Why Do Blacks Die Young?

By Christine Gorman

The birth of a child is a time of joy and promise. In a land as rich as the U.S., all parents have the right to expect a life long and healthy for their sons and daughters. But the odds that this wish will come true are shockingly reduced if the baby happens to be black.

A white baby stands a 70% better chance of reaching its fourth birthday than a black child. And the average life expectancy of African Americans is 70.3 years, much less than the 76 years that white Americans can expect.

The life-spans of both races have lengthened over the decades, but the gap between white and black has remained stubbornly wide, and it increased sharply during the Reagan years, when many social programs that helped minorities were slashed. The gap has since begun to narrow, but it is just as large now as it was in 1982. This lack of progress has become one of the most studied issues of public health and one of the greatest challenges facing government policymakers. Why are blacks dying so much younger than whites?

One cause is the crime and violence that plague many inner cities. Black boys between the ages of one and four are three times as likely as white toddlers to be the victims of homicide. Black teenagers are murdered six times as often as whites.

But crime is only a small part of the story. Study after study shows that blacks are just not as healthy as whites or other racial groups -- at any age. Black toddlers are three times as likely as white youngsters to die from meningitis, pneumonia or influenza. Black men are three times as likely to contract AIDS, and 50% more likely to die from a heart attack, even if they make it to a hospital. Death from stroke is five times as common in African Americans of both sexes between the ages of 35 and 55. Advanced kidney disease is 15 to 20 times as common.

Better medical treatment and health education for African Americans could reduce the black-white mortality gap by an estimated 60%. "We have a whole segment of our population dying unnecessarily, and we're worried about whether to eat oat-bran or wheat-bran muffins," fumes Dr. David Ansell, director of ambulatory screening at Chicago's Cook County Hospital. "It's the medical equivalent of Marie Antoinette's saying 'Let them eat cake.' "

Much of the difference between black and white life-spans results from poverty and discrimination. But the problem is a maddening mosaic involving many other factors as well. New evidence suggests that part of the reason blacks suffer more from high blood pressure, for example, may lie in genetics. Many analysts have also cited lack of preventive care and cultural differences -- such as a fattier diet and a higher rate of smoking among blacks. None of these factors, however, can be completely separated from the others.

Poverty. One-third of African Americans live below the official poverty line (an income of $12,000 a year for a family of four), in contrast to 12% of whites. Although the Medicaid program offers free treatment to the poorest citizens, many low-income working people are not fully insured. Moreover, the everyday struggle to survive often takes precedence over health care. "For many people the question may be 'Do I go to work today, or do I see the doctor?' " says Dr. Earl Scott, medical director of the Sydenham Clinic, part of a network of free clinics in Harlem.

Perils of living in poverty also take their toll. The sharing of contaminated needles among drug users speeds the spread of AIDS. Alcoholism, stress and poor diet help fuel increases in cardiovascular disease, diabetes, cancer and liver failure. A study in Washington found that 50% of black men living in public housing suffer from hypertension, in contrast to 20% of all black men in the city. And 25% of the projects' women suffer from diabetes, against 7% in Washington as a whole.

Unfortunately, preaching about health care can seem laughable in crime- ridden inner cities. "We went door to door in half a dozen black neighborhoods in St. Louis looking for young men who had significant hypertension," says Dr. H. Mitchell Perry of Washington University. "These guys said, 'Look, this is not my biggest problem.' They were wondering whether they would live to age 35."

Lack of Preventive Care. Measles, syphilis and other infectious diseases staged deadly comebacks during the 1980s, hitting blacks particularly hard. Much of this increase can be tied to breakdowns in the public health system. In 1982, when the federal immunization program against measles was cut, health officials counted 1,700 cases nationally. Last year there were more than 27,000 cases -- primarily in poor urban areas -- with 89 deaths. In the early days of the AIDS epidemic, health officials cannibalized their syphilis programs, which had focused on the inner city, in order to combat the new threat. As a result, the incidence of syphilis among African Americans doubled between 1985 and 1989.

The high rate of infant mortality (18 per 1,000 births for blacks, vs. 9.2 per 1,000 for whites) results in large part from the lack of prenatal care, which is perhaps the most cost-effective type of health care available. Each dollar spent on prenatal care saves between $3 and $20 in medical expenses in the infant's first year of life alone. And yet total government funding for prenatal care -- on both the local and federal levels -- fell throughout the 1980s.

Meanwhile, fewer blacks are seeing private physicians than ever before. In 1977, 3 out of 5 were covered by private health insurance. By 1987, the ratio had dropped to less than half. Black doctors tend to treat more black patients than do their white colleagues. Yet the number of black doctors declined from 26,000 in 1984 to 16,000 last year, largely because federal scholarship programs for medical students have been cut back.

