Economic Stress and Mental Health Hugh F. Butts, MD Bronx, New York
This paper correlates economic stress with minority status, resource allocations for mental health programs, and vulnerability to mental disability. Several hypotheses are advanced: 1. A major and recurring psychological pattern of the American national character is prowhite, antiblack paranoia. 2. Mental health fiscal allocations and programmatic determinations in ghetto, lower socioeconomic, minority-populated urban areas are predicated on political and racist considerations, the underlying motivation being to keep minorities at greater risk of mental disability. 3. Economic privation and stress increase vulnerability to mental illness, especially in a minority population for whom health, mental health, educational, and social services are grossly inadequate. 4. Poverty and economic stress combine with health systems that are unresponsive to the needs of blacks and other minorities, resulting in the perpetuation of disabilities and other conditions in blacks that are potentially preventable. 5. Health and mental health resources should be increased rather than diminished during periods of economic stress, especially in the public sector. 6. In order to provide each citizen with access to quality health and mental health care regardless of race and/or economic status, there must be enacted a national health insurance program based on tax-levy monies that will cover all aspects of health and mental health care. 7. Racism and social status will continue to be powerful determinants of the quality of service that white professionals render to black patients and to poor white patients, unless our training institutions mount a massive campaign to train appropriately and to include significant numbers of minority candidates and trainees in the effort. To date this effort is virtually nonexistent.
In what is probably the greatest love story in American fiction,1 Herman Melville describes a number of relationships in which the redemptive love of man and man is represented. One of the several romantic duos in Moby Dick is between Ahab the captain, and Pip, the black cabin boy. There is no more precise explication of aspects of the American experience and of the American national character than that furRequests for reprints should be addressed to Dr. Hugh F. Butts, Bronx Psychiatric Center, 1500 Waters Place, Bronx, NY 10461.
nished us by Melville in his monumental tome. Pip, abandoned at sea, when finally rescued is blatantly psychotic. "He saw God's foot upon the treadle of the loom, and spoke it; and, therefore, his shipmates called him mad. So man's insanity is heaven's sense; and wandering from all m'ortal reason, man comes at last to that celestial thought, which, to reason, is absurd and frantic; and weal or woe, feels then uncompromised." Pip's "insanity" has resulted from abandonment and his consequent sense of isolation. Ahab adopts Pip and shares his cabin with the
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 4, 1979
boy. Dr. Jose Barchilon (unpublished data, 1976) states: "Ahab understands the depth and wisdom of Pip's craziness, identifies with him, and takes him to his cabin as a son. Not in an attempt to make amends for the harm done to Pip . . ., but to find company in his misery, because Ahab knows that he and Pip are different sides of the same crazed coin. He also knew that, were he to like Pip and grow too tender towards him, it would soften his hatred and make him give up his pursuit of white hooded phantoms." Ahab is in a sense doing that for Pip which was never done for him (he had been doubly-orphaned by 12 months of age). "This is his attempt at restitution, at recapturing by projective identification, the parents he didn't really have." (Barchilon, unpublished data, 1976). Thus, Melville, nearly 128 years ago, comprehended the genesis of psychotic decompensation, the therapeutic effectiveness of relatedness to another human, the nature of projective identification, the nature of the type of developmental arrest that follows parental loss, and the nature of primary process thinking.
Hypothesis 1 A major and recurring psychological pattern of the "American National Character" has been well stated by the literary critic Leslie Fiedler:2 "To express this 'blackness ten times black' (original sin) and to live by it in a society in which, since the decline of orthodox Puritanism, optimism has become the chief effective religion." This pattern is reflected in American literature which is a literature of "darkness and the grotesque in a land of light and affirmation." The major literary concerns from Cooper to Baldwin are with death, incest, and homosexuality. The child's world (in literature) is asexual, terrible, and a world of fear and loneliness. Little wonder that child abuse is epidemic in the United States. The companion of the lonely, frightened "man-child" who ventures forth into the unexplored world is "pagan and 375
Table 1. Rank Order* of Indices of Social Poverty Which Affect Needs for Mental Health Services in the Five Boroughs** Borough Bronx Brooklyn Richmond Queens Manhattan
Per/Capita Income
% Population on Welfare
% Population Unemployed
% Population Medicaid
1 2 3 4 5
1 2 5 4 3
3 2 5 4 1
1 2 5 4 3
* Rank of one (1) indicates greatest poverty ** Based on 1975 Census update
unashamed," but the companion is described as simultaneously both a dream and a nightmare. This literary, metaphoric companion (Chingachgook, Nigger Jim, Babo), is concretized in the form of the black American. One could at this point expatiate on the psychodynamics of unconscious racism. The "pagan" companion possessed of both material and demonic features permeates all of American literature. Splitting the imagery in this way attests to and evokes ambivalent responses, in addition to allowing for or facilitating projection of unacceptable feelings and thoughts ("Racismprowhite, antiblack paranoia"). The colonial world is a world cut in two. The dividing line, the frontiers are shown by barracks and police stations. In the colonies it is the policeman and the soldier who are the official, instituted go-betweens, the spokesmen of the settler and his rule of oppression. In capitalist societies the structure of moral reflexes handed down from father to son, the exemplary honesty of workers who are given a medal after 50 years of good and loyal service, and the affection which springs from harmonious relations and good behavior-all these esthetic expressions of respect for the established order serve to create around the exploited person an atmosphere of submission and of inhibition which lightens the task of policing considerably. In the capitalist countries, a multitude of moral teachers, counsellors, and bewilderers separate the exploited from those in power . . . This world divided into compartments, this world cut in two, is inhabited by two different species. The originality of the colonial context is that economic reality, inequality, and the immense difference of ways of life never come to mark the human realities. When you examine at close quarters the colonial context, it is evident that what parcels out the world is, to begin with, 376
