- Email: [email protected]
Health Disparities in African American Males
Prim Care Clin Office Pract 33 (2006) 35–43
Health Disparities in African American Males Deborah K. Witt, MD Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, 833 Chestnut Street, Suite 301, Philadelphia, PA 19107, USA
American demographics are changing. It is projected that a dramatic racial and ethnic shift will occur by 2050, as the US population continues to age and become more ethnically diverse [1,2]. The 2000 census reports that 36.4 million Americans, or 12.9% of the population, identified themselves as black or African American [3]. Projections for 2050 indicate that minority groups will account for nearly 50% of the population. In light of these changing demographics, the health of minorities and its impact on the overall health of the nation will become one of the major issues facing health care professionals during the next decade. Unequal Treatment, a report from the Institute of Medicine, indicates that minority Americans have disproportionately poorer outcomes than the majority population for preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV [4]. There is a well-documented theme that runs through much of the literature; African Americans, and other minorities, bear a disproportionate burden of disease, injury, premature death, and disability [2,4]. A major goal of Healthy People 2010 is to work to eliminate the nation’s significant health disparities. According to that document, health disparities lead to: (1) lower life expectancy, (2) decreased quality of life, (3) loss of economic opportunities, (4) perceptions of injustice, (5) overall decreased productivity, (5) increased health-care costs, and (6) social inequality. Racial and Ethnic Approaches to Community Health (REACH) 2010, a program launched in 1999 by the Centers for Disease Control and Prevention (CDC), was developed to support community coalitions in designing, implementing, and evaluating community-driven strategies to eliminate health disparities in six priority areas, recognizing that it is impossible to achieve a healthy nation without eliminating racial and ethnic health E-mail address: [email protected] 0095-4543/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.pop.2005.11.010 primarycare.theclinics.com
36
WITT
disparities [5]. In 2001, as part of the REACH 2010 project, risk factor surveys were conducted in specific minority communities. Of the 21 communities surveyed, it was found that there were substantial variations in the prevalence of risk factors, chronic conditions, and use of preventive services, even among communities with the same racial and ethnic backgrounds. These demonstrated variations indicate the need to tailor awareness, education, and prioritize the needs of specific communities [5]. This article focuses specifically on health disparities among African American men, a community in itself. It will offer insight into the historic and socioeconomic factors upon which their health care paradigms are based, and discuss the link between their perceptions and the gap in health disparities that they experience. The article reviews the literature on African American men’s health and describes the importance of continual attention to this issue. Eliminating health disparities among African American men will help play a critical part in eliminating overall health disparities in minority populations. Identifying and addressing the problems also will help clinicians, researchers, policy makers, and institutions formulate effective solutions for the future. The African American community is divided on its preference of terminology when describing this ethnic group. Some prefer the term AfroAmerican, black or African American. The term African American will be used in this article to designate this ethnic group. Society and African American men Often referred to as the forgotten population, overlooked, underserved, African American men continue to struggle against oppression and discrimination that result in reduced opportunities with regards to employment, housing, education, and health care. This leads to greater barriers to care, poorer quality care, and poorer health outcomes [6]. African American men die prematurely and at a higher rate than the general population. The life expectancy preliminary data for 2003 for African American men is 6.2 years less than for Caucasian men [7]. Columbia University investigators reported that African American men in Harlem had a shorter life expectancy than men in Bangladesh. The authors also concluded that ‘‘Harlem and probably other inner-city areas with largely black populations have extremely high mortality rates that justify special consideration analogous to that given to natural disaster areas’’ [8]. The premature death of African American men has far-reaching negative implications for the future of families and communities because of the integral role they play. There are numerous specific issues that complicate the response of African American men to health-seeking behaviors. Although some of these concerns affect all men, there are important factors unique to African American men.
