For most of his adult life, 55-year-old Alton Graves did not have a doctor he saw regularly. He sought medical care only when the need was dire. “The emergency room was my doctor,” he said.
Graves found himself in such a situation a couple of years ago, when he developed a staph infection in an unhealed wound on his leg that eventually spread to his spine. Though he was in severe pain with a high fever, Graves still didn’t want to seek care. He says his neighbor at the time noticed he “didn’t look right,” and told the building’s security guard to call 911.
The damage to his spine put Graves in a wheelchair, but he has started seeing a primary care provider regularly since he was hospitalized. He attributes his former resistance to his distrust of “authority” writ large. Graves views medical providers as belonging to the same category as other authority figures, such as the police, whose discriminatory and harmful actions toward the Black community, he said, have proven they are not to be trusted.
Live Chair Health, a community outreach platform that targets Black men as well as other hard-to-reach groups, is working to counteract that distrust and close the life expectancy gap by connecting members of low-income communities with primary care providers and other services to improve their health.
They do so by “meeting people where they’re at” — in community hubs such as barbershops, beauty salons, churches, apartment complexes and parks — and providing practical assistance, education and incentives to take care of their health. On a recent Friday, the organization was set up outside the CVS at the Penn-North metro station in West Baltimore, where they go on a frequent basis.
The incentives often take the form of grooming services, such as barbering for men and manicures for women. Outreach events often include a barber providing free haircuts and shaves. People complete health risk assessments that include questions about chronic diseases, smoking, mental health and whether they see a doctor regularly. A LifeBridge Health mobile van will sometimes park on-site, and people can see providers and get basic health screenings.
Outreach staff can help people make an appointment with one of Live Chair Health’s listed “culturally relevant or sensitive” primary care providers or assist them in connecting to other resources for care or basic needs, founder and CEO Andrew Suggs said.
People can also log into the Live Chair Health app to schedule a doctor visit and complete other personalized, health-related tasks identified during the assessment, such as smoking cessation education. With each box checked, they accumulate points that can be redeemed for grooming services at certain barbershops and beauty salons.
Even if the person does not connect with staff or log into the app, Live Chair Health will contact them to follow up and help with setting up appointments or connecting to resources.
Suggs and partners started Live Chair Health in 2020 as a scheduling and payment processing app for hair professionals. At the same time, Sugg’s father’s health was declining and his ongoing heart problems inspired Suggs to integrate health care into his business model.
“We made a pivot into health care after realizing we could leverage community spaces such as barbershops as an access point to serve people like my father, who went in multiple times a month to help them look good,” he said.
Suggs’s father had not seen a primary care provider consistently throughout his adult life, and used the emergency room for health care. He passed away from congestive heart failure in 2020 at the age of 56 following a visit to the emergency room.
At the end of 2021, Live Chair Health began to expand to other community hubs besides barbershops, and now offers services at dozens of sites in low-income areas throughout Baltimore City and Baltimore County, as well as Prince George’s and Montgomery counties.
Live Chair Health recently forged a partnership with CareFirst Community Health Plan of Maryland, the Medicaid plan administered by Blue Cross Blue Shield, to bring outreach efforts to its members. Forty percent of CareFirst members have not seen a primary care provider in the last year — a number the organization is looking to drastically reduce, according to president and CEO Mike Rapach.
“We’re excited to see what we learn probably more than anything else, because it’s a new way to try to reach a difficult-to-reach community of people,” Rapach said. “It’s huge for us just to be able to know more and understand more of what they need and why.”
Live Chair Health also partners with two other Medicaid managed care organizations.
Distrust and distress
This distrust of the medical system is one of the many reasons why Black men are less likely to be engaged with a personal doctor than their white counterparts, which in turn contributes to their lower average life expectancy. Black men in Baltimore City have the lowest life expectancy of any demographic group in the state, at 64 years — also the age when most Americans retire. It is eight years less than the average overall 72-year life expectancy in Baltimore City.
