Dennis Mitchell owns a small ground-floor barbershop in the heart of Harlem, where he presides over rows of gleaming salon chairs, cutting fades and shaves and earning the nickname Denny Moe. For years, one of the regular customers sitting in front of Moe's mirrors has been Dr. Joseph Ravenell, an associate professor in the Departments of Population Health and Medicine at New York University's School of Medicine. Barbershops have been havens for Ravenell since he was a kid, when he accompanied his father to his regular haircuts and witnessed the bonds that men formed in these safe places, "talking about everything under the sun."
As an adult, Ravenell focuses his research on the medical disparities black men face in America.
"As a man myself, and a father and a brother, I have an enlightened self-interest in the topic," he says, laughing. Black men, because of both logistical barriers and mistrust, are often cut off from health-care systems—but as he was thinking about haircuts one day, Ravenell says, "a lightbulb went off." Barbers, he thought, as trusted confidants and community leaders, could become a powerful bloc to promote health in black communities.
Ravenell began to teach barbers how to measure blood pressure and to identify clients who might be at risk for hypertension, a condition where chronically high blood pressure can cause heart failure and strokes. You can have hypertension for years without symptoms, Ravenell explains. "It's called the silent killer for a reason." Black men have the highest hypertension death rate of any group in the country—and 75 percent of black men have high blood pressure by the time they're 55.
For three years, Ravenell worked with 17 barbershops around Dallas to measure thousands of blood pressures and encourage healthy habits. The results were striking: In barbershops where barbers measured blood pressure, the number of men in each shop who achieved their target blood pressures increased by an average of 20 percent.
Encouraged, Ravenell expanded the program to barbershops around New York City. This time the barbers hosted community health workers to provide information about colorectal cancer screenings, another illness that disproportionately plagues black men. Ravenell found that men who'd spoken to one of these health workers were twice as likely to go on to get screened, compared to men who received referrals from their doctors.
Then, Ravenell did something even more revolutionary: He created an easy-to-read infographic with the hypertension and cancer screening rates for each shop and brought them back to the barbers. "The least we could do was share their own information with them in a germane and relevant way," he says.
It may sound simple, but few researchers make this kind of effort to report back to the communities they study. Ravenell calls the normal approach the "Seagull Effect"—"swoop in, swoop out." In contrast, he believes he found success in the barbershops because he communicated clearly how the community might benefit, mobilized a racially congruent staff, and left the clinical setting to meet people in their own cultural contexts.
This kind of community-based participatory research—studies that consider their subjects' values and goals, and take a collaborative approach to gaining and sharing knowledge—has been slowly gaining traction in public-health circles over the past few decades. A literature review of participatory research published between 2007 and 2010 suggests that such an approach has comparatively high success rates. Another review of 21 federally funded research centers, published in BioMed International, reports that participatory research often leads not only to successful interventions, but also to other positive long-term impacts, like resilience.
Baked into the participatory model is the idea that social and environmental factors play a huge role in how and when we get sick. Though there's a well-established body of research showing a gap in medical outcomes between genders and races, "Many people tend to assume disparities in health reflect disparities in health care, and then don't look behind it," says Paula Braveman, director of the Center for Health Equity at the University of California–San Francisco. "Disparities in health care are real and important—but not what determines who gets sick in the first place."
Black women, for example, are twice as likely as white women to give birth prematurely; for Hispanics, the rate is 25 percent. Pre-term births are a major cause of childhood development disabilities, and have been linked to everything from adult cardiovascular disease to diabetes.
Troubled by these statistics, Braveman conducted a study in 2017 asking thousands of Californian women a question shortly after they gave birth: "How often have you worried that you might be treated or viewed unfairly because of your race or ethnic group?" Over 36 percent of black women reported chronic worry about racial discrimination; disturbingly, the rates were actually highest in women with higher income and education levels. In contrast, only 5.5 percent of white women said they worried about discrimination.
Braveman explains there's consensus among neuroscientists that chronic stress can lead to activation of inflammatory mechanisms, which are thought to be involved with pre-term births. Though further research is needed, she says, "It's highly plausible that worrying about being treated in a racist way is a contributing cause of the disparity in pre-term births." That likelihood is a clear illustration of the need for science to start asking questions that delve beyond clinical settings.
Stress caused by racism doesn't hurt just pregnant women. Braveman's study only adds, she writes, to a "growing—but not widely known—literature linking racism-related stress with physical health in general." Take, for example, a longitudinal study published last year in Developmental Psychology, for which scientists at the University of Georgia followed approximately 900 black families in Georgia and Iowa for 20 years. In addition to considering factors like income, how many parents lived at home, and tobacco use, the researchers asked people how often they'd experienced discrimination. Then they took blood samples to measure small proteins called cytokines, which help direct our immune system's responses; higher levels are correlated with increased inflammation.
The scientists found that, if young people report experiencing systematic discrimination, it actually triggers biological changes, causing them to develop an elevated inflammatory response—which magnifies the impact of any future stress, and can lead to illnesses like cardiovascular disease and strokes. Racism, it seems, can literally cause disease.
Experiencing discrimination produces this response even in well-educated and high-income people. This wouldn't likely be news to Braveman: In a 2009 qualitative study, she found that education and higher incomes didn't reduce worry; they only made black women more aware of inequalities. Economic privilege, in other words, didn't help them escape the structural forces of racism—or its health consequences. Poorer, less-educated black women were simply more likely to blame themselves for their lack of success.
Behind these hard numbers is a simple but difficult truth: Personal behavior changes do not fix structural problems.
As science slowly reveals the outlines of these inequalities, community-based research like Ravenell's becomes all the more important.
"Of course we want everyone to be healthy," Ravenell says. "But what often gets lost is the root causes of those [health] disparities," including social factors, like health insurance and neighborhood safety and access to healthy food, all of the elements that can help prevent, or invite, disease.
"You really can't have a meaningful conversation about how to fix those disparities," Ravenell says, "unless you talk about underlying causes."