Dr. Gary Belkin
For more than four years, Gary served as the Deputy Health Commissioner for New York City in charge of the ambitious mental health programs spearheaded by Chirlane McCray and her husband Mayor Bill de Blasio. A psychiatrist by training and public health expert, he has spent much of his career advocating for “task sharing,” teaching teachers, social workers, clergy, and service workers to tackle some of the work traditionally dedicated to doctors and therapists. Much of his work for the city fell under the banner of ThriveNYC, a new initiative intended to increase the capacity of grassroots organizations to serve the mental health, resilience and wellness needs of their community. Part of that work included looking for ways to transfer mental health work carried by the police and to inject such work with critical consciousness on race and socioeconomic disparities. He left city government in the fall to start an organization, A Billion Minds, dedicated to solving the mental health challenges arising from the climate crisis and through which he advises governments and organizations world-over. Months ago, he would have been on the frontlines of the pandemic, helping to coordinate the city’s response.
Gary’s Piece in the New England Journal of Medecine, “Leadership for the Social Climate”
Gary’s Piece on the Launch of the Billion Minds Institute
Learn More About ThriveNYC and Mental Health Resources Available From Home
Join 7 Cups as a Volunteer Listener and Help Provide Free Emotional Support to Millions
I’m no longer in in city government. So it’s been weird watching and reading about people that I know, people that I worked with for five years, taking the lead on this epidemic.
I have this mixed feeling, like survivor’s guilt. Like I should be in this battle with them and What am I doing? And on the other hand, I’m really grateful because I’d be separated from my family.
It’s a helplessness from watching something you love… this city, go to pieces…
What hasn’t been answered is more about what happened at the city level. And that’s a hard thing to discuss now, but it should be. There could be crucial lessons: What conversations happened? What was raised about preparedness? What response did it get when it was raised? It’s important to open up what went on in especially the last weeks of February, first weeks of March.
It’s not enough to blame the wide spread in NYC on our density. Density is not nothing—but it doesn't explain an order of magnitude difference in cases and deaths from the next hardest hit US areas at the time. The density put an added premium on acting early. But the city acted late.
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I mostly worry about the social and emotional hit of this on our city.
There’s a diagram that’s being used by some planners internationally to get at the range of health impacts of COVID-19. It shows this thing called the fourth wave. The first wave refers to death and illness from the infection spike itself. The second wave is the lasting population health and damage that results from that. Then there’s a wave of all the other worsening health care and chronic medical needs that have not gotten care while the health system was swamped.
And then the fourth wave, which is increasing throughout all of this, is the mental health stuff. A large bundle from burnout, to trauma, to frank illness such as depression and PTSD, to just a lot of social distress and disconnection, all of which are toxic. Loneliness kills, as does PTSD, as does burnout. For example, the ER physician, a director of emergency medicine at Cornell, who killed herself. All this emotional damage, especially when we need to lean so much on our connectedness, could prove to be the hardest thing to address.
There could be more violence, disaffection, a marked escalation in disparities of suffering in what remains a residentially and racially segregated city. These things becoming flashpoints rather than things people cope with or work on together. So it could get ugly.
It can become a cascade unraveling: people lose confidence in public life, because they lose confidence in the city to be effective, and they lose confidence in their neighbors’ confidence. It can unravel pretty fast. And the way to stem that tide is aggressive civic action.
The greatest antidote to distress is action.
To pull back from disintegrating as a city, we really have to rethink participation, empowerment, involvement in a very redistributed way. We have to flip tables here. And it’s not only in spreading who has a say in deciding things, but in doing things and implementing things.
This is not so radical… and is actually a quite practical idea. A real community health worker approach is participatory action that would markedly add to the ability to take on this pandemic moving forward. When I was in the health department, we worked with Health and Hospitals to try to get them to become a hub for networks of community health workers—especially in high disparity neighborhoods. People from the neighborhood who go block by block and see people in their homes, navigate them through the system, impart knowledge, identify and support health needs, and get knowledge back about what’s happening in the neighborhood. If we’d had that in place, Health and Hospitals maybe wouldn’t have been as besieged as it was in some areas. And the scale of these mortality differences might’ve been softened.
We have to see people as partners. I am increasingly involved in building ways that mental health work enrolls communities as an extension of the system. This is the well researched notion of “task-sharing”—basically identifying care tasks and skills that non-specialists can do. It includes counseling methods and interventions for protecting emotional resilience that can be done by priests and teachers and your neighbor. Now there actually might be fertile ground to do that at scale.