the fact of belonging to or not belonging to a given race . . . The cause is the consequence; you are rich because you are white, you are white because you are rich.3
Ten years after the issuance of the Kerner report, which predicted that America was moving toward two societies, one black, one whiteseparate and unequal, that prediction has been borne out. In the areas of employment, poverty, education, and medical care, black Americans are woefully behind white Americans. At the end of 1977, the jobless rate was 6.3 percent for whites, 13.2 percent for blacks. For white teenagers, it was about 15 percent, for black youth about 40 percent. The poverty rate for blacks is three times the rate for whites. Ninety-two percent of all white 17year-olds are functionally literate, as opposed to only 58 percent of the blacks. Black life expectancy is 67 years, in contrast to 73 years for whites. Health and mental health fiscal allocations are determined by political and racial considerations rather than need. Fanon's formulation is directly applicable to a colony of 1.4 million souls called the Bronx. Two thirds of the residents of that colony are black or hispanic. The per capita income is $2,943 (lowest in New York City); 172,913 families receive aid to dependent children; 284,322 persons receive welfare (20 percent of the' population); and 27 percent of the borough's population receive Medicaid assistance. Despite the high incidence of mental disability in the borough of the Bronx and the existence of the aforementioned indices of social pathology, the borough receives a per capita allocation
of state mental health monies that are half the amount allocated to Manhattan (which has the same population as the Bronx). Table 1 rank orders the five boroughs for various indices of social poverty and indicates that the Bronx ranks highest among the five boroughs on most of these indicators. Table 2 shows the relationship of borough residents' income to the number of inpatient beds provided by state, municipal, and voluntary agencies and indicates gross inequities between the five boroughs. These data are computed per 100,000 population. As is obvious, the Bronx ranks lowest in per capita income and other indicators of social distress, yet has the least beds per 100,000 population. It is equally clear, and important, that the number of beds available for the care of acutely disturbed patients in the Bronx is at the very lowest level among the five boroughs. That is, the Bronx has the lowest number of municipal and voluntary hospital beds set aside for psychiatric patients. As if this were not enough, these numbers include 26 beds at one municipal hospital which at this writing have not been made completely available. The consequence of this glaring inadequacy for the Bronx is that the state psychiatric facility, Bronx Psychiatric Center (BPC), has been forced to function as an acute care facility. In 1977, for example, the Bronx Psychiatric Center admitted approximately 600 patients who had never before been in a psychiatric hospital, a function which should rightly have been assumed by the municipal and voluntary sector. The demand for acute care services became so great that BPC established a 24-hour, seven-day-a-week admission service, one of whose functions was to provide emergency care to acutely disturbed patients coming from areas of the Bronx without adequate acute care service. This admission service also provides overnight care in its holding area for patients who would otherwise be most appropriately treated at an acute care facility.
Hypothesis 2 Mental health fiscal allocations and programmatic determinations in ghetto, lower socioeconomic, minority-populated urban areas are predicated on political and racist considerations, the
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 4, 1979
Table 2. Relationship of Borough Residents' Income* to the Number of Inpatient Beds Provided by State, Municipal, and Voluntary Agencies
Borough
Manhattan Queens Richmond Brooklyn Bronx
Per Capita Income
$5,255 4,046 3,516 3,072 2,943
Number of available beds per 100,000 residents** State Municipal Voluntary
(1977-1978)***
(1977)t
(1977)t
105 78 88 43 51
32 10 None 12 10
34 11 9 5 3
* ** *** t
Ranked by average income-data from 1970 census. Population data as of 1975. Data from NY State Governor's Budget for 1977-1978. Data from NYC Health and Hospitals Corporation, January 1977. t Data from NYC Mental Health and Retardation Services, January 1977.
underlying motivation being to keep minorities at greater risk of mental disability. During the past four years, the personal service budget at Bronx Psychiatric Center has been reduced by $3.5 million, and there are now 200 fewer employees at the institution than were there four years ago. During the same four-year period, there was an 85percent increase in the admission rate and a 20-percent increase in the inpatient census. This same four-year period was marked by local and national economic depression, increased unemployment, and a worsening economic plight on the part of an already endangered species-residents of the Bronx. During the same period Bronx Psychiatric Center was innundated with investigations, audits, media harrassments, and the coup de grace-an investigation by the New York State Investigation Committee. As many as 15 investigative bodies reviewed institutional practices, several "tripping over" each other with concurrent audits.
