Would it surprise you to know that African Americans are, in general, faced with more chronic illness and more likely to die early? No? Well, the reasons why may surprise you. Our assumptions about race and health are intertwined, but factors related to genetics, culture and environment are currently under vigorous study by health care professionals. It’s a long twisty road, but here’s what you need to know to get started.
Admit that Racial Health Disparities Exist
The World Health Organization calls them “health injustices,” but in the United States we call them health disparities. The difference may be whether we believe as a society whether those differences are avoidable or not.
According to U.S. Census data, African Americans have shorter lives and a higher disease burden. According to CDC reports in the 1990s, simply being born black meant that you could expect to live seven years less than your white counterparts. Today, that life expectancy has increased but the gap is still more than three years.
A 2002 report from the Institute of Medicine concludes that, “Evidence of racial and ethnic disparities in healthcare is, with few exceptions, remarkably consistent across a range of illnesses and healthcare services.”
Dr. Raymond Samuel, the principal investigator of the Minority Men’s Health Initiative at Hampton University in Hampton, Virginia, says many health outcomes for African Americans are stark.
“Infant mortality for African Americans looks like a Third World country. And HIV/AIDS in the U.S. kills African Americans like a sub-Saharan African country, while for many whites it’s a chronic condition.” He’s right: the Centers for Disease Control’s 2010 report cites “16.5 percent of deaths from HIV for Black or African American men compared to 2.3 percent for white men. For women, it’s 7.5 percent and .5 percent.” Infant mortality rates are also shocking: black infants are 230 percent more likely than white infants to die before their first birthday. (For more information about infant mortality, see our website.)
Dr. John Anderson, a physician, lawyer and executive in Williamsburg, Virginia, says, “Don’t get sidetracked on process. Outcomes are what’s killing us. Cardiovascular outcomes are 29 percent higher than white, stroke 40 percent higher, diabetes twice as frequent, and (African Americans) make up 80 percent of TB cases. These are significant differences between races and communities.”
What Kills African Americans vs. What Kills Everyone Else
Life expectancy has gone up overall but there are large variations. The leading causes of death in the United States, according to the CDC are heart disease, cancer, chronic respiratory diseases, stroke, accidents, Alzheimer’s disease and diabetes, in that order. While many people of all races share these conditions, African Americans are much more likely to die from them sooner.
Health care experts compare health care in the Mississippi Delta as similar to conditions in Latin America—basically, living in Mississippi (where 38 percent of the population is black) is comparable to living in Honduras. Does this support the common refrain of the United States having “the best health care system in the world?”
Local journalist Wil LaVeist and his brother Thomas LaVeist are working on a documentary called “The Skin You’re In,” a film about African American health disparities. The movie trailer points out that African Americans “live sicker and die younger.”
C’mon…Isn’t There Another Reason? Poverty? Bad Choices? Genetics?
Thomas LaVeist, Ph.D. is a professor at Johns Hopkins University and the director of the Hopkins Center for Health Disparities Solutions, and has extensively studied some of the commonly cited alternate reasons for health disparities.
“There are disparities across all diseases, life expectancy, infections, chronic, injuries and accidents. For any manner of death, African Americans have a higher rate than anyone else. The question is, why is that?” wonders Thom LaVeist.
Isn’t it genetic? “That’s not true—there are no biological/difference between race groups to account for these disparities. None of the biggest killers (cancer, heart disease, stroke) linked to genetics. For diseases that are gene-related, very few deaths from Sickle cell anemia, Tay-Sachs disease or hemophilia,” Thom LaVeist points out.
Isn’t it poverty? The Institute of Medicine report concludes “The majority of studies, however, find that racial and ethnic disparities remain even after adjustment for socioeconomic differences and other healthcare access-related factors.” Even when taking socioeconomics into account, the differences in outcomes remain. It means that in a direct comparison of people with similar income and education, being Black tips health outcomes in a negative direction.
Isn’t it lack of insurance or access to health care? “Most of how long a person lives is not determined by health care. Environment and health behavior you engaged in, where you live, what you are exposed to,” LaVeist states.
Both Anderson and Thom LaVeist point to disparity studies in universal health care programs: such as the Veterans Administration, Medicare and Medicaid.
“If this is an access issue, then there would be no disparities in these systems,” declares Thom LaVeist.
A Neighborhood Full of Soot is Not a Healthy Neighborhood
“Your zip code has more to do with your health than your genetic code,” says Thom LaVeist.
According to the 2000 Census, African Americans are 79 percent more likely to live near an environmental health threat—particularly industrial air pollution.
“The environments that we live in are not conducive to good health incomes. For example, in Newport News, most African Americans live at the foot of the tunnel, near a highway, with a giant coal pile. It’s a stunning thing to see,” says LaVeist. Rates of asthma in southeastern Newport News are twice as high than other parts of the city, according to the Peninsula Health District.
In addition, housing that’s substandard or not well-maintained can lead to mold or rodent infestation. Beyond individual homes, the built environment of a place where people live can be healthy or unhealthy. If there are sidewalks, safe parks, working streetlights and green space, that benefits the health of the community.
