Whittling down North Carolina’s extraordinary racial disparity in death rates for prostate cancer requires finding men like Llewellyn Etheridge in places like Bertie County.
Then you would have to interest them in starting regular preventive care visits to a doctor. Then ensure that insurance somehow covered those visits and that the men showed up for the appointments.
If they were found to be sick, you would have to help them over the hurdles of treatment, including cost, logistics for being treated in another county and follow-up care.
Etheridge, a soft-spoken man who moves carefully because of herniated discs in his spine, is 50 years old. That’s the age when doctors used to tell men to begin regular prostate screening.
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In any case, because he’s black, his chances of developing prostate cancer by his age are higher; in Bertie, in Eastern North Carolina, black men are 2.4 times as likely to get the cancer than white men, and nearly three times as likely to die of it.
Etheridge, a disabled material handler, has no insurance. He would be eligible for federally subsidized insurance under the Affordable Care Act – Obamacare – but said that he got confusing information on the cost and couldn’t afford it at almost any price.
Normally when he has a health care problem, he waits until he has symptoms, then goes to Windsor’s tiny six-bed hospital.
Prostate cancer, when caught early, is almost universally survivable. It can be treated if it appears immediately dangerous, or monitored if not.
Etheridge was sitting alone recently at the Little Golden Skillet, a fast-food restaurant in Bertie County’s largest town, Windsor, that’s a hangout for African-American men. The sweet tea comes in Styrofoam cups, and a fried trout plate is $6.25.
At the next table were seven men in their 60s and 70s. Some said they get regular prostate cancer screenings.
They were asked: How would you reach younger black men who didn’t get regular checkups? They all agreed that ministers who talked it up reached some, but that only covers people who go to church.
Etheridge listened then said that he had never been screened. The last time he was at a hospital, someone told him it might be a good idea, but he’s not sure where he would find the money for a screening, let alone getting it done regularly.
One of the toughest puzzles in public health has long been how to reach black men – particularly those in rural communities – with health information and then persuade them to act on it. In addition, access to health care is often limited for those who decide to seek it.
Repeated studies have shown that African-Americans are less likely to use the medical system for several reasons, including mistrust of the white-dominated medical establishment. And with the focus by county health departments on maternal issues, black women are more familiar with the medical system and more apt to seek health care than their fathers, spouses and sons.
The question of where to reach black men with health information is as important as what information to give them. Health educators from local health departments and other outreach experts have used health fairs and screening events and public service announcements.
They also have used some less-traditional methods, notably training volunteers and ministers at black churches and encouraging them to educate men on basic health information.
Outreach efforts aimed at prostate cancer in the state seem scattered and ad hoc. There are small groups involved in the fight, such as a nonprofit organization in Halifax County, the Gregory B. Davis Foundation, which tackles public health issues mainly in Eastern North Carolina. It has conducted modest outreach events on men’s health and a fundraiser for prostate cancer education and prevention.
And sometimes it’s just individuals, prostate cancer survivors who take it upon themselves to tell pretty much every black man they meet about the importance of screening, especially their sons and fathers.
“Around here, it’s like a brotherhood,” said Maurice Davis of Roanoke Rapids, whose family started the foundation. “And if you talk to a survivor, they always know of others who got it.”
In Durham, Duke Cancer Institute operates an aggressive outreach program aimed at closing disparities. It conducts a popular annual free health screening in September for men and works with black churches all year long for outreach.
The events target black men in particular but include all races. Duke promoted one last year with marketing that included minority radio stations, billboards, even an advertisement and a story in a Chinese-language newspaper. More than 310 men came to be checked for health issues, including prostate cancer, hypertension and diabetes.
Many came in after hearing about it at their churches. It was a cheerful, diverse, almost festive scene at Duke South Clinic in Durham, with interpreters who spoke Mandarin and Spanish and men lining up to consult with health care workers. Free screening was available.
The screenings were just part of the plan. If a potential health problem were identified, “navigators,” or case managers, worked with the patients to make sure they overcame any barriers to getting health care, such as access to a doctor, transportation, payment and even fear of treatment.