It also means instilling “critical consciousness” in such work. If we’re going to be training people working in food pantries about how to help their clients and themselves with suicidal depression, we can’t just give them breathing exercises, as much as those might be helpful. We have to make room to ask, “How can we be explicit about the structures and layers of decisions that contribute to this problem we are facing?” “What are the ways that we and our neighbors can do something about that?”
This is the kind of work I was doing at the Health Department when I developed ThriveNYC. Unfortunately City Hall dialed back and became more cautious just as Thrive[NYC] was getting more ambitious. They were under all this weird critical fire, completely baseless and ad hominem stuff. Just Google, “ThriveNYC New York Post,” and it’s a year’s worth of nonsense.
A dogged but wrongheaded stereotype had reared its head: that the only purpose of public mental health policy is to get homeless people out of the subway. And if you’re not doing that, you’re doing nothing. We’d hear, “All of this coddling of kids who have been traumatized, they can just pull themselves up by their bootstraps.” Or, “All this namby-pamby well-being crap is a waste of taxpayers’ money.”
Whereas the evidence tells you quite the opposite. Yes, of course we have to make good on the people who have unraveled so much with the most serious needs. But they’re sleeping on the subway now precisely because we didn’t invest in earlier solutions when they needed them.
We have to build a system with that broader foundation. Otherwise we’re going to keep chasing our tails around crises and moments like now. We have too weak a social connecting infrastructure, so let’s build that out. We were headed in that direction but it got curtailed. What would have been in place now—more street level, community collaboration, easier access and locally driven support, etc.—is the kind of stuff that is sorely needed now.
A participatory lens can enhance a lot of what we are doing. Take the new contact tracing program in the city. Twist the vision a little: Give this role not to Health and Hospitals, but to an NGO, like Massachusetts did. Give this to a coalition of not-for-profit groups. It then can offer an opportunity to rapidly build a community health workforce and grassroots health activity that’s locally owned. They’re the ones who should be doing contract tracing. Or the ones talking to the bars and restaurants and neighbors on their streets about keeping the crowds down, social distancing, etc. Or handing out information on street corners about masks and so forth.”
We’ve just not seriously invested in the value of civic muscle—not in public health and not in participatory democracy either. And you can’t rent that overnight. Now is the time. I think the survival of the city as we know it, depends on that.
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A few weeks later, we spoke again, after the deaths of George Floyd, Ahmaud Arbery, Breonna Taylor following countless others sparked nationwide protests and calls for police reform.
It’s no coincidence that George Floyd’s death got the reaction that all the others before it did not.
It’s related to some degree to the anger of the moment: A death toll from COVID-19 that broke out by race. The hardships of lockdown. The only venting of anger, for a time, being white people resisting wearing a mask.
I have empathy for the hardships so many are facing and the various forms that takes---including the fierceness of that resistance, the fragile sense of personal autonomy underneath it, so that some are practically willing to commit suicide over these small things to feel they still have their “freedom.”
But whether it’s explicit or implicit—and sometimes it’s been very explicit—it’s all also part of this wounded assumption of white privilege. Because any sense of privilege in this country, of asserting “freedom” as a reason to flout the public good, is an assertion of or response to racial privilege. It’s not about being a free American; no, it’s, at bottom, about being a white American, or being an American of color who just wants to be free like a white American. It’s all wrapped in that ecology of privilege and race. It’s been that way since the beginning, and we haven’t extricated it.
So after protests with signs like, “I want to get my hair done,” you had a massive response that felt like it was saying, “You want to get your hair done? We’re fucking dying. Your community, your hair’s growing longer. Our community, everyone’s dying. Our lives matter.”
The racial disparities in who is infected by and dying of COVID-19 is at once stunning and yet the predictable result of generations of racial health disparities coming home to roost. It is an obscene failure of humanity.
With respect to over policing and racist policing and profiling, the response hopefully will be more efforts to shift some resources, circumscribe the footprint of what police are in charge of, and fill it in with other ways that you can keep civic peace.
My experience with this idea is, for example, in how to offload the mental health emergency function from police. One thing we tried very concretely: NYC gets about 170,000, what they call, emotionally disturbed person [EDP] calls. We wanted to bypass a chunk of those calls from the police to the city’s crisis and support call center, NYCWell, which could dispatch a mobile mental health team if need be. There was a whole protocol we developed—things that would trigger whether someone would get an EMS or NYCWell response instead of a police response. We had the fire department behind it, the EMS system behind it. But it proved too much of a stretch to take root.