Stress, Eating, Coping
“Black culture is young compared to the cultures of the world. Our main goal was ‘How do we survive this?’” LaVeist says. “Turning organ meats into soul food—it’s part of a creative and resilient culture. We learned to use what is available. But…maybe that’s not conducive to life in the 21st century. It’s increased our risk of hypertension.”
Wil LaVeist notes these historical factors were very stressful and many ways of coping are unhealthy.
“Obesity is directly tied to nutrition and mental health—food has the same stimulation of the brain as sex. You want to comfort yourself, consciously or unconsciously—this is also part of the high rates of drug addiction. People want to feel better,” Wil LaVeist explains.
Stress comes from many places, including racism, caregiving, economics and violence.
“We live in risky social environments, too. Living in a more violent area, you have more risk of being victimized. There’s the stress of knowing that, with your body constantly in flight/fight mode. These are all positive hormones to survive but are only supposed to be in your body for short-term responses. Longterm, they erode the functioning of your organs, and you get chronic diseases sooner,” LaVeist says.
A public health term coined “weathering” is the theory that Blacks experience early health deterioration because of repeated exposure and adaptation to stressors. A 2006 study in the American Journal of Public Health concluded that Blacks had higher scores that were not explained by poverty, but may be more likely the effects of living in a race-conscious society. Dr. Arlene Geronimus, who coined the term, points to the early onset of chronic disease for African-American women in particular.
Racism–it’s Not Just History
African Americans experience more race-related stress, and research documents how that affects physiological responses.
“We aren’t in a post-racial society. Don’t let anyone tell you that,” advises Anderson. “There’s residual segregation—and that affects health.”
Thom LaVeist points out that there are several types of racism, and says that interpersonal racism is the least of them.
“People talk about bigotry, where someone doesn’t like people from a group. But what’s really damaging is institutional racism: where no one person has to behave in a racist manner, but where the system is set up to create disparities. It doesn’t matter who is the mayor or governor—unless the system changes, there will be racially differential outcomes,” says LaVeist.
He goes further, to say that internalized racism is a serious concern, maybe the most alarming.
“If you are a member of a group, you may begin to believe that you deserve this. So you don’t worry about competing with others. You may be more likely to use drugs. If you don’t value yourself, you may victimize others. Or not take care of yourself or your family if you don’t love yourself. This might be the most damaging,” explains Thom LaVeist says.
We Need Better Health Education— Not Just at School
As part of the push for health, education is a big concern—particularly how communities share information about health.
“We know what’s needed, but how to disseminate it? We need to share best practices today, not tomorrow. For example, education on nutrition and exercise — what’s the best way to share that?” asks Samuel.
Prevention is a critical factor, along with factual health education—which means avoiding bad health information and “old wives tales.”
“There’s all this great information out there in academic journals but it’s not getting to people who really need to benefit from it. Like Grandma, or parents trying to find nutrition information for their child. People don’t always get the info. Media needs to disseminate it,” Wil LaVeist says.
Show Us the Money… Economics, Jobs and Insurance
Besides knowing healthy behaviors, access to health insurance in the United States has long been tied to employment—full-time employment. Health insurance reform has changed this, to a degree.
“I’m glad to see more emphasis on prevention. The Affordable Care Act has changed this. Everyone can get some insurance in order to survive in a healthy way. And previously, insurance companies wouldn’t provide prevention coverage, like vaccines, screenings, monitoring blood pressure and diabetes,” says Anderson.
Even with that access, people with private health insurance still have deductibles and copays to consider. People who have health insurance but aren’t paid a salary may have to take unpaid time off to go to doctor’s visits.
Income also provides better nutrition, housing, recreation and school options. Education adds not only the better likelihood of a solid future occupation, but also the ability to find and understand health information.
What You Do and What You Think Matters
Anderson lists a number of cultural restrictions and false beliefs: that a larger body size indicates strength, that no one wants to take shots, that people don’t like drinking water, or that avoiding medication shows that you are a tough person.
“I think that more involvement of nurses would help—they can often get closer to people than doctor and dispel some of these myths,” Anderson believes.
Health literacy, or the ability to understand health-related information, is a growing area of focus for the health care community.
“These skills are needed to manage our own health, make decisions and get information. What you see is that people who are challenged by health literacy incur medical expenses four times greater than those with adequate health literacy, including unnecessary visits to doctors and hospitals,” he says.
Open Doors…Health Care Access
Once patients are able to access the health care system by seeing their primary care doctor, going to an urgent care center or using the emergency room for professional help, there can still be communication issues.
The Institute of Medicine report lists a number of concerns, including physician’s bias, stereotyping and uncertainty, combined with patient’s mistrust and refusal to comply with the prescribed care.
“There are communication problems, and diagnosis issues. The paternalistic style continues. Patients may feel they aren’t being cared for; the physicians are under too many demands. This can short circuit the process—if he feels the patient won’t do it, he may provide less explanation of the problem,” Anderson says.
Stereotypes about African Americans include: that they are more likely to abuse drugs/alcohol, less likely to follow advice, less likely to go to rehab, less educated, decreased expectation of benefits of care, less likely to follow instructions.
In order to have a successful society that includes all Americans, health disparities will have to be addresses, or they will continue to grow.
