Abstract
The overall life expectancy of African American men significantly lags behind that of other major demographic groups in the United States. African American men as a group suffer extremely high rates of cancer, heart disease and many other conditions that cause substantial morbidity as well as premature and unnecessary loss of life. However, it is now widely accepted that lifestyle and environmental factors play a major role in shaping mortality and morbidity outcomes in the United States. As a result, substantial opportunities exist for improved health outcomes among African American men through intervention involving disease prevention education and lifestyle modifications aimed at promoting as well as maintaining health promoting behavioral change. This commentary examines key contributory factors to preventable morbidity and mortality among African American men as well as promising interventions for reducing existing health disparities. Such adverse factors include limited heath care access, relative underutilization of the healthcare system compared with other demographic groups, suboptimal overall levels of physical activity, poor dietary habits leading to excessive caloric intake, tobacco and alcohol use, substance use disorders (often with co-morbid infectious diseases), sexual risk behaviors, unrecognized mental health disorders driving high homicide and suicide rates, and greatly disproportionate rates of incarceration. Several intervention methodologies with potential for widespread replication are discussed. In addition, African American men’s health is presented as an integral but commonly overlooked aspect of African American community health, with wide ranging impact on African American women and children in terms of economics, relationships and overall health status.
‘In addition to inadequate health care access, poor lifestyle options and unfavorable environmental conditions may contribute to African American men’s measurably poorer health outcomes.’
Introduction
The overall life expectancy of African American men has remained well below that of other major demographic groups nationally. The 2010 Statistical Report of the US Census predicts the average life expectancies for Caucasian women and men to be 80.3 and 76.5 years, respectively, whereas the corresponding life expectancies for African American women and men are 77.2 and 70.2 years, respectively. It is now well established that lifestyle and environmental factors play a major role in mortality and morbidity outcomes. Because an overwhelming majority of adverse health outcomes are strongly related to these potentially modifiable factors, there is substantial opportunity for improved health outcomes for African American men through disease prevention education and other interventions aimed at promoting and maintaining lifestyle and behavioral change. Not commonly considered is the adverse effect of African American men’s relatively poor health status on the African American community as a whole.
The genders are highly interactive, and their health outcomes are intertwined on many levels. Families and communities are negatively affected in terms of economics, relationships, and health status. Achieving optimal health for African American women and men is not an “either/or” question, but it is a “both or neither” issue. African American men’s health may be considered an integral but commonly overlooked aspect of African American community health. This article will present key causal factors contributing to preventable morbidity and mortality among African American men as well as promising existing interventions aimed at reducing these disparities.
Disconnection From the Health Care System
Men overall and African American men in particular are less likely to participate in preventive health care than women, contributing to measurably worse health outcomes in many respects. A significant factor in the disproportionate mortality and morbidity of African American men may be lack of health insurance: 25% of African American men and 20% of African American women are uninsured, whereas only 10% of white men and women lack coverage. 1 In addition to inadequate health care access, poor lifestyle options and unfavorable environmental conditions may contribute to African American men’s measurably poorer health outcomes. In Fulton County, Georgia, which comprises most of the city of Atlanta, the average African American male life expectancy remains below 65 years. 1 The Fulton County Department of Health and Wellness reported that in 1997, African American males constituted only 24% of the population but 42% of all premature deaths and 50% of all years of potential life lost (42 300 of 84 952). 1 HIV/AIDS, homicide, heart disease, stroke, and cancer account for 66% of these excess deaths. Among African American men aged 18 to 44 years, HIV/AIDS and homicide are the leading causes of death. For African American men of all ages, the leading causes of death are cardiovascular disease and cancer.
