Facts of Life:
Issue Briefings for Health Reporters
Vol. 8, No. 5
May 2003

The Forgotten Population:
Health Disparities and Minority Men

The Issue
The Facts
Interview: David R. Williams, Ph.D. Explaining the Crisis: Why Poor Men of Color Have the Worst Health
Interview #2: Dean Robinson, Ph.D. Searching for Solutions: From Community Demonstrations to National Models
The Role of Race, Racism and Discrimination in Health Outcomes
Men’s Health Initiative: Laboratories for Community Innovation
Addressing the Issue of Unequal Treatment
Bibliography

A/ Minority men — especially African-American men, where we have the best evidence — have much higher rates of illness and mortality than non-minorities. It’s been 400 years and the United States hasn’t made much progress in reducing the gap. Both minorities and non-minorities have improved in the last 50 years, but the relative difference has remained unchanged in virtually every way. [7]

This is significant because we live in a society that values equal opportunity and health is a prerequisite to that opportunity. To the extent that a particular group is unhealthy, they are less likely to make it to the starting gate. In addition, much of the excess loss of life experienced by minority men occurs during what should be their most productive years — exactly the time they could be contributing to society economically and in other ways. Finally, research suggests that where there are small pockets with a very concentrated level of pathology it can actually spread to the larger society.

Q/ Low-income minority men seem to be triply disadvantaged — by socioeconomic status, race and gender. Could you discuss the importance of these three factors and how they are interrelated?

A/ One of the strongest determinants of health in the United States and throughout the world is socioeconomic status. This is true for all men and women, but beyond the effect of SES, ill health is also linked to race/ethnicity. And in virtually every country, men are sicker and die sooner than women. The three factors interact in complex ways. It’s not easy to disentangle one from the other, but together they create enormous disadvantage. [2]

Q/ What are the pathways by which these three factors affect health?

A/ Let’s talk about SES first. Virtually every protective characteristic or health risk is distributed by SES. Smoking, alcohol and drug use are all less common among those with higher income and education. Access to care and quality of care are higher. Stress is lower, and we know that stress is a very powerful determinant of health, present in many pathways.

Gender works in several ways. There’s no magic bullet. Economic marginality and the absence of work are linked to SES for men and women, but men in particular see themselves as providers. When they can’t play that role, their lives and health are affected. Men are over-represented among the homeless, the prison population, substance abusers and people with severe mental illness.

Working at a lousy job is also bad for your health. More men than women are in dangerous and stressful occupations.

Cultural beliefs about masculinity also affect health behaviors. Women are more likely to seek care and to engage in health-promoting activities, and it appears that they have more effective coping mechanisms and social support. Men are more likely to respond to stress by using alcohol, drugs and tobacco.

Race also affects health in multiple ways. The problems of work and marginality that are present in men generally are more pronounced among minority men. Research has shown that among men with the same job titles and advancement, minorities are more likely to face occupational hazards and stress. Location of residence is also linked to race. One study of the 171 largest cities showed there was not one where the average African-American neighborhood was better than the worst white neighborhood (in terms of quality and living conditions). Finally, the experience of racial discrimination is an added source of stress — one that makes an incremental contribution to ill health. [8]

Q/ Do you think the roles of genetics and personal behavior have been overemphasized?

A/ It’s important to note that the pathways of race are linked to the structure of society and to social experience — not to biology and genetics. We have known for some time that racial categories don’t capture much biologic distinctiveness, and they are unlikely to be a major explanation for heath disparities. Still, we need research on how genetic and other biological factors may interact with the social environment to create pervasive health problems.

Behavior is much more complicated. It’s clearly an important pathway in determining health. At the same time, we cannot understand behavior in a vacuum. The larger challenges individuals face in their lives affect their behavior. For example, nicotine is a drug that provides momentary relief from stress; so smoking is more prevalent among those where stress is highest. I hasten to add that there’s also a profit motive at work here. Low-income and minority neighborhoods are targeted by billboards advertising cigarettes and alcohol, liquor stores and fast food outlets.

