The following lecture (sorry, this is long, about 7,500 words in several segments) was delivered as the 2016 Elizabeth Lockwood Wheeler Lectureship at Central Michigan University, on Wednesday, April 20, 2016. Thank you so much to Dr. Leah Markel, Eta Sigma Gamma, and the entire CMU Public Health department for the privilege of discussing this topic with you.
What is sustainability and what does it have to do with embracing difference?
Tonight, I want to push you to think about the embracing of difference as not just a social justice issue, but as truly an immensely under-considered public health issue, and an untapped reservoir for public health initiatives that can build better community health, both in the sense of making individual people in communities healthier, but also in the sense of making the community, as a gestalt, healthier.
I hope that what I can do is not teach you public health, but rather to contextualize your work in this area, and maybe even convince you that your field is important in ways you haven’t thought very much about.
This conversation starts for me with two data points that occurred in the last two years. In April of 2014, Forbes named Grand Rapids the second best place in the US to raise a family. This is just one of many merits Grand Rapids has gotten – besides Beer City, USA, we’ve also been called things like the number one place to visit in 2015, a top performing market, one of the eight most underrated cities in America. A list at Experience Grand Rapids, our Convention and Visitor Bureau, has thirty of these distinctions in the last five years. But there are some designations you won’t find on their website. In January 2015, less than a year after the Forbes designation of second best place in the US to raise a family, Grand Rapids was in second place in a Forbes listing, again. In a listing ranking the 52 largest metropolitan areas in the United States on their economic outcomes for African Americans, we were again second. Second from last, that is.
I had heard this idea, I believe F. Scott Fitzgerald is at least one person who has remarked on it, that it is a sign of intelligence to hold two incompatible ideas in one’s mind at the same time. Here were two deeply incompatible ideas, although their simultaneity is no credit to our intelligence. What I want to talk to you about tonight is the idea that this sustainability crisis is precisely something we have because we hold these two concepts in our mind simultaneously, that we accept that we can have a great city that is awful for some people. That we can be in many ways, the world’s leading nation, and yet the United Nations can send foreign investigators here, and they can be appalled at the plight of American women. That, until just last year, Hollywood marriages that don’t even last until the end of the reception could be “valid,” but my friends, a lesbian couple who’ve been together 47 years, were rendered by the law little more than “roommates.” And lately, that we can have world-class schools in which transgender students cannot even use the bathroom.
My argument today is that these imbalances threaten the sustainability of gains we have made, societally, in economic prosperity, healthcare outcomes, and many other things that contribute to human quality of life. And that this makes this entire conversation directly relevant to the public health community.
Sustainability can sound like a buzzword. I think we are learning that it is much more. Look at our lives. Defense, healthcare, and education spending in the US are all not only experiencing unsustainable growth over time, but that growth is clearly failing to deliver the outcomes we expected. We are already facing and will continue to face enormous consequences of the delamination of American wages from GDP. We are incredibly dependent on products that we build but have no idea how to dispose. We create problems like BPA where we don’t even know they’re problems until almost everybody alive has the chemical in their bodies. Even if it will take a long time to deplete our fossil fuel resources, they are inarguably finite. In our lifetimes, for most of us in the room, we will see devastation caused in the so-called “Global South” by global warming, with ourselves being chief among the culprits, and devastation caused everywhere, by its close cousin, sometimes called “global weirding.” Not environmentalists, but military experts, are now saying that water security will be a leading future cause of war.
Tonight, I want to make the argument that minority stress, too, prevents the sustainability of all the progress we’ve made societally, progress like our health and longevity outcomes, and that this is a rich field for people like you and me to engage in. If I can be a little flippant but also set a high bar, I want to argue that teaching people to embrace and celebrate difference, for our rising Millennial and Plural (or Generation Z or whatever you end up being called) generations can be your generation’s equivalent to putting fluoride in water.
What is Minority Stress & how does it affect public health
The discussion of minority stress has a long history – like feminism, it was in discussion long before it had a name, and it has many names – I believe in public health language, it falls into the category of social determinants of health.
The way I like to think of minority stress is that it is a sort of milieu toxicity. Like air pollution, living in a world in which minority stress is placed upon you has complex and variable effects, although like air pollution, I suspect it isn’t really good, per se, for anybody.