A study on ambulatory health care use found that even when pregnancy-related visits are excluded, “the rate of doctor visits for such reasons as annual examinations and preventive services was twice as high for women as for men.” 2 One third of men, compared with 19% of women, have no regular physician, whereas 24% of men had no physician contact in the past year compared with 8% of women. 3 Strikingly, only about 18% of men stated that they would seek help promptly if sick or in pain; 24% of men would delay seeking health care as long as possible, and 17% would delay for a week or more. 3 African American and Latino men are half as likely to have had physician contact in the past year and less likely to carry health insurance than their female counterparts. 4 Fatalism, distrust of the health care system exacerbated by such misguided medical experimentation as the Tuskegee syphilis trials, and inadequate information about African American men’s specific health concerns further contribute to African American men’s health care avoidance. 5 Men as a group are often taught from childhood to ignore pain and that “a man takes care of his own problems” and thus may fail to seek help. 5 These unhealthy expressions of stoicism may affect African American men disproportionately because traditionally certain dirty, painful, and dangerous jobs were actually referred to as “negro work,” 6 and African American men to this day continue to be excessively associated with jobs involving heavy, unsafe manual labor. Deeply ingrained stoic attitudes, distrust of the health care system, literacy barriers, and overall lack of familiarity with health issues and the health care system contribute to widespread underuse of preventive health services by African American men relative to other demographic groups.
Physical Inactivity
Whereas African Americans as a group can point to many outstanding athletes, the overall level of physical activity among African Americans is significantly less than among whites. Physical inactivity is known to be an important contributor to the genesis of a number of chronic diseases, including hypertension, type II diabetes mellitus, coronary artery disease, and stroke. Predictably, health problems associated with inadequate physical activity occur at higher rates among African Americans. 7 Physical inactivity is considered an independent primary risk factor for cardiovascular disease, comparable with smoking and high blood cholesterol. 8 Part of the issue is that physical inactivity has been shown in recent studies to be associated with lower levels of formal education, especially as the individual ages. 9 Poorer educational accomplishment is more prevalent in the African American community, with African American men in particular lagging behind in educational achievement. 10
A great deal of the healthful physical exertion that was a simple fact of daily life for past generations, such as labor jobs, housework, and walking from location to location, has been engineered out of modern life. 11 Many contemporary jobs are essentially deskbound. In addition, ample options for motorized transportation exist: elevators and escalators have replaced stairs, and cars and buses have replaced walking. Numerous nonathletic forms of entertainment are widely available. In concurrence with declining levels of physical activity, there has been an ongoing epidemic of increasing obesity over the past several decades in the United States among children as well as adults. Physical inactivity in adolescence is a strong predictor of obesity in adulthood. 12 At present, 71.7% of African American men in the United States older than 20 years are classified as overweight or obese, a phenomenon compounded by the numerous additional health risk factors in this demographic group. In his 2001 Call to Action Against Obesity, Surgeon General David Satcher stated that the health risks associated with overweight and obesity may rival those risks associated with tobacco use. 13 This phenomenon shows no sign of slowing or reversing at this time, with African Americans continuing to demonstrate exceptionally high rates of obesity. 14
Significant structural and environmental barriers exist for African American men in attempting to adopt more physically active lifestyles. Increasing physical activity requires a substantial dedication of discretionary time, often competing with daily activities such as work, commuting, and personal care. Men may face more social and/or financial pressure to engage in these sedentary activities and may receive more rewards for doing so. 15 In addition, increasing physical activity may require a substantial economic outlay for use of modalities such as exercise equipment, gym or club memberships, or specialized physical education (eg, boot camps, martial arts schools, dance lessons, or other training). This financial burden may place some options for physical activity out of reach of many African Americans. 16 Economically disadvantaged neighborhoods may not have well-maintained sidewalks, which may discourage activities such as walking or running. 17 In these same neighborhoods, free and low-cost places for physical activity such as parks or public recreation facilities may be unavailable, unsafe, or poorly maintained. 18 An additional factor compounding access to physical activity for African American men is the issue of neighborhood safety because many men would prefer the relative safety of staying inside the home. 19 In addition, fear over the safety of the neighborhood might limit the option of men engaging in outdoor sports with their children, such as softball or basketball games. For these reasons, many physical activities such as swimming, cycling, aerobics, jogging, running, hiking, backpacking, racquet sports, dancing, skating, rowing, jumping rope, and competitive group sports like soccer and basketball may not be readily accessible to African American men.