HEALTH DISPARITIES AMONG AFRICAN AMERICAN MEN
37
Perspective of a real man African American men often are raised to view a typical man’s behavior as emotionally strong with the ability to withstand a high tolerance of physical and emotional pain. This ultimately influences how African American men will access health care, as early access of the health care system might be seen as displaying weakness or failure [9]. Social conditioning Statements such as, ‘‘strong men don’t get sick’’ and ‘‘if it isn’t broke, don’t fix it’’ become part of the language of African American men, and such sentiments are used to avoid visits to the doctor. These social pressures to be fearless are ingrained deeply and can lead to stoic attitudes toward pain, lack of or desire to familiarize themselves with the health care systems, and delay in seeking health care [8]. These factors can contribute to making African American men an especially difficult group to engage in preventive health care. Mistrust and suspicion of the health system The abuses of the Tuskegee Syphilis Study are well known in the African American community. The US Public Health Service conducted the Tuskegee Syphilis Study from 1932 to 1972. It was discovered that during this study, appropriate treatment was withheld from a group of male African American sharecroppers who had syphilis. Extensive awareness of Tuskegee is one factor that exacerbates mistrust and deters African American men from engaging in health-related activities. There exists compelling historical evidence, however, that the mistrust predated public revelations about the Tuskegee study, and may further explain the deeply entrenched and complex attitudes within the African American community [10]. Historical examples of African Americans being used as unwilling subjects for experimentation have been passed from generation to generation and continue to foster mistrust between health care providers and patients. Confronting the past acknowledges the inappropriate past behavior, attempts to understand the origin of conspiracy beliefs in the context of historical discrimination, and begins the dialog toward educating communities about controlling the future. Longstanding suspicion of the health care system has even led to doubts to the origins of HIV, doubts about the effectiveness of treatment with antiAIDS therapies, and decreased rates of flu and pneumonia vaccination among eligible African Americans [10,11]. Differences in communication style also may contribute to suspicions and mistrust. There can be a misalignment or a disconnection between the health care provider and the patient because of jargon, cultural differences, or prejudices. African American men have noted that providers talk down to them,
38
WITT
do not take them seriously, and do not entertain equal dialogue. Providing culturally sensitive health care providers and specially trained community lay workers to reach community leaders and assist with health communication campaigns could help create an important link between African American men and the health system. Financial pressures African American men are less likely to have health insurance, to have seen a physician, or to have had a physical exam in the past year than Caucasian men [12]. Many African American men are employed at entry-level or part-time positions ineligible for employment-based insurance. Additionally, employment-related insurance is on the decline even for industries that traditionally provided coverage. As the head of the household, the traditional role of the African American man was to provide for the entire family and even the extended family. It was believed that once he was able to get a job, he was not encouraged to take off of work to go to the doctor, because the employer would foresee an illness or weakness that possibly could compromise the organization. Use of home remedies The use of home remedies as the first choice for African American men often has been an alternative to mainstream medical care because of lack of access and trust of the mainstream medical system. Lifestyle factors Substance abuse (alcohol, tobacco, or drugs) contributes to overall health and complicates many illnesses, leading to poor outcomes, particularly with African American men. Either embarrassed by their past experiences or unable to cope with the challenges of addiction, African American men may be hesitant to confide in the health system, as they chance disrespect and rejection. Other lifestyle factors such as exercise and eating a healthy diet become a low priority, as other life issues can be overwhelming. Because women often view themselves as overseers of their families’ health needs, increasing their interest in men’s health issues will encourage the men in their lives (husbands, brothers, uncles, and sons) to seek medical attention and adhere to recommendations [29].
The contribution of specific health conditions Cardiovascular disease and stroke Heart disease is the leading cause of death and disability among all Americans; however, African American men experience earlier onset of disease, more severe disease, higher rates of complications, and more limited access
HEALTH DISPARITIES AMONG AFRICAN AMERICAN MEN
39
to medical care than Caucasian men or African American women [13]. Deaths that occur from cardiovascular disease before the age of 65 are considered premature, preventable deaths and adversely affect African American men. According to a 2005 report from the American Heart Association, 2002 data indicate the overall preliminary death rate from cardiovascular disease was 320.5 deaths per 100,000 population. The death rates were 373.8 for Caucasian males and 492.5 for African American males, and 265.6 for Caucasian females and 368.1 for African American females [14]. Hypertensive heart disease, the most common cause of cardiovascular disease complications and death among African American men, occurs more often, begins at an earlier age, and is usually more severe, resulting in greater target organ damage [14]. The end-organ manifestations of hypertension include higher rates of stroke, significantly increased rates of renal disease and end-stage renal disease requiring dialysis, higher risk of left ventricular hypertrophy, and an associated higher rate of heart failure. Cancer Cancer is the second-leading cause of death in both blacks and whites; however, cancer incidence and deaths are substantially higher for African Americans. In addition to the disproportionate rates of incidence and mortality among many racial and ethnic groups, there are cancer