Hypothesis 3 Economic privation and stress increase vulnerability to mental illness, especially in a minority population for whom health, mental health, educational, social services, and housing facilities, and services are grossly in-
adequate. The cost of mental health services is
staggering. In the Bronx, a crude estimate is that approximately $50 million are spent per annum on mental health services. Table 3 shows a rough breakdown of these expenditures. In a fascinating study Willie and Rothney4 establish a definite correlation between economies, race, and neonatal mortality. They write: It may be concluded: (1) that Negro and native white populations have similar neonatal mortality rates when socioeconomic status is held constant; (2) that native white population in lower-income neighborhoods have neonatal mortality rates greater than the rates of white populations in higher income neighborhoods; (3) that neonatal mortality rates are inter-correlated with family income in neighborhoods where at least half of the households receive less than $2,700 per year; and (4) that no association exists between the distribution of neonatal mortality by neighborhoods and family financial status above the critical median income level of $2,700 per year.
The crucial element accounting for the higher neonatal mortality rate in lower-income black women is their failure to receive such prenatal care. The authors astutely observe: Why pregnant women in lower-income families do not seek prenatal care, even when it may be available without charge, is a sociological problem worthy of further research and study. One possibility is that lower-income people are constricted in their ability to reach out to community health and welfare services for help. Were this hypothesis confirmed it would indicate the importance of professional workers in health and welfare seeking out the poor rather than waiting for community services to be
JOURNAL OF THE NATIONAL MEDICAL ASSOC'ATION, VOL. 71, NO. 4, 1979
sought. A second possibility is that many lower-income women do not know what services are available. A third possibility is that variations in the use of medical services during pregnancy may be a function of variation in cultural values of different populations of people. As stated by Odin Anderson, "the next steps in research in infant mortality which may yield useful information . . . should be directed toward relationships between infant mortality .. . .and mothercraft, specific infantcare customs, and practices . . ." As the total rate decreases, the proportion of infant deaths attributable to different causes may increase. Thus, several hypotheses should be studied.4 Reference is made to this fascinating study not only because the reference to
economic status has a bearing on this topic, but for other reasons. The hypothesis advanced by Willie and Rothney to the effect that mental health workers err seriously by assuming that poor black women will step forward and request health and mental health services has significant mental health implications. A comprehensive view of racism and the psychology of poverty should result in a realization that blacks have been thoroughly disenchanted by the insensitivity, irrelevance, and noninvolvement of the health and mental health systems to which they are exposed. Accordingly, it is insufficient to establish services and invite blacks to avail themselves of them. A much more active approach is needed in order to undo and reverse the views of health and mental health institutions held by blacks. 377
Table 3. Annual Mental Health Expenditures
Voluntary Agencies in Contract with the New York City Department of Mental Health, Mental Retardation, and Alcoholism Services (1976-1977) Bronx Citywide Dollars Dollars Expenditure Per Capita Expenditure Per Capita Inpatient Outpatient 24-Hour Emergency Day Treatment Rehabilitation Residential Care
$
513,707 6,920,059 475,710 1,330,496 436,159 93,640
$ 4,638,733 44,048,003
0.36 4.94 0.33 1.30 0.31 0.06
1,892,065 4,910,417 4,096,367 583,118 1,156,153
Partial Hospitalization
Other Totals
572,084
0.40
6,778,912
$10,842,755
7.74
$68,103,768
II. State Facility Expenditures Bronx Psychiatric Center
Manhattan Psychiatric Center
Personnel item ceiling Personal services cost Inpatient Outpatient Personnel item ceiling Personal services cost
$ 1,240 16,332,956 12,410,939 4,422,017 1,351 24,849,500
0.58 5.57 0.23 0.62 0.51 0.07 0.14 0.85 8.62
($12.02 per capita)
($16.56 per capita)
Ill. Municipal Psychiatric Program Expenditures (Bronx) Bronx Municipal Hospital $9,829,154 Lincoln Hospital 3,649,099 North Central Bronx 2,191,979 Morrisania Neighborhood 1,446,926 Family Care Center Total $17,117,158 (12.22 per capita)
Hypothesis 4 Poverty and economic stress combine with health and mental health systems that are unresponsive to the needs of blacks and other minorities, resulting in the perpetuation of disabilities in blacks as well as in conditions that are potentially preventable. Ewalt is quoted as suggesting that six factors are contributory toward positive mental health:5 1. Attitudes of the individual toward himself. 2. The degree to which the person realizes his potentialities through action. 3. Unification of function in the individual's personality. 4. The individual's degree of independence of social offices. 5. How the individual sees the world around him. 378
6. An ability to take life as it comes and master it. Implicit in this listing is the fact that an individual's attitude toward himself, his view of the world around him, and his ability to attain a sense of mastery is not predicated solely on his innate potentialities but also on conditions that abound in his milieu that will markedly affect his health and mental health. Human services rank at an extremely low order in the American value system. Accordingly, when budgetary choices must be made, huinan services are readily sacrificed. Since economic crisis is the catalyst for compelling budgetary choices, human services are sacrificed at precisely the time when the population at risk (due to economic stress) is consequently at increased risk of mental disability or stress.
