Cutting Blood Pressure
Feb 25, 2019 Sherry Angel
Dangerously high blood pressure affects African-American men more than almost any other group in the world. Yet many go untreated because they are ill at ease in the doctor’s office. A Cedars-Sinai clinical scientist navigated around this problem by meeting these men on their turf: the barbershop. The new model of care teams pharmacists with barbers to fight the deadly health epidemic of hypertension.
Nothing brings Xavier Chavis more peace than cruising through the larger-than-life landscape of California’s coastal Highway 1 on his shiny Harley-Davidson bike.
With the wind on his face and the “craziness of L.A.” behind him, he can think clearly and put things in perspective.
“There’s no traffic, no smog, no skyscrapers. I get in line with nature,” he says. “You can solve all your problems out on the open road. Just go down your list.”
The Compton resident recently turned 50 and celebrated by buying a black 2018 Road Glide Ultra with a Milwaukee-Eight engine that has more power and a smoother ride than the five other bikes he has owned since his mid-20s. He calls it “Black Mamba,” after a deadly sub-Saharan African snake known for its strength and agility—a nickname borrowed from one of his favorite basketball stars, Kobe Bryant. Chavis says the bike provides a big incentive to remain vigilant about his health.
“When you reach this age, it gets real serious health-wise. Now I really have to watch it if I want to live long and keep riding my Harley,” says Chavis, who has hypertension and Type 2 diabetes.
As his milestone birthday approached, he found the help he needed in an unexpected place—at the barbershop a mile from home, where he’d been getting his hair cut for years.
Chavis was part of a landmark Cedars-Sinai clinical trial that engaged 52 African-American-owned barbershops across a 450-square-mile area of Los Angeles in an effort to help patrons lower their blood pressure. The late Ronald Victor, MD, who led the study while serving as director of the Hypertension Center in the Smidt Heart Institute, saw an opportunity for barbershop patrons to swivel from a cut and shave to a potentially lifesaving visit with a pharmacist. This turned out to be a winning combination to combat hypertension, a major health problem that has a disproportionate impact on African-American men.
Xavier Chavis had never spent more than five or 10 minutes in a doctor’s office. “Coming to our playing field was a smart move,” he says.
A North Carolina native who left the South in 2005 to join his future wife in Los Angeles, Chavis has had high blood pressure almost as long as he’s been riding motorcycles. He has a daunting family history of heart disease, and was only 20 when he was diagnosed with hypertension while serving a four-year stint in the U.S. Marines.
In the rural community where Chavis grew up, people only went to doctors in a crisis. He knew, though, that hypertension puts you on that road. But even multiple physicians’ visits over the years failed to stabilize his blood pressure at a normal level. At times, it was dangerously high—even with medication.
Time was a factor. Chavis says he never spent more than five or 10 minutes in a doctor’s office. “It was always rushed.”
The barbershop study offered an entirely different healthcare experience in a relaxed setting.
“Coming to our playing field was a smart move,” Chavis says.
Called the “silent killer” because it usually has no obvious symptoms, hypertension causes more deaths among African-American men than in any other racial, ethnic, or gender group in the United States.
“Uncontrolled hypertension is one of the biggest health problems facing the African-American community today,” Victor said. “We are looking for new ways to reach out to this high-risk population so we can prevent strokes, heart attacks, heart failure, and early death.”
Barbershops, which are often neighborhood hubs, seemed to hold a solution. “Barbers are a unique workforce of potential community health advocates because of their loyal clientele,” Victor noted.
Science and barbering may seem like strange bedfellows, but Victor’s study brought them together so successfully that his findings were published in the New England Journal of Medicine in April 2018. The 2017 Los Angeles Barbershop Blood Pressure Study (known as Barbershop L.A.) involved 319 African-American male barbershop patrons with systolic blood pressure of 140 mm Hg or greater. This first number in a blood pressure reading refers to the pressure in blood vessels when the heart beats. It is a strong predictor of heart attack and stroke risk.
The men in the study were randomly assigned to one of two groups: The intervention group met with a pharmacist every two to three weeks and received blood pressure medication as well as health education. The control group got educational pamphlets and blood pressure tips from barbers during their haircuts. The barbers were trained to encourage their patrons to make healthy lifestyle changes and follow up with a primary care physician. Study participants were rewarded with free haircuts.
Both groups reduced their blood pressure over a six-month period, but those receiving medical attention from pharmacists made far greater strides. Nearly two-thirds lowered their blood pressure to a normal level—six times more than the control group (see sidebar below).