disparities that exist among various geographic locations [15]. Lung cancer According to the American Cancer Society, lung cancer accounts for the greatest number of cancer deaths among African American men, at 28.4%. The average incidence of cancer of the lung is 54% higher in African American men than in white men. The death rate is 36% higher than that of Caucasians [16]. In 2002, 5.2 million African Americans were smokers, with a smoking prevalence of 27%, compared with 25.2 percent for white men. Prostate cancer African American men have the highest incidence of and mortality rate from prostate cancer in the world [17]. The death rate from prostate cancer is 2.4 times higher in African American men than in white men. The annualized average incidence rates per 100,000 population for the period 1992 to 1999 were 275, 172, and 128 for African Americans, Caucasians, and Hispanics, respectively [18]. African American men have higher serum prostate-specific antigen levels, worse Gleason scores, and more advanced stage of disease at diagnosis than Caucasian men, although the reasons for these discrepancy are unclear [19,20]. In the population-based Prostate Cancer Outcomes Study, the increased risk of advanced stage disease persisted in African American men, even after adjustment for socioeconomic, clinical, and pathologic variables [21]. On the other hand, in a later report
40
WITT
from the study with Powel and colleagues, African American men aged 60 and older (but not other age groups) with clinically localized prostate cancer received aggressive treatment significantly less often than either Caucasian or Hispanic men [22]. The reasons for these differences in care received are not completely known. As mentioned previously, geographic variations exist, and the highest prostate cancer incidence rate and highest prostate cancer death rate occurred among men in the District of Columbia [23]. Colorectal cancer Colorectal cancer is the third most common cancer and third leading cause of cancer deaths in African American men, accounting for 9.4% of cancers and 10.1% of cancer deaths. In 1996, the colorectal cancer death rate was 22.5 deaths per 100,000 population for African Americans compared with 16.4 deaths per 100,000 population for Caucasian men [16]. Varying rates of colorectal cancer risk factors, which include a personal or family history of colorectal cancer, a history of colorectal polyps, lack of regular physical activity, low fruit and vegetable intake, a low-fiber and high-fat diet, obesity, alcohol consumption, and tobacco use, contribute to these disparate numbers. Kentucky has the highest incidence rate of colorectal cancer for men [23]. Clinical trials participation Increased participation of minority men and women in cancer clinical trials may lead to a reduction in cancer mortality. As previously mentioned, the impact of the Tuskegee Syphilis Study and other similar past experiences has been a deterrent to participation by African Americans in clinical trials [24,25]. With proper education regarding the importance of clinical trials participation, however, it was found that when African American men were provided with information on the opportunities for participation in research studies, they were more receptive to participation [26].
Diabetes The prevalence of diabetes in the United States is 18.2 million (6.3% of population), including 13.0 million who have been diagnosed and 5.2 million who have not been diagnosed. By comparison, 2.7 million African Americans, or 11.4%, are estimated to have diabetes, a rate 1.6 times that of the population as a whole.
HIV The proportional distributions of HIV diagnosis have changed among racial and ethnic groups since the beginning of the epidemic. HIV is the
HEALTH DISPARITIES AMONG AFRICAN AMERICAN MEN
41
leading cause of death for African American men between the ages of 25 and 44. At the same time as there has been a decline in incidence among non-Hispanic whites, in 2003 African American men had the highest rate of HIV diagnoses of any racial and ethnic population, approximately seven times the rate seen among Caucasian men and twice the rate seen among African American women [27]. Although non-Hispanic blacks constituted 13% of the population of the 32 states keeping HIV statistics by race, nonHispanic blacks account for 49% of Americans with HIV [28]. Mental health A critical area of concern is the mental health of African American men. In the African American community, mental health issues often are underdiagnosed and undertreated. The stigma associated with mental illness has kept African American men hesitant to confide in the health care system [30]. In addition, many who desire assistance are unable to afford care, as they lack sufficient health coverage. The lack of available appropriate mental health services is especially severe in the criminal justice system. In many cases, jails become a poor substitute for mental health treatment [9,31]. Mental health is a sensitive subject that carries a stigma in the African American community and warrants health care professionals skilled at handling the challenges of diagnosing and treating psychiatric illness among African American men. Summary The demographic changes that are anticipated over the next decade magnify the importance of addressing disparities in health status. African American men currently have a life expectancy 6.3 years less than that of the average American man. There is a growing awareness of this challenge. Health care providers are partnering with social service and community health organizations to conduct research and developed creative interventions to close the gap. A greater response, however, is necessary to span the chasm. Particular efforts must be made to assist minority populations with regaining trust and respect in the health care arena. Health care providers must address their patients’ fears by describing the need, process, and possible outcomes of recommended treatment. This information will help to dispel myths and alleviate fears and suspicions. Efforts must be made toward effective recruiting of African American men to participate in clinical trials. Efforts must be made to implement creative, effective interventions specific to the community to increase screening and modify risk behaviors common among African American men. The future health of America as a whole will be influenced substantially by improving the health of minority groups. Failure to address these specific
42
WITT
health needs of African American men will lead to an ever-widening gap of quality care.
