Are Barbershops the Cutting Edge of Healthcare Delivery?

Bapu JENA: 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, welcome to Freakonomics, M.D.

I’m your host Bapu Jena. I’m an economist but I’m also a medical doctor. And in each episode, I’ll dissect a fascinating 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?

A little later in the show, we’ll hear from former F.D.A. Commissioner Scott Gottlieb about the specific issue of vaccine hesitancy. But first, we’re going to dig into an innovative study about Black barbershops that illustrates the kind of thinking we may need to rebuild trust in the medical system. And here’s why this issue is so important. Of all the racial and ethnic groups in the United States, Black men rank lowest in health. On average, Black men die younger than all other demographic groups except Native American men. They are also more likely than other groups to have diabetes, cancer and heart disease that’s either undiagnosed or just not treated right. We’ve known about these problems for decades. And we really 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. 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 doctors, who were primarily white men, took blood and did spinal taps, all the while advising the participants in the study to not 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 the relationship between Black men and the medical establishment. Researchers from the Harvard Kennedy School and the University of Tennessee looked into the erosion of trust after the Tuskegee experiments became public. They published their findings in 2017. They found that after the Tuskegee experiments became public in 1972, the closer Black men lived to Tuskegee, the less likely they were to visit a doctor. In general, Black men were less likely to seek medical care after learning about Tuskegee, and when they did go to the hospital, their health conditions were more likely to be further advanced. That meant they were delaying care. The consequences of all of this were severe. The researchers found that distrust caused by the Tuskegee study was ultimately linked decades later to a higher likelihood of Black men dying before age 75. This legacy and many other factors, all embedded in systemic racism, mean that physicians may need to find other ways 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 it 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 control hypertension among the customers. Rates of hypertension are higher among Black men than among 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 patients wasn’t easy at first. There was this understandable skepticism about the intentions of the study and how it would feel to have doctors from Cedars-Sinai, which is nicknamed “the hospital to the stars,” taking blood pressure in the middle of a local barbershop. But Eric Muhammad didn’t hesitate for a moment.

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 pretty regularly. She seemed worried that 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[ly] because they stopped taking their medication.

The study didn’t just diagnose and move on. They actually embedded into the barbershops. For the first eight weeks, interviewers set up tables at the front of the shop, and Eric would advise 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, guess what, they would 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 repeated at 25 other barbershops across the county.

BLYLER: When we, as healthcare professionals, see patients in a clinic setting or a hospital setting, the relationship is 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. The percentage of customers who were diagnosed with high blood pressure and ended up taking a medication nearly doubled for the intervention group, from 55 percent to 100 percent, whereas for the control group, the rate went from 53 percent to just 63 percent. 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 wouldn’t 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 came to Eric’s shop, and this customer was one of the people interviewed.

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 by the end of the study, I went from putting him on three medications to down to just one medication, because 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 studies like this one can teach us about the creative approaches we need to help people access healthcare, including the Covid vaccine.

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Here’s another part of this story that I love. Eric was included as an author on the published study. I think 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.

But 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 problem that affects Black men disproportionately. And this study didn’t even include Black women, who are also at higher 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 work days 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. For Eric, the end of the program carries a risk of starting a new cycle of mistrust.

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. And if we continue to do things like that, then the validation and the trust that we are trying to receive, we will soon lose again.

The team faced another challenge. Soon after the study finished, Dr. Ronald Victor, the cardiologist who started it, 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 this study was completed, another team used the data to calculate what the impact could be if the same approach 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. In addition to saving lives, there’s actually a business-case for this approach as well. In the fall of 2019, an entrepreneur from Maryland named Andrew Suggs started bringing medical care to barbershops in the area. A large medical provider in the region joined forces to add coronavirus testing in the spring of 2020, with a plan to add screening for chronic diseases later on. Suggs is hoping to expand the business into Washington, D.C. and other nearby areas. He sees it as the beginning of a whole healthcare system based in these barbershops.

Adair still wants to see this model grow. She says the Cedars-Sinai team is taking steps toward 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.

The Covid-19 pandemic has really highlighted how important it is to make care accessible. And to borrow Adair’s words, you need to meet people where they are.

Scott GOTTLIEB: We need to recognize that for a host of reasons, including bias in the healthcare system and in our system more generally, there was a disproportionate impact on communities of color.

That’s Dr. Scott Gottlieb. He was the commissioner of the Food and Drug Administration from 2017 to 2019. I got a chance to talk to him recently about the pandemic. I asked him what he thought could improve how we reach underserved and vaccine hesitant communities.

GOTTLIEB: We set up these mass vaccination sites. That’s good. If getting vaccinated is a half a day affair that’s okay for a lot of people. That’s not so easy if you live in a city, if you work in a job where you’re sort of in shift work, where you can’t take off, where you can’t get a car to drive to a site. And so how do you create vaccinations that are accessible to people in those environments? Well, you create mobile vans. You create 24/7 vaccination sites. In urban environments, those are the kinds of strategies I think were very effective. We didn’t do that initially. We went towards the mass distribution sites, and I think that’s why, early on, you saw the rates of vaccination were much lower in communities of color.

I told Scott that the low vaccination rates that we’re seeing in some communities of color reminds me of the important research done about the long-lasting effects of Tuskegee on how much Black men felt they could trust doctors.

GOTTLIEB: Yeah, and it brings up another element, which was making the vaccines available through venues that people trust. If you can get the vaccines distributed through local organizations, through local providers, there’s a relationship there. And I think it’s going to be easier for a local medical provider to have an informed discussion with a patient to try to encourage them to get vaccinated. But once again, this wasn’t planned for, and it wasn’t the way we initially rolled out the vaccine distribution early on. And that more bespoke effort took shape, but it didn’t take shape quickly enough. It needed to be built up from day one.

You can hear more of my conversation with former F.D.A. chief Scott Gottlieb on an upcoming episode of the show. He wrote a book coming out later this fall called Uncontrolled Spread: Why Covid-19 Crushed Us and How We Can Defeat the Next Pandemic.

But before we go, I want to take us back to where we started: the silent killer that is high blood pressure. And I want to mention one other approach that I think can also help improve health outcomes for folks with this disease. And that’s figuring out how to make it easier for patients to take the drugs their doctors prescribe. We’ve talked before on the show about the three C’s that make healthcare difficult: cost, complexity and comprehension. The complexity of medical care can really be a barrier. For example, building new habits, like taking one or more new medications each day, can be hard. 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 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, it’s worth thinking seriously about.

All right. That’s it for Freakonomics, M.D. this week. You can find links to all the studies we mentioned at freakonomics.com. Also, please consider subscribing to or following the show. And, if you leave a review on Apple Podcasts or another app, you’ll help introduce the show to new listeners. Most of all, thanks for being a listener yourself. See you next time.

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Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. This show is produced by Stitcher and Renbud Radio. You can find us on Twitter and Instagram at @drbapupod. This episode was produced by Jessica Wapner and engineered by Adam Yoffe. Original music composed by Andrew Edwards. Our staff also includes Stephen Dubner, Alison Craiglow, Greg Rippin, Joel Meyer, Tricia Bobeda, Eleanor Osborne, Jasmin Klinger, Emma Tyrrell, Lyric Bowditch and Jacob Clemente. 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.