Racial inequality negatively influences the lives of people of color in the United States. Although race refers to differential concentrations of specific genes, the impacts are confined to physical characteristics such as skin color, hair type, and eye color. Rather than designating meaningful biological categories, race is a social construct. Yet, where there are inevitable intersections with institutional structures and interpersonal health relationships, race and racism produce inequities.
Racism occurs within and permeates the overarching political, social, cultural, and economic systems of American society. It can take several forms: structural, institutional, interpersonal, and internalized. Institutional racism in the healthcare system yields adverse effects on the physical and mental health and well-being of racialized individuals and communities. These inequities are well documented.
Recommendations are offered for creating a fairer and more just healthcare system in America. Equality and equity in the country’s healthcare system will be achieved only if racism is challenged in all its forms.
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Institutional Racism and Effects on Health and Well-Being
Valire Carr Copeland, Betty Braxter, and Sandra Wexler
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Social Isolation
Sandra Edmonds Crewe and Robert Cosby
Social isolation is both a social and public health problem that is lethal across the life span. Its harmful effects have both psychological and physiological impact and is recognized by social workers and allied health professionals as a major barrier to quality of life for individuals and groups. The effects of social isolation have been reported to be as harmful as smoking 15 cigarettes a day and four times as harmful as obesity. These facts have galvanized the social work profession around eradicating social isolation with a focus on defining social isolation and identifying its causes, strategies for eradication and prevention, and addressing the differences between perceived isolation (loneliness) and objective isolation. Additionally, social isolation is examined through a cultural lens using both micro- and macroperspectives giving attention to social exclusion as well as to groups who have higher risks such as older persons, at-risk youth, prisoners, stigmatized groups, and historically oppressed populations.
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Psychosocial Support in Emergency Settings
Maryanne Loughry
The integration of psychosocial support into emergency responses is a recent development. In the 1990s, the need to address the mental health and psychosocial well-being of individuals and communities affected by emergencies became clear following the breakup of the former Yugoslavia (1991–1992) and the Rwandan genocide (1994). Prior to this, mental health in emergencies was primarily addressed in clinical settings. However, the humanitarian field was divided between the medical sector, which asserted that psychiatric clinical intervention was best, and many nonmedical actors, who preferred a person-in-environment approach. The need for consensus resulted in the Inter-Agency Standing Committee (IASC) working group’s establishment of the framework of Mental Health and Psychosocial Support (MHPSS), which combined both approaches. The IASC Guidelines on MHPSS in Emergency Settings, published in 2007, are widely recognized as explaining how best to administer psychosocial support in emergencies. This ended decades of tension between mental health and psychosocial experts in emergency and humanitarian settings.
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Abolition of Involuntary Mental Health Services
Brianna Suslovic
Apart from a few dissenting perspectives, social workers have not coherently engaged with the moral dilemmas inherent in the profession’s participation in coercing or mandating patients to mental health treatment. With roots in the development of asylums in 1400s Western Europe, involuntary mental health services continue to rely on processes involving the state in order to detain individuals who are deemed severely mentally ill. Legal precedent and practices in the United States as they pertain to involuntary mental health treatment reflect tensions about promoting individual freedom while maintaining safety. Given the diversity of circumstances that social workers may navigate in this particular area of practice, the profession’s ethical commitments to self-determination are potentially in conflict with practices of involuntarily hospitalizing or providing mental health services to individuals. In fact, international health and human rights bodies have weighed in on the role of coercion in mental health treatment, advocating for decreased use of coercive means of confining and treating patients with severe mental illness. Critical perspectives on involuntary mental health services are often rooted in the critiques of psychiatric consumer/survivor/ex-patient organizers, who argue that detaining patients against their will and mandating them to participate in treatment or take medication is a form of violence that violates their rights. There are also some promising approaches to severe mental illness that promote self-determination and attempt to reduce the likelihood of involuntary or coerced treatment, reorienting toward the value of peer support and denouncing the use of nonconsensual active rescue in crisis hotline work. Abolitionists also advocate for the elimination of involuntary mental health services, advocating instead for the development of non-coercive forms of crisis response and care that rely on alternatives to the police.
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Home Visits and Family Engagement
Barbara Wasik and Donna Bryant
The importance of engaging families in home visiting was recognized more than a century ago as M. E. Richmond provided guidelines for involving families in the visiting process. She stressed individualizing services and helping families develop skills that would serve them after the home visiting services ended. During the 20th century, early organized efforts in home visiting in the United States built on methods used in other countries, especially European countries. Although interest fluctuated in the United States during the past century, since 2010 interest has increased due primarily to the passage of the Patient Protection and Affordable Care Act that provided for home visiting services to respond to the needs of children and families in order to improve health and development outcomes for vulnerable children and their families.
Engaging families is essential for a productive home visiting experience requiring thoughtful program activities as well as knowledge and skills on the part of the visitor. Program responsibilities begin with the need to make good employment decisions regarding home visitors and then to provide effective training, supervision, and ongoing professional development. Providing professional training in helping skills such as observation, listening, and ways of asking questions to gain or clarify information is essential to ensure visitors can engage families. Using principles for effective home visiting—including establishing a collaborative relationship with the family; individualizing services; being responsive to family culture, language, and values; and prompting problem-solving skills—can enhance the ability of the visitor to engage the family. Programs can provide opportunities for visitors to enhance their skills in developing relationships with and engaging families. Engaging families is a reciprocal process. Some families will have a positive orientation toward working with visitors to accomplish their own goals and objectives; others may be less willing to engage. Although the program and visitors have the main responsibility for engagement, they will face challenges with some families and may need to seek creative solutions to actively engage.