Hypertension in African-Americans has been a topic of interest since at least the 1940s. By the 1980s, racial differences were noted in the way that the body regulated stress impacts on blood pressure. At least as early as 1989 – more than 25 years ago – scientists started demonstrating differential responses to racist stimuli on blood pressure in white and black Americans. You’ve heard the expression, “That makes my blood boil.” And the idea, outside of formal scientific analysis, that the emotions and physiology are deeply linked is, in fact, much older. As you remember, long ago, at least in some places, the very fluids of the body, then called “humors,” were thought to be emotions that were kept in physiological balance. And yet the work of Cheryl Armstead and others began demonstrating for an allopathic model of medicine that had “forgotten” the connections between brain and body, that this social disease, racism, had physical health impacts – and not through some complex indirect channel (although there are many such channels) but directly.
The term minority stress came along half a decade later, and the phenomenon was first noted by Ilan Meyer. In 1995, in the Journal of Health and Social Behavior, Meyer described stress that was “derived from minority status… the concept of minority stress is based on the premise that gay people in a heterosexist society are subject to chronic stress related to their stigmatization… [this stress] had a significant independent association with a variety of mental health measures.” Since then, the term “minority stress” has appeared in 209 journal articles, and the trend is, as you can see, increasing. This is an underrepresentation, since this term is most dominant in the LGBTQIA+ discourse, and so there is not yet unified usage of a term for this phenomenon (for comparison, “social determinants of health” appeared in 722 articles in PubMed in 2015). I want to share a few examples of this in different minority contexts. Both expanding on and paying homage to Meyer’s work and that of the pioneers in health impacts of racism, I want to emphasize that minority-stress-related issues have broad impacts, not only in mental illness, but in a whole variety of non-mental medical health contexts, and ultimately, in longevity.
Mental health, itself, even if those other areas were not considered, is a public health issue. My dissertation research was on adherence behaviors in epilepsy patients and the impacts of depression on adherence, and one of the key motivating factors in doing this particular research was that “secondary” depression, across broad classes of chronic or serious illness, is actually a much stronger predictor of disability than the underlying non-psychiatric disease itself. Even if the questions we ask to ascertain mental health were not deeply intercorrelated with questions appearing on most quality of life measures, we would most likely find other ways to show that mental health deeply affects quality of life. But I want to talk about some examples outside of mental health just to emphasize how interconnected mental and physical health are, and how pervasive the impacts of minority stress are.
Of course, I should point out, that although I engage in public health dialog, none of my degrees are in public health. I am certainly not here to explain your field to you, and I hope you forgive me when I fail to do it justice. But I am a long-term appreciator of broader perspectives outside my technical field (whatever technical field I’ve represented at different times in my life). I didn’t study any psychology between 11th grade, when I fell asleep in the middle of an essay exam in high school psychology, and the latter half of my 20s, when I decided I would become a psychologist. Nonetheless, freshman year, I answered most of my roommates’ intro psychology questions, because they were really easy and occasionally interesting, and perhaps more, because my roommate was terribly frustrated that I knew all the answers. Later, when I was in engineering graduate school, I was good friends with public health students, particularly in health behavior and health education, and I helped them with projects just because their work sounded interesting, when I wasn’t blowing things up with lasers in an NSF ultrafast optics lab, which was my own primary gig at the time.
When I decided Psychology was what I wanted, I started taking night courses at Wayne State University, trying to make up for not really having the appropriate undergraduate education at all to start a PhD clinical psychology program. But the statistics courses, in turn, that the psychologists were teaching looked awful, and I took my statistics instead, from the sociologists. In return, I got a chance to make some new friends, and, importantly, to be exposed to thinking in different ways than either the psychologists I wanted to be with or the engineers from whence I had come. Statistics is actually pretty easy, so I had plenty of time to gab and learn from the sociologists.
You might be starting to see how my entire professional career is like that friendly child on the field trip who wanders off and makes friends and misses the official tour.
