In her 1998 book Breaking the Fine Rain of Death, theologian Emilie M. Townes examines the socio-economic, cultural, and genetic factors that affect African-American health. She goes beyond the well-known fact that poverty disproportionately affects African-Americans, exploring healing models sensitive to class and cultural context, and providing recommendations relevant to the Black Church and the African-American community.

Untitled by Tricia L. Townes

Regardless of where African Americans are on the socioeconomic ladder, health problems have a greater impact on Blacks than on other Americans. Two key reasons for this are genetic and environmental. Indeed, environment and its attendant living patterns can trigger the manifestation of the genetic potential for disease in any human being. Black folks have their own traditions, experiences, and health risks.

By 1991, the Health and Human Services Annual Report on U.S. health revealed some sobering statistics: the mortality rate for African-American and Native-American infants was double that of Whites; the life expectancy for Blacks was six years less than Whites; the rate of strokes for Blacks was almost double that for Whites, and within this figure was the alarming statistic that for Blacks between thirty-five and fifty-four, the rate was four times higher . . . [dietitian and author] Barbara Dixon points out that poverty is at the base of most of the health problems of African Americans. More important, she notes that there is more to poverty than low income. There is poor diet, poor housing, overcrowded clinics, and inadequate information about health and nutrition—all these help form the foundation for larger lament about Black (un)health.

As HMOs emerged, many racial-ethnic providers were squeezed out of practices in areas where they had long ties. African-American physician Randall C. Morgan, Jr. suggests that managed care may ultimately help break down strong doctor-patient relationships as people change physicians, change plans, or see a number of physicians in the same plan rather than have their own doctor who may have generations of experience with the same family.

Morgan is also concerned that there will be fewer doctors available who know the kinds of indicators that need to be monitored regarding culture and the specific illnesses and diseases that Black genetics can foster. It is possible, says Morgan, that Black physicians may "get outbid for the managed care contract of the patients that are in their practice if they can't compete, either price-wise or access-wise, with larger groups and organizations. This is due to the fact that many Black doctors are in solo practices or in small group practices.

Yet as we approach managed care with some caution, we must also evaluate the ways in which the overall current health-care delivery system works or fails to work in the lives of many African Americans. First, Medicaid has never lived up to its promise to eliminate our two-tiered system of health care. The income restrictions have been and remain so tight that the program currently covers less than one-half of the poor . . . [A 1996 study found] that African American beneficiaries in general and Black and White low-income beneficiaries have fewer doctor visits for ambulatory care, fewer mammograms, and fewer immunizations against influenza. They are hospitalized more often and have higher mortality rates. The researchers also suggest that these patterns indicate Black folks and poor folks receive less primary and preventative care than either White or more affluent beneficiaries . . . Because of the dearth of primary-care services in poor neighborhoods, a tragic adversarial relationship has developed between public health and private medicine in poor communities across this nation. The long history of circumscribing and tight monetary control of these primary-care services has turned some neighborhoods in the United States into medical wastelands.

Doctors perceive the urban poor as difficult patients. And often the urban poor are difficult cases because their ailments have been made worse by delays in getting care. These folks may show up at doctor's offices with more of what one physician calls "sociomas"—social problems that range from not having a ride to the doctor's office, to drug addiction, to homelessness, to despair.

From Breaking the Fine Rain of Death, by Emilie M. Townes. Copyright © 1998 by Emilie M. Townes. Reprinted by permission of The Continuum Publishing Company, New York.