Another example: after a couple of incidents where NYPD shot people who had a mental illness affecting their behavior, I co-chaired a mayoral task force, and the centerpiece recommendation was a task-shifting one.
It had a lot of buy-in locally. We picked maybe five neighborhoods, and proposed to give seed and planning money in each to build a community coalition that would do crisis management response work. Anyone brought to an emergency room by a police officer for a mental health emergency, we’d have the coalition try to take over rather than the police.
We ran some data, and, most of the time, the police intervention doesn’t result in all that much. People get brought to the emergency room, they’re usually discharged, and often they get re-involved with the mental health system or the criminal justice system. The police deal with a very complex and personal problem like it is a public disturbance. But from a rehabilitative/treatment/care perspective, sending in the police isn’t the most effective intervention in a mental health crisis moment.
Also there are examples where local organizations do more of what we think of as policing. A lot of low-level charges, like disturbing the peace, that are often the flashpoints of these tragic excessive force events, a lot of those things could be managed at first pass at the ground level by people from the neighborhood.
The tools, the models, the examples are there. We showed some of them and built some of them— rethinking how we support mental health and emotional wellbeing and resilience, how we keep our social fabric the humane action-backbone we need it to be—but we didn’t sustain it. And again, it would be so priceless to have all that in place now—all that community-owned capacity and energy that got spooked out of ThriveNYC—what could have been but is not there,
So these gaps on race, and on emotional wellbeing, converge. They have to be tackled with more than small changes in policies, or police footprints, though… It’s the whole society. It’s not simply about whether you’re prejudiced, or about colorblind laws. And it’s also not about more therapist appointments. It’s about purposefully and intentionally turning a racist country into an anti-racist country. It’s about seeing people as participating problem solvers and supports for one another. And it’s about connecting those last two things.
And doing that’s only going to happen block by block, organization by organization.
* * *
This is a marathon. The virus is not going away soon. There’s not going to be an “All clear.”
It is an almost existential question: Eventually everyone’s going to be exposed to this thing. I don’t know a way around it. For me, it’s this lifelong struggle with accepting the fact that I’m going to die. I wonder how long I can continue to be afraid of getting sick because it’s probably inevitable.
We’re told that there’s going to be testing galore. Hmm. Really? Without that, eventually we have to dive into life again.
Maybe it’s going to be like 1900 when you just lived in a context of greater background infectious disease risk. Nobody locked down for tuberculosis, it was a different kind of life. It was a harder life, and people didn’t live as long. I hope that’s not where we’re heading, but we don’t know. Well, much of the world does know what living like that is like.
Are you familiar with the book, The Great Leveler? If ever you feel like you have confidence in our ability as humans to get to better equity, that book will depress you. We are a country that is always eating each other alive. Winners matter; the disparities that we just allow; it’s an unusually violent society where a commitment to our shared wellbeing is fragile.
We have in too many places been nihilistic and fatalistic about this virus, and that seems part of our lack of reckoning, our lack of truth-telling, part of the damage and violence we have borne historically but have yet to fully acknowledge, collectively mourn or repair.
This book chronicles how the only things that have started to get societies to equity across recorded history are horrible plagues, catastrophic wars, basically just great disruption and loss. Even those, however, yield only a brief window of short-lived change, and inequity eventually returns.
It exemplifies the notion of this moment, as perhaps—and I hesitate at the kind of hallmark-cardish way this can get played—but as an “opportunity.” Because, to get to a place of equity, it means shifting a lot of things that are usually in concrete, and a fair bit is shifting now.
Maybe there’s an opening here, and we will take it. But so much has to change—hence my continued drive to get the socio-emotional and the political to connect on the ground.
Because if not this pandemic, I guess the only other thing that might jolt us into getting our shit together is the climate crisis. And the pandemic is actually easier to manage—because at least we have food.
So far…
Gary’s Piece in the New England Journal of Medecine, “Leadership for the Social Climate”
Gary’s Piece on the Launch of the Billion Minds Institute
Learn More About ThriveNYC and Mental Health Resources Available From Home
Join 7 Cups as a Volunteer Listener and Help Provide Free Emotional Support to Millions