Some of the disparity in life expectancy can be attributed to the increased likelihood of Black men developing and dying from diseases that can either be prevented or controlled via consistent access to a personal health care provider, like hypertension (high blood pressure), heart disease, and diabetes.
The Black community’s distrust of the medical system stems in part from the historical legacies of some of Baltimore’s largest medical institutions, said Lawrence Brown, research scientist at the Center for Health Equity at Morgan State University. Both Johns Hopkins and the University of Maryland are “historically segregating institutions” that either did not allow Black students to enroll or separated Black and white patients, he said.
Patient experiences, such as one high-profile case where a Black woman was discharged from the University of Maryland Medical Center in a hospital gown without treatment — as well as unethical research practices — have compounded that distrust, Brown said. This includes the case of Henrietta Lacks, a Black woman whose cervical cancer cells were taken without her consent while she was undergoing treatment at Johns Hopkins in the 1950s, Brown said, later contributing to medical advances that helped save countless lives.
“With everything that happens to Black people, they psychologically don’t trust doctors,” says Kentwion “Gravy” Rawlins, a mobile barber who contracts with Live Chair Health to provide free grooming services at its outreach sites. He says stories are passed down from Black elders who have been mistreated by the medical system, and when the mistreatment is perpetuated, the distrust becomes entrenched.
Rawlins says this is one reason Live Chair Health’s efforts are so important: The organization acts as a culturally relevant information source that can help heal distrust by educating people that “doctors are here to help,” and getting them connected with care.
Dr. Lisa Cooper, director of Johns Hopkins Center for Health Equity and the Urban Health Institute, said the conversation around trust must also focus on the trustworthiness of institutions versus just the distrust of the Black community. Institutions must focus on transparency, benevolence and competency, she said, which includes cultivating an understanding of how inequities and social injustice impact certain communities.
Distrust is not the only issue that affects the way Black men access medical care, Cooper said. They also experience greater economic and social stressors generally than white men, a phenomenon at least partly driven by discrimination in education, the workplace, the criminal justice system and other realms.
When people must focus almost entirely on survival — just keeping their heads above water and averting potential crises, like getting stopped by police — “it doesn’t leave them a lot of bandwidth” to focus on more long-term concerns like preventive healthcare, Cooper said. Black men often have competing, high-stakes demands on their attention, she said.
Research shows there’s also a gender component to men’s overall greater reluctance to seek preventive care. Even amid changing gender norms, men are still largely expected to be tough and stoic — which means they often access care only when they can no longer feasibly avoid it.
“The wording, ‘I’m fine’ is probably the most common that’s used” by Black men to talk about their health, Suggs said. “But the thing is most men are not fine, we don’t have these low life expectancy rates and high disease rates because most men are fine,” he said.
“A safe space”
Barbershops have been a common space where nonprofits and researchers attempt to reach Black men to get them involved in health programs, Cooper said. She says outreach efforts at other predominantly Black spaces, such as churches or clinics, tend to reach many more Black women than men.
Soloman Hilton, field operations manager at Live Chair Health, said barbershops are a “sanctuary” for Black men, where they can “decompress” and “talk about whatever issues they’re going through.”
Outsiders, though, must be careful to build relationships and seek participation and buy-in from those they aim to “help” before co-opting their spaces, Cooper said. She said any research or programs should be both formed and carried out through a collaborative effort between community members and health professionals. Members should be the ones to identify the most pressing issues they face and what approach might work to address them, while professionals can offer expertise on implementation and effectiveness of similar programs, she said.
“People who live in communities that are disparately impacted by negative social determinants and poor health understand their communities and their concerns much better than I do,” Cooper said.
Suggs’ own father visited the barbershop twice a month, sometimes with his son in tow, and Suggs knew it would be the best way to reach other Black men to connect them with primary care. Although Live Chair Health has diversified its sites to reach other underserved populations, such as single parents and the elderly, Hilton said, “We focus on Black men.”
Rawlins said when he barbers at other community hubs people will often talk to him about stressful situations they’re going through. Grooming services can lift people’s spirits and help shift their perspectives, he said, which “inspires them to keep moving forward.”