires me to go the extra mile to fit in or be accepted because many of the employees don’t share my background or life experiences. I can do the job just fine, however, there are other factors of one’s life that are considered whenever they are in a critical and highly competitive environment.” - Black man, systems administrator, 305 These wide disparities in treatment, from recruitment to promotion and beyond, highlight barriers that prevent BIPOC from even being ‘in the room’ where important decisions in healthcare are made. It is important that all perspectives are given a seat at the table. We need to be very intentional about seeking out others who are not represented and lifting them up. Creating a safe space and opportunities for difficult conversations, that extend beyond the scope of standard messages of support and inclusivity, can help set the tone for positive visibility and empowerment. Additionally, cluster hiring, where multiple positions are advertised at once without stipulating specific fields to increase the applicant pool, can open doors for BIPOC in research fields, especially if the communities we serve look more like those who are underrepresented than those in the majority.7

CONCLUSION Getting to the table is critical, but it is only the first step. Being seated in silence will not advance the movement forward. We need to reconstruct the current culture to encourage an open platform where all can be heard without flippant dismissal. Ostensibly, being seen but not heard can deter and inhibit someone from wanting to speak up and participate. Diversity for the sake of optics alone discourages the inclusion of different perspectives and ideas, which can stifle innovation and problem solving within the workplace.

REFERENCES 1. Hehman, E., Calanchini, J., Flake, J. K., & Leitner, J. B. (2019, June). Establishing construct validity evidence for regional measures of explicit and implicit racial bias. Journal of Experimental Psychology. General, 148(6), 1022–1040. https://doi.org/10.1037/xge0000623 2. FitzGerald, C., & Hurst, S. (2017, March 1). Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18(1), 19. https://doi.org/10.1186/s12910-017-0179-8 3. Obermeyer, Z., Powers, B., Vogeli, C., & Mullainathan, S. (2019, October 25). Dissecting racial bias in an algorithm used to manage the health of populations. Science, 366(6464), 447–453. https://doi.org/10.1126/science.aax2342 4. Agrawal, S., & Enekwechi, A. (2020). It’s time to address the role of implicit bias within health care delivery. Health Affairs Blog. https://doi.org/10.1377/hblog20200108.34515 5. Funk, C., Parker, K., & Center, P. R. (2018). Women and men in STEM often at odds over workplace equity (Issue January). Retrieved from: https://www.pewsocialtrends.org/2018/01/09/women-and-men-instem-often-at-odds-over-workplace-equity/ 6. Duke University. (2020). Research suggests bias against natural hair limits job opportunities for Black women. Fuqua School of Business. Duke Fuqua Insights. Retrieved from: https://www.fuqua.duke.edu/duke-fuqua-insights/ashleigh-rosetteresearch-suggests-bias-against-natural-hair-limits-job 7. Gewin, V. (2020). Fighting racism demands more than just words. Nature, 583, 319–322. https://doi.org/10.1038/d41586-020-01883-8

We would like to use this article as a call to action for all in STEM fields. Diversity and inclusion should be consciously embedded in everything we do, and thus the responsibility falls on all of us to do our part. While the STEM fields have seen historic gains in BIPOC inclusion and involvement, our work is far from over. The acknowledgment of our biases and the elevation of voices that are frequently underrepresented are two of many approaches to tackle systemic racism in STEM. We must continue to strive for equity and equality for all populations, no matter how uncomfortable the journey may get.

“Not everything that is faced can be changed, but nothing can be changed until it is faced.” -James Baldwin Correspondence: Alexandra Mapp, amapp@christianacare.org


We Must Act Now: Building Trust and Increasing Minority Participation in COVID-19 Clinical Trials Marshala Lee, M.D., M.P.H. Director, Harrington Value Institute Community Partnership Fund; Physician Scholar, Harrington Trust; ChristianaCare

Scientists and clinicians across the world are racing against time to find effective treatments and a vaccine to combat COVID-19. Not only has COVID-19 magnified current racial and socioeconomic health disparities, but the race to find an effective treatment has once again reminded us of the numerous historical abuses that were performed against people of color. The Tuskegee Syphilis Study, Henrietta Lacks, and gynecological experimentation conducted on enslaved women are among a few of the many past racist acts that were conducted in the name of medicine and science. These studies continue to have longstanding impacts on African Americans’ trust and participation in clinical research and medicine. African Americans, Latinxs, and other racial and ethnic minorities have been the most affected by the novel coronavirus. African Americans account for 13% of the U.S. population, yet they account for approximately 22% of the coronavirus deaths for which racial or ethnic information was available as of August 12, 2020, according to The COVID Tracking Project.1 Research supports the fact that COVID-19 disparities, like the majority of other health disparities that exist, are not a result of genetic differences, but occur secondary to social determinates of health inequities which are largely a result of systemic racism directed towards racial and ethnic minority populations.2–4 Despite a compelling need for effective therapeutics geared towards fighting COVID-19 disparities, African Americans have been underrepresented in many COVID-19 clinical trials.5 Remdesivir, a broad-spectrum antiviral, was approved in May 2020 by the U.S. Food and Drug Administration under Emergency Use Authorization. Preliminary data from two studies showed that it was effective in reducing the recovery time for patients infected with COVID-19 by 31 percent in comparison to the placebo group.6,7 African Americans accounted for about 20% of the Adaptive COVID-19 Treatment Trial (ACTT-1) funded by the National Institute of Allergy and Infectious Diseases (NIAID) and 11% of the 397 patients randomly assigned to Remdesivir in the Gilead-funded study.8 Some subgroups of patients may respond differently to medical therapies. Thus, more research is needed to fully evaluate Redemsivir’s safety and effectiveness among African Americans and other minority groups that were unrepresented in these studies. COVID-19 vaccines and therapeutics developed without adequate minority inclusion have the potential to delay treatment development, impact generalization of study results, and exacerbate disparities. As scientists race to find effective strategies to treat COVID-19, we must simultaneously work to increase minority participation in clinical trials and acceptance of medical therapeutics. Mistrust, lack of comfort with the clinical trial process, lack of information about clinical trials, poor communication, time and resource constraints associated with participation, and lack of 34 Delaware Journal of Public Health – November 2020

awareness about the existence and importance of clinical trials are critical barriers that limit minority participation.9–11 In order to overcome these barriers, scientists must invest time, money, resources to build long-term, genuine, and mutually beneficial partnerships with minority communities. Community advisory boards, minority representation on research teams, culturally and linguistically appropriate study materials, research navigators, and comprehensive recruitment and retention strategies have been shown to be effective strategies for building trust and increasing minority participation in clinical trials.12–15 Hopefully, similar strategies can be effective in increasing minority participation in COVID-19 clinical trials and acceptance of treatments and vaccines once they are developed and determined to be safe. Continued exclusion of minorities in clinical research has the potential to worsen disparities in the communities that need them the most. We must act now and invest the time, money, resources necessary to increase minority participation in clinical research. Correspondence: Dr. Marshala Lee, Marshala.r.lee@christianacare.org

REFERENCES 1. Miller, K., & Curry, K. (n.d.). The COVID tracking project. Retrieved from: https://github.com/COVID19Tracking 2. Garcia, M. A., Homan, P. A., García, C., & Brown, T. H. (2020). The color of COVID-19: structural racism and the pandemic’s disproportionate impact on older racial and ethnic minorities. The Journals of Gerontology: Series B. https://doi.org/10.1093/geronb/gbaa114 3. Laurencin, C. T., & Walker, J. M. (2020, July 22). A pandemic on a pandemic: Racism and COVID-19 in Blacks. Cell Systems, 11(1), 9–10. https://doi.org/10.1016/j.cels.2020.07.002 4. Laster Pirtle, W. N. (2020, August). Racial capitalism: A fundamental cause of novel coronavirus (COVID-19) pandemic inequities in the United States. Health Educ Behav, 47(4), 504–508. https://doi.org/10.1177/1090198120922942 5. Borno, H. T., Zhang, S., & Gomez, S. (2020, July 30). COVID-19 disparities: An urgent call for race reporting and representation in clinical research. Contemporary Clinical Trials Communications, 19, 100630. https://doi.org/10.1016/j.conctc.2020.100630 6. Hendaus, M. A. (2020, May 20). Remdesivir in the treatment of coronavirus disease 2019 (COVID-19): A simplified summary. Journal of Biomolecular Structure & Dynamics, •••, 1–6. 10.1080/07391102.2020.1767691 7. Beigel, J. H., Tomashek, K. M., Dodd, L. E., Mehta, A. K., Zingman, B. S., Kalil, A. C., . . . Lane, H. C., & the ACTT-1 Study Group Members. (2020, October 8). Remdesivir for the treatment of Covid-19—Final report. The New England Journal of Medicine. https://doi.org/10.1056/NEJMoa2007764

8. Goldman, J. D., Lye, D. C. B., Hui, D. S., Marks, K. M., Bruno, R., Montejano, R., . . . Subramanian, A., & the GSUS-540-5773 Investigators. (2020, May 27). Remdesivir for 5 or 10 days in patients with severe Covid-19. The New England Journal of Medicine. https://doi.org/10.1056/NEJMoa2015301 9. Clark, L. T., Watkins, L., Piña, I. L., Elmer, M., Akinboboye, O., Gorham, M., . . . Regnante, J. M. (2019, May). Increasing diversity in clinical trials: Overcoming critical barriers. Current Problems in Cardiology, 44(5), 148–172. https://doi.org/10.1016/j.cpcardiol.2018.11.002 10. Hussain-Gambles, M., Atkin, K., & Leese, B. (2004, September). Why ethnic minority groups are underrepresented in clinical trials: A review of the literature. Health & Social Care in the Community, 12(5), 382–388. https://doi.org/10.1111/j.1365-2524.2004.00507.x 11. Crawley, L. M. (2001, December). African-American participation in clinical trials: Situating trust and trustworthiness. Journal of the National Medical Association, 93(12, Suppl), 14S–17S. 12. Fuqua, S. R., Wyatt, S. B., Andrew, M. E., Sarpong, D. F., Henderson, F. R., Cunningham, M. F., & Taylor, H. A., Jr. (2005, Autumn). Recruiting African-American research participation in the Jackson Heart Study: Methods, response rates, and sample description. Ethnicity & Disease, 15(4, Suppl 6), S6–S18, 29.

13. Vickers, S. M., & Fouad, M. N. (2014, April 1). An overview of EMPaCT and fundamental issues affecting minority participation in cancer clinical trials: enhancing minority participation in clinical trials (EMPaCT): laying the groundwork for improving minority clinical trial accrual. Cancer, 120(Suppl 7), 1087–1090. https://doi.org/10.1002/cncr.28569 14. Quinn, S. C. (2004, June). Ethics in public health research: protecting human subjects: the role of community advisory boards. American Journal of Public Health, 94(6), 918–922. https://doi.org/10.2105/AJPH.94.6.918 15. Seifer, S. D., Michaels, M., & Collins, S. (2010, Spring). Applying community-based participatory research principles and approaches in clinical trials: Forging a new model for cancer clinical research. Prog Community Health Partnersh, 4(1), 37–46. https://doi.org/10.1353/cpr.0.0103

ChristianaCare coordinates a variety of learning opportunities for doctors, nurses, pharmacists and medical professionals working in Delaware, Maryland, New Jersey and Pennsylvania. All activities are accredited by the Accreditation Council for Continuing Medical Education and Medical Society of Delaware.

For our current offerings, visit ChristianaCare.org/CME ChristianaCare Office of Continuing Medical Education 302-623-3882 | CME@ChristianaCare.org

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It Don’t Take Much to Piss Off a Cop: A Commentary on Systemic Racism in Policing Warren A. Rhodes, Ph.D. Professor Emeritus, Delaware State University

In 1991, I was a tenured, associate professor of psychology at Delaware State College during the height of the national discourse regarding the televised police attack on Rodney King. At that time, I was compelled to write an unpublished commentary on King’s beating, titled, It Don’t Take Much to Piss Off a Cop. I wrote the commentary not only because of the extent of the brutality inflicted upon King, but also because, as a teenager, I had both witnessed and experienced unwarranted attacks by Baltimore City police officers. Those attacks left me scarred for decades. As a result, I knew instinctively that the attack on Rodney King was no isolated incident, and that the police daily inflict unjustified attacks on Blacks much more often than the public realizes or acknowledges. In light of the current national and international outrage over the public brutalization and murder of George Floyd and countless others at the hands of police, I thought it timely to update that commentary, highlighting the impact of systemic racism in policing throughout the USA. I submit for your consideration, ‘It Don’t Take Much to Piss Off a Cop.’1 In 1963, my 16-yr-old brother, Sonny, was being arrested for public drunkenness. As he stumbled into the patrol wagon, he fell backward against the arresting officer, who then repeatedly hit Sonny in the head with a “billy club” (baton) as he threw Sonny into the patrol wagon. I was angered and frightened by the situation but felt helpless to do anything about it. I would have my day in court, I thought; I would tell the judge about it. In court, the judge saw that my brother had bandages around his head, having been carried to the hospital sometime during the night and receiving numerous stitches. The judge asked the arresting officer what happened to my brother’s head, to which the cop replied, “We had to subdue him, your honor; he was resisting arrest.” The judge would not even listen to protests to the contrary from Sonny or me. This situation was one of several incidents with the police that supported my belief that there was no justice for Blacks in the criminal justice system. Sometime later, two policemen chased two buddies and me for shooting dice, lined us up against a wall, and patted us down. My buddy, Clay, started giving the cops lip because they found no evidence on us (we had thrown the dice away while running). One cop hit Clay several times in the side with the baton. Robert and I said nothing, but the cop hit us both anyway, I guess as ‘required’ by Baltimore City Police SOP. If you have not been hit by a police baton, you don’t know what pain really is; the pain is excruciating. As a result, my mouth has been forever sealed when around cops. Fear, anxiety, and immediate submission always overcome me whenever I am approached by a cop. 36 Delaware Journal of Public Health – November 2020

At 16, I was arrested for a status offense, i.e., being a minor in possession of an alcoholic beverage, and I was placed in a holding cell, awaiting trial the next day. ‘Fella,’ a guy I knew from the neighborhood, was in the next cell. Fella was a known police fighter -- that is, if they hit him, he’d hit them back. All during the night, cops came in and took turns beating and kicking the s--t out of him. It still echoes in my head: “Where’s that f---ing nigger who likes to fight?” cops would ask as they came in for their turn at Fella. I prayed to God that they did not get confused and mistakenly come into my cell to give me some of what they were giving Fella. Even now, as I approach middle age, when the police stop me for anything -- anything -- I am automatically gripped with fear, and I become what I can only describe as “overly submissive.” My wife doesn’t understand this; “Why do you let them intimidate you?” she asks. But I know very well that it doesn’t take much to piss off a cop! I believe many of those not outraged by the brutalization of Rodney King rationalized that he was of dubious character and that he had clearly violated the law during the high-speed chase surrounding his arrest for drunk driving. The upshot of this stance is that the police are justified in exercising whatever degree of force they desire once you piss them off. Besides the fact that it takes very little to piss off a cop, the problem with that rationalization is that it grants the police powers well beyond their official mandate to protect, serve and, when necessary, to apprehend and detain; it allows cops to mete out whatever punishment they deem appropriate. Some authorities would have us believe that the Rodney King incident is a result of a few policeman gone bad; but truth be known, it happens much more often than we think. ***** Today, nearly 30 years after writing that commentary, I find myself revisiting it, now that – thanks to cell phone videos – the country, in fact the world, has witnessed the dispassionate murder of George Floyd at the hands of Minneapolis police officers who apprehended Floyd on May 25, 2020 for the horrendous, very violent crime of allegedly passing a counterfeit $20 bill. This follows nearly 6 years after the public’s witness to the murder of Eric Garner in July 17, 2014 at the hands of New York City police for the equally heinous crime of allegedly selling untaxed cigarettes. Both Floyd and Garner pleaded that they could not breathe prior to their deaths. In the intervening six years, we’ve also seen cell phone video of cops’ totally unwarranted use of deadly force against many Blacks, including Michael Brown in Ferguson, MO; 12-yr-old Tamir Rice in Cleveland, OH; Freddie Gray in Baltimore, MD; Walter Scott in Charleston, SC; Philandro Castille in St. Paul, MN; Alton Sterling in Baton Rouge, LA; and

Stephon Clark in Sacramento, CA just to name a few. Heaven knows how many other Blacks have been murdered by police without benefit of video documentation. Large segments of the American public now recognize the reality of police brutality and demand change. However, like in the Rodney King incident, some people, even at the highest level of government – still want the public to believe that excessive force incidents result from the actions of “a few bad apples.” For example, “President Donald Trump flatly denied that systemic racism exist in American police departments, declaring that as many as 99.9 percent of the nation’s officers are great, great people…”2 The fact that these incidents of unwarranted police action against Blacks occur virtually nationwide, with horrible frequency, and have a history dating back to Slavery shows that Trump’s assertions are not based in reality. In contrast, former President Barak Obama, speaking about civil rights and policing at recent virtual town hall meetings in the wake of the world-wide protests surrounding the police killing of George Floyd, observed that systemic racism is a contributing factor in police conduct. He urged police departments and city governments to review and revise their institutional policies to increase trust between police and the communities they are tasked to protect and serve.3 Regardless of where one stands with respect to the existence of institutionalized racism in policing, it is difficult to ignore the data that clearly reveal differential racial treatment in the criminal justice system. According to the Sentencing Project, “racial disparity in the criminal justice system exists when the proportion of a racial or ethnic group within the control of the system is greater than the proportion of such groups in the general population.”4 Racial disparity is reported by the Stanford Open Policing Project.5 This policing project represents an interdisciplinary research team consisting of researchers and journalists at Stanford University. The team has established a process for the collection, analysis, and reporting of data on pedestrian and vehicle stops across the country. They report having collected and made available over 200 million records. Some key findings from The Stanford Open Policing Project are: 1) 50,000 Americans are pulled over by police every day; 2) Black and Hispanic drivers are ticketed, searched and arrested at higher rates than Whites; and 3) Black and Hispanic drivers are searched based on less evidence than are White drivers. Clearly the Stanford Open Policing Project findings support the complaint of discriminatory policing in cities and states throughout this country and are consistent with other research. For instance McPhillips’ Mapping Police Violence study indicated that, on average, 1,100 unarmed people were killed as a result of harm by police between January 2013 and December 2019.6 Nearly one-third were Black, though Blacks comprise less than 14% of the US population. These findings are even more disturbing when one considers that minorities’ interactions with the police may, of themselves, lead to increased psychological stress and criminality.7 The research literature is replete with studies supporting the existence of differential treatment of minorities by police and go beyond the scope of this presentation. There remains a common misconception that law-abiding citizens

have no reason to fear the police. I contend that police have long discounted the rights and safety of innocent Black citizens. Isaiah McKinnon, the retired police chief of the Detroit Police Department and retired college professor described his brutal attack by police when he was just 14 years old: “In 1957, I was a freshman at Cass Technical High School. As I walked home after speaking with my favorite teacher, four White police officers jumped out of their cruiser, threw me against it and beat me severely. I hadn’t done anything wrong. Officers in the feared “Big Four” were well-known in the Black community for brutally maintaining their kind of “Law and Order.” The more I screamed, the more they beat me. Time seemed to stand still as I saw the anger on their faces and the horror on the faces of Black people who gathered around us, yelling for the police to stop. After what felt like hours, they told me to get my ass out of there. I ran home crying but did not tell my parents, fearful that it would put them in danger. I was 14, the same age as Emmett Till when he was killed in Mississippi two years earlier. I was scared, angry and confused. Why did they hurt me?”8 Furthermore, police, armed with “no-knock” warrants, as well as a disregard for the rights and safety of Black citizens, have caused the deaths of many blameless Blacks that we know of, including 75-year-old Minister Acelynne Williams in 1994; 54-year-old Alberta Spruill in 2003; 92-year-old Kathryn Johnston in 2006; 7-year-old Aiyana Mo’Nay Stanley-Jones in 2010; and 26-year-old Breonna Taylor in 2020. The important takeaway here is that police assaults on Blacks, as in the killing of George Floyd, are not unfortunate aberrations, but are the consistent and logical result of the systemic racism that permeates police departments throughout this country. The typical police mandate “to protect and serve” should produce a sense of comradery between the police and individuals in the community. However, a recent Baltimore survey of police and community relations reveals that fear of and dissatisfaction with the police is commonplace.9 The survey of over 600 residents revealed that 60% of the participants were dissatisfied with the police department, which included 57% who were very dissatisfied. Furthermore, most of the participants did not trust the Baltimore Police Department (BPD), including 45% of the participants reporting that they were nervous when they saw the police. The survey yielded individual reports of harassing interactions with police that were remarkably similar to my own decades earlier. “… [one] resident said his brother was “brutally attacked by six police officers. He showed no resistance and had his hands up, but the officers continued to beat him and then tased him. He did not touch any officers but was charged with six counts of assaulting an officer — supposedly one count for each officer that was beating him up. Those counts were later all thrown out.”9 As a result of investigations regarding racial discrimination by the BPD, Baltimore became one of several cities that entered a consent decree signed by the United State Department of Justice to promote reform within the police department.9 Specifically, the consent decree established mediation procedures designed to … “build trust and improve public safety by mitigating the 37

impacts of discrimination.” Additionally, implicit bias training and community policing have been key pillars adopted by various police departments to address systemic racism. Unfortunately, Black parents across this country are forced to have “the talk” with their children because of the fear that their children may be harmed when approached by those who are “sworn to protect and serve”. “The talk” is a rite of passage for many Black adolescents. According to Luke, “For most White families, “the talk” deals with the birds and the bees, but for Black families, it has increasingly centered around a different topic: How to behave if stopped by a police officer. It’s a conversation that parents of Black children say they feel is necessary to protect their kids, and it typically happens in elementary school.”10 Despite mounting evidence that racial discrimination in policing exist throughout this country, the question of what can be done to effect change remains. Cries to “defund the police” have been heard nationwide, but the meaning is variable and unclear. For many, the idea of defunding the police conjures up images of a lawless society. However, an increase in criminal behavior does not necessarily follow a reduction in police presence. In fact, crime went down as a result of defunding the police in Camden, N.J.11 Consistent with the defund the police momentum, according to Zerkel the outcry for change demands that more resources be diverted from traditional police departments and redirected to community resources which must be bolstered to effectively address issues requiring social and/or economic intervention rather than police intervention.12 “That’s why we must stop investing in police and incarceration and instead intentionally invest in alternative models that are centered in community and address the root causes of harm, in addition to making greater investments in schools, health care, and other human needs that keep our communities safe.”12 Zerkel’s proposal for defunding the police is rooted in the belief that the current policing model is outdated. That is, traditionally police are trained to take total control, dominate, and use all force they deem necessary. “…our criminal legal system was built to reinforce deep structural racism in our society. For most individuals and communities of color, policing has brought terror rather than safety.”12 Training can lead police officers to believe that every encounter and every individual is a threat and potentially life-threatening; hence, they must always be on their guard. They can be shown heart-wrenching dash-cam footage of officers being beaten, disarmed, or gunned down after a moment of inattention or hesitation. This major focus on “expecting the worst” in every situation produces an officer who is more likely scared for their own safety and likely to overreact. Training offers little on understanding unconscious biases and their potential impact on officer behavior. Such lack of awareness may lead officers to perceive a greater threat from Black men than from others. There is often insufficient training on deescalation and other flexible tactics that may reduce conflicts. Moreover, administrators must be more open to reviewing officer’s use of force and use the review process to improve training. Armed with a better understanding of why it doesn’t take much 38 Delaware Journal of Public Health – November 2020

to piss off a cop, perhaps we can now reconceptualize policing so that officers can indeed protect and serve, rather than intimidate and oppress. Correspondence: Dr. Warren Rhodes, warhodes@yahoo.com

REFERENCES 1. Rhodes, W. (1991). It don’t take much to piss off a cop. Unpublished manuscript. 2. Baker, P., & Haberman, M. (2020, Jun 8). Trump rebuffs protests over systemic racism and calls police “Great People’. New York Times. Retrieved from https://www.nytimes.com/2020/06/08/us/politics/defund-police-trump.html 3. Pace, J. (2020, Jun 3). Obama calls on mayors for action against systemic racism. LA Times. Retrieved from https://www.latimes. com/politics/story/2020-06-03/obama-calls-action-against-systemicracism 4. The Sentencing Project. (2008). reducing racial disparity in the criminal justice system. A Manual for Practitioners and Policymakers. Retrieved from https://www.sentencingproject. org/wp-content/uploads/2016/01/Reducing-Racial-Disparity-inthe-Criminal-Justice-System-A-Manual-for-Practitioners-andPolicymakers.pdf 5. Pierson, E., Simoiu, C., Overgoor, J., Corbett-Davies, S., Jenson, D., Shoemaker, A., . . . Goel, S. (2020). A large-scale analysis of racial disparities in police stops across the United States. Nature Human Behaviour. Retrieved from https://www.nature.com/ articles/s41562-020-0858-1 6. McPhillips, D. (2020, Jun 3). Deaths from police harm disproportionately affect people of color. U.S. News & World Reports. Retrieved from https://www.usnews.com/ news/articles/2020-06-03/data-show-deaths-from-police-violencedisproportionately-affect-people-of-color 7. Del Toro, J., Lloyd, T., Buchanan, K. S., Robins, S. J., Bencharit, L. Z., Smiedt, M. G., . . . Goff, P. A. (2019, April 23). The criminogenic and psychological effects of police stops on adolescent black and Latino boys. Proceedings of the National Academy of Sciences of the United States of America, 116(17), 8261–8268. PubMed https://doi.org/10.1073/pnas.1808976116 8. McKinnon, I. (2020, Jun 11). It’s time to restructure police departments so they truly serve and protect. Retrieved from https://www.freep.com/story/opinion/contributors/2020/06/11/isaiahmckinnon-former-detroit-police-chief-restructure/5333368002/ 9. Anderson, J. (2020, Apr 21). Baltimore residents don’t trust officers and are dissatisfied with police, according to scathing survey. Baltimore Sun. Retrieved from https://www.baltimoresun. com/news/crime/bs-md-ci-consent-decree-survey-20200421acwplfsskbhepm2ihaja5a5ruy-story.html 10. Luke, S. (2020, June 4). ‘The Talk’: A Rite of Passage for Black Families. Retrieved from https://www.nbcsandiego.com/news/ local/the-talk-a-rite-of-passage-for-black-families/2339523/ 11. Andrew, S. (2020, Jun 9). This city disbanded its police department 7 years ago. Here’s what happened next. CNN. Retrieved from https://www.cnn.com/2020/06/09/us/disbandpolice-camden-new-jersey-trnd/index.html 12. Zerkel, M. (2020, Jun 4). 6 reasons why it’s time to defund the police. American Friends Service Committee. Retrieved from https://www.afsc.org/blogs/news-and-commentary/6-reasons-whyits-time-to-defund-police


Connie’s Story: A View Inside Constance Malone

I enlisted in the military in 1963 as a sophomore student at Tuskegee Institute, now known as Tuskegee University. I chose the Army Student Nurse Program to complete my education at the government’s expense and to gain experience. In order to be accepted into the program, all applicants had to complete a physical examination at Maxwell Air Force Base in Montgomery, Alabama. It was at Maxwell Air Force Base where I encountered my first experience with systemic racism. We believed that the doctor chosen to perform the physical exams on the nursing students from my school was a segregationist because the office personnel instructed us to enter through a back door marked “colored only.” We asked, as students, why the military would contract with someone who practiced segregation if the military, specifically the Army, was an integrated organization. As students, we thought this was a fair question; however, no answer was ever given. Instead, we were told to get the physical exams as soon as possible so we could get back to campus. I graduated from the Tuskegee Institute in May 1965, and was commissioned as a Second Lieutenant in the U.S. Army. After graduation, my first duty station was at Fort Sam Houston, in San Antonio, Texas. All new recruits in the medical core, including nine of my classmates and I, went there for basic training. Fort Sam Houston was where we were given our uniforms for all occasions. Learning there was safety in numbers, we experienced little systemic racism because my classmates and I always stayed together as a group. The group cohesiveness concept was taught to us as students at Tuskegee for safety reasons. It also served to teach us the ability to work with each other and anyone else. We were taught the fundamentals (sociology and psychology) of dealing with attitudes and differences between people we encountered in life. We were not only ‘book smart’ but we were ‘people smart’ with bedside manners. Having this knowledge served me well. One of my many encounters with racism came in July 1965. It was an extremely hot month and we had drill in the oppressive heat. During this particular drill, the comment was made that “Y’all used to heat because of picking cotton.” I did not know how to respond to such a racist remark. I was shocked and bewildered as to why someone would think that comment was okay to make. I finally said, “I’m glad you know about cotton because I’m city born and raised. My first encounter with cotton was in Alabama. Are you from Alabama?” Unbeknownst to me, it was at this moment that I became prepared for any challenge the military or my future career would bestow upon me, including the racism and sexual harassment that was to follow. After completing my basic training, my next duty station was at Fort Carson in Colorado. It was here that I received my first real experience in a military hospital setting. Being the only Black nurse in the hospital was a strange feeling for me. Coming from a Historically Black College, I was surrounded by people who looked like me. The head nurse, who was a Major, made me feel welcome and put me at ease. Wearing the Army nurses’ uniform with Second Lieutenant Bars and nursing cap distinguished me and nurses from the rest of the staff. I had a sense of pride for my accomplishments to date and a longing to strive for even greater heights. My first assignment was on a pediatric unit as a Charge Nurse. Visitors would come in and often have questions. These questions were often asked of the enlisted personnel rather than the 40 Delaware Journal of Public Health – November 2020

Officer in Charge Nurse, me. The enlisted personnel would relay the questions to me as they were not equipped or qualified to know the answer. Despite my frustration, I would introduce myself as the Charge Nurse to the visitor and answer any question(s) they might have, in addition to explaining the care being given to their child. Due to the blatant disrespect shown to me, the Black female Officer in charge, by family members and visitors, a unit policy was instituted informing all staff working with me that all visitors had to see the Charge Nurse before being allowed to see their child and my patient. In March of 1966, I left Colorado and was off to Vietnam with the 67th Evacuation Unit as the only Black officer and nurse aboard the plane. I knew I had to put on my armor, including the full armor of God, to survive this experience. I knew I had to be a quick thinker to ward off racist and sexist insults, and sexual harassment, as well as to be prepared to serve in combat. I was challenged every day and I never knew where I would be assigned. Other nurses in the unit had permanent assignments and enjoyed a sense of stability. Appreciating the obvious discrimination, I asked the Chief Nurse what was going on with me being moved to different units so frequently. Her response was that I needed the experience. Needless to say, that rationale did not work well for me. Taking into consideration that several of the other nurses also graduated in May 1965, as I did, I retorted that those nurses needed the same amount of experience, hence the same rotation in units. As expected, that fell upon deaf ears. As such, I decided to make the most out of the situation, knowing that I would be a better, more well-rounded nurse when I returned to the States. Since I gained more skills and knowledge, the Chief Nurse later assigned me to the Medical Intensive Care Unit (MICU) as a permanent assignment. Vietnam was a difficult place to be, so even with my unit permanent assignment, the discrepancies continued. In addition to the MICU, I was assigned to a second unit and the night shift. My patient assignments were determined by the Charge Nurse and influenced by her attitude towards me. Patients with the most complicated illness and required more care were assigned to me. Not being intimidated, I would have whoever was in charge assist me with my most difficult patients. She soon realized I was not going to be bullied and she began to make assignments equal for all. Those earlier experiences could be considered inconsequential compared to the more blatant racism and sexism I was soon to experience in Vietnam. Some of my experiences were so traumatic that I shudder at the thought of sharing. One of those instances would be with the Klu Klux Klan (KKK). The KKK was alive and well on our unit. The United States was in the middle of a war and this group of Americans had the audacity to hold Klan meetings in the tent where all enlisted personnel were housed. I had the distinct pleasure of informing the chief of the hospital of these inappropriate actions. He observed the meeting and subsequently took proper action for such an activity in our unit. In addition to racism, sexual harassment was a daily occurrence for me. All of the females in our hospital were officers. Due to our rankings, off duty communications with males was limited; however, that limitation was not reciprocal. All of the males were able to talk to us while off duty. However, when I went to the Officer’s Club, I had to be careful as I was verbally and physically abused and harassed by some of the White

officers. This behavior included pawing and unwanted, unsolicited prepositions. Defending myself was a constant, so I would only go to the Officer’s Club on special occasions. I wanted to enjoy my time off without being harassed or assaulted. I would occasionally ask the White officers where the Black officers were as they were more prone to show me respect. In fact, I always received respect and was treated with dignity by the Black officers and enlisted men. So instead, I would go to the Non-commissioned Officer’s Club. There I could communicate with fellow servicemen and was able to enjoy my time without concerns of racism or sexism. A stark contrast from the verbal abuse and harassment I received from White officers in the area. As such, I did not communicate with those who chose to be disrespectful and degrading of my race, feminism and title as an officer unless absolutely necessary. After I left Vietnam in 1967, my last assignment was at Fort Benning in Georgia. Being back in the States was a refreshing experience. I was assigned to the pediatric unit at Fort Benning. I loved working with children because they had, for the most part, no preconceived ideas about people unless they were teenagers. Once again, I was Charge Nurse and the only Black officer on the unit, although there was a Black civilian nurse, who worked night shift. I could feel the tension mounting in the unit as the weeks began to pass. I noticed tempers and attitudes would become an issue when certain nursing assistants worked together. Blacks would come to me to complain, while Whites would go to the White nurses. I realized that we needed standardized procedures on the unit in order for us all to be working toward the same goals. So, I set up Standard Operating Procedures (SOP) to follow. These procedures made working together on the floor a lot better. It was at this point the White nurses began complaining that I was making too many mistakes and reported my actions to the Chief of Pediatrics. The Chief subsequently called me into his office to discuss the mistakes I had made, specifically those made with the children’s medications. I informed him that I was unaware of any errors in the children’s medications. Furthermore, the nurse making the report needed to show me “my errors.” That nurse was asked to provide proof of my errors to him. Upon review, the Chief of Pediatrics concluded that I was correct and no errors had been made in the dispensing of medications to the children. The Chief also concluded that the nurse making the report had been incorrectly mixing intravenous fluids, thereby being the one making mistakes with patient medications. The Chief instructed that nurse to write a letter of apology to me, attach it to the complaint and place both in my record.

