A Shave, a Haircut, and a Blood Pressure Test (Update)

A little while back, we brought you an episode about a really interesting study being conducted at barbershops around Los Angeles. We’re going to play it for you again, and talk about some new research of mine that touches on one of the themes in that episode: representation in medicine.

One problem for African American men, and other underserved populations, is access to health care. And part of the problem with access to care is a lack of physicians with whom these patients can identify. I spoke about this issue with one of my co-authors, Dr. Utibe Essien from the University of Pittsburgh. Our study, which was spearheaded by Dan Ly at U.C.L.A., was just published in the Annals of Internal Medicine. We looked at how state bans on affirmative action programs have impacted the racial and ethnic makeup of medical students in the U.S. It’s an issue with a lot of implications for diversity in medicine — and for patients. Here’s my discussion with Utibe, followed by a rebroadcast of the episode we’re calling, “A Shave, a Haircut, and a Blood Pressure Test”

JENA: Let me start by having you introduce yourself.

ESSIEN: My name’s Utibe Essien. I’m an assistant professor of medicine at the University of Pittsburgh, and my research focuses on ensuring health equity for patients with chronic disease, especially cardiovascular diseases.

JENA: What is it that is brought to the table when a Black male patient is seen by a Black male doctor?

ESSIEN: We all want to figure out what that mechanism is, so we can just change that and apply it to the white male doctor or the Asian female doctor. I think one study looked at time spent with patient and did show that, actually, there’s differential amount of time that Black physicians spend with Black patients compared with white physicians. I think that is something that potentially matters. There are some things that we’re just not going to be able to capture trust is a big one. Trust is built in decades and centuries of unfortunately, a health care legacy that has treated certain groups in ways that they should never have been treated. And that’s something that’s going to be really hard to break. And I do think education can play a role there, but it’s not going to be enough to be able to fix that.

JENA: Can you think of a situation where something like this came up where you were treating a Black patient who you thought had better outcomes because you were the one who was involved in the care of that patient?

ESSIEN: Absolutely. When I got into medical school — third-year medical student rotating on internal medicine and we were really struggling with communicating with one of the patients on our team, predominantly white, a couple of Asian individuals on our team. And my attending said, “You know what, why don’t you go chat with, with Mr. L. He’s someone that I think you guys could really bond with, really relate with.” And I think I kind of got what he was saying. I was the one African American member of the team. This was an African American patient. And our relationship did influence the way that we were providing care for that patient, who again, was kind of giving us the cold shoulder and not really interested in our recommendations for his care. And I think him and I really connected in a way that was meaningful, not just because that was a third year med student who had more time than the rest of my team members, but because of that relationship. And I’ve seen this time and time again throughout residency, in Boston, here as a faculty member in Pittsburgh. Patients saying, “You know, this is the first time I’ve had a Black primary care doctor,” asking if I can work with their family members or with their friends. and again, these are just conversations that I know my peers aren’t having. And this is something that I imagine a lot of my colleagues who are also African American are experiencing across the country every day. We’ve seen study after study that suggests that actually having a physician who is the same race as a patient really matters, in terms of getting health care and appropriate health care. So, we really were interested in how state affirmative action bans end up influencing the rate of underrepresented in medicine medical students. And we defined underrepresented in the same way the Association of American Medical Colleges has. So, Black, Hispanic, American Indian, Alaskan Native individuals. And we looked at these eight states that have had these affirmative action bans in 21 public schools in those states. And so, that includes Arizona, California, Florida, and a few others. And we looked at the five years after that affirmative action ban to see how their numbers of underrepresented in medicine students changed. we saw this nearly over 30 percent drop in underrepresented in medicine students, at these medical schools in states that had affirmative action bans. Policy actually influences the diversity of our medical schools and ultimately our physician workforce. As we already have been talking about, I do personally believe — and I think the data suggest — that diversifying our workforce matters for the health of our patients. If we’re not addressing this specific point, I think we’re missing out on an important opportunity to actually achieve this goal

JENA: What are things that you think that individual hospital systems/medical schools can do to address these issues — above and beyond what state policies might be?