Diet
Whereas physical inactivity is a proven factor in the etiology of overweight and obesity through lack of caloric expenditure, excessive caloric intake owing to poor dietary habits is also driving the obesity epidemic. Dietary patterns in the African American community have been shaped in part by the experience of slavery, and they have been compounded and perpetuated by the economic limitations faced by them. 20 For much of the 20th century, the typical southern diet for African Americans has included staples such as greens heavily seasoned with animal fat, bleached flour, refined sugar, fatty salted pork, molasses, cornmeal, and sweet potatoes coupled with markedly excessive sodium intake. Migration to the north altered but did not eradicate the intergenerational transmission of these customary so-called “soul food” dietary patterns. 21 Also contributing to the dietary threat are traditional food preparation methods, such as extensive use of frying using lard and heavy seasoning of vegetables using pork fatback, excessive use of salt, and heavy use of refined foodstuffs such as sugar and white flour in food preparation.22,23 This traditional diet may be particularly harmful to African America men as a group especially prone to early fatal heart disease.
The types of food readily available in African American communities tend to be less healthy than food available in other communities. In predominantly black neighborhoods, food sources that lead to healthier diet quality, such as supermarkets, are less prevalent, whereas food sources that are much lower in quality such as fast-food restaurants and convenience stores are more widespread. 24 A New Orleans study demonstrated that 2.4 fast-food restaurants per square mile was the norm in predominantly black neighborhoods, whereas only 1.5 fast-food restaurants per square mile was the average in predominantly white neighborhoods. 25
Legal Substance Use
Nicotine is responsible for more deaths in the United States than any other substance. More than 400 000 Americans die yearly from tobacco-related diseases, and smokers die an average of 13 to 14 years earlier than nonsmokers. 26 Many smoking-related diseases affect African Americans disproportionately. The American Lung Association states that “despite lower smoking rates, African Americans are more likely to develop and die of lung cancer than whites. African American men are 37 percent more likely to develop lung cancer than white men, even though their overall exposure to cigarette smoke—the primary risk factor for lung cancer—is lower.” 27 Diseases widely held to be linked to smoking include cancer of the bladder, esophagus, larynx, lung, mouth, throat, and pancreas; leukemia; chronic lung disease (chronic bronchitis and emphysema); chronic heart and cardiovascular disease; reproductive dysfunction; and periodontal disease. New diseases are constantly being added to the list of smoking-related ailments over time.
The Centers for Disease Control and Prevention (CDC) states that “tobacco use is the single most preventable cause of death and disease in our society. Most people begin using tobacco in early adolescence, typically by age 16; almost all first use occurs before high school graduation. Children buy the most heavily advertised brands, and are three times more affected by advertising than adults.” 28 Targeting of vulnerable demographic groups by tobacco advertisers has been established. A marketing barrage, including sexually oriented advertising, fruit flavors, menthol, glamour, hip-hop culture, and celebrity role models, has targeted minority youth in particular. On August 19, 2004, Morehouse School of Medicine reported that new tobacco products are being specifically aimed at minority youth by using lures from the black culture that are decidedly “hip-hop” and youth oriented. 29 Former presidents of Morehouse School of Medicine—James Gavin III, MD, Louis Sullivan, MD (also former secretary of HHS), and David Satcher, MD (also former CDC director and Surgeon General)—called on tobacco companies to remove their products from store shelves. Tobacco companies refused, claiming to be in compliance with the tobacco settlement agreements. RJ Reynolds, a major tobacco manufacturer, markets “New Kool Mixx, Kool Smooth Fusion, and Camel Exotic Blends.” Phillip Morris, another tobacco manufacturer, markets “Marlboro Menthol 72 millimeter,” to Black, Latino, and other minority youth. Bidis and kreteks, which are cheap, highly toxic, small, rolled, flavored cigarettes made from tobacco residue, are becoming increasingly popular among minority youth. Inexpensive cigars, in particular the “Black and Mild” brand, are especially popular among African American male youth, who may not recognize that cigar smoke may have higher levels of nicotine and carcinogens than cigarette smoke. 30 Having begun tobacco use before being able to fully understand the long-term health consequences, many young African American men will carry unremitting tobacco habits throughout their adult lives.
