Structural racism and health inequities in the USA: evidence and interventions.

Despite growing interest in understanding how social factors drive poor health outcomes, many academics, policy makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public discourse remain reluctant to identify racism as a root cause of racial health inequities. In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources. We argue that a focus on structural racism offers a concrete, feasible, and promising approach towards advancing health equity and improving population health.

Disparities in Mental Health Referral and Diagnosis in the New York City Jail Mental Health Service.

OBJECTIVES: To better understand jail mental health services entry, we analyzed diagnosis timing relative to solitary confinement, nature of diagnosis, age, and race/ethnicity. METHODS: We analyzed 2011 to 2013 medical records on 45,189 New York City jail first-time admissions. RESULTS: Of this cohort, 21.2% were aged 21 years or younger, 46.0% were Hispanic, 40.6% were non-Hispanic Black, 8.8% were non-Hispanic White, and 3.9% experienced solitary confinement. Overall, 14.8% received a mental health diagnosis, which was associated with longer average jail stays (120 vs 48 days), higher rates of solitary confinement (13.1% vs 3.9%), and injury (25.4% vs 7.1%). Individuals aged 21 years or younger were less likely than older individuals to receive a mental health diagnosis (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.93; P < .05) and more likely to experience solitary confinement (OR = 4.99; 95% CI = 4.43, 5.61; P < .05). Blacks and Hispanics were less likely than Whites to enter the mental health service (OR = 0.57; 95% CI = 0.52, 0.63; and OR = 0.49; 95% CI = 0.44, 0.53; respectively; P < .05), but more likely to experience solitary confinement (OR = 2.52; 95% CI = 1.88, 3.83; and OR = 1.65; 95% CI = 1.23, 2.22; respectively; P < .05). CONCLUSIONS: More consideration is needed of race/ethnicity and age in understanding and addressing the punishment and treatment balance in jails.

Data-Driven Human Rights: Using Dual Loyalty Trainings to Promote the Care of Vulnerable Patients in Jail.

Dual loyalty is an omnipresent feature of correctional health. As part of a human rights quality improvement committee, and utilizing the unique advantage of a fully integrated electronic health record system, we undertook an assessment of dual loyalty in the New York City jail system. The evaluation revealed significant concerns about the extent to which the mental health service is involved in assessments that are part of the punishment process of the security apparatus. As a result, dual loyalty training was developed and delivered to all types of health staff in the jail system via anonymous survey. Six clinical scenarios were presented in this training and staff members were asked to indicate whether they had encountered similar circumstances and how they would respond. Staff responses to the survey raised concerns about the frequency with which they are pressured or asked to put aside their primary goal of patient care for the interests of the security mission. The online training and follow-up small group sessions have revealed widespread support for more training on dual loyalty.

Traumatic Brain Injury Focus Groups as a Means to Understand Violence among Adolescent Males in the NYC Jail System.

Because we previously identified high rates of past TBI among adolescents arriving in the New York City (NYC) jail system we engaged adolescents in nine TBI focus groups to characterize better the level of understanding regarding the relationship between TBI and violence. During these groups, the following themes emerged: 1) physical and psychological impacts of violence; 2) roots of violence; 3) the use of violence as capital in the face of a marginalized social status; and 4) the inevitability of violence, particularly in a jail setting. Although these focus groups were initiated as a means to engage adolescents around the clinical problem of TBI, their observations are strongly centered in the larger context of violence. These results suggest that intervening in the problem of TBI among our patients will require broad-based changes in the environmental and interpersonal realities, both in the jail setting, and the communities where these adolescents reside.