It was during my time at Fort Benning that I found my place in nursing. I was invited to teach a class on immunizations and communicable diseases at my alma mater, the Tuskegee Institute. It was at this point I realized that teaching and working with children was what I wanted to do with my career. Upon my discharge from the military, I worked in community health and nursing education. Teaching became my passion. It was this passion for teaching that I carried throughout my life and career, retiring in 2004 after nearly 30 years in nursing. It was during my retirement that I was introduced to the Veteran’s Administration (VA) Services for veterans. I attended a meeting in which information about the services offered to veterans was discussed. I discovered that I might qualify for disability so when I returned home, I immediately applied. Unfortunately, the VA informed me that I did not qualify for disability benefits because I had not been in a war zone. That was surprising since it was well understood that Vietnam was a war zone. I reapplied and after several attempts to receive my rightfully earned benefits, I was recognized as a war veteran and determined to be eligible to receive benefits. Through the process, I also learned that I, like many veterans, suffered from post-traumatic stress (PTSD). The diagnosis of PTSD was a surprise for me. My primary care physician recognized my need when I got severely depressed and referred me to Mental Health. I shared my combat and systematic racism experiences with my psychiatrist. From my conversations, I gained a clear picture of how I coped with stress over the years. Realizing that I needed to care for myself first, the healing began to take place. I became less controlling, and more willing to let others be active participants in my life and wellbeing. So that’s “Connie’s Story”. I have confronted racism, sexism and a mental health challenge. All of these constitute examples of trauma. Sometimes the system helped, other times the system enabled the trauma, but I am here to tell my story with the hope and expectation that the telling will lead to healing for someone else. Systems are in place to support veterans but more work needs to be done to improve and strengthen those systems. That work will take all of us.


“Enough Is Enough.” An Historical Perspective: Long Lasting Health Disparities in the African American Population in the Midst of the COVID-19 and the George Floyd Incident Marlene Saunders, D.S.W., M.S.W., L.M.S.W. Chairperson, DE-CTR ACCEL; Chairperson, Department of Social Work, Delaware State University, Retired

INTRODUCTION The disproportionate health disparities seen in the African American population today resemble the health inequalities that existed in the population during enslavement and up to the Civil Rights period when the group’s health status began to improve in the 1940s. Using life expectancy data, national health statistics show the difference in life expectancy of Black and White men decreased from a differential of approximately 11 years in 1940 to a 6-year difference in 1960. Despite this improvement, currently, African Americans are more likely to live close to polluted areas, have incomes below the poverty line, and live in substandard housing. Having connected presented day health inequality so apparent in the African American population today to structural racism dating back to pre-emancipation, Noonan, VelascoMondragon and Wagner have concluded that “The history of slavery and the current racial discrimination this group continues to suffer clearly underlie the inexcusable poor health status of African Americans as a whole.” Using an historical-ecological perspective, this article will link present day health inequities in the African American population to the antebellum period (1861-1865). At first, African Americans were Christian indentured servants and no negative distinction based on ethnicity or color was attached to them. Then, around mid-1700, they became enslaved chattel and by law were ascribed slave status by virtue of color. The group’s caste status in American society by virtue of color and ethnicity prevails today. As Gunnar Mydral noted in his study of race in the United States, in 1944, [T]he caste or, as it is more popularly known, the color line – is not only an expression of caste differences and caste conflict, but it has come itself to be a catalyst to wide differences and engender conflicts. To maintain the color line has, to the ordinary White man, the “function” of upholding the caste system itself, of keeping the “Negro in his place.”1 Accepting that health disparities in the Black population is a public health crisis, this article will utilize selective historical moments in Black history and public health as reference points for linking the county’s public health response to Black health disparities. The reprehensible murder of Mr. George Floyd at the hands of a police officer while unarmed and handcuffed, coupled with African Americans having the highest rates of infections, hospitalizations and deaths due to COVID-19, has generated the outcry, “Enough is Enough.” Millions of African Americans, along with their fellow Whites, Hispanics, and Asians; and young citizens from all age groups, all over the United States, are marching and demanding justice. Specifically, the demand 42 Delaware Journal of Public Health – November 2020

is for justice from the courts that should hold police officers accountable for the deaths of Black men and women. These grassroots and professional advocates are also demanding social justice for African American citizens who are currently living under the burden of structural racism. The harmony among diverse individuals representing multiple ethnic groups and every socio-economic class is awe-inspiring. In fact, the hundreds of demonstrations, Zoom meetings, and interracial group discussions involving police officers, mayors, governors, ministers and former U. S. Presidents, highlight what appears to be an unprecedented, and genuine awakening to structural racism and its burden on the Black community, manifested as ongoing police brutality and in the high, differential impact of COVID-19 in the African American population. In-depth examination of racism and health began receiving serious attention in the literature in 1991. An important consequence of this historical moment of outcry is that it is prompting public health experts to look more closely at the efforts and impact of America’s public health system relative to reducing the on-going and sustained health disparities in the Black population. But, of course, thinking in this manner means that the public health workforce - physicians, epidemiologists, researchers, academics, social workers, nurses and others - must honestly discuss how the field has historically responded to persistent race-based inequities within the context of and with a clean acknowledgment of structural racism.

HISTORICAL CONTEXT FOR SOCIAL JUSTICE In 1928, Louis Israel Dublin wrote, An improvement in Negro health, to the point where it would compare favorably with that of the White race, would at one stroke wipe out many disabilities from which the race suffers, improve its economic status and stimulate its native abilities as would no other single improvement. Dublin’s analysis is applicable to discussions that connects current health disparities in the Black population to the group’s health status in the past. His statement brings attention to the fact that to be Black and of African descent in the U.S. in 1928 was a risk factor and one that impacted Black lives over the life span in many ways, including health. In 1920, the life expectancy of African American men was 47.6 years, compared to 59.1 for White males. For African American women, the life expectancy was 46.9, compared to 58.9 for White counterparts. There is no need to argue that if one stroke [of the opportunity wand] eliminated all barriers to optimal health, Black Americans would have boldly waved the wand. However, the opportunity wand has never been in the possession of African Americans, and they have never had the power to obtain or control it.

PUBLIC HEALTH AS SOCIAL JUSTICE A review of the literature did not yield any definitions of public health that did not highlight and discuss social justice as its core value. For example, Turnock stated, “Social justice is said to be the foundation of public health.”2 Krieger and Birn discussed public health as social justice by precisely linking it to other movements, like anti-lynching, which emerged at the same time and were similarly grounded on the philosophical tenets of social justice.3 For the purposes of this article, Rawls’ definition of social justice provides a fitting foundation for measuring a public health response to health disparities in the Black population throughout history.4 His definition states that a society’s resources must be distributed in a way that benefits the least advantaged. His philosophy allows just societies to have a wealth/asset hierarchy where some members can have greater economic means than others. Rawls’ definition, then, does not eliminate the opportunity for America to be a just society because of a class structure that ranks individuals according to their economic resources. However, Rawls’ theory does stipulate that the differences in such a hierarchy are acceptable only if those who are the less well-off benefit. A second premise of this article is that Rawls’ conception of social justice provides a rationale for a special approach to addressing health inequalities among African Americans henceforward referred to as “societal redress.” This concept refers to an accepted obligation on the part of society to compensate African Americans for the impact of enslavement and discrimination from 1619 to the present by providing comprehensive public health services and programs that will eliminate health disparities in the African American population. This application of social justice also accepts that having originated from structural racism, racial health inequalities impacting the lives of African Americans must be regarded as a social determinant of health. Indeed, a growing body of literature has revealed that racism is associated with poor physical and mental health. This concept maintains that racism has been and continues to be an environmental factor that is an impediment to optimal health. Equally important is the perennial situation where structural racism has and continues to be beyond the control of the African Americans to the extent of having the power to eliminate it as an obstacle to good health. Under this conception, social justice as a conduit for “societal redress” further accepts that the tools of structural racism that were employed by all of this society’s institutions, including public health, created significant economic benefits to American society as a whole social advantage to all White citizens (poor and wealthy) specifically in terms of superior social status and white privilege. In his article written for the New York Times’ 1619 Project, Mathew Desmond wrote “By the eve of the Civil War cotton cultivated by enslaved Africans was the nation’s most valuable export.” Respected historians Johnson and Smith have written, By the mid-nineteenth century, slavery was the way American breathed.5 Indeed, there may have been no America without it. It was an institution with thick, tangle roots, one that even touched the lives of those who had never owned slaves. Translating social justice as the tool by which society pays the debt the society owes to African Americans should not be

interpreted as indifference to or a devaluation of the labor of other ethnic groups who contributed to America’s status as the dominant, global economic power. Nevertheless, the African American experience is unique because of constitutionally sanctioned and governmentally enforced slavery and its legacy. Perhaps placing “societal redress” next to an explanation of the rewards America derived from Black subordination clarifies the “societal redress” relationship to public health as social justice: Finkenstaedt wrote: The Black has, in effect, been responsible for the material success of America. His relegation to outcast status was how the nation reunited, centralized its territory and economy, consolidated a heterogeneous work force and burst on the international scene in two world wars as a productive giant.6 The belief that society is obligated to protect and promote the health of citizens (except to respond to uncontrollable circumstances, e.g., hurricane) totally deviates from principles and values associated with individualism, the Protestant work ethic and obtaining society’s benefits (and largess) through merit rather than personal need. Regarding this matter, Turnock notes, social justice rests on the notion that “significant factors within the society impede fair distribution of benefits and burdens.”2 In the case of African Americans, structural racism is not only a social determinant for health disparities but, in addition, explains the occasions when public health abandoned its social justice mandate. Such historical moments resulted in uneven delivery of public health services, unethical conduct by physicians, social workers and researchers and patient abuse.

SOCIAL JUSTICE WITHIN THE CONTEXT OF PUBLIC HEALTH A third premise of this article is that social justice and public health should not be viewed as separate and mutually exclusive. Rather, combining Turnock’s and Rawls’ conceptions of social justice with “societal redress” considers public health an institutional means by which to ameliorate race as a social determinate of health disparities among Black Americans. The food deserts that characterize poor African American communities and pollution that is killing African Americans living in overburdened communities are examples of structural equality manifestations which include environmental racism, reinforced by redlining and gentrification. “Societal redress” through public health is an approach to mediate the problems of disparities in this population. This line of thinking is supported by the Institute of Medicine’s (IOM) conception of public health as social justice. In their 1988 report, The Future of Public Health, they stated the following: As a part of the assurance function, in the interest of justice public health agencies should guarantee certain health services. Such a guarantee expresses a measurable public commitment to each member of society. In operational terms, this implies guaranteeing both that the services are available (present somewhere in the community) and, in the case of services to individuals, that the costs will be borne by the government for those unable to afford them. When these services are not and cannot be present in the larger community, it is the public health agency’s responsibility to provide them directly.7 43

The objective of the discussion up to this point is to provide an historical and conceptual framework for comprehending present-day health inequities in the African American population as problems that are directly connected to the group’s caste status established when Africans were brought to the country as enslaved chattel over 400 years ago. This position has been inescapable. Therefore, the health disparities seen, for example, in the disproportionate high levels of COVID-19, as well as the belated responses on the part of public health profession to the crisis reflects a longstanding reluctance on the part of the public profession to: (1) acknowledge historical racism as an explanatory variable for the disturbingly high level of poor health in the Black population and (2) to consequently develop and advocate for policies and programs that frame public health services to African American communities within the context of public health for the purpose of social justice. The next section of the discussion that follows provides examples of structural racism in public health and the outcomes for African American during selected historical periods.

PLANTING THE PERMANENT SEEDS FOR PERSISTENT RACIAL DISPARITIES IN THE AFRICAN AMERICAN POPULATION: ANTEBELLUM TO 1860 Diseases like smallpox, diphtheria, yellow fever and tuberculosis created massive illness and death for the White settlers in the New World and for Europeans who became city dwellers during the early processes of urbanization and industrialization. During the seventeenth and eighteenth centuries, attitudes toward the cause of disease changed, and methods of containing disease and public responsibility for assuring optimal health for all citizens evolved from isolation of the ill and quarantining of the exposed, to the establishment of voluntary hospitals and sanitation boards, to acceptance of public responsibility for the establishment of the first public agency for health. The New York City Health Department began in 1866. However, the perspective that public health should assure good health for all of society’s inhabitants did not apply to enslaved Africans after they arrived in the colonies. Interceding to ease the conditions under which enslaved Africans lived and worked was not compatible with the profit motives of plantation owners. Indeed, “the planters had reckoned that it was cheaper to lose and replace slaves then it was to feed them, treat their illnesses, punish them humanely, and keep them alive.” Though some plantation owners provided medical attention, an owner’s decision to dispense medical attention or authorize treatment by a physician was often determined by whether it was believed his human property was malingering. Under this mindset enslaved Blacks labored from dawn to dusk, doing continuous back breaking work. Work included picking cotton, digging ditches, and cutting and hauling wood. Their diets were nutritionally inadequate and insufficient to maintain the level of health and stamina their workload demanded. They lived in rudimentary quarters that exposed them to extreme heat and cold. The most dangerous work was cultivating rice. America’s Black unpaid workforce had to stand in water for hours at a time in the blistering sun. Although malaria was widespread in colonial 44 Delaware Journal of Public Health – November 2020

America, life in a climate that contained malaria had given many West Africans (through the sickle-cell trait) a partial resistance to the disease. Living under such conditions created susceptibility to respiratory illnesses like pneumonia, tuberculosis, and infections caused by parasites. Working conditions were similarly inhumane for those working the tobacco, cotton and sugar cane fields where the enslaved Africans were expected to work from sun up to sundown regardless of the weather. Although the Public Health Act was passed in 1848, a social justice mandate was not used as leverage to stop either plantation doctors or the medical profession from routinely using African Americans for medical research without consent. This was an example of systemic racism within the medical profession, scientific research community and the health care system. Harriet Marineau, often identified as the first woman sociologist, once commented “[t]he bodies of the coloured are exclusively taken for dissection ‘because the Whites do not like it and the coloured people cannot resist.” Between 1845 and 1849, Dr. Mirian J. Sims, the father of modern gynecology, completed 30 operations on three Black women without anesthesia to develop a procedure for White women suffering from a condition that resulted in the leakage of urine through the vagina. Ignoring the Hippocratic Oath, “First do no harm” corresponded to the scientific racism of the period. Bogus research was the basis for describing Blacks as inferior, subhuman and possessing a physique that made them perfect for medical experimentation. After the procedure to treat was perfected, he used anesthesia when performing surgery on White women. Some have said that Sims’s abuse of African American women resolved a medical problem many women suffered. However, there is no ignoring that Sims’ grave injustice against African American women was among previous and future grave misjustices in medical health that created a situation where no group mistrusts the American medical system, particularly medical research, more than present-day African Americans.

RACIAL DISPARITIES: CIVIL WAR AND RECONSTRUCTION 1861-1900 Although they were without civil rights, 186,000 formerly enslaved and free African Americans enlisted in the Union Army. The health status of Black soldiers during the Civil War revealed that disease and sickness had a more catastrophic impact for ex-enslaved men, compared to White soldiers. In 1864 in Camp Kentucky, hundreds of freed slaves died of malnutrition and exposure, while White soldiers in the same camps did not. The War Department also did not assign doctors to the Black encampments. This historical moment provides further evidence for a historical perspective that supports connecting longstanding health disparities in the Black population to structural racism that prevailed during this period. This reality stings even more with the realization that the measures used to improve the sanitary conditions in military camps with the intention of returning White soldiers to their families alive led to creating America’s organized public health system. This historical moment also highlights how neglecting the health needs of the African American population led to practices in public health that significantly benefits the country’s White population but were not equally applied to African Americans.

Byrd and Clayton describe Reconstruction as the “nadir of Black health status.”8 Following the Emancipation Proclamation, four million Africans transitioned from penniless chattel to helpless paupers beset with problems that included epidemics, poverty, poor housing, poor sanitation, and unequal access to formal healthcare and epidemics, all of which can be linked to structural racism. The Bureau of Refugees, Freedman, and Abandoned Lands, created in 1865, was designed to provide aid to formerly enslaved Black people. In their history of the Bureau, Franklin and Moss report that the organization provided public type services that yielded positive outcomes.9 For example, the death rate among formerly enslaved Blacks was reduced and sanitation conditions improved. This was accomplished before the advent of medical insurance. Bowing to pressure from White politicians who viewed the Bureau as an encroachment on state’s rights, it was disbanded after a short seven years in 1872. After being enslaved for 250 years, seven years was certainly not sufficient to address the cumulative effects of disease and illness on African Americans. The continuing condition of ill health and disease would be apparent in the population as they settled in rural areas and cities.

RACIAL DISPARITIES: EARLY TWENTIETH CENTURY 1901-1929 In his classic study, the Philadelphia Negro, DuBois uncovered disparate health outcomes in the Seventh Ward, an area where Blacks were concentrated.10 Health disparities were apparent in death rates attributable to illnesses involving the urinary system, pneumonia, diarrheal diseases, cancer and tumor. For example, the mortality rate for Blacks due to pneumonia was 356.67 per 10,000 people, compared to 180.31 for Whites. His study uncovered tuberculosis as the leading cause of death among African Americans, noting “Bad ventilation, lack of outdoor life for women and children, poor protection against dampness and cold are undoubtedly the chief causes of this excessive death rate.” Consistent with DuBois’ reputation of holding the Black community accountable for some of their problems as well as their uplift, he also stated, The most difficult social problem in the matter of Negro health is the peculiar attitude of the nation toward the well-being of the race. There have, for instance, been few other cases in the history of civilized peoples where human suffering has been viewed with such peculiar indifference.

RACIAL DISPARITIES: THE GREAT DEPRESSION TO WORLD WAR II (1929-1945) The consequences of the Great Depression in the areas of health were devastating for White and Black Americans. Poverty, among other things, created homelessness and unemployment. This situation meant that people were not living in the most sanitary environments, regularly eating healthy foods, or maintaining sanitary habits. But, while the depth of poverty, hunger, sickness and mortality was severe for everyone, it was greater for African Americans. In 1929, the first year for which national figures are available, White life expectancy at birth was 58.6 years, and Black life expectancy was 46.7 years for men and women combined. By approving and carrying out the Tuskegee Experiment, public health earned a permanent stain on its reputation as an agency

that contradicted its mission to prevent disease especially in a disadvantaged, underprivileged populations. Sponsored by the U. S. Public Service in Macon County, Alabama, this research followed the progression of untreated syphilis in more than 400 poor African American men, most of whom were sharecroppers or day laborers. The study was conducted from 1932 to 1972. Later research showed that there was, “no evidence that informed consent was secured from human participants in the study.” It was only after the study was reported by the Associated Press in 1972 that it was ended.11

RACIAL DISPARITIES: CIVIL RIGHTS PERIOD PRE-COVID-19 (1960S-2020) The Civil Rights Era expanded the African American population’s pathway to health outcomes that are equal to those of White Americans. By doing so, the period demonstrated how civil rights laws and their enforcement added leverage to public health as an instrument for social justice. Literature not only links enforcement of civil rights laws to better health outcomes for African Americans, but also designates civil rights as a social determinant of health. For example, until the start of the Civil Rights Movement, hospitals in the North and the South either denied admission to African Americans or restricted their inpatient care to segregated wards, frequently situated in cold attics or damp basements. The 1963 decision in Simkins v. Moses H. Cone Memorial Hospital found that the separate-but-equal clause of the 1946 Hill-Burton Act, which provided federal monies for hospital construction, was unconstitutional. The ruling ended segregation in hospitals. Subsequent Medicare and Medicaid legislation in 1965 mandated the integration of hospitals; thereby, giving the African American population access to “decent,” mainstream health care after 300 years of indecent healthcare. Hahn, Truman and Williams concluded that civil rights break down barriers to access to care and, in addition, reduce health disparities in the African American population.12 For example, following enforcement of Title VI of the Civil Rights Act, data showed that in hospitals that were previously segregated (most were in the South) between 1965 and 1971, the infant mortality rate among non-whites (approximately 99% of whom were Black) fell by 40% from 40 to 28 per 1,000 live births, while the rate among Whites changed little. Overall, it is estimated that between 1965 and 2002, approximately 38,600 Black infant deaths were prevented by implementation of Title VI of the Civil Rights Act. The Heckler Report, published in 1985 and authorized by then Secretary of Health, Education and Human Services, Margaret Heckler, produced the first complete examination of the burden of health disparities carried by African Americans and other people of color. She described health inequalities among disadvantaged African Americans and other minorities “as an affront both to our ideals and to the on-going genius of American medicine.” At the end of the Great Depression, the age-adjusted mortality rate for Black men was 53 percent greater than that for White men. By 1984, it was 46 percent greater. A National Center for Health Statistics Report published in 1985 indicated that African American children were twice as likely as White children to die before reaching one year of age. 45

Eighteen years later in 2003, the Institute of Medicine (IOM) would publish an incisive report that would also link health inequities in the Black population to structural racism.13 In its discussion of health disparities in the Black population the IOM’s review of the problem, said, Despite steady improvement in the overall health of the U.S. population, racial and ethnic minorities, with few exceptions, experience higher rates of morbidity and mortality than non-minorities. African Americans, for example, experience the highest rates of mortality from heart disease, cancer, cerebrovascular disease, and HIV/ AIDS than any other U.S. racial or ethnic group. The report also noted that when socioeconomic factors are equal among Whites and Blacks, inequality in quality of health care is still present and thus is a reason for concern.

MR. GEORGE FLOYD AND OTHERS: POLICE VIOLENCE AS A PUBLIC HEALTH CRISIS: Including the deaths of African Americans at the hands of police officers in a discussion about race and health disparities and race and public health might seem out of place until the American Public Health Association’s (APHA) policy statement declaring police violence a public health crisis is considered. The statement, in part, states, “Physical and psychological violence that is structurally mediated by the system of law enforcement results in deaths, injuries, trauma, and stress that disproportionately affect marginalized populations…”14 With respect to African Americans, the salient literature includes research that shows that Black men in America are 3.5 times more likely to be killed by police, compared to their White counterparts. For Black women, the rate is 1.4 times more likely. In fact, other important studies reveal that the impact of police brutality goes beyond physical death and physical harm. That inequities in terms of the negative outcomes also include negative psychological consequences. For instance, two large studies revealed that African Americans were more likely than White respondents to report stress as a consequence of interactions with police. The APHA’s response is particularly instructive in the way it not only connects police brutality to structural racism but, in facilitating viewing the crisis through a historical lens. Accordingly, the association offers the ecosocial theory of disease distribution as a conceptual framework for such an approach, noting that the concept “holds that to meaningfully analyze and interpret the population distribution of health exposure, a grounding in historical context from which the exposure emerged is necessary. Having applied the theory to the status of Blacks before and after emancipation, the APHA maintained that “U. S. policing was historically deployed for the social control of communities deemed socially marginal (i.e., in the 19th century, it evolved from ruling-class efforts to control the immigrant working class in the North and the slave patrols in the South.” Myrdal made this point in his classic study, An American Dilemma, in which he concluded, “In the policeman’s relation to the Negro population in the South…he stands not only for civic order…but for white supremacy.”1 46 Delaware Journal of Public Health – November 2020

Thus, the police brutality seen in African American communities is not a recent phenomenon but rather represents part of a legal institution with interlocking policies and procedures that support a system of discriminatory policing that creates and maintains a disproportionately high burden of health disparities in the form of death, physical injury and psychological trauma and other form of mental disorders in the African American population. Furthermore, this situation is not a recent phenomenon. Its origin can be traced to periods before the Civil War, from 1619 to the Civil War, and after African Americans’ emancipation from enslavement in 1865. This ascribed position immediately translated into inequities in the areas of health and law enforcement that are long standing and have pointed the eyes of public, public health professional and the health care system, in general to an even deeper look toward history as a conveyor to the present day health disparities so readily apparent in the African American population

CONCLUSION AND RECOMMENDATIONS The past really does inform the present. Accordingly, this paper supported the point of view that the “Enough Is Enough” protests that erupted across America following the death of George Floyd, and the longstanding health inequities the COVID-19 pandemic brought front and center for many Americans can be traced back to the 17th century. During the mid-1600s the ancestors of present-day African Americans were relegated to the lowest rung of American society legally and in terms of social status. The rationalizations for the rulings and subjective judgements that placed this population in a caste position were based on race, color, scientific racism, and, the need for a free labor force that was the life line for the economic future of the colonies. The laws that held enslaved Africans and maintained their descendants in an unequal status did so not because they were poor, or because they were vagrant or because they were guilty of committing crimes, “but simply because they were African” and of African descent. Their ancestry and ethnicity became the maker for indelible subordination and inequality. This situation, in turn, directly contributed to health inequities that have persisted up to present day. Thus, the outcomes have been cumulative and have negatively impacted the health status of millions of African Americans. Herein lies the essence of this article. Namely, the “caste status” to which African Americans were assigned during the country’s formation created immediate and on-going inequities in health outcomes that are continual and diffuse in today’s African American population. The article emphasizes that the differentials in health status are manifestations of structural racism that have impacted generations of Black people. Moreover, not just the public health profession, but the health care system, as a whole, has been complicit in the persistence of health disparities we are witnessing. In other words, structural forces and interconnected systems including, but not limited to, discrimination, segregation and police violence combined to create long-standing structural racism as a factor that explains the situation where African Americans were and remain less healthy physically and psychologically, compared to their White counterparts. Therefore, this article maintains that structural racism should be included in the social determinants of health.

Unless the public health profession declares the elimination of health inequality in the African American population as its top priority, the health disparities among African Americans will remain a major healthcare problem for health care professionals, medical researchers and policy makers. Furthermore, this article has demonstrated that including history as a variable in the analysis of the morbidity and mortality gaps between Black and White Americans certainly provides a basis for framing public health as a medium for social justice. That is, redressing deliberate public health and health care policies, the results of which include health disparities, that created cumulative health outcomes since the 1700s that are readily apparent in the health disparities that exist today. A historical context gives credence to specific recommendations that can lead to equity in health outcomes for African Americans: 1. Public health for social justice should be grounded on an historical understanding of the manner by race and related structures, processes, ideologies, and connected institutions (e.g., healthcare, law enforcement) influence present day health outcomes for African Americans. Although there is research that suggests that past events have substantial impacts for future generations, few studies focus on health outcomes or health inequities. 2. Public health organizations should frame necessary policies, programs and services to African Americans as a form of material restitution for enslavement and the burden it exacted on African Americans for 400 years. 3. Public health organizations and the medical profession in general should address the widespread mistrust among African Americans toward medical research. Such acknowledgement should begin by acknowledging the notorious ethical misconduct by public health officials and practicing physicians that occurred and the group’s understandable reluctance to participate in medical research. The mea culpa should be followed by research universities, medical institutions and research agencies giving African Americans clear explanations regarding need for participation in medical research on the part of African Americans. African Americans desperately need the medical advantages and revelations that only ethical, essentially therapeutic research initiatives can give them.15 4. The health profession should expand the number of community-based health and public health programs that include a required community-engagement component. Membership on advisory and research boards must include ordinary people who can offer workable and effective ways to: (1) obtain community buy-in to research and (2) offer the kind of knowledge, insights and creative solutions based on lived experiences that cannot be provided by mainstream-oriented professionals who do not reside in the communities most beset by health inequities. Such programs involve grassroots residents in every step of the research process including identifying the problem, selecting

methodology, collecting and analyzing data, and disseminating and advocating for policies and programs to legislators, governors, and other constituents. The DE-CTR ACCEL and Citizen Science offer concrete examples of participation in research with satisfactory results for both scientists and citizen participants. 5. Structural racism should be included in the social determinants of health; that is a condition in which people function that impacts quality of life. Structural racism - historical and contemporary - as an impediment to access to health care and as an explanation for health disparities among African Americans that have passed from generation to generation is a social determinant of health. However, obtaining healthcare does not necessarily lead to reducing health inequities. Mathew, Reeves and Rodrique report health care alone accounts for only approximately 10 percent of health impacts, where social and environmental factors account for 20 percent, genetics, 30 percent and behavior 40 percent.16 They also note that closing the gap in health outcomes for Blacks and Whites means addressing inequity in upstream social and environmental factors that impact health. 6. Public health professionals should more frequently employ ethnographic research models that provide contextual data in the areas of behavior, culture, physical, psychological status and history that cannot be gleaned solely from quantitative data. 7. Undertake recruitment efforts that aim to increase African American health professionals. Health inequities are connected to cultural and psychosocial factors related to patient views of health, health status, and the health care system, all of which determine health care-seeking behavior and are influenced by structural characteristics of our health care system. A Stanford study revealed that, when patients and doctors had an opportunity to meet face to face, patients assigned to an African American doctor increased their request for preventive measures, even invasive procedures. 8. Increase funding to Historical Black Colleges and Universities to develop training centers for African American public health professionals. In 2018, figures published by the American Medical Association reported that among practicing doctors, 56.2 percent self-identified as White, 17.1 percent Asian, 5.8 percent Hispanic and 5.0 percent Black or African American.17 Of the top ten undergraduate feeder institutions applying to medical schools, three HBCUs- Spellman, Howard and Xavier (LA)- are the top producers of individuals who plan to become doctors. 9. Increase funding to support universal public health system that has the capacity to assure equal access and quality and non-disparate outcomes. Correspondence: Dr. Marlene Saunders, marlenesaunders145@gmail.com 47

ADDITIONAL RESOURCES Akbar, N. (1984). Chains and images of psychological slavery; Almond D., Chay K., & Greenstone M. (2006). Civil rights, the war on poverty, and Black-White convergence in infant mortality in the rural South and Mississippi; Alsan, M., & Garrik, O. (2018) Does diversity matter for health? Experimental evidence from Oakland; Azibo, A. (1996). African psychology in historical perspective & related commentary; Bennett, Jr. L. (1962). Before the mayflower: A history of the negro in America 1619-1964; Boon, A. S., Valasco-Mondragon, H. E., &, Wagner F. A. (2016). Improving the health of African American in the USW: an overdue opportunity for social justice; DuGruy, J. (2005). Post traumatic slave syndrome: America legacy of enduring legacy of enduring injury and healing; Gamble, V. N. (2010). There wasn’t a lot of comforts in those days: African American, public health, and the 1918 influenza epidemic; Gee, G. C., &, Ford, C. L. (2011). Structural racism and health inequities: Old issues, new directions; Gostin, L. O., & Powers, M. (2006). What does social justice require for the public’s health? Public ethics and policy imperative; Grills, Cheryl Tawede. (2006). African Centered Psychology: Strategies for Psychological Survival & Wellness; Jaynes, G. D., & Williams, Jr., R. M. (Eds.). 1989. A common destiny: Black and American society; Public Broadcasting Station (1998). Africans in America; Shabazz, J. (2018). An Identity Healing: Socialization and African-Centered Practices with At-Risk Youth; Thomas, S. B., & Casper, E.C. (2019). The burdens of race and history on Black people’s health 400 years after Jamestown; Union of Concerned Scientists (2017). Environmental justice for Delaware: Mitigating toxic pollution in New Castle Delaware community; U.S. Department of Commerce (1979). The social and economic status of the Black population in the United States: An historical view, 1790-1978; U. S. Department of Health and Human Services (1985). Report of the Secretary’s task force report on Black and minority health; Wilkerson, I, (2020). Caste: The origins of our discontent.

