ATLANTA -- Decades after the civil rights movement forced America to confront racial inequities, disturbing disparities remain on one of the most basic human levels: Blacks get sick, stay sick and die sooner than whites.
From day one, a black baby's life expectancy is six and a half years shorter than a white baby's. Blacks are more likely to be born too little and less likely to survive their first year.
At work and in schools, blacks have made impressive gains. Poverty has fallen. Still, disparities in health remain and in some cases are worsening -- even among middle-class blacks with health insurance and college degrees.
Asthma, hypertension, cancer. Name the disease and chances are blacks face a higher risk. They're nearly twice as likely to die of a stroke than whites, 40 percent more likely to die of heart disease. Blacks' cancer death rates are 35 percent higher.
Other racial minorities also face disparities -- Vietnamese women have five times as much cervical cancer, and American Indians have twice as much diabetes than whites. But among African-Americans, the gap cuts across nearly every major disease.
"We have been -- and remain -- two nations: one majority, one minority -- separated by the quality of our health," said Secretary Donna Shalala, whose Department of Health and Human Services has launched a $400 million program to attack the problem. "The time has come to stop accepting disparities with resignation."
It's 9 a.m. and 26 people wait at the West End Medical Center in a poor part of Atlanta.
"We're in the trenches here," says Dr. Miguel Stubbs, who like most of the staff and patients is black.
On the first floor, pediatricians give immunizations with a shot of advice about reading aloud to children. Upstairs, nutritionists counsel diabetics to avoid sugar. Midwives encourage pregnant women to stay away from cigarettes.
The problems are multifaceted. It's poverty and the poor access to care that comes with it. It's nutrition. And it's a health system that blacks don't always trust -- and that's not always trustworthy.
Standing in West End's gray hallway, Lillian Boodle waits to talk with a nutritionist about her diabetes. She doesn't always take her medicines because they're so expensive.
"I take it one day and not the next," she says. "I don't discuss it with the doctor because I know he wouldn't agree."
It's not unusual for poor patients to take medicine every other day to stretch out a prescription, doctors say. And blacks are more than twice as likely as whites to be poor and nearly twice as likely to be without health insurance. That means they're less likely to see a doctor.
Health care, particularly preventative, has to compete with so many other things, said Dr. John Maupin, president of Meharry Medical College in Nashville, which has trained 40 percent of the nation's black doctors and dentists.
"You're trying to deal with everyday survival -- with everyday issues of food, clothing and shelter -- and someone wants to tell you how to prevent a problem 20 years from now?" he said. "That's not going to be a priority."
Still, health problems go beyond the ability to pay. Hispanics are less insured and poorer as a group, yet the health gap between Hispanics and whites is not as dramatic.
In fact, health disparities persist even among blacks who are in the middle class. Health improves for all races as income and education increase, yet the gap between blacks and whites remains.
Why? Public health experts note that even middle-class blacks face extra stresses of living in a white-dominant society that still contains racism.
And they suggest that some middle-class blacks may have grown up poor, with early influences still affecting their health.
"You're never dealing with a person just today. You're dealing with everything they've been exposed to throughout their lives," says the nation's surgeon general, Dr. David Satcher. "Does it ever end? Our hypothesis is that it never ends."
Indeed, a legacy of poverty can affect diet, perhaps the single-most important thing people can do to improve health.
It's harder to find good, fresh produce in many inner-city grocery stores. While fancy supermarket chains offer the best foods at low prices for suburban shoppers, the poor often rely on mom-and-pop stores.
Dr. Claud Young, who has practiced in inner Detroit since 1961, believes poor eating habits go back to the days of slavery, when blacks had few choices. Even when black people, especially young people, become more affluent and eat better, some foods remain a cherished part of their lives.
"I loved pig tails," Dr. Young says. "I don't eat it much any more, but I still eat it sometimes."
At West End, nutritionist Garima Mathur teaches new habits to those with diabetes, where a strict diet can be the difference between relative health and losing a limb or eyesight.
Erronteen Evans meets weekly with Mathur, reviews her menus, steps on the scale and checks her blood sugar level.
A 65-year-old retired school teacher with diabetes, she loves fried foods, dumplings and sweet potato pie. Her mother put salt pork into vegetables, so she did too.
Living outside Chicago, she says she never felt much peer pressure to lose weight among black friends. Dr. Satcher remembers the same thing growing up in rural Alabama.
"It was not unusual for people to see someone who was overweight and say 'My goodness, you look healthy,"' he said.
Mrs. Evans has lost more than 50 pounds and her blood sugar level has come down since she started exercising and watching what she eats.
"Last night I thought about you when I had ice cream," she tells her nutritionist. "I had only one scoop."
Overall, biology plays only a small role in explaining racial health differences, because people of the same race often have vastly different biological makeups.
But it does explain some of the gap, experts say.
Sickle cell anemia, a crippling, painful and sometimes deadly disease, afflicts blacks almost exclusively.
Black men have higher levels of a certain growth protein linked to prostate cancer. According to another recent study, black smokers appear to absorb more nicotine than white smokers.
Studies also have found that blacks' blood vessels react differently than whites' do, helping to explain why they are more likely to suffer from high blood pressure and heart disease.
And just this month, researchers reported that interferon, the most commonly used drug against chronic hepatitis C, is much less effective for blacks than other racial and ethnic groups.
Even blacks who have access to the health care system might not trust it.
A national poll by the Kaiser Family Foundation and the National Association of Black Journalists found blacks are much less likely to trust health information from doctors, government and the media. Seventy-nine percent of whites said they always or most of the time trust doctors and other health care providers; only 63 percent of blacks agreed.
That distrust is evident when the government tries to recruit blacks for research trials, Satcher adds. If blacks aren't in trials, it's difficult to assure the results apply to them as well as whites.
Robert Mayberry, studying the racial health gap at Morehouse College, says his own family doesn't trust the system. An aunt went into the hospital, was diagnosed with cancer and died quickly. "From their standpoint, she didn't have cancer before she went to the hospital," he says.
Many remember the Tuskegee experiments of the 1930s, when the government left Alabama men untreated for syphilis to see what would happen.
"You just don't go beyond that experiment in a short period of time," said Mr. Mayberry. "There's a tremendous fear factor."
Sometimes, outright racism has prevented blacks from getting topnotch care. And there are more subtle problems.
Some white doctors and nurses don't ask the right questions, or won't see patients after hours, said Dr. Aaron Shipley, a black pediatrician who has practiced in Jackson, Miss., since the mid-1960s. "They're not members of the community. That matters."
The surgeon general agrees, saying some doctors use language that their patients don't understand.
The situation is exacerbated because there are relatively few black doctors. With affirmative action programs declining, many fear it will get worse.
Then there's Angelita Covington, a black pediatrician at West End who uses her life experiences to relate to patients.
"Are you reading to him? And singing?" she asks Deanna Ludvig as she examines her infant son. "Do you have a smoke detector at home?"
She asks teen-agers what they want to do when they grow older, and when one girl says she's thinking about fixing hair, Dr. Covington asks, "What about computers?"
"I was raised by my grandmother," she explains. "Their lives are not so different from how my life started."
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