Hypothesis 5 Health and mental health resources should be increased rather than diminished during periods of economic stress, especially in the public sector. To predicate the existence or quality of health and mental service on a citizen's financial ability may at times be tantamount to condemning that citizen to inadequate services or to no services. The current health/mental health care system in America is a two-class system: an impoverished system for the impoverished and an affluent system for the affluent. There is no earthly reason why the quality of care at Bronx Psychiatric Center should not be comparable to, or surpass that at Shepherd Enoch Pratt Institute, a private psychiatric facility in Maryland. It is a sad commentary on our society's attitudes toward the poor that we ac-
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cord them inferior facilities, staffed by overburdened and disenchanted staff, and then proceed finally to maliciously and calculatedly decimate these institutions. The poor get poor care because our society does not believe that they are entitled to good care. This is borne out by a comparison between the New York State per capita expenditure per mental health services on the five boroughs of New York City and the per capita incomes of the residents of these boroughs (Table 4). The correlation is undeniable. The Bronx and Brooklyn with the two lowest per capita incomes in the region also have the two lowest state expenditures for mental health services on a per capita basis. Their inequities are reinforced by the discriminatory Medicaid/Medicare reimbursement formula in which private/voluntary facilites receive $253 per day and public facilities, only $56 per day.
Hypothesis 6 In order to provide every citizen with access to quality health and mental health care regardless of race and/or economic status, there must be enacted a national health insurance program based on tax levy monies that will cover all aspects of health and mental health care. Struening and Rabkin6 remind us that "white psychiatrists are influenced in their diagnostic decisions by the patient's race." Pasamanick7 (1963) suggested that because of the inability of white psychiatrists to comprehend nuances in the black subculture and the behavior of individuals socialized in this subculture, they tend to overdiagnose psychosis among blacks. In the study of symptomatology differentials in the records of black and white schizophrenics, deHoyos and deHoyos8 reported that white psychiatrists under-reported symptoms of black patients due to the greater social distance between psychiatrist and patient. This does not necessarily influence the primary diagnosis, but leads to less detail and explanation in descriptions of the patient's psychiatric status. While conscious and unconscious racism seem operative in these instances, class differences may also be a crucial factor. The author has observed the same tendency toward under-reporting in poor white patients.
Table 4. New York State Per Capita Mental Health Expenditures in the Five Boroughs of New York City
Borough Bronx Brooklyn Queens Richmond Manhattan
State Per Capita Expenditure
Per Capita Income
$18.25 12.84 26.31 42.31 35.55
$2,943 3,072 4,046 3,516 5,255
Struening and Rabkin6 add: Treatment procedures are generally acknowledged to vary in relation to patient characteristics. Lower-class and minority patients are less likely to be accepted for treatment at outpatient facilities due to factors such as 'insufficient motivation' or 'lacks readiness.' If accepted they are more apt to be seen by lower-ranking personnel and to be healed with somatic methods. They are more likely to drop out of treatment and, if they do remain, they are seen for a shorter period of time. Within social classes, minority patients receive less treatment than whites. Altogether, the double handicap of low social status and race make it appreciably more difficult for black patients to receive help from outpatient psychiatric facilities.
. . . Here is a program for those who have not lost hope and who yet believe in America . . . Insist on a chance to vote for peace, for the total abolition of the color line; for no family income above $25,000 or below $5,000; for free education from kindergarten through college; for housing on a nationwide scale; for training of all for the work they can do in so far as work is needed for the best interests of all. Insist on discipline for this work. Allow no laborer to be paid less than his product is worth; and let no employer take what he does not make Heal the sick as a privilege, not as a charity. Make private ownership of natural resources a crime . . . . Preserve the utmost freedom for dreams of beauty, creative art, and joy of living. Call this socialism, communism, reformed capitalism, or holy rolling. Call it anything-but get it done!9
Hypothesis 7
Perhaps some would call this insane, but to this author it is reason, right, and justice. As Bert Williams once said: "I may be crazy, but I ain't no fool!"
Racism and social status will continue to be powerful determinants of the quality of service that white professionals render to black patients and to poor white patients, unless our training institutions mount a massive campaign to train appropriately and to include significant numbers of minority candidates and trainees in the effort. To date this effort has been virtually nonexistent. This has been an effort to tease out and define some of the parameters on what may be regarded as the politics of mental health. Politics refers to the science of how who gets what, when, and where. Having begun with a literary reference, it seems appropriate to close with one. The author is indebted to that great American scholar, William Edward Burghardt DuBois, who writes: . . .The United States is no longer a democracy. Most citizens know this well and do not waste time going to the polls.