REFERENCES 1. Myrdal, G. (1944). An American dilemma: New York: McGraw Hill. 2. Turnock, B. J. (2009). Public health: What it is and how it works. Boston: One and Bartlett Publishers. 3. Krieger, N., & Birn, A. E. (1998, November). A vision of social justice as the foundation of public health: Commemorating 150 years of the spirit of 1848. American Journal of Public Health, 88(11), 1603–1606. https://doi.org/10.2105/AJPH.88.11.1603 4. Rawls, J. (1971). A theory of social justice. Cambridge, MA: Harvard University Press. 5. Johnson, C., & Smith, P. (1998). Africans in America: America’s journey through slavery. New York: Harcourt Brace & Company. 6. Finkenstaedt, R. L. H. (1994). Face to face: Blacks in America: White perceptions and black realities. New York: William Morrow and Company, Inc. 7. Institute of Medicine. (1988). The Future of Public Health. Washington, DC: The National Academies Press. https://doi.org/10.17226/1091 48 Delaware Journal of Public Health – November 2020

8. Byrd, W. M., & Clayton, L. A. (1992, February). An American health dilemma: A history of Blacks in the health system. Journal of the National Medical Association, 84(2), 189–200. https://pubmed.ncbi.nlm.nih.gov/1602519/ 9. Franklin, J. H., & Moss, Jr., A. A. From slavery to freedom: A history of African Americans (3rd ed.). New York: Alfred A. Knopf. 10. DuBois, W. E. B. (2007). The Philadelphia negro: A social study. Series Editor Henry Louis Gates. New York: The Oxford Press. (Original work published 1899). 11. Turner, G. (n.d.). Disease does not discriminate but U.S. public health does. Retrieved from https://www.mphonline.org/racism-public-health/ 12. Hahn, R. A., Truman, B. I., & Williams, D. R. (2017). Civil rights as determinants of public health and ethnic health equity: Health care, education, employment, and housing in the United States. SSM-Population Health, Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730086/citedby/. doi:10.1016/j.ssmph.2017.10.006 13. Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2003). Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: Institute of Medicine. 14. American Public Health Association. (2018). Addressing law enforcement violence as a public health issue. Retrieved from https://www.apha.org/policies-and-advocacy/public-health-policystatements/policy-database/2019/01/29/law-enforcement-violence 15. Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on Black Americans from colonial times to the present. New York: Anchor Books. 16. Mathew, D. B., Reeves, R. V., & Rodrigue, E. (2017). Time for justice: Tackling race inequalities in health and housing. In M. O’Hanlon (Ed.), Brookings: Big ideas for America, pp. 28-47. Washington, DC: Brookings Institution Press. 17. American Medical Association. (2019). Diversity in medicine: Facts and figures, 2019. Retrieved from https://www.aamc.org/ data-reports/workforce/interactive-data/figure-18-percentage-allactive-physicians-race/ethnicity-2018



The Promise of Good Health for All: Transforming Public Health in America

OCTOBER 2020 49

Racism is a Public Health Crisis Spring and summer 2020 were trying seasons, provoking multiple reactions including despair, confusion, and anger, but also hopefulness and a determination that once and for all, conditions must change for the better. As America’s emergency departments filled with COVID-19 patients, America’s streets filled with protesters in response to more murders of unarmed Black people by police. In addition to the profound sadness and anger about what were preventable and unjustifiable deaths, millions of Americans were asking what could be done to convert the outrage into actionable transformation. They were asking, how can we plant the seeds of meaningful change? Essential elements to bringing about such change involve acknowledging and overcoming structural racism and its impact on communities of color across multiple sectors including education, housing, employment, healthcare, policing, and criminal justice. This will not be easy, given how thoroughly racism in the United States is baked into the nation’s systems and structures, devaluing the lives of people of color, but it is work that must be done.16 Racism impacts people of color in nearly every facet of their lives from where they live, to where they go to school and work, to where they shop and feel safe. Racism and its legacies are often at the root of the conditions in today’s communities of color that drive disproportionately poor health outcomes. The COVID-19 pandemic made this reality starkly obvious. According to CDC, as of July 2020, Blacks have died from COVID-19 at a rate that was double the rate of deaths for whites, 92.3 deaths per 100,000 people for Blacks, and 45.2 deaths per 100,000 people for whites.17 As of August 2020, age-adjusted COVID19 mortality rates showed that Blacks died as a result of the virus at a rate 3.6 times higher than whites; Latinxs died at a rate 3.2 times higher than whites and Pacific Islanders died at a rate 3 times higher than whites.18

tetiana.photographer / Shutterstock.com

Additional examples of the impacts of structural racism include the fact that Black women are up to four times more likely to die due to pregnancy related complications than white women19 and Black men are twice as likely to be killed by police than are white men.20 A higher proportion of Black people have underlying medical conditions such as heart disease and diabetes due largely to policies that have created obstacles to healthy, affordable foods, opportunities for physical activity and safe and affordable housing.21 In addition, during the COVID shutdown, a higher proportion of people of color are working in jobs designated as “essential,” such

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as frontline jobs in grocery stores, healthcare and mass transit systems.22 Another factor that impacts the health status of Black Americans, and, puts them at greater risk of a serious outcome during an infectious disease outbreak, is the cumulative effect of having to navigate a racist world.23 These experiences range from police violence to perpetual microaggressions which can result in continual stress and damaging physiological changes. The consequences of disparities in health insurance coverage and access to high quality care also impact the health of people of color during so-called normal times, and are exacerbated during public health emergencies. Increases in the TFAH • tfah.org


Source: The Aspen Roundtable on Community Change

numbers of American Indian/Alaska Native, Black and Hispanic families with health insurance coverage created by the Affordable Care Act began to slip in 2017 due to changes in the program. According to the Kaiser Family Foundation, in 2018, almost 22 percent of the American Indian/ Alaska Native community did not have health insurance. Within the Hispanic and Black communities, the uninsured rates were 19.0 and 11.5 percent respectively. Approximately 8 percent of Native Hawaiians and Pacific Islanders were uninsured and slightly over 7 percent of Asian Americans were uninsured. The uninsured rate for whites is 7.5 percent.24 8

TFAH • tfah.org

Dr. Gail Christopher, the chairperson of TFAH’s Board of Directors, asked the following question in an essay published in The Crisis Magazine: “Could this pandemic help us, as a whole society, to finally see and understand the dire consequences and overwhelming implications of racism? If a critical mass of people is now seeing and recognizing our structural inequities — some for the first time — the next step involves acknowledging the consequences of those inequities.”25 Structural racism requires systemic and structural responses. Institutions within society from schools to

workplaces and housing, from healthcare to policing and criminal justice are in dire need of significant change. The only way to ensure everyone has the same opportunity to live a long and healthy life is to reconstruct the institutions that are rooted in racist legacies and, once and for all, remove the societal barriers to good health in every community. Racism in the United States has robbed people of color of their physical safety and economic opportunities for generations. It has impacted their physical and mental health and it has cut short too many lives. Collective change is urgently needed.





Make substantial and sustained investments in a more effective public health system, including a highly skilled public health workforce.

Public health emergencies are not only growing in frequency, severity and complexity, they happen in the context of an already inadequate public health system. These new threats include the growing risks associated with climate change, environmental toxins, health inequities, and increasing levels of chronic and infectious disease. The nation’s public health and emergency preparedness infrastructure does not currently possess sufficient resources to ensure the well-being of all communities during health emergencies. The magnitude of the impact of COVID-19 would be staggering by itself, but sadly, it also magnifies a life-threatening pattern, that is, a public health system that is only considered important during a crisis.

THE SOLUTION The nation’s public health system must be comprehensive and nimble. It should focus on prevention and be able to meet everyday priorities as well as surge its capacity during an emergency. It requires not only increased funding for disease-specific prevention programs but also increased and more flexible investments to rebuild a strong and robust public health infrastructure. In addition to a strong infrastructure, the public health sector needs increases in its categorical, i.e. issue or disease specific, funding. Such funding will allow it to address critical issues, such as the impact of climate change and the continuing epidemics of suicide, substance use, and obesity and the devastating impacts of structural racism.

A STRONG PUBLIC HEALTH SYSTEM IS THE KEY TO ENSURING AMERICANS’ HEALTH AND SAFETY The public health system is most appreciated in the midst of a crisis, but typically neglected at other times. The result of this habitual underinvestment is a public health infrastructure unprepared to meet 21st century health challenges. The COVID-19 crisis is a stark illustration of the degree to which the public health system needs to be rebuilt and protected against politicization.

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determinants of health. Unfortunately, in the United States today we are facing 21st century health challenges armed with 20th century tools. This weakened system is a threat to Americans’ health and welfare.


A 21st century public health system needs to be grounded in expertise in disease surveillance, data analytics, environmental monitoring, emergency preparedness, illness and injury prevention, health equity, and the social


To meet the nation’s growing public health demands, the sector needs to both be prepared for short-term priorities and adopt a Public Health 3.0 approach. The Public Health 3.0 model is designed to meet health risks and to address the social determinants of health and health inequities. The 3.0 model enables public health leaders at the local level to be chief health strategists for their communities, working across sectors and leveraging data to improve health at the population level.26 Public health infrastructure refers to the essential core components of a health department including: l

A well-trained and well-resourced workforce.


A state-of-the-art data and information system to assess and monitor population health status and factors that influence health and community needs.


A public health laboratory system that can rapidly and accurately meet the demands of a steady flow of viruses and other organisms, novel and long-standing.


Empowered public health leaders able to make recommendations and decisions devoid of political considerations.


An emergency preparedness system that is well prepared and equipped to address all hazards at the earliest possible point and surge capacity when necessary.


The capacity to address social determinants of health, end health disparities, and promote optimal health in all communities.


Community partnership development, including engagement with key groups representing populations experiencing health disparities.


Communicable disease control


Chronic disease and injury prevention


Environmental public health


Emergency preparedness and response


Policy development, support, and evaluation


Advancing health equity


Addressing the social determinants

Foundational Capabilities: l

including surveillance, epidemiology and laboratory capacity l

Maternal, child, and family health


Healthy aging


Social, emotional, and behavioral health


All-hazards preparedness and response


Policy development and support


Public communications


Community outreach and partnership development

of health l

Health monitoring and assessment


Organizational and administrative competencies, i.e. leadership, governance and health equity


Accountability and performance management

Access and linkages to social services and clinical care


TFAH • tfah.org


FROM HEALTHY PEOPLE 2020 AND 203028 Why Is Public Health Infrastructure Important? Public health infrastructure provides communities, states,

who have cross-cutting competencies and technical skills, up-

and the nation the capacity to prevent disease, promote

to-date information systems, and public health organizations

health, and prepare for and respond to both acute

with the capacity to assess and respond to community health

(emergency) threats and chronic (ongoing) challenges

needs. Public health infrastructure has been referred to

to health. Infrastructure is the foundation for planning,

as “the nerve center of the public health system.” While a

delivering, evaluating, and improving public health.

strong infrastructure depends on many organizations, public

All public health services depend on the presence of basic infrastructure. Every public health program—such as immunizations, infectious disease monitoring, cancer screening, asthma prevention, drinking water quality, and injury and suicide prevention—requires health professionals

health agencies (health departments) are the central players. Federal agencies rely on the presence of solid public health infrastructure at all levels of government to support the implementation of public health programs and policies and to respond to health threats, including those from other countries.

RECOMMENDATIONS FOR POLICY ACTIONS Rebuild and modernize the public health system by creating a mandatory $4.5 billion per year Public Health Infrastructure Fund to support foundational public health capabilities at the state, local, territorial and tribal levels. These infrastructure needs include modern facilities and health information and data systems. The funding may focus on “bricks and mortar” and systems development, but it should also include ongoing support for the workforce necessary to successfully leverage the investment. For example, skilled laboratory workers as well as up-to-date public health laboratories and equipment and sophisticated data managers and analysts as well as hardware and software investments, are needed. Additional funding should be provided to allow CDC and other federal agencies to have the internal resources to meet their own infrastructure needs and to provide data, technical assistance, oversight, and evaluations of resources to states, territories and tribes.

Preserve and protect the Prevention and Public Health Fund. The Prevention and Public Health Fund was created by the Affordable Care Act and is the only dedicated, mandatory funding source for prevention and public health programs within the federal budget. By statute, it is intended “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public healthcare costs.”29 Due to funds being directed to other spending, the Prevention Fund has lost nearly $12 billion.30 Congress should restore funding to the level of $2 billion per year and direct that all future spending from the fund be focused on critical public health needs.

Congress should create a Health Defense Operations budget designation. TFAH supports a bipartisan call for Congress to exempt health security funding lines from Budget Control Act spending caps to enable sustainable resources for

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relevant programs at CDC and other U.S. Department of Health and Human Services (HHS) agencies.31 Such an exemption is needed to ensure responsible funding that meets the needs of the nation’s health security, rather than leaving health security subject to sequestration and other budget constraints.

Modernize public health surveillance and data. The nation’s public health surveillance infrastructure currently relies on antiquated, disconnected systems and methods for tracking and responding to diseases. Local, state, and federal data systems have not kept pace with current technologies and result in delayed detection and response to public health threats. The COVID-19 crisis illuminates many of these weaknesses, as public health officials try to track disease patterns with incomplete data and archaic reporting mechanisms. Cross-cutting investments are needed to revitalize the CDC’s data infrastructure, as well as to shore up state and local public health surveillance capabilities.

TFAH • tfah.org


TFAH supports an additional $450 million in immediate funding and $100 million per year over the next 10 years to modernize the public health surveillance enterprise and build secure, interoperable systems and a highly trained workforce. $50 million was included in the FY20 spending bill as a down payment on public health data modernization, and $500 million was including in the Coronavirus Aid, Relief, and Economic Security Act (P.L.116-136) but more immediate and annual funding is needed to modernize and sustain these systems.

packages do not allow for permanent recruitment and retention of public health staff. Congress should prioritize development of the public health workforce, including public health national service programs; funding incentives to enter and remain in the public health workforce, such as loan repayments; recruiting and retaining a workforce with needed skills, such as informatics; and improving training.

Recruiting and retaining the public health workforce. A 21st century

politics into public health decisionmaking puts the public’s health at risk.

public health system, equipped to address emergencies and serve as chief health strategists for communities, requires a 21st century workforce. The most recent Public Health Workforce Interests and Needs Survey found that the public health workforce faces major challenges in turnover and attrition, putting the public’s health at risk.32 Reductions in federal, state and local public health budgets have undermined efforts to hire, train, and retain a strong public health workforce, which in turn limits governments’ ability to effectively protect and promote the health of their communities. In the 10 years following the 2008 recession, local public health departments lost an estimated 26,000 (16 percent) FTE staff positions due to federal, state, and local budget cuts.33 Already operating from this deficit, the loss of state and local revenues due to COVID-19 is likely to have a similar, if not worse impact on the public health workforce. Short-term funding from COVID-19 response


TFAH • tfah.org

Empower public health officials to make decisions based on science and devoid of political considerations. Any efforts to infuse

Provide full-year funding for federal agencies to allow for uninterrupted planning and program implementation. Many federal agencies play a role in protecting and improving public health. When the government is operating under a short-term continuing resolution—or worse, a shut-down—public health and other programs that promote health can be crippled.34 Temporary funding through emergency supplementals or short-term continuing resolutions, followed by stagnant budgets, do not allow for recruitment and retention of highly skilled, full-time workers nor long-term project planning. Congress should enact full-year appropriations measures that fund federal agencies for the entire fiscal year. This is essential for effective and efficient use of taxpayer dollars and for planning and maintaining the workforce, supplies, and other capacities necessary to support all public health functions.




Mobilize an all-out effort to combat racism and other forms of discrimination and to advance health equity by providing the conditions that optimize health. THE PROBLEM Structural racism, systemic inequities, discrimination, and poverty have existed in the United States for generations and have been documented as predominant drivers of health inequities.35 Their impact results in higher rates of deaths from illness and injury among people of color,36 and this increased risk of poor health persists even when controlling for socioeconomic factors.37 Many marginalized groups, including communities of color, gender and sexual minorities and people with disabilities, have been historically prevented from obtaining what is necessary to be healthy – a safe place to live, a job that pays a living wage, and access to quality education and healthcare services. Therefore, an explicit focus on ending systemic discrimination is fundamental to advancing equity, providing everyone fair and just opportunities for optimal health, and improving the nation’s health outcomes.

THE SOLUTION To achieve health equity, opportunities and community conditions that allow all residents to live the healthiest life possible regardless of who they are, where they live, or their income level, are needed. This means overcoming centuries of inequitable policies and practices and addressing discrimination that persists today in virtually every sector, including education, employment, healthcare, housing, environment, policing and criminal justice. Central to addressing these inequities is acknowledging the history and current practices that have caused them, addressing their root causes, and taking action steps in multiple areas of social, economic and health policy to drive systemic change and to overcome the harmful barriers to health and well-being.


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Health disparities are preventable differences in the burden of disease, injury, violence, or in opportunities to achieve optimal health experienced by socially disadvantaged racial, ethnic, and other population groups, and communities.38 While the underlying causes of health inequity and healthcare disparities are complex and interwoven, the COVID-19 pandemic has put a spotlight on the alarming disparities between people of color and whites, further heightening the urgency and critical need for leadership, commitment, and increased and directed resources to address these disparities.


An expert committee of the National Academies of Sciences, Engineering, and Medicine affirmed that, “Health inequities are the result of more than individual choice or random occurrence. They are the result of the historic and ongoing interplay of inequitable structures, policies, and norms that shape lives.�43

The drivers of health inequities largely stem from structural racism, which fuels poverty and discrimination, undermines equity and opportunity, and is far reaching in health, education, economic opportunity, employment, housing, transportation, and criminal justice, among many other systems.39, 40 The toll from racism is evident in the impact of the disinvestment in and marginalization of communities of color, unhealthy social, economic, and environmental conditions, and the lack of opportunities within those settings, which result in deaths at earlier ages and high rates of chronic and infectious diseases.41 It is important to note that health inequities continue to exist even when controlling for socioeconomic factors such as income or education level.42 Because the structural drivers of these disparities are largely rooted in system-level inequities, socioeconomic drivers, and biases, a multi-agency, multi-sector, coordinated effort will be required to correct them. People of color have a shorter life expectancy of 10 years or more than whites in neighboring areas.44 For example, researchers have tied the legacy of historic redlining, which has led to intergenerational, concentrated poverty and environmental health risks, to persistently higher rates of asthma,45 obesity,46 and mortality from chronic disease.47 The infant mortality rates among Black infants and American Indian/Alaska Native infants are respectively 2.3 times and 2.0 times that of non-Hispanic white infants.48, 49 Blacks, Latinxs, American Indians/ Alaska Natives, Asian Americans, Native Hawaiians, and Pacific Islanders have higher rates of diabetes than non-Hispanic whites.50, 51 Black and


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American Indian/Alaska Native women die from pregnancy-related causes at rates approximately three times higher than that of non-Hispanic white women.52 Similar disparities have borne out in the COVID-19 pandemic. While all populations, regardless of race, ethnicity, socioeconomic status, age, and sex are at risk for COVID19 infection, people of color have experienced disproportionate health and economic impacts from COVID-19. The death rate among Blacks is nearly two times their percentage of the U.S. population;53 the Navajo Nation has the highest per capita rate of infection in the United States;54 and Latinxs and Native Hawaiians and Pacific Islanders represent a greater percentage of confirmed cases than their share of the population in several states.55 Other groups face additional challenges. LGBTQ+ individuals face health disparities linked to societal stigma, discrimination and denial of human rights.56 Individuals with disabilities are less likely to receive preventive health services, are at higher risk for poor health outcomes, and may be overlooked in public health data.57 These disparities are compounded at intersections of demographics, such as Black LGBTQ+ people, who are subjected to higher rates of violence than white counterparts.58 Daily occurrences of prejudice and discrimination result in adverse mental and physical health effects such as chronic stress, trauma, and elevated blood pressure. There is strong evidence that discrimination is associated with unhealthy changes to the body that can take their toll over time, such as long-term stress.59, 60 A 2017 survey found that 92 percent of Blacks and about 75 percent of Latinxs


and American Indians reported being treated differently when seeking health services, looking for housing, interacting with the police and even doing day-to-day tasks.61 Such treatment can result in the avoidance of necessary healthcare and can reinforce social isolation. Given the longstanding existence of health inequities, it is not realistic to expect a single program or policy to solve the nation’s health inequities. Action steps, however, can be taken to promote health equity. Policy, systems, and environmental changes with an intentional focus on health equity can lay the foundation for transformative efforts to end inequities. Attention

should be paid to the allocation of resources to the populations most impacted and to meaningful and authentic engagement of members of those communities to set priorities and develop and implement initiatives to promote equity. Other sectors must also be involved as is the case when addressing the social determinants of health. For example, the elimination of racial segregation requires involvement from the housing, community finance, transportation and educational sectors. Approaches are needed to reduce health risks such as identifying the most pressing health needs in every community and prioritizing those areas for investment.

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RECOMMENDATIONS FOR POLICY ACTIONS The administration and Congress should make advancing health equity and eliminating health disparities a national priority. Policy,

and annually and publicly report on efforts and progress towards achieving health equity goals. Investment in the design of rigorous and innovative evaluation methods will be needed to effectively capture the impact of comprehensive, upstream interventions and strategies including policy analyses and evaluation. All HHS Operating and Staff Divisions should assess and heighten the impact of policies, programs, and resources decisions to reduce health disparities and advance health equity.

systems, and environmental changes must have an explicit focus on equity to yield the desired outcome of preventing and reducing disparities. Moreover, evaluation of these efforts is vital to monitor progress, demonstrate impact, and ensure accountability for federal policies and programs. l




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Create a Truth, Racial Healing and Transformation Commission and fund communities to begin the process of acknowledging the history of racism and working to dismantle the myth of hierarchy based on race. The process of racial healing and transformation is a necessary building block for reforming the systems and beliefs that inhibit health. This process should be complemented by grants to local communities, built from the framework developed by the W.K. Kellogg Foundation, to implement multisector truth, racial healing and transformation collaborations at the local level.62, 63 Reinforce the senior-level, federal interdepartmental task force on advancing equity for the nation, including a review of federal policies and programs in housing, employment, health, environmental justice and education that have contributed to health inequities. Federal departments must hold senior leadership accountable for developing concrete goals that are matched by policies, resources, and public reporting. All HHS Operating and Staff Divisions should be required to establish goals, develop related strategies and actions


The HHS Office of Minority Health, the National Institute on Minority Health and Health Disparities, and the agency Offices of Minority Health (Agency for Healthcare Research and Quality, CDC, Centers for Medicare & Medicaid Services, Food and Drug Administration, Health Resources and Services Administration, and Substance Abuse and Mental Health Services Administration) are all vital to minority health and health equity leadership, infrastructure and expertise within HHS. The COVID-19 pandemic has underscored the importance of these offices and institutes, in light of the greater impact of the pandemic on communities of color. These offices and institutes must have the authorities, budget, and resources comparable to other offices, institutes, and centers within the respective agency and/or aligned to the statutory mandate of that office or institute.

Further develop and expand funding for programs that serve under-resourced and marginalized communities. Longstanding disinvestment in and marginalization of many communities of color across the country has resulted in fewer 59

resources and services for optimal health. These limited resources and services manifest as less access to healthcare services, less availability of healthy food grocers, and fewer community-based and social services. l

Congress should enact, fund and build on the Health Equity and Accountability Act (HEAA) and similar legislation to improve healthcare access and to reduce disparities among communities of color and populations at higher risk.64 HEAA can serve as a framework for multiple federal agencies to address underlying causes of health inequities.


Congress should increase funding for existing programs that address health inequities such as CDC’s Racial and Ethnic Approaches to Community Health (REACH) program and Good Health and Wellness in Indian Country program so that every state has targeted resources for promoting health equity.65, 66



The HHS secretary and all HHS operating and staff divisions should review HHS grant programs to ensure that such programs are directing their federal funding to close gaps in health outcomes in the most affected communities and evaluate the impact of such programs on health inequities. Congress and HHS operating and staff divisions should expand and fund programs throughout the Department to address health inequities that disproportionately impact people of color.

Ensure that federal funding to address equity engages those within the most affected communities. l

Establish policies, trainings and technical assistance to ensure that funded agencies establish meaningful

mechanisms for community members to be involved in all program planning, implementation and evaluation. Provide funding for community leaders development programs. l

Adapt grantmaking practices to account for differential needs, resources, and capacity: federal agencies should consider disease burden and social context when determining grantmaking eligibility criteria, so that communities with the greatest health-related needs can benefit from competitive grant mechanisms.


Create mechanisms within the grant funding process across all federal agencies that assist underresourced communities and build capacity for those communities and organizations which are most often at a disadvantage in the grant application process, allowing them to develop competitive and successful grant applications.

Congress and state legislatures should create and appropriately fund programs to assist in the recruiting, hiring, and retention of a diverse public health workforce at all levels, including in senior leadership roles. Workforce diversity is essential to improving the quality of services, reducing health disparities, and advancing health equity. Studies document that minority practitioners are more likely to practice in underserved and minority communities.67, 68 Evidence has shown that organizations with a more diverse workforce provide higher quality services and more culturally and linguistically appropriate services.69 Furthermore, an organization with a workforce that reflects the

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community it serves can help build trust amongst community members for that organization. Diversity should exist at all levels of an organization, including in governance and leadership to promote organizationwide commitment and action to equity. Given the growing cultural diversity and changing racial and ethnic demographics of the U.S. population, a diverse public health workforce is imperative to meeting the needs of the population. Such programs could include tuition assistance or student loan forgiveness programs. l

The Office of Personnel Management should create and publish a government-wide diversity and inclusion strategic plan, and follow-up annual reports, including disaggregated data by race and ethnicity of federal workforce leaders. The plan should set goals to ensure that the composition of the federal workforce leadership reflects and is responsive to the nation’s diverse population such that varied perspectives are represented to address longstanding systemic inequities.

Improve publicly reported data collection quality and availability, require all agencies collect, disaggregate and report health data in such a way that the impact of health conditions, policies or interventions on specific population groups are known. In order to eliminate health disparities, it is vital to have quality, comprehensive, and consistently available disaggregated data to identify disparities, develop targeted, culturally and linguistically appropriate policies and programs, and monitor progress in reducing health inequities. The gaps in data are due in part to the nation’s fragmented and antiquated public health surveillance 18

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systems and the lack of interoperability between clinical and public health systems, all of which make it more difficult for clinicians to collect and report accurate data to public health agencies. The COVID-19 pandemic magnified the inadequacy of currently available disaggregated data and the challenges to data surveillance systems that are essential to monitoring testing; collecting data on confirmed cases, hospitalizations, and deaths; and developing tailored interventions, in particular among communities of color. If public health officials and policymakers cannot accurately assess differences in the health of different population groups, including at a more granular demographic level than broad racial categories, they cannot effectively address health disparities and disease prevention. l

Sustain and grow investments in public health data modernization at the federal, state, tribal, territorial and local levels, including by enabling electronic case reporting to state and local health agencies, educating providers on data collection and reporting, and reducing duplicate reporting systems to the federal government. All data should be collected and disaggregated by race and ethnicity.


Ensure that all HHS programs and public health agencies collect and publicly report standardized health and administrative data in a timely fashion and disaggregated by race and ethnicity, in accordance with the Office of Management and Budget Standards for the Classification of Federal Data on Race and Ethnicity,70 as well as by age, sex, primary language, disability status, sexual orientation, gender identity, and pregnancy status.


The Impact of Racism and the Influence of Faith on the Mental Health of African Americans W. James Thomas, II, B.S., M.Div., D.Min. Senior Pastor, Calvary Baptist Church, Dover, Delaware

Revisiting one of the videos of the funeral services for Mr. George Floyd, one of the immediate factors of concern was the comfort of the family. As much of what needed to be said was expressed, as a Pastor and helping professional, the concern was the mental space within which the family was living at that moment. All of what was said by the various speakers was true – systemic racism, racial disparity, police reform, white privilege – all of these topics deserve and require dialogue. However, the mental health impact of racism is a concern that should be given equal treatment. When reflecting on the murders of Rashard Brooks, a 27-yearold married father of four children, George Floyd, a 46-year-old African American man, Ahmaud Arbery, a 25-year-old African American man, and Breonna Taylor, a 26-year-old African American woman, there is no doubt that these deaths were horrific, unnecessary, and the result of systemic issues. But equally as horrific are the long-term mental effects associated with these types of incidents, as well as the long litany of stories that have been told and retold by family members and friends, as well as those yet to be told that share the same narrative. As horrific and tragic as these stories are, there will be other murders just as horrific and just as tragic in the days to come. The American Journal of Public Health has concluded that continued racism has very real mental health effects, such as depression and anxiety. Dr. Laia Bécares, a public health researcher, wrote, “awareness of racial discrimination experienced by others can continue to affect the mental health of ethnic minority people.1 Dr. Bécares suggests that we can even be impacted secondhand. Then, there are direct incidences, such as the occurrence in an area of Central Park called the Rambles, where Amy Cooper, a White woman, who was walking her unleashed dog, encountered Christian Cooper (of no relation), a Black man, who was bird-watching in a wooded area. Mr. Cooper informed Ms. Cooper that, per the ordinance of the city of New York, her dog needed to be on a leash. Ms. Cooper became agitated, called the police, and informed them that she had encountered a Black man in the park and feared for her life. Mr. Cooper, who amazingly remained calm, was guilty of nothing but informing Ms. Cooper of the law. This was an explicit example of the development of insecurities and avoidance that can be invoked by racial discrimination. Black people constantly live in a guarded state, which inevitably affects our mental, physical, and even our spiritual health. Insecurities and avoidance are stressors that are created by racism and discrimination when, for no other reason than being in proximity of White people, there is the false assumption of danger or some other life-threatening possibility. Not only does the proximity create the opportunity of a false narrative, but it causes Black people always to be aware of the 62 Delaware Journal of Public Health – November 2020

possibilities within that proximity and raises the awareness of the physiological and psychological impact of racism and discrimination. Often, just being in the same area as White people can create unrealized stress. Mary Gregory, a nurse at the St. Vincent Medical Center in Toledo, Ohio, said, “It is important to refer to racism as a public health “crisis” instead of an “issue.” Gregory’s rationale was that racism met the criteria of the CDC’s guidelines of a public health problem: 1) a burden on society that continues to increase, 2) the impact on certain parts of the population more than others, 3) preventative strategies could help, but 4) nothing has been done to address the matter adequately. Since racism is, in fact, a public health matter, the availability of and access to medical and mental healthcare must be addressed. There are obvious disparities in regards to medical and mental healthcare for African Americans, and these ethnic inequalities and race-based exclusions from both medical and mental healthcare threaten the hope and future of people of color. This is exacerbated by the stigma and lack of education in our communities on the issue of mental health. Some of the stigmatization stems from the historical context of mental health among African Americans. Racial disparities in diagnosing mental health conditions are sometimes presented as an effect of biology, but they are not. Those diagnoses were the direct result of the racist thinking that existed in psychology, which dates to at least the 18th century. African American Stories of Oppression recalls how slave owners and their White physicians invented psychiatric “disorders” such as “draeptomania” to explain the reason slaves felt the need to escape. These White physicians went so far as to distort statistics to suggest that freedom would be a threat to the mental stability of slaves.2 When considering the historical context, it is reasonable to understand the apprehension of African Americans toward mental health. In the area of mental health, Primm has suggested that African Americans have been misdiagnosed at higher rates than White patients.3 Culturally, mental health is viewed as a weakness, which is counter-cultural to the expectation of African Americans to be survivors and overcomers. Even spiritually, African American theology insists that because God is on the side of the oppressed, our faith in God will provide for us the necessary healing. So, the slow embrace of the reality of mental illness and the importance of therapeutic approaches to mental health stems from historical encounters, cultural expectations, and religious fortitude. The past president of the American Public Health Association accurately defines racism as “…a system of structuring opportunity and assigning value based on the social interpretation of how one looks, that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and

communities, and saps the strength of the whole society through the waste of human resources” (APHA Past-President Camara Phyllis Jones, MD, MPH, Ph.D.). We see this reenacted daily in various forms and fashions. It is primarily for this reason, this imposing of value, that African Americans are more often than not struggling with the proper valuation of worth in a society that has historically devalued us. As much as the professional services offered by mental health providers are needed in African American communities, the institution most often approached for assistance are faith-based institutions. The church was the first source of ownership for African Americans, and it has become the “resource center” whenever there arose a crisis in both the community and the individual; it has always been considered a place of refuge. From emotional strength to educational opportunities, to financial assistance, to simple inspiration, the Black church has been the “one-stop-shop” for African Americans. The church in the African American community embodies community values and exhibits the virtues that the community understands. Despite the current rhetoric related to the relevancy of the African American church, it was and continues to be the church that provides safety and security for African Americans when society excludes them because of race and class. In the pulpit, the pews, and the basements of African American churches, Historically Black Colleges and Universities (HBCUs) and the Civil Rights movement were birthed. The African American church has long been a place of safety and security for Black people. In 1964, a group of Black men in Jonesboro, Louisiana, founded a group called “The Deacons for Defense,” an organization purposed to protect the Congress for Racial Equality against violence from the Ku Klux Klan. The group would be noted as one of the first visible defense forces for African Americans in the South. Historically, the church has become a place where survival strategies have been developed, and protection of the rights of African Americans has been demanded. Today, the church endeavors to be a pivotal force as it redefines itself to declare that “Black lives matter forcibly.” The African American church continues to provide the affirmation and dignity to people who are yet struggling for equality and justice. It should not be considered strange that people eventually turn to their faith when the impact of racism manifests itself. The perfunctory aspects of the African American church may be somewhat antiquated, such as suggestions to simply pray or trust God; however, the power and strength that comes from the faith that is promulgated from the church have provided African Americans the mental solitude they could not get elsewhere. The theology of the African American church embodies the very character of the community. The sense of community, ritual, and discipline can be therapeutic and positively functional for one’s mental health. Rush University Medical Center published a study in the Journal of Clinical Psychology observing how faith actually helps protect patients against the symptoms of depression. The study indicated that “…for patients diagnosed with clinical depression, belief in a concerned God can improve

response to medical treatment.”4 The study found that persons with strong religious convictions were more likely to experience an improvement in feelings of hopefulness, measured by feelings of expectation for the future and motivation for the present. Specifically, participants who scored in the top third of the Religious Well-Being Scale were 75-percent more likely to get better with medical treatment for clinical depression. Wendy Cadge, a Brandeis university sociologist, reviewed eighteen published studies on prayer that were conducted between 1965 and 2006. From her review, she discovered the evolution of ideas about the relationship between religion and medical science. “I do not know why physicians and scientists conducted these studies,” according to Cadge, “but personal religious beliefs appear to have played a significant role, along with curiosity.”5 Of course, this is no strange phenomenon in the African American community – prayer was always the “gold standard” when dealing with any issue. Faith and science need not clash but can be complimentary. Faith does have a significant role in the conversation on racism and its view on the mental health of those who are Christians. Any truly biblically conscious individual cannot deny the fact that racism is a sin. It is a sin, like other sins, that requires a power greater than the human resolve alone to conquer. Faith, in general, and the Christian faith in particular, depends on a power greater than that which we possess. When analyzing the impact of racism and the influence of faith on the mental health of African Americans, the outcomes are profound. The profundity is due to the systemic nature of race and how racism impacts nearly everything that touches the daily lives of African Americans – where we shop, where we bank, where we live. That does not necessarily suggest that African Americans are alone in being subjected to racism and its mental effects. We know that is not true. However, it is to suggest that in the United States, African Americans have been the most frequently targeted when it comes to racism and have suffered significant negative consequences as a result. The Bureau of Labor Statistics shows that 54% of employed Asians worked in management, professional, and related occupations — the highest-paying major occupational category — compared with 41% of employed Whites, 31% of employed Blacks, and 22% of employed Hispanics. It is suggested that these statistics speak to the racist hiring practices that kept African Americans out of business for decades under Jim Crow. It can also be explained by more subtle forms of prejudice today. The point of racist hiring practices is further evidenced by a Harvard University study that found that when Blacks and Asians “whitened” their resumes — used “American” or “White”-sounding names — they got more callbacks for corporate interviews. Twenty-five percent of Black candidates received callbacks from their whitened resumes, while only 10% got calls when they left ethnic details on their resume. Our faith provides for us the framework to think through racism and see a path forward – but that does not come without the challenge to first see racism for what it is. Our faith becomes the lens through which we respond to the pain and brokenness and exclusion that racism has historically inflicted and justified for centuries. Our faith informs us that racism is a sin. It must be 63

dealt with in the heart first before there can be a changing of the mindset that perpetuates racist thinking, white privilege – the historical and contemporary advantages in access to a better quality of life that is based on race – and white supremacy – the belief that White people constitute a superior race and should therefore dominate society.

contact a mental health professional. This has little to do with the mental health professional, although there are some stigmas attached to the mental health profession. Consulting with their faith leader, however, has more to do with the fact that what they receive will be more aligned with their own beliefs and perspectives on mental healthiness.

