Dear Black men: We can all be Superheroes
I went for a colonoscopy at the ripe young age of 49, a little over two years ago. I wasn’t experiencing abdominal pain, weight loss, rectal bleeding, or black tarry bowel movements. I had a primary care provider and insurance that allowed me the opportunity to set up the appointment with a colorectal specialist for the procedure at minimal cost. I was working a full-time salaried position and had the privilege to schedule an appointment without having to worry about a workday’s pay.
The evening before I ingested a liquid concoction that tasted like cherries but whose sole purpose was to evacuate my entire colon. Instead of giving me superpowers, this elixir forced me to be on the toilet for most of the night and I had the chaffing to prove it. My nephew drove me to the clinic the next morning, where I encountered a pleasant and affirming medical team. The surgeon doing the procedure explained everything with precision and intention while making sure I had no questions. They made me count backwards “5…4…3…” and the next thing I knew I awoke in a recovery room, hazy like I had drunk too much tequila the night before. The colorectal surgeon came in.
“Everything went well,” he exclaimed. “Found a small polyp I didn’t feel was cancerous but removed it and sent to pathology to make sure.”
I left the ambulatory suite without incident and with instructions to follow up in five years.
A week later the biopsy results came back negative.
I was blessed to have the experience I did with getting a colonoscopy. Thinking back on it, I probably should have gotten the procedure earlier, as I knew that the American Cancer Society and the American College of Gastroenterologists had recommended earlier colorectal cancer screening (particularly for people of African descent) starting at 45 years of age. I wasn’t fighting these guidelines, but adhering to them wasn’t necessarily anything I was looking forward to for a variety of reasons: having to take a preparatory regimen that makes your bowel movements sound like urination; up all night going back and forth to the bathroom; being put to sleep; having a tube with a camera put up your butt and the image displayed on a TV screen for the entire medical team to see; getting pieces of tissue inside your colon removed or biopsied while sleeping; the fear of being diagnosed with colon cancer.
Its human to feel that none of this sounds good. Even clinicians in the medical field understand this.
As a Black man and an internal medicine physician, I know the importance of colon cancer screening, and am particularly aware that Black and Hispanic non-whites have lower rates of screening than our white counterparts, and suffer higher rates of mortality from this disease as well. Rates have also been going up among younger populations at a time when many still believe colon cancer is just an older person’s disease.
Chadwick Boseman died from colon cancer over a week ago at the age of 43. His untimely passing shook me to my core. It has been noted that his death is like when Christopher Reeve, who played Superman in the 1970s movies, died at age 52 from complications due to a spinal cord injury that had left him paralyzed years before. Except with Chadwick, it was sudden. There were no media reports documenting his insidious decline from action hero to mere mortal. One day he was here. The next he wasn’t.
Chadwick Boseman was our Superman. He was our Black Panther. He was our African warrior. Hearing the news of his death was a shock, but the bigger surprise was realizing that he had been fighting colon cancer and enduring surgeries and other treatments for four years — while continuing to film movies. Only the people closest to him knew what he was going through, and only they can speak on his journey through screening, diagnosis, and treatment while everyone else speculates.
A local news reporter reached out to me as she was planning to do an article on “why Black men are not getting screened for colon cancer.” My immediate reaction was that it would likely be a piece detailing and placing all the blame for racial inequities in colorectal cancer screening and mortality on Black men ourselves, as if the personal desire not to screen is the only factor to consider. True, issues such as fear of a cancer diagnosis and the procedure itself may serve as barriers, as do lack of health insurance, cost, and a justified distrust of medical systems.
Anecdotally I have heard many Black men, particularly heterosexual men, profess discomfort with the notion of having a healthcare provider put a finger up their butt as a colon cancer screening test, much less a long tube with a camera. Some feel it compromises their masculinity, as if allowing such a procedure to happen puts you on the express train to Gayville, adorned in a rainbow flag and newly-discovered effeminate mannerisms. Others just see the anus and rectum as an anatomical conduit for the excretion of waste, not the insertion of anything. Any procedure involving the anus could also serve as a trigger to a childhood sexual assault or another traumatic event that deters one from seeking this preventive screening. Many other explanations exist, some expressed by Black men, yet echoed by men of other races and ethnicities as well. We don’t have a monopoly on these sentiments.
Yet individual level considerations and responsibility when it comes to colon cancer screening among Black men are only part of the picture. Yes, while being unemployed and uninsured can be barriers among Black men in the United States, many insurance companies choose not follow earlier screening guidelines and won’t fully cover screening procedure costs unless symptoms are documented as present. Moreover, different states may have varying policies regarding coverage of colorectal cancer screening so that people who are uninsured or underinsured can have access to this preventive health and wellness recommendation.
If one can hurdle those structural, procedural, and insurance-related barriers, there may be dynamics between medical providers and Black men as patients that dictate if colon cancer screening is recommended or not. Similar to inequities in receiving optimal care for pain, cardiovascular procedures, or HIV prevention/treatment, Black people are less likely to report receiving a colorectal screening recommendation from their provider than their white counterparts. Racial and gender concordance between physician and provider has also been found to be associated with higher rates of colon cancer screening. In other words, an employed and insured Black man could go to a medical facility seeking colon cancer screening and be turned away — not because his request goes against medical guidelines, but simply because a clinician’s racial bias sees him as unworthy.
None of us know if any of these circumstances played a role in Chadwick Boseman’s untimely passing at such a young age. We can say that he had the access to screening and medical treatment, and who knows if anything else would have changed his eventual outcome. There are clear recommendations from the American Cancer Society about colorectal cancer screening, and insurance companies are mandated to cover costs including deductibles and copays for this preventive procedure. Those without insurance may have more difficulties taking advantage of early colon cancer screening, and may be dependent upon local state-run initiatives, as a successful one in South Carolina demonstrates.
What I do know is that Chadwick Boseman, a brilliant actor, scholar, and community advocate, is no longer with us. He handled his diagnosis and treatment journey in private and with selfless grace. Considering this, we can honor his legacy and work by exercising our personal responsibility as Black men to educate and empower ourselves and our communities to seek out colorectal cancer screening in medical settings. At the same time, we must hold our healthcare systems and their staff accountable for meeting us at our level of knowledge and empowerment, not letting institutional and personal bias dictate who is worthy of this screening. For ourselves, our loved ones, and our patients, this is the opportunity to be like the superhero Chadwick Boseman truly was.
David Malebranche, MD, MPH, is a board-certified internal medicine physician with expertise in sexual health and HIV/STI prevention and treatment. He is also a public health official, activist, and educator who lives in Atlanta, Georgia, and appears in the YouTube series “Revolutionary Health” as part of The Counter Narrative Project and also on the #AskTheHIVDoc video series. Dr. Malebranche’s writings and research have been published in JAMA, the Annals of Internal Medicine, the American Journal of Public Health, and Lancet. In 2015, he penned a memoir entitled “Standing on His Shoulders,” about his relationship with his father, which is available on Amazon.