ESSIEN: Yeah, I think we need to continue to collect and report these data. You know, we also had the opportunity to write a piece in the L.A. Times talking about the new U.S. News and World Report that’s demonstrating and grading hospitals based on their diversity in medical schools. Like, what does the diversity of these medical schools look like? Locally, I think we have to improve our efforts in our communities to actually increase the diversity of our trainees. I went to medical school in the Bronx, New York and there were 18 individuals — 10 percent of us in our 180-person class — that identified as African American or Hispanic. That just does not add up. And that is something that we must, must continue to address. And really, a key strategy used to address that is addressing the cost of medical school, which is just not accessible to a lot of individuals, a lot of communities.

JENA: A number of medical schools have actually eliminated tuition. And one of the reasons that they’ve said they’ve done that is to try and encourage students from populations that have historically been underrepresented in medical schools — be able to apply and to attend medical school. So, you know, we’ll see if those policies have worked in the way that you just outlined.

ESSIEN: I think that is one lever that we can pull or that has been shown to be pulled, erasing loans on the other side. So, whether it’s certain family medicine programs that have been helpful to try and alleviate those costs for trainees, like you mentioned — the data are still out there for us to actually examine and hopefully we’ll be able to lead some of those studies, too.

JENA: So, Utibe, I want to ask you a question, and I’m not sure how quite to ask this it’s a sensitive topic. There are political issues around affirmative action that people may disagree about. But there’s also scientific issues around the effect of affirmative action bans on things that we might care about. So, for example, if we care about the health of Black people, then bans on affirmative action policies seem to have an adverse effect on health, which is sort of a pure scientific question. There’s no politics involved in that. How do you sort of navigate the tension between how it is that affirmative action policies can affect educational outcomes, health outcomes — versus sort of the trade-offs that these policies may induce, which is why they’re so controversial?

ESSIEN: I think that a lot of my training I’ve spent trying to stay out of the fray of the “political determinants of health,” because it’s felt too icky to get involved in, too risky. And I want to be able to get my first job. I want to have the support of my — my mentors and colleagues. There is still that kind of triggering experience personally from friends who said I got into my undergrad because I was Black, who wondered if I got into medical school because I was Black. There’s a lot of personal baggage there, so to speak. I think we’ve seen improvements in diversity of Asian medical students into medical schools — American Indian, Alaska Native, and it’s not just a Black and white issue. so, having these conversations be politically driven as opposed to data-driven, science driven, but here we have the data. We have the data suggesting that this is a key lever to pull to actually achieve health equity. All of these anti-racist themes that have come out of our medical schools, our academic medical centers over the last couple of years — here’s what you can actually do to address this point. You don’t have to look around wondering how we’re going to help achieve health equity. You don’t need another huge grant from some neat foundation out there We have our lever to pull. Let’s do it. Let’s advocate for it. I hope that that’s going to be the outcome of the study rather than kind of pushing against some of the political challenges.

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In the late 1980s, Eric Muhammad was a teenager growing up in Venice, California. And he needed a job.

Eric MUHAMMAD: I wandered into a barbershop and asked him if I could help him by sweeping hair. And he said, sure. And I started sweeping hair for him and watching him cut, I learned how to cut hair.

The job kept Eric busy. Helped keep him out of trouble. And started him on a career path that he’s continued for almost three decades.

MUHAMMAD: I noticed some guys would come and get their hair cut and stay. And then you just said to yourself, ”Why is he still here?” Well, there’s a vibe here. There’s a community here. There’s a conversation going on. This is the community hub.

And that makes barbershops ideal for something else: medical care.

From the Freakonomics Radio Network, this is Freakonomics, M.D. I’m Bapu Jena. I’m a medical doctor and I’m also an economist. Each episode, I dissect an interesting question at the sweet spot between health and economics. Today: Can bringing medical care to barbershops improve the health of Black men? And can it help heal the fractured trust between the Black community and the medical establishment?

Of all the racial and ethnic groups in the United States, Black men rank lowest in overall health. On average, Black men die younger than all other demographic groups except Native American men. They’re also more likely than other groups to have undiagnosed or poorly managed diabetes, cancer, and heart disease. We’ve known about these problems for decades, and still — we haven’t made much progress. These racial disparities are partly due to the fact that history has made it difficult for America’s Black population to trust doctors. As I’ve talked about on this show before, in 1932, the U.S. Public Health Service began a study of hundreds of poor Black men in Tuskegee, Alabama, who’d been diagnosed with syphilis. The primarily white, male doctors took blood and did spinal taps, all the while advising study participants not to seek treatment, and even denying them effective medication. This exploitation continued for 40 years, until a journalist finally exposed it in 1972. Most of the men enrolled in the study died from syphilis.

