Structural Health and the Politics of African American Masculinity

Abstract

This commentary describes ways in which notions of African American men’s “health” attained by individual choice—embedded in the notion that African American men should visit doctors or engage in fewer risky behaviors—are at times in tension with larger cultural, economic, and political notions of “health.” It argues that efforts to improve the health of Black men must take structural factors into account, and failure to do so circumvents even well-intentioned efforts to improve health outcomes. Using historical examples, the article shows how attempts to identify and intervene into what are now called social determinants of health are strengthened by addressing on-the-ground diagnostic disparities and also the structural violence and racism embedded within definitions of illness and health. And, that, as such, we need to monitor structural barriers to health that exist in institutions ostensibly set up to incarcerate or contain Black men and in institutions ostensibly set up to help them.

African American men’s health is often discussed through the language of imperatives. African American men suffer disproportionately from certain ill-health outcomes because they live harder and drive faster. Or, because they fail to visit physicians. Or, because they lead unhealthy lives. In response, the logic continues, we should improve the health of Black men by teaching them to take better care of their bodies and their souls, or imploring them to seek medical attention, or delivering more health care, or developing any number of other interventions that assume linear relationships between individual actions and communal health outcomes. Get screened, we thus tell Black men. Drive slower. Exercise, eat less fat and salt, track your blood pressure. Step up to stop violence in your homes and communities.

These are vital and important interventions, to be sure. At the same time, connections between African American men and “health” are far more complicated than they once seemed. Increasingly, scholars and researchers recognize that notions of “health” attained by individual choice—embedded in the notion that African American men should visit doctors or engage in fewer risky behaviors—are at times in tension with larger cultural, economic, and political notions of “health.” This is because men’s health, in general, and Black men’s health, in particular, is a desired state, but it is also a prescribed state that tells us as much about American social hierarchies and political economies as it does about individual lifestyle choices or treatment options. Moreover, in certain instances, attempts to improve the morbidity and mortality of African American men come up against structures and institutions that afford, enable, and occasionally block attempts to achieve longevity and well-being.

For instance, many low-income African American men are unable to comply with doctors’ orders to take their medications with food or to lose weight, not because they might harbor cultural mistrust of the medical establishment, but because they live in food deserts with no access to real grocery stores (Bostic & Lavizzo-Mourey, 2011; Davey, 2011; Welch, 2009). African American men also work disproportionately in unsafe work environments and reside disproportionately in prisons (Alexander, 2010; E-race, 2013). Meanwhile, evidence suggests that tobacco, gun, and fast-food companies bolster their bottom lines by selling ever-more cigarettes, guns, and unhealthy foods to lower income Black men in urban areas (Terhune, 2006). These and other examples suggest ways in which Black men’s health is shaped by men’s own actions and by larger, repressive, structural, and institutional forces. And that attempts to improve the health of African American men are potentially most effective when they combine individual-level interventions with attention to the economic and political conditions that produce and racialize inequalities in health in the first place.

Concerns about what might be called the structural aspects of African American men’s health are not new. For instance, in 1968, the civil-rights activist Stokely Carmichael famously scolded mental health professionals for attributing mental illness in Black men to individual factors, such as the factors that might arise when individual African American men appeared at doctors’ offices. “I don’t deal with the individual,” he told a large gathering of psychiatrists and psychologists. “I think it’s a cop out when people talk about the individual.” Instead, Carmichael attributed threats to Black men’s sanity to structural and institutional forces, which he called “established and respected forces in the society” that propagated racism and worked to circumvent attempts at liberation and improvement. These forces functioned above the level of individual perceptions or intentions and worked to maintain the status quo through structures such as zoning laws, economics, schools, medical clinics, and courts. Carmichael argued that structural forces were “less overt, far more subtle, less identifiable in terms of specific individuals committing the acts,” but were “no less destructive of human life” (Carmichael, 1968).

We have progressed in many ways since that time. Yet Carmichael’s point remains vital: Efforts to improve the health of Black men must take structural factors into account, and failure to do so circumvents even well-intentioned efforts to improve health outcomes. Moreover, history reveals that attempts to identify and intervene into what are now called social determinants of health are strengthened by addressing not just on-the-ground diagnostic disparities but also the structural violence and racism embedded even within definitions of illness and health. And, that, as such, we need to monitor structural barriers to health that exist in institutions ostensibly set up to incarcerate or contain Black men and in institutions ostensibly set up to help them.

The Structural Underpinnings of Mental Illness

A host of clinical conditions that affect the health of African American men reflect the downstream implications of upstream decisions about matters such as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health. Hypertension, obesity, cancer, and sickle-cell anemia are but a few of the diseases that historians, sociologists, and public health scholars believe represent the complex interplays between social and biological etiologies (e.g., Wailoo, 2001; Washington, 2006).

