Our Health: Men's Health

As Black Men Move Into Middle Age, Dangers Rise

By LINDA VILLAROSA
New York Times

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."

African American Men and Prostate Cancer

A recent study offers a bit of good news for African American men and their greater risk for getting -- and dying from -- prostate cancer. A new Wayne State University study shows the survival gap may be narrowing between African-Americans and Caucasians who had their prostate surgically removed after suffering from prostate cancer.

The researchers discovered that while white men were more likely than blacks to remain free from cancer from 1990 to 1995, the gap between the races narrowed from 1996 to 1999. During the earlier period, cancer was diagnosed before it spread outside of the prostate in 38 percent of African-Americans and 48 percent of whites. From 1996 to 1999, however, the rate of prostate-confined cancer was 54 percent in blacks and 62 percent in whites. Relapse occurs most often during the first three years after surgery.

One of the researchers, Dr. Fernando Bianco, a WSU urologist, says earlier detection of prostate cancer helps explain the decline in relapse rates because more cases were caught at an earlier stage before the cancer spread outside the prostate. He believes this is due to prostatic-specific-antigen (PSA) testing that measures a protein made by the prostate and can indicate prostate cancer.

Not Created Equal

African-American males have the highest incidence of prostate cancer in the world and suffer two to three times higher mortality than Caucasian men. For every 100,000 African-American men, for example, about 180 will have prostate cancer this year, and more than 50 will die from the disease.

While diet, quality of care, and other environmental and behavioral factors are suspected of contributing to the higher rate of prostate cancer in African-Americans, many researchers believe genetic factors play a large role. These factors may be associated with a higher tendency for tumor progression, recurrence and metastasis in African-American compared to Caucasian men.

Scientists are just beginning to study the role of inherited factors. Recently, scientists at the National Human Genome Research Institute (NHGRI) mapped the location of a gene associated with increased risk of prostate cancer. They estimate alterations in this gene, called HPC-1, are responsible for at lease one-third of the prostate cancer that runs in families. Approximately 1 in every 500 men is believed to possess an altered version of HPC-1. Initial studies suggest that HPC-1 may play a particularly prominent role in early onset familial prostate cancer among African-Americans, but only a few such families have been analyzed.

Better Test for African Americans

Peter Littrup, M.D., a radiologist at the Barbara Ann Karmanos Cancer Institute, recommends African-American men have a modified PSA test that incorporates prostate size or density, if their PSA level is elevated. Littrup says the new test -- called color doppler ultrasound-guided biopsy (CDUGB) -- is more accurate in African-American men than other men.

The CDUGB test, when performed immediately following the detection of a PSA abnormality, may improve the diagnosis of prostate cancer for some men. Typically, men with mildly elevated PSA levels are advised to wait for six months to a year, then have a second PSA test, rather than having an immediate biopsy.

"Because prostate cancer is twice as common and three times as deadly in African-American men, immediate biopsy is recommended for African-Americans and others at high risk, instead of watchful waiting," says Dr. Littrup. "Cancers caught in an earlier stage may lead to better cure rates and save more lives."

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Fatherless Families Damages Boy's Self-esteem

Living in a fatherless family damages a black boy's self-esteem, says an American study released recently.
"In the black community, there's a slogan, 'Black mothers raise their daughters and love their sons,' " says one of the study's authors, Carolyn B Murray, an associate professor at the University of California, Riverside. "It's the father who holds that boy accountable. He has that boy toe the line; he holds the rules and responsibilities."

But when fathers aren't present in black families, regardless of such things as family income and education, young boys' self-esteem drops, the study says. That doesn't appear to happen with young girls in these families, it says. What this means for the boys, experts say, can range from their having problems in school to participating in gangs as part of their search for male role models. It's a "real crisis," Murray says.

Just 25 per cent of black children were raised in homes in which only the mother was present in 1960, she says, but that number had climbed to 54 per cent by 1993. In addition, she says, 78 per cent of all black families were headed by married couples in 1950, down to 34 per cent by 1996.