Chavis was in the pharmacists’ group. He looks younger than his years and is not prone to the obesity that runs through his mother’s side of the family. He knows the risks from hypertension because he witnessed its devastating impact on his parents and other relatives. His father fought heart disease for years and died of a heart attack at 82. His mother also had heart disease but died of complications from Type 1 diabetes at 79. She was the oldest of 18 children, many of whom also suffered from heart disease and diabetes as adults.
Having worked in barbershops himself for years, Chavis easily falls into the friendly banter that is a barber’s trademark. When he heard about the study, he’d just left a job as a train operator for the Los Angeles Metropolitan Transportation Authority. He had long battled post-traumatic stress disorder (PTSD) related to the horrors he saw on the frontlines of the Gulf War in Saudi Arabia and Kuwait in 1990, and wanted to focus on healing. As he confronted hypertension with help from Cedars-Sinai and his local barber, he also received treatment for PTSD through the Department of Veterans Affairs.
These health issues had haunted him for too long. He was done with fear. “If you go through life scared, you don’t live,” he says.
A complex mix of economic, medical, and cultural factors contribute to the high incidence of hypertension among African-American men.
Many of the participants in the barbershop study live below the poverty line in neighborhoods with fast-food restaurants on every corner. They also struggle to gain access to affordable care and health insurance.
Some studies suggest genetics also may elevate risk, notes LaVonna B. Lewis, PhD, director of Diversity and Inclusion Initiatives at the USC Price School of Public Policy. She has been studying racial disparities in cardiovascular disease and diabetes since 1999, starting with the African Americans Building a Legacy of Health project, led by Community Health Councils in Los Angeles.
“There is still a conversation around the biology and physiology and stress that puts African-American men at higher risk,” she says. “Given the risks of premature death and disability, we have to figure out why blacks are overrepresented in hypertension and cardiovascular disease categories.”
Culturally, she is concerned about the prevalence of high-fat, high-salt diets in some African-American communities. Chavis’ life in the South included large family gatherings centered around foods like fried chicken, ham, sweet potato pie, and biscuits, along with greens. In Compton, it’s more convenient to buy fast food than fresh produce, so it’s not easy to follow through on a decision to make healthy choices.
Lewis says lack of trust in the medical system is also a significant health barrier for African-Americans. The Tuskegee Syphilis Experiment, an unethical clinical study conducted from 1932–1972, notoriously deprived African-American men of medical treatment. While guidelines protecting human subjects in government-funded research projects have since been instituted, the bitter memories of the study’s damaged lives linger on.
“They knew the cure and refused to give it to people because they wanted to see the disease run its course,” Lewis says. “The issue of trust is a big deal. This is one of the reasons why people of color are underrepresented in a lot of clinical trials today. We need trusted messengers in the community.”
C. Adair Blyler, PharmD, a Cedars-Sinai pharmacist, prescribed medication for Chavis and guided him toward a healthier lifestyle during the clinical trial. She says the study’s barbers are “champions” of health who were critical to the study’s success.
“There’s a different level of trust and respect that’s earned when you meet people where they are, instead of in a hospital or clinic,” Blyler says. “The rapport I was able to establish with this group of patients has been unlike any other I’ve had in my professional career.”
We can’t talk straight in the barbershop, then where can we talk straight?” says actor Cedric the Entertainer in the 2002 hit film Barbershop. Chavis similarly describes the barbershop as a “men’s sanctuary” where conversations range from sports to politics to relationships.
The social importance of barbershops is the subject of multiple scholarly books. In Barbershop Talk: The Other Side of Black Men, Melvin Murphy calls them places of “social harmony” where black men have “no fear of being treated differently.” Vassar history professor Quincy T. Mills reflects on how they “help facilitate community formations that are important for local neighborhoods and critical for barbers, who remain trusted members of black communities,” in his 2013 book, Cutting Along the Color Line: Black Barbers and Barber Shops in America.
Bringing medical care into this environment is not a new idea. In fact, it goes back to the Middle Ages (see timeline below). Victor, who was the Burns and Allen Chair in Cardiology Research at Cedars-Sinai, brought his own contemporary spin to the barber–healthcare connection with a scientific approach in the federally funded Barbershop L.A. project.
The clinical trial follows up on a pioneering study Victor conducted in barbershops in Dallas. When the study began a decade ago, barbershop-based health programs were gaining popularity nationwide. Victor was the first to bring scientific scrutiny to this trend with randomized, controlled testing.