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Literature Cited 1. Melville H: Moby Dick or The Whale. New York, Modern Library, 1960 2. Fiedler L: Love and Death in the American Novel. New York, Criterion Books, 1960, p 22 3. Fanon F: The Wretched of the Earth. New York, Grove Press, 1963, p 31 4. Willie CV, Rothney W: Racial, ethnic and income factors in the epidemiology of neonatal mortality. In Willie CV (ed): The Family Life of Black People. Columbus, Ohio, Merrill, 1970 5. Jahoda M: The Current Concepts of Positive Mental Health. New York, Basic Books, 1968, p 4 6. Struening E, Rabkin J: Ethnicity, Social Class, and Mental Illness. New York, Institute of Pluralism and Group Identity, 1976, p 8 7. Pasamanick B, Roberts DW, Lemkau PW, et al: A survey of mental disease in an urban population: Prevalence by race and income. In Pasamanick B (ed): Epidemiology of Mental Disorders. Washington, DC, American Association for the Advancement of Science, 1963, pp 183-191 8. deHoyos A, deHoyos G: Symptomatology differentials between negro and white schizophrenics. Int J Soc Psychiatr 11:10-11, 1965 9. DuBois WEB: A program of reason, right, and justice for today. In Lester J: The Seventh Son: The Thought and Writings of WEB DuBois. New York, Random House, 1971, p 67
379
This paper correlates economic stress with minority status, resource allocations for mental health programs, and vulnerability to mental disability. Several hypotheses are advanced: 1. A major and recurring psychological pattern of the American national character is prowhite, antiblack paranoia. 2. Mental health fiscal allocations and programmatic determinations in ghetto, lower socioeconomic, minority-populated urban areas are predicated on political and racist considerations, the underlying motivation being to keep minorities at greater risk of mental disability. 3. Economic privation and stress increase vulnerability to mental illness, especially in a minority population for whom health, mental health, educational, and social services are grossly inadequate. 4. Poverty and economic stress combine with health systems that are unresponsive to the needs of blacks and other minorities, resulting in the perpetuation of disabilities and other conditions in blacks that are potentially preventable. 5. Health and mental health resources should be increased rather than diminished during periods of economic stress, especially in the public sector. 6. In order to provide each citizen with access to quality health and mental health care regardless of race and/or economic status, there must be enacted a national health insurance program based on tax-levy monies that will cover all aspects of health and mental health care. 7. Racism and social status will continue to be powerful determinants of the quality of service that white professionals render to black patients and to poor white patients, unless our training institutions mount a massive campaign to train appropriately and to include significant numbers of minority candidates and trainees in the effort. To date this effort is virtually nonexistent.
In what is probably the greatest love story in American fiction,1 Herman Melville describes a number of relationships in which the redemptive love of man and man is represented. One of the several romantic duos in Moby Dick is between Ahab the captain, and Pip, the black cabin boy. There is no more precise explication of aspects of the American experience and of the American national character than that furRequests for reprints should be addressed to Dr. Hugh F. Butts, Bronx Psychiatric Center, 1500 Waters Place, Bronx, NY 10461.
nished us by Melville in his monumental tome. Pip, abandoned at sea, when finally rescued is blatantly psychotic. "He saw God's foot upon the treadle of the loom, and spoke it; and, therefore, his shipmates called him mad. So man's insanity is heaven's sense; and wandering from all m'ortal reason, man comes at last to that celestial thought, which, to reason, is absurd and frantic; and weal or woe, feels then uncompromised." Pip's "insanity" has resulted from abandonment and his consequent sense of isolation. Ahab adopts Pip and shares his cabin with the
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 4, 1979
boy. Dr. Jose Barchilon (unpublished data, 1976) states: "Ahab understands the depth and wisdom of Pip's craziness, identifies with him, and takes him to his cabin as a son. Not in an attempt to make amends for the harm done to Pip . . ., but to find company in his misery, because Ahab knows that he and Pip are different sides of the same crazed coin. He also knew that, were he to like Pip and grow too tender towards him, it would soften his hatred and make him give up his pursuit of white hooded phantoms." Ahab is in a sense doing that for Pip which was never done for him (he had been doubly-orphaned by 12 months of age). "This is his attempt at restitution, at recapturing by projective identification, the parents he didn't really have." (Barchilon, unpublished data, 1976). Thus, Melville, nearly 128 years ago, comprehended the genesis of psychotic decompensation, the therapeutic effectiveness of relatedness to another human, the nature of projective identification, the nature of the type of developmental arrest that follows parental loss, and the nature of primary process thinking.
Hypothesis 1 A major and recurring psychological pattern of the "American National Character" has been well stated by the literary critic Leslie Fiedler:2 "To express this 'blackness ten times black' (original sin) and to live by it in a society in which, since the decline of orthodox Puritanism, optimism has become the chief effective religion." This pattern is reflected in American literature which is a literature of "darkness and the grotesque in a land of light and affirmation." The major literary concerns from Cooper to Baldwin are with death, incest, and homosexuality. The child's world (in literature) is asexual, terrible, and a world of fear and loneliness. Little wonder that child abuse is epidemic in the United States. The companion of the lonely, frightened "man-child" who ventures forth into the unexplored world is "pagan and 375
Table 1. Rank Order* of Indices of Social Poverty Which Affect Needs for Mental Health Services in the Five Boroughs** Borough Bronx Brooklyn Richmond Queens Manhattan
Per/Capita Income
% Population on Welfare
% Population Unemployed
% Population Medicaid
1 2 3 4 5
1 2 5 4 3
3 2 5 4 1
1 2 5 4 3
* Rank of one (1) indicates greatest poverty ** Based on 1975 Census update