We need to acknowledge that behavior is a factor but not the only factor, and that there are various ways to try to improve it. For example, there has been a dramatic decline in smoking in the last three decades, but the decline has been much more common among people with higher educational levels. They tend to have healthier alternatives for dealing with stress, such as gyms and spas. When your options are constrained you are more likely to cling to an unhealthy but temporarily satisfying behavior.

Q/ You have said that in some cases middle-class African-American men may face even higher health risks than lower-income African-American men. [7] Could you address this apparent paradox?

A/ I believe this is one example of the added burden of race. The health of middle class African-American men is generally better than that of poor African-American men. But for some conditions — hypertension, suicide and stress — it’s worse. The same is not true for African-American women.

Research shows instability and tenuousness and more unemployment among the African-American middle class — especially the first-generation middle class — compared with whites. African-Americans have made a lot of progress in closing the education gap with whites, but not the income gap. They earn less at every level of achievement, and they don’t expect their investment in education to pay off at the same rate.

Q/ Could you discuss how residential segregation affects health?

A/ Residential segregation by both race and income is one of those fundamental causes that has received inadequate attention as to its effect on factors linked to health. Segregation by race and income is increasing, leading to loss of neighborhood resources. In the United States, dollars for education come largely from local taxes, so segregation tends to mean lower-quality schools for minority students.

Employment options also decrease as an area becomes more segregated. Pharmacies are not well stocked; groceries are of lower quality and fresh fruit and vegetables are either unavailable or very expensive; playgrounds, walkways and opportunities to exercise are rarer. Safety is a factor, and tends to reinforce both lower use of facilities and withdrawal of services. The more severe the concentration of problems, the less the possibility of the neighborhood ever recovering. [3]

Q/ What do you see as some possible solutions to these problems?

A/ One central point is that the health of men is embedded in larger experiences in society. We have to improve the quality of life through good, well-paid, safe jobs and livable neighborhoods and communities. For men, it’s also important to think of serious, active educational outreach — ways of dealing with cultural biases and reinforcing positive behavior. And, more narrowly, we need to improve access to health services and address findings that minorities receive less timely and intensive treatment and poorer care.

Regarding residential segregation, it’s not inherently bad to live with one’s own race. Communities of like culture can be important sources of support. What’s damaging is the accumulation of ills linked to poverty. Our neighborhoods need a massive commitment of resources to rebuild their physical and social structures.

We need better schools, employment and training and retooling programs, and transportation to where the jobs are. Every child growing up should have access to good opportunities. We need to think long and hard about the next generation, and the high levels of poverty we tolerate among kids, especially minority kids.

In the last 50 years, there have been few signs of dramatic change in our living patterns. But it’s important to evaluate every government policy’s impact on health. We need to understand how things like housing, agriculture, labor, transportation and economics shape individuals’ lives — and how health is embedded in all of them.

Q/ Why do you think it’s important to study the health of minority men?

A/ I first became interested when I was at UMass and working on a state universal health care campaign, before I had read much public health literature. It was obvious to me that the distribution of illness and disease was disproportionately skewed to low-income people and racial/ethnic minorities — and that this was related, at least in part, to differential access to care.

Q/ How does this affect men in particular?

A/ Poor men’s need for health services is not well understood. For example, Medicaid, the federal/state program financing care for low-income people, is so tied to people with kids. There are only 11 states where individuals who are neither disabled nor on-site parents qualify just because they are poor or near-poor. [9]

And even that coverage is at risk as state budgets grow tighter and programs are slashed. [10] When push comes to shove, they will protect women and children first.

Yet low-income men — especially minorities — are least likely to be insured. [4] So they don’t get preventive services, their health is poorer and they die sooner. [1]

Men themselves tend not to seek care and community programs, even those that care for the uninsured, don’t always reach out to them.

Q/ Do you think this happens because we see men as less deserving?