How does our faith become the tool of our survival and the consolation of the disruption of our mental stability? John Calvin, in his work, “Institutes of the Christian Faith,” poses two critical questions: “Who is God?” and “Who am I?” If the first question is answered incorrectly, the second question will inevitably be answered incorrectly as well.6

Obviously, this can be problematic on both sides of the spectrum. On one side of the spectrum, some Pastors are not formally trained in mental health disciplines. On the other side of the spectrum, many times, the mental health professional may not be immediately open to the acknowledgment of a person’s religious values, beliefs, and faith orientations. There is space for continued conversation on the incorporation of a faith perspective within the context of racism and its impact on mental health.

Faith, in the African American tradition, challenges the Western epistemological perspective of humanity. Faith, in the African American tradition, resists the notion of a white coded humanity as being the “correct” standard. Faith, in the African American tradition, resists the notion that Africans needed to be rescued from heathenism, barbarianism, and uncultured behavior. As much as some would decry Christianity, as with anything else, it is not Christianity that is the problem; it is the misuse of Christianity and the abuse of the name of God to justify oppression, colonialism, racism, and injustice that is the true problem. Faith, when it is accurately and authentically practiced, provides hope in the time of mental anguish and anxiety. Faith is where we educate ourselves and unlearn false and unhealthy narratives and embrace the truth concerning who God is and who we are. Our faith creates space for us to reimagine a different world. For Christians, this is the picture of Christ on the cross, creating new possibilities and the space to become and overcome; to embrace and motivate us not to accept anything other than the truth of God – especially when people have been wounded by injustice, oppression, and suffering. Lest we think of the space that our faith provides us as some unattainable utopia, hope provides the platform for the creation of a new agency, a new experience, and a new reality. Hope provides the strength to move beyond empty rhetoric that excites us for the moment - especially when that hope becomes intentional praxis and not just poetic pleasantries. Faith, therefore, reinforms our experiences of racism, provides an informed perspective, and encourages us toward a more robust practice and demand for change. Our faith reinforms our experiences of racism by encouraging us to reimagine our world and work toward that renewal. By faith, we can have the “beloved community” that is based on justice, equal opportunity, and authentic and intentional love for one another. By faith, we can imagine better days and a better life. However, we are not naïve – we know that faith without works is dead. For African Americans, faith is an incredibly important part of the context of mental health. This is evident by how we discuss or relate to mental health. When African Americans refer to mental health, usually, our faith interjects itself in the script (i.e., depressions as a loss of faith). This is why, more often than not, African Americans will reach out to their Pastor before they 64 Delaware Journal of Public Health – November 2020

Every faith leader who is true to their calling understands the social responsibility that is required to spiritually lead people in a fallen context. It is our faith that allows us to reimagine a better, more enriching life for all people. Why? Our faith informs us that our differences extend past our ethnic and racial differences – we are all sinners who are in need of a Savior. When we recognize that we all are human beings with equal dignity who are individually struggling to become who God intended us to be, it should provoke a generous spirit, attentiveness to the inherent dignity of people who are different from us, and goodwill that reflects godliness. Our faith informs us that “better” is possible. If we can get past the hubris of our present mindset and honestly give consideration to context, the societal wounds of racism can be adequately addressed. When we read the Gospels, we see human weakness, but we see a church and a faith that has survived. That is just one example of how faith can lead to hope despite human weakness. It is our faith that informs us of the image of God in every human being, it is our faith that helps us to understand the evil that defaces that dignity, and will be our faith that causes us to seek forgiveness when we fail. So, when we incorporate faith into our mental health perspective, it enables us to dig deep and have a potentially different conversation – a conversation that makes a difference. Mental health has most recently confronted the faith community and insisted that it be included in conversations on faith and wellness. Although dealing with mental health has always been a part of the faith journey of African Americans, it has been cloaked in spiritual verbiage. Today, mental health must be identified and acknowledged for what it is and how it has affected African Americans both historically and currently. Despair, depression, and feelings of hopelessness are not “demonic,” but are issues that require professional help. These are mental health issues that must be addressed and not merely relegated to a “deliverance service.” Faith communities are now confronted with the urgency of addressing mental health. Addressing issues of mental heath start with the faith community itself, becoming comfortable with the conversation, and destigmatizing mental health. When this occurs, more individuals will become more comfortable with discussing their struggles

in real ways and not in ways that undermine their need to be directed to mental health professionals for assistance. That also means that faith leaders must acknowledge and recognize when their skills are not sufficient to help individuals who are dealing with mental health issues. The influence of faith on the mental health of African Americans must include recognizing when people need to be referred to professionals. The influence of the faith community concerning mental health also means educating faith communities. Educating faith communities includes raising awareness, providing congregations with ways to recognize mental health, hosting seminars, and having conversations with mental health experts. People cannot be “healed” from what they cannot recognize or acknowledge. Conversations on mental health can be part of the process of the destigmatization and lead to the normalization. None of the above-mentioned ideas negate faith. It is our faith that has sustained us. That is why there can be no underestimation of prayer. The Bible instructs us to “…pray for each other so that you may be healed. The prayer of a righteous person is powerful and effective” – James 5:16. There is no competition between mental health professionals and the faith of believers. If nothing else, they work together to re-ignite hope and healing. The church must remind itself to do what it has historically done, and that is to listen, learn, and lament while pointing people to the reason for leaning on faith – to be made whole.


1. Wallace, S., Nazroo, J., & Bécares, L. (2016, July). Cumulative effect of racial discrimination on the mental health of ethnic minorities in the United Kingdom. American Journal of Public Health, 106(7), 1294–1300. https://doi.org/10.2105/AJPH.2016.303121

2. Jackson, V. (2017). In our own voices: African American stories of oppression, survival, and recovery in the mental health system. pp 1-36, p. 4-8. Retrieved from: https://power2u.org/wp-content/uploads/2017/01/ InOurOwnVoiceVanessaJackson.pdf 3. Primm, A. B., & Lawson, W. B. (2010). African Americans. In Disparities in Psychiatric Care, Ruiz, P. & Primm, A.B., eds. Washington, DC: Lippincott, Williams & Wilkins. 4. Fitchet, G. (2010, Feb). Belief in a caring god improves response to medical treatment for depression. Rush University Medical Center. Retrieved from: https://www.sciencedaily.com/releases/2010/02/100223132021.htm 5. Cadge, W. (2009). Saying your prayers, constructing your religions: Medical studies of intercessory prayer. The Journal of Religion, 89, 299–327. https://doi.org/10.1086/597818 6. Calvin, J. (2002). The Institute of the Christian Religion. Translated by Henry Beveridge. Christian Classics Ethereal Library, Grand Rapids, MI

Correspondence: Pastor Thomas, bishopwjt@gmail.com


Racism as a Stressor Impacting the Health of African Americans Zollie Stevenson, Jr. Adjunct Faculty, Howard University; Vice President for Academic Affairs, Philander Smith College, Retired.

With the advent of the COVID-19 pandemic, who is getting sick and dying has been one of several focal points. One of the most significant racial/ethnic subgroups in the United States, African Americans, are disproportionately represented among COVID-19 deaths. Overall, African Americans makeup about 13% of the United States population but represent 20% of the COVID-19 infections and 22% of the COVID-19 deaths. White Americans comprise 37% of the COVID-19 infections, and nearly 50% of the deaths. White Americans represent 61% of the American population; thus, their percentage of COVID-19 infections and deaths is below their representation in the American population. Hispanic Americans represent the most populous subgroup in the United States after White Americans (18% and 61%, respectively). Hispanics make up 32% of the COVID-19 infections, which exceeds their representation in the country’s population; however, slightly more than half (17%) of the Hispanics infected by COVID-19 died. Thus Hispanic Americans are disproportionately overrepresented in the number affected, but their deaths from COVID-19 related illnesses are on par with their representation in the American population. Therefore of the three largest racial groups in the United States, African Americans are disproportionately represented in both the percentage of COVID-19 illnesses and deaths.1 Abraar Karan of Brigham & Women’s Hospital notes that counties in this country with the largest African American populations account for up to 60 percent of COVID-19 deaths in America. He also notes that Black patients are less likely to receive a COVID-19 test if they need it and that in most states in America, COVID-19 disproportionately affects Black Americans compared to Whites.2 For example, African Americans and White Americans (non-Hispanic) each make up 32% of the population of Chicago, Illinois.3 However, African Americans represent 64% of the COVID-19 infections and 69% of the COVID-19 deaths.4 Several major medical and health organizations have expressed concerns about the disproportionality that exists for African Americans when there is a focus on health disparities. The American Academy of Pediatrics (AAP) has written that “racism is a core social determinant of health that is a driver of health inequities.5 The American Medical Association has formulated a policy that recognizes police violence among Black and Brown communities where those incidents are more prevalent “is a critical determinant of health.”6 AMA supports additional research into the health impact of those types of violent interactions. The AMA authors also speak of police violence as a part of the legacy of racism in the United States.6 Perhaps the most outspoken organization regarding the classification of racism as a social determinant of health disparities and disproportionate illness and death rates for African Americans has been the American Public Health Association.7 APHA and organizations such as AMA and AAP are attributing the disproportionate severity of chronic illnesses such as cancer, heart disease, and diabetes, as well as COVID-19 illnesses and deaths among African Americans, to racism and the stressors that racism 66 Delaware Journal of Public Health – November 2020

adds to everyday life.8 Pamela Aaltonen, Immediate Past President of APHA, has stated, “Let’s respond to this growing [public health] problem by examining hatred and racism through a public health lens.”9 Questions that are being raised by potential advocates for the classification of racism as a public health issue include: How is racism being defined? How do African Americans perceive racism? How is racism related to the disproportionate illnesses and deaths of African Americans? What data and research are available to support advocacy for racism as a public health issue? For purposes of this article, a definition of racism provided by Camara Phyllis Jones, M.D., a past president of the APHA, is being utilized: Jones states that, “Racism is a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call race), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.”7 Georges Benjamin, APHA Executive Director, defines “a public health issue”: “By definition, a public health issue is something that hurts and kills people “or impedes their ability to live a healthy, prosperous life… Racism certainly falls in that category.“2 Leading medical organizations such as the AMA, the American College of Physicians, and the AAP have already released statements citing racism as a public health issue. In addition to those leading medical and public health organizations, the State of Ohio and cities such as Cleveland, Ohio; San Bernardino County, California; and two counties in Maryland (Anne Arundel and Montgomery), have either declared racism as a public health issue or are in the process of doing so.10 A 2019 survey conducted by the Pew Research Center documents the perception of Black and White Americans that the United States has not made sufficient progress in eliminating racism.11 Fifty-eight percent (58%) of the respondents to the 2019 Pew Research Center survey indicated that race relations in the United States are generally bad. Since 2016, fifty-six percent (56%) reported that race relations have gotten worse. Also, since 2016, sixty-six percent of the respondents (66%) agreed that it has become more common for racist views to be expressed publicly.11 Another sixteen percent (16%) responded that it is not too likely that Black people will eventually have equal rights in the United States. Jones’s reference to structuring opportunities and the distribution of opportunities, as well as Benjamin’s definition of a public health issue, underpin this paper.

Sixty percent (60%) of African American respondents from the Discrimination in America survey reported that they or a family member had been unfairly stopped or treated by the police because they are Black.12 Forty-five percent (45%) said in the same survey that the court system had mistreated them because they are Black. Recent examples that support the survey data include recent alleged homicides of African Americans that have received international attention. The recent video recorded murder of George Floyd by a police officer, kneeling for eight minutes and forty-six seconds on his neck, cutting off Floyd’s ability to breathe while he continually uttered that he couldn’t breathe, shocked the world.13 This event happened after the world became aware that a district attorney in Glynn County, Georgia, decided not to press charges against a White father and son, for the videotaped shooting of a second African-American, Ahmaud Arbery.14 The father and son, private citizens, chased and shot Arbery after first assaulting him with their truck, based on their perception that he had stolen something. It took a video recorded by a third White suspect in the Aubrey death that resulted in all three White men being arrested and charged with murder and aggravated assault three months after Aubrey was murdered! The murder in Glynn County was considered inconsequential by the county district attorney, who never filed charges against Aubrey’s assailants, and ultimately recused himself from the case after the arrest of the three men. Those two police officer-involved deaths, as well as the shooting death of Breonna Taylor by police officers in Louisville, Kentucky, have caused a shock wave to erupt across the county and the world. In the Taylor case, police officers entered her home using a no-knock warrant while she was sleeping. Preliminary information indicates that it was the wrong home.15 These are examples of institutional forms of discrimination, acts inflicted on African Americans by institutional representatives who believed they possessed the power to act in the way that they did. The Discrimination in America survey12 further documents that 50% of the African American respondents perceived that they had personally been discriminated against because they were Black when interacting with police. The three referenced died as a result of their interaction. Bor, Venkataramani, Williams, and Tsai reported that police killings and their spillover effects had created physiological stresses that have harmed the mental health of African Americans.16 This perspective has also been supported by the American Academy of Family Physicians (AAFP).17 Is racial attitudinal change afoot? After the inhumane murders of Floyd, Aubery and Taylor became public knowledge, public demonstrations and protests began to explode across the United States and in international cities such as Barcelona, London, and Paris. Those protests so shocked humanity that the demonstrations, riots, and subsequent events have stimulated the active outcries, protests, and involvement of people of many different races, ethnicities, and orientations.13 For many people of color, especially African Americans, those incidents have provoked anger, stoked fears, and for some, angst. Most African Americans of a certain age can share incidences of being racially profiled falsely accused of crimes by law enforcement. African Americans have also been reported acts of discrimination and microaggressions in their personal and work lives.11 These actions are ongoing and repeated and serve as daily stressors for African Americans; actions that have impacted their physiological health.11,18

Anecdotally, I can remember being stopped by police when driving a high-end car in a predominantly White neighborhood that some law enforcement officers profiled as being out of place for an African American. I have colleagues who have reported being called into a Human Resources office for a face-to-face job interview only to experience a different tone to the conversation than was conveyed when interviewed by telephone. I have sat in meetings as a manager where the work quality and work ethic of an African American has been called into question when the work performance of a White employee performing the same work but at a subpar level has not. National Public Radio partnered with the Robert Wood Johnson Foundation and Harvard’s T.H. Chan School of Public Health in 2017 to conduct a large national statistically representative survey of 3,453 adults from January 26 to April 9, 2017, regarding their experiences with discrimination in the United States.12 Summary data from the Discrimination in America survey indicated that the top three areas in which African Americans respondents perceived racial discrimination “often” happens where they live are when interacting with police, being paid or promoted equally, and applying to jobs.12 Submerged anger about the discrimination and microaggressions of racism and the angst experienced by African Americans who are conscious of racism exploded with the apparent homicides by police officers. The responses by some law enforcement agencies and political representatives to the Floyd, Arbery, and Taylor murders has added additional fuel to the uproar. For example, the specter and reality of racism that regularly exists, sometimes compartmentalized in the lives of many African Americans, was triggered. Folk like me began to recall the incidences of racism we had experienced. Some of us, shocked by what we had seen and observed on the television, reflected on the impact racist experiences have had on our and our family’s health and well-being. One comes to understand that as an African American in the United States, discrimination because of our race can occur in our personal and work lives, and we need to be prepared to respond or not to respond to such acts. Imagine the stress that must come with having to respond to an unexpected microaggression and on the spot determine how to react, not knowing if how we acknowledge the racist act will result in life or death consequences? Based on conversations with family, friends, and colleagues, most of us have concluded that little has changed in terms of the fact that African Americans are still experiencing racism and acts of discrimination. These concerns were documented in recent surveys of racism and discrimination.11,12,19 So how is racism related to the disproportionate illnesses and deaths of African Americans? What is the relationship of ongoing stress and sublimation of negative experiences related to health conditions? Williams reported that the effect of day-to-day stress on African Americans creates physiological responses that contribute to premature aging. Williams indicates that: “A large and growing body of research shows that day-to-day experiences of African Americans create physiological responses that lead to premature aging (meaning that people are biologically older than their chronological age).”19 67

Further, Williams and Mohammed reported that the stress from racial discrimination could also cause behavioral changes that further impede health conditions.20 Behaviors can include erratic sleeping patterns, overeating, and substance abuse.

• 60% of African Americans say they or a family member has been unfairly stopped or treated by the police because they are Black, and 45% say the court system has mistreated them because they are Black.

When our physiological system reacts to stress, the physical impact can result in hypertension, diabetes, premature aging, or other health issues.18,19 Health surveillance data on the incidence of cancer, heart attacks, and diabetes, stress-related illnesses in African Americans serve as examples of the failure of physiological systems.19 Additionally, Bor, et al. wrote that reports of unwarranted police killings of African Americans and their spillover effects had created physiological stresses that have harmed the mental health of African Americans.16 Persistent stress can cause our physiological system to become overwhelmed and subsequently to fail.

• Blacks living in suburban areas are more likely than those in urban areas to report being unfairly stopped or treated by police and being threatened or harassed because they are Black.

Williams, on the Robert Wood Johnson Foundation blog, reported that: “Researchers have found that racial and ethnic discrimination can negatively affect health across lifetimes and generations. Health varies markedly by income within every racial group, and racial or ethnic differences can be seen at each level of income. These patterns are seen across a wide range of health conditions. At the same time, findings from studies in the US and other countries have found that perceived racial/ ethnic bias—and the resulting toxic stress—makes an additional contribution to racial or ethnic disparities in health.”19 Williams reminds us that discrimination, which is the evidence of racism, is often linked to historical experiences such as the denial of the right to vote, discriminatory practices in hiring, access to quality housing, and treatment in the court system.18 Discrimination exists in policies that are more institutionalized such as zoning codes, funding of schools, and the location of health facilities in communities as well as bank lending practices for home purchases. Those factors can impact your well-being, such as where you live, go to school, the quality of the school setting, proximity to libraries, the location of health care services, and access to grocery stores and pharmacies. The discriminatory factors noted are linked to racism and serve as everyday life stressors. According to a survey administered jointly by NPR, the Robert Wood Johnson Foundation, and the Harvard University T.H. Chan School of Public Health, stress impacts health and quality of life issues.12 For African Americans, the survey results indicated that: “Overall, African Americans report extensive experiences of discrimination across a range of situations. • In the context of institutional forms of discrimination, half or more of African Americans say they have personally been discriminated against because they are Black when interacting with police (50%), when applying to jobs (56%), and when it comes to being paid equally or considered for promotion (57%). 68 Delaware Journal of Public Health – November 2020

• In the context of individual discrimination, a majority of African Americans have personally experienced racial slurs (51%) and people making negative assumptions or insensitive or offensive comments about their race (52%). • Four in ten African Americans say people have acted afraid of them because of their race, and 42% have experienced racial violence. • Higher-income Black Americans are more likely to report these experiences. • African Americans also report efforts to avoid potential discrimination or to minimize their possible interactions with police. • Nearly a third (31%) say they have avoided calling the police. • Around 22% say they have avoided medical care, even when in need, both for fear of discrimination. • Similarly, 27% of Black Americans say they have avoided doing things they might regularly do to minimize the possibility of interacting with police.”12 Several researchers have conducted or reviewed research related to the connections between racial discrimination and health disparities among African Americans. Owens states that when one has a racial encounter, not only is your mind reacting, your heart is reacting as well.21 This phenomenon is known as sympathetic over-activity and is occurring because the person experiencing racism is facing a social threat. Your body is attempting to prepare itself for whatever happens next. Other physical aspects of your body also begin to react to the social threat; blood vessels contract, your hormonal system starts to react, kidneys begin to function at a faster pace as the adrenaline begins to kick in, and glucose levels start to rise. These are physiological reactions to threats that happen in an average body. These physiological responses raise the stress level and contribute to the reason why health experts are concerned with the stresses of racism as a health concern, particularly if those physiological reactions are regularly occurring as a result of racial discrimination. The impact of racism and the stresses associated with racial discrimination on the physiological health of African Americans, as well as issues such as the lack of access to adequate health care and health insurance, contributes to the public health perspective of racism as a public health issue.2,18,19,21 Figure 1 shows that the overall age-adjusted death rates for cancer, diabetes and heart disease for Black females and males exceed the rates of White females and males based on 2017 data provided by the Centers for Disease Control and Prevention (for diabetes and heart disease) and the 2016 data provided by the National Cancer Institute (for cancer).22

Figure 1. Death rates per 100,000 for Black and White Americans by gender22

Ong, Williams, Nwizu, and Gruenewald reviewed research contained in sixty-six publications that studied the relationship between self-reported discrimination and unfair treatment as determinants of mental and physical health.23 The authors reported that chronic exposure to discrimination regularly seems to increase risk factors related to poor health. The process of coping with day-to-day discrimination can trigger several physiological responses that, over time, are detrimental to good health. Their review of research concluded that the sixtysix studies add to the body of confirmatory knowledge that unfair treatment and discrimination over time can contribute to physiological issues that result in increased morbidity and mortality among African Americans. The American Academy of Family Physicians reported that the US health care system has historically been segregated and has discriminated against patients of color based on race and ethnicity, which has resulted in inequities in access to quality health care. The AAFP supports its member’s efforts to dismantle racism and discriminatory practices.17 Williams, Lawrence, and Davis studied the various types of racial discrimination, and how structural racism, cultural racism, and individual discrimination continue to impact the mental and physical health outcomes of African Americans and other racial/ ethnic minorities.24 Structural racism focuses on the institutional factors that determine where one lives and the quality of life that one has as a result of where they are permitted to live. Structural racism can impact such things as the economic status for adults affecting access to education in quality schools for their children, which influences the type of colleges and jobs that their children can secure. Segregation can box people into settings where criminal activity is pervasive and where lack of access to grocery stores, access to health care, health insurance, and the availability of health care facilities.

Williams et al. further stated that: “Segregation can also adversely affect health by creating communities of concentrated poverty with high levels of neighborhood disadvantage and low-quality housing stock, and with both government and the private sector demonstrating disinterest or divestment from these communities. In turn, the physical conditions (poorquality housing and neighborhood environments) and the social conditions (co-occurrence of social problems and disorders linked to concentrated poverty) that characterize segregated geographic areas lead to elevated exposure to physical and chemical hazards, increased prevalence and co-occurrence of chronic and acute psychosocial stressors, and reduced access to a broad range of resources that enhance health.”24 Cultural racism focuses on ideology, including notions of the inferiority of minority racial groups language, values, imagery, symbols, and other assumptions based on the values, beliefs, and mores of the majority racial group.24 Williams et al. reported that: “Cultural racism can also lead to individual-level unconscious bias that can lead to discrimination against outgroup members. In clinical encounters, these processes lead to minorities receiving inferior medical care compared with care received by Whites. Research indicates that across virtually every type of diagnostic and treatment intervention Blacks and other minorities receive fewer procedures and poorer-quality medical care than do Whites. Recent research documents the persistence of these patterns and reveals that higher implicit bias scores among physicians are associated with biased treatment recommendations in the care of Black patients.”24 69

Discrimination, the most studied area of racism as it relates to health care, exists in two forms: • The actual differential treatment of minority racial groups by institutions or individuals which results in inequitable access of African Americans and other racial/ ethnic groups to resources such as health care, education or employment, and • Self-reported discrimination, where a minority group member or individual is conscious of the bias. Williams et al. posit that: “Linkages between self-reported racial discrimination and physical health outcomes have been documented in multiple recent reviews, with research indicating positive associations between reports of discrimination and adverse cardiovascular outcomes, body mass index (BMI) and incidence of obesity, hypertension and nighttime ambulatory blood pressure, engagement in high-risk behaviors, alcohol use and misuse, and poor sleep. Research also indicates that experiences of discrimination can shape health care–seeking behaviors and adherence to medical regimens. A 2017 review and meta-analysis of studies on discrimination and health service utilization revealed that perceived discrimination was inversely related to positive experiences with regards to health care (e.g., satisfaction with care or perceived quality of care) and reduced adherence to medical regimens and delaying or not seeking health care.”24 Priest, Paradies, Trenerry, Truong, Karlsen, and Kelly conducted a systematic review of 121 studies examining the relationship between reported racism and health and well-being for children and youth 12-18 years of age.25 Overall, mental health outcomes such as depression and anxiety were most often reported outcomes from the studies that were statistically related to racial discrimination in over two-thirds of the studies. Like Priest, et al., Pieterse, Todd, Neville, and Carter conducted a meta-analytic review of the perceived racism and mental health of African American adults addressed in 66 research studies.26 The authors found a positive association between the participant’s perceived racism and psychological distress. The psychological factors had a stronger association with racism that with quality of life factors analyzed in their meta-analysis.


APHA Past President Jones defined racism as a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which we call race), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.7 This paper has documented some of the literature, press reports, and anecdotes which confirm the reality that racism and its expression in acts of discrimination and microaggressions continue to exist as stressors for the African Americans.8,10–12 Racially related stressors negatively impact the health conditions experienced by African Americans.18,19,25,26 Several studies and 70 Delaware Journal of Public Health – November 2020

meta-analyses document that perceived racism is associated with adverse psychological and physiological outcomes for African Americans.21,23,24 Owens focused on the physiological aspects of racial discrimination and health by summarizing the changes that take place in the human body that produce stress when confronted with a racial situation.21 Williams et al. also focus on the changes that take place in the body and noted that persistent stress could result in chronic illnesses.24 Ong et al.,23 Priest, et al.,25 and Pieterse, et al.26 shared information on the harmful impact of racism on mental health, especially depression and anxiety, of children, youth and adults. Perhaps this following statement from Williams best summarizes the impact of racism on health factors. “…Research has shown that the impact of race on health stems largely from differences in access to resources and opportunities that can hurt or enhance health. Additionally, researchers have found that racial and ethnic discrimination can negatively affect health across lifetimes and generations.”24 The research cited in this article indicates that African Americans experience racism, which has implications for their health and the health of the country. Overall, 92% of African Americans believe that discrimination against African Americans exists in America today.12 Of these, nearly half (49%) say that discrimination is based on the prejudice of individual people, compared to 25% who say the more significant issue is discrimination based on laws and government policies. Another 25% say both are equally problematic. The survey data shared the respondent’s perception that, rather than isolated incidents, these racialized experiences reflect a broader, systemic pattern of discrimination in America, with significant implications for the health of both individual Americans and the nation as a whole.12 Is there light at the end of the tunnel regarding the amelioration of health disparities for African Americans? APHA President Benjamin has some thoughts about this: “While jurisdictions are framing racism as a public health issue isn’t going to dismantle racist institutions and support community healing on its own,” Benjamin says, “it’s a step in a positive direction. Looking at racism in this way offers legislators, health officials, and others a clear way to analyze data and discuss how to dismantle or change problematic institutions. Public health can be part of that process in a meaningful way,” he says. “It remains to be seen whether or not many of the pushes to declare racism as a public health issue will succeed, and if so, whether those declarations will provoke meaningful change. Communities need to start looking at racism in their particular context, he says. That could mean changes as straightforward as removing outmoded, and no-longer-used racist legislation from the books, or as complex as looking at how police violence impacts specific local communities of color. But it’s not just about actions from the top,” he says. “At the end of the day, you have to continue to win over people. Not just their heads, but you have to really win over their hearts and minds. And then we can have a real, serious public discussion around racism. We have to not be afraid of the word.”2 Whether APHA’s efforts to have racism declared as a public health issue will receive traction, and if it does, what specific changes to racism as a critical societal and public health issue in the United States remains to be seen. Since Africans were introduced to the United States 401 years ago as slaves, racism

and acts of discrimination have existed. Neither emancipation of slaves in 1863, nor the various Civil Rights or Voting Rights Acts, the Interstate Commerce Act, Supreme Court decisions (e.g., Brown v Board of Education), nor college/graduate degrees have moved the needle very much in terms of eliminating racist actions directed towards African Americans in the United States. If the door is now open for a renewed focus to upend racism, it will take many strategies, desensitization, and time for the full effect of any efforts to make a difference. Perhaps the notion of formalizing racism as a public health issue is one of the strategies that will help in the effort to ease the burden of racism in the United States. Correspondence: Mr. Zollie Stevenson, Zstevenson1@comcast.net

REFERENCES 1. Centers for Disease Control and Prevention. (n.d.). Demographic trends of COVID-19 cases and deaths in the US reported to CDC. COVID Data Tracker. Retrieved from https://www.cdc.gov/covid-data-tracker/index.html#demographics 2. Eschner, K. (2020, Jun 4). Racism is undeniably a public health issue, Identifying racism in this view could lead to positive change, Popular Science. Retrieved from: https://www.apha.org/topics-and-issues/health-equity/racism-and-health 3. US Census Bureau. (2011). 2010 census interactive population search. Retrieved from: https://catalog.data.gov/dataset/2010-census-interactive-population-search 4. City of Chicago. (n.d.). Department of Public Health. COVID Dashboard. COVID-19 Daily Summary. Cumulative Summary (March 1 – August 18, 2020). Retrieved from: https://www.chicago.gov/city/en/sites/covid-19/home/covid-dashboard.html 5. Trent, M., Dooley, D., & Douge, J. (2019). The impact of racism on child and adolescent health. Pediatrics,144,2,1-9 e20191765. https://pediatrics.aappublications.org/content/144/2/e20191765 6. Ehrenfeld, J., & Harris, P. (2019). Police brutality must stop. American Medical Association. Retrieved from: https://www.ama-assn.org/about/leadership/police-brutality-must-stop 7. American Public Health Association. (2020). What is racism. American Public Health Association, Topics & Issues, Health Equity, Racism and Health. Retrieved from: https://www.apha.org/topics-and-issues/health-equity/racism-and-health 8. Haskins, J. (2018). Historical lynching tied to mortality today. The nation’s health, American Public Health Association, 48, 8, e40. Retrieved from: thenationshealth.aphapublications.org/node/7513.full.print 9. Aaltonen, P. (2019). Applying public health tools to our crisis of hate and violence. The Nation’s Health. 49, 8, 3. http://thenationshealth.aphapublications.org/content/49/8/3.1 10. Price, L. (2020.) Racism is a public health issue in Anne Arundel County. Coronavirus pandemic shows what that means. Capital Gazette. Retrieved from: https://www.capitalgazette.com/news/ac-cn-racism-public-healthanne-arundel-20200608-mgejek3xufh7jch357monq5s5m-story.html 11. Horowitz, J., Brown, A., & Cox, K. (2019). Race in America 2019. Pew Research Center. Retrieved from: https://www.pewresearch.org/ 12. NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health. (2017, Oct). Discrimination in America: experiences and views of African Americans. Retrieved from: https://www.rwjf.org/en/library/research/2017/10/ discrimination-in-america--experiences-and-views.html

13. Rahim, Z., & Picheta, R. (2020, Jun 1). Thousands around the world protest George Floyd’s death in global display of solidarity. Cable News Network (CNN). Retrieved from: https://www.cnn.com/2020/06/01/world/george-floyd-globalprotests-intl/index.html 14. McArdle, M. (2020, May). Father and son charged with murder of Ahmaud Arbery. National Review. Retrieved from: https://www.nationalreview.com/news/father-and-son-chargedwith-murder-of-ahmaud-arbery/ 15. Schladebeck, J. (2020, Jul 18). Breonna Taylor was still alive after police shooting but did not get medical care, boyfriend says. New York Daily News. Retrieved from: https://www.nydailynews.com/news/national/ny-breonnataylor-alive-no-medical-help-police-shooting-20200718tzxg43nkj5gdteffknxfbkhx2e-story.html 16. Bor, J., Venkataramani, A. S., Williams, D. R., & Tsai, A. C. (2018, July 28). Police killings and their spillover effects on the mental health of Black Americans: A population-based, quasi-experimental study. Lancet, 392(10144), 302–310. https://doi.org/10.1016/S0140-6736(18)31130-9 PubMed 17. American Academy of Family Physicians. (2020). Institutional racism in the health care system. Retrieved from: https://www.aafp.org/about/policies/all/institutional-racism.html 18. Williams, D. R. (2017, Oct 24). Why discrimination is a health issue. Culture of Health Blog, Robert Wood Johnson Foundation. Retrieved from: https://www.rwjf.org/content/rwjf/ en/blog/2017/10/discrimination-is-a-health-issue.html 19. Williams, D. R. (2017). Race, Racism and Health. Examining the connections between racism, race and health in the United States. Culture of Health Blog, Robert Wood Johnson Foundation. Retrieved from: https://www.rwjf.org/en/library/collections/racism-and-health.html 20. Williams, D. R., & Mohammed, S. A. (2013, August 1). Racism and health I: Pathways and scientific evidence. The American Behavioral Scientist, 57(8), 1152–1173. https://doi.org/10.1177/0002764213487340 21. Owens, C. (2020, Jul 15). What racism does to your heart and your health. The Philadelphia Inquirer. Retrieved from: https://www.inquirer.com/news/racism-health-disparitiescoronavirus-pandemic-protests-microagressions-wellnessadvice-20200715.html 22. Office of Minority Health. (n.d.) US Department of Health and Human Services. Retrieved from: https://minorityhealth.hhs.gov/omh/browse.asph?lvl=4&lvlid=19 23. Ong, A. D., Williams, D. R., Nwizu, U., & Gruenewald, T. L. (2017, January). Everyday unfair treatment and multisystem biological dysregulation in African American adults. Cultural Diversity & Ethnic Minority Psychology, 23(1), 27–35. https://doi.org/10.1037/cdp0000087 24. Williams, D. R., Lawrence, J. A., & Davis, B. A. (2019, April 1). Racism and health evidence and needed research. Annual Review of Public Health, 40, 105–125. https://doi.org/10.1146/annurev-publhealth-040218-043750 25. Priest, N., Paradies, Y., Trenerry, B., Truong, M., Karlsen, S., & Kelly, Y. (2013, October). A systematic review of studies examining the relationship between reported racism and health and wellbeing for children and young people. Soc Sci Med, 95, 115–127. https://doi.org/10.1016/j.socscimed.2012.11.031 26. Pieterse, A. L., Todd, N. R., Neville, H. A., & Carter, R. T. (2012, January). Perceived racism and mental health among Black American adults: A meta-analytic review. Journal of Counseling Psychology, 59(1), 1–9. https://doi.org/10.1037/a0026208 71

Molly Magarik, Secretary Jill Fredel, Director of Communications 302-255-9047, Cell 302-357-7498 Email: jill.fredel@delaware.gov

