This article first appeared in the St. Louis Beacon, Nov. 22, 2009 - Thanks to Medicare, the federal health insurance for the elderly, African-American seniors enjoy unprecedented access to medical treatment -- and yet their health status still lags relative to whites.
One explanation is the Jim Crow effect, what Harvard epidemiologist Nancy Krieger calls the price many elderly African Americans pay in old age for poor treatment during the years when health care was segregated and programs like Medicaid didn't exist.
Dr. Consuelo Wilkins, an associate professor at Washington University Medical School, says there's truth to that argument.
"Because of the direct effect of racism on that age group," she says, "people weren't given equitable care, had to go into different entrances to hospitals ... all sorts of thing happened that made them skeptical about the health-care profession."
The challenge now, Wilkins says, is to teach older adults that aging and illness don't have to go hand in hand. Seniors can remain fit and independent and deal with health conditions that their bodies began developing when medical services were segregated and inequitable.
Wilkins directs a program called CARE in Our Community. CARE stands for Collaborative Assessments to Revitalize the Elderly. Its aim is to take prevention to seniors in St. Louis, offering them help ranging from bone density screening for osteoporosis to therapy to help the elderly stay fit and healthy.
"A lot of older adults expect to be ill," she says. "One thing that really bothers me as a geriatrician is that they don't complain. They think, 'I'm old and I'm going to get sick.' Because of past experiences, they really don't think they should go to the doctor unless they are very ill."
Wilkins says she encourages the elderly to think beyond the obvious health concerns, such as diabetes and heart disease. Too few of them, she says, think about mobility, the ability to cross a major intersection, for example, as an important sign of health.
"A lot of people have arthritis and break bones as they get older. These things are likely to have more of a functional impact because they don't exercise and stay as active as they should. They worry about things like blood pressure and diabetes. These also are important, but don't keep them from going to the grocery store or church or interacting with family."
CARE at the Y
Wilkins is delighted whenever she takes the CARE program to the Monsanto Family YWCA , 5555 Page Boulevard, where she sees many older folks she wishes others would emulate.
"If I remember correctly, it has the largest percentage of older African Americans than any Y in the country," Wilkins says. "When we go there, we have to struggle to find new ways to keep them active because they are very, very active people."
A recent study about health-care inequities found that residents in north St. Louis, where the Y is located, have the most serious health problems in St. Louis. But you'd never know that from the energetic crowd of seniors at the Y. There's no visible Jim Crow effect on this Wednesday morning.
On a typical morning, elderly Y members spend time doing cardiovascular exercises in the pool, low-impact aerobics and line dancing in the gymnasium, and working out on treadmills and other machines.
Augusta "Gus" Boyd, 81, a retired waiter, goes three times a week. Like nearly everybody else, Boyd comes as much to socialize as to exercise. "I like to see people come in smiling and not have a frown on their faces," he says. "That's not me. Exercise keeps me in pretty good healthy. At least that's what my doctor tells me. But I'm really here because of my kids. They enrolled me in a membership six or seven years ago. I tell them I'm protecting their investment."
In another part of the building, Marcella Piper, 85, a retired guidance counselor, has joined other seniors in a light, slow-paced "aquacise" in the pool. Piper, a niece of the late photographer Gordon Parks, says she likes the social atmosphere at the Y as much as she enjoys her three-times a week workout.
"I have arthritis in my right leg, and my doctor prescribed the water exercise program. It's hard work, but I know that I feel better whenever I get out of the water. I also use the treadmill, and I read while I'm doing that. I wish I could encourage all seniors to participate rather than stay home and watch television."
At age 67, Diane Nathan is one of the younger seniors there. A retired nutritionist, she knows better than most the value of a good workout and good eating habits. She enjoys the company at the Y so much that she drives from her home in St. Charles daily to join friends, including college sorority sisters, in aerobics classes and line dancing.
"People do have legitimate excuses for not being here," she says. "Some lack transportation and others are afraid to come out because of the (crime in) neighborhoods where they live. But I think some just haven't bought into the importance of exercise because we haven't done it all of our lives."
The woman who coordinates the morning programs for seniors is Jessie Scott, 75, who joined the Y a few years ago to swim, work out and keep a healthy blood pressure. As coordinator, she focuses on social events as well as exercise activities. One event she and others look forward to was the popular Tuxedo and Tennis Gala, a dance to help raise money for Y activities. The annual event now takes place at a downtown hotel. When the gala began nine years ago, it was held in the Y's gymnasium. Participants were told to wear tennis or track shoes so they wouldn't harm the floor. Now, everybody still shows up in tennis or track shoes.
Beyond Racial disparities
Although a recent study showed that racial disparities in health care are widespread in St. Louis, Wilkins says research is beginning to show not all health problems are due to racism.
"We talk about heart disease and diabetes being more common among African Americans. But there are lifestyle factors, such as diet, the things that you eat, as well as access to health care and socio-economic status that play into your likelihood of having diabetes or heart disease."
Researchers are beginning to examine biological factors that previously were not thought to affect common health problems. One example, she says, is vitamin D deficiency.
"Vitamin D is a hormone made through exposure to sun. The darker your skin, the less vitamin D you make. You can take 10 different people, even if all are African Americans with different shades of skin, and everyone is going to make a different amount of vitamin D."
Inadequate levels of vitamin D may be related not only to osteoporosis, she says, but to other deficiencies, such as high blood pressure, diabetes and heart disease.
"We have for a long time really disregarded a lot of the potential effects of vitamin D deficiency. We didn't think it was as important, but now we're learning it's probably much more important than we think."
It's one reason CARE emphasizes vitamin D at the Y and makes sure residents receive free advice on this and other issues that affect the mobility and well-being of the elderly.
Wilkins came to St. Louis a decade ago after completing medical school at Howard University, with plans to head for Duke University for a geriatric medicine fellowship. A few months before leaving for Duke, she met her future husband, Kenneth Wilkins, also a St. Louis physician. He wasn't interested in moving to North Carolina, so they looked around and she found that Washington University had a similar program in geriatrics, which brought her to St. Louis. Her husband, meanwhile, did his family medicine residency at St. Louis University.
"We had planned to be here a few years, but 10 years later, we're still here," she says, smiling.
No matter where she landed, Wilkins would have worked to increase the number of black doctors. She has headed the Mound City Medical Forum, an organization that represents African-American doctors; she also is health editor for the St. Louis American weekly newspaper. When she first walked the corridors at the med school or at BJC, she saw few physicians who looked like her, but now she's noticing more.
"We have a number of training programs at Washington University and Barnes. It's unusual to see more than one African American in any one of them at a time."
But during the last few years, she says, "we've actually had somewhat of an influx of African Americans, and that was a head turner for me. We're making progress but not enough."
She stresses that point to make another: "If we are going to tackle the issues affecting the community, we need to get more (minority) health professionals in the pipeline, not just physicians but health professionals in general.
"If you look at who takes care of minorities, it's going to be people who have something in common with the community. Minorities are more likely to give back their service to the community and work in the underserved areas."
Meanwhile, she wished more blacks would learn what the elderly members of the Monsanto Y have discovered. These residents know they will not be able to erase all the side effects from the Jim Crow era. But, in their old age, they also know that regular exercise and other measures, like those through CARE, can keep them healthier. In the Y's program, many just might have found one key to longevity.