Alcohol is another legal substance that is strongly associated with poor health outcomes. CDC attributes 79 000 deaths per year in the United States to alcohol use. 31 The health risks of excessive alcohol use include chronic liver disease; falls; drowning; motor vehicle and other accidents; fetal alcohol syndrome; head, neck, stomach, and breast cancers; homicide (either as a victim or a perpetrator); risky sex behaviors leading to unplanned or unwanted pregnancies and/or sexually transmitted diseases (STDs); and suicide. Alcohol use is encouraged, especially among minority males, by a markedly greater prevalence of liquor stores in predominantly African American census tracts, a disparity that persists in multivariate analysis even when controlling for socioeconomic status. 32
Comorbid Conditions Associated With Substance Use Among African American Men
HIV disease affects African Americans disproportionately and is commonly related to drug use or high-risk sexual activity. A significant amount of high-risk sexual activity is drug related, such as sex for money to buy drugs or impaired judgment caused by intoxication. Even noninjected mind-altering substances (including alcohol and marijuana) can impair judgment, leading to risky sexual behavior. CDC estimates that at some point in their lifetimes, 1 in 16 black men will be diagnosed with HIV infection, as will 1 in 30 black women. 33 The presence of other STDs common among African Americans, especially those that create ulcers in the genital tract, increase the risk of HIV transmission by sexual exposure by a factor of 2 to 5 times. 34
The highest prevalence of hepatitis C virus (HCV) infection in the United States, an ailment spread primarily through contact with infected blood, exists among African Americans, at 3.2%. African Americans account for 22% of the US population with HCV. The rate is higher for both African Americans (odds ratio = 1.7) and men (odds ratio = 1.9), thus affecting African American men disproportionately. 35 HCV infection becomes chronic in approximately 80% of cases, potentially leading to cirrhosis or liver cancer, usually decades after the initial infection. Nearly half of approximately 4000 liver transplantations performed in the United States each year have been a result of HCV. Because of the several decades of lag time between infection and apparent clinical disease, the HCV death rate may have yet to peak, with some estimates predicting that HCV deaths may even triple in the coming decades. 36
Many sexually transmitted infections (STIs) are common among drug users. STIs, notably HIV and hepatitis, often affect African American men disproportionately, indicating the need for much greater emphasis on safer sex practices in this population. A cross-sectional survey of STIs and risk behaviors was conducted among 407 drug users in treatment facilities. 37 The participants were tested for HIV, hepatitis B virus (HBV), HCV, herpes simplex virus type-2 (HSV-2), syphilis, chlamydia, and gonorrhea. Out of the 407 participants, approximately 62% demonstrated markers for STIs. The percentages of patients testing positive were as follows: HSV-2 antibodies 44.4%; HCV, antibodies 35.1%; HBV antibodies, 29.5%; HIV antibodies, 2.7%; syphilis antibodies, 3.4%; chlamydia nucleic acid, 3.7%; and gonorrhea nucleic acid, 1.7%. Logistic regression identified significant demographic and behavioral associations. HIV infection was associated with African American race, smoking freebase (crack) cocaine, and STI history. HBV infection was associated with age more than 30 years, injecting drug use (IDU), needle sharing, history of drug abuse treatment, and African American race. HCV infection was associated with an age over 30 years, injecting drugs, and needle sharing. HSV-2 infection was associated with an age more than 30 years, female sex, and African American race. Syphilis was associated only with a history of STIs.
Mental Health
A specific term, John Henryism was coined by Sherman James as a metaphor for African American men who expend great effort to cope with high-level psychological and environmental stressors. 38 Like the John Henry of legend, who won the steel driving contest against a machine at the ultimate cost of his own life, African American men may drive themselves to unreasonable, health-impairing extremes in trying to overcome the adverse life circumstances they face. Unacknowledged mental health issues undoubtedly drive disproportionately high rates of homicide and suicide among African American males. African American men aged 15 to 19 years are victims of homicide at 46 times the rate of their white counterparts. 39 Adolescent African American males previously had lower suicide rates than their white counterparts, but suicide is now believed to be equally or more prevalent among young African Americans. 39 During the 15-year period from 1980 to 1995, suicide rates among African American men aged 15 to 19 years increased from 5.6 to 13.8 per 100 000 population.