A/ It’s a combination of things. The safety net covers kids first. It scoops up more women than men because women are, by and large, the caregivers for the kids. Then there are norms and socialization. We think guys don’t get sick and we don’t have the same concerns about them. In addition, in recent times we’ve emphasized dependence on the private market to distribute health care.

Free market solutions don’t work with a group that has entrenched difficulties with the labor market, or jobs that don’t provide insurance and incomes too low to purchase it themselves.

Q/ What are some of the specific health care issues of low-income minority men?

A/ Recently I was a participant/ observer in focus groups held by the Denver Health program to get at just this question. For African American men, trust of the health care system was an issue. Several members of the focus group mentioned the Tuskegee experiments that took place years ago — African-American men diagnosed with syphilis were allowed to go untreated so that researchers could track the progress of the disease.

Lack of respect from caregivers was also an issue. “Money equals respect,” one man said. “And there’s no money to be made on us.”

Hispanic men focused less on mistrust; more on language barriers and the fact that they don’t readily ask questions in a clinical setting for fear of not being understood.

It was interesting that recent immigrants were accustomed to government-provided health care, while those who were more assimilated didn’t expect much from the government.

Both groups were concerned about costs. While most of the men were getting care from public agencies, they feared increases in the income-related fees they pay, as well as cutbacks in services.

Q/ What are some of the things that predispose men to illness and lack of services?

A/ At the end of the focus groups, the men were asked what kept them up at night. Most of them mentioned getting and keeping a job; providing for their families. Jobs that don’t pay a living wage, high rents and lack of affordable housing are exacerbated by low educational status and discrimination.

Also, they buy into the masculine myth. Out of necessity, work comes first. Men don’t prioritize health unless they’re really ill. They postpone care, compromising outcomes later in life.

Q/ What is the Kellogg Foundation Men’s Health Initiative doing about these problems?

A/ Kellogg became aware of the gaps in men’s health services through the Kellogg Foundation Community Voices program, focusing on health care for the underserved generally. They launched a $3 million initiative in six areas with high concentrations of low-income minority men, access problems and poor health outcomes.

The grantees are meant to demonstrate a number of approaches to improving men’s health.

Most of the projects function through existing providers of health care to the underserved — municipal health facilities or federally funded community health centers. But Baltimore has chosen to create a freestanding men’s health center and Boston has established a nine-month program to train community health workers to conduct outreach and case management among high-risk men.

Q/ Who benefits from these projects, and how?

A/ That varies by project. Some serve low-income minority men generally, combining health services with outreach and special programs.

The project in Mississippi sets aside specific sessions and hours for men at convenient times for them. Within a general focus, the projects in Boston and Denver are taking a particular interest in men recently released from prison.

Miami is targeting homeless men, especially those in need of mental health and substance abuse services. Atlanta focuses on educating and counseling adolescents on reproductive health issues and prevention of violence against women.

Q/ What do you see as the policy implications of these projects?

A/ The Kellogg men’s health projects demonstrate innovative and effective ways of reaching a hard-to-reach population, and they are already providing poignant evidence of the need for policy change.

But our goal should be to get public dollars to promote similar efforts in major areas of need in all 50 states.

Beyond that, we should be looking at improved health insurance — if not universal coverage, at least extension of Medicaid eligibility to all low-income persons, without regard to sex or family status.

We need to extend the Family and Medical Leave Act so that men as well as women receive paid leave for medical care. We need to address the need for affirmative action among health care providers; improved communication, including interpretation for non-English speaking patients; and assuring that people are treated with dignity. And we also should be thinking about issues of employment, housing, education and discrimination that underlie health problems.

In other words, health care itself is sorely needed, but community health also teaches us the relevance of the other factors that affect well being.

There are important policy implications here — health can be an entry point to learn about, organize and deal with a broad range of issues.

One thorny issue raised by the existence of health disparities is the role played by overt racism and discrimination. What is the proof that racism, per se, makes you sick?

The role of stress as a determinant of health has been understood for years. Stress has been identified as a villain that causes disease by sources from Newsweek cover stories to highly technical studies of animals.