unashamed," but the companion is described as simultaneously both a dream and a nightmare. This literary, metaphoric companion (Chingachgook, Nigger Jim, Babo), is concretized in the form of the black American. One could at this point expatiate on the psychodynamics of unconscious racism. The "pagan" companion possessed of both material and demonic features permeates all of American literature. Splitting the imagery in this way attests to and evokes ambivalent responses, in addition to allowing for or facilitating projection of unacceptable feelings and thoughts ("Racismprowhite, antiblack paranoia"). The colonial world is a world cut in two. The dividing line, the frontiers are shown by barracks and police stations. In the colonies it is the policeman and the soldier who are the official, instituted go-betweens, the spokesmen of the settler and his rule of oppression. In capitalist societies the structure of moral reflexes handed down from father to son, the exemplary honesty of workers who are given a medal after 50 years of good and loyal service, and the affection which springs from harmonious relations and good behavior-all these esthetic expressions of respect for the established order serve to create around the exploited person an atmosphere of submission and of inhibition which lightens the task of policing considerably. In the capitalist countries, a multitude of moral teachers, counsellors, and bewilderers separate the exploited from those in power . . . This world divided into compartments, this world cut in two, is inhabited by two different species. The originality of the colonial context is that economic reality, inequality, and the immense difference of ways of life never come to mark the human realities. When you examine at close quarters the colonial context, it is evident that what parcels out the world is, to begin with, 376
the fact of belonging to or not belonging to a given race . . . The cause is the consequence; you are rich because you are white, you are white because you are rich.3
Ten years after the issuance of the Kerner report, which predicted that America was moving toward two societies, one black, one whiteseparate and unequal, that prediction has been borne out. In the areas of employment, poverty, education, and medical care, black Americans are woefully behind white Americans. At the end of 1977, the jobless rate was 6.3 percent for whites, 13.2 percent for blacks. For white teenagers, it was about 15 percent, for black youth about 40 percent. The poverty rate for blacks is three times the rate for whites. Ninety-two percent of all white 17year-olds are functionally literate, as opposed to only 58 percent of the blacks. Black life expectancy is 67 years, in contrast to 73 years for whites. Health and mental health fiscal allocations are determined by political and racial considerations rather than need. Fanon's formulation is directly applicable to a colony of 1.4 million souls called the Bronx. Two thirds of the residents of that colony are black or hispanic. The per capita income is $2,943 (lowest in New York City); 172,913 families receive aid to dependent children; 284,322 persons receive welfare (20 percent of the' population); and 27 percent of the borough's population receive Medicaid assistance. Despite the high incidence of mental disability in the borough of the Bronx and the existence of the aforementioned indices of social pathology, the borough receives a per capita allocation
of state mental health monies that are half the amount allocated to Manhattan (which has the same population as the Bronx). Table 1 rank orders the five boroughs for various indices of social poverty and indicates that the Bronx ranks highest among the five boroughs on most of these indicators. Table 2 shows the relationship of borough residents' income to the number of inpatient beds provided by state, municipal, and voluntary agencies and indicates gross inequities between the five boroughs. These data are computed per 100,000 population. As is obvious, the Bronx ranks lowest in per capita income and other indicators of social distress, yet has the least beds per 100,000 population. It is equally clear, and important, that the number of beds available for the care of acutely disturbed patients in the Bronx is at the very lowest level among the five boroughs. That is, the Bronx has the lowest number of municipal and voluntary hospital beds set aside for psychiatric patients. As if this were not enough, these numbers include 26 beds at one municipal hospital which at this writing have not been made completely available. The consequence of this glaring inadequacy for the Bronx is that the state psychiatric facility, Bronx Psychiatric Center (BPC), has been forced to function as an acute care facility. In 1977, for example, the Bronx Psychiatric Center admitted approximately 600 patients who had never before been in a psychiatric hospital, a function which should rightly have been assumed by the municipal and voluntary sector. The demand for acute care services became so great that BPC established a 24-hour, seven-day-a-week admission service, one of whose functions was to provide emergency care to acutely disturbed patients coming from areas of the Bronx without adequate acute care service. This admission service also provides overnight care in its holding area for patients who would otherwise be most appropriately treated at an acute care facility.
Hypothesis 2 Mental health fiscal allocations and programmatic determinations in ghetto, lower socioeconomic, minority-populated urban areas are predicated on political and racist considerations, the
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 4, 1979
Table 2. Relationship of Borough Residents' Income* to the Number of Inpatient Beds Provided by State, Municipal, and Voluntary Agencies
Borough
Manhattan Queens Richmond Brooklyn Bronx
Per Capita Income
$5,255 4,046 3,516 3,072 2,943
Number of available beds per 100,000 residents** State Municipal Voluntary
(1977-1978)***
(1977)t
(1977)t
105 78 88 43 51
32 10 None 12 10
34 11 9 5 3
* ** *** t
Ranked by average income-data from 1970 census. Population data as of 1975. Data from NY State Governor's Budget for 1977-1978. Data from NYC Health and Hospitals Corporation, January 1977. t Data from NYC Mental Health and Retardation Services, January 1977.
underlying motivation being to keep minorities at greater risk of mental disability. During the past four years, the personal service budget at Bronx Psychiatric Center has been reduced by $3.5 million, and there are now 200 fewer employees at the institution than were there four years ago. During the same four-year period, there was an 85percent increase in the admission rate and a 20-percent increase in the inpatient census. This same four-year period was marked by local and national economic depression, increased unemployment, and a worsening economic plight on the part of an already endangered species-residents of the Bronx. During the same period Bronx Psychiatric Center was innundated with investigations, audits, media harrassments, and the coup de grace-an investigation by the New York State Investigation Committee. As many as 15 investigative bodies reviewed institutional practices, several "tripping over" each other with concurrent audits.
