Before I launch into the subject matter of this post, I just want to make a quick comment on the recent decisions made by SCOTUS. As a physician-in-training, I recognize that my career in medicine does not operate outside the realm of politics. It is not only the legislation regarding healthcare (such as the recent Affordable Care Act decision) that is relevant but also the other major decisions such as (1) fair housing, (2) marriage equality, and (3) clean air — decision is pending.
SCOTUS backing for same-sex marriage a huge step in combating stigma, which is such a barrier to prevention and treatment for #HIV
— The Lancet HIV (@TheLancetHIV) June 26, 2015
The legal fabric of our society gravely impacts the quality of life of our future patients and thereby their health status. It’s important, as our patients’ advocate, for us to care about politics; for us to speak up for equality (in whatever form that comes). I’m proud of my country.
This is a week in which Confederate flags fell and the LGBT flag soared.
This is a week in which marginalized populations were granted access to affordable health care, to marriage, and to fair housing. This is a week in which the United States has made important steps toward equality.
— Kristian Ramos (@kramos1841) June 26, 2015
I believe that medical practitioners have a special responsibility to the members of marginalized populations under their care. In this post, I want to discuss some issues in healthcare delivery to boys and men of color. What better time to discuss these issues than during Men’s Health Month and Minority Health Month?
Men’s Health Month and Minority Health Month are swiftly coming to a close. Over the past month, the U.S. Surgeon General (Vivek — note the casual use of the first name) as well as many health advocacy groups have highlighted issues in relation to men’s health concerns. Discussion of healthcare disparity amongst men of color has been minimal and unsatisfactory. You can imagine how excited I was to hear about the “Advancing Health Equity for Boys and Men of Color” webinar hosted by the Office of Minority Health. I found the webinar (which occurred yesterday) to be quite informative and I wanted share what I learned as well as my reflections with you guys.
Incarceration as a Barrier to Health Equity
This year marks the 30th anniversary of the Heckler Report — the Report on Black and Minority Health. This report marked the first time that a government agency / government officials convened in order to discuss the health disparities between Caucasian and minority men. Since then, some disparities are less drastic such as: (1) life expectancy and (2) vaccination rates. One disparity that has a monumental impact on the health status of boys and men of color is incarceration rates. People of color (in particular, African American males) have higher rates of incarceration. The big concern is successful integration of prisoners into society; an unsuccessful integration gravely affects health status.
Marc Mauer, the Executive Director of The Sentencing Project, mentioned in his presentation that our country is in a state of mass incarceration. From 1925-1972, there was a relatively steady number of individuals in state and federal prisons. There was a slight increase in the prison population during the Depression and a slight decrease in the prison population during World War II — the prison population was about 200,000.
Over the past four decades, there have been more than a million individuals added to the prison population — this is mass incarceration. As a country, the United States, imprisons 5x – 6x as many citizens as other countries.
The rates of imprisonment are not equal across ethnic groups. As of 2001, an African American man has an 1 in 3 chance of facing jail time at some point in his lifetime. A Hispanic man has a 1 in 6 chance of facing jail time at some point in his lifetime. Both statistics are much lower than those of their Caucasian counterparts.
Can the disparity be explained by greater involvement in crime across different ethnic groups? Not for all crimes. The most telling example is that of drug-related imprisonment. Did you know that sentencing for crack-cocaine (primarily utilized by minority populations) possession is more severe than sentencing for powder-cocaine (primarily utilized by affluent populations) possession. Yep — that piece was legislation was introduced almost a quarter of a century ago. In 2010, Congress made efforts to reduce the severity disparity but it’s still not equal. Awkward, right?
So there are more people in prison in current-day America, does that mean that America is safer? Marc Mauer doesn’t think that is the case.
How can that be? Marc Mauer suggests that as our prisoner population expands, the number of imprisoned ‘serious’ offenders has not dramatically increased. We’re essentially getting less bang for our buck at a certain point.
The collateral consequences on incarceration are diverse.