If there is no physical outlet for the “fight or flight” stimulus, emergency-response chemicals remain in the body, causing depression, increased susceptibility to infection, diabetes, cholesterol and fat buildup and high blood pressure. Repeated exposure exacerbates these problems.

Most experts agree that it’s stress that underlies the social theories about health — the added disadvantage beyond just physical conditions faced by those who experience poverty, inequality, lack of education and unemployment. [14]

There is growing proof that racism is an added burden that works through stress — one that may be even more damaging for minority men because they lack women’s coping ability.

Sociologist David Williams reviewed the current literature about racial/ethnic discrimination. He found an association with multiple indicators of physical and mental health, despite measurement gaps in many of the studies, the dose-response relationship and how the process works over time. [8]

Williams’ own work suggests that for race-related stress, the chronic presence of day-in and day-out discrimination is more important than major life events, but for stress in the general population, life events are more significant. [15]

Camara Jones, a physician and epidemiologist who directs research on the social determinants of health for the Centers for Disease Control and Prevention, has described how this might happen.

“We know that black folks are at greater risk of hypertension,” she says, “but in childhood, there are no differences between black and white blood pressure rates.”

It’s only later that the rates diverge, she adds, and blood pressure drops at night for whites but not for blacks.

Jones theorizes that constant stress results from others’ perceptions of blacks and subtle race-based biases.

“It’s the little things that count,” she says — like being treated differently by a store clerk. Each event may be insignificant, but the repetition builds up. She has found that whites rarely think about race in the course of a day, but 50 percent of blacks do. [13]

The W.K. Kellogg Foundation Men’s Health Initiative was launched to demonstrate new and effective ways of filling the gaps in care for low-income minority males. Six organizations in some of the nation’s neediest communities are splitting $3 million in grants. Differing in focus and administrative structure, the projects are yielding important information about outreach, counseling, provision of health services and training of culturally competent staff.

Baltimore City Health Department
Baltimore, Md.

The Baltimore project has established a freestanding men’s health center, offering a full range of primary care and social services to a largely uninsured African American population with high disease risk. Contact Sherry Adeyemi at (410) 396-4502.

Boston Public Health Commission
Boston, Mass.

The Boston Public Health Commission is training young minority men to be community health workers, implementing case management teams and developing a young men’s health coalition. The teams are geared to link men coming out of prison, victims of violence and others in need to health services in existing primary care facilities. Contact Dr. John Rich at (617) 534-7148 or (617) 534-2662.

Camillus House
Miami-Dade County, Fla.

Through this project, licensed mental health clinicians provide outreach and case management and link homeless men with a full range of housing, behavioral and health services. Contact Karen Mahar at (305) 374-1065.

Delta Community Partners in Care
Clarksdale, Miss.

Three primary care clinics in the Mississippi Delta, a predominantly African American area with high levels of poverty and uninsured people, are developing male-dedicated entry points, conducting outreach, case management, community screening and education and allocating specific days and times for men’s services. Contact Lela Keys at (662) 624-3484.

Denver Health
Denver, Colo.

Denver’s comprehensive safety net public health care system, including its community health centers and hospital, has male health advisers to conduct outreach, screening and case management and assure continuity of care for men who are uninsured, treatment dropouts or recently released from prison. Contact Richard Wright, M.D., at (303) 436-6850.

Grady Health System Teen Services
Atlanta, Ga.

Atlanta’s centrally located public care hospital aims to help adolescent males establish lasting beneficial attitudes and behaviors regarding their health by providing reproductive healthcare services, education and counseling. Another goal of the project is a reduction in unintended pregnancy, sexually transmitted infections and violence in peer relationships. Contact Marie E. Mitchell at (404) 616-3543.

In 2002, the Institute of Medicine issued Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The report was notable not so much for its conclusions, many of which have been long documented while others were at least suspected, but for the fact that a committee of wide-ranging backgrounds and political persuasions agreed that action is needed.