A few years later, I had somehow made it into one of the most competitive neuropsychology programs in the world, and my dissertation chair was an internationally renowned leader in that specialty area, in spite of the fact that, when I first interviewed with him, I admitted I did not know just what neuropsychology was, exactly. But now I was ready to launch my dissertation. Most doctoral students approach forming a dissertation committee as an exercise in selecting a group of people least likely to bicker with each other, whose schedules are most amenable to actually getting them in the same room at the same time, and who will ultimately most likely look favorably on one’s dissertation. This is the approach my dissertation could have used — it was a wonderful idea that did not work at all well, and I am thankful my committee let me defend it, let alone that they accepted it.
This is not, however, the approach I took with my dissertation. Coming from engineering into psychology, I was attuned to the power of teams and, though they brought unpleasantness and difficulties, the strength that a diversity of opinions within a team can hold. One of my choices was to ask an epidemiologist, Dr. Elena Andresen, who is now at Oregon Health & Science University, onto my team, not because I knew much about her or her campus politics, but because I thought her perspective would be valuable for my project, which was on how depression affects acquisition of knowledge about and positive beliefs towards epilepsy and epilepsy treatment. So one of my first formal brushes with public health as a field was that, while other graduate students were looking for outside committee members who would cause them the least trouble, I was looking for one who would broaden my thinking and bring perspectives my own department wouldn’t offer.
I tell you all of this to give you a little entry into my background, but also to demonstrate the point that my professional career, in which I’ve worked in applied physics, manufacturing and production engineering, management consulting, hospital-based neuropsychology, autism, and most recently diversity/inclusion/equity consulting and even dipping my toes into tech startup culture, creating mobile learning games for preschoolers, has been entirely about celebrating difference.
Emilie Wapnick has a wonderful TED talk, in which she describes people like herself and me, as multipotentialites. We are sometimes also called polymaths. Emilie’s talk is valuable not just in teaching people like me that this is okay, but in helping us understand that this is a statement not about what we’ve done, but who we are. We are people who embrace intellectual diversity. Whereas most people spend their life trying to avoid being in environments where they are beginners, where they are surrounded by people who know how to do whatever it is that they’re doing better than they do (an example would be giving an invited lecture about public health to a public health department when one is, in fact, not a public health expert), we actually embrace it with a fervor. We are the world’s best beginners, and we set the bar for what it means to be quick studies.
If any kind of diversity ought to be easy to accept, it ought to be this sort of diversity. We live in a world where few people – even academics – live or work in isolation. Although things like redistricting, suburbanization and subsequent urban re-entry, and gentrification have created a world in which we are quite possibly more socially isolated from people unlike us than ever, we also live in a world where very few problems are solved by disciplines working in isolation.
The video games I’m learning to design require artists, musicians, and storytellers, and also businesspeople and programmers and developers – or when all of those people aren’t available, I must be all of those people. This is the way a rapidly moving world works. You’ve heard the statistic, probably, that 65% of schoolchildren will eventually work in a job that doesn’t currently exist. As I built Hope Network’s Center for Autism, over the past five years, this was a big example of being a beginner. I had the diagnostic and treatment planning skills, but the entire workforce I needed to build was in a different technical area than mine, and I had to learn, and learn very quickly, to be good friends with them, to understand and appreciate their perspective, and then, somehow, to create one of the best environments in Michigan for young professionals to grow in a skill set that I, who built the place, didn’t have. In fact I had to build a better workplace for behavior analysts than the leaders of other similar centers. And they were behavior analysts.
This all sounds a little like bragging, and I’m sorry, because the point I want to make isn’t about me being special, but about the way we view diversity. When I became Director of my Center, I found a print out of an e-mail in the prior Director’s desk (there had been six in 18 months, before me). The e-mail was from recruiting, saying I was not a particularly impressive candidate and probably not worth interviewing at all, because I didn’t have enough experience working in settings exactly like the one in which for which I was being interviewed, but the recruiter thought she would at least pass my resume on anyways.
I’m not like most people — I love that e-mail, and someday I will get around to framing it. I was hired, in spite of not having 10 years of experience doing exactly the same thing I was being asked to do. Twice, later, ironically, after having done all this, I was not taken seriously applying for jobs doing similar things in other states, even though I had actually been doing what they were asking for, and very successfully, for several years. I suppose that’s good. In the values of the world inside my head, I hope never to find myself doing exactly the same thing for ten years, let alone being hired for yet another job to continue doing any one thing for even longer.
