New York Times, September 23, 2002
THE RACIAL DIVIDE
By LINDA VILLAROSA
The most dangerous time of life for a black man in America is middle age.
After a decade of intense efforts to investigate and reduce the stark gap in life expectancy between between black and white men, researchers and health officials are broadening their focus beyond the violence, drugs and diseases like H.I.V. that claim the lives of many African-American males aged 18 to 35. They are asking not just why so many black men die young, but why so many die younger than they should — of diseases that should not be so deadly.
Death rates for black men are higher than for whites at all ages below 84, but the divide reaches its peak between 45 and 64, the years when diseases that afflict many older Americans begin to hit black men sooner and harder. Stroke and diabetes killed black men between 55 and 64 at about three times the rate for white men their age in 2000, according to the National Centers for Health Statistics, while cancer and heart disease killed black men in that group at rates 50 percent above those for their white peers.
"When you look at what is killing black men, it is diseases that are preventable or treatable with great survivability," said Dr. Claude A. Allen, deputy secretary for the federal Department of Health and Human Services.
The fact that there are well-established cures or preventive steps for these conditions gives health officials hope. But turning the thought around shows the frustrating core of the problem: if these diseases can be dealt with, why do black men continue to live an average of seven years less than white men?
The answers, experts say, lie in a tangle of medical, racial and economic factors. To Dr. Allen, the central task is improving access to health care. "These deaths are associated with not seeking out care soon enough," he said. "We should not be losing men because we have not provided access to care, treatment, information and education in a timely manner."
But recent experience indicates that doing so will not be easy. In 1990, an article in The New England Journal of Medicine focused attention on the problem when it reported that a black man living in central Harlem was less likely to reach 65 than a comparable man in Bangladesh. Though the mortality gap has narrowed slightly since then, a recent report on the health of minority men, issued by the W. K. Kellogg Foundation, concluded that "from birth, a black male on average seems fated to a life so unhealthy that a white man can only imagine it."
THE threat of premature death looms large in Woodlawn, a predominantly black neighborhood on the South Side of Chicago. The average life span for African-American men there is 58.3 years, according to the city's Department of Health.
Which is why one afternoon a week at the Woodlawn Health Center, Dr. Bonnie Thomas Jr. switches from his usual white coat and tie into jeans, a sports T-shirt, an African beaded necklace and, sometimes, a baseball cap bearing the logo of his alma mater, Xavier. Introducing himself to patients, he skips a handshake and does a "pound" instead, one fist on top of the other. During exams, he tries to drop as much of the "medical speak" as he can.
On Thursdays from 4 to 7 p.m., the clinic switches from its usual focus on women into Project Brotherhood, for men. They start to trickle in at 1 p.m., and by the time the clinic opens, the waiting area is full of men of all ages in suits, hip-hop garb and African clothing, Dr. Thomas said. While they are waiting, they listen to music, eat a meal provided by the clinic or even get a haircut.
Dr. Thomas and the project's co-director, Donald McDaniels, have made the atmosphere comfortable — and free — for a reason. "It's extremely hard to get black men into the system, so we wanted to tear down every barrier and design a place that said, I want to be there," said Dr. Thomas, who grew up on the South Side. "I don't want to be someone in a white coat who is going to talk down to them, but a guy at the corner Y.M.C.A., or someone they grew up with, which is not far from who I am anyway. But no matter how informal I can get, I'm always giving these men the standard of care they deserve; it's just packaged differently."
Distrust of the system and difficulties in communication are pervasive. A recent survey of health care quality conducted by the Commonwealth Fund found that almost twice as many blacks as whites thought their doctor "looked down on them" or treated them disrespectfully.
Many observers point to an exaggeration of a common male trait: a reluctance to go to the doctor at all. "Men, overall, have a particular set of pressures to show strength and not reveal weakness, and this feeling is intensified in black men," said Ellis Cose, a Newsweek columnist and author of "The Envy of the World: On Being a Black Man in America."
"There is an ethic of toughness among black men, built up to protect yourself against racial slights and from the likelihood that society is going to challenge you or humiliate you in some way," he said. "This makes it very hard to admit that you are in pain or need help either physical or psychological."
Dr. Jean Bonhomme, president of the National Black Men's Health Network, a nonprofit advocacy and education organization in Atlanta, calls this trait "pathological stoicism," a problem he sees even in himself.
"African-American men have had to deal with tremendous hardships and not complain, because complaining didn't help," Dr. Bonhomme said. "Now we push ourselves to distorted extremes without asking for help in order to `be a man.' It is a matter of pride to brush off pain. Several years ago, I injured my back so badly that I could hardly walk. My wife saw me drop to my knees in order to get out of a chair, and said to me, `What the hell are you doing?' I looked at myself and realized how crazy I was being."