References [1] Centers for Disease Control and Prevention. Health disparities experienced by racial/ethnic minority populations. MMWR Morb Mortal Wkly Rep 2004;53(33):755. [2] Centers for Disease Control and Prevention. Health disparities experienced by black or African Americans. MMWR Morb Mortal Wkly Rep 2005;54(01):1–3. [3] McKinnon J. The black population 2000. Census 2000 brief. Available at: http://www. census.gov/prod/2001pubs/c2kbr01-5.pdf. Accessed March 5, 2005. [4] Smedley BD, Stith AY, Nelson AR. Unequal treatment: confronting racial and ethnic disparities in health care. Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington (DC): Institute of Medicine; 2003. [5] Centers for Disease Control and Prevention. Reach 2010 surveillance for health status in minority communitiesdUnited States, 2001–2002. MMWR Morb Mortal Wkly Rep August 27, 2004;53(SS06):1–36. [6] Satcher D. Overlooked and underserved: improving the health of men of color. Am J Public Health 2003;93(5):707–9. [7] Hoyert DL, Kung HC, Smith BL. Deaths: preliminary data for 2003. Natl Vital Stat Rep 2005;53(15):3. [8] McCord C, Freeman HP. Excess mortality in Harlem. N Engl J Med 1990;322(3):173–7. [9] Rich JA, Ro M. A poor man’s plight: uncovering the disparity in men’s health. Community voices. Battle Creek (MI): W.K. Kellogg Foundation; 2002. [10] Gamble V. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health 1997;87:1773–8. [11] Guinan M. Black communities’ belief in ‘‘AIDS as genocide’’: a barrier to overcome for HIV prevention. Ann Epidemiol 1993;3(2):193–5. [12] Sandman D, Simantov E, An C. Out of touch: American Men and the health care system. New York: The Commonwealth Fund; 2000. [13] Barnett E, Casper ML, Halverson JA. Men and heart disease: an atlas of racial and ethnic disparities in mortality. Atlanta (GA): Office of Social Environment and Health Research, West Virginia University, and Centers for Disease Control and Prevention; 2001. [14] American Heart Association. 2002 Heart disease and stroke statistical update. Dallas (TX): American Heart Association; 2005. [15] US Cancer Statistics Working Group. United States cancer statistics: 1999–2001 incidence and mortality web-based report version. Atlanta(GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute, 2004. Available at: http://www.cdc.gov/cancer/minorityawareness. Accessed February 13, 2005. [16] American Cancer Society. Cancer facts & figures for African Americans 2005–2006. Atlanta (GA): American Cancer Society; 2005. [17] Division of Cancer Prevention and Control. Prostrate cancer: the public health perspective. Available at: http://www.cdcgov/cancer/prostate/prospdf/Prostate-FS2002.pdf. Accessed March 5, 2005. [18] Ries LA, Eisner MP, Kosary CL, et al, eds. SEER cancer statistics review, 1973–1999. Available at: http://seer.cancer.gov/csr/1973_1999/, 2002. Accessed May 29, 2005. [19] Powell IJ, Banerjee M, Sakr W, et al. Should African American men be tested for prostate carcinoma at an earlier age than Caucasian men? Cancer 1999;85:472–7. [20] Cross CK, Shultz D, Malkowicz SB, et al. Impact of race on prostate-specific antigen outcome after radical prostatectomy for clinically localized adenocarcinoma of the prostate. J Clin Oncol 2002;20:2863–8.
HEALTH DISPARITIES AMONG AFRICAN AMERICAN MEN
43
[21] Hoffman RM, Gilliland FD, Eley JW, et al. Racial and ethnic differences in advancedstage prostate cancer: the Prostate Cancer Outcomes Study. J Natl Cancer Inst 2001; 93:388. [22] Harlan LC, Potosky A, Gilliland FD, et al. Factors associated with initial therapy for clinically localized prostate cancer: Prostate Cancer Outcomes Study. J Natl Cancer Inst 2001; 93:1864. [23] US Cancer Statistics Working Group. United States cancer statistics: 1999–2001 incidence and mortality web-based report version. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2004. [24] Corbie-Smith GM. Minority recruitment and participation in health research. N C Med J 2004;65(6):385–7. [25] Gamble V. A legacy of distrust: African Americans and medical research. Am J Prev Med 1993;9(Suppl 6):35–8. [26] Underwood SM. African American men. Perceptual determinants of early cancer detection and cancer risk reduction. Cancer Nurs 1991;14(6):281–8. [27] Centers for Disease Control and Prevention. HIV/AIDS surveillance report. Available at: http://www.cdc.gov/hiv/stats/hasrlink.htm. Accessed May 29, 2005. [28] Centers for Disease Control and Prevention. Diagnoses of HIV/AIDSd32 states, 2000– 2003. MMWR Morb Mortal Wkly Rep 2004;53(47):1106–10. [29] Norcross WA, Ramirez C, Palinkas LA. The influence of women on the health care-seeking behavior of men. J Fam Pract 1996;43:475–80. [30] US Dept of Health and Human Services. Mental health: a report of the surgeon general. Rockville (MD): National Institutes of Mental Health; 1999. [31] W.K. Kellogg Foundation. What about men? Exploring the inequities in minority men’s health. Available at: http://www.wkkf.org. Accessed March 5, 2005.