If you’ve been on the job market, especially the non-academic job market, you know about this. You students are going to experience it, most likely not just once but at many times in your lives. You know you are not going to get a job because you “know how to make graphs in Excel.” No one who hires you will view that skill as a serious enticement to you.
It will never reach a point where it will not make you angry – at least, I hope it won’t.
But to start with how we view diversity, given that we live in a world where we expect people to work in fields that don’t even exist yet, it’s shocking how much we still go about hiring people for jobs in which we supposedly offer “significant advancement potential” but we only want to hire someone who has done the exact same thing for the past ten years.
Before I dive into talking about embracing ethnic diversity, girls and women, gender and sexual diversity, and even neurological diversity, I want to just spend a few minutes talking about how remarkable it is that we don’t embrace professional diversity, even though we’ve been building, especially since World War II, a world that would increasingly demand it.
Psychologists have known, however, for decades, about the cognitive processes that drive us to do exactly the opposite. Groupthink is one of the most famous of these, and the basic idea of groupthink, that a desire for harmony within a group results in a dysfunctional or irrational decision-making process, rides on top of a wave of psychological data that two heads aren’t always better than one.
We’ve known more recently, that we don’t just suffer when groupthink happens, but rather we build the circumstances actively in which it happens. Thus this research, published in 2012, by Lauren Rivera, a sociologist at Northwestern. She analyzes firms that have things like diversity hiring policies. And yet she quotes a hiring manager: “We have a weekend getaway for our new summer associates their first week here. When one of our summers got back the next week, he said to me, ‘We’re all so different in our different ways but you can tell we were all recruited to come to [our firm] because we all have the same personalities. It’s clear like we’re all the same kind of people.’” In analyzing this, she points out that these diversity policies don’t really create a true, broad diversity, because: “In essence, firms sought surface-level (i.e., demographic) diversity in applicant pools but deep-level (i.e., cultural) homogeneity in new hires.”
One way companies and the commercial world in general measures “health” is economically. Of course, when we only measure dollars and cents, that’s catastrophic, but we do know that, in the long term, a stronger economy is good for everyone. Consider the gender pay gap. The gender pay gap is one small way the working world can be unfair and uninclusive to women, alongside lack of paid parental leave and a vast array of policies that were designed for men. But starting with the pay gap, the Institute for Women’s Policy Research, for instance, has estimated that closing the gender pay gap would create an economic stimulus sufficient to raise the US economy by “at least 3-4 percentage points.” That’s 2-3 times as much as the $800 billion economic stimulus package from 2009.
And a non-hypothetical piece of economic evidence, since we haven’t eliminated the gender pay gap, comes from LGBT inclusion in the workplace. A Denver-based investment firm tracked companies over a long period of time, and they actually demonstrated that, compared to benchmark financial performance, companies underperformed prior to implementing LGBT inclusion policies, and over-performed following implementation of those policies. The data are actually impressive, with zero on the horizontal axis being the implementation of the initiative.
So there are measurable impacts of diversity, inclusion, and equity – of celebrating difference and not hiding from it – and I’m going to show you measurable impacts much more closely related to public health.
But this example highlights something important about this conversation. The mechanism by which the gender pay gap exists, itself, is complex, as are the mechanisms by which sexism in the workplace, more generally, and lack of diversity, inclusion, and equity even more generally. And it isn’t like other economic conversations. It isn’t like discussing whether we should do more durable goods manufacturing or more software development, whether the interest rate should be lower or higher, or whether banks should be bigger or smaller. It is much more fundamentally tied to attitudes.
This is important. You’ve probably seen research from the neuroscience community that has increasingly shown that one’s politics can be predicted by relatively stable, observable cognitive and emotional information processing traits. This isn’t a political talk — I’m not talking about whether you’re an elephant or a donkey. I hope you’re actually humans, of course, not that I am speciesist.
But I’m pointing out that, for many of us, embracing diversity is actually not a behavior we do in isolation, but is rather part of a broader brain architecture, one with epigenetic underpinnings, that predisposes us to embrace diversity, just like the multipotentialite nature of my brain makes me embrace professional diversity both inside and outside of myself. Some of us may be hard wired to do this more intuitively, but it may also be a teachable skill. This is the other necessary piece to even have this conversation that I’m trying to have today. Really, to have a public health conversation about minority stress, we have to both demonstrate that it causes public health harms, and that there might be some way to actually change the situation, even if that some way looks fundamentally different than public health interventions about reducing sodium intake or reducing use of refined sugar or increasing exercise.