The committee chair prefaced the report by acknowledging the sensitive nature of its charge: “[H]ealth care workers are professionals, and beneficence, as an element of professionalism, is supposed to be color blind.” Nevertheless, he said, “The committee finished its work convinced that the real challenge lies not in debating whether disparities exist, but in developing and implementing strategies to reduce and eliminate them.” [6]

Suggestions that disparities are related not only to lack of access but to differential treatment within the health care system are implicit in the findings of researchers like Marian Gornick, who has been plumbing the Medicare database for years. Gornick has found consistently that Medicare beneficiaries who are racial and ethnic minorities are less likely to receive regular doctor visits and beneficial procedures such as flu shots, eye care, cancer screening, heart bypass surgery and angioplasty, and more likely to experience limb amputations and radical cancer surgery that might have been prevented by regular primary care. [5] Most recently she has described the disparities faced by minority men. [11]

Uncovering the reasons for the disparities is more complex. Cultural attitudes, communication problems and mistrust of the medical care community by minorities are elements that may enter into the equation. But in addition, the IOM said, “Bias, stereotyping, prejudice and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care.” [6]

Jack Geiger, a physician and human rights activist at the City University of New York Medical School who studies the impact of racism on health, helped research the IOM report. He says doctors share some of the responsibility. [12]

“It’s not that they practice overt racism,” Geiger says. “It usually happens without awareness. And that’s one reason why most physicians are very reluctant to recognize this in themselves and their peers.” [13]

Most experts agree that conventional “cultural competence” training is not the way to go.

“Focusing on the behavior of different groups may reinforce negative stereotypes,” according to sociologist David Williams, a member of the IOM committee. “We need to look instead at the process of how the provider relates to each individual patient.”

Data collection on disparities within specific health care plans and institutions, research on provider attitudes and widespread use of treatment protocols are also suggested.

1. National Center for Health Statistics. Health, United States, 1999. Hyattsville MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

2. Williams, D.R. Race and health: trends and policy implications, in Auerbach, J.A. and Krimgold, B.K., eds., Income, Socioeconomic Status and Health: Exploring the Relationships. 2001; Washington DC: National Policy Association.

3. Williams, D.R. and Collins, C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Reports. 2001; 116:404-416.

4. Brown, E.R., et al. Racial and Ethnic Disparities in Access to Health Insurance and Health Care 2000; Los Angeles CA: UCLA Center for Health Policy Research and the Henry J. Kaiser Family Foundation.

5. Gornick, M.E. Vulnerable Populations and Medicare Services: Why Do Disparities Exist? 2000; New York NY: The Century Foundation Press.

6. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2002; Washington DC: National Academies Press.

7. Williams, D.R. The health of men: structured inequalities and opportunities. American Journal of Public Health. 2003; 93(5):724-731.

8. Williams, D.R. Racial/ethnic discrimination and health: findings from community studies. American Journal of Public Health. 2003; 93(2):7-15.

9. Holahan, J. and Pohl, M. States as Innovators in Low Income Health Coverage. 2002; Washington DC: The Urban Institute.

10. Hyde Park Communications. Daily Monitoring Report. 2003; see reports for January-April, online, access by writing apagoulatos@hydeparkcomm.com.

11. Gornick, M.E. A decade of research on disparities in Medicare utilization: lessons for the health and health care of vulnerable men. American Journal of Public Health. 2003: 93(5): 753-758.

12. Geiger, H.J. Racial and ethnic disparities in diagnosis and treatment: a review of the evidence and a consideration of causes, in Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2002; Washington DC: National Academies Press.

13. Kirchheimer, S. Racism should be a public health issue. Medscape, Jan. 9, 2003. http://www.medscape.com/view-article/447757 (Registration required.)

14. Adler, N.E., et al. (eds.) Socioeconomic Status and Health in Industrial Nations: Social, Psychological and Biological Pathways. 1999; New York NY: Annals of the New York Academy of Sciences, Vol. 896.

15. Williams, D.R. et al. Racial differences in physical and mental health. Journal of Health Psychology. 1997; 2(3):335-351.

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