Health Disparities in African American Males Deborah K. Witt, MD Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, 833 Chestnut Street, Suite 301, Philadelphia, PA 19107, USA
American demographics are changing. It is projected that a dramatic racial and ethnic shift will occur by 2050, as the US population continues to age and become more ethnically diverse [1,2]. The 2000 census reports that 36.4 million Americans, or 12.9% of the population, identified themselves as black or African American [3]. Projections for 2050 indicate that minority groups will account for nearly 50% of the population. In light of these changing demographics, the health of minorities and its impact on the overall health of the nation will become one of the major issues facing health care professionals during the next decade. Unequal Treatment, a report from the Institute of Medicine, indicates that minority Americans have disproportionately poorer outcomes than the majority population for preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV [4]. There is a well-documented theme that runs through much of the literature; African Americans, and other minorities, bear a disproportionate burden of disease, injury, premature death, and disability [2,4]. A major goal of Healthy People 2010 is to work to eliminate the nation’s significant health disparities. According to that document, health disparities lead to: (1) lower life expectancy, (2) decreased quality of life, (3) loss of economic opportunities, (4) perceptions of injustice, (5) overall decreased productivity, (5) increased health-care costs, and (6) social inequality. Racial and Ethnic Approaches to Community Health (REACH) 2010, a program launched in 1999 by the Centers for Disease Control and Prevention (CDC), was developed to support community coalitions in designing, implementing, and evaluating community-driven strategies to eliminate health disparities in six priority areas, recognizing that it is impossible to achieve a healthy nation without eliminating racial and ethnic health E-mail address: [email protected] 0095-4543/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.pop.2005.11.010 primarycare.theclinics.com
36
WITT
disparities [5]. In 2001, as part of the REACH 2010 project, risk factor surveys were conducted in specific minority communities. Of the 21 communities surveyed, it was found that there were substantial variations in the prevalence of risk factors, chronic conditions, and use of preventive services, even among communities with the same racial and ethnic backgrounds. These demonstrated variations indicate the need to tailor awareness, education, and prioritize the needs of specific communities [5]. This article focuses specifically on health disparities among African American men, a community in itself. It will offer insight into the historic and socioeconomic factors upon which their health care paradigms are based, and discuss the link between their perceptions and the gap in health disparities that they experience. The article reviews the literature on African American men’s health and describes the importance of continual attention to this issue. Eliminating health disparities among African American men will help play a critical part in eliminating overall health disparities in minority populations. Identifying and addressing the problems also will help clinicians, researchers, policy makers, and institutions formulate effective solutions for the future. The African American community is divided on its preference of terminology when describing this ethnic group. Some prefer the term AfroAmerican, black or African American. The term African American will be used in this article to designate this ethnic group. Society and African American men Often referred to as the forgotten population, overlooked, underserved, African American men continue to struggle against oppression and discrimination that result in reduced opportunities with regards to employment, housing, education, and health care. This leads to greater barriers to care, poorer quality care, and poorer health outcomes [6]. African American men die prematurely and at a higher rate than the general population. The life expectancy preliminary data for 2003 for African American men is 6.2 years less than for Caucasian men [7]. Columbia University investigators reported that African American men in Harlem had a shorter life expectancy than men in Bangladesh. The authors also concluded that ‘‘Harlem and probably other inner-city areas with largely black populations have extremely high mortality rates that justify special consideration analogous to that given to natural disaster areas’’ [8]. The premature death of African American men has far-reaching negative implications for the future of families and communities because of the integral role they play. There are numerous specific issues that complicate the response of African American men to health-seeking behaviors. Although some of these concerns affect all men, there are important factors unique to African American men.