Perhaps no condition illustrates the complex relationships between African American men’s individual-level and structural-level “illness” more than schizophrenia. From a historical perspective, individual-level concerns about Black men’s mental capacities or the functioning of their brains embody structural-level anxieties about politics, economics, and the maintenance of social “order.”

For instance, starting in the late 1960s, U.S. health agencies initiated a series of large-scale efforts to better recognize and treat mental illness in Black men. These efforts resulted from an increasing sense, in many corners of the U.S. mental health system, that Black men were going insane in record numbers. Physicians voiced alarm about psychic distress. Meanwhile, research studies uncovered rising rates of schizophrenia in Black men. Authors of a 1969 National Institute of Mental Health study found that “Blacks have a 65% higher rate of schizophrenia than whites” (Taube, 1971). Several years later, a series of articles published in the Archives of General Psychiatry discovered that African American men were “significantly more likely” than White men to receive schizophrenia diagnoses and “significantly less likely” than White men to receive depression diagnoses (Simon, Fleiss, Gurland, Stiller, & Sharpe, 1973). During this same period, best-selling books, such as the Malcolm X-inspired Black Rage written by psychiatrists William Grier and Price Cobbs, warned that Black men suffered from “emotional trauma” and “psychic stresses” that potentially produced rage and psychosis (Grier & Cobbs, 1968).

The American medical establishment responded to these findings through a series of on-the-ground imperatives. They initiated programs that trained physicians to better identify mental illness in African American men and tailored treatment modalities toward minority populations (Adebimpie, 1981; De Hoyos & De Hoyos, 1965; Thomas & Sillen, 1979). And yet, the very problems that these interventions sought to address—potentially underdiagnosed mental illness in minority populations and presumably overdiagnosed schizophrenia in African American men—worsened over time. Through the 1970s and 1980s, studies consistently showed that doctors overdiagnosed schizophrenia in Black men, while at the same time failing to improve mental health outcomes in non-White populations (Baker & Bell, 1999).

From the privileged position of retrospection, we now know that part of the reason why these efforts fell short of their desired results was that they failed to take account of larger American meanings affixed to Black men’s mental “health” and “illness” and of the ways in which changing structural or institutional meanings affected changing psychiatric ones. Specifically, American notions of schizophrenia shifted during the 1960s and 1970s in response to mainstream anxieties about political and economic events—and particularly anxieties about the political strivings of African American men (Metzl, 2010). Prior to the 1960s, mainstream American medical and popular opinion often assumed that patients with schizophrenia were, for the most part, White and docile. From the 1920s to the 1950s, psychiatric textbooks depicted schizophrenia as a condition, manifest by “emotional disharmony,” that negatively affected White people’s abilities to “think and feel” (Noyes, 1927). Leading American newspapers similarly described schizophrenia as an illness that afflicted docile White women or intellectuals (“Insanity Ascribed To,” 1935; “Shyness Is Blamed,” 1929).

At that time, these associations made logical sense to American doctors and laypeople in no small part because the structural frames surrounding mental illness in the 1920s to 1950s marked schizophrenia as a disease of the mainstream in ways that conveyed the message that persons with the illness were largely White and generally harmless to the economic fabric of society. Popular magazines in the 1920s to 1950s assumed that schizophrenia was a psychoanalytic condition connected to neurosis, and as a result published articles about schizophrenic middle-class White housewives. Meanwhile, researchers conducted most published clinical studies in White-only wards. Such strategies occluded recognition of the countless men and women diagnosed with schizophrenia that resided in so-called “Negro Hospitals” and suffered well outside most realms of public awareness.

American assumptions about the race, gender, and temperament of schizophrenia changed beginning in the 1960s—indeed at the precise moment when public health officials sounded alarms about insanity in African American men. Growing numbers of research articles from leading psychiatric journals asserted that schizophrenia was a condition that also afflicted “Negro men” and that Black forms of the illness were more hostile and aggressive than were “White ones” (Bromberg & Simon, 1968). Advertisements for antipsychotic medications such as Haldol showed “assaultive” and “belligerent” men wild in the streets (Figure 1).

Figure 1.

Haldol advertisement.

Meanwhile, mainstream White newspapers in the 1960s and 1970s described schizophrenia as a condition of angry Black masculinity, or warned of crazed, Black, schizophrenic killers on the loose (New York Times, 1966).

