For her 40th birthday in October 2011, Khadijah Tribble had one wish: to jump out of an airplane.
“I had been planning the event for four months,” Tribble recalled.
The jump never happened. But it wasn’t because of a last-minute fear of heights or poor weather. It was the excess body weight she was carrying. At more than 300 pounds, she was 70 pounds over the skydiving company’s recommended weight.
For African-American girls who grew up in her hometown of Tuscaloosa, Alabama, being “big-boned,” or “thick,” was something to be desired. Her cousins, who were thinner, “had a tougher time than [she] did as a big girl, because people were always referring to them as ‘stick and bones,’ and telling them they needed to go eat,” she said.
According to 2011 data from the Centers for Disease Control and Prevention (CDC), Tribble’s home state ranks second in the United States (behind Mississippi) in theprevalence of obesity. Thirty-two percent of Alabama's adult population qualifies as either obese or overweight.
For Tribble, the skydive that never happened was the wake-up call of her life. She had a serious talk with her health care provider. And in December 2012, she decided to undergo gastric bypass surgery. Since then, she has dropped nearly 80 pounds. What’s more, she has become an advocate for healthy living in her predominantly African-American community in Washington, D.C.
Her story is one of the millions that highlights the close calls, cultural norms and tough conversations about health happening across Black America, as one epidemic gives way to another and the community struggles to fight back.
Today, obesity is the scourge that stalks the African-American population (as with most Americans). But it wasn’t so long ago that HIV/AIDS and infant mortality were top of mind for blacks. Though the causes, symptoms and outcomes of these epidemics are varied, their impact -- and, ultimately, their treatments -- are best understood as part of society as a whole, rather than as siloed issues whose solutions rest on any one individual or community.
Why is it, for example, that childhood obesity rates for African-American kids currently top 25 percent, compared to nearly 15 percent for whites? Why is it that African-American adults are twice as likely as white adults to be diagnosed with diabetes? Why are one in five African Americans uninsured? And why is it that black women in America are 40 percent more likely to die of breast cancer than white women today?
These problems are much bigger than genetics. And they’re disparities that cost the country somewhere in the neighborhood of $1.24 trillion every four years.
For Tribble, a look around the neighborhood she has called home for the past 13 years offers insight on some of the reasons for the disparity. Washington’s Ward 8 is a neighborhood divided geographically from much of the city by the Anacostia River, and socioeconomically by a higher-than-average poverty rate of 35 percent.
“Where I live, there is not a gym within two miles; there is one grocery store that serves 73,000 folks; there is high crime, which is a big deterrent for me being outside; and five rec centers, which are subpar at best,” Tribble said. “In terms of restaurants … there is an IHOP, a McDonald's, a Popeye’s, about six or seven Subways, a 7-Eleven, and maybe 10 to 15 carryouts,” she described.
Her observation could apply to many neighborhoods across the U.S.: a recent study from the University of Texas found that for every mile participants lived from their closest fast-food restaurant, there was a 2.4 percent decrease in their body mass index, one generally accepted metric of fitness.
In other words, Tribble’s poor community has plentiful bad options, and very few healthy ones -- an all-too-common story.
Valerie Montgomery Rice, dean and executive vice president of the Morehouse School of Medicine in Atlanta, points to stories like Tribble’s as displaying key drivers in the health disparities seen across the country.
“When we think about social determinants, we think about those circumstances in which people are born, where people live, where people play and where people pray,” Montgomery Rice explained.
And if one is born into a circumstance that provides less-than-optimal access to basics like healthy, fresh food; safe areas to exercise; and accessible medical care, it stands to reason that one’s health will suffer in the long run.
Thomas LaVeist, director of the Johns Hopkins Center for Health Disparities Solutions, believes there are several major obstacles African Americans face in obtaining those basic elements of a healthy lifestyle -- even in 2013.
“There are two categories of barriers -- one external and one internal,” he said.
On the inside: A dangerous mixture of denial, health illiteracy and cultural norms that date back to the trans-Atlantic slave trade.
“The culture evolved ... but some of the strategies that we used to survive through that period in our history are no longer functional for us in the 21st century, and are now doing harm to us,” LaVeist said.
Those harmful practices? Mistrust of the medical establishment and its recommendations, a reluctance to update treasured family recipes for a healthier era and a general lack of understanding about serious symptoms, to name a few.
LaVeist points to an even more pernicious external barrier to a healthier Black America.
“Racism plays out in many different ways,” he added. “Not only in terms of the differential treatment people receive when they go into the health care system, but also the kinds of communities people are able to live in and get access to. Because the country is so racially segregated, black people and white and Hispanic [people] are being exposed to very different risks."
One wide-ranging study published in the March 2012 American Journal of Public Health found that two-thirds of doctors held “unconscious” racial biases toward patients.