HEALTH DISPARITIES AMONG AFRICAN AMERICAN MEN
37
Perspective of a real man African American men often are raised to view a typical man’s behavior as emotionally strong with the ability to withstand a high tolerance of physical and emotional pain. This ultimately influences how African American men will access health care, as early access of the health care system might be seen as displaying weakness or failure [9]. Social conditioning Statements such as, ‘‘strong men don’t get sick’’ and ‘‘if it isn’t broke, don’t fix it’’ become part of the language of African American men, and such sentiments are used to avoid visits to the doctor. These social pressures to be fearless are ingrained deeply and can lead to stoic attitudes toward pain, lack of or desire to familiarize themselves with the health care systems, and delay in seeking health care [8]. These factors can contribute to making African American men an especially difficult group to engage in preventive health care. Mistrust and suspicion of the health system The abuses of the Tuskegee Syphilis Study are well known in the African American community. The US Public Health Service conducted the Tuskegee Syphilis Study from 1932 to 1972. It was discovered that during this study, appropriate treatment was withheld from a group of male African American sharecroppers who had syphilis. Extensive awareness of Tuskegee is one factor that exacerbates mistrust and deters African American men from engaging in health-related activities. There exists compelling historical evidence, however, that the mistrust predated public revelations about the Tuskegee study, and may further explain the deeply entrenched and complex attitudes within the African American community [10]. Historical examples of African Americans being used as unwilling subjects for experimentation have been passed from generation to generation and continue to foster mistrust between health care providers and patients. Confronting the past acknowledges the inappropriate past behavior, attempts to understand the origin of conspiracy beliefs in the context of historical discrimination, and begins the dialog toward educating communities about controlling the future. Longstanding suspicion of the health care system has even led to doubts to the origins of HIV, doubts about the effectiveness of treatment with antiAIDS therapies, and decreased rates of flu and pneumonia vaccination among eligible African Americans [10,11]. Differences in communication style also may contribute to suspicions and mistrust. There can be a misalignment or a disconnection between the health care provider and the patient because of jargon, cultural differences, or prejudices. African American men have noted that providers talk down to them,
38
WITT
do not take them seriously, and do not entertain equal dialogue. Providing culturally sensitive health care providers and specially trained community lay workers to reach community leaders and assist with health communication campaigns could help create an important link between African American men and the health system. Financial pressures African American men are less likely to have health insurance, to have seen a physician, or to have had a physical exam in the past year than Caucasian men [12]. Many African American men are employed at entry-level or part-time positions ineligible for employment-based insurance. Additionally, employment-related insurance is on the decline even for industries that traditionally provided coverage. As the head of the household, the traditional role of the African American man was to provide for the entire family and even the extended family. It was believed that once he was able to get a job, he was not encouraged to take off of work to go to the doctor, because the employer would foresee an illness or weakness that possibly could compromise the organization. Use of home remedies The use of home remedies as the first choice for African American men often has been an alternative to mainstream medical care because of lack of access and trust of the mainstream medical system. Lifestyle factors Substance abuse (alcohol, tobacco, or drugs) contributes to overall health and complicates many illnesses, leading to poor outcomes, particularly with African American men. Either embarrassed by their past experiences or unable to cope with the challenges of addiction, African American men may be hesitant to confide in the health system, as they chance disrespect and rejection. Other lifestyle factors such as exercise and eating a healthy diet become a low priority, as other life issues can be overwhelming. Because women often view themselves as overseers of their families’ health needs, increasing their interest in men’s health issues will encourage the men in their lives (husbands, brothers, uncles, and sons) to seek medical attention and adhere to recommendations [29].
The contribution of specific health conditions Cardiovascular disease and stroke Heart disease is the leading cause of death and disability among all Americans; however, African American men experience earlier onset of disease, more severe disease, higher rates of complications, and more limited access
HEALTH DISPARITIES AMONG AFRICAN AMERICAN MEN
39
to medical care than Caucasian men or African American women [13]. Deaths that occur from cardiovascular disease before the age of 65 are considered premature, preventable deaths and adversely affect African American men. According to a 2005 report from the American Heart Association, 2002 data indicate the overall preliminary death rate from cardiovascular disease was 320.5 deaths per 100,000 population. The death rates were 373.8 for Caucasian males and 492.5 for African American males, and 265.6 for Caucasian females and 368.1 for African American females [14]. Hypertensive heart disease, the most common cause of cardiovascular disease complications and death among African American men, occurs more often, begins at an earlier age, and is usually more severe, resulting in greater target organ damage [14]. The end-organ manifestations of hypertension include higher rates of stroke, significantly increased rates of renal disease and end-stage renal disease requiring dialysis, higher risk of left ventricular hypertrophy, and an associated higher rate of heart failure. Cancer Cancer is the second-leading cause of death in both blacks and whites; however, cancer incidence and deaths are substantially higher for African Americans. In addition to the disproportionate rates of incidence and mortality among many racial and ethnic groups, there are cancer