(2) Employment: broad utilization of criminal records is a major barrier to job acquisition and licensing.
(3) Public Housing: limitations on people with particular convictions as well as the family members of a previously convicted person
(4) Public Benefits: food stamp restrictions for individuals with previous drug-related charges
(5) Voting: many states do not restore voting rights after incarceration; some states such as Vermont and Maine allow prisoners to vote.
It is unsurprising that it is hard for the previously incarcerated to re-integrate into society. Legislation makes it difficult for this population to find a steady job, to find safe housing, and to eat. This is problematic and contributes to the poor health status of this population.
Should there be an Office of Boy’s and Men’s Health?
Roland Thorpe, Director of the Program on Men’s Health at Johns Hopkins University Bloomberg School of Public Health, stated that men’s health has fallen through the cracks. He mentioned that attention to / funding for maternal and child health programs is far exceeds that of boy’s and men’s health. Yet, the health concerns of men have a grave economic impact.
Thorpe illustrated this point: total direct medical care for African American men is approximately 447.6 billion dollars. Indirect costs (which includes lost productivity) is 317.6 billion dollars. This value is approximately 115 billion dollars for the Hispanic male population.
How can we resolve these issues? Thorpe suggests that research is necessary so that we better understand what factors contribute to men’s health disparities (across racial lines). Thorpe also emphasizes that approaches to repair health disparities should address social determinants of health.
Key determinants of health for men and boys of color include masculinity, medical distrust, and discrimination — these factors are not often included in studies.
I admit that I rarely think about health issues specific to that of boy’s and men’s and maybe that’s Thorpe’s point. Perhaps, the establishment of a national office would bring more attention, more funding, and more research. What do you guys think about an Office on Boy’s and Men’s Health?
There is a correlation between education and health.
The correlation between higher education and better health status has been well documented. The graduation rates of men of color are lower than their Caucasian counterparts. Graduation rates vary across state lines. Graduation rates of men of color is below 50% in Nevada; graduation rates of men of color is greater than 70% in Louisiana, Texas, Maine, and a smattering of other states. The graduation rate of men of color falls between 50-70% in majority of the states. It probably comes as no surprise, but programs have been initiated in order to increase the graduation rates of men of color. One such program is My Brother’s Keeper which was launched in 2014. More than 200 communities have committed to the initiative which aims to help all young persons (particularly boys of color) reach his/her fullest potential.
Victor Rios, Associate Professor in the Department of Sociology at University of California at Santa Barbara, studies education equity among marginalized youths. Boys of color, he says, are treated as an “at-risk” population rather than an “at-promise” population. This translates to a culture of fear and punishment. Such an atmosphere limits transformative relationship between teachers and their students of color.
Rios suggests that across institutional settings, boys of color are stripped of their dignity. It’s no wonder that the graduation rates of boys of color are low.
There is a network of discipline and control that does little to encourage the success of boys of color. Rios has termed this network the Youth Control Complex. This complex leads to health-compromising behavior among boys of color.
Tyrell, a student interviewed by Rios, speaks to the Youth Control Complex in a succinct fashion: “Man, it’s like everyday teacher’s gotta’ sweat me, police gotta’ pocket check me, mom’s gotta’ trip on me, and my P.O.’s (public offender) gotta’ stress me.”
How can we promote health equity for boys and men of color?
We invest more in punitive social control than we do on education. That’s surprising…that’s unacceptable. Rios stated: “Punishment has become the social fabric of everyday life.” I don’t disagree. This emphasis on punishment pushes boys of color out of school and into the streets. This emphasis on punishment pushes men of color out of the streets and into overcrowded jails. This emphasis on punishment creates health problems.
This webinar impressed upon me that the issue of men’s-minority health is complex. Efforts to promote health equity should address many social determinants of health. If we are able to reduce the number of incarcerated persons (by reducing mandatory sentencing for example) we could redirect prison savings toward disadvantaged communities. After all, stronger communities are healthier communities.
Feel free to share your thoughts in the comment box below.