So first, let me show you some examples, integrating across different minority groups, of the public health impact of minority stress or minority milieu toxicity.
If you pay close attention to income disparity, you know that actually, buried in estimates of life expectancy in our country is not only the fact that women live longer, on average, than men, but that the wealthy live substantially longer than the poor. This difference is actually widening with wealth disparity in the US, and it particularly affects men. Longevity also varies between ethnic/racial groups in the US, and African Americans are a particular example of a group for whom life expectancies are shorter. They are shorter in part because of the higher rates of poverty to which black Americans are subjected. In a 2015 article compellingly titled, Black Jobs Matter, Megan Doede of the University of Maryland explores the multiple ways in which systemic exposure of black communities to poverty causes negative health outcomes, such as via the increased infectious disease risks in impoverished housing situations. This was brought more tragically into context when it was revealed recently that a paper written 70 years ago, analyzing economic and urban planning trends in two midwestern cities, and suggesting that one would rise and the other fall, was confirmed to be about Grand Rapids and Flint, the latter being a city where impoverished African Americans are disproportionately subjected to public health harms including toxic levels of lead in the water supply, a still evolving Legionnaires disease spike, and more.
But this is not all. Controlling for that factor, racism itself still causes excess mortality in a variety of ways. This has actually been estimated – about ten years ago, a multi-site group used the Medical Expenditure Panel Survey to show that black Americans lose a total 900,000 quality-adjusted years of life compared to whites of comparable SES, due to racism.
Girls and women are a really, really big minority group. We’re not technically the minority at all, there are so many of us, we’re supposed to be the majority. But it doesn’t really work out that way. We are systemically underrepresented and sometimes actively excluded from positions of power and influence, economically, politically, and in other ways. Does sexism have an impact on our health?
Lisa Molix of Tulane reviewed the evidence for cardiovascular impacts of sexism. Her starting point was that much less progress has been made in the last thirty years in reducing cardiovascular disease mortality in women than men. Trying to understand this, she noted that, following up on the research in blood pressure and racism, researchers likewise found an immediate (and unsurprising) sympathetic activation associated with sexism. One culprit pathway, which is becoming ubiquitous in this kind of work, is the hypothalamic-pituitary-adrenal, or HPA axis. Chronic activation is a known contributor to psychological distress, stress smoking and drinking, and even PTSD, all things that have been associated with sexism experiences. In turn, serving as an indirect pathway, all of these have been associated with CVD mortality. Women may face a “double” disadvantage in that sexism follows them into the exam room – we know for instance that women are less likely to have pain experiences taken seriously by doctors. We also know that older women have lower rates of successful management of hypertension than older men, even though they go to the doctor more often. There are many possible explanations. But we should explore both why we as lay people still have an image of a middle aged or older man having a heart attack, in our minds, and never a woman, and why as doctors, our exemplars likewise do not seem to cause us to take cardiovascular risks very seriously in women.
One more example I want to share comes from the work of Eugene Richardson and colleagues at Stanford and the Desmond Tutu HIV Center in Cape Town. Looking at HIV in 133 countries, they found that countries with higher gender inequality generally had higher HIV infection rates as reported in the 2010 UNAIDS Global Report. This was particularly true when countries with a predominantly heterosexual epidemic were considered. They found that, in contrast, the economic situation of the country, the dominant religion, and even the circumcision rate (a topic of great interest in this area in the last decade) were poor predictors. Among the countries with the lowest Gender Inequality Index, scores lower than 0.3 (this is right around where the United States is), none had a generalized heterosexual epidemic. The countries that had predominantly heterosexual transmission had on average a gender inequality index twice that of those where other routes, men having sex with men or intravenous drug use, predominated. The countries with the highest GII’s were 15 times more likely to have a heterosexually driven epidemic. So one of the things I care about personally is finding ways to integrate my passion in the things I care about. And here is sexism driving infectious disease trends. And this health impact doesn’t just affect women – much of its effect is on men, who benefit from aspects of sexist process, but in the context of HIV transmission, suffer as well.