Date: October 7, 2020 DHSS-10-2020

DELAWAREANS HAVE MORE OPTIONS WHEN DISPOSING OF UNWANTED MEDICATIONS DOVER (Oct. 6, 2020) — Delawareans now have more options when it comes to keeping their unused medications out of the wrong hands. In the last year, seven new permanent prescription drug drop boxes have been added to the state’s existing locations, boosting the statewide count to 28. The drop boxes are available year-round. There are 10 permanent drop box sites in New Castle County, seven in Kent County and 11 in Sussex County. Statewide, there are prescription drug drop boxes inside 10 pharmacies, one behavioral health center, and the remainder are located in the lobbies of town or city police agencies. “Now more than ever, while people are spending more time at home and are facing a great amount of stress, it is important to properly dispose of unwanted medications,” said Division of Public Health (DPH) Director Dr. Karyl Rattay. “Studies show that most opioid addictions start with a prescription. These same studies show us that more than half of the people who misused these prescriptions received them from a friend or family member. You can save lives by simply taking your unused medications to a secure drop box location.” Disposing of unused medications at safe drop box sites can save lives and, in many cases, can prevent addiction before it even begins. According to the 2018 National Survey on Drug Use and Health, prescription pain reliever misuse was the second most common form of illicit drug use in the United States. Other studies show that prescription drugs such as benzodiazepines, often used for anxiety, and stimulants also are also frequently misused. More than half of the people who misused pain relievers obtained them from a friend or family member, according to the report “Key Substance Use and Mental Health in The United States: Results from the 2019 National Survey on Drug Use and Health.” The need to secure opioid prescriptions medication is even more pressing in Delaware because it has the highest rate of highdose and long-acting/extended release opioid prescriptions written in the nation, according to the Centers for Disease Control and Prevention (CDC). Medical providers have written 60.6 opioid prescriptions for every 100 Delaware residents, according to the National Institute on Drug Abuse (NIDA). Delaware also has the second-highest rate of overdose deaths in the nation, according to the CDC. In 2018, 400 people died from a drug overdose in Delaware, according to the Delaware Division of Forensic Science. Eighty-eight percent of those deaths involved an opioid, according to NIDA. As of October 2, 2020, 276 people are suspected to have died from a drug overdose in Delaware, according to the Delaware Division of Forensic Science. Properly discarding prescription medications at secure drop box locations — particularly opioid prescriptions — can keep these medications from being stolen, misused, or out of the hands of small children and animals who may accidentally be poisoned by them. Proper disposal at drop box locations also protects Delaware’s groundwater from contamination that occurs when medications are flushed down the toilet. 72 Delaware Journal of Public Health – November 2020

The 28 permanent prescription drug drop box locations are listed below by county. Check in with each location, as some have implemented COVID-19-related restrictions. New Castle County Newark Police Dept. 220 S. Main St. Newark, DE 19711 New Castle County Police Dept. 3601 N. DuPont Hwy. New Castle, DE 19720 Wilmington Police Dept. 300 N. Walnut St. Wilmington, DE 19801 Walgreens 1120 Pulaski Hwy. Bear, DE 19701 Walgreens 6317 Limestone Road Hockessin, DE 19707 Walgreens 2119 Concord Pike Wilmington, DE 19803 CVS Pharmacy 1545 Pulaski Hwy. Bear, DE 19701 CVS Pharmacy 4020 Concord Pike Wilmington, DE 19803 University of Delaware Police Dept. 413 Academy St. Newark, DE 19716 Rite Aid 2034 New Castle Ave. New Castle, DE 19720 Kent County Dover Police Dept. 400 S. Queen St. Dover, DE 19904 Smyrna Police Dept. 325 W. Glenwood Ave. Smyrna, DE 19977 Felton Police Dept. 24 E. Sewell St. Felton, DE 19943 Camden Police Dept. 1783 Friends Way Camden, DE 19934 Harrington Police Dept. 20 Mechanic St. Harrington, DE 19952 Milford Police Dept. 400 NE Front St. Milford, DE 19963 Walgreens 1001 Forrest Ave. Dover, DE 19904 Sussex County Selbyville Police Dept. 68 W. Church St. Selbyville, DE 19975 Greenwood Police Dept. 100 W. Market St. Greenwood, DE 19950 Ocean View Police Dept. 201 Central Ave. Ocean View, DE 19970 Georgetown Police Dept. 335 N. Race St. Georgetown, DE 19947 Laurel Police Dept. 205 Mechanic St. Laurel, DE 19956 Delmar Police Dept. 400 S. Pennsylvania Ave. Delmar, MD 21875 Walgreens 17239 Five Points Square Lewes, DE 19958 Walgreens 22898 Sussex Hwy. Seaford, DE 19973 CVS Pharmacy 17229 N. Village Main Blvd. Lewes, DE 19958 SUN Behavioral Health Delaware 21655 Biden Ave. Georgetown, DE 19947 Millsboro Police Dept. 307 Main St. Millsboro, DE 19966 For further information on addiction recognition, prevention and treatment, visit www.helpisherede.com. A person who is deaf, hard-of-hearing, deaf-blind or speech-disabled can call the DPH phone number above by using TTY services. Dial 7-1-1 or 800-232-5460 to type your conversation to a relay operator, who reads your conversation to a hearing person at DPH. The relay operator types the hearing person’s spoken words back to the TTY user. To learn more about TTY availability in Delaware, visit http://delawarerelay.com. Delaware Health and Social Services is committed to improving the quality of the lives of Delaware’s citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations. DPH, a division of DHSS, urges Delawareans to make healthier choices with the 5-2-1 Almost None campaign: eat 5 or more fruits and vegetables each day, have no more than 2 hours of recreational screen time each day (includes TV, computer, gaming), get 1 or more hours of physical activity each day, and drink almost no sugary beverages. ### 73

Towards a More Healthy America: Reallocation of Health Care Resources In An Inequitable Health Care System Carole Guy, M.D., F.C.C.P. Pulmonary, Critical Care And Sleep Medicine; Sleep Disorder Centers of Delaware

The COVID-19 pandemic and the video recorded murder of George Floyd have brought long overdue national mainstream focus and discussion to the persistent inequities in our American health and healthcare system. It is my belief and hope that these horrific events will serve as a catalyst for more rapid solutions. A brief historical journey may help us find solutions towards the creation of a more equitable healthcare system. Since the institution of slavery in 1619, our country has experienced over 400 years of systemic racism. The institution of slavery was later replaced by harsh systems of sharecropping and convict leasing and by Black Codes and Jim Crow laws well into the late 19th and early 20th century. The legacies of such systems continue to this day – affecting all aspects of life, including healthcare. During slavery, the United States healthcare system was in its infancy. In 1848, a survey by the American Medical Association (AMA) found that 23% of practicing physicians in Virginia were practicing medicine without either an apprenticeship or medical school education.1 Those enslaved suffered from cholera, pneumonia, dysentery and dietary deficiencies. In order to avoid the expenses of physicians for enslaved persons, those maintaining slavery, including masters and overseers, often provided the “care” for sick or ailing enslaved persons themselves. Equally troubling, Virginia medical schools used Black persons, enslaved and free, for both clinical and anatomical medical studies more often than Whites.1 Scholars have determined that medical experimentation on enslaved persons and freed Blacks was often done without anesthesia and used to develop certain medical techniques and professionalize medicine.1 After the American Civil War (1861-1865) and the Emancipation Proclamation (1863), Black American citizens were held back from obtaining their constitutional rights promised under three new constitutional amendments (the 13th, 14th, and 15th Amendments) by Black Codes and Jim Crow laws. The Black Codes, sometimes called Black Laws, were instituted to limit the rights and freedoms of both free and recently freed Black persons, and to compel them to work for low wages. Such laws existed in both northern and southern states before and after the Civil War – denying Black persons the right to vote, to attend public schools, and to equal treatment under the law. For example, in 1865, Mississippi had a Black Code or law that required Black workers to have written evidence of employment for the coming year. If they left before the end of the employment contract, they would be forced to forfeit earlier wages and they were subject to arrest.2 As is true today, with low or no wages it is difficult, if not impossible, to obtain sufficient, consistent or quality healthcare. Following the Reconstruction Era (1863-1877), during which period gains were made by African-Americans, the Black Codes were expanded by Jim Crow Laws - state and local laws that enforced racial segregation in southern states. Such laws 74 Delaware Journal of Public Health – November 2020

were upheld by the U.S. Supreme Court in Plessy v. Ferguson and remained in effect until the mid to late 1960’s. Thus, our American Constitution failed to secure the blessings of liberty to all her citizens. As late as 1942, Kentucky’s laws required separate but “equal” accommodations for nursing homes for African-Americans.3 Such accommodations and healthcare were rarely if ever “equal” during this period. Facilities for African-Americans were consistently inferior and underfunded; and sometimes, there were no facilities at all. Although such laws were not adopted by northern states, discrimination in healthcare, housing, and education existed there as well. W.E.B. DuBois wrote in 1906, “The high infant mortality in Philadelphia today is not a Negro affair but an index of social condition.”4 DuBois advocated for improved sanitary conditions, education, and better economic opportunities to improve the health of Blacks. American hospitals denied Blacks admission or treated them in segregated wards in attics and damp basements. Due to segregation and discrimination, Black doctors and health professionals found it necessary to establish separate hospitals and professional organizations such as the National Medical Association (NMA), which was formed in 1895. In 1917 in the Journal of the National Medical Association, Black physicians wrote about health disparities created from socioeconomic inequalities not physiologic or biologic differences or inferiority.4 Such laws and practices created both unequal access to healthcare and segregated healthcare facilities which laid the foundation for present health and healthcare system inequities. In 1965, President Johnson signed into law legislation that created the Medicare and Medicaid Programs.5 The formation of Medicare proved to be a tipping point for our then-segregated healthcare system, because it forced the rapid desegregation of American hospitals. Hospitals that practiced racial discrimination could have their now necessary Medicare federal funds withheld under Title VI of the Civil Rights Act of 1964. Delaware, like the rest of the United States, has a long history of segregation in its healthcare system. The history of tuberculosis treatment of African Americans in Delaware provides a lens from which to view this segregated system. The Delaware Anti-Tuberculosis Society and the Tuberculosis Commission worked to build the first TB sanatorium in the United States dedicated exclusively to the treatment of Black patients. The Edgewood Sanatorium was built with funds from the Delaware State legislature and the Delaware Anti-Tuberculosis Society and opened in 1915.6 Dr. Conwell Banton, an African American physician who graduated from the University of Pennsylvania School of Medicine in 1900 and was licensed to practice in

Delaware, served as the medical director for many years.7 The sanatorium was expanded in 1939. Tuberculosis disproportionally infected and affected Blacks then and now. In 1951 African Americans accounted for 24% of all cases of TB in Delaware despite making up only 14% of the Delaware population at the time.6 In 2018, the CDC reported an eight times higher case rate of TB amongst African Americans compared to Whites.8 I, an African American female physician, had the privilege of providing clinical care to tuberculosis patients at the Delaware Department of Public Health clinics during the late 1990s until 2001. I was able to provide care to Black, Latino, White and Asian patients in a desegregated health care system, unlike Dr. Banton who served his patients tirelessly in a segregated sanatorium. While we have made progress towards our goal of eliminating health inequities, there is much work to be done and a more accelerated progression is necessary. Prior to completing medical school in 1988 and practicing in a desegregated healthcare system, my personal history is that I was born 13 days before the March on Washington in 1963 in a segregated Philadelphia hospital, Mercy Douglass. The Frederick Douglass Memorial Hospital and Training School was founded in 1895 by African American physician, Dr. Nathan F. Mossell, to care for the sick, to afford hospital opportunities for Black physicians and to train Black nurses. After merging with Mercy Hospital in 1948, it closed in 1973. Founded on a systemically racist system, though our healthcare system is now desegregated it remains inequitable, and the COVID-19 pandemic has magnified these inequities. Blacks and Latinos are suffering disproportionately and we have not been spared that reality in Delaware. As of August 17, 2020, the case rate of COVID-19 in Delaware was 474/10,000 among Latino/ Hispanics, 205/10,000 among Blacks and 87.6/10,000 among Whites.9 Health care providers can no longer be silent or neutral about inequities in health and healthcare. Some have recognized this and are speaking out. We knew about these inequities prior to COVID-19 and solutions are necessary. There is evidence that African Americans have a higher incidence of conditions requiring Intensive Care Unit (ICU) level care compared to Whites after adjustment for differences in poverty and region.10 African Americans also have higher age adjusted rates of both in and outpatient cardiac arrest, acute lung injury, noncardiogenic acute respiratory failure, and venous thromboembolism.10 We can no longer ignore what we know. The healthcare community must find solutions. Increased access to health insurance and medical care to improve chronic pre-existing conditions is necessary. Black and Brown patients must receive medical care early when they develop a critical illness. Differential access to post-acute care, including post-acute COVID-19 care, must be eliminated. Public health advocates, practitioners, activists, legislators and other policy makers must also fight together to improve education, decrease poverty, and increase healthcare literacy. Each is an important variable to health outcomes. Broken public school systems contribute to inequity in health and healthcare by decreasing the pipeline of physicians to our communities and decreasing the ability of minority patients to fully advocate on behalf of themselves and their family members in health care contexts. America in general – and Delaware specifically – must

fix our schools and create successful pipelines to increase the number of Black and Brown physicians and healthcare providers. Blacks make up 13% of the U.S. population and 21% of the Delaware population, but only make up 7% of U.S. medical students and 5% of active U.S. physicians.11 Delaware mimics this inequity with non-Hispanic Blacks making up only 6.6% of the primary care physicians in Delaware.12 African American physicians and health care providers must feel welcome and supported in Delaware. Feeling “alone” in medicine may be felt by Black physicians. Despite having board certifications, medical degrees and clinical expertise, Black medical students, residents and attending physicians may find themselves continuously having to “prove” themselves to colleagues. Dr. Banton advocated for Black tuberculosis patients in the early 1900s; more than 100 years later, Black physicians continue to tirelessly advocate for Black and Brown patients too often “alone.” Minority students have been found to be more likely to report that race/ethnicity negatively impacted their medical school experience and have cited “racial discrimination, racial prejudice, feelings of isolation and different cultural expectations.”13 The legacy of my father graduating from Temple University School of Medicine in 1961 certainly assisted me in becoming a physician, and likely contributed to my decision to specialize in Pulmonary, Critical Care and Sleep Medicine. However, after graduating almost three decades later from the same medical school as my father, his legacy could not shield me from the entrenched racism of America’s medical schools and healthcare system. I’ll never forget my excitement of starting my first clinical exposure. It was sullied by a White clinical instructor who informed me unprovoked that, “It did not matter” how smart I was or that I had received all Honors and High Passes in my first two years of medical school, but that this was “different now” and that he was now in charge of the grading during my clinic course. The NMA is the largest and oldest national organization representing African American physicians and their patients in the United States. It is the collective voice of African American physicians, and the leading force for parity and justice in medicine and for the elimination of disparities in health. The local Delaware First State Chapter of the NMA was an active voice in the fight to ensure Black and Brown Delawareans were counted during the COVID-19 pandemic. By providing a community of physicians with shared experiences, the NMA helps Black physicians to not feel “alone,” and to assist in the advancement of social justice in medicine. The formation of the NMA in 1895 was in response to the exclusion of African-American physicians from the AMA (American Medical Association) and local state medical societies. In 1968, the AMA voted against motions prohibiting racial discrimination by member/local medical societies despite “condemning racial discrimination,” thereby sending the implicit message that such discrimination was permissible. In 2008, the AMA issued a formal apology to the NMA and African American physicians for one and a half centuries of systemic and overt racism towards African American physicians, their families and patients. In 2020, I am optimistic but vigilant. 75

The COVID-19 pandemic has exposed the inequitable allocation of health care resources and resultant disparities in the health of Blacks and Latinos/Hispanics. During the regional peak of the COVID- 19 pandemic in Delaware, I wrote an opinion piece entitled, “Delaware Needs Statewide Ethics Board To Oversee Allocation of Ventilators, COVID-19 Supplies.”14 At the time, my concern was that a possible surge in hospital admissions could make ventilators a scarce resource that would require attention to the necessity of fair and just allocation. I recommended creation of a statewide ethics board for pandemic COVID-19 with representation from our Delaware community, including young and old, Black, Brown, White and Asian individuals. Subsequently, on the Journal of the American Medical Association (JAMA) published a systematic review, “Variation in Ventilator Allocation Guidelines by US States during Coronavirus Disease 2019 Pandemic.”15 Only 26 states provided guidance on how this allocation should occur. Guidelines varied significantly and it was concluded that there could be inequity in allocation of mechanical ventilator support during a public health emergency such as the COVID-19 pandemic.15 I remain concerned that this statewide inequity could again mimic the racial inequities in our health care system in the US. As a State, a refocus on social justice work was spurred by the storm of the COVID-19 pandemic and the murder of George Floyd, as demonstrated by the passage of Delaware Senate Bill 191.16 SB 191 is a Delaware Constitutional amendment to protect against discrimination on the basis of race, color and national origin with protections that parallel those provided in the National Civil Rights Act of 1964. After the passage of SB 191, the legislative Black Caucus of Delaware announced their “Justice for All Agenda” in June, which includes establishment of an African American Task Force “entrusted with exploring the disparities experienced by people of color throughout Delaware and proposing remedies to address those inequities.”17 It is our duty as health care providers to not only care for our patients at their bedsides, but to improve their health through advocacy and education of our legislators to ensure that racial inequities in health and healthcare systems are eliminated. A similar effort was seen in Michigan when Governor Whitmer created the Coronavirus Task Force on Racial Disparities to ensure all Michiganders have equal access to critical health care resources; we can do the same in Delaware. Fortunately, Delaware never required ventilator allocation. But we may require COVID-19 vaccine allocation, and we should ensure this allocation is just and equitable. Additionally, our entire health and healthcare system, at the State and national level, requires just and equitable allocation of resources. I believe we are up for the task. We have the resources, the skill sets, and our efforts are now refocused due to the intersecting impact of COVID-19 and the civil discourse related to the “Black Lives Matter” movement. When I graduated from medical school three decades ago, I took a modified Hippocratic Oath. One current version is “as a member of the medical profession I WILL NOT PERMIT considerations of age, disease, disability, creed, ethnic origin, gender, nationality, political affiliation, RACE, sexual orientation, social standing or any other factor to intervene between my duty and my patient” [emphasis mine]. We know “We can’t breathe” and we need to fix this. 76 Delaware Journal of Public Health – November 2020

REFERENCES 1. Kaufman, M., & Savitt, T. L. (1979). Medicine and slavery: An essay review. The Georgia Historical Quarterly, 64(3), 380–390. https://www.ncbi.nlm.nih. gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ uids=11614504&dopt=Abstract 2. Black Codes. (n.d.). Retrieved from: https://www.history.com/topics/black-history/black-codes 3. Jim Crow Laws. (2020, Aug 19). Retrieved from: https://www.history.com/topics/early-20th-century-us/jim-crow-laws 4. Gamble, V. N. (2010, April). “There wasn’t a lot of comforts in those days:” African Americans, public health, and the 1918 influenza epidemic. Public Health Rep, 125(Suppl 3), 113–122. https://doi.org/10.1177/00333549101250S314 5. Centers for Medicare and Medicaid. (n.d.). History. Retrieved from: https://www.cms.gov/About-CMS/Agency-Information/History 6. A History of the DE Anti Tuberculosis Society, 1904-1954. Chapter 6: Building Program [Retrieved by archivist Delaware Academy of Medicine] 7. Edgewood Sanatorium (1947, Jan 12). Anniversary Edgewood Sanatorium, 1915-1947, Open House Program. 8. Centers for Disease Control and Prevention. (n.d.). Tuberculosis. Retrieved from: https://www.cdc.gov/tb/statistics/default.htm 9. Delaware Department of Health and Social Services. (n.d.). My healthy community portal. Retrieved from: http://myhealthycommunity.dhss.delaware.gov/locations/state 10. Soto, G. J., Martin, G. S., & Gong, M. N. (2013, December). Healthcare disparities in critical illness. Critical Care Medicine, 41(12), 2784–2793. https://doi.org/10.1097/CCM.0b013e3182a84a43 11. American Association of Medical Colleges. (2019). Diversity in medicine: facts and figures 2019. Retrieved from: https://www.aamc.org/data-reports/workforce/report/diversitymedicine-facts-and-figures-2019 12. Mitchell, K., Iheanacho, F., Washington, J., & Lee, M. (2020). addressing health disparities in Delaware by diversifying the next generation of Delaware’s physicians. Delaware Journal of Public Health, 6(3), 26–28. 13. Dyrbye, L.N., Thomas, M.R., Eacker, A. (2007). Race, Ethnicity, and Medical Student Well-being in the United States. Arch Intern Med, 167(19), 2103 - 2109. https://doi.org/10.1001/archinte.167.19.2103 14. Guy, C. A. (2020, Apr 6). Delaware needs statewide ethics board to oversee allocation of ventilators, COVID-19 supplies. DelawareOnline. Retrieved from: https://www.delawareonline. com/story/opinion/2020/04/06/delaware-needs-statewide-ethicsboard-oversee-allocation-ventilators-covid-19-supplies/2947360001/ 15. Piscitello, G.M., Kapania, E.M., Miller, W.D., Rojas, J.C., Siegler, M., Parker, W.F. (2020, Jun 19). Variation in ventilator allocation guidelines by US State during the coronavirus disease 2019 pandemic. JAMA New Open, 3(6). doi.org/10.1001/jamanet-workopen 2020./2606 16. Delaware Senate Bill 191. (2020). Retrieved from: https://legis.delaware.gov/BillDetail/48031 17. Delaware House Democrats. (2020). Delaware Legislative Black Caucus announces package of racial justice legislation. Retrieved from: http://www.dehousedems.com/press/delawarelegislative-black-caucus-announces-package-racial-justice-legislation

From the history and archives collection


Advancing Racial Equity: Leading, Learning and Unlearning Tia Taylor Williams, M.P.H., C.N.S. Director, Center for Public Health Policy, Center for School, Health and Education, American Public Health Association

It feels odd to write this in the middle of a pandemic, but now is an exciting time to be both an employee and member of the American Public Health Association (APHA). I am in a moment where the back- and heart-breaking work of all of those who came before me is finally getting the attention, recognition and action it merits. In my first few years on staff at APHA, we, like many others, danced around addressing racism as a core part of our work, despite its seemingly obvious connections to our mission and values. APHA’s mission is to improve the health of the nation and achieve equity in health status. Health equity is a guiding principle and core value of the Association. Our engagement in explicit advocacy for racial equity dates back to 1965 with the passage of a resolution, The Health of Minorities and the Relationship of Discrimination Thereto. Over the past 30 years APHA’s work has broadened from reducing disparities, with the launch of a national campaign in 1998 with the U.S. Department of Health and Human Services to Eliminate Racial and Ethnic Health Disparities, to adopting “Creating Health Equity” as a strategic priority in 2011. Still, like many others we were reluctant to take consistent and meaningful actions in naming and addressing racism and the role it plays in the inequities and disparities in health and life outcomes. Today, thanks to a core group of dedicated and passionate staff, our staunch members and Affiliates, the national discourse on racism fueled by the inequities in the COVID-19 pandemic and the uprising over police violence, we have been afforded another opportunity to act on our values. We are leading while learning (and unlearning) as we work to dismantle racism to achieve our vision of creating the healthiest nation.

WHERE ARE WE LEADING? Naming and Addressing Racism as a Driving Force of Health Inequities1 APHA was among the first national public health organizations to be explicit about naming racism as a driving force for social determinants of health. Our efforts on racism began to increase in momentum about five years ago. In the summer of 2015, prompted by a mass shooting in Charleston, SC, the Black Lives Matter Movement rising out of Ferguson, MO, and other racism-fueled violent attacks, APHA launched a four-part webinar series, entitled, The Impact of Racism on the Health and Well-Being of the Nation. The series highlighted the intersection between racism and various social determinants, including violence, health care and education. At the time, it was APHA’s most successful series, attracting over 10,000 live participants with over 40,000 replays to date. In addition, the 2016 APHA President, Dr. Camara Jones, made a national campaign against racism the focus of her presidency 78 Delaware Journal of Public Health – November 2020

and galvanized APHA members, affiliates and partners to name and address racism as a driving force of the social determinants of health. While these efforts lacked the financial or resource support required for broad scale impact and reach, they made an indelible impression on the Association staff, members, affiliates and partners. In a 2016 survey, 65% of APHA leaders and 74% of general members who responded ranked addressing racism as very important for a member of APHA. An average of 43% of survey respondents also reported being involved in racial equity efforts outside of APHA. Over the past four years, we’ve seen an uptick in programming from our member components and affiliates on the topic of racism and racial equity. This includes scientific sessions and other activities at our annual meeting, National Public Health Week activities, research projects, advocacy activities and book publishing.2 Meanwhile, staff have continued to strengthen capacity to apply a racial equity lens through training, grant proposals, and member and Affiliate engagement. Given the popularity of the 2015 series, we knew we wanted to launch another webinar series that would focus more explicitly on advancing racial equity and elevating strategies.

DEVELOPING TOOLS AND RESOURCES TO GALVANIZE ACTION Producing the Advancing Racial Equity Webinar Series3 Our advancing racial equity webinar series had been in the works for some time. However, in an odd case of déjà vu, the launch of the webinar series was aptly timed with the Summer 2020 uprising and the Black Lives Matter movement. Once again, the timing is ripe for open, honest and uncomfortable conversations about the insidious ways in which racism operates within all aspects of our society. APHA is pleased to provide a platform for frank discussions that lift up the voices and experiences of people of color. The intention with the series is to explore historical policies and practices and their present- day impact and implications. The planning committee felt it imperative that participants have a sense that current inequities are not happenstance, or the result of bad luck, or worse, bad “choices” among communities of color. We deemed it essential that the webinars explore how the belief in white superiority and Black inferiority guided the founding of the United States and permeate all of its institutions, policies, norms and values. These webinars allow us to both serve our members and broader audiences who are especially hungry for solutions right now. In addition to the webinars, we developed discussion guides to help walk viewers through prompts and activities to deepen their thinking on the various subjects.

Tracking Racism Declarations Across the Country4 As governors, county and city officials declared racism a public health crisis, we realized it would be important to track and monitor these declarations, and provide this as a resource to our members and the greater public health community. While some may view these declarations as purely symbolic, there is significance in naming racism. For far too long the U.S. has denied and avoided talking about racism and the belief in racial hierarchy as the key drivers of inequities. Explicitly naming racism as the root cause for the inequities in opportunities, access, and outcomes is an important step towards creating systems of accountability and taking meaningful action towards change. APHA will also be monitoring what actions state and local leaders are taking in alignment with these declarations. We will work with our members, affiliates and partners to help hold leaders accountable for meaningful policy and practice changes to dismantle structural racism and create new systems, polices, practices and norms. Over the next year, we will be hosting mini-webinars to walk participants through various tools and processes that they can use to deepen their understanding of structural racism, and for practical application of a racial equity lens to policies and programs.

WHAT ARE WE LEARNING (WHILE UNLEARNING)? We approach this work with intention and an understanding that, as professionals educated by and indoctrinated in systems built on the belief in racial hierarchy, white supremacy culture5 influences how we approach and execute our work. As a result, we are simultaneously learning and unlearning as we work to dismantle racism and advance racial equity. When to lead and when to follow. As a national organization representing nearly 50,000 individual, organizational and affiliate members, we know that we have an incredible reach, responsibility, and influence. There are many cases in which we are not the leaders or experts, and our role is to amplify voices that are often silenced or unheard. Walking the talk is required. To serve our members and the greater public health community with integrity, we have to do the work internally. We are taking steps to create an organizational culture of race equity among APHA staff and members. Organizationally, APHA has worked to build awareness and capacity of staff, leadership and affiliates through mandatory trainings on equity, diversity and inclusion; brown bag presentations; and film screenings and discussion. We are in the process of exploring how we can apply what we’re learning about racial equity across all aspects of the organization including procurement, hiring and recruitment, professional development, and membership. We have to be explicit about centering voices of color. We are becoming more comfortable and confident in acknowledging that there are some conversations for which people who are White should be listeners. We are also becoming more direct in asserting that certain topics and discussions should center Black voices given the strong anti-Black sentiment that undergirds racism and discrimination across systems, cultures and communities. This is a divergence from an (unspoken) norm to not alienate our White staff, members and partners.

Lived experience is as important as work experience. When considering who to invite to speak or present on a topic, there are often intense debates about what voices and perspectives to include: the researcher or clinician with name recognition and accolades; or the community organizer or member of an impacted community? All perspectives are necessary and we are more intentional about ensuring that the community voice is highly valued and sought out. Silence equals complicity. There is no longer room for neutrality on this topic. We are either actively anti-racist or complicit with maintaining and perpetuating racism and a belief in racial hierarchy. This work is not easy to do. As a Black woman who is helping to lead these efforts, it can be downright exhausting. As an organization, we don’t always get it right and will likely continue to make flubs along the way. We also operate from a place of humility and curiosity with a firm commitment to doing better and deepening our practice of anti-racism. It also must be acknowledged that, quite frankly, not everyone in the Association is on board or has bought into anti-racism and racial equity as priorities. We continue to encounter active resistance internally and externally from those who fail to see (or choose to ignore) the connections between racism and discriminations and the outcomes they wish to achieve. But for those of us who live and breathe this work, we are forging ahead so that those coming behind us will have a less steep hill to climb.

REFERENCES 1. American Public Health Association. (n.d.). Racism and Health. Retrieved from: https://www.apha.org/topics-and-issues/health-equity/racism-and-health 2. Ford, C. L., Griffth, D. M., Bruce, M. A., & Gilbert, K. L. (Eds.). (2019). Racism: Science and Tools for the Public Health Professional. Washington, DC: APHA Press 3. American Public Health Association. (n.d.). Advancing Racial Equity Webinar Series. Retrieved from: https://apha.org/events-and-meetings/webinars/racial-equity 4. American Public Health Association. (n.d.). Declarations of Racism as a Public Health Issue. Retrieved from: https://apha.org/topics-and-issues/health-equity/racism-andhealth/racism-declarations 5. Okun, T. (n.d.). White Supremacy Culture. Dismantling Racism Works. Retrieved from: https://www.dismantlingracism.org/uploads/4/3/5/7/43579015/ okun_-_white_sup_culture.pdf


The Traumatic Impact of Structural Racism on African Americans Gwendolyn Scott-Jones, Psy.D., M.S.W., C.A.A.D.C. Mozella Richardson Kamara, P.E. Department of Psychology, College of Health and Behavioral Sciences, Delaware State University

ABSTRACT Many African Americans in the United States have been impacted by structural racism since slavery and continue to experience trauma because of health disparities, economic disadvantages, and segregation. This article will define race, racism, and structural racism, which has perpetuated trauma for African Americans. The authors present a theory called Post Traumatic Slavery Syndrome (PTSS) by Dr. Joy DeGruy, a social work researcher, to explain why many African Americans continue to experience trauma. PTSS is a condition that exists as a consequence of multigenerational oppression of African and their descendants resulting from centuries of chattel slavery. Looking at history and the inherent long-standing trauma that has and continue to plague African Americans can assist in addressing systemic racism and provide an opportunity to look at holistic restoration.

RACE Race, racism, and race relations affect everyone in this country, especially African Americans.1 The U.S. Census Bureau defines a person’s race based on that person’s self-identification of the race or races with which he or she most closely identifies.2 In addition, the U.S. Census Bureau defines ‘Black or African American’ as a person having origins in any of the Black racial groups of Africa. African American is the term currently preferred by most people of African ancestry in the United States.1 It is important to note that many Africans, who migrate to the United States do not selfidentify as African American but identify as African. The definition of race has no consensual theoretical or scientific meaning in psychology, although it is frequently used in psychological theory, research, and practice as if it has obvious meaning.3 Race is a cultural category that remains meaningful in the United States because of its continuing social and economic significance.4 Race shapes how we experience the world and continues to be used as the basis for the mistreatment of African Americans. The impacts of racism continue to significantly affect those who identify as African-American.

RACISM Racism in this article is operationally defined as the beliefs, attitudes, institutional arrangements, and acts that tend to denigrate individuals or groups because of phenotypic characteristics or ethnic group affiliation.5 This is not a recent phenomenon. Racism has plagued the United States since the 17th century, around the time of European colonization. In the 17th century era, millions of Africans were shipped from Africa to the Americas as slaves. This dispersion of Africans across the Americas is what is known today as the African Diaspora.6 Most of the Africans were separated from their families, stripped of their names and identities, beaten, raped, tortured, and in many cases lynched or hanged at the whims of their Caucasian masters. The psychological, physical, sexual, and emotional abuse Africans experienced during enslavement in the United States had longlasting traumatic effects. More specifically, African Americans 80 Delaware Journal of Public Health – November 2020

were traumatized in the United States. The marginalization of African Americans based on race has been normalized across systems and institutions of the United States, and continues to impact African Americans today.