Mental health systems at present are not well attuned to the mental health needs of men, and the needs of African American men are no exception. 40 Typically, men’s gender role training emphasizes socialization to remain stoic and to drive out thoughts about problems from their consciousness and teaches them to disconnect themselves from their emotions. Men appear more likely to convert vulnerable emotions to anger and take action in response to their feelings. Some psychologists call anger the “male emotional funnel,” as one of the few emotions society permits men to express openly. 40 Some of the acting out behaviors that are commonly criticized in men, such as chronic anger, self-destructiveness, alcohol and drug use, gambling, womanizing, and workaholism, may be actually behavioral expressions of underlying depression. However, men’s socialization to avoid introspection and awareness of helpless feelings leads many men to fail to recognize that they may have a mental health problem requiring intervention. A man who reports difficulty concentrating, loss of motivation, distractibility, or sleep disturbance might not even be consciously aware of underlying feelings of sadness. 40 Men are taught to have an external focus, to think that “life is tough,” not “I feel bad.” Whereas twice as many women as men are diagnosed with major depression, men commit suicide 4 times more often than women, abuse alcohol and other drugs at least twice as often, and are believed to commit 86% of all violent crimes. 40 Given the adverse life circumstances characteristically faced by African American men and the lack of cultural competence in the mental health care system in working with this demographic group, it is likely that African American men have vast, unaddressed mental health needs. For these reasons, mental health professionals need to become much more attuned to male styles of expression and more knowledgeable concerning the specific life challenges faced by African American men in order to recognize when an underlying affective disorder or other mental health problem may be present. 40
Disproportionate Incarceration: The Impact on African American Men’s Health
Any discussion of the health consequences of African American men’s lifestyles would not be complete without some mention of the impact on lifestyle imposed by high rates of incarceration. The United States is known to have the largest prison population of any developed nation, and significant racial disparities in incarceration rates have been demonstrated nationally. The Bureau of Justice Statistics estimated that in 1991 an African American man had a 29% lifetime chance of serving at least 1 year in prison, which was 6 times higher than the rate for white men in the United States. 41 In 1999, 9% of African American males aged 25 to 29 were in prison. By contrast, only 1% of white men in the same age group were in prison that same year. 42 More than one third of young, black male high school dropouts were in prison or jail in the late 1990s according to 1 estimate—more than were employed. 43
Striking disparities in drug sentencing based on the form of cocaine commonly used by ethnicity has dramatically increased the percentage of African American men in correctional facilities because African Americans are more likely to use the smokable “crack” form rather than cocaine powder. 44 Crack possession typically incurs a mandatory minimum 5-year sentence, up to a possible maximum of 20 years for possession of only 5 g (the weight of about 2 pennies). In contrast, possession of half a kilogram of powder cocaine carries the same penalty. US District Judge Clyde S. Cahill of Missouri declared that the federal guidelines for possession of crack have “been directly responsible for incarcerating nearly an entire generation of young African American men.”
High-risk activities that could lead to HIV, HBV and HCV, and STI transmission are very prevalent among the incarcerated. Up to one third of inmates report homosexual activity, and up to one half report IDU.45-48 Furthermore, these activities take place in an environment where disease prevention measures such as condoms and sterile needles are typically considered contraband. Estimates hold that more IDU takes place in correctional facilities than in drug treatment centers. Up to 25% of inmates report IDU even while in prison.46,49 Inmate populations are drawn heavily from the IDU population outside of prison, and IDU has always been the most prevalent risk factor for HIV transmission among the incarcerated.