Gender & Sexual Diversity
Moving to gender and sexual diversity – the LGBT community – I want to show you some data that we collected locally, that really puts a great picture to the idea that being a member of the LGBT community in Michigan can be challenging. This is a sample of over 400 LGBT people from West Michigan – it’s one site from a multi-site convenience sample collected two years ago in conjunction with MDHHS and LGBT community centers throughout the state. I actually administered a lot of these surveys myself, at my first Pride Celebration.
We found that less than 20% of LGBT people in the Grand Rapids area considered their neighborhood very friendly. What does it mean when your neighborhood isn’t very friendly, say only neutral? I think it probably means something along the lines of, “You can be gay, but just keep it in the bedroom. I don’t want to see it or hear it.” But that raises all kinds of complex questions. Will I get invited to the parties on my street? If there’s a block party, will I get asked awkward questions? Will anyone stand up for me? Would everyone be more comfortable if I didn’t come? Can I bring my partner? Can I call my neighbors if I’m in a pinch, need to borrow some eggs or sugar, need a power tool we don’t have? That’s not really sounding much like community at all.
A similar number – about 1 in 5 – considered their doctors very friendly. There are some obvious potential health consequences of that. Are you really going to be thorough and honest with the doctor who you’d rate as neutral on this scale? Are they going to ask the right questions? Would they even listen to the right answers? We found slightly better numbers for the workplace, but even these can use work. Who hasn’t come in to work on a Monday morning and talked with co-workers about what they did over the weekend. If you’re in a neutral workplace, is it okay to talk about the date you and your partner went on? Is it okay to mention the argument you and your partner had? Is it okay to mention you went to Pride and you got too much sun?
So this data is the back-end to the minority stress work, showing higher rates of preventable mental and physical health problems in LGBT people. This is the data that shows that minority stress is experienced in our communities. Putting the two together, there are real health consequences of our lack of inclusion in Michigan communities.
Here’s a wrinkle. When I talk about the business case for inclusion, I introduce something I call a “queered” value equation. I say that, rather than having to give things up in order to have a more inclusive corporate culture, you actually just have to be a better you – a better organization or a better person. That is, my claim is that by being more inclusive, you make things not just better for people who are different, but for you, too. In 2014, a team from Columbia and Nebraska actually demonstrated it in a kind of amazing way. In their analysis, even after controlling for a wide variety of factors, in the GSS data, they found a Cox hazard ratio of 1.25 for all cause mortality in homophobic heterosexuals. Yes, you heard me correctly. Homophobia is killing straight people. And it’s time someone spoke up about it.
If I can dip back to talking personally, again, I’m an eating disorder survivor. I’m actually pretty close to what people think of when they think of eating disorders – type A girl who feels incredibly pressured to be perfect. But I’m not the stereotype when people think of mental illness. That’s a problem on multiple levels. First, anorexia and other eating disorders are thought of as a rich girl’s problem, and intersecting with the misogyny that exists in our society (and doing no favors to people who have eating disorders and aren’t girls or women, while we’re on the topic), we mostly think of anorexia not really as a health problem but as a bad behavior – bad isn’t an appropriately misogynistic word – as a petulant behavior. So we respond mostly by criticizing the sick person or telling them to pull themselves together. In fact, the standard of care in many ways, if looked at critically, for anorexia is to not really treat it all, and really, to only treat the physical effects of starvation that occur due to the chronic neglect of the mental illness itself. All of this put together is a dangerous game to play with a class of disorders with estimated mortality rates around 4-6%. It is not the sort of game we would play with a physical illness that killed you one in twenty times. And eating disorders are thought to have the highest mortality rate of any psychiatric disorder. So if something that can kill you doesn’t get taken seriously, what hope do we have if we suffer from something that will “only” ruin our lives without killing us?
Beyond that, it is a problem that we have a very restricted notion of mental illness, typically informed by really brief encounters with the severely mentally ill, or even worse, by reruns of Law and Order: SVU.
Sometimes, this leads to offensive questions – I used to get routinely called to comment on whether the latest mass shooter was autistic or not, to which I would patiently respond as an ally to autistic people, no there has not been any evidence to support that claim, no, as far as we know, autistic people are, if anything, less likely to engage criminal acts than the general population, no, (in my head) I hope you have the opportunity to meet and befriend an autistic person someday, so you won’t ask such ignorant questions. Autism is a neurological difference and not really a mental illness, but the conversation sounds very similar.