Merritt Short, 44, part of the leadership at The River Church in Durham, said about 30 members of his congregation went.
Short said the higher incidence of the illnesses among black men made getting the word out a priority with the church’s pastor, Ronald Godbee.
“He is a really big proponent that our congregation remain healthy, and he had all of us men challenging each other to come,” he said.
A missionary zeal
In much of the state, though, church outreach is driven only by individual ministers who decide spreading health information is important.
At Ebenezer Missionary Baptist Church in Rocky Mount, the Rev. Thomas L. Walker, 66, has been preaching to black men about the harsh facts of prostate cancer for nearly two decades. A cousin died of it, and he was diagnosed himself at age 47.
After undergoing aggressive treatment and learning more about the disease along the way, he wrote a book, “Brother to Brother: You Don’t Have to Die With Prostate Cancer,” to reach other black men.
Sometimes he gives it away; sometimes he sells it to raise money for things such as TV public service ads, prostate cancer fliers to hand out and posters to put up in public places.
Walker talks about the disease from his own pulpit, when guest-preaching elsewhere and when on the road for gospel singing engagements.
“We try to reach them by any means available,” he said. “When I do concerts, I’ll talk about it. When I do preaching, I try to talk about it. I try to mix it in.
“It’s like Grandma trying to get the grandkids to eat certain dishes; she mixes it in with other ingredients.”
And people who are diagnosed with prostate cancer reach back. Walker said he hears from a steady stream of black men, and said that he has talked with black men as young as 39 with late-stage, dangerous cases.
Send a letter
Men such as Etheridge can often find an affordable answer to their health care problems, but often they need someone to direct them to it, health care experts say. And that can come only after someone who works in the system makes a lasting connection.
There are health education workers spread across the state in county health departments. But there are often just one or two per county, and they are spread thin, so they must focus on more widespread chronic diseases, such as diabetes and heart issues, and on general health.
“I think county health departments work pretty hard to address health care disparities, but I think that many men are just a little reluctant to seek health care,” said Lisa Harrison, director of the health department that serves both Granville and Vance counties, and head of the state public health association.
Making screening available can be easier than figuring out how to get people to take advantage of it, she said.
Her budget is tight: There’s just $50,000 for health education and promotion. Budgets like that mean counties would struggle to afford those creative interventions working through churches and barbershops.
“We need to make a good connection,” she said. “It takes a minimum standard, and we should as a state determine what is a minimum standard that would do this in every county.”
Etheridge, standing up, Styrofoam cup in hand, to leave the Little Golden Skillet, said he hasn’t received any information from health department outreach about men’s health. He said he can’t recall prostate cancer being a topic at his church.
He wasn’t sure how a health education outreach effort could get in touch with men like him, how he could be persuaded to make that healthy choice.
“Maybe by mail?”
Tuesday: Five ways to help
Sunday: ‘It’s an epidemic’
Today: Obstacles to care
Tuesday: What can be done?
A poor region
Windsor is the seat of Bertie County. With a population of just 3,600 people, the town where Llewellyn Etheridge lives is lucky to have even a tiny hospital, and the county is, too.
No other town in the county has a population greater than 1,000 people, according to the 2010 census. And in Bertie, in part because young people leave for places where jobs aren’t as scarce, people tend to be older, the median age of 42.3 is nearly seven years higher than that in Wake and nearly nine years higher than the median in Durham County.
Health in the general population there isn’t great. Like many neighboring counties – where black men also have unusually high rates of prostate cancer – it has high rates of chronic illnesses, including diabetes and heart disease.
A national county-by-county health ranking issued in March by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute rated Bertie 86th of North Carolina’s 100 counties. Two of its neighbors fared worse, with Northampton 90th and Halifax 96th.
In Bertie, the population of 20,000 is 62 percent African-American, and it’s spread thinly across the county. And it’s served by only a handful of doctors, about 4.5 for every 10,000 people, according to a community health assessment in 2013. That’s only about a fifth of the state and national averages.
About the series
This series of stories was produced with support from the Dennis A. Hunt Fund for Health Journalism, a program of the USC Annenberg School of Journalism’s California Endowment Health Journalism Fellowships.