Hypothesis 3 Economic privation and stress increase vulnerability to mental illness, especially in a minority population for whom health, mental health, educational, social services, and housing facilities, and services are grossly in-
adequate. The cost of mental health services is
staggering. In the Bronx, a crude estimate is that approximately $50 million are spent per annum on mental health services. Table 3 shows a rough breakdown of these expenditures. In a fascinating study Willie and Rothney4 establish a definite correlation between economies, race, and neonatal mortality. They write: It may be concluded: (1) that Negro and native white populations have similar neonatal mortality rates when socioeconomic status is held constant; (2) that native white population in lower-income neighborhoods have neonatal mortality rates greater than the rates of white populations in higher income neighborhoods; (3) that neonatal mortality rates are inter-correlated with family income in neighborhoods where at least half of the households receive less than $2,700 per year; and (4) that no association exists between the distribution of neonatal mortality by neighborhoods and family financial status above the critical median income level of $2,700 per year.
The crucial element accounting for the higher neonatal mortality rate in lower-income black women is their failure to receive such prenatal care. The authors astutely observe: Why pregnant women in lower-income families do not seek prenatal care, even when it may be available without charge, is a sociological problem worthy of further research and study. One possibility is that lower-income people are constricted in their ability to reach out to community health and welfare services for help. Were this hypothesis confirmed it would indicate the importance of professional workers in health and welfare seeking out the poor rather than waiting for community services to be
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sought. A second possibility is that many lower-income women do not know what services are available. A third possibility is that variations in the use of medical services during pregnancy may be a function of variation in cultural values of different populations of people. As stated by Odin Anderson, "the next steps in research in infant mortality which may yield useful information . . . should be directed toward relationships between infant mortality .. . .and mothercraft, specific infantcare customs, and practices . . ." As the total rate decreases, the proportion of infant deaths attributable to different causes may increase. Thus, several hypotheses should be studied.4 Reference is made to this fascinating study not only because the reference to
economic status has a bearing on this topic, but for other reasons. The hypothesis advanced by Willie and Rothney to the effect that mental health workers err seriously by assuming that poor black women will step forward and request health and mental health services has significant mental health implications. A comprehensive view of racism and the psychology of poverty should result in a realization that blacks have been thoroughly disenchanted by the insensitivity, irrelevance, and noninvolvement of the health and mental health systems to which they are exposed. Accordingly, it is insufficient to establish services and invite blacks to avail themselves of them. A much more active approach is needed in order to undo and reverse the views of health and mental health institutions held by blacks. 377
Table 3. Annual Mental Health Expenditures
Voluntary Agencies in Contract with the New York City Department of Mental Health, Mental Retardation, and Alcoholism Services (1976-1977) Bronx Citywide Dollars Dollars Expenditure Per Capita Expenditure Per Capita Inpatient Outpatient 24-Hour Emergency Day Treatment Rehabilitation Residential Care
$
513,707 6,920,059 475,710 1,330,496 436,159 93,640
$ 4,638,733 44,048,003
0.36 4.94 0.33 1.30 0.31 0.06
1,892,065 4,910,417 4,096,367 583,118 1,156,153
Partial Hospitalization
Other Totals
572,084
0.40
6,778,912
$10,842,755
7.74
$68,103,768
II. State Facility Expenditures Bronx Psychiatric Center
Manhattan Psychiatric Center
Personnel item ceiling Personal services cost Inpatient Outpatient Personnel item ceiling Personal services cost
$ 1,240 16,332,956 12,410,939 4,422,017 1,351 24,849,500
0.58 5.57 0.23 0.62 0.51 0.07 0.14 0.85 8.62
($12.02 per capita)
($16.56 per capita)
Ill. Municipal Psychiatric Program Expenditures (Bronx) Bronx Municipal Hospital $9,829,154 Lincoln Hospital 3,649,099 North Central Bronx 2,191,979 Morrisania Neighborhood 1,446,926 Family Care Center Total $17,117,158 (12.22 per capita)
Hypothesis 4 Poverty and economic stress combine with health and mental health systems that are unresponsive to the needs of blacks and other minorities, resulting in the perpetuation of disabilities in blacks as well as in conditions that are potentially preventable. Ewalt is quoted as suggesting that six factors are contributory toward positive mental health:5 1. Attitudes of the individual toward himself. 2. The degree to which the person realizes his potentialities through action. 3. Unification of function in the individual's personality. 4. The individual's degree of independence of social offices. 5. How the individual sees the world around him. 378
6. An ability to take life as it comes and master it. Implicit in this listing is the fact that an individual's attitude toward himself, his view of the world around him, and his ability to attain a sense of mastery is not predicated solely on his innate potentialities but also on conditions that abound in his milieu that will markedly affect his health and mental health. Human services rank at an extremely low order in the American value system. Accordingly, when budgetary choices must be made, huinan services are readily sacrificed. Since economic crisis is the catalyst for compelling budgetary choices, human services are sacrificed at precisely the time when the population at risk (due to economic stress) is consequently at increased risk of mental disability or stress.
Hypothesis 5 Health and mental health resources should be increased rather than diminished during periods of economic stress, especially in the public sector. To predicate the existence or quality of health and mental service on a citizen's financial ability may at times be tantamount to condemning that citizen to inadequate services or to no services. The current health/mental health care system in America is a two-class system: an impoverished system for the impoverished and an affluent system for the affluent. There is no earthly reason why the quality of care at Bronx Psychiatric Center should not be comparable to, or surpass that at Shepherd Enoch Pratt Institute, a private psychiatric facility in Maryland. It is a sad commentary on our society's attitudes toward the poor that we ac-
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cord them inferior facilities, staffed by overburdened and disenchanted staff, and then proceed finally to maliciously and calculatedly decimate these institutions. The poor get poor care because our society does not believe that they are entitled to good care. This is borne out by a comparison between the New York State per capita expenditure per mental health services on the five boroughs of New York City and the per capita incomes of the residents of these boroughs (Table 4). The correlation is undeniable. The Bronx and Brooklyn with the two lowest per capita incomes in the region also have the two lowest state expenditures for mental health services on a per capita basis. Their inequities are reinforced by the discriminatory Medicaid/Medicare reimbursement formula in which private/voluntary facilites receive $253 per day and public facilities, only $56 per day.