Now there are epidemiologists in the room, and you probably know these statistics. But the point isn’t that you know them, the point is that our system doesn’t act like it knows them. So we think of that example or prototype in our head of a seriously mentally ill person, right? And because people who fit that prototype are rare, that prototype makes us think mental illness itself is rare. But it isn’t. The lifetime prevalence of mental illness, as estimated by the CDC, is 1 in 2. The point prevalence is around 1 in 5. But in a world where 1 in 2 people will experience a mental illness in their lives, only 5.6% of US healthcare spending – and we spend a lot of money on healthcare – is spent on mental illness. That’s what I mean when I say the system doesn’t act like it knows or believes the data. The system acts like much more like the person whose only notion of mental illness is from the Law and Order reruns.
And I’ve already mentioned in passing the linkages between mental and physical health outcomes, which make the combination of a disparate, silo’d mental health system that is funded at a tiny fraction of the rate of the physical health system, all the more untenable. But, much like the situation with racism, with sexism, and with homo- and transphobia, because the milieu toxicity we live in with respect to the minorities involved makes us not take these issues seriously, it’s also not surprising that we are not policy- or money- aligned to be really addressing mental health.
Community as a child we nurture
As I move away from these examples and, in wrapping up, get us thinking about how we engage as public health professionals (like you) and public health amateurs (like me) in addressing these issues, I want to talk a little bit about my leadership perspective.
As a businesswoman (I promise, this isn’t going to be a call to run government like a business), I am particularly influenced by the book Reinventing Organizations. Frederic Laloux powerfully argues that organizations themselves can be thought of as existing in evolutionary stages, and the most dynamic emerging organizations fall into a category he calls “Evolutionary Teal.” The reason I bring this up is that a popular metaphor that I grew up with for doing great business was that a company or organization was like a family – I think of the kids we serve, and even the young professional “kids” I groomed at the Center, as a sort of family, but that analogy seemed to not really represent what I felt about what we were doing. Evolutionary organizations describe themselves not as a family, but rather, they see the organization itself as an organism, that has a life of its own. Organism sounds too clinical for me, so I think of my organizations as children, because being a mother is something I can wrap my head around – something I still very much hope I have the opportunity to do in the next few years.
This is where the gestalt notion of the health of a community comes in. My health as a human being is not a total summed from the health of each of my cells. The health of a community likewise has emergent properties that cannot be seen at the level of the health of each individual member of that community. I think there’s something here of tremendous value for building health communities. If we think of healthy communities purely in the sense of percentage of residents who are obese, or who smoke, or who saw their primary care physician in the last 12 months, we have a hard time seeing how addressing minority stress could be a priority. It also makes it hard for us to put in place policies that think not 12-36 months into the future, but 50 or 100 years. But if we think about healthy communities as children trying to live out a life and a destiny of their own, then we can leverage tools we already have, as parents – every one of you who is a parent, you are thinking about what your child will be, do, have, the opportunities and the challenges, not just tomorrow, but in some distant future in which you won’t even be alive anymore. If we add this kind of holistic sense of nurturing – something that itself is absent from the conversation because some kinds of people are absent from the leadership table – we start to see why, when we have a community that is very safe for some people, and very dangerous for others, it doesn’t just wash out, any more than it would average out if your arms were 120 degrees but your legs were 80 degrees. If we start to think about our communities in this kind of more holistically nurturing way, then we see these minority issues as actually being the things that might kill (or render soulless) the whole community.
I wear my heart on my sleeve, and so I feel like whenever I give a talk like this, I have to make a caveat that I’m not advocating for a political party. For this not to seem like a call to vote for a particular presidential candidate. The existence of a political plurality that is engaged in a democratic process is a really important thing. In a feminist social media forum in which I participate, this struggle comes up – why do we talk about the business or economic or healthcare outcome cases for doing the right thing? Part of the reason I do it is that I don’t think that reducing minority stress is something that some political parties ought to do in isolation while others actively oppose it – much like the way I talked about communities, I am much more suspicious that this is a disease than a healthy process, no matter the outcome. I think we need to get to understanding that we all get something out of this. Yes, doing the right thing, which should be a major motivation. But longer, better lives. More prosperity. For the people who can’t buy into the idea that this is doing the right thing quite yet, I think these utilitarian motivations may be a good, I don’t know, gateway drug.