With nowhere else to go, many African Americans rely on the local emergency room for all their medical needs. "The emergency room may treat a patient's pneumonia, but it won't do a Pap smear or screen a woman for breast cancer," says Dr. Marc Rivo, director of the division of medicine at the Department of Health and Human Services. Without early detection, more than half of black women with breast cancer admitted to Harlem Hospital are already incurable, in contrast to 8% of whites at a nearby facility.

Discrimination. For unknown reasons -- prejudice may be the only explanation -- many doctors and hospitals do not treat blacks' medical problems as seriously as those of whites. In one study, researchers found that, regardless of income, blacks are half as likely as whites to receive bypass operations for their heart problems. Another investigation revealed that among patients undergoing dialysis for kidney disease, whites are 33% more likely to get a kidney transplant. A third study showed that blacks who were hospitalized for pneumonia received less-intensive treatment than whites.

No doubt anticipating inferior care, many blacks avoid doctors and hospitals altogether. Black women report a prevalent attitude among gynecologists that anything wrong might be the patient's own fault. "Back a few years ago, I was having excruciating abdominal pain, and I wound up at a hospital in my area," says Alicia Georges, who lives in the Bronx and is a professor of nursing at Lehman College. "The first thing they began to ask me was how many sexual partners I'd had. I was married and owned my own house. But immediately, in looking at me, they said, 'Oh, she just has pelvic inflammatory disease.' "

Life-Style. Louis Sullivan, Secretary of Health and Human Services and the highest-ranking black in the Bush Administration, warns African Americans not to exaggerate the effects of poverty and bias on their health. Says he: "The top 10 causes of premature death in our nation are significantly influenced by personal behavior and life-style choices." Sullivan has exhorted blacks to quit smoking, cut down on drinking and lose weight. Such personal initiative, he claims, "could eliminate up to 45% of deaths from cardiovascular disease, 23% of deaths from cancer and more than 50% of the disabling complications of diabetes."

The evidence tends to back him up. A half-century ago, blacks developed cancer less often than whites. Now, in large part because of smoking, the mortality rate for malignancies is 25% greater for blacks than it is for whites. Almost half of black women and one-third of black men are severely overweight, vs. one-fourth of white men and women. In addition, the salt in soul food can aggravate high blood pressure. "We have to teach people that diet is important," says Dr. Harold Freeman, a surgeon at Harlem Hospital. "As the saying goes, if you can control your mouth, you can control your life."

Genetics. In a study of 50 black and 219 white physicians, who presumably have access to care and can make improvements in their diet, researchers found a marked difference in the ability to handle cholesterol. Compared with their white colleagues, the black physicians exhibited higher blood levels of a type of lipoprotein believed to aggravate blockage of coronary arteries. Other research found that elderly black men are twice as likely to develop tuberculosis as white men living under the same socioeconomic conditions. Perhaps, scientists speculated, genetic differences affected the body's ability to knock out the bacteria.

More controversial has been the search for a hereditary factor underlying hypertension. Stress and diet are known to affect high blood pressure. Racism may also play a role. But "there is so much excess hypertension in blacks that it's inconceivable to me that these factors alone are the ones that balance the equation upward," says Dr. Elijah Saunders, a cardiologist at the University of Maryland Medical System. Some researchers have even suggested that African Americans have inherited a greater sensitivity to salt. But any explanation along genetic lines will have to account for the fact that modern- day Africans do not appear to be particularly susceptible to high blood pressure.

However important it may be, genetics is not destiny. Nor is poverty, culture or racism insurmountable. In fact, a number of developing countries, working with meager budgets over the past 20 years, have surpassed many parts of the U.S. in health care. A man living in Bangladesh, one of the poorest nations, has a better chance of reaching age 65 than a man in Harlem.

Given the limited amount of government aid for preventive medicine, a few American communities have started up their own public-health-education programs. One of the most promising is in the Mississippi Delta counties of Humphreys and Leflore, where nearly half the primarily black population lives under the national poverty line. Three years ago, the Freedom from Hunger Foundation joined two state agencies to create the Partners for Improved Nutrition and Health. The program enlists volunteers, such as Bertha Thurman, to serve as health advisers in their communities. After completing a 10-week training course, Thurman has become a crucial bridge to the medical system. "We get called on to do everything from provide an aspirin to pay the utility bill," she says. "And we reinforce what the local health department has already mentioned to people."

This kind of self-help program is only a beginning. Secretary Sullivan's emphasis on individual responsibility is only a beginning. After decades of nothing but beginnings, governments at all levels need to put more effort into bridging the gap between black and white health.

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CREDIT: TIME Chart

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Life expectancy

With reporting by Julie Johnson/ Washington, Andrew Purvis/New York and Don Winbush/Atlanta