Just as home visitors need to engage parents in order to facilitate new knowledge and skills, parents need to engage their children to foster development. Recent research identified a set of parent–child interactions that visitors can incorporate to foster parent engagement with young children. These challenges are shared across home visit programs, as well as across cultures and countries, regardless of the professional training of the visitors or the goals and procedures of the programs.
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Black Women and Maternal Death
Valire C. Copeland and Betty Braxter
The upward trend in the number of Black maternal deaths between 2005 and 2020 warrants an in-depth assessment of risk factors associated with the increased maternal mortality rate in the United States for this subgroup population. The risk factors are multifactorial and, in part, have been organized into several categories: demographics, social determinants of health (SDOH), medical conditions, and the quality-of-care interventions by health systems providers. In addition, the overall trends, causes, and solutions to decrease maternal mortality current rates reflect the social inequities in our society.
Black maternal deaths have been rising in recent years due to complex causes which stem from structural and systemic health inequities. In part, unvaccinated pregnant women were at greater risk of severe illness and hospitalization and even death if they were diagnosed with COVID-19. While Black Americans were disproportionately impacted by the pandemic, the disparities in maternal mortality predate and extend beyond the pandemic. In part, and together, the leading causes of pregnancy-related deaths include cardiovascular disease, other medical conditions and infections, cardiomyopathy, blood clots in the lung hypertensive disorders related to pregnancy, adverse pregnancy outcomes, racial bias of providers, and perceived racial discrimination from patients. In addition, an overview of nonmedical factors referred to as SDOH, which intersect with health status outcomes, will be discussed.
An overview of Black women’s maternal mortality and morbidity, factors contributing to poor maternal health status outcomes, and intervention strategies at the provider, health systems, and policy levels are provided. Social workers in health care systems function as health care providers and clinicians. Therefore, contributing medical and nonmedical issues are factors to consider for a holistic perspective during engagement, assessment, and intervention. The terms Black women and Black birthing persons are used interchangeably.
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Deinstitutionalization in Macro Practice
Steven P. Segal
The deinstitutionalization policy sought to replace institutional care for populations in need of care and control with prosocial community-based alternatives. U.S. institutional populations, however, have increased since the policy’s inception by 205%. As implemented, with the assistance of advocacy and cost-cutting factions, it has succeeded only in enabling the divestiture of state responsibility for target groups. It sought to prevent unnecessary admission and retention in institutions. As implemented, deinstitutionalization initiated a process that involved a societal shift in the type of institutions and institutional alternatives used to house its target groups, often referred to as trans-institutionalization. For many in need of institutional placements, it has succeeded in preventing all admissions, expanding admissions for others. In seeking to develop community alternatives for housing, treating, and habilitating or rehabilitating its target groups, it has succeeded in establishing a variety of alternative living arrangements and showcase and model programs illustrating what can be done; yet, it has failed to deliver on investments in such programs to serve the majority of its target groups. It has resulted in the abandonment of substantial numbers to homelessness. It has been documented, from political, economic, legal, and social perspectives, how this policy has affected the care and control of populations such as older adults, children, people with mental illness or developmental disabilities, people under correctional-system supervision, and, more recently, individuals without a home. Suggestions for a truer implementation of deinstitutionalization’s initial aspirations are available.
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Indigenous and Tribal Communities
Megan G. Sage
Indigenous populations have experienced hundreds of years of historical trauma, systemic racism, and oppression since colonization began in the Americas, Australia, and New Zealand. Settler colonialism has created and continues to perpetuate historical and ongoing trauma and systemic racism in Indigenous populations. Despite considerable diversity and resilience among Indigenous populations globally, there is a clear pattern of significant disparities and disproportionate burden of disease compared to other non-Indigenous populations, including higher rates of poverty, mortality, substance use, mental health and health issues, suicide, and lower life expectancy at birth. Substantial gaps related to access to healthcare and service utilization exist, particularly in low-income Indigenous communities. Implementation and sustainment of White dominant-culture frameworks of care in Indigenous communities perpetuate these systems of oppression. Development and implementation of culturally informed services that address historical trauma and oppression, and systematically integrate concepts of resiliency, empowerment, and self-determination into care, are issues of policy as well as practice in social work. The co-creation and subsequent implementation, monitoring, and sustainment of effective systems of care with Indigenous populations are essential in addressing health disparities and improving outcomes among Indigenous populations globally.
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Pandemics and Social Work
Sangeun Lee
A pandemic contains three key components: extensiveness, novelty, and severity. For the past century, humankind experienced the Spanish flu in 1918 and COVID-19 in 2020 as major pandemics. The global impact has been extensive in terms of their origin, international transmission, and mortality rates. Public health measures to slow and stop pandemics have been implemented. During the COVID-19 pandemic, disparate impacts on health in different populations have been witnessed due to existing social inequalities, detriments of health, and structured racism. The interests of social workers have been adversely impacted in those pandemic times. Spanish flu bolstered social work with a professional presence. COVID-19 has confirmed the need for community engagement and community development to follow large-scale social policy reforms as a response to the disproportionate impact on diverse marginalized communities, which is the core of macro social work practice and would be more strongly called on to prepare for future pandemics.
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Suicide and Public Policy
Janelle Stanley and Sarah Strole
The historical context of suicidal behavior and public policies addressing suicide arose simultaneously within the United States, and both reflect a culture of discrimination and economic disenfranchisement. Systems of oppression including anti-Black racism, restrictive immigration policy, displacement of American Indigenous communities, religious moralism, and the capitalist economic structure perpetuate high-risk categories of suicidality. Suicidal behavior, protective factors, and risk factors, including firearms, are examined in the context of twentieth and early twenty first century public policy. Recommendations for public policy will be discussed with consideration for policies that impact communities disproportionately and social work ethics, such as right to die laws and inconsistent standards of care.