Barriers to successful community reentry after incarceration include inadequate access to health and social services, lack of drug treatment, lack of discharge planning prior to release, lack of job training and job opportunities, and inflexible prejudicial attitudes. These factors add to the already extant hurdles of racism and economic disenfranchisement facing African American men even before incarceration and create a vicious cycle that often relegates ex-offenders to a permanently marginalized economic and social status. 50 Stable family relationships and support systems facilitate positive and successful community reintegration and both physical and mental health outcomes. However, Prison Fellowship estimates that only 15% of married couples are able to endure a 1-year period of incarceration of 1 partner. Of the 15% who do stay together during the prison term, only an estimated 3% to 5% are still together 1 year after release. 51
Mortality Outcomes for Male African Americans
A breakdown of the 10 leading causes of death for African American males according to CDC (in 2006) gives the following percentages: heart disease, 24.4%; cancer, 21.9%; unintentional injuries, 6.5%; homicide, 5.2%; stroke, 5.0%; diabetes, 3.9%; HIV disease, 3.0%; chronic lower-respiratory diseases, 2.8%; kidney disease, 2.6%; and perinatal conditions, 1.9%. 52 Regarding heart disease as the leading cause of death among African American men, CDC also found (in 2001) that African American men as a racial group had the highest heart disease death rate in the United States, with a rate that was 29% higher than that for white men. In addition, African American men were stricken earlier by fatal heart disease, with 40% of the cardiac deaths among African American men taking place before the age of 65 years (defined as premature death) as compared with only 21% for white men. 53
Summary, Opportunities, Partnerships, Collaborations, and Working Models
Clearly, African American men are frequently faced with limited health care access, poor lifestyle options, and highly unfavorable environmental conditions. However, what is most striking about the overwhelming majority of the mortality outcomes discussed is that they are largely dependent variables, strongly related to potentially modifiable lifestyle factors—diet, tobacco use, drug use, unsafe sex, and so on. As such, there is substantial potential for improved health outcomes for African American men through public health education and other interventions aimed at promoting and maintaining lifestyle and behavioral change.
Increasing participation of African American men in preventive health care is possible. In Atlanta, 10 public health screenings were held that evinced substantial African American male participation: specifically, Men’s Health Day (1999), the Health Initiative for Men (HIM; 2002), and the annual Community Health and Men’s Promotion Summit (CHAMPS; 2003 to 2010). 54 Collaborators included the American Cancer Society, Atlanta Medical Association, Morehouse, Fulton County Department of Health and Welfare, National Black Men’s Health Network, and the Georgia Prostate Cancer Coalition. Factors contributing to high turnouts in these events included engaging entire families to bring men in and help them understand health regimens, taking time to explain and promote understanding of disease processes and management, treating the male individual as a whole person and “not just a prostate,” providing good tasting samples of healthy food, treating health screenings as a group event like going to a football game, and a peer-to-peer approach using African American male health care providers. Role models that African American men look up to provided public service announcements endorsing the health screening event: for example, prostate cancer patients James Brown and Andrew Young.
There are a number of other health initiatives being conducted locally and nationally either specifically targeting African American men or the general African American community, including African American men. First Lady Michelle Obama’s initiatives for diet and food access are addressing the poor dietary habits of the African American community. As African American hair is ethnically specific, successful health interventions such as hypertension screenings and health education pamphlet distribution have been conducted in barbershops. 55 In the setting of barbershops, the waiting time for haircuts offers ample opportunities for providing health screening and education as well as potential referrals to health care providers, thereby forging a much-needed connection between African American men and the health care system. Many African American churches are holding health fairs, including prostate screenings and other health issues relevant to African American men. The African American church–based approach potentially lends itself to especially widespread replication across the entire denomination of the church holding the event. 56
African American women have a potentially important role in increasing African American men’s health care participation. Women have been described as the “health police” of the family because women are usually more knowledgeable about health issues. 57 Men appear to do best when they have partners motivated to help them maintain health. In general, the best approaches are tactful, nonblaming, and tailored to a man’s personality. For example, if a man values his appearance, commenting on his “spare tire” may help motivate him to diet. If he likes to be in charge, challenging him to take control may be effective: for example, “Your blood pressure was high. What are you going to do about it?”
The benefits to the African American community of promoting African American men’s health include improving family stability, reducing health care costs through preventing advanced disease, reducing work absenteeism, preventing disability, and increasing economic productivity. Increased attention to African American men’s health should be seen as a logical complement to women and children’s health, a requisite component of building an inclusive health care system, and an essential means of achieving optimal overall community health.