As in South Africa, being black in the US means you are more likely to be poor, homeless, jailed or HIV positive than your white counterparts.

“The infant mortality rate is two and a half times greater for black babies than white babies in Philadelphia,” says Dr Walter Tsou, president of the American Public Health Association.

“Most people without health insurance wait until they get sick and desperate then they show up in the emergency wards of hospitals,” he adds.

Poverty has a black face in the US. Three times as many black households (24.4%) are living below the official poverty level as white households (8.2%), according to the US Census for 2003. The real median income for whites is $48 000 a year and $30 000 for blacks.

The gap between rich and poor is widening, partly as a result of Republican tax breaks to the rich. Over the past 20 years, the income level of the richest 20% of the population rose by 43% but dropped by 8% for the lowest 20%.

“Poor black people are at the bottom of the health system in the US,” says Marie St Cyr, director of Iris House, which assists black women with HIV in New York.

“They have the highest rates of breast cancer, obesity, cardio-vascular diseases and, of course, HIV infection.”

Although African Americans make up about 12% of the US population, they account for 39% of HIV/AIDS cases and have the poorest survival rate, according to the Centres for Disease Control and Prevention (CDC).

“It doesn’t surprise me that we are hit hardest by HIV,” says Gary Bell, who heads Blacks Educating Blacks about Sexual Health Issues (Bebashi), an advocacy group based in Philadelphia that serves 15 000 people a year.

“African American people have disproportionately lower incomes. Many of us are not getting preventive health care. There is a high level of depression, which people often self-medicate with drugs or sex. Homelessness is a problem. We don’t value our lives because there is not a lot of hope.”

An African American woman is 23 times more likely than a white woman to become HIV infected. She is most at risk of getting HIV through heterosexual sex, followed by intravenous drug use.

African American men are most likely to get HIV from sex with men, followed by injection drug use and heterosexual sex.

“In the past, most of our clients were women who had been infected by sharing dirty needles during intravenous drug use. But today over 50% of our clients were infected through heterosexual sex,” says St Cyr.

This change, says Bell, means that a lot of attention in the African American community of late has focused on men “on the down low” — men who have secret sexual relations with men while being involved with women.

“The new villain is the man is on the down low. But I don’t think that is the point,” says Bell.

 “One of the driving issues affecting HIV in our community is prison,” she adds.

An estimated 30% of young African American men have been in prison or probation at some stage. Many get infected with HIV through sexual contact with other men while in prison.

Interestingly, in some US states ex-prisoners and those on parole or probation are not allowed to vote – something that clearly disadvantages young black men.

In addition, the penalty for possession of crack cocaine, the drug of poor black users, is far higher than those of power cocaine, the white yuppies’ drug of choice.

In 2002, half of all new HIV infections were of African Americans and Bell says government cuts to HIV prevention problems are partly to blame.

“We are trying to fight a war with sticks and stones, ” says Bell. “We get requests all the time for condoms but they are like gold. There are also fewer HIV messages and they’re fuzzier.”

Jodi Bishop, Bebashi’s development director, adds: “Between 2002 and 2003,there was a statistically significant increase in HIV incidence [44 000 new cases]. That tells us what we’re doing isn’t working. A lot is going to hinge on who gets elected as president. There’s been a lot of damage in the last four years. We have the resources to provide universal healthcare but not the will.”

Another problem hampering healthcare efforts, however, is attitude. “African Americans usually get diagnosed late when they are really sick and it’s harder to treat them,” says James Loyce, who heads the AIDS office in San Francisco.

Part of the problem, says Loyce, is that there is a deep distrust of the medical establishment which “stems from Tuskagee”. Between 1932 to 1970, the Tuskagee Institute withheld life-saving syphilis treatment from 399 African American men in Alabama, so that scientists could see what the disease did to the human body. The study was stopped only after details were leaked to the press. By that time, many of the study participants were dead or disabled, and their wives and children infected.

Partly as a result of this legacy, Loyce says San Francisco has battled to recruit black volunteers to test an AIDS vaccine, while 43% of African American patients in San Francisco General Hospital said in a recent survey that believed they were given lesser treatment than whites and experimented on by hospital staff.

Lisa Hirshhorn, medical director of a community clinic in Roxbury, a rundown area of Boston, says that the antiretroviral drug AZT “was never used in my clinic because people said it was white man’s poison”.

However, she says that her patients, most of whom are African American, are all able to get state assistance for their antiretroviral treatment.

Medicaid (sometimes called Medicare) is available for people with no or low incomes. While the requirements vary from state to state, Medicaid generally covers hospital expenses, and doctors’ and dentists’ fees.

Those who apply for Medicaid need to fill in forms and produce a number of documents, including birth certificates and proof of income, often difficult requirements for people who are homeless or mentally ill.

“Some people are intimidated by the process, especially if they don’t read very well,” says Bell.

But getting access to free healthcare, is complicated as most health institutions are privately owned.

“The healthcare system in America is very fragmented and fragile,” says Tsou, former head of health in Philadelphia.

“There are no public hospitals in Philadelphia. Poor people get treated at community health centres, where they can get some free prescription drugs.

Private hospitals are required to admit and stabilise very sick people. They can apply for Medicare on your behalf. If you are not eligible, they will send you bills and if you don’t pay up, you can be handed over to a collection agency.”

Over the past year, 1,4 million more people have been unable to afford private health insurance, which means that an estimated 45 million Americans – 15.6% of the population – do not have health cover. Democratic presidential candidate John Kerry’s healthcare plan advocates an expansion of government spending on Medicare to reach 25 million uninsured people, with the aim of ensuring all children have adequate healthcare.

President George Bush’s plan is tailored to encouraging working people to buy their own insurance by offering them tax breaks to do so. His plan, while significantly cheaper, would only reach about 8 million people.

For Bell, Loyce and St Cyr, addressing the health needs of African American communities has to be done in tandem with other services.

“For the disenfranchised population, HIV is low on their list of priorities in comparison to homelessness,” says Loyce. “They face a myriad of problems, and if we are going to address health issues, we need to do them in the context of addressing issues such as violence, homelessness and substance abuse.”

Sounds like home.

E-mail Kerry Cullinan