Schizophrenia’s rhetorical transformation from an illness of White, feminine docility to one of Black, masculinized hostility resulted from a confluence of forces. Some of these forces indeed resulted from individual-level interactions, such as the biased actions of individual doctors or the presenting symptoms of individual patients. But many other forces functioned at structural levels beyond individual perceptions. Antipsychotic medications released in the 1960s allowed psychiatrists to “control” symptoms and behaviors previously treated with hospitalization or psychotherapy. As a result, the system sent many patients, particularly African American men, to prisons instead of asylums. As the Haldol ad vividly demonstrates, representations of Black men’s mental illness clearly merged with cultural anxieties about political protest and change. Perhaps most important, the language associated with official psychiatric definitions of schizophrenia shifted in ways that had tragic consequences for African American men. Prior to the 1960s, psychiatry posited that schizophrenia was a psychological “reaction” to a splitting of the basic functions of personality. Official descriptors emphasized the generally calm nature of such persons in ways that encouraged associations with middle-class housewives. But in 1968, in the midst of a political climate marked by profound protest and social unrest, psychiatry published the second edition of the Diagnostic and Statistical Manual. That text recast the paranoid subtype of schizophrenia as a disorder of masclinized belligerence. “The patient’s attitude is frequently hostile and aggressive,” the DSM-II claimed, “and his behavior tends to be consistent with his delusions.” Evidence suggests that doctors in the 1960s and 1970s used this language to overdiagnose schizophrenia in African American men and to posit that Black forms of the illness were more hostile and aggressive than were White ones (American Psychiatric Association, 1952, 1968; Metzl, 2010).

To be clear, this brief history does not suggest that clinicians, public health activists, patients, or families in the 1960s and 1970s should have discounted individual- or group-level efforts to improve African American men’s mental health. Rather, history teaches us that the barriers these parties may have faced when they attempted to improve Black men’s mental health included individual-level factors, such as decision-based risk factors for disease, as well as silent structural and institutional forces that helped shift the frames aggregating certain symptoms into particular psychiatric diagnoses in racialized ways. And that attempts to help Black men live their lives in mentally healthy ways were made more difficult by economic and diagnostic systems that coded the psychological or political strivings of Black men as a priori pathological.

The Present Day

Attention to the social and economic structures that affect African American men’s health is particularly important at the present moment. In the 1960s and 1970s, structural barriers to health manifest in what now seem to be overtly racist ways. Now, however, we recognize with a level of specificity that would have been unimaginable several decades ago how social structures affect Black men’s health at microscopic levels. Epigenetics research demonstrates at the level of gene methylation that living in a resource-poor environment can produce risk factors for cardiovascular disease that last for generations (Johnstone & Baylin, 2010). Meanwhile, neuroscientists show neuronal linkages between poverty, hampered brain development, and various forms of mental illness (Evans & Schamberg, 2009). And economists argue that low-income persons can reduce their rates of obesity, diabetes, and major depression by moving to safer, more affluent neighborhoods (Judwig, 2011).

And yet, although research increasingly shows the impact of social structures on Black men’s metabolisms or genetics, concepts of actual social forces, mechanisms, and stressors lag behind. Studies that demonstrate the physiologic effects of racism on cortisol levels contain little discussion of the nature of racism itself, or of the social hierarchies that promote its ill effects (Tull, Sheu, Butler, & Cornelious, 2005). Meanwhile, research that so effectively illuminates the ways in which particular infrastructures lead to specific bodily illness often provides less details about structural-level interventions that might address complex social problems. Biomedicine thus conveys highly advanced knowledge of the biological impacts of lived environments alongside relatively undertheorized analyses of the structures that produce and sustain them.

The present moment thus suggests that attempts to improve African American men’s health—and indeed, everyone’s health—need to include ongoing attempts to promote healthy behaviors. But they also need to promote ongoing recognition of, and intervention into, the hierarchies, economies, networks, and structural biases through which health and illness are produced and maintained. In other words, physicians, patients, public health scholars, and laypersons must remain vigilant about medical knowledge when they attempt to make positive changes to African American men’s health. But they must also recognize that, for true and sustained improvement, medical and public health knowledge is not enough. Increasing awareness of the barriers to African American men’s health must be combined with ongoing awareness of the forces that produce, sustain, and even at times benefit from these barriers. Central questions in this regard might include—What structures help define African American men’s illness and health? By what means, and to what ends? What public health competencies and interdisciplinary sensibilities are required to make these structures visible?

Meanwhile, increasing awareness about the complex and shifting meanings of Black men’s health and illness needs to join with analytics that impart humility about the impact of social biases on diagnostic practices. Questions here might include—How do definitions of health and illness shift over time in relation to shifting cultural assumptions about race, gender, and class? How might awareness of these shifts promote increasing awareness of the structures that operate within institutions, such as medicine, that are ostensibly set up to help Black men? And how might the lessons of history help shape present-day interventions?

Ultimately, increasing recognition of the ways in which social and economic forces produce symptoms or methylate genes needs to be coupled with calls for more economic, political, and social justice interventions for Black men’s health-related problems. Again, this is in no way to subvert the importance of public health messages, medical treatments, or individual choices. Yet we must increasingly ask how growing awareness of the health effects of structural problems produces the vital need for medical and public health inflected calls, methods, politics, and proposals for structural change.