Norman Jackson, who is 49 and and lives in Detroit, knew diabetes ran in his family, but avoided seeing a doctor because the visits made him feel "vulnerable." Even though he was often thirsty, was urinating frequently and his vision changed so much that he said he could hardly see to drive, he insisted there was nothing wrong. Finally, about two years ago, Mr. Jackson was tested for diabetes and high blood pressure at a health screening sponsored by the African American Initiative for Male Health Improvement. He found that he had both.
"My father was diabetic and I knew I should get my sugar checked out, but I didn't want to feel weak," said Mr. Jackson, who now takes medication to control both his blood sugar and blood pressure and also exercises and watches his diet. "Eventually, I realized that this is dangerous, and you can't mess around with your health. I haven't neglected myself since."
While access to treatment is one problem, there are also problems with the treatment African-American men actually receive. Last spring, the Institute of Medicine reported on a review of more than 100 studies, and the findings were startling: even when African-Americans and other minorities have the same incomes, insurance coverage and medical conditions as whites, they receive notably poorer care. Biases, prejudices and negative racial stereotypes, the panel learned, may be poisoning the reaction of doctors and other health providers.
"Some of the most esteemed scientists in the world proved that medical care is not being dished out fairly," said Dr. James W. Reed, a professor of medicine at the Morehouse School of Medicine in Atlanta and a co-author of "The Black Man's Guide to Good Health: Essential Advice for African-American Men and Their Families." "White men were referred for sophisticated procedures like cardiac catheterization three or four times more frequently than blacks with the same symptoms at a V.A. hospital, where ability to pay doesn't matter.
"Is it overt racism? I don't know," Dr. Reed continued. "Maybe it's more subtle, like physicians don't think blacks will adhere to therapy. But in the final analysis, whatever the definition, it is still discrimination based solely on skin color."
PERHAPS the most puzzling part of the equation has to do with high blood pressure, a major contributor to heart disease, stroke and many other diseases. It strikes one-third of all black men, and is twice as deadly for blacks as it is for whites. Interestingly, West Africans, from whom most American blacks are descended, have low rates of hypertension. Some experts suggest that stress and societal racial discrimination that black men (and women) suffer in this country play a major role. During a stressful incident, the body produces adrenaline and the heart rate and blood pressure increase. Experts speculate that constant engaging of a fight-or-flight mechanism by racial insults can contribute to chronically elevated blood pressure.
Public and private institutions are pushing to close the racial gap in health disparities. The bulk of programs and projects for African-Americans, however, are aimed at women. A survey of state health departments by Dr. Ronald L. Braithwaite, the director of the Center for Research on Health Disparities at Emory University, found that few were specifically for African-American men's health.
For instance, Racial and Ethnic Approaches to Community Health 2010, an initiative of the federal Centers for Disease Control, was created to finance community coalitions with the goal of eliminating racial and ethnic disparities in health over the next decade. But the majority of its 42 programs are either not gender-specific or are aimed at African-American women and children. "The communities were allowed to choose health priority areas, and none said just African-American men," said Dr. Imani Ma'at, director of the program. "Women are the ones who are involved in the health care system, present at schools and in churches, so they are an easier group to reach out to and communicate with."
STILL, there are some programs to specifically improve the health of black men. In addition to the screening program Mr. Jackson saw in Detroit and Project Brotherhood, the African-American Male Empowerment Network offers support groups and a 10-week health promotion and disease prevention course to men in the Atlanta area. The Young Men's Clinic, a joint project of Columbia University's Mailman School of Public Health and New York Presbyterian Hospital, provides free medical care to mainly black and Hispanic patients.
"Traditional approaches often don't work with black men," said Dr. Braithwaite, who is a co-editor of the book "Health Issues in the Black Community." "There is an increasing recognition that we have to go to the pockets of critical mass. That means going to where men convene."
The Detroit project sends a medical van into black communities and has screened nearly 8,000 men over the last few years. On Sept. 7, about 2,000 people, mostly black men, attended the first annual Health Initiative for Men, a prostate cancer walk and health summit in Atlanta.
Finally, many African-American men have simply decided to beat the odds and take responsibility for their health. Nathaniel Plowden, a supervisor for U.P.S. in Atlanta, became strict about scheduling annual physicals when his father received a diagnosis with advanced prostate cancer 16 years ago. Thanks to his vigilance, his prostate cancer was caught early, and he considers himself recovered. He and other family members are now part of a clinical trial looking for hereditary causes of prostate cancer in black men.
"My father took care of himself, but he never went to the doctor," said Mr. Plowden, who is 54. "He was in severe pain by the time he saw someone and by then we found out his cancer was very advanced. What happened to him spurred me into continuing to go to the doctor. The notion of being dumb and happy never motivated me. I want to know what's going on so I can deal with it."