The stakes are high. Data from Victor’s Texas study showed that, with the right intervention in the 18,000 African-American-owned U.S. barbershops, the first year alone would see about 800 fewer heart attacks, 550 fewer strokes, 900 fewer deaths, and savings of as much as $110 million in healthcare costs.
The rapport I was able to establish with [these] patients was unlike any other I’ve had in my professional career.” Pharmacist C. Adair Blyler
The L.A. study raised the ante—and got far better results—by giving pharmacists a central role while still involving barbers as health advocates. The pharmacists worked in collaboration with participants’ primary care physicians, keeping them informed after each barbershop visit and providing individualized reports at the end of the study to help ensure continuity of care.
The barbershop turned out to be the first place Chavis experienced a trusting relationship with a healthcare professional. He looked forward to his visits with Blyler at L&D’s Barbershop in Compton. “It was an appointment I made sure I kept,” he says.
He never felt rushed. During each visit, Blyler took Chavis’ blood pressure and conducted metabolic tests to monitor the effects of the medication she’d prescribed. Then they would talk about exercise, diet, and any challenges Chavis was experiencing.
“Adair was attentive, professional, sincere, and very patient,” Chavis says. “I could tell she cared. She would get on me: Are you doing this? Are you doing that? We talked like a doctor and patient should talk. She’s a pillar of health herself. She practices what she preaches, and that’s very important.”
Blyler was equally impressed with Chavis. “He was a model patient, the type that healthcare providers dream of,” she says. “He was always serious about taking control of his health, but, like a lot of us, he was trying to figure out what changes he needed to make and how best to fit them into his lifestyle.”
Chavis developed a cough while using the first medication Blyler prescribed, but the second one proved effective without side effects. “I was amazed it worked after so many years of taking medication without these excellent results. Now, my blood pressure is perfect, 120 over 80,” Chavis says, noting that lifestyle changes also have helped keep his diabetes under control.
With Blyler’s help, Chavis began drinking more water, reduced sodium, and added more fruits, vegetables, and fish to his diet, but he still indulges in a hamburger and fries about once a month.
He also started exercising regularly—walking, taking yoga classes, and doing resistance training. Having been “beat up” by extreme workouts in the Marines, he avoids heavy weight training. “I’m not trying to be the Incredible Hulk. I just want to get the heart pumping and the blood flowing,” he says.
During Blyler’s barbershop visits, customers not participating in the study often asked her questions and requested blood pressure. “There were always a lot of people at the barbershops chatting, joking, watching sports on TV. It was like hanging out in a man cave. They were super welcoming. I loved it.”
She helped study participants set realistic goals for diet and exercise, and stressed the importance of reading food labels and avoiding processed foods to reduce salt intake.
“One barber who became part of the study ate terribly and was quite overweight when I first met him,” she recalls. “He cleaned up his diet and started working out. By the end of the study, he had lost more than 20 pounds and was down from three medications to one to control his blood pressure.”
My clients’ health is important to me... anything that will help them I consider a blessing.” Barber Eric Muhammad
Barbers were so crucial to the study that one, Eric Muhammad, coauthored the resulting paper. Owner of A New You Barber and Beauty Salon in Inglewood, Muhammad was among the first barbers to join the study. He also helped recruit nearly half the other participating barbershops.
“For me, it was a no-brainer,” he says. “My clients’ health is important to me. We get pretty close through the years. Anything that will help them I consider a blessing.”
Most of his clients come in every week, and the average participant in the study had been with his barber 10 years. This customer loyalty made it easier to keep a close eye on how patrons were responding to new hypertension medication regimens.
Muhammad tried to break down his patrons’ aversion to doctor visits. “We can’t fear what the doctor will tell us,” he says.
He was disappointed that a number of his patrons chose not to join the study. “Even with a caring push from a friendly face, some are still scared,” he says. “Two of them have had strokes since the study started. It’s sad. I asked them why they didn’t join, and they said they didn’t want to take medication. Well, they’re in worse shape and they’re on a lot of medication now.”
Although the clinical trial has ended, Muhammad keeps a blood pressure monitor in his shop, next to the clippers and neck duster. Posters sharing success stories are still on the wall. “It opens the door for conversation with people who missed the opportunity to participate,” he says. “The study may be over, but the problem isn’t. It’s important to continue to raise awareness.”