Hypothesis 6 In order to provide every citizen with access to quality health and mental health care regardless of race and/or economic status, there must be enacted a national health insurance program based on tax levy monies that will cover all aspects of health and mental health care. Struening and Rabkin6 remind us that "white psychiatrists are influenced in their diagnostic decisions by the patient's race." Pasamanick7 (1963) suggested that because of the inability of white psychiatrists to comprehend nuances in the black subculture and the behavior of individuals socialized in this subculture, they tend to overdiagnose psychosis among blacks. In the study of symptomatology differentials in the records of black and white schizophrenics, deHoyos and deHoyos8 reported that white psychiatrists under-reported symptoms of black patients due to the greater social distance between psychiatrist and patient. This does not necessarily influence the primary diagnosis, but leads to less detail and explanation in descriptions of the patient's psychiatric status. While conscious and unconscious racism seem operative in these instances, class differences may also be a crucial factor. The author has observed the same tendency toward under-reporting in poor white patients.
Table 4. New York State Per Capita Mental Health Expenditures in the Five Boroughs of New York City
Borough Bronx Brooklyn Queens Richmond Manhattan
State Per Capita Expenditure
Per Capita Income
$18.25 12.84 26.31 42.31 35.55
$2,943 3,072 4,046 3,516 5,255
Struening and Rabkin6 add: Treatment procedures are generally acknowledged to vary in relation to patient characteristics. Lower-class and minority patients are less likely to be accepted for treatment at outpatient facilities due to factors such as 'insufficient motivation' or 'lacks readiness.' If accepted they are more apt to be seen by lower-ranking personnel and to be healed with somatic methods. They are more likely to drop out of treatment and, if they do remain, they are seen for a shorter period of time. Within social classes, minority patients receive less treatment than whites. Altogether, the double handicap of low social status and race make it appreciably more difficult for black patients to receive help from outpatient psychiatric facilities.
. . . Here is a program for those who have not lost hope and who yet believe in America . . . Insist on a chance to vote for peace, for the total abolition of the color line; for no family income above $25,000 or below $5,000; for free education from kindergarten through college; for housing on a nationwide scale; for training of all for the work they can do in so far as work is needed for the best interests of all. Insist on discipline for this work. Allow no laborer to be paid less than his product is worth; and let no employer take what he does not make Heal the sick as a privilege, not as a charity. Make private ownership of natural resources a crime . . . . Preserve the utmost freedom for dreams of beauty, creative art, and joy of living. Call this socialism, communism, reformed capitalism, or holy rolling. Call it anything-but get it done!9
Hypothesis 7
Perhaps some would call this insane, but to this author it is reason, right, and justice. As Bert Williams once said: "I may be crazy, but I ain't no fool!"
Racism and social status will continue to be powerful determinants of the quality of service that white professionals render to black patients and to poor white patients, unless our training institutions mount a massive campaign to train appropriately and to include significant numbers of minority candidates and trainees in the effort. To date this effort has been virtually nonexistent. This has been an effort to tease out and define some of the parameters on what may be regarded as the politics of mental health. Politics refers to the science of how who gets what, when, and where. Having begun with a literary reference, it seems appropriate to close with one. The author is indebted to that great American scholar, William Edward Burghardt DuBois, who writes: . . .The United States is no longer a democracy. Most citizens know this well and do not waste time going to the polls.
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Literature Cited 1. Melville H: Moby Dick or The Whale. New York, Modern Library, 1960 2. Fiedler L: Love and Death in the American Novel. New York, Criterion Books, 1960, p 22 3. Fanon F: The Wretched of the Earth. New York, Grove Press, 1963, p 31 4. Willie CV, Rothney W: Racial, ethnic and income factors in the epidemiology of neonatal mortality. In Willie CV (ed): The Family Life of Black People. Columbus, Ohio, Merrill, 1970 5. Jahoda M: The Current Concepts of Positive Mental Health. New York, Basic Books, 1968, p 4 6. Struening E, Rabkin J: Ethnicity, Social Class, and Mental Illness. New York, Institute of Pluralism and Group Identity, 1976, p 8 7. Pasamanick B, Roberts DW, Lemkau PW, et al: A survey of mental disease in an urban population: Prevalence by race and income. In Pasamanick B (ed): Epidemiology of Mental Disorders. Washington, DC, American Association for the Advancement of Science, 1963, pp 183-191 8. deHoyos A, deHoyos G: Symptomatology differentials between negro and white schizophrenics. Int J Soc Psychiatr 11:10-11, 1965 9. DuBois WEB: A program of reason, right, and justice for today. In Lester J: The Seventh Son: The Thought and Writings of WEB DuBois. New York, Random House, 1971, p 67
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