The Tuskegee study caused terrible and lasting damage to Black men’s health, and their faith in medicine. In 2017, researchers found that after the Tuskegee experiments became public, the closer Black men lived to Tuskegee, the less likely they were to visit a doctor. And if they did seek medical attention, their health conditions were more likely to be further advanced. Which means: they were delaying care. The researchers also found that distrust caused by the Tuskegee study was linked decades later to a higher likelihood of Black men dying before age 75. This legacy, along with other factors, indicates that physicians need to find other ways – and maybe other places – to reach Black patients. Here’s Eric Muhammad again.

MUHAMMAD: Thinking outside of the box is what is necessary to reach the people that are outside of the box. If you stay in your office, then you’ll never see the people that are not coming to your office. Generally, in the Black community, Black men get a haircut at minimum every two weeks. Most of them get a haircut every week. How many Black men are seeing their doctor weekly?

So, why not bring the healthcare into the barbershop? Turns out that wasn’t a totally novel idea.

Adair BLYLER: There’s a long history of either health outreach in the barbershop or actually healthcare being delivered in the barbershop.

That’s C. Adair Blyler, a clinical pharmacist at Cedars-Sinai Medical Center, in Los Angeles. A few years ago, she joined a team led by cardiologist Dr. Ronald Victor. They  wanted to study whether a barbershop-based health intervention could help customers control hypertension. Rates of hypertension are higher in Black men than in any other segment of the population in the U.S. But high blood pressure is often called “the silent killer” because it doesn’t show many symptoms. You need to get tested to know you have it.

BLYLER: It’s one of the leading risk factors for negative downstream cardiovascular events, like heart attacks and strokes. And it’s one of the easiestly modifiable cardiovascular risk factors.

The researchers randomized 52 barbershops in Los Angeles County. Blood pressure testing was set up at all of the shops. But at half of them, the barbers encouraged customers with high blood pressure to meet with pharmacists right on site who could prescribe medication. In the other half, the barbers encouraged lifestyle changes and doctor’s visits, but there were no pharmacists on-site. The study lasted 12 months. For Adair, that meant a year of driving around barbershops spread across L.A. County.

BLYLER: We really felt like it was important to meet with people face-to-face. I think my being in the shop day in and day out really allowed me to establish a rapport with folks. And with that came trust, which honestly, I think we could all say is foundational to any successful relationship or partnership. And I’ve met some really incredible people through this work. There are participants I still text with to this day, and not always about blood pressure medications. We chat about the latest sports scores. We check in on birthdays and holidays. It means a lot to them, but not only to them — to me as well.

Recruiting participants wasn’t easy at first. There was an understandable skepticism about the intentions of the study and how it would feel to have doctors from Cedars-Sinai, which is nicknamed “hospital to the stars,” taking blood pressure in the middle of a local barbershop. But Eric Muhammad didn’t hesitate.

MUHAMMAD: So, I get a call one afternoon. And there’s a young lady on the phone saying they were doing a blood pressure study, and would I be interested in being a part of it? And I immediately said, “Sure, that’s no problem.”

The person on the phone that day emphasized to Eric that joining the study meant a yearlong commitment, and that a pharmacist would be in his shop regularly. She seemed worried he may not realize what he was getting into.

MUHAMMAD: And that was actually what attracted me more to the program than anything else, because we’ve had several people come in and they would be there for a day, and nothing would change. So, when she explained to me that this was a program that was going to be much more interactive and much more aggressively working towards actually eradicating the problem, then I definitely wanted to make sure that it was a success. Here’s the funny thing — I believe that most of the men that joined the study had an idea that they had high blood pressure prior to. However, they weren’t being serious about taking care of it. So, what I mean by that is most men had already seen their doctor. They’ve already been told they have high blood pressure. They were given medication and sent home. The problem with that is there’s no follow up. So, with some of these medications and some of the side effects, these men would take the medicine for a day, a week, a month, and the side effects would hit them, and they would stop. High blood pressure is called the silent killer for a reason. They feel fine. So, if I’m taking something that’s given me side effects, then why would I take them when I feel fine already? So, they would stop and then they’d see the doctor again six months later and find out that they still have high blood pressure. And that’s obvious because they stopped taking their medication.