Despite Victor’s untimely death, the effort continues. Recent presentations at the American Heart Association show that the benefits of intervention are sustained for at least 12 months. Meanwhile, Ravi Thadhani, MD, MPH, vice dean for Research and Graduate Research Education and chair, Department of Biomedical Sciences, is spearheading efforts to take Barbershop L.A.’s principles to the next level by testing whether the paradigm works elsewhere, in an NIH-funded collaboration with Vanderbilt University. The team is also exploring partnerships with insurance companies to see whether the principles are scalable and cost-effective.
Eduardo Marbán, MD, PhD, the Mark Siegel Family Foundation Distinguished Chair and Director of the Smidt Heart Institute, says Victor’s “out-of-the-box thinking has created a new paradigm for serving neglected populations: Bring medicine to at-risk people rather than waiting for sickness to rear its ugly head, when it’s often too late.”
“Dr. Victor showed genuine care and concern for our community,” Muhammad says. “He was an exceptional human being and one of the most humble men I’ve ever met. He didn’t see color or class. He didn’t see anything but our blood pressure problem.” He notes that Victor’s impact in the black community goes far beyond the study because “the men now teach their children and their sisters and their brothers and their friends.”
Chavis continues to lead a lifestyle that he hopes will keep him around a long time for his wife, Bianca, and 6-year-old grandson, Nasir. “I want to be a good role model for him, the way Adair was for me,” he says.
And then there’s the desire to stay healthy so he can ride his Harley well into the future. Sometimes Bianca joins him on the road, but he often travels alone. “I need that,” he says. “The bike is my quiet place. It’s freedom.”
Barbershop L.A. Study At a Glance
By the Numbers
319 participants at 52 barbershops
35 to 79 years of age (average in mid-50s)
30.8 average BMI
35% of participants were smokers
21% had diabetes
35% had high cholesterol
10.2 years average time with same barber
The men were randomly assigned to two groups:
Intervention group received hypertension medication and health education. On average, their systolic blood pressure dropped from 153 mm Hg at the start of the study to 126 mm Hg after six months, and 63.6 percent of participants brought their blood pressure below 130/80.*
Control group received health education from barbers. On average, their systolic blood pressure dropped from 155 mm Hg to 145 mm Hg after six months, and by the six-month mark, 11.7 percent had blood pressure below 130/80.
Medication management by pharmacists trained as hypertension clinicians, coupled with health promotion by barbers, brought about significant blood-pressure reduction for African-American patrons with uncontrolled hypertension.
A follow-up study that extended the pharmacist visits for another six months showed the improvements had been sustained.
*In November 2017, after completion of this study, the American College of Cardiology and American Heart Association issued revised guidelines that lowered the definition of hypertension to 130/80 instead of 140/90. The new guidelines also recommend that high blood pressure be treated earlier with lifestyle changes and, in some patients, medication—making expanded outreach to those at risk even more vital.
The Longstanding Link Between Barbers and Medicine
The role of barbers in healthcare doesn’t just date to the 21st or even the 20th century. The strands that lead to strengthening African-American men’s health in barbershops extend back to the Middle Ages.
Barber-Surgeons European barbers double as medical practitioners, amputating limbs in wartime, extracting teeth, and performing leeching and bloodletting. The red-and-white stripes on traditional barber poles represent blood and bandages.
Figaro! Figaro! Figaro! The infamous Figaro, in Gioachino Rossini’s comic opera The Barber of Seville, is a jack-of-all-trades: baritone, barber-surgeon, pharmacist, wigmaker, herbalist, veterinarian—and matchmaker for the young lovers, Count Almaviva and Rosina.
Barbershop Health Outreach Barbershop-based health outreach programs begin to emerge in the U.S. as a way to address medical problems that have a disproportionate impact on African-American men, including diabetes, prostate cancer, and hypertension.
The Demon Barber Stephen Sondheim’s Broadway musical Sweeney Todd: The Demon Barber of Fleet Street gives new life to a psychopathic barber-surgeon who first appeared in Victorian serial fiction. He cuts clients’ throats while his neighbor turns the corpses into profitable meat pies.
Scientific Scrutiny A pioneering study conducted by Ronald Victor, MD, in 17 Texas barbershops shows a significant drop in blood pressure among patrons who receive blood pressure readings from their barber with every haircut.
Barbershop L.A. An $8.5 million, five-year grant from the National Heart, Lung, and Blood Institute funds a Cedars-Sinai clinical trial with a twist: Pharmacists come to barbershops to deliver medical treatment to patrons with uncontrolled hypertension.
Dynamic Duo The New England Journal of Medicine publishes the results of the Barbershop L.A. clinical trial, which show that barber buy-in plus pharmacist intervention is a powerful antidote against hypertension in a high-risk population.