Book Review

Health Issues in the Black Community

N Engl J Med 1993; 329:668-669August 26, 1993

Article

Health Issues in the Black Community
Edited by Ronald L. Braithwaite and Sandra E. Taylor. 371 pp. San Francisco, Jossey-Bass, 1992. $39.95 ISBN: 1-55542-477-5

Periodically, another Cassandra publishes more bad news about the health of African Americans. No one likes to see it coming because, short of eliminating racism or overhauling the health care system, there seems so little one can do about it.

This book may change such attitudes. State-of-the-art overviews, with abundant evidence of careful scholarship, describe the generally deplorable state of African Americans' health. But the message is not one of unrelenting gloom. Each chapter ends with a plan for remedying the problem discussed, and the grim statistics are put into proper perspective. The message is that low socioeconomic status, institutional racism, and adverse labeling created the problems at hand; creativity and an infusion of resources will end them.

This book consists of 25 chapters by different authors, divided into five main sections. The first describes health status in a social context; the second section deals with critical health topics including AIDS, drug use, cancer, diabetes, and violence, as well as heart disease, stroke, and hypertension. Sections on the special health challenges that face the young and the old, on health education, and on future prospects for African Americans' health complete the book.

As authors with different styles cover a variety of topics, two messages recur regularly. African American society is, as sociologist Creigs C. Beverly states, “neither monolithic nor homogeneous.” And that society, despite the deadly combination of racism and poverty, has strengths that have been ignored or discounted by the medical establishment -- strengths that must now be tapped.

Most of the writing is clear and inviting, revealing the sometimes surprising stories behind the lugubrious headlines about the health problems of African Americans. The authors are adepts who display their communication skills and demonstrate why they are prominent in their areas of expertise. Faye Wattleton writes about reproductive rights; Deborah Prothrow-Stith about eliminating violence; Byllye Avery about black women's health; Elijah Saunders about heart disease, stroke, and hypertension; M. Joycelyn Elders about diabetes; and Joyce Ladner about adolescent pregnancy.

This book is sorely needed. A plethora of articles and some book-length works have limned the ethnic disparity in discrete facets of health care for medical professionals, -- for example, Saunders's Cardiovascular Disease in Blacks (Philadelphia: F.A. Davis, 1991) and Prothrow-Stith's Deadly Consequences (New York: HarperCollins, 1991). However, relatively few books, among them R.A. Williams's Textbook of Black-Related Diseases (New York: McGraw-Hill, 1975), have attempted a more holistic view of African American health. Periodic reports like the Report of the Secretary's Task Force on Black and Minority Health (Washington, D.C.: Department of Health and Human Services, 1985-1986) and the Urban League's State of Black America (New York: National Urban League, 1976) have attempted to bridge this gap. Yet it is a gap that must be filled with adequate information and strategies, not merely bridged. Some books have covered the same topics in broader, more political strokes for nonmedical readers, but relatively few have been written for medical professionals.

This book responds to that need with state-of-the-art analyses and provides the promised “futuristic perspective” by offering strategies for the solution of questions that many seem to despair of answering. The inclusion of 30-odd authors means frequent changes in density of detail, depth of analysis, and tone. However, the quality of scholarship is consistent enough that the general impression is of a quilt, not a patchwork. The readability and wealth of detail mean that this work can be read in toto as an introduction to the issues and returned to repeatedly as a source of detailed scholarship.

The book encompasses three general styles. MacArthur fellow Avery's piece, “The Health Status of Black Women,” is clear and readily accessible to all, with more challenges to conventional wisdom and fewer citations than other chapters. She is not afraid, for example, to challenge the medical and political implications of messages such as that linking black women's high rate of cervical cancer with alleged sexual licentiousness. But Avery's contribution is atypical.

Most chapters are more scholarly and nearly as readable, like that of Prothrow-Stith, whose chapter on violence deftly analyzes the calculus of rage with ample scholarship, specific recommendations, and detailed research agendas. She makes a powerful case for the “medicalization” of youthful violence. Saunders also offers lucid prose, rich with references, to support his insights about the genetics of sodium retention.

And then, in the crocodile-tears category, there is the group of scholars who plead for a democratic clarity of speech even as they strive for pedantry. Mercifully, only one or two chapters are bogged down in arcane language here -- among them a chapter that managed to reduce the wrenching quandary of homeless women to a ponderous analysis of the obvious and an unwieldy-looking model.

This book will prove invaluable for all public health practitioners, both for overview and for reference. It will also prove a treasure-trove of reference material for all medical students and clinicians who have or will have African American patients.

The book should also be required reading for another group -- medical journalists. The authors take on the cynical mythology surrounding culturally loaded issues such as adolescent pregnancy and relieve widespread misapprehensions about the relative risks of disease from cancer to depression in lucid detail. For example, Avery points out that the intense focus on pregnant teenagers in the African American community obscures the fact that teenage whites in the United States have not only higher pregnancy rates than blacks but also the highest pregnancy rates in the industrialized world. Epidemiologist Bill Jenkins questions the wide media play given the atypical transmission of HIV by Florida dentist David Acer, an event of little public health importance, when the rapid proliferation of AIDS in a small town in the same state, which portends the “coming tragedy” of the heterosexual spread of AIDS, received little media attention.

Perhaps this recommendation should not be restricted to medical journalists. Prothrow-Stith states, “The news media report stranger, gang and racial violence preferentially, yet these are not the dominant types of violence.” Moreover, she quantifies her findings: 50 percent of the 23,000 annual homicide victims are murdered by friends, family, or acquaintances. Only 1 percent die in gang violence.

I was surprised by the fact that little reference was made to the common complaint of physicians and epidemiologists that African Americans benefit from high-technology interventions less frequently than do whites. A handful of typographic errors and indexing that did not locate such topics as “lupus” and “renal disease” despite their treatment in the text were minor annoyances.

Harriet A. Washington
Harvard School of Public Health, Boston, MA 02115