disparities that exist among various geographic locations [15]. Lung cancer According to the American Cancer Society, lung cancer accounts for the greatest number of cancer deaths among African American men, at 28.4%. The average incidence of cancer of the lung is 54% higher in African American men than in white men. The death rate is 36% higher than that of Caucasians [16]. In 2002, 5.2 million African Americans were smokers, with a smoking prevalence of 27%, compared with 25.2 percent for white men. Prostate cancer African American men have the highest incidence of and mortality rate from prostate cancer in the world [17]. The death rate from prostate cancer is 2.4 times higher in African American men than in white men. The annualized average incidence rates per 100,000 population for the period 1992 to 1999 were 275, 172, and 128 for African Americans, Caucasians, and Hispanics, respectively [18]. African American men have higher serum prostate-specific antigen levels, worse Gleason scores, and more advanced stage of disease at diagnosis than Caucasian men, although the reasons for these discrepancy are unclear [19,20]. In the population-based Prostate Cancer Outcomes Study, the increased risk of advanced stage disease persisted in African American men, even after adjustment for socioeconomic, clinical, and pathologic variables [21]. On the other hand, in a later report
40
WITT
from the study with Powel and colleagues, African American men aged 60 and older (but not other age groups) with clinically localized prostate cancer received aggressive treatment significantly less often than either Caucasian or Hispanic men [22]. The reasons for these differences in care received are not completely known. As mentioned previously, geographic variations exist, and the highest prostate cancer incidence rate and highest prostate cancer death rate occurred among men in the District of Columbia [23]. Colorectal cancer Colorectal cancer is the third most common cancer and third leading cause of cancer deaths in African American men, accounting for 9.4% of cancers and 10.1% of cancer deaths. In 1996, the colorectal cancer death rate was 22.5 deaths per 100,000 population for African Americans compared with 16.4 deaths per 100,000 population for Caucasian men [16]. Varying rates of colorectal cancer risk factors, which include a personal or family history of colorectal cancer, a history of colorectal polyps, lack of regular physical activity, low fruit and vegetable intake, a low-fiber and high-fat diet, obesity, alcohol consumption, and tobacco use, contribute to these disparate numbers. Kentucky has the highest incidence rate of colorectal cancer for men [23]. Clinical trials participation Increased participation of minority men and women in cancer clinical trials may lead to a reduction in cancer mortality. As previously mentioned, the impact of the Tuskegee Syphilis Study and other similar past experiences has been a deterrent to participation by African Americans in clinical trials [24,25]. With proper education regarding the importance of clinical trials participation, however, it was found that when African American men were provided with information on the opportunities for participation in research studies, they were more receptive to participation [26].
Diabetes The prevalence of diabetes in the United States is 18.2 million (6.3% of population), including 13.0 million who have been diagnosed and 5.2 million who have not been diagnosed. By comparison, 2.7 million African Americans, or 11.4%, are estimated to have diabetes, a rate 1.6 times that of the population as a whole.
HIV The proportional distributions of HIV diagnosis have changed among racial and ethnic groups since the beginning of the epidemic. HIV is the
HEALTH DISPARITIES AMONG AFRICAN AMERICAN MEN
41
leading cause of death for African American men between the ages of 25 and 44. At the same time as there has been a decline in incidence among non-Hispanic whites, in 2003 African American men had the highest rate of HIV diagnoses of any racial and ethnic population, approximately seven times the rate seen among Caucasian men and twice the rate seen among African American women [27]. Although non-Hispanic blacks constituted 13% of the population of the 32 states keeping HIV statistics by race, nonHispanic blacks account for 49% of Americans with HIV [28]. Mental health A critical area of concern is the mental health of African American men. In the African American community, mental health issues often are underdiagnosed and undertreated. The stigma associated with mental illness has kept African American men hesitant to confide in the health care system [30]. In addition, many who desire assistance are unable to afford care, as they lack sufficient health coverage. The lack of available appropriate mental health services is especially severe in the criminal justice system. In many cases, jails become a poor substitute for mental health treatment [9,31]. Mental health is a sensitive subject that carries a stigma in the African American community and warrants health care professionals skilled at handling the challenges of diagnosing and treating psychiatric illness among African American men. Summary The demographic changes that are anticipated over the next decade magnify the importance of addressing disparities in health status. African American men currently have a life expectancy 6.3 years less than that of the average American man. There is a growing awareness of this challenge. Health care providers are partnering with social service and community health organizations to conduct research and developed creative interventions to close the gap. A greater response, however, is necessary to span the chasm. Particular efforts must be made to assist minority populations with regaining trust and respect in the health care arena. Health care providers must address their patients’ fears by describing the need, process, and possible outcomes of recommended treatment. This information will help to dispel myths and alleviate fears and suspicions. Efforts must be made toward effective recruiting of African American men to participate in clinical trials. Efforts must be made to implement creative, effective interventions specific to the community to increase screening and modify risk behaviors common among African American men. The future health of America as a whole will be influenced substantially by improving the health of minority groups. Failure to address these specific
42
WITT
health needs of African American men will lead to an ever-widening gap of quality care.