The study didn’t just diagnose high blood pressure and move on. They embedded pharmacists into the barbershops. For the first eight weeks, interviewers set up tables at the front of the shop and Eric advised his customers to get their blood pressure checked. After that, Eric and the other barbers continued to monitor any customers who had been diagnosed with high blood pressure. They would send the readings to the Cedars-Sinai folks and every time the customers had an appointment for a haircut, they’d also have an appointment with a pharmacist. In collaboration with the customer’s doctor or a community physician, the pharmacists usually prescribed a two-drug regimen approved for hypertension. That same pattern was repeated at 25 other barber shops across the county.

BLYLER: When we, as healthcare professionals see patients in a clinic setting or a hospital setting, the relationship’s sort of dictated by the environment. It can feel a little bit formal. Meeting someone outside of the clinic or hospital setting allows you to get to know them on a deeper level.

Six months later, blood pressure among the intervention group had dropped by nearly 30 points. That’s a lot. For the group without a pharmacist on-site, the decrease was just a third of that. And Eric Muhammad says that the benefits went beyond those numbers.

MUHAMMAD: As the program went on, the pharmacists gained ease with the customers. And once you get someone to open up to you, then you can really find out what’s wrong and you can really help. And if you gain the genuine feeling of care, then you can also gain trust from that person.

Eric recalled one customer who initially refused to have his blood pressure tested. He said he already knew his blood pressure was high, and so he didn’t need the test. The gentleman actually booked a haircut for 6 a.m. on a Saturday, a time when he thought that medical people would not be there. But Eric asked the researchers to come in then, and together they managed to convince the customer to get tested.

MUHAMMAD: And then he became the biggest advocate for the study. Because once we dispelled what he thought was going to happen and then gave him genuine care, and his blood pressure began to get better, he began to take a personal reflection on his lifestyle. And he stopped smoking, he changed his diet, and he stopped drinking.

The study was published in the New England Journal of Medicine in 2018. When it came out, a reporter visited Eric’s shop and interviewed this customer.

MUHAMMAD: And the reporter asked him, what made him decide to do it and he got a little emotional and he said, “I have to be around here for my son.”

Adair recalled several similar success stories.

BLYLER: There was a barber whose blood pressure was measured and was high. Similarly, he was sort of like, “Eh, I don’t know if I want to participate.” So, he sat and watched as I met with some of his clients, and then eventually he came to me one day and said, “Okay, let’s do this.” We had to put him on three medications to get his blood pressure controlled. But over the time that I met with him, we kept talking about lifestyle modifications for him as well. And eventually, he had lost 30, 40 pounds. He had stopped smoking. Initially when I would walk into the barbershop, he was always drinking a soda and eating chips and he really cleaned up his diet. And so, by the end of the study, he needed just one medication to have perfectly controlled blood pressure.

Coming up, what can the barbershop study teach us about helping people access health care? How creative do we need to get?

BLYLER: The current healthcare paradigm doesn’t work for all patients.

I’m Bapu Jena, and this is Freakonomics, M.D.

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Here’s another part of this story that I love. The barber Eric Muhammad was included as an author on the published study. It’s a safe bet that he is one of the only modern-day barbers in the New England Journal of Medicine.

MUHAMMAD: To be named as a co-author in a medical journal on a study of this magnitude meant a tremendous amount to me. So, from my professional point of view, it helped to validate my career.

Yet among the authors, Eric was probably the least surprised by the results.

MUHAMMAD: Well, not to sound arrogant, but I already knew the value of the barbershop. I knew that it was going to work from the beginning. And my stance was sort of, “What took you so long?” Because this is something that could have been done a long time ago.

It’s one thing to show this kind of benefit in a small study, even one that stretched across all of L.A. County. It’s another thing entirely to take this approach on a larger scale. Hypertension is only one health problem that affects Black men disproportionately. And this study didn’t include Black women, who are also at increased risk for many serious illnesses. Adair Blyler says the doctor who championed the barbershop study wanted it to be just the beginning.

BLYLER: Dr. Victor always spoke about expanding on this model to include treatment of high cholesterol, diabetes. We always wanted to reach out to other at-risk populations. We’ve discussed at length, the potential to reach Black women in beauty salons and/or churches. What would this look like for Latinx men or women? At present, we’re working on sort of fine-tuning the model to make it a bit more efficient, a bit more cost effective because we know, ultimately, that will determine its ability to be replicated at scale.