STRUCTURAL RACISM Structural racism in the U.S. is the normalization and legitimization of an array of dynamics that stem from historical, cultural, institutional and interpersonal aspects that routinely advantage Caucasians while producing cumulative and chronic adverse outcomes for people of color.7 Lawrence and Keleher reported that structural racism lies underneath, all around and across society. Furthermore, Lawrence and Kelecher found that structural racism encompasses: (1) history, which lies underneath the surface, providing the foundation for white supremacy in this country; (2) culture, which exists all around our everyday lives, providing the normalization and replication of racism and, (3) interconnected institutions and policies, the key relationships and rules across society providing the legitimacy and reinforcements to maintain and perpetuate racism. Structural racism creates trauma. The impacts of structural racism, can take a mental toll on African Americans. Mental health disparities based on minority racial status are well identified, including inequities in access, symptom severity, diagnosis, and treatment.8 However, African Americans have a history of experiencing structural racism through economic disadvantages and segregation, which have been existent since slavery. Therefore, the factors of economic disadvantages and segregation are identified stressors that may have an effect on the mental health of African Americans. Mental health inequities began during the time of colonialism and slavery, when myths of racism were being integrated into the developing field of psychiatry and psychology.8 By the end of the 19th century, many psychologists accepted an idea that African Americans were biologically inferior, with smaller brains and a natural instinct for labor. Studies have found that African Americans who participated in the Abolitionist and Civil Rights movements were met with prejudice by mental health practitioners, who labeled them schizophrenic due

to their supposed pathologic desire for equality. To date, the research shows that African Americans are over diagnosed with schizophrenia and they are more likely to be treated with antipsychotic medications that can have lasting, negative side effects. Additionally, African Americans have higher rates of severe depression yet lower rates of treatment compared to Caucasians. African Americans are less likely to receive officebased counseling for psychological stressors and are more likely to be seen in emergency rooms.9 Dr. Joy DeGruy, a social work researcher, developed a theory called Post Traumatic Slave Syndrome (PTSS). This theory explains the etiology of many of the adaptive survival behaviors in African American communities throughout the United States and the Diaspora. PTSS is a condition that exists as a consequence of multigenerational oppression of Africans and their descendants resulting from centuries of chattel slavery.10 This form of slavery is predicated on the belief that African Americans are inherently/ genetically inferior to their Caucasian counterparts. Dr. DeGruy identified three key patterns of PTSS behaviors that are exhibited by African Americans.10

1. Vacant Esteem This is insufficient development of one’s primary esteem, along with feelings of hopelessness, depression and a general selfdestructive outlook. Vacant esteem, the belief that one has little or no worth, manifests a feeling that an individual and their partner are unworthy of healthy monogamous relationships. Under strained economic conditions, and in an effort to increase self-esteem, masculinity may move from the acquisition of socioeconomic goods to the belief that the more women one sleeps with, the more masculine he becomes.11

2. Marked Propensity for Anger and Violence Individuals can feel extreme feelings of suspicion, and perceived negative motivations of others. Violence against self, property and others, including the members of one’s own familial or social group, i.e. friends, relatives, or acquaintances can be seen. Instead of acknowledging the barriers created by systematic racism and oppression, some African American men may hold African American women responsible for their inability to obtain traditional masculinity.11

3. Racist Socialization and (Internalized) Racism This pattern includes behaviors like learned helplessness, literacy deprivation, distorted self-concept, antipathy or aversion for the following: • The members of one’s own identified cultural/ethnic group, • The mores and customs associated one’s own identified cultural/ethnic heritage, and/or • The physical characteristics of one’s own identified cultural/ ethnic group. Racist socialization manifests in the idealization of white norms and values by African Americans. The emphasis on the promotion of the nuclear family and traditional gender roles has resulted in many African Americans idealizing this model despite their inability to obtain it.11

STRUCTURAL RACISM TODAY Structural racism continues to perpetuate trauma for African Americans today. Taking a look at history and the inherent long-standing trauma that has and continues to plague African Americans can assist in addressing systemic racism that is present today. Many medical providers, behavioral health practitioners, educators, and law enforcement officers seek to understand the African American culture and how they can provide equitable service delivery. To heal African Americans, service providers must first understand the overt systemic trauma, then examine the covert systemic and institutional aspects that continue to perpetuate racism in the United States. Trauma-informed care and services could offer an important opportunity to African Americans who have been harmed and emotionally injured. In addition to being trauma-informed, service providers should provide healing centered engagement in their approach to working with African Americans. Healing centered engagement is akin to the South African term “Ubuntu” meaning that humanness is found through our interdependence, collective engagement and service to others.12 Additionally, healing centered engagement offers an asset driven approach aimed at the holistic restoration of African Americans and their well-being. Ginwright found that healing centered engagement advances the move to “strengths-based” care and away from the deficit based mental health models that drive therapeutic interventions.12 In order to dismantle structural racism, we must take a close look at the historical, cultural, institutional and interpersonal aspects that lack equity for African Americans. Combatting structural racism is the responsibility of everyone, because we all must become conscious of our own responsibility as individuals. This is how we can be a part of something bigger than ourselves. Former President Barack Obama once stated, “I see what’s possible when we recognize that we are one American family, all deserving of equal treatment.” Therefore, it is a call to action for all Americans, regardless of your race, ethnicity, social economical status, gender, or status to put a stop to structural racism.

REFERENCES 1. Belgrave, F., & Allison, K. (2019). African American Psychology: From Africa to America, (4th ed). Thousand Oaks, CA: SAGE Publications. 2. Census, U. S. (2016). People in families by family structure, age, and sex, iterated by income-to poverty ratio and race. Retrieved from https://www.census/gov/data/tables/time- series/ demo/income-poverty/cps-pov/pov-02.html 3. Helms, J. E., Jernigan, M., & Mascher, J. (2005, January). The meaning of race in psychology and how to change it: A methodological perspective. The American Psychologist, 60(1), 27–36. https://doi.org/10.1037/0003-066X.60.1.27 4. Mukhopadhyay, C. C., Henze, R., & Moses, Y. T. (2013). How real is race?: A sourcebook on race, culture, and biology. ProQuest Ebook central https://ebookcentral.proquest.com 5. Clark, R., Anderson, N. B., Clark, V. R., & Williams, D. R. 81

(1999, October). Racism as a stressor for African Americans. A biopsychosocial model. The American Psychologist, 54(10), 805–816. https://doi.org/10.1037/0003-066X.54.10.805 6. Rotimi, C. N., Tekola-Ayele, F., Baker, J. L., & Shriner, D. (2016, December). The African diaspora: History, adaptation and health. Current Opinion in Genetics & Development, 41, 77–84. https://doi.org/10.1016/j.gde.2016.08.005 7. Lawrence, K., & Kelecher, T. (2004). Chronic disparity: strong and pervasive evidence of racial inequalities poverty outcomes: Structural racism. Paper presented at the Race and Public Conference. 8. Medlock, M., Weissman, A., Wong, S., Carlo, A., Zeng, M., Borba, C., Curry,M., & Shtasel, D. (2017). Racism as a unique social determinant of mental health: development of a Didactic curriculum for psychiatry residents. MedEdPortal: Association of American Medical Colleges. (13), 1-9. https:// doi.org/10.15766/mep_2374-8265.10618

82 Delaware Journal of Public Health – November 2020

9. Miller, J. (2020). A statement of the American mental health counselor association on racism as a social determinant of mental health. [AMHCA]. American Mental Health Counselors Association, 17(04), 1–6. 10. DeGruy, J. (2017). Post Traumatic Slave Syndrome, Revised Edition: America’s Legacy of Enduring Injury and Healing. Milwaukie, Oregon: Uptone Press. 11. St. Vil, N. M., St. Vil, C., & Fairfax, C. N. (2019, April 1). Posttraumatic slave syndrome, the patriarchal nuclear family structure, and African American male-female relationships. Social Work, 64(2), 139–146. https://doi.org/10.1093/sw/swz002 12. Ginwright, S. (2018). The future of healing: Shifting from trauma care to healing centered engagement. Medium Psychology. Retrieved from https://medium.com/@ginwright/thefuture-of-healing-shifting-from-trauma-informed-care-to-healingcentered-engagement-634f557ce69c

PLEASE PROVIDE YOUR CONTACT INFORMATION Provide your server or host with your name and email address or phone number to be contacted in the event of a COVID-19 concern arising.

Thank you. For more information please visit:

de.gov/coronavirus *Provided contact information is kept for 28 days and may be shared with the Delaware Division of Public Health.


Black Health Matters in the United States Timeline Dr. Lori Crawford, M.F.A., Associate Professor, College of Humanities, Education and Social Sciences, Delaware State University

1st Documented Africans Arrive to Virginia for Enslavement 1619

Henrieta Lacks Immortal Cells 1953

F inUrban Acces O ofFood Hig Ob Hype OO DESER

Civil Rights Movement 1954-1968

The Tuskegee Syphilis Experiment 1932


B lack H e a 1600-1800’s 1865 Emancipation Proclamation Signed



N The Segregated Tuskegee Army Airfield Base Nurses 1940’s


The Clark Doll Test 1947


1st World Aids Day 1988


20 B Are M to R M Dis T W

dits:1. Public Domain 2. Dr. Clark with Child, Gordon Parks Photography, Credit Library of Congress 3. Image from Pixabay 4. Photo by Lori Crawford

84 Delaware Journal of Public Health – November 2020

n Disparities ss to Healthy ds Lead to gh Rates besity and ertension


Black Maternal and Infant Mortality Disparities 2019

COVID-19 Is Disproportionately Effecting People of Color


alt h Ma tters

0% Of Blacks MoreLikely Report Mental stress Than Whites

2015-2018 The National Memorial of Peace and Justice, 2018




The 1619 Project

by Nikole Hannah-Jones

The Legacy of Slavery Examined in 2019


Racial Justice Protests Erupt Across U.S. Cities In Reaction to Police Brutality 2020



www.fic.nih.gov www.fic.nih.gov www.fic.nih.gov


Inside this issue Inside thisScholar issue Former Fogarty Inside this issue


Fogarty allocates $4M to support early-career scientists Fogarty allocates $4M to support early-career scientists Fogarty allocates $4M to support early-career scientists Photo courtesy PhotoPhoto courtesy of University courtesy of University ofofUniversity the West of theof Indies West the West IndiesIndies

molecular pathways and activation signals that determine Fogarty is providing $3.75 million over five years to support susceptibility to HIV infection and whether males with seven promising early-career scientists in low- and middlemolecular pathways and activation signals that determine Fogarty is providing $3.75 million over five years to support asymptomatic sexually transmitted infections are more at income countries (LMICs). Issued through the Center’s molecular pathways activation signals that determine Fogarty is providing $3.75 million over five years to middlesupport susceptibility to HIV and infection and whether males with seven promising early-career scientists in lowand risk of HIV infection, as well as the Emerging Global Leader Award program, susceptibility HIV infection and whether males seven scientists in lowand middleasymptomaticto sexually transmitted infections are with more at incomepromising countriesearly-career (LMICs). Issued through the Center’s role of the ubiquitin- proteasome the grants are intended to provide a period asymptomatic sexually transmitted infections as arewell more income countries (LMICs). Issued through the Center’s risk of HIV infection, asat the Emerging Global Leader Award program, system in the development of of protected time for research under the risk HIVubiquitininfection, as well as the Emerging Leaderto Award program, role of the proteasome the grantsGlobal are intended provide a period severe malaria anemia. guidance of experienced mentors. role of the ubiquitinproteasome the grants are intended to provide a period system in the development of of protected time for research under the system in the development of of protected time for research under the severe malaria anemia. guidance of experienced mentors. The program intends for recipients The new awards will support scientists in severe malaria anemia. guidance of experienced mentors. to launch independent global Jamaica, Kenya, Nigeria, Peru and South The program intends for recipients The new awards will support scientists in health research careers following Africa. Research projects will explore The program intends forglobal recipients The new awards support in to launch independent Jamaica, Kenya, will Nigeria, Peruscientists and South this sustained period of training topics ranging from the long-term effects to launch independent Jamaica, Kenya, projects Nigeria, Peru and South health research careersglobal following Africa. Research will explore and research career development. of tuberculosis on children’s lungs, the health researchperiod careers Africa. Research projects will explore this sustained of following training topics ranging from the long-term effects Co-funding NIH partners for ways schools can support children with this perioddevelopment. of training topics ranging from the long-term and sustained research career of tuberculosis on children’s lungs,effects the these awards include the National HIV, stroke prevention in children with and research career development. of tuberculosis onsupport children’s lungs, with the Co-funding NIH partners for ways schools can children Cancer Institute and the National sickle cell disease, efforts to address Co-funding NIH partners ways schools can support childrenwith with these awards include the for National HIV, stroke prevention in children Institute of Neurological Disorders prostate cancer disparities in Black these awards include the National HIV, prevention in children with Cancer Institute and the National sicklestroke cell disease, efforts to address Dr. Simone Badal of the University of the West Indies and Stroke. men and the use of text messaging in is one of seven early-career scientists to receive an Cancer Institute and the National sickle cell disease, efforts to address Institute of Neurological Disorders prostate cancer disparities in Black HIV care. Other projects will investigate Emerging Award from Dr. SimoneGlobal Badal Leader of the University of Fogarty. the West Indies Institute of Neurological Disorders prostate in Blackin and Stroke. men andcancer the usedisparities of text messaging is of seven early-career scientists an Dr.one Simone Badal of the University of to thereceive West Indies and Stroke. men and the useprojects of text messaging in HIV care. Other will investigate Emerging Global Leader Award from Fogarty. is one of seven early-career scientists to receive an HIV care. Other projects will investigate Emerging Global Leader Award from Fogarty.

NIH issues two awards for COVID research in Africa NIH issues two awards for COVID research in Africa NIH issues two awards for COVID research in Africa A robotic lung ultrasound machine will be tested for COVID-19 triage in Nigeria and a cohort of South A robotic lung ultrasound machine will be tested for African children will be studied for serological response A robotic lung ultrasound will be COVID-19 triage in Nigeriamachine and a cohort of tested South for to coronavirus—both with emergency support awarded COVID-19 triage will in Nigeria and for a cohort of South African children be studied serological response through revisions to existing NIH Common Fund grants. African children will be studied for serological response to coronavirus—both with emergency support awarded to coronavirus—both with emergency support awarded through revisions to existing NIH Common Fund grants. Dr. Haichong (Kai) Zhang—a robotics engineering prothrough revisions to existing NIH Common Fund grants. fessor at Worcester Polytechnic Institute in MassachuDr. Haichong (Kai) Zhang—a robotics engineering prosetts—received funding to assess his prototype of a Dr. Haichong (Kai) Zhang—a robotics engineering professor at Worcester Polytechnic Institute in Massachugantry-style lung ultrasound machine that can be fessor at Worcester Polytechnic Institute in Massachusetts—received funding to assess his prototype of a operated remotely and easily. He is collaborating with a setts—received funding to assess his prototype gantry-style lung ultrasound machine that can of bea team in Nigeria to check the suitability of the new robot gantry-style lung ultrasound that can bewith a operated remotely and easily.machine He is collaborating to standardize diagnoses of COVID-19 patients, lower operated remotely and easily. He is collaborating a team in Nigeria to check the suitability of the newwith robot costs and keep medical staff safer in a resource-limited team in Nigeriadiagnoses to check the suitabilitypatients, of the new robot to standardize of COVID-19 lower setting. Zhang holds an NIH Director’s Early Independence to standardize of COVID-19 lower costs and keepdiagnoses medical staff safer in a patients, resource-limited costs and keep holds medical safer in a resource-limited setting. Zhang an staff NIH Director’s Early Independence setting. Zhang holds an NIH Director’s Early Independence

Award to study an imaging-based approach to identifying aggressive prostate cancer. Award to study an imaging-based approach to identifying Award to study an imaging-based approach to identifying aggressive prostate cancer. Meanwhile, Human Heredity and Health in Africa aggressive prostate cancer. grantees Drs. Heather Zar and Mark Nicol received Meanwhile, Human Heredity and Health in Africa funding to investigate the spectrum of SARS-CoV-2 Meanwhile, Human Heredity and Health inreceived Africa grantees Drs. Heather Zar and Mark Nicol infection and COVID-19 symptoms in 900 wellgrantees Drs. Heather the Zarspectrum and MarkofNicol received funding to investigate SARS-CoV-2 characterized children in an existing cohort in South funding investigate thesymptoms spectrumin of 900 SARS-CoV-2 infectiontoand COVID-19 wellAfrica. The children, 6-8 years old, will be followed to infection and COVID-19 900 wellcharacterized children insymptoms an existingincohort in South discern if previous infection with seasonal coronaviruses characterized children in years an existing cohort in South Africa. The children, 6-8 old, will be followed to protects against infection with SARS-CoV-2 or the Africa. children, 6-8 years old, will be followed to discernThe if previous infection with seasonal coronaviruses effects of COVID-19. In addition, the team will integrate discern previous infection with seasonal coronaviruses protectsifagainst infection with SARS-CoV-2 or the serological data with other information such as diet to protects infection with SARS-CoV-2 or integrate the effects ofagainst COVID-19. In addition, the team will identify factors contributing to the mildness of COVID-19 effects of COVID-19. addition, the team will serological data with In other information such asintegrate diet to symptoms in most infected adolescents. serological datacontributing with other information such of asCOVID-19 diet to identify factors to the mildness identify factors contributing to the mildness of COVID-19 symptoms in most infected adolescents. symptoms in most infected adolescents.

NIH hosts virtual conference on data science in Africa

FOCUS FOCUS FOCUS 86 Delaware Journal of Public Health – November 2020

• Encouraging public-private partnerships increaseinimpact NIH hosts virtual conference on data to science Africa • Harnessing innovation and entrepreneurship for health advances NIH hosts virtual conference on data science in Africa • Encouraging public-private partnerships to increase impact • Training the next generation of data science leaders • Encouraging public-private to increase impact Harnessing innovation and partnerships entrepreneurship for health advances Read more on pages 6–9 Read More on 91-94 • Harnessing and entrepreneurship forpages health advances Training the innovation next generation of data science leaders • Training the next generation of data Read science leaders more on pages 6 – 9 Read more on pages 6 – 9


NIHinvests invests$14M $14Mfor forNCD NCDresearch researchand andtraining training NIH NIH invests $14M for NCD research and training Cancer, diabetes, mental illness and other noncommuniCancer, diabetes, mental illness and other noncommuniCancer, diabetes,(NCDs) mentalare illness andrise other cable diseases on the andnoncommuninow claim more cable diseases (NCDs) are on the rise and now claim more Cancer, mental other noncommunicable (NCDs) areillness on theand rise and now claim than more livesdiseases indiabetes, low- and middle-income countries (LMICs) lives in lowand middle-income countries (LMICs) than cable diseases (NCDs) are on the rise and now claim more lives in lowand middle-income countries (LMICs) than infectious diseases. To help address this, Fogarty and its infectious diseases. To help address this, Fogarty and its lives in lowand middle-income countries (LMICs) than infectious diseases. To help address this, Fogarty and funding partners have awarded about $13.9 million its in 17 funding partners have about $13.9 million in 17 infectious diseases. To awarded help address this, Fogarty and funding partners have awarded about $13.9 million in its 17 new grants to support NCD research and training new grants to support NCD research and training funding partners have awarded about $13.9 million in 17 new in grants LMICs.to support NCD research and training in LMICs. new grants to support NCD research and training in LMICs.

level capacity building program in environmental and level capacity program in environmental and level capacity building building program environmental and occupational health for Costa in Rican scientists. The occupational health for Costa Rican scientists. The level capacity building program in environmental occupational health for Costa Rican scientists. The University of California, San Francisco will use and its award University of San will use its award occupational health for Costa Rican scientists. University of California, California, San Francisco Francisco will use The its training award to produce an interdisciplinary cancer research to produce an interdisciplinary cancer research training University of California, San Francisco will use its award to program produce in anTanzania interdisciplinary training to build cancer a cadreresearch of scientists program in Tanzania to build a cadre of scientists to produce an interdisciplinary cancer research training program in Tanzania to build a cadre of scientists throughout East Africa capable of advancing discoveries throughout East Africa of discoveries program in Tanzania to capable build a cadre of scientists throughout East cancer Africa capable of advancing advancing discoveries and informing control planning in the region. and informing cancer planning in region. throughout East Africacontrol capable of advancing and informing cancer control planning in the the discoveries region. Photo PhotoPhoto bybyDavid David by David Rochkind Rochkind Rochkind forforFogarty Fogarty for Fogarty

screening in Uganda. In Mexico, the National Institute of Public Health will In Mexico, the Institute of Health In study Mexico, the National National Institute of Public Public Health will willin exposure to aflatoxin, a fungal contaminant study exposure to aflatoxin, a fungal contaminant in In food, Mexico, Institute of Public Health will study exposure to aflatoxin, fungal contaminant in andthe its National impact on theacountry’s increasing rates food, and its impact on the country’s increasing rates study exposure to aflatoxin, a fungal contaminant in food, and its impact on the country’s increasing rates of hepatocellular cancer. Peru’s Universidad Cayetano of hepatocellular cancer. Peru’s Universidad Cayetano food, and its impact on the country’s increasing rates of hepatocellular cancer. Peru’s Universidad Cayetano Heredia will investigate barriers to multimorbidity care Heredia will to care of hepatocellular cancer.barriers Peru’s Universidad Cayetano Heredia will investigate investigate barriers to multimorbidity multimorbidity care management through patient interviews and other management through patient interviews and other Heredia will investigate barriers to multimorbidity management methods. through patient interviews and other care methods. management through patient interviews and other methods. methods. Researchers at two hospitals in Nepal will build capacity Researchers at hospitals in Nepal build capacity Researchers at two two inpackage Nepal will will capacity to implement andhospitals evaluate a of build essential NCD to implement and evaluate a package of essential NCD Researchers two hospitals inbyNepal will build capacity to implementatand evaluate a package of essential NCD interventions recommended the WHO, as well as interventions recommended the as to explore implement and evaluate aby package of implementation. essential NCD interventions recommended by thetoWHO, WHO, as well well as as facilitators and barriers its explore facilitators and barriers to its implementation. interventions recommended by the WHO, as well as explore facilitators and barriers to its implementation. Finally, the American University in Beirut (AUB) will Finally, the American in Beirut (AUB) will explore andUniversity barriers to implementation. Finally, the American University inits Beirut willand form afacilitators multidisciplinary collaboration to(AUB) examine form a multidisciplinary collaboration to examine and Finally, the American University in Beirut (AUB) will form a multidisciplinary collaboration to examine and address the social, cultural and biological determinants address the social, cultural and biological determinants form a multidisciplinary collaboration to examine andand address the social, cultural and biological of diabetes and cardiovascular disease indeterminants Lebanon of diabetes and cardiovascular disease in Lebanon and address theand social, cultural and biological determinants of diabetes cardiovascular disease in African Lebanon and throughout the Middle East and North region. throughout the Middle East and North African region. of diabetes and cardiovascular in Lebanon and throughout the Middle East anddisease North African region. throughout thenine Middle East and North research African region. In addition, grants will support training In addition, nine grants will support research training In projects. addition,For nine grants will support research training instance, the Icahn School of Medicine projects. For instance, the School of In at addition, nine grants willIcahn support research training projects. ForSinai instance, the Icahn of Medicine Medicine Mount will develop andSchool conduct a multiat Mount Sinai will develop and conduct a multiprojects. For instance, the Icahn School of Medicine at Mount Sinai will develop and conduct a multi-

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in Eight LMICs. and informing cancer control planning in the region. awards will fund exploratory Meanwhile, the University of North Eight awards will fund Meanwhile, the University of Eight awards fund exploratory exploratory Meanwhile, the University of North North research onwill a variety of NCD topics. For Carolina at Chapel Hill aims to address research on variety NCD For Carolina at Chapel Hill aims to address Eight awards will fundof exploratory Meanwhile, the University of North research onaa achecklist variety ofdesigned NCD topics. topics. For Carolina at Chapel Hill aims to address example, to improve the mental health treatment gap in example, a checklist designed to improve the mental health treatment gap in research on a variety of NCD topics. 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Uganda, the Mbarara first genetic studies of a craniofacial impact. In Uganda, the Mbarara A second KNU award fund the policy and practice to first genetic studies ofwill a craniofacial impact. In Uganda, themaximize Mbarara birth defect in a sub-Saharan African University of Science and Technology birth defect a African University Science and Technology first genetic studies of researchers a craniofacial impact. In of Uganda, the Mbarara birth defect in in a sub-Saharan sub-Saharan African University of Science and Technology population. In Mali, at the will increase junior faculty expertise population. In Mali, researchers at the will increase junior faculty expertise birth defect in a sub-Saharan African University of Science and Technology population. In Mali, researchers at the will increase junior faculty expertise University of Sciences, Techniques and in multi-morbidity through a holistic University of Techniques in multi-morbidity through a population. Mali, researchers at and the will increase junior faculty expertise University ofInSciences, Sciences, Techniques and in understanding multi-morbidity a holistic holistic Technologies of Bamako will adapt an ofthrough health and a focus on Technologies of will an understanding of and focus University of Sciences, Techniques and in multi-morbidity through Technologies of Bamako Bamako will adapt adapt an understanding of health health anda a aholistic focus on on existing diabetes prevention program social-behavioral and environmental existing diabetes prevention program social-behavioral and environmental Technologies of Bamako willcouples adapt an understanding health and a to focus on existing diabetes prevention program social-behavioral and environmental targeting individuals and and determinants,ofwhile a grant targeting individuals and couples and determinants, while grant to existing diabetes prevention program social-behavioral anda targeting individuals and couples and determinants, while a environmental grant to evaluate its impact. If successful, the Makerere University will strengthen evaluate its impact. If successful, the Makerere University will strengthen targeting individuals couples and determinants, whileand awill grant to evaluate its impact. Ifand successful, the Makerere University strengthen educational materials produced in research training mentorship to Diabetes, multi-morbidity care management educational materials produced in research training and mentorship to Diabetes, multi-morbidity care management evaluate impact. If successful, Makerere University will strengthen and mental health issues are some of the educational materials produced inthe research training and mentorship to Frenchits could be scaled up throughout improve brain health. The University Diabetes, multi-morbidity care management andtopics mental health issues are some of theFogarty French could be scaled up improve brain health. The University being addressed through new educational produced in research training andcollaborate mentorship to and mental health issues are of the French couldmaterials beWest scaled up throughout throughout improve brain health. The University Diabetes, multi-morbidity caresome management Francophone Africa. Meanwhile, of Washington will with topics being addressed through new Fogarty noncommunicable disease research and topics being addressed through new Fogarty Francophone West Africa. Meanwhile, of Washington will collaborate with and mental health issues are some ofand the French could be scaled up throughout improve brain health. The University Francophone West Africa. Meanwhile, noncommunicable disease research of Washington will collaborate with Makerere University scientists will partners in Nepal and Kenya to address training grants. disease research and noncommunicable topics addressed through new Fogarty Makerere University scientists will partners in Kenya to address trainingbeing grants. Francophone Africa. of Washington willand collaborate Makerere scientists will partners in Nepal Nepal and Kenya towith address training grants. develop University andWest test a socialMeanwhile, networkcardiometabolic diseases and risk factors noncommunicable disease research and develop and test a social networkcardiometabolic diseases and risk factors Makerere University scientists will partners in Nepal and Kenya to address training grants. develop test a intervention social networkcardiometabolic diseases and risk factors drivenand advocacy to promote cervical cancer through educational programs, strong mentorship and driven advocacy intervention to promote cervical cancer through educational programs, strong mentorship and develop and test a social networkcardiometabolic diseases and risk factors driven advocacy intervention to promote cervical cancer through educational programs, strong mentorship and screening in Uganda. relevant research experiences. screening in relevant experiences. driven advocacy intervention to promote cervical cancer through research educational programs, strong mentorship and screening in Uganda. Uganda. relevant research experiences. relevant research experiences. Rutgers University will expand its existing botanicalsRutgers University will expand its botanicalsRutgers University expand its existing existing botanicalsfocused research will training program in Tajikistan and begin focused research training program in Tajikistan and begin Rutgers University will expand its existing botanicalsfocused research training program in Tajikistan and begin offering training to Indonesian scientists as well. Local offering training to Indonesian scientists as well. Local focused research training program in Tajikistan and offering training to Indonesian scientists as well. Local plants are studied for the prevention and treatmentbegin of plants are studied the and treatment of offering training to for Indonesian scientists as well. Local plants are studied for the prevention prevention and treatment of inflammation-associated conditions, such as diabetes, inflammation-associated such as diabetes, plants are studied for theconditions, prevention and inflammation-associated conditions, such as diabetes, arthritis and neurological disorders. Thetreatment New YorkofState arthritis and neurological disorders. The New York State inflammation-associated conditions, such as diabetes, arthritis and neurological Themental New York State Psychiatric Institute willdisorders. leverage the health Psychiatric Institute will leverage the mental health arthritis and neurological disorders. New York Statefor Psychiatric Institute will leverage theThe mental health research training program it developed in Portuguese research training program it developed in Portuguese Psychiatric Institute will leverage the mental health for research training program it capacity developed Portuguese for Brazilian trainees to build inin Mozambique, where Brazilian trainees to build capacity in Mozambique, where research training program it developed in Portuguese forAUB Brazilian trainees to build capacity in Mozambique, where there are 29 million people and only 18 psychiatrists. there are trainees 29 and only psychiatrists. AUB Brazilian to people build capacity in18 Mozambique, there 29 million million people and only 18 psychiatrists. AUB will are strengthen its existing NCD research training where program will strengthen its existing NCD research training program there are 29 million people and only 18 psychiatrists. will strengthen its existing NCD research training program by developing advanced research methods modules,AUB by developing advanced research methods modules, will strengthen its existing NCD research training program bycultivating developing advanced research methods modules, grassroots mentorship and offering fellowships cultivating grassroots mentorship and offering fellowships by developing advanced research methods modules, cultivating grassroots and offering fellowships to enhance researchmentorship productivity. to research cultivating mentorship and offering fellowships to enhance enhance grassroots research productivity. productivity. to Fogarty enhanceissued research the productivity. NCD awards with co-funding provided Fogarty issued the NCD with provided Fogarty NCD awards awards with co-funding co-funding by theissued Office the of Dietary Supplements, Office of provided Research on by the Office of Dietary Supplements, Office of Research on Fogarty issued NCD awards withfor co-funding provided by the Office of the Dietary Supplements, Office of Research on Women’s Health, National Center Complementary and Women’s Health, National Center for Complementary and byIntegrative the Office of Dietary Supplements, Office of Research on Women’s Health, National Center for Complementary and Health, and National Institute of Mental Health. Integrative Health, and of Women’s Health, National CenterInstitute for Complementary and Integrative Health, and National National Institute of Mental Mental Health. Health. Integrative Health, and National Institute of Mental Health. RESOURCES RESOURCES RESOURCES http://bit.ly/NCDgrants http://bit.ly/NCDgrants RESOURCES http://bit.ly/NCDgrants http://bit.ly/NCDgrants



African African experts share COVID contact tracing tips African African experts experts experts share share share COVID COVID COVID contact contact contact tracing tracing tracing tips tips tips By BySusan SusanScutti Scutti By BySusan SusanScutti Scutti

Image Image courtesy courtesy of Dr.ofSabin Dr. Sabin Nsanzimana Nsanzimana Image Image courtesy courtesy of Dr.ofSabin Dr. Sabin Nsanzimana Nsanzimana

