“The Invisible Man”

Research by: Keith Elder and Keon Gilbert, both of Saint Louis University School of Public Health

“He is missing from the health care system. He is less likely to hold a job that provides health insurance. Otherwise, he is underinsured. Despite chronic poverty that cries out for relief, he often slips through the cracks of a frayed social safety net. Medicaid, focused on pregnant women and children, rarely includes him. He bears a disparate burden of disease. He dies early and struggles frequently against structures that render him invisible.”

That reflection, delivered by Keith Elder, flows from the shared mission he and his colleague Keon Gilbert have embraced: bringing Black men into public conversations about health, health care, and health reform. They say their goal is to spotlight the dire need for more resources focused on Black men.

Elder, PhD, MPH, chairs the Department of Health Management and Policy at Saint Louis University’s School of Public Health. His work moves beyond disparities and dysfunction, expanding the research to expose the breadth and depth of Black men’s health issues from cradle to grave. Gilbert, DrPH, MPH, MPA, an assistant professor in the department of Behavioral Sciences and Health Education, focuses on outreach, education, and interventions that increase Black men’s access to social capital in order to improve overall health outcomes.

Keith Elder

Keon Gilbert

Gilbert’s goal is to redefine Black men’s health—and not just as wellness, illness, or an absence of disease. “Black men should embrace the broadest definition of health, including how health can fuel their educational and economic ambitions, their dreams, and their well-being,” he says.

They are co-authors of two recent studies: “Men’s Health Disparities in Confidence to Manage Health,” published in the fall 2013 issue of the International Journal of Men’s Health, and “Trust Medication, Adherence and Hypertension Control in Southern African American Men,” which appeared in the American Journal of Public Health in December 2012.

They both credit New Connections—a Robert Wood Johnson Foundation (RWJF) initiative that works to expand the diversity of perspectives informing RWJF program strategy—with helping to enhance their research agendas, and deepening their network of scholars and support.

Elder (a 2009 New Connections alumnus), whose research marked some of the seminal data on Black men’s health status, encouraged Gilbert to seek RWJF support. A current fellow, Gilbert is using his New Connections grant to engage Black men around access to the Affordable Care Act (ACA).

The goal is to understand how to help those without insurance obtain it, and to persuade those who have it to use it more often by seeking routine and preventive health care services.

Black Men Missing From Health Care Conversation

One of the first hurdles confronting Black men is health coverage. Second, and more fundamentally, many Black men do not readily access health care even when they are insured. Elder notes that Black men with health insurance are two times less likely to use it than other groups.

“Black men are one of the hardest groups to reach. No one is looking to engage them, and they are just not plugged into the systems,” says Gilbert.

Education and outreach, vital to improved health status, are not isolated from the other challenges to advancing Black men’s health. “We have to expand the science when it comes to a myriad of processes, from access to health care outcomes,” says Elder. His New Connections research focused on predictors, perceptions, and evaluation of health care quality by Black men in non-emergency medicine.

“Our published research is important, but the people we need to reach aren’t in the academic world,” says Elder. “They are in the barbershop, on the basketball court, and in communities that are medically underserved.”

Health Disparities’ Effect on Black Men

The health disparities suffered by Black men are stunning: The death rate from heart disease is 30 percent higher than that of white male counterparts; from stroke, it is 60 percent higher. The diabetes death rate is 200 percent higher for Black men, and the death rate from prostate cancer is more than 200 percent higher.

Gilbert notes that the disparities exist in specific outcomes, such as chronic disease and unintentional injuries. “These are the barriers men face starting early in life, when those diseases begin and then manifest over time,” he says. “The question becomes, what can we do in the realm of prevention? And what can we do to address social determinants that may limit opportunities for access to care, education, and quality employment?”

He suggests that encouraging young men to complete high school and go to college may be one answer. Paying attention to their health at an earlier age is another solution.

Gilbert points out that another impediment comes from Black men’s sense of self, perceived masculinity, and gender identity.

He adds that they are not socialized to go to the doctor on a regular basis: Research shows that men younger than 18 tend to go to the doctor when prompted by a parent, or because they are active in sports, but after the age of 18 health care utilization drops off dramatically.

Moreover, says Gilbert, there is a history in America of rendering Black men invisible, which puts them at greater risk. He believes engagement has to start on parallel tracks, in small, incremental, and systemic measures. “When men have the opportunity to talk about things that are important to them and participate in decision-making, it almost always makes a difference. It increases their engagement and the chances of improved outcomes.”

This spills over into policy as well. Gilbert notes that the states choosing to expand Medicaid provisions under ACA now include people with felony convictions, who previously were ineligible for Medicaid coverage. This provides an important opportunity to introduce and expand access to a large segment of the excluded and marginalized population.

Familiar Settings, Fresh Dialogue

Gilbert says men have to be part of the discussion in varied situations. “The conversation has to happen at the dining room table…in churches, barbershops, fraternities, and other settings. There’s a need to really focus and dig deep, to expand the definition of manhood—your need to be healthy, eat a good diet, and get exercise and health screenings. It’s not just taking care of your families and communities, but understanding that you must be a healthy participant in your family and community.”

Elder underscores the importance of access, coupled with trust in the medical system. “From a medical encounter and management perspective, we need to make sure the experience is good and fruitful. That’s what the Affordable Care Act can do. Men need a good medical home.”

According to Elder, a good medical encounter includes every interaction. “From the time they enter the door, with the first person they meet, that first interaction has to be positive. The encounter with the physician should be participatory,” he says.

Elder explains that physicians should offer information, but also listen and engage the patient, adding that patients need to be active in the encounter. “I know I have to take the lead in my health,” he says. “I take a detailed approach during my doctor visits, and I always plan to do a lot of talking and ask questions during the medical encounter.”

He emphasizes the importance of recognizing that good health practices needn’t be restricted to a doctor’s office. “We have to manage the prevention and self-care for ourselves.”

 Ending Disparities, Building a Culture of Health

Elder believes the answer is to take steps in the right direction. “Health disparities are not going away in our lifetime,” he says. “Even men who know better don’t do better. Black men still don’t have a 100 percent adherence rate to medical advice.”

The challenges can be combated by a national and sustained commitment to researching Black men’s health throughout the lifespan. No one has really taken a systemic look at Black men. Gilbert adds, “The majority of research is focused on cancer, violence, or HIV.”

Elder advocates for more funding and support at the undergraduate and graduate levels. This will build a pipeline of students who will increase their educational achievement and expand the cadre of scholars devoted to Black men’s health.

“If we don’t have the science, we can’t change the policy and how we deliver care. Who are you going to compare Black men to?” Elder asks.

Both Gilbert and Elder conclude that Black men are not monolithic, but have too often been reactive: waiting for a health crisis to arise before taking action. Engaging Black men more directly through peer and family networks can empower them with the skills and resources to attain better health.