The children's scores on the study's tests reflect these statistics.

Measuring general self-esteem, for instance, boys from families headed by married couples scored higher than boys from families headed solely by a mother, the researchers say. Girls scored similarly, but with much less difference between the two groups.

Scores on specific self-esteem issues paint an even darker picture, Murray says, citing the question of how a boy sees his body, or how macho he feels. Boys coming from families with a father scored higher -- meaning they felt stronger, more competitive -- than did boys from families without fathers, the study says.

The findings, based on a study of 116 African-American 15-year-olds from Southern California, appeared in the September issue of the Journal of Family Psychology.

The dangers this poses for young black boys can be serious, Murray says, though she cautions that it's important not to generalize.

"They're at risk for joining gangs because they're looking for a male influence, for direction, for a male model," she says. "And they're also at risk for not doing as well at school."

The absence of a father seems to lead to lower self-esteem because fathers expect more from their sons than mothers do, Murray says. Where a mother might expect a daughter to do homework, get dinner prepared and clean the house after school, she says, the mother might expect little from a son.

And expectations that are met yield higher self-esteem, she says. "Mothers hold girls accountable; fathers hold boys accountable," Murray says. "Two parents are better than one."

George Garrow, executive director of the National Organization of Concerned Black Men, says boys growing up in fatherless families seem to do well until the age of 9 or 10, when they begin to need focus. Lacking a father's influence, he says, they begin to seek male role models elsewhere.

"Then they find their role model experience from other young boys, who are equally clueless," Garrow says.
If the father role is never filled, he says, the boys may join gangs or find unhealthy mentors. "The young man is going to play out what he thinks this image is, to be a man," Garrow says.

In the end, he says, it's not just the self-esteem that's damaged by the absence of a father. "It impacts the psychological, social and emotional development of young boys," Garrow says.

The California study shows family income playing a small part in boys' self-esteem, as does how the family is organized. Boys probably feel more responsible for a family's income and how power is divided in the family, Murray speculates. How well a family actually functions, however, had a much greater effect on girls than boys, she says, probably because girls take responsibility for relationships.

Marriage counselling and jobs programs that would help black men remain at home could help the situation portrayed in the study, Murray says.

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High Blood Pressure Rates Vary Widely Among Blacks

African Americans have one of the highest rates of high blood pressure in the world, but the prevalence of the condition varies widely within the US black population, according to researchers.

Their study of national survey data found that when it comes to high blood pressure, African Americans could be separated into 12 "distinct subgroups" whose rates of the disease range from a low of 11% to a high of 78%.

Among the nearly 3,400 study participants, those in the two highest risk groups were older than 45, mostly overweight or obese, often physically inactive and frequently had diabetes. In fact, all of those in the top risk group had diabetes, according to findings published in the October issue of the journal Preventive Medicine. Both high blood pressure and diabetes, which often occur together, are major risk factors for heart disease, stroke and kidney disease.

The researchers, led by Dr. Rakale Collins of Morehouse School of Medicine in Atlanta, Georgia, also found that men, younger individuals and those who infrequently saw a doctor were less likely to have their high blood pressure under control with medication. "This study has clearly identified those African American subgroups in greatest need of intervention programs," write Collins and colleague Dr. Marilyn A. Winkleby.

For example, they point out, among the factors most strongly tied to high blood pressure was excess weight--in the two highest risk groups, 80% and 100% of participants were overweight or obese. A majority of these participants also had not finished high school. Collins and Winkleby note that the way health information is communicated, as well as the cost of medical care and drugs, need to be addressed in order to serve those at greatest risk of high blood pressure.

The researchers also point out that even in the study group with the lowest rate of high blood pressure--those who were younger than 37 and had a relatively lower weight overall--there were substantial risk factors for future high blood pressure. Half were overweight or obese, and 40% smoked. "These risk factors must be addressed in a primary prevention effort," the study authors write, "or they will become a problem" as these individuals grow older.