Nsanzimana, Nsanzimana,director directorof ofRwanda’s Rwanda’sBiomedical BiomedicalCentre. Centre.An An African Africannations nationshave haverecorded recordedlower lowerrates ratesof ofCOVID-19 COVID-19 advisory advisory group group of ofRwandan Rwandan scientists scientists also alsoprovided provided data data Nsanzimana, Nsanzimana, director director of ofRwanda’s Rwanda’s Biomedical Biomedical Centre. Centre. An An than than many many high-income high-income countries, countries, which which is attributable, African African nations nations have haverecorded recorded lower lower rates ratesis of ofattributable, COVID-19 COVID-19 and evidence-based evidence-based recommendations. recommendations. Nearly Nearly 20,000 20,000 advisory advisory group groupof ofRwandan Rwandan scientists scientistsalso also provided provided data data some some say, say,to to the thecontinent’s continent’s robust robustwhich public publicisis health health response. response. and than thanmany many high-income high-income countries, countries, which attributable, attributable, contacts have havebeen beentraced traced and andchecked, checked, he hesaid, said, noting noting and andevidence-based evidence-based recommendations. recommendations. Nearly Nearly 20,000 20,000 Several Several leaders leaders of of coronavirus coronavirus response response teams teams in inAfrica Africa some somesay, say, to tothe the continent’s continent’s robust robust public public health health response. response. contacts some some contacts contacts were weretraced not notaccessible accessible but but“they're “they're not not many.” many.” contacts contacts have havebeen been traced and andchecked, checked, he hesaid, said, noting noting presented presented best bestpractices practices of ofcontact contact tracing tracing in inaain recent recent Several Severalleaders leaders of ofcoronavirus coronavirus response response teams teams in Africa Africa To To decentralize decentralize contact contact tracing efforts, efforts, Rwanda Rwandanot adapted adapted some some contacts contactswere were not nottracing accessible accessible but but“they're “they're not many.” many.” webinar webinar organized organized by byAFREhealth’s AFREhealth’s Dr. Dr.Jean Jean and presented presented best bestpractices practices of ofcontact contacttracing tracing in inNachega aNachega arecent recentand “a “a complexity of ofcontact IT ITsolutions,” solutions,” he he added. added. This Thisincludes includes To Tocomplexity decentralize decentralize contact tracing tracing efforts, efforts, Rwanda Rwanda adapted adapted Fogarty’s Fogarty’s Deputy DeputyDirector Director Dr. Dr.Peter PeterKilmarx. Kilmarx. Presenters webinar webinarorganized organized by byAFREhealth’s AFREhealth’s Dr. Dr.Jean JeanPresenters Nachega Nachegaand and a a geospatial mapping mapping system, system,an an IT notification notification system system “a “ageospatial complexity complexity of ofIT ITsolutions,” solutions,” he heIT added. added. This Thisincludes includes from from Nigeria, Nigeria, South South Africa, Africa, Uganda Uganda and Rwanda Rwanda said saidtheir their Fogarty’s Fogarty’s Deputy Deputy Director Director Dr. Dr. Peter Peterand Kilmarx. Kilmarx. Presenters Presenters previously used used in inthe thesystem, HIV HIVprogram, program, an anelectronic electronic tool tool apreviously ageospatial geospatial mapping mapping system, an anIT ITnotification notification system system countries countries responded responded to tothe theUganda pandemic pandemic with with largely largely similar similar from fromNigeria, Nigeria, South SouthAfrica, Africa, Uganda and and Rwanda Rwanda said said their their for conducting conducting home-based home-based monitoring monitoring and aaGPS GPStool app app previously previously used used in inthe theHIV HIVprogram, program, an anand electronic electronic tool measures, measures, and andtransitioned transitioned from fromcentralized centralized contact contact tracing tracing for countries countriesresponded responded to tothe thepandemic pandemic with withlargely largely similar similar fortruck truck drivers. drivers. Stigma Stigmawas was aaproblem problemand initially, initially, yet yet as as conducting conducting home-based home-based monitoring monitoring and aaGPS GPS app app efforts efforts to todecentralized decentralized models models over over time. time. measures, measures, and andtransitioned transitioned from from centralized centralized contact contacttracing tracing for people people to tobetter better understand understand for fortruck truckdrivers. drivers.Stigma Stigma was wascame acame aproblem problem initially, initially, yet yetas as efforts effortsto todecentralized decentralizedmodels modelsover overtime. time. the the disease, disease, “this isisno no longer longeran an people people came came“this to tobetter better understand understand Nigeria Nigerialeveraged leveragedcommunity community issue,” issue,” said saidNsanzimana. Nsanzimana. the thedisease, disease, “this “thisisisno nolonger longeran an networks networks established established in inresponse response Nigeria Nigerialeveraged leveraged community community issue,” issue,”said saidNsanzimana. Nsanzimana. to to Lassa Lassafever fever and andEbola, Ebola, said saidDr. Dr. networks networks established established in inresponse response In InSouth SouthAfrica, Africa,the thegovernment government Rhoda Rhoda Atteh, Atteh, leader of ofher her nation’s nation’s to toLassa Lassa fever feverleader and andEbola, Ebola, said said Dr. Dr. declared declared aAfrica, national national disaster In InSouth SouthaAfrica, the thedisaster government government COVID COVID operation operation center. center. Contact Contact Rhoda RhodaAtteh, Atteh, leader leader of ofher her nation’s nation’s followed followed travel travelrestrictions, restrictions, declared declaredby aby anational national disaster disaster tracers tracers primarily primarilyrelied relied on on in-person in-person COVID COVIDoperation operation center. center. Contact Contact distancing distancing measures and andaa followed followedby bymeasures travel travelrestrictions, restrictions, interviews—not interviews—not phone phone calls—to tracers tracersprimarily primarily relied reliedcalls—to on onin-person in-person coronavirus coronavirus testing testingprogram. program. Drs. distancing distancingmeasures measures and andaa Drs. connect connect the thedots dots between between Nigeria’s Nigeria’s interviews—not interviews—not phone phone calls—to calls—to Hassan Hassan Mahomed Mahomed and and Masudah Masudah coronavirus coronavirus testing testing program. program. Drs. Drs. confirmed confirmed and and suspected suspected cases. connect connectthe the dots dots between betweencases. Nigeria’s Nigeria’s Paleker Paleker coordinated contact contact Hassan Hassancoordinated Mahomed Mahomedand and Masudah Masudah “We “We focus focuson on doing doing self-isolation self-isolation at confirmed confirmed and and suspected suspected cases. cases. at tracing tracing in Western WesternCape Cape Province. Province. Paleker Palekerin coordinated coordinated contact contact home home and andon also also monitoring monitoring contacts contacts “We “Wefocus focus on doing doing self-isolation self-isolation at at Paleker, Paleker, who who believes believes geography geography tracing tracingin in Western Western Cape Cape Province. Province. remotely,” remotely,” she shesaid, said, acknowledging acknowledging home homeand andalso also monitoring monitoring contacts contacts itself itself posed posed aabelieves challenge challenge to tocontact contact Paleker, Paleker, who who believes geography geography that that it’s it’sbeen been difficult difficult to toassess assess remotely,” remotely,” she she said, said,acknowledging acknowledging tracing tracing in inaaaprovince with with rural itself itselfposed posed aprovince challenge challenge to torural contact contact adherence. adherence. “There's “There's aato lot lotassess of of that thatit’s it’sbeen been difficult difficult to assess and and urban urban areas, said said “we “werural started started tracing tracing in inaaareas, province province with with rural misinformation misinformation and anda stigma stigma around adherence. adherence.“There's “There's a lot lotof ofaround Rwanda’s Rwanda’sCOVID-19 COVID-19response responseincluded includedusing usingaaGPS GPSapp app to to monitor monitorCOVID-19 and andconduct conduct contact contactincluded tracing tracingofusing ofusing truck truck drivers. a a decentralized decentralized process process from from quite quite and and urban urbanareas, areas, said said“we “we started started COVID-19,” COVID-19,” said said Atteh, Atteh, who whoaround heard heard misinformation misinformation and and stigma stigma around Rwanda’s Rwanda’s COVID-19 response response included aadrivers. GPS GPSapp app totomonitor monitorand andconduct conductcontact contacttracing tracingofoftruck truckdrivers. drivers. early on.” on.” aearly adecentralized decentralized process processfrom fromquite quite reports reports of ofcontact contact tracing tracing teams teams COVID-19,” COVID-19,” said saidAtteh, Atteh, who who heard heard early earlyon.” on.” being being attacked. attacked. “For “For aalot lotof of cases casesidentified, identified,not notaasingle single reports reports of ofcontact contact tracing tracing teams teams Preexisting Preexistingdistrict districtteams teamsdrove drovethe theeffort effortaided aidedby bythe the contact contact isisactually actually traced,” traced,” said Atteh. Atteh. More Morecommunity community being beingattacked. attacked. “For “For aalot lotof ofsaid cases cases identified, identified, not notaasingle single provincial provincial health health department. department. AAthe single single patient patient viewer viewer Preexisting Preexisting district district teams teamsdrove drove the effort effort aided aided by bythe the engagement, engagement, both bothbefore before and and during during the the contact contact tracing tracing contact contactisisactually actually traced,” traced,” said said Atteh. Atteh. More More community community (SPV) (SPV) electronic electronic database database was wasA repurposed repurposed to toconduct conduct provincial provincial health health department. department. A single singlepatient patient viewer viewer process, process, would would improve improve Nigeria’s Nigeria’s response, response, she shesuggested. suggested. engagement, engagement, both both before before and andduring during the thecontact contact tracing tracing contact contact tracing tracingand and case casereporting reporting due dueto toits its accessibility accessibility (SPV) (SPV)electronic electronic database database was wasrepurposed repurposed to toconduct conduct process, process,would wouldimprove improveNigeria’s Nigeria’sresponse, response,she shesuggested. suggested. and and sorting sorting capabilities. capabilities. The health health department department developed developed contact contact tracing tracing and andcase caseThe reporting reporting due due to toits itsaccessibility accessibility When Whenthe thevirus virusbegan beganto tocirculate circulatein inUganda, Uganda,the the two two additional applications applications for for monitoring monitoring symptoms symptoms and and and andadditional sorting sortingcapabilities. capabilities. The The health health department department developed developed government government activated activated an incident incidentmanagement management system, system, When Whenthe thevirus virus began beganan to tocirculate circulate in inUganda, Uganda,the the uploading uploading contact contact details. details. for two twoadditional additional applications applications formonitoring monitoringsymptoms symptomsand and according according to toactivated Dr. Dr.Alex AlexR. R. Ario, Ario, of ofthe the country’s country’sNational National government government activated an an incident incident management management system, system, uploading uploadingcontact contactdetails. details. Institute Institute of of Public Public Health. Health. Non-pharmacological Non-pharmacological according according to to Dr. Dr.Alex Alex R. R.Ario, Ario, of ofthe thecountry’s country’sNational National “Both “Bothof ofthese theseapplications applicationshad hadfairly fairlylimited limiteduptake uptake interventions interventions combined combined with with regional regionalcontact contacttracing tracing Institute Instituteof ofPublic Public Health. Health. Non-pharmacological Non-pharmacological by by the theof population, population, although although they they were were quite quiteactively actively “Both “Both of these theseapplications applications had had fairly fairly limited limited uptake uptake helped helped interrupt interrupt the thecountry’s country’s outbreak. outbreak. Regional Regional teams teams interventions interventions combined combined with withregional regional contact contact tracing tracing promoted,” said saidMahomed. Mahomed. Isolation Isolation facilities facilities were werealso also by bythe thepopulation, population, although although they theywere were quite quiteactively actively linked linked with the theincident incident management management operation operation to toteams maintain maintain promoted,” helped helpedwith interrupt interrupt the thecountry’s country’s outbreak. outbreak. Regional Regional teams underused, “partly “partly because becauseIsolation of ofstigma, stigma, partly partlybecause because of of promoted,” promoted,”said said Mahomed. Mahomed. Isolation facilities facilities were werealso also communication communication with withlaboratories laboratories and andoperation case casemanagement management linked linkedwith withthe theincident incident management management operation to tomaintain maintain underused, fear fear of ofloss lossof of aaposition position or orwhat what would wouldpartly happen happen to totheir their underused, underused, “partly “partly because because of ofstigma, stigma, partly because because of of workers, workers, explained explained Ario, Ario, noting notingthat that “established “established communication communication with with laboratories laboratories and and case casemanagement management homes,” homes,” he heof said, said, while whileanecdotal anecdotal reports reports suggest suggest low fear fearof ofloss loss of aaposition position or orwhat whatwould would happen happen to tolow their their community community systems” systems” required required less less expense expense and andwere weremore more workers, workers,explained explained Ario, Ario, noting noting that that “established “established adherence adherence to quarantine quarantine measures. measures. Still, Still,suggest Mahomed Mahomed said said homes,” homes,”he heto said, said, while whileanecdotal anecdotal reports reports suggest low low efficient efficient than than aacentralized centralized approach. approach. community community systems” systems” required required less lessexpense expenseand andwere weremore more he he believes believesto the the SPV SPVdatabase database was wascrucial crucial to tothe theoutbreak outbreak adherence adherence to quarantine quarantine measures. measures. Still, Still,Mahomed Mahomed said said efficient efficientthan thanaacentralized centralizedapproach. approach. response, response, while while best bestdatabase practices practiceswas include include community community he hebelieves believes the theSPV SPV database was crucial crucial to tothe theoutbreak outbreak In InRwanda, Rwanda,pandemic-related pandemic-relatedpublic publichealth healthmeasures measures preparation preparation and andbest planning, planning, and andinclude population-based population-based infection infection response, response,while while best practices practices include community community included included handwashing handwashing stations, stations, face-masking face-masking and and In InRwanda, Rwanda, pandemic-related pandemic-related public public health healthmeasures measures control practices. practices. He Headded added that that South SouthAfrica Africaisispreparing preparing preparation preparation and andplanning, planning, and and population-based population-based infection infection physical physical distancing. AAnational national preparedness preparedness and response control included includeddistancing. handwashing handwashing stations, stations, face-masking face-maskingand andresponse for for future future waves wavesof of the the disease. disease. “Our “Our current current strategies control control practices. practices. He He added added that that South South Africa Africastrategies is ispreparing preparing command command post postmanaged managed epidemiology epidemiology surveillance, surveillance, case case physical physicaldistancing. distancing. AAnational national preparedness preparedness and andresponse response are are to tobe beagile agile and and scalable in inorder order to respond respond quickly.” quickly.” for forfuture future waves waves of ofscalable the thedisease. disease. “Our “Ourto current current strategies strategies management, management, laboratory laboratory operations, data data science, science,logistics, logistics, command commandpost post managed managedoperations, epidemiology epidemiology surveillance, surveillance, case case areto tobe beagile agileand andscalable scalablein inorder orderto torespond respondquickly.” quickly.” communications communications and andadministration, administration, said saidscience, Dr. Dr.Sabin Sabin management, management,laboratory laboratory operations, operations,data data science, logistics, logistics, are communications communicationsand andadministration, administration,said saidDr. Dr.Sabin Sabin RESOURCES RESOURCES 88 Delaware Journal of Public Health – November 2020

RESOURCES RESOURCES http://bit.ly/africa-contact-tracing http://bit.ly/africa-contact-tracing http://bit.ly/africa-contact-tracing http://bit.ly/africa-contact-tracing

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PPRROOFFIILLEE PROFILE Fogarty Fogarty Scholar characterized FogartyScholar Scholarcharacterized characterized Scholar characterized aaaFogarty diabetes diabetes syndemic in India diabetessyndemic syndemicin inIndia India aSusandiabetes syndemic in India By BySusan Scutti Scutti By Susan Scutti By Susan Scutti

Indian Indianattitudes attitudesabout abouttype type22diabetes diabetestook tookDr. Dr.Emily Emily Indian attitudes about type 2 diabetes took Emily in Mendenhall Mendenhall by bysurprise. surprise. “People “People were werekind kind of ofDr. dismissive dismissive in Indian attitudes about type 2alittle diabetes tookof Dr. Emily Mendenhall by surprise. “People were kind dismissive in Delhi, Delhi, saying, saying, ‘Everybody ‘Everybody has hasa little diabetes,’” diabetes,’” observed observed Mendenhall by surprise. “People were kind of dismissive in Delhi, saying, ‘Everybody a little diabetes,’” observed the the former former Fogarty Fogarty Scholar. Scholar.has “This “This was was very very different different than thanin in Delhi, saying, ‘Everybody has a little diabetes,’” observed the former Fogarty Scholar. “This was very and different than in the the U.S., U.S., where where there’s there’s aalot lotof of moral moral blame blame andpeople people say, say, the former Fogarty Scholar. “This wasblame very different than in the U.S., there’s lot of moral and people say, ‘You ‘You didn’t didn’twhere eat eatright, right, you youadidn’t didn’t exercise—it’s exercise—it’s all allyour your fault fault thedidn’t U.S., where there’s adidn’t lot of moral blame and people say, ‘You eat right, youResearch exercise—it’s your fault that that you youhave have diabetes.’” diabetes.’” Research in inIndia Indialed ledall to togreater greater ‘You didn’t eat right, you didn’t exercise—it’s all your fault that you haveisis diabetes.’” Research in India led to greater insight, insight, which which exactly exactlywhat what she shehoped hoped to togain gain from from her her that you haveisdiabetes.’” Research in India greater insight, which exactly what she hoped to led gaintofrom her Fogarty Fogarty fellowship, fellowship, said saidMendenhall. Mendenhall. insight,fellowship, which is exactly what she hoped to gain from her Fogarty said Mendenhall. Fogarty fellowship, said Mendenhall. Mendenhall Mendenhallhad hadbegun begunstudying studyingdiabetes diabetesamong amongMexican Mexican Mendenhall had at begun studying diabetes among Mexican immigrants immigrants while while at Northwestern Northwestern University, University, which which Mendenhall had begun studying diabetes among Mexican immigrants while atabout Northwestern University, which inspired inspired her her to to think think about the the disease disease “as “as an an interinterimmigrants while at Northwestern University, which inspired her to think about the disease “as an interconnected connected condition that that reflected reflected social socialchange.” change.” inspiredcondition her to think about the disease “as an interconnected condition that American reflected social change.” Re-envisioning Re-envisioning a a common common American disease disease paved paved connected condition that reflected social change.” Re-envisioning a common American disease paved the the way way for for research research in in a a lower lower resource resource country. country. The The Re-envisioning a common American disease paved the way for research in a lower resource country. The scientists scientists behind behind the the Center Center for for Cardiometabolic Cardiometabolic Risk Risk the way for research in a lower resource country. The scientists behind the Center for Cardiometabolic Risk Reduction Reduction in in South South Asia Asia (CARRS) (CARRS) Surveillance Surveillance Study—a Study—a scientists behind the Center for Cardiometabolic Risk Reduction Asia (CARRS) Surveillance Study—a community-based community-based survey survey in India Indiaand and Pakistan—learned Pakistan—learned of ReductionininSouth South Asiain (CARRS) Surveillance Study—a of community-based survey in India and of community-based survey in India and Pakistan—learned Pakistan—learned Mendenhall’s Mendenhall’s diabetes diabetes work work and and promised promised her herfreedom freedomto to of Mendenhall’s and promised her freedom to Mendenhall’s diabeteswork work and promised her freedom to design design her herown owndiabetes research research if ifshe she joined joined them themin in Delhi Delhi on onher her design her joined in on her design herown ownresearch researchififshe she joined them them in Delhi Delhi on yearlong yearlong Fogarty Fogarty fellowship. fellowship. Historically Historically in inIndia, India, type type 22her yearlong Fogarty fellowship. Historically in type yearlong Fogarty fellowship. Historically in India, type 22 diabetes diabetes was was considered considered an anillness illness of ofthe theelite, elite, but butCARRS CARRS diabetes was an of but rates CARRS diabetes wasconsidered anillness illness of the the elite, CARRS data data indicated indicated aaconsidered socioeconomic socioeconomic reversal reversal as aselite, diabetes diabetes rates data indicated a asocioeconomic reversal as rates data indicated socioeconomic reversal as diabetes rates began began to to rise riseamong among less lessfortunate fortunate Delhi Delhiresidents. residents. began riseamong amongless lessfortunate fortunate Delhi Delhi residents. residents. began totorise

expectations—Is expectations—Isconspicuous conspicuousconsumption consumptionnecessary necessaryto to expectations—Is conspicuous consumption necessary to maintain maintain respect respect in in this this brave brave new new society? society? If If so, so, what what expectations—Is conspicuous consumption necessary to maintain respect in this bravepeople new society? If so, what must must I I buy? buy? Yet, Yet, lower-income lower-income people struggled struggled with with maintain respect in this brave new society? If so, what must I buy? Yet,kinds lower-income people due struggled “intense “intense familial familial of ofexpectations” expectations” dueto tothe thewith need need must I buy? Yet, kinds lower-income people struggled with “intense familial kinds ofsending expectations” dueto toschools, the need for for amassing amassing dowries dowries and and sending children children to schools, “intense familial kinds of expectations” due to the need forsaid. amassing dowries and sending children to schools, she she said.Diabetes Diabetes was was “experienced “experienced and andperceived perceived and and for amassing dowries and sending children to schools, she said. Diabetes was “experienced and perceived and embodied embodied differently” differently” by by low-income low-income patients patients compared compared she said. Diabetes was “experienced and perceived and embodied differently” low-income patients compared to to those thosewith with higher higherincomes, incomes, Mendenhall’s Mendenhall’s analysis analysis embodied differently” byby low-income patients compared tothose thosewith with higher incomes, Mendenhall’s analysis indicated. indicated. The The findings findings also alsoshowed showed an aninequitable inequitable to higher incomes, Mendenhall’s analysis indicated.The The findingsalso also showed an inequitable indicated. findings showed an inequitable distribution distribution of ofdepression, depression, with with 55% 55% of of the the lowest lowestincome income distributionreporting ofdepression, depression, with 55% lowest income distribution of with 55% of of thethe lowest income participants participants reporting symptoms symptoms compared compared to to 38% 38% and and participants reporting symptoms compared to 38% participants symptoms compared torespectively. 38% andand 29% 29% middlemiddle-reporting and and high-income high-income participants, participants, respectively. 29%middlemiddleandhigh-income high-income participants, respectively. 29% and participants, People People with withdiabetes diabetes and andlow lowincomes incomes were wererespectively. more more likely likely People with diabetes and low incomes were more likely People diabetes and low incomes were more likely to to delay delaywith seeking seeking care, care, have have lower lower rates rates of oftreatment treatment and and todelay delay seeking care,have have lower rates treatment to seeking care, lower rates of of treatment andand higher higher levels levels of ofstress. stress. higher higherlevels levelsofofstress. stress.

As AsaaFogarty FogartyScholar, Scholar,Mendenhall Mendenhallwas wasable ableto todevelop developher her Fogarty Scholar, Mendenhall was able able to develop develop her AsAs aa Fogarty Scholar, was her research research skills, skills, such suchas asMendenhall designing designinginstruments, instruments, training training research skills, such as designing instruments, training research skills, such as designing instruments, training researchers researchers and andanalyzing analyzing data. data.Paired Paired with withDr. Dr.Roopa Roopa researchersand andanalyzing analyzingdata. data.Paired Paired with with Dr. Dr. Roopa Roopa researchers Shivashankar Shivashankar of ofthe theCARRS CARRSstudy, study,Mendenhall Mendenhall developed developed Shivashankar of the CARRS study, Mendenhall developed Shivashankar of tools the CARRS study, Mendenhall developed two two new newresearch research tools for forethnographic ethnographic research—one research—one two newresearch researchtools toolsfor forethnographic ethnographic research—one research—one new aatwo qualitative qualitative interview interviewcovering covering five fivedomains, domains,the theother other a qualitativeinterview interviewcovering coveringfive five domains, domains, the the other qualitative other aaanarrative narrative interview interviewfocused focusedon onstress. stress. Unable Unableto tospeak speak a narrativeinterview interviewfocused focusedon onstress. stress. Unable Unable to to speak a narrative speak Hindi, Hindi, Mendenhall Mendenhalltrained trainedtwo tworesearch researchassistants assistants to to Hindi, Mendenhall trained two research assistants to Hindi, Mendenhall trained tworesidents researchdivided assistants toageconduct conduct interviews interviews of of 60 60 Delhi Delhi residents divided into into conduct interviews of 60 Delhi residents divided intoageageconduct interviews of 60representing Delhi residents divided into ageand-sex-matched and-sex-matched groups groups representing low-income, low-income, middlemiddleand-sex-matched groups representing low-income, middleand-sex-matched groupscategories. representing low-income, middleincome income and and high-income high-income categories. income and high-income categories. income and high-income categories.

Overall, Overall,the theMendenhall Mendenhallteam’s team’sresearch, research,published publishedin in Overall, the team’s research, published in in Overall, theMendenhall Mendenhall team’s research, published Social Social Science Science and andMedicine, Medicine, suggested suggested synergies synergies among among Social and suggested synergies among SocialScience Science andMedicine, Medicine, suggested synergies among diabetes, diabetes, depression depression and andsocial social inequality inequality in inurban urban India. India. diabetes, depression and social inequality in urban India. diabetes, depression and social inequality in begun urban Since Since her herFogarty Fogarty fellowship, fellowship, Mendenhall Mendenhall has has begun India. Since her Fogarty fellowship, Mendenhall has begun Sincethe herterm Fogarty fellowship, Mendenhall has begun using using the term “syndemics” “syndemics” to todescribe describesimilar similar co-existing co-existing using the term “syndemics” to describe similar co-existing using theshe term “syndemics” describe similar co-existing epidemics epidemics she has has studied studiedin into South South Africa, Africa, Kenya Kenya and and epidemics she inin South Africa, Kenya and epidemics shehas hasstudied studied South Africa, Kenya and Ethiopia. Ethiopia. Recently, Recently, Fogarty Fogarty awarded awarded the the Georgetown Georgetown Ethiopia. Fogarty awarded the Georgetown Ethiopia.Recently, Recently, Fogarty awarded Georgetown University University associate associateprofessor professor aaglobal globalthe noncommunicable noncommunicable University associate professor a global noncommunicable University associate professor a global noncommunicable diseases diseases research grant grant to toexamine examine examine the theapplication application application of diseases research research grant to the ofof diseases research grantato examine the application of syndemics syndemics theory theory within within a framework framework of of implementation implementation syndemics theory within a framework of implementation syndemics theory within a framework of implementation science. science. science. science.

Everyone Everyone in inDelhi, Delhi, no nono matter matter their their social social status, status, Everyone in Delhi, matter their social status, Everyone in Delhi, no matter their social status, reported reported feeling feeling stressed stressed within within the the rapidly rapidly transforming reported feeling stressed within the rapidlytransforming transforming reported feeling stressed within the rapidly transforming society, society, the the interviews interviews revealed. revealed. “People “People were were dealing dealing society, the interviews revealed. “People were dealing society, the interviews revealed. “People were dealing with with important important cultural cultural experiences experiences that that elicited elicited strong strong with important cultural experiences that elicited strong with important cultural experiences that elicited strong emotional emotional responses,” responses,” Mendenhall Mendenhall explained. explained. Both Both middlemiddleemotional responses,” Mendenhall explained. Both middleemotional responses,” Mendenhall explained. Both middleand upper-income folks felt tension due evolving and and upper-income upper-income folks folks felt felt tension tension due due to totoevolving evolving and upper-income folks felt tension due to evolving

“Because “Because aman ananthropologist, anthropologist,and and andnot not notaaa doctor doctor or “Because IIIam am an anthropologist, doctor oror “Because I amIIan anthropologist, and not taking ataking doctor or epidemiologist, epidemiologist, am am an an example example of of Fogarty Fogarty a a epidemiologist, I am an example of Fogarty taking a epidemiologist, I am an example of Fogarty taking a risk,” risk,” said said Mendenhall. Mendenhall. “Syndemics “Syndemics is is a a way way to to bring bring us said Mendenhall. “Syndemics is a way to bring usus risk,” said to Mendenhall. “Syndemics is ahow way to bring us all all together together tohave haveaaconversation conversation conversation about about how how interactions interactions together to have about interactions all together to have a conversation about how interactions matter matter so sofundamentally fundamentally to towhat what whathealth health health and and illness illness mean.” mean.” matter so fundamentally to and illness mean.” matter so fundamentally to what health and illness mean.” R ES O U R CES RESOURCES RESOURCES RESOURCES Profile: http://bit.ly/DiabetesSyndemic http://bit.ly/DiabetesSyndemic Profile: Profile: http://bit.ly/DiabetesSyndemic Profile: http://bit.ly/DiabetesSyndemic

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Emily EmilyMendenhall, Mendenhall,Ph.D. Ph.D. Emily Mendenhall, Ph.D. Fogarty FogartyScholar: Scholar: 2011-2012 2011-2012 Emily Mendenhall, Ph.D. Fogarty Scholar: 2011-2012

US USInstitution: Institution: Northwestern NorthwesternUniversity University Fogarty Scholar: 2011-2012 US Institution: Northwestern University Foreign Foreign Institutions: Institutions: Public PublicHealth HealthUniversity Foundation FoundationofofIndia India US Institution: Northwestern Foreign Institutions: Public Health Foundation of India Research ResearchInstitutions: area: area: Type Type22Health diabetes diabetes among amongdifferent different incomegroups groups Foreign Public Foundation of India income Research area: Type 2 diabetes among different income groups Research area: Type 2 diabetes among different income groups




Dr. Bruce Tromberg is the director of the NIH’s National Institute of Biomedical Imaging and Bioengineering (NIBIB), where he oversees a $400 million per year portfolio of research programs focused on developing engineering, physical science and computational technologies for their application in biology and medicine. In addition, he leads NIBIB’s $500 million Rapid Acceleration of Diagnostics Tech (RADx Tech) innovation initiative to increase SARS-CoV-2 testing capacity and performance. Together with Fogarty, NIBIB is a partner on the Harnessing Data Science for Health Discovery and Innovation in Africa (DS-I Africa) project, led by the NIH Common Fund.

What is NIBIB’s role at NIH? Our formal mission is leading the development and accelerating the application of biomedical technologies. A large part of that is data science, which includes modeling, computation and machine intelligence. We use these approaches to simulate or emulate biologic systems or devices and their interactions, and to extract information—with images and sensors—so we can gain further insight into those systems. We are working to advance engineered biology, which involves treating cellular systems, multicellular systems, tissues and entire organs as engineerable devices that can potentially be reprogrammed to prevent, slow, or reverse disease. We develop sensors and point-of-care devices. These can be wearable sensors that are based on a variety of different mechanisms including photonic, acoustic or electrical types of sensing for transducing biologic processes into signals that can be measured and quantified. These technologies are rapidly moving into implantable devices where the sensors have been engineered to be very specific for chemistries that are critical for monitoring and predicting disease. We’re also very engaged in supporting imaging technologies, which can span from devices that are small enough to be at the bedside, to very large physics imaging devices. With increasing attention to innovation, computation, new materials and costs, we can reduce the size and the complexity of these devices, and still be able to extract very complex and rich information. Finally, we are working to develop new therapeutic devices, many of which are completely noninvasive.

What is the potential of DS-I Africa? What’s driving a lot of our progress is the fact that we have access to technologies that are entirely new and much of this is coming from the consumer device industry. In fact, there’s a very thin line separating what we think of as consumer devices from medical devices, and we’re seeing a convergence in these technologies. Many of the consumer devices are helping us prevent 90 Delaware Journal of Public Health – November 2020

disease and are used in home care settings. It's clear much of the innovation and entrepreneurial community is interested in leveraging this kind of technology, which necessarily will involve a lot of data generation, hence, the great partnership between innovative engineering and data science.

What excites you about DS-I Africa? For a number of years, I’ve been helping develop African bioengineering expertise through a spectral imaging network led by Professor Jérémie Zoueu at the National Polytechnic Institute in Cote d'Ivoire. It’s evolved into a training and education course that examines new technologies, develops an understanding of how they work and encourages their repurposing for new applications to meet the emerging needs of the population. We believe this is foundational for the future of health and that building technology innovation networks is the way to get there. That's what we're hoping to do through our DS-I Africa program as well. This will help African scientists understand, prevent and detect disease, and advance their ability to personalize diagnosis and treatment. Ultimately, this will extend the population’s health span, reduce costs and barriers to access, and continue to drive innovation.

How else is NIBIB engaged in global health? One of the recent major programs that we've developed and launched in collaboration with the Bill and Melinda Gates Foundation is the NIH Technology Accelerator Challenge (NTAC). The challenge is a million-dollar competition for developing noninvasive devices to leverage those types of consumer technologies to diagnose, track and assess response to therapy for diseases of the vasculature, with a focus on malaria, sickle cell and anemia. We recently announced the prize winners who came up with some quite stunning projects. Our goal is to drive innovation and commercialization and to encourage widespread dissemination of these technologies. Note: this article is based on Dr. Tromberg’s August 12th DS-I Africa presentation.



NIH meeting examines data science potential for Africa


ata science holds enormous potential to spur health discoveries and catalyze innovation in Africa and is the topic of a new $58 million NIH funding initiative. A virtual symposium and networking platform was launched to foster collaborations across disciplines, sectors and geographies in the hopes of cultivating quality applications for the program. It contains videos of keynote addresses and panel discussions, technical grant application advice, chat rooms, networking bulletin boards and other features. The Harnessing Data Science for Health Discovery and Innovation in Africa (DS-I Africa) program is intended to encourage interdisciplinary partnerships that bring together data specialists, computer scientists and engineers with biomedical researchers, clinicians and other health experts. The program aims to create a culture of innovation and entrepreneurship that will result in new software solutions and technologies, produce start-ups and spinoff companies and partner with governments and businesses to reach scale and impact. More than 1,700 registrants participated in the virtual DS-I Africa forum, with more than half coming from Africa. In his keynote address, NIH Director Dr. Francis Collins said the continent is witnessing an incredible time

NIH had originally planned to hold the Data Science in Africa conference in Kampala. The virtual networking platform paid tribute to traditional Ugandan musical instruments.

Table 1 Enkwanzi “Panpipe”

Table 5

Ennanga “Wooden Zither”

Embuutu “Big Drum”

Endere “Flute”

DS-I AFRICA East Lounge

Collins noted that the NIH has been helping to develop research capacity throughout Aftica in preparation for the coming decade, when rapid advances are expected to transform biomedical and behavioral research and lead to improved health care. This African-led data science initiative is intended to build on previous large-scale NIH collaborations on the continent, including the Human Heredity and Health in Africa (H3Africa) program, the Medical Education Partnership Initiative (MEPI) and the Health-Professional Education Partnership Initiative (HEPI). H3Africa advanced genomics capacity and research partnerships, while MEPI and HEPI strengthened and expanded training for doctors and health care professionals. DS-I Africa is an NIH Common Fund program guided by a working group led by the Office of the Director, Fogarty, the National Institute of Biomedical Imaging and Bioengineering, the National Institute of Mental Health and the National Library of Medicine. Applications for DSI-Africa opportunities are due in late 2020 with projects slated to begin in September 2021. The four unique categories of funding are: • Research Hubs: Advance and demonstrate feasibility of data science research and innovation to improve health in Africa.

Table 6

Table 2

of growth and change. “Africa is very well situated to play an increasingly significant role in this area of scientific opportunity,” he said. “We want to see partnerships that go beyond the traditional academic research arena, partnerships that connect up with government, with the private sector and with NGO partners. We want to be sure that this is focused in a way that solves health challenges in Africa in a sustainable way.”

Table 4

• Training: Increase capacity for data science research in Africa. • ELSI Research: Explore ethical, legal and social implications of data science research from an African perspective and contribute to policy discussion on the continent. • Open Data Science Platform & Coordination Center: Facilitate the development of a trans-African network of data scientists.

Table 3

Sekitulege “Musical Bow” Akadinda “Wooden Xylophone”

Articles in this section are by Susan Scutti Resources: http://bit.ly/data-science-africa 91


Data science applicants urged to find diverse partners Multidisciplinary collaborations will be key to the success of NIH’s new DS-I Africa program. Applicants are encouraged to form partnerships that reach beyond academia to include governments, the private sector, NGOs and other stakeholders. An additional requirement is to bridge disciplinary divides, where health scientists collaborate with engineers, computer scientists, data experts and others. The goal is to build a sustainable and robust ecosystem for health discovery in Africa.

Partnerships with study participants are also of great importance, emphasized Dr. Julie Makani of Tanzania’s Muhimbili University of Health and Allied Sciences. She said she looks forward to the development of “wellcoordinated prospective and longitudinal cohorts in Africa” so that data scientists might better understand the physiological response to illness and so “identify novel, therapeutic interventions to reduce the burdens of disease.” Makani mentioned a cohort of 5,000 sickle cell disease patients that have been followed over 15 years. The enormous amount of data generated by this research raised questions far beyond the project itself: How can these data be used to inform policy? How can these data improve both basic science and clinical science research? “Data science is one of the ways that we can ensure that we integrate health, education, advocacy and research so that we improve health,” said Makani. To bring about real change, partnerships with governments and other policymakers are necessary, said Brian Gitta, a tech entrepreneur based in Uganda. “We need to build awareness of the importance of data for medicines, for disease tracking and community health monitoring such that we work with a variety of stakeholders, taking ownership of this data in the process,” he said. Gitta said harnessing health data will require more than innovative technologies—it will also take creative management and

92 Delaware Journal of Public Health – November 2020

Philips, which developed this portable ultrasound device, is one of many private companies hoping to partner with academic researchers on data science activities.

bold action from governments to ensure that Africans have the resources, tools and skills to lead this transformation. That opinion is shared by Sierra Leone’s chief innovation officer, Dr. David Moinina Sengeh. “We want to be in a place to ensure that the economy, the identity and governance becomes digital,” said Sengeh. To achieve this goal of “digitization for all,” Sierra Leone administrators rely on three principles when choosing partners. First, potential collaborators need to prioritize mobile solutions, the lifeblood of his nation’s computing power. Second, they must believe the goal of evidence-based policies is achieved through the use of artificial intelligence and other tools. Third, partners must design hybrid technology systems, Sengeh said. “Everything we do has to work online and offline, has to work on web, mobile and paper, and it has to work when there's power and when there's no power,” Alignment in views and methodology was a key concern for all panelists but they agreed soft skills also matter. “You want that excitement, that energy on the ideas that you all are putting forth, and you want folks that you can talk with about difficult things,” observed Dr. Aisha Walcott-Bryant of IBM Research Africa. Simply wanting to be a team member goes a long way as well, she added. Humility is the most important feature of any collaboration, Makani suggested. Each partner must understand the value of all the partners involved, from governments to patient communities. “Data science is a fantastic platform that will bring disparate people and disparate communities together. No one body or institutional sector can do this alone,” said Makani. “We really need to work together.”