References [1] Centers for Disease Control and Prevention. Health disparities experienced by racial/ethnic minority populations. MMWR Morb Mortal Wkly Rep 2004;53(33):755. [2] Centers for Disease Control and Prevention. Health disparities experienced by black or African Americans. MMWR Morb Mortal Wkly Rep 2005;54(01):1–3. [3] McKinnon J. The black population 2000. Census 2000 brief. Available at: http://www. census.gov/prod/2001pubs/c2kbr01-5.pdf. Accessed March 5, 2005. [4] Smedley BD, Stith AY, Nelson AR. Unequal treatment: confronting racial and ethnic disparities in health care. Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington (DC): Institute of Medicine; 2003. [5] Centers for Disease Control and Prevention. Reach 2010 surveillance for health status in minority communitiesdUnited States, 2001–2002. MMWR Morb Mortal Wkly Rep August 27, 2004;53(SS06):1–36. [6] Satcher D. Overlooked and underserved: improving the health of men of color. Am J Public Health 2003;93(5):707–9. [7] Hoyert DL, Kung HC, Smith BL. Deaths: preliminary data for 2003. Natl Vital Stat Rep 2005;53(15):3. [8] McCord C, Freeman HP. Excess mortality in Harlem. N Engl J Med 1990;322(3):173–7. [9] Rich JA, Ro M. A poor man’s plight: uncovering the disparity in men’s health. Community voices. Battle Creek (MI): W.K. Kellogg Foundation; 2002. [10] Gamble V. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health 1997;87:1773–8. [11] Guinan M. Black communities’ belief in ‘‘AIDS as genocide’’: a barrier to overcome for HIV prevention. Ann Epidemiol 1993;3(2):193–5. [12] Sandman D, Simantov E, An C. Out of touch: American Men and the health care system. New York: The Commonwealth Fund; 2000. [13] Barnett E, Casper ML, Halverson JA. Men and heart disease: an atlas of racial and ethnic disparities in mortality. Atlanta (GA): Office of Social Environment and Health Research, West Virginia University, and Centers for Disease Control and Prevention; 2001. [14] American Heart Association. 2002 Heart disease and stroke statistical update. Dallas (TX): American Heart Association; 2005. [15] US Cancer Statistics Working Group. United States cancer statistics: 1999–2001 incidence and mortality web-based report version. Atlanta(GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute, 2004. Available at: http://www.cdc.gov/cancer/minorityawareness. Accessed February 13, 2005. [16] American Cancer Society. Cancer facts & figures for African Americans 2005–2006. Atlanta (GA): American Cancer Society; 2005. [17] Division of Cancer Prevention and Control. Prostrate cancer: the public health perspective. Available at: http://www.cdcgov/cancer/prostate/prospdf/Prostate-FS2002.pdf. Accessed March 5, 2005. [18] Ries LA, Eisner MP, Kosary CL, et al, eds. SEER cancer statistics review, 1973–1999. Available at: http://seer.cancer.gov/csr/1973_1999/, 2002. Accessed May 29, 2005. [19] Powell IJ, Banerjee M, Sakr W, et al. Should African American men be tested for prostate carcinoma at an earlier age than Caucasian men? Cancer 1999;85:472–7. [20] Cross CK, Shultz D, Malkowicz SB, et al. Impact of race on prostate-specific antigen outcome after radical prostatectomy for clinically localized adenocarcinoma of the prostate. J Clin Oncol 2002;20:2863–8.
HEALTH DISPARITIES AMONG AFRICAN AMERICAN MEN
43
[21] Hoffman RM, Gilliland FD, Eley JW, et al. Racial and ethnic differences in advancedstage prostate cancer: the Prostate Cancer Outcomes Study. J Natl Cancer Inst 2001; 93:388. [22] Harlan LC, Potosky A, Gilliland FD, et al. Factors associated with initial therapy for clinically localized prostate cancer: Prostate Cancer Outcomes Study. J Natl Cancer Inst 2001; 93:1864. [23] US Cancer Statistics Working Group. United States cancer statistics: 1999–2001 incidence and mortality web-based report version. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2004. [24] Corbie-Smith GM. Minority recruitment and participation in health research. N C Med J 2004;65(6):385–7. [25] Gamble V. A legacy of distrust: African Americans and medical research. Am J Prev Med 1993;9(Suppl 6):35–8. [26] Underwood SM. African American men. Perceptual determinants of early cancer detection and cancer risk reduction. Cancer Nurs 1991;14(6):281–8. [27] Centers for Disease Control and Prevention. HIV/AIDS surveillance report. Available at: http://www.cdc.gov/hiv/stats/hasrlink.htm. Accessed May 29, 2005. [28] Centers for Disease Control and Prevention. Diagnoses of HIV/AIDSd32 states, 2000– 2003. MMWR Morb Mortal Wkly Rep 2004;53(47):1106–10. [29] Norcross WA, Ramirez C, Palinkas LA. The influence of women on the health care-seeking behavior of men. J Fam Pract 1996;43:475–80. [30] US Dept of Health and Human Services. Mental health: a report of the surgeon general. Rockville (MD): National Institutes of Mental Health; 1999. [31] W.K. Kellogg Foundation. What about men? Exploring the inequities in minority men’s health. Available at: http://www.wkkf.org. Accessed March 5, 2005.