For Montgomery Rice back at Morehouse, those biases start with a lack of understanding about the culture from which many poor black patients hail. Often, that means looking beyond a patient's physical symptoms and addressing the socioeconomic factors that may be contributing to them.
"What you must do ... is look at every patient and ask one question: What’s possible?” Montgomery Rice said. “[Take] a 68-year-old woman who has limited resources, so if I prescribe for her a medication that I know she can’t afford, then I’m not going to have done her a service.
"I have to get creative about providing her with some social support if this is the only drug that she can take, or look at alternatives. Does she have transportation to get down here for the rehab treatment that I’m saying she needs to do every week?"
It’s health care professionals like Montgomery Rice who have ushered in much progress for the health of African Americans over the past several decades.
Public policy professor Sherman A. James highlighted the period from 1965 to 1980 when African Americans -- especially those living in the rural South -- experienced an unprecedented reduction in both infant mortality and deaths from cardiovascular disease. There were several key moments that helped narrow those gaps: The federal government's passage of pivotal anti-discrimination laws, such as the 1964 Civil Rights Act and the 1965 Voting Rights Act, and then-president Lyndon B. Johnson's implementation of social safety-net programs. These programs included the 1964 Economic Opportunity Act, or Head Start, and the 1965 Social Security Act, which created Medicare and Medicaid, withheld federal funds from segregated hospitals and increased funding for infant and maternal care programs.
But by the 1980s, the health gap had begun to widen again, with the federal government’s retreat from the war on poverty, the creation of the war on drugs and the ramping up of mass incarceration of African Americans.
In 1985, the U.S. Secretary of Health and Human Services' task force on black and minority health issued a report that acknowledged the stark differences between racial and ethnic minorities and white populations in the United States. And in 2002, a report commissioned by Congress to study the extent of racial disparities in health care further proved the unequal treatment of minority populations in the health system.
"If you take the long view, you have to say that we have made some progress in narrowing some of the race disparities," LaVeist said, noting the smaller-than-ever gap in life expectancy between black and white Americans, due largely to a decline in deaths from heart disease and HIV.
So how does one take those gains seen in fighting these epidemics and apply them to the obesity problem, or to the next major health crisis for black Americans?
Prevention.
Montgomery Rice recalls how the lack of quality preventive medicine during her childhood in Macon, Georgia, informed her thinking about treating people from lower incomes.
"As a child, in a single-parent household, I remember utilizing public [insurance] for our health care. I remember going to what was described as ‘the clinic,' for my pediatric care, and going to some type of mobile unit or van for dental care," she recounted. "Once we got commercial insurance [in high school], we started to do some preventive things like getting our teeth cleaned or going for check-ups before we went into a sport," she said.
Her point hits upon one of the most important conversations in America today: Whether the health care overhaul led by President Obama will actually improve the lot of African Americans.
"Just because we give someone an insurance card -- which to me equals 'access' -- doesn’t mean that they’re going to have the same experience and therefore have the same outcome," Montgomery Rice added, echoing the belief of many that the Affordable Care Act, while not a cure-all, is a cause for hope amid all of the setbacks in minority health.
With complete implementation of the law, which is slated to roll out fully in 2014,the ACA is expected to provide 6.8 million African Americans with health insurance.
Nadine Gracia, director of the U.S. Office of Minority Health, said the preventive care afforded under the ACA is what is truly game-changing.
"The healthcare law’s recommended preventive services, such as blood pressure, diabetes screening, cancer screening, (such as mammograms and pap smears), are now provided at no cost -- no copay or deductible, which were often barriers to communities of color," Gracia said.
But, many experts argue, as Montgomery Rice does, that access alone isn't enough.
"On its face, the Affordable Care Act offers unprecedented opportunities to realize or advance a vision of equity in the country," said Dennis Andrulis, senior research scientist at the Texas Health Institute in Austin, which has been tracking how certain provisions of the ACA directly impact African-American and other minority populations.
"In reality, there is great uncertainty and there’s likely to be great unevenness in the implementation of the law, which will lead to considerable shortcomings in terms of service and care of African-American populations," he said, naming 26 states that have been resistant to the law as a major cause for concern.
The ACA may not be perfect. But how effective the rollout of the law is across the country will provide a clue as to how willing the United States is in 2013 to face the very real fact that holds back success for so many: On average, it’s easier in America to grow to be a healthier white adult than a healthier person of color.
LaVeist outlined the costs for such inequity.
"As a society, we invest in people," he said, "we have public schools, we provide social services, we do things to help develop them, but then they are either sicker than they should be, or they die before the society gets to benefit from the investment that we make in [them]."
Wingspan Portfolio Advisors Blogspot