Photo courtesy of Philips

Multidimensional connections serve pragmatic purposes, according to the partnership panel at the recent virtual DS-I Africa conference. Teams of diverse colleagues raise and address a wider range of issues than siloed collaborations and this greater scope offers a higher probability of success, according to Dr. Beatrice Murage, who develops partnerships in Africa and Asia for Philips. She said she is hoping to work with academic researchers who are customer-focused, able to develop products tailored to “pain points”—what customers ask for and need—and who take the long view. “We want to build solutions that last beyond, let’s say, one pilot or one study or one thesis, solutions that we can scale over time and over market and that have actual business value.”


Harnessing innovation to advance research discoveries

Photo courtesy of Mama-Ope

who are ignorant and deliver everything that he has acquired and the students are just listening,” he said. Today, engineering education relies on more interactive ways of transferring knowledge to students. This newer style of education suits Malawi’s growing need for lowcost, robust and effective technologies, said Gamula, who explained that foreign health care equipment The best way to understand often does not work in his innovation is to think nation’s high temperatures of it as the antithesis of and humidity. Malawi needs research, according to devices designed by homeDr. Robert Karanja, cogrown engineers. The change founder of Villgro Kenya, in education has already made an investment company. a difference, with MalawianIf the goal of the scientific developed products such as a process is a product, then Recent African tech innovations include this tool for diagnosing pneumotool to treat infant jaundice, it is the “process called nia in children. It was a project of the business incubator Villgro Kenya, low-cost ventilators and innovation” that is able founded by Dr. Robert Karanja, who spoke at the DS-I Africa conference. portable solar sample coolers to take new knowledge having been rolled out in the country’s hospitals. discovered through research and “create money at the end of the tunnel,” he said. “Intellectual property in itself is Yet the issue of brain drain remains a painful topic. not an end tool.” Africa has a huge advantage compared to “Africa has very many young brains, young people, other nations because it can exploit the “fourth industrial but when they grow up, they are looking towards revolution” in faster and cheaper ways than high-income the U.S.A., looking towards Europe,” noted Uganda’s countries that are already invested in older technologies, science minister, Dr. Elioda Tumwesigye. Given access Karanja added. to resources, he believes young scientists would remain in Africa, where they can help “our continent to develop Teaching approaches also must be modernized, said Dr. our own capacity, to produce products that are needed Gregory Gamula of Malawi Polytechnic. Until recently, and bring solutions to the challenges that we face as in engineering education was much too old-fashioned. Africa.” An “all-knowing teacher” would stand before “students At the heart of the DS-I Africa project are research hubs that are intended to become recognized centers of excellence in data science fields, and advance affordable and scalable solutions to improve health. One conference session was devoted to a discussion of how innovation can be sparked and channeled to achieve maximum impact.

Unique methods needed to train data scientists When capacity building came under the microscope at the DS-I Africa conference, discussants agreed more educational opportunities are needed. While demand for data science degrees is great, the supply of qualified teachers is lacking, according to the University of Rwanda’s Dr. Ignace Kabano. The discipline is “a blend of mathematics, statistics and computer science, yet most lecturers have expertise in just one of these fields,” he noted. Rare is the expert equipped with skills related to data manipulation and data capture who also has the statistical chops to analyze big data. Kabano also suggested Africa’s data science programs should seek accreditation by the Data Science Council of America to achieve global parity.


A well-rounded data science education includes theoretical training for the development of research skills and “real world” problem-solving, said Dr. Mahadia Tunga, of the Tanzania Data Lab. In 2018, Tunga’s team partnered with the University of Dar es Salaam to design a master’s program in data science. For their capstone projects, students work directly with NGOs to identify and solve data challenges. Data science training also needs to address and promote inclusion, Tunga proposed. Since fewer than 30% of her participants are female, she is targeting women early in their careers for skill development and matching them with appropriate mentors to encourage them to stay in the field.


Conducting ethical data science research in Africa


Data science poses inherent difficulties vis-à-vis participants and privacy, according to Pamela Andanda of the University of Witwatersrand. “Data is always related to some human person. We need to consider the role of ethics in ensuring that individuals are respected,” she said. “We get their consent, but consent is not a once-off encounter. It’s an ongoing process.” Ananda’s ultimate strategy for integrating an ELSI framework into data science requires reflection on four values—honesty, care, respect and fairness. She believes a data scientist needs to take a few steps back at each stage of research and ask: "Am I being honest? Am I caring for people that are

Bold action from African governments will be required to fully harness the potential of health data, according to Ugandan tech entrepreneur Brian Gitta, a speaker at the Data Science in Africa conference.

behind the data that I’m handling? Am I respectful? Am I fair in my dealings with other stakeholders?” Researchers have the obligation to describe potential risks and benefits for the entire community—not just study participants, said Dr. Josephine Agyeman-Duah of Oxford University. She said it is necessary “to empower the community, empower people, to understand the research, what we’re trying to do, how it will be of benefit to them and the implications—and also sensitize them so that they know when to speak out when people breach their rights.” Because data can be transferred and manipulated beyond the original study consented by participants, research subjects should have the right to withdraw at any point. She added that “withdrawing from research should not affect the rights that they have to medical care that they receive.”

Leveraging data systems to foster research networks Africa’s data science ecosystem was examined during the DS-I Africa conference to consider the open data science platform component of the program. The successful applicant will develop and maintain a data-sharing gateway and provide the organizational framework for the direction and management of the initiative’s common activities. Cloud computing, data security and interoperability were some of the issues considered. “We've been making amazing progress in generating increasingly vast datasets that offer tremendous research capabilities,” said Dr. Benedict Paten, of the University of California, Santa Cruz. Yet, massive amounts of information mean “it's no longer possible to take the data and bring it to you, bring it to your laptop or bring it to your institution,” he said. Continuing the familiar, outmoded ways of handling data not only 94 Delaware Journal of Public Health – November 2020

leads to great expense, it causes security problems and sharing difficulties. Data scientists need to “invert the model” by creating data biospheres that are modular, community-focused, open and standards-based, said Paten. Crowdsourcing is another promising aspect of data science, said Notre Dame University’s Dr. Geoffrey Siwo. He helped organize the Malaria DREAM Challenge, a project to identify problems in malaria that could be solved using genomic data, which involved 360 participants from 31 countries working together. The primary lesson learned, he said, was “you get a huge diversity of solutions that you as an individual or your lab or your company could not have imagined” when you open a data science problem to “basically anyone in the world.”


Photo courtesy of Royal Academy of Engineering

rivacy, research subject consent and other issues pose major concerns for data science studies. The DS-I Africa project includes a component specifically to ensure the ethical, legal and social implications (ELSI) of data science research are an integral part of the initiative. In a panel discussion on the topic, the unique challenges were considered. “Whereas in most research projects, we are concerned about individual level interaction and data, data science often engages with big data, huge amounts of structured and non-structured data, that may have been captured with the active or non-active participation of the human subject,” explained the University of Maryland’s Dr. Clement Adebamowo. Because of this, the risks, benefits and burdens of data science may be distributed unevenly and inequitably across society.


ByBy Dr.Dr. Roger Roger I. I. Glass, Glass, Director, Director, Fogarty Fogarty International International Center Center By Dr. Roger I. Glass, Director, Fogarty International Center

Now Nowisisthe thetime timetotocatalyze catalyze Now isscience the time tohealth catalyze data datascience and and health data science health innovation innovation ininand Africa Africa innovation in Africa Data Data driven driven science, science, discovery, discovery, and and care care are are the the health health currencurrenData driven science, discovery, cies cies of of the the future. future. They They have have and care are the health currenenormous enormous potential potential toto revolurevolucies of the future. They have tionize tionize science, science, speed speed health health enormous potential to revoludiscoveries discoveries and and strengthen strengthen the the tionize science, speed health health health care care system system inin Africa. Africa. discoveries and strengthen the ToTo ensure ensure African African scientists scientists are are health care system in Africa. prepared prepared toto lead lead the the coming coming To ensure African scientists are surge surge of of big big data data research, research, NIH NIH prepared to lead the coming is is investing investing $58 $58 million million over over surge of big data research, NIH five five years years inin the the Harnessing Harnessing Data Data Science Science forfor Health Health is investing $58 million over Discovery Discovery and and Innovation Innovation inin Africa Africa (DS-I (DS-I Africa) Africa) program. program. five years in the Harnessing Data Science for Health It It will will leverage leverage data data and and technologies technologies toto help help African African Discovery and Innovation in Africa (DS-I Africa) program. scientists scientists develop develop knowledge knowledge and and craft craft solutions solutions forfor the the It will leverage data and technologies to help African continent’s continent’s most most pressing pressing clinical clinical and and public public health health scientists develop knowledge and craft solutions for the problems. problems. The The first first awards awards will will bebe made made inin 2021. 2021. continent’s most pressing clinical and public health problems. The stands first awards will be made in 2021. The The continent continent stands atat anan inflection inflection point. point. Expansion Expansion

of of R&D, R&D, manufacturing, manufacturing, and and connectivity connectivity have have positioned positioned The continent stands at an inflection point. Expansion Africa Africa forfor explosive explosive growth growth inin health health innovation. innovation. ItsIts of R&D, manufacturing, and connectivity have positioned population population is is rapidly rapidly expanding, expanding, with with the the number number of of Africa for explosive growth in health innovation. Its people people under under the the age age of of 2525 predicted predicted toto almost almost double double byby population is rapidly expanding, with the number of 2050, 2050, rising rising from from 230 230 million million toto 450 450 million. million. High-speed High-speed people under the age of 25 predicted to almost double by internet internet connectivity connectivity is is improving improving and and sub-Saharan sub-Saharan 2050, rising from 230 million to 450 million. High-speed Africa Africa is is expected expected toto have have over over 600 600 million million unique unique mobile mobile internet connectivity is improving and sub-Saharan phone phone subscribers subscribers byby 2025. 2025. Africa is expected to have over 600 million unique mobile phone subscribers by are 2025. Some Some African African leaders leaders are eager eager toto embrace embrace innovation innovation and and transition transition toto knowledge-based knowledge-based economies, economies, recogrecogSome African leaders are eager to embrace innovation nizing nizing the the opportunity opportunity toto “leapfrog” “leapfrog” the the adoption adoption of of and transition to knowledge-based economies, recoghealth health innovations innovations and and implement implement new new approaches approaches nizing the opportunity to “leapfrog” the adoption of unburdened unburdened byby legacy legacy systems. systems. With With novel novel technologies technologies health innovations and implement new approaches designed designed toto improve improve health health promotion, promotion, diagnosis diagnosis and and unburdened by legacy systems. With novel technologies disease disease treatment, treatment, these these leaders leaders believe believe they they can can imimdesigned to improve health promotion, diagnosis and prove prove efficiency, efficiency, cost cost effectiveness effectiveness and and quality quality of of care care disease treatment, these leaders believe they can imwhile while leveraging leveraging automation automation toto mitigate mitigate health health workforce workforce prove efficiency, cost effectiveness and quality of care shortages. shortages. while leveraging automation to mitigate health workforce shortages. With With DS-I DS-I Africa, Africa, NIH NIH will will bebe building building anan innovation innovation and and data data science science consortium consortium that that seeks seeks toto disrupt disrupt the the With DS-I Africa, NIH will be building an innovation status status quo quo and and spur spur new new mechanisms mechanisms toto utilize utilize data data and data science consortium that seeks to disrupt the inin ways ways that that can can transform transform how how countries countries work. work. WeWe status quo and spur new mechanisms to utilize data in ways that can transform how countries work. We

envision envision a robust, a robust, African-led African-led network network of of public public and and private private partners partners that that fosters fosters a culture a culture of of innovation innovation and and envision a robust, African-led network of public and entrepreneurship, entrepreneurship, accelerating accelerating scientific scientific discoveries, discoveries, private partners that fosters a culture of innovation and devising devising new new software software solutions solutions and and technologies, technologies, entrepreneurship, accelerating scientific discoveries, generating generating start-ups start-ups and and spinoff spinoff companies, companies, and and devising new software solutions and technologies, collaborating collaborating with with governments governments and and businesses businesses toto reach reach generating start-ups and spinoff companies, and scale scale and and improve improve health. health. collaborating with governments and businesses to reach scale and improve health. WeWe aim aim toto attract attract collaborators collaborators from from multiple multiple sectors, sectors, uniting uniting data data specialists, specialists, computer computer scientists scientists and and We aim to attract collaborators from multiple sectors, engineers engineers with with biomedical biomedical researchers, researchers, clinicians clinicians and and uniting data specialists, computer scientists and other other health health experts experts inin interdisciplinary interdisciplinary teams. teams. WeWe engineers with biomedical researchers, clinicians and invite invite African African governments, governments, industry industry and and other other research research other health experts in interdisciplinary teams. We funders funders toto join join our our efforts efforts toto synergistically synergistically increase increase invite African governments, industry and other research their their reach reach and and impact. impact. funders to join our efforts to synergistically increase their reach and impact. WeWe plan plan toto fund fund anan open open data data science science platform platform and and coordinating coordinating center, center, support support the the development development of of robust robust We plan to fund an open data science platform and research research hubs, hubs, train train a cadre a cadre of of skilled skilled data data scientists, scientists, coordinating center, support the development of robust and and advance advance understanding understanding of of the the ethical, ethical, legal legal and and research hubs, train a cadre of skilled data scientists, social social implications implications (ELSI) (ELSI) of of data data science science approaches approaches inin and advance understanding of the ethical, legal and anan African African context. context. Discoveries Discoveries made made possible possible byby data data social implications (ELSI) of data science approaches in science science advances advances inin Africa Africa have have the the potential potential toto benefit benefit an African context. Discoveries made possible by data the the entire entire world, world, since since wewe are are allall from from Africa—the Africa—the cradle cradle science advances in Africa have the potential to benefit of of humanity—and humanity—and share share a common a common inheritance. inheritance. the entire world, since we are all from Africa—the cradle of humanity—and shareexpertise aexpertise common inheritance. NIH NIH has has much much relevant relevant toto contribute contribute toto DS-I DS-I Africa, Africa, which which leverages leverages the the substantial substantial investments investments NIH has much relevant expertise to contribute to DS-I NIH NIH has has already already made made across across the the continent. continent. DS-I DS-I Africa, which leverages the substantial investments Africa Africa is is a program a program of of the the NIH NIH Common Common Fund Fund that that NIH has already made across the continent. DS-I supports supports innovative innovative endeavors endeavors with with the the potential potential forfor Africa is a program of the NIH Common Fund that extraordinary extraordinary impact. impact. DS-I DS-I Africa Africa is is guided guided byby a working a working supports innovative endeavors with the potential for group group ledled byby Common Common Fund Fund staff staff inin the the Office Office of of the the extraordinary impact. DS-I Africa is guided by a working Director, Director, Fogarty, Fogarty, the the National National Institute Institute of of Mental Mental group led by Common Fund staff in the Office of the Health, Health, the the National National Institute Institute of of Biomedical Biomedical Imaging Imaging and and Director, Fogarty, the National Institute of Mental Bioengineering, Bioengineering, and and the the National National Library Library of of Medicine. Medicine. Health, the National Institute of Biomedical Imaging and Bioengineering, and the National Library of Medicine. ToTo encourage encourage networking networking across across disciplines, disciplines, sectors sectors and and geographies geographies and and toto foster foster collaborations collaborations forfor DS-I DS-I To encourage networking across disciplines, sectors Africa Africa applications, applications, NIH NIH is is hosting hosting a virtual a virtual symposium symposium and geographies and to foster collaborations for DS-I platform platform with with videos videos of of keynote keynote presentations, presentations, panel panel Africa applications, NIH is hosting a virtual symposium discussions, discussions, technical technical grant grant advice advice and and networking networking platform with videos of keynote presentations, panel tools. tools. discussions, technical grant advice and networking tools. WeWe hope hope others others who who share share our our vision vision forfor advancing advancing data data science science toto transform transform health health inin Africa Africa will will join join our our We hope others who share our vision for advancing effort effort toto empower empower and and bolster bolster African African partnerships. partnerships. data science to transform health in Africa will join our It It is is only only right right that that allall the the world’s world’s people—especially people—especially effort to empower and bolster African partnerships. those those who who have have the the fewest fewest resources resources and and the the greatest greatest It is only right that all the world’s people—especially disease disease burden—benefit burden—benefit from from the the power power of of big big data. data. those who have the fewest resources and the greatest disease burden—benefit from the power of big data. RESOURCES RESOURCES


http://bit.ly/DataScienceAfrica http://bit.ly/DataScienceAfrica RESOURCES




PEOPLE New NIH eye institute director has global ties Dr. Michael F. Chiang is the new director of NIH’s National Eye Institute. An ophthalmologist, Chiang most recently was professor at Oregon Health & Science University and associate director of OHSU’s Casey Eye Institute. He has research ties to Asia, Europe, the Middle East and South America.

NIH taps Criswell to lead arthritis, skin disease research NIH has selected Dr. Lindsey A. Criswell as the new director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Criswell was vice chancellor of research at the University of California, San Francisco. She has been principal investigator on multiple NIH grants and published more than 200 peerreviewed papers.

D’Souza is the new director of NIH dental research Dr. Rena D’Souza is the new director of the National Institute of Dental and Craniofacial Research. A past president of the International Association for Dental Research, D’Souza is vice president of health sciences at the University of Utah. Born in India, she has lived in the U.S. since 1978.

Fauci to receive RF Kennedy Ripple of Hope Award Dr. Anthony Fauci will receive the Robert F. Kennedy Ripple of Hope Award during a virtual ceremony in December. The honor celebrates outstanding leaders who have demonstrated a commitment to social change. Fauci is recognized for his work as director of the National Institute of Allergy and Infectious Diseases.

Fogarty mHealth grantee wins NIH tech competition Fogarty grantee Dr. Young Kim has won the $400,000 first prize in the NIH Technology Accelerator Challenge. The Purdue University engineering professor’s proposal aims to develop a non-invasive, smartphone-based spectroscopy platform to detect anemia and sickle cell disease by analyzing photos of the microvasculature of the inner eyelid.

Meshnick remembered for dedication to global health Fogarty grantee Dr. Steven Meshnick died of cancer in August. He was a professor of epidemiology at the University of North Carolina (UNC) and a member of the UNC Institute for Global Health and Infectious Diseases. Meshnick is being remembered for his work on malaria and other tropical diseases.

Former Fogarty bioethics trainee is honored University of Ghana bioethicist Dr. Paulina Tindana has received the inaugural Forum on Bioethics in Research award for her paper, which explores the issue of informed consent regarding genomic research and establishment of biobanks in sub-Saharan Africa. Tindana is a former Fogarty bioethics trainee. 96 Delaware Journal of Public Health – November 2020

Global HEALTH Briefs G-FINDER urges increased R&D investment

Funding for emerging infectious disease basic research and product development reached $886 million in 2018, up 14%, according to the new G-FINDER report issued by Policy Cures Research, a global health think tank. However, the report’s lead author says spending is “very reactive” and urged for more consistent investments to prepare for the next pandemic. Full report: http://bit.ly/Gfinder2020

WHO: sepsis causes 20% of global deaths

Sepsis—the body’s potentially deadly response to infection—is responsible for 1 in 5 deaths worldwide, the WHO warns in a new report. While most sepsis research is conducted in high-income countries, the majority of cases occur in lowresource settings. Nearly half of the 49 million cases each year occur among children, causing 2.9 million deaths. Full report: http://bit.ly/WHOsepsis

NCD agenda should be reframed

The global approach to noncommunicable diseases and injuries needs an “urgent upgrade” to meet the needs of the world’s poorest people, according to a recent Lancet Commission report. Potential solutions have placed an outsized focus on changing behavior, the authors maintain, instead of examining root causes of NCDs. Full report: http://bit.ly/LancetNCD

Report examines AI’s role in global health

A roadmap for applying artificial intelligence to global health problems was recently released by the Broadband Commission for Sustainable Development’s Digital Health Working Group. The report identifies high-leverage opportunities for AI to support global health projects for low- and middle-income settings and emphasizes the need to systematically integrate AI into healthcare infrastructures. Full report: http://bit.ly/AIglobal

Child lead poisoning is global problem

A third of the world’s children have been poisoned by lead, according to a new analysis by UNICEF and Pure Earth. The report says that around 1 in 3 children—up to 800 million globally—have blood lead levels higher than is deemed safe. Informal and substandard recycling of lead-acid batteries is a leading contributor. Full report: http://bit.ly/UNICEFlead



Funding Opportunity Announcement



Global Infectious Disease (GID) Research Training Program

Oct 28, 2020


Emerging Global Leader Award

Nov 4, 2020


Global Brain and Nervous System Disorders Research Across the Lifespan

Nov 6, 2020


Reducing Stigma to Improve HIV/AIDS Prevention, Treatment and Care in LMICs

Nov 12, 2020


Chronic, Noncommunicable Diseases and Disorders Research Training

Nov 13, 2020


Ecology and Evolution of Infectious Diseases

Nov 18, 2020


Harnessing Data Science for Health Discovery and Innovation in Africa U2R Research Training Program U01 Ethical, Legal, and Social Implications Research U2C Open Data Science Platform and Coordinating Center U54 Research Hubs – non-AIDS applications U54 Research Hubs – AIDS applications

Nov 24, 2020 Dec 1, 2020 Dec 3, 2020 Dec 8, 2020 Feb 8, 2021


Mobile Health: Technology and Outcomes in LMICs - AIDS applications

Dec 3, 2020


HIV-associated Noncommunicable Diseases Research at LMIC Institutions

Dec 3, 2020


For more information, visit www.fic.nih.gov/funding

Global Health Matters

New report warns US leadership in R&D is slipping

September/October 2020 Volume 19, No. 5 ISSN: 1938-5935 Fogarty International Center National Institutes of Health Department of Health and Human Services Managing editor: Ann Puderbaugh Ann.Puderbaugh@nih.gov Web manager: Anna Pruett Ellis Anna.Ellis@nih.gov Writer/editor: January W. Payne January.Payne@nih.gov Writer/editor: Susan Scutti Susan.Scutti@nih.gov Designer: Carla Conway

U.S. leadership in research and development (R&D) is waning while China’s is on the rise, according to a new study from the American Academy of Arts and Sciences and Rice University.

All text produced in Global Health Matters is in the public domain and may be reprinted. Please credit Fogarty International Center. Images must be cleared for use with the individual source, as indicated.

China is increasing its R&D investment by double-digit percentages each year while the U.S. has fallen to tenth place among OECD nations in investment in R&D, measured as a fraction of GDP, according to the report. The lag in U.S. funding is exacerbated by current strains on the research system and higher education, COVID-19, restrictions on foreign researchers and proposed cuts to federal investment in research, the study authors say.

SUBSCRIBE: www.fic.nih.gov/subscribe

R ESOURCE Full report: http://bit.ly/ChinaRD 97

Delaware Journal of

Public Health

Submission Guidelines

updated April, 2020

About the Journal Established in 2015, The Delaware Journal of Public Health is a bi-monthly, peer-reviewed electronic publication, created by the Delaware Academy of Medicine/Delaware Public Health Association. The publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, relating to the public health sector. Each issue is largely devoted to an overarching theme or current issue in public health. The content in the Journal is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know. If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact DJPH Deputy Editor Elizabeth Healy at ehealy@delamed.org, or the Executive Director of The Delaware Academy of Medicine and Delaware Public Health Association, Timothy Gibbs, at tgibbs@delamed.org

Information for Authors Submission Requirements The DJPH accepts a wide variety of submission formats including brief essays, opinion editorials pieces, research articles and findings, analytic essays, news pieces, historical pieces, images, advertisements pertaining to relevant, upcoming public health events, and presentation reviews. If there is an additional type of submission not previously mentioned that you would like to submit, please contact a staff member.

Cover Letters must address the following four article requirements: 1. A description of what the paper adds to current knowledge, in particular with respect to material previously published in DJPH, and if systematic reviews exist on the topic. 2. The public health importance of the paper. 3. One sentence summarizing the main message(s) of the paper, which may be used to disseminate the paper on social media.

The initial submission should be clean and complete, without edits or markups, and contain both the title and author(s) fulls name(s). Submissions should be 1.5 or 4. For individual or group randomized trials, provide the double spaced with a font size of 12. Initial submissions date of trial registration and the NCT number from must also contain a cover letter with concise text www.Clinicaltrials.gov or other approved registry. (maximum 150 words). Once completed, articles In the cover letter only, not in the paper. Do NOT should be submitted via email to Elizabeth Healy at include the trial registration or NCT number in the ehealy@delamed.org as an attachment. Graphics, images, abstract or the body of the manuscript during the info-graphics, tables, and charts, are welcome and initial submission. encouraged to be included in articles. Please ensure that all pieces are in their final format, and all edits and track All manuscripts must be submitted via email to Elizabeth Healy at ehealy@delamed.org. changes have been implemented prior to submission. 98 Delaware Journal of Public Health – November 2020

To view additional information for online submission requirements, please refer to the website for the Delaware Journal of Public Health: https://djph.org/sample-page/submit-an-article/. Submission Length While there is no prescribed word length, full articles will generally be in the 2500-4000-word range, and editorials or brief reports will be in the 1500-2500-word range. If you have any questions regarding the length of a submission, or APA guidelines, please contact a staff member. Copyright Opinions expressed by contributors and authors do not necessarily reflect the opinions of the DJPH or affiliated institutions of authors. Copying for uses other than personal reference or interest without the consent of the DJPH is prohibited. All material submitted alongside written work, including graphics, charts, tables, diagrams, etc., must be referenced properly in accordance with APA formatting. Conflicts of Interest Any conflicts of interest, including political, financial, personal, or academic conflicts, must be declared prior to the submission of the article, or in conjunction with a submission. Conflicts of interest are any competing interests that may leave readers feeling misled or deceived, and/or alter their perception of subject matter. Declared conflicts of interest may be published alongside articles in the final electronic publication.

Additional Documents and Information for Authors Please Note: All authors and contributors are asked to submit a brief personal biography (3 sentences maximum) and a headshot along submissions. These will be published alongside final submissions in the final electronic publication. For pieces with multiple authors, these additional documents are requested for all contributors. Abstracts Authors must submit a structured or unstructured abstract along with their article. The word limit is 200 words, including headings. A title page should be submitted with this abstract as well. Structured abstracts should employ 4-5 headings: Objectives (begins with “To…”) Methods Results Conclusions A fifth heading, Policy Implications, may be used if relevant to the article. Trial Registration information is required for clinical trials and must be included in the final version abstract All abstracts should provide the dates(s) and location(s) of the study is applicable. Note: There is no Background heading.

Nondiscriminatory Language Use of nondiscriminatory language is required in all DJPH submissions. The DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements.


RACISM AND PUBLIC HEALTH – RESOURCES Addiction and Mental Health Mobile Crisis Hotline and Resources Statewide mobile crisis hotline and resources. HOTLINE: 888-427-2643 | https://www.namidelaware.org/

Beautiful Gate Outreach Center

A non-profit community organization that provides rapid HIV testing, individual private counseling, education, and referral services. 604 N. Walnut Street, Wilmington | 302-472-3002 www.bgate.org

Black News

A national, comprehensive listing of Black Health Resources nationwide. www.blacknews.com/directory/black_african_american_health.shtml

Bright Spot Urban Farm

Mobile farmers’ markets and fresh produce stands serving underserved and under-resourced communities. West End Neighborhood House, Wilmington | 302-255-2993 | brightspotventures@gmail.com

Child Priority Response Services

Delaware’s 24-hour Child Mental Health Mobile Crisis. Services are available to any child physically present in the state who is under the age of 18 and is determined to be “at imminent danger to self or others as a result of a mental health or substance abuse disorder.” https://kids.delaware.gov/pbhs/families-emergency-services.shtml

Community Legal Aid Society

A non-profit community organization that aids with homelessness. • 100 W. 10th St. Wilmington | 302-575-0660 • 840 Walker Rd. Dover | 302-674-8503 • 20151 Office Circle, Georgetown | 302-856-0038

Connections Community Support Programs, INC.

A statewide, non-profit community organization that provides a variety of services ranging from health care, housing to employment opportunities. 3821 Lancaster Pike, Wilmington | 833-886-2277 https://www.connectionscsp.org/

Delaware Department of Health and Social Services https://dhss.delaware.gov/dhss/ •

Division of State Service Centers https://dhss.delaware.gov/dhss/dssc/

Friendship House

A non-profit community organization that aids with homelessness. 720 N. Orange Street, Wilmington | 302-652-8033 1503 W. 13th Street, Wilmington | 302-652-8133 Middletown: 302-416-0982 www.friendshiphousede.org

100 Delaware Journal of Public Health – November 2020

Health Resources and Services Administration (HRSA)

An agency of the U.S. Department of Health and Human Services providing information and resources for improving healthcare for the uninsured, isolated, or medically vulnerable. www.hrsa.gov

Henrietta Johnson Medical Center

A Federally Qualifie d Health Center (FQHC) providing comprehensive health services to under-resourced communities. 601 New Castle Ave, Wilmington | 302-655-6187

Housing Alliance Delaware

A statewide non-profitt hat helps with housing opportunities. 100 W. 10th Street, #611, Wilmington | 302-654-0126 www.housingalliancede.org

Metropolitan Wilmington Urban League

A community-based organization devoted to the empowerment of African Americans in the areas of economic self-reliance, parity, power and civil rights. 100 W. 10th Street #602, Wilmington | 302-622-4300 www.mwul.org



National Alliance on Mental Illness (NAMI)

A national organization to access an array of black mental health resources. www.nami.org

OfďŹ ce of Minority Health & Health Equity (OMHHE)

A national resource from the Centers for Disease Control and Prevention (CDC) that provides educational resources and information pertaining to minority health. www.cdc.gov/healthequity/

Rose Hill Community Center

A community based organization providing social services, health education and resource referrals. 19 Lambson Lane, New Castle | 302-656-8513

Urban Acres

Mobile farmers’ markets and fresh produce stands serving underserved and under-resourced communities. 839 N. Pine Street, Wilmington | 302-660-8124 www.centralbaptistcdc.org/urban-acres/

Westside Family Healthcare

A statewide Federally Qualifie d Health Center providing comprehensive health services to under resourced communities. www.westsidehealth.org

The Women of Color Health Data Book https://orwh.od.nih.gov/sites/orwh/fi les/docs/WoC-Databook-FINAL.pdf


A community based organization providing social services, health education and resource referrals. www.ywcade.org 101

RACISM AND PUBLIC HEALTH – LEXICON Allostatic Load The cost of chronic exposure to elevated or fluctuating endocrine or neural responses resulting from chronic or repeated challenges that the individual experiences as stressful.

Desensitization To make less likely to feel shock or distress at scenes of cruelty, violence, or suffering by overexposure to such images.

Ethnoviolence An act or attempted act that is motivated by group prejudice and intended to cause physical or psychological injury.

Health Equity The absence of avoidable, unfair, or remediable differences in health among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification.

Health Inequities Barriers preventing individuals and communities from accessing and reaching their full potential of health.

Implicit bias The attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.

Jim Crow Laws A collection of state and local statutes that legalized racial segregation (learn more).

Microaggressions A statement, action, or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalized group such as a racial or ethnic minority.

Multi-Generational Trauma The concept that trauma can be passed down from generation to generation. This trauma is related to major events that oppress a particular group of people because of their status as oppressed (e.g. slavery, the Holocaust, forced migration, etc.). Many in the group may not experience any effects of this trauma, but others may experience poor overall physical and behavioral health, and factors stemming from this.

Recidivism The tendency of a convicted criminal to reoffend.

SOP An acronym meaning Standard Operating Procedure

Structural Racism Also known as: institutional racism. A system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity. It identifies dimensions of our history and culture that have allowed privileges associated with ‘whiteness’ and disadvantages associated with ‘color’ to endure and adapt over time.

Trail of Tears A series of forced relocations of approximately 60,000 Native Americans between 1830 and 1850 by the United States government. The relocated peoples suffered from exposure, disease, and starvation while en route; thousands died before reaching their destinations or shortly after from disease (learn more).

White Privilege A system of benefits, advantages, and opportunities experienced by White persons in society simply because of their skin color.

102 Delaware Journal of Public Health – November 2020

Index of Advertisers Communicable Diseases Health Summit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Delaware Academy of Medicine DJPH Press Release. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Delaware Academy of Medicine The DPH Bulletin - October 2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Delaware Division of Public Health The Nation's Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 American Public Health Association Continuing Medical Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 ChristianaCare Robert O. Y. Warren M.D. Memorial Seminar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Nemours/Alfred I. duPont Hospital for Children The Promise of Good health for All. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Trust for America's Health DHSS Press Release. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Delaware Health and Social Services Submission Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Delaware Journal of Public Health


Delaware Academy of Medicine / DPHA 4765 Ogletown-Stanton Road Suite L10 Newark, DE 19713

www.delamed.org | www.delawarepha.org Follow Us:

The Delaware Academy of Medicine is a private, nonprofit organization founded in 1930. Our mission is to enhance the well being of our community through medical education and the promotion ofpublic health. Our educational initiatives span the spectrum from consumer health education tocontinuing medical education conferences and symposia. The Delaware Public Health Association was officially reborn at the 141st Annual Meeting of the American Public Health Association (AHPA) held in Boston, MA in November, 2013. At this meeting, affiliation of the DPHA was transferred to the Delaware Academy of Medicine officially on November 5, 2013 by action of the APHA Governing Council. The Delaware Academy of Medicine, who’s mission statement is “to promote the well-being of our community through education and the promotion of public health,” is honored to take on this responsibility in the First State.

ISSN 2639-6378

Delaware Journal of Public Health - Racism and Health