Cost is definitely an issue. Remember, Adair spent a year driving to more than a dozen barbershops. That’s a lot of paid travel time for a professional to rack up. And she wasn’t the only pharmacist doing that. They were spending nearly a quarter of their workdays driving. Adair said that she and other researchers involved with the work are looking into whether telemedicine could be an option after a few months of in-person care. But, for Eric, the end of the program highlighted the beginning of a new problem.

MUHAMMAD: So, we have to do a better job of continuing the process because although it wasn’t a one-day program — it was a year program — since it ended and it wasn’t continued, it could be looked at in the community as an extended version of the norm.

Soon after the study finished, Adair and her colleagues faced another challenge: Dr. Ronald Victor, the cardiologist who started the research, died from pancreatic cancer.

BLYLER: Dr. Victor was a tremendous leader. The Los Angeles barbershop study was the culmination of probably 20 plus years of work in this space for him. And even when he was dying, he kept working fervently to create a path forward. And I think that sort of perfectly encapsulates who he was and his passion for this as well. And I don’t think I’m overstating it, but I do think the success of this study was really sort of the pinnacle of his career. And I say that knowing that his contributions to the field were already enormous. He’s sorely missed. Sorely missed.

After the study was completed, another team used the data to calculate the impact of the barbershop approach if it were applied nationwide. Their model predicted that pharmacists working on site at barbershops could reach more than 800,000 men per year and prevent more than 1,300 deaths from heart disease.

Adair still wants to see this model grow. She says the Cedars-Sinai team is taking steps towards the next phase of this work. And she says they’ve had some interest from insurance companies, which is key to making this approach sustainable.

BLYLER: The current healthcare paradigm doesn’t work for all patients. And I think it’s really important that we continue to think creatively and come up with models that are more accessible and more responsive to patients’ needs. That might mean as healthcare professionals, we have to leave the comfort of our clinics and hospitals and begin to meet people where they are.

There’s another strategy I think can help improve health outcomes for folks with high blood pressure. And that’s figuring out how to make it easier for patients to take the drugs their doctors prescribe. That’s why I was so intrigued when I heard about a recent study published in the Lancet that evaluated a new treatment for high blood pressure. It’s a very low dose of four different medications, but — here’s the thing — delivered in one pill, and it’s designed to make it easier for patients who need to take several blood pressure drugs a day. The study, appropriately called the QUARTET study, found larger blood pressure reductions in patients who received the four-drug pill compared to usual care they would have gotten with several different drugs. I’m saying this as your podcast host, not recommending it as your doctor, but anything we can do to make it easier for patients to do what we recommend, is worth thinking about.

Anyway, that’s it for Freakonomics, M.D.. You can find links to all the studies we mentioned at freakonomics.com. Thanks to my guests Eric Muhammad, C. Adair Blyler, and Utibe Essein. Coming up next week: we are living in a hotter world than ever before. So, how is it affecting us?

EBI: Mortality is quite obvious. People are injured during these kinds of events, and there’s also growing research on mental health consequences

We’ll look at research on the different ways heat impacts our health, and whether adapting to a changing climate will be worth it.

MILLER: We should be focusing our attention on how we’re going to live in this hotter world.

Thanks for listening. If you haven’t done so, don’t forget to subscribe and leave us a review wherever you get your podcasts.

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Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, People I (Mostly) Admire and Off Leash. All our shows are produced by Stitcher and Renbud Radio. You can find us on Twitter and Instagram at @drbapupod. This episode was produced by Jessica Wapner and Julie Kanfer, and engineered by Adam Yoffe and Eleanor Osborne. We had help this week from Emma Tyrrell. Original music composed by Luis Guerra. Our staff also includes Neal Carruth, Gabriel Roth, Greg Rippin, Rebecca Lee Douglas, Zack Lapinski, Morgan Levey, Ryan Kelley, Jasmin Klinger, Lyric Bowditch, Jacob Clemente, Alina Kulman, and Stephen Dubner. If you like this show or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.

JENA: So, Utibe, you had what for lunch today? You had yogurt and pasta?

ESSEIN: Yogurt and pasta man, the lunch of champions. A.K.A., I’m trying to get my fitness back from COVID.

JENA: Oh, okay. You’re trying to get beach ready. Okay.