It also draws us, and all our know-how and tools, into the discussion, and we bring a much needed perspective. To emphasize that point, I want to talk about one piece of evidence for our ability to start thinking about interventions to address minority stress, or milieu toxicity, on a public health level. You might have heard about a fraudulent, and ultimately redacted 2014 study, published in Science, that claimed a 20 minute door-to-door conversation with a gay or lesbian canvasser could “flip” a person opposed to marriage equality. This study claimed that it was crucial that the messenger be gay or lesbian themselves. But it led to a follow-up study done in Miami, and published last year, in which canvassers randomly spoke to residents for 10 minutes about acceptance of the transgender community or recycling. They found that the 10 minute conversation reduced transphobia and that the reduction persisted for at least three months (irrespective of whether the canvasser was transgender or not). The doorside intervention that this study used had two key components. One is perspective taking – canvassers were trained in eliciting empathic experiences from the residents with whom they spoke – and the other is eliciting deep cognitive processing, that is, getting people to actually do some thinking. I want to share an example of this, quoting from the New York Times Article.
“Is this the first time you’ve thought about transgender people?” Fleischer asked her soon after she backtracked.
“Yeah, I would say so,” she said. “I know it exists, and I hear stories, and I see them on TV. But I don’t have any friends like I do my gay friends.”
Fleischer nodded and removed a picture of his friend Jackson from his wallet. “For me, I never had a transgender friend I was really close to until I was 56,” he said, handing Nancy the picture. “Jackson grew up as a girl, but he knew even when he was 5 or 6 that he was really a boy. It was only in his 20s that he started to tell his folks the truth, and he started making the transition to living as a man. He’s married to a woman now, and he’s so much happier. And he can grow a better beard than I can!”
Nancy laughed. “That’s the thing — they’re happier when they come out, whenever everybody knows,” she said. She seemed to be connecting Jackson’s experience to that of her gay friends.
“Right, because otherwise you have the biggest secret in the world, and everyone thinks something about you that’s not true,” Fleischer said, before pivoting to a story about Jackson’s being demeaned by a waiter in a restaurant. “I don’t like seeing people mistreat Jackson. To me, protecting transgender people with these laws is just affirming that they’re human.” Fleischer then steered the conversation to Nancy’s experiences with discrimination. “You’ve probably had a time when people have judged you unfairly?” he asked.
“Oh, yes,” Nancy said. Over the next few minutes, she recounted several instances of racism after moving to Los Angeles from Central America with her husband. Still, she didn’t appear emotional in retelling the experiences. Fleischer wasn’t surprised; people rarely feel safe enough at first to express deep hurt. It usually isn’t until Fleischer opens up about his own experience — including feeling different in his small, conservative Ohio town — that voters feel safe to “get vulnerable, too,” he says. Nancy had mostly dismissed Fleischer’s “how did that make you feel?” questions, but his personal story prompted a shift. As Fleischer returned to the discrimination she had faced, Nancy paused and said, “It felt terrible.” A few minutes later, when he asked her if she saw a connection between “your experience and how you want to treat transgender people,” she said she did. “I see transgender people as the same as I see myself,” Nancy told him. She ended a solid 10, a rating he was confident could survive opposition messaging.
This is just one example of a potential intervention tool that we might use in engaging in public health interventions aimed at reducing minority stress. You could imagine a similar conversation educating a resident about what it’s like to be an ethnic minority in their community. You could imagine a similar conversation in a workplace intervention educating workers about what it’s like for their female colleagues. You could imagine a similar conversation challenging and expanding the limited prototype we have for mental illness. We will need many more tools. Again, public health experts such as health educators are well poised to help devise and validate these tools. And in an era where we are seeing plateauing of health improvement in the US, in spite of disproportionately large healthcare spending, suggesting that simply pumping more money and resources into our old ways of achieving healthier communities may be hitting a dead end, perhaps this can be a new way for us to think about solving our age old problem, namely how to create communities in which people experience long, happy, high quality lives.