Los Angeles Times, September 24, 2007
TERRY DAVIS didn’t know he was having a stroke, much less that, as an African American male, he had a three to four times greater risk of suffering one than a white man. When a transient ischemic attack, or mini-stroke, hit nearly a year ago, he was 49. He woke up early, felt a little slackness on his right side, a little slowness in his speech. He was dizzy and headachy. A professional tennis teacher, he canceled the day’s lessons and, thinking more sleep was what he needed, went back to bed.
His wife, Carrie, still feels guilty that she got a little annoyed with his lethargy that day. “I thought, ‘Snap out of it. Help me get the kids going,’ ” she says.
Davis is fine now. But the stroke scared him for his future, and those of his four sons, ages 8, 16, 18 and 21. These days, they all keep a more watchful eye on one another’s health habits.
Statistically, black males in America are at increased risk for just about every health problem known. African Americans have a shorter life expectancy than any other racial group in America except Native Americans, and black men fare even worse than black women. Some of it can be chalked up to poverty, the most powerful determinant of health, or to lifestyle factors. But even when all those factors are accounted for in studies, the gap stubbornly persists. Now researchers are beginning to examine discrimination itself. Racism, more than race, may be cutting black men down before their time.
It is possible, they believe, that the ill health and premature deaths can be laid — at least in part — at the feet of continuous assaults of discrimination, real or perceived. “We have always thought of race-based discrimination as producing a kind of attitude,” says Vickie Mays, psychologist and director of the UCLA Center on Research, Education, Training and Strategic Communication on Minority Health Disparities. “Now we think we have sufficient information to say that it’s more than just affecting your attitude. A person experiences it, has a response, and the response brings about a physiological reaction.”
The reaction contributes to a chain of biological events known as the stress response, which can put people at higher risk of cardiovascular disease, diabetes and infectious disease, says Namdi Barnes, a researcher with the UCLA center. That protective response includes the release of cortisol, often called the stress hormone. It increases blood pressure and blood sugar levels and suppresses the immune system. Those are all good things when it comes to fleeing a wild beast or a suspicious sound in a dark parking lot. But for many African Americans, these responses may occur so frequently that they eventually result in a breakdown of the physiological system.
“This whole phenomenon of cumulative biologic stress is real,” says Nicole Lurie, director of the Rand Center for Population Health and Health Disparities.
Racism, Davis says, is something a black man lives with, although these days, teaching tennis to, mostly, wealthy white people,he doesn’t often feel its sting. “Sometimes there’s stress, but you’ve got to keep on living,” he says.
Still, the Compton native has troubling memories of being pulled over by police as a young man for no apparent reason, and worries that such things could still happen to his boys. “When I was a kid, we never went through Culver City,” he says. “They’d watch you go in, sometimes stop you. I don’t want my kids getting stopped because of the color of their skin. They’re good boys.”
Having survived a childhood of poverty, with eight siblings, an alcoholic father and a churchgoing mother who kept the family centered and straight, the thought of sudden illness at this comfortable point in his life didn’t enter his mind. Although neither Davis nor his wife thought the 6-foot-3, 250-pounder who plays tennis for a living could be seriously sick, a day after the first symptoms, an MRI showed that he had suffered a mini-stroke. He was lucky. A transient ischemic attack is a kind of low-level warning that conditions are ripe for a more serious stroke unless the patient follows medical advice, most typically blood-thinning drugs, improved diet and exercise.
Death comes sooner
The shorter life expectancy of black men has been an inflexible truth since slavery. The gap has slowly narrowed throughout the last century, and the most recent improvement is attributed to lower accident and homicide rates, along with life-sustaining treatments for AIDS, all of which afflict a greater proportion of black men.
Still, heart disease, stroke, hypertension, diabetes, obesity and most cancers strike black men sooner, and cut them down more often, than white men. And the higher incidence of disease among black men is set against a backdrop of an increased incidence of poverty, which carries with it a multitude of health problems.
Violence, including accidents and homicide, lays its claim on black men early. Homicide is the leading cause of death for black men ages 15 to 34, followed by unintentional injuries. (For white men those ages, unintentional injuries are the leading cause of death, followed by suicide.) In every decade that follows, for every leading cause of death, the rates of disease for black men are disproportionately high. Once they become sick, they are more likely to suffer worse consequences and die sooner of the disease.
It adds up to an average life span for black men that is 6.2 years less than for white men, and 8.3 less than the national average, 77.8 years, for all races and both genders.
The major culprit in the black-white mortality gap is cardiovascular disease. The death rate from heart disease is about 30% higher among blacks than whites, according to the Centers for Disease Control and Prevention. The prevalence of diabetes is about 70% higher, and diabetes significantly increases the risk of heart disease.
High blood pressure is the leading risk factor for heart disease in African Americans, and some researchers have speculated that the cause is genetic. About half the people in the world are salt sensitive, but about 80% of African Americans are salt sensitive. That means that a diet high in salt is more likely to result in high blood pressure. But blacks living in African countries have few blood pressure problems, casting doubt on a genetic link. “Salt sensitivity is completely related to potassium intake,” says Dr. Karol Watson, cardiologist and co-director of preventive cardiology at UCLA. “And that’s related to fruit and vegetable intake.” More veggies equals less salt sensitivity.
But fresh produce is hard to come by in poor neighborhoods.
Poverty and lack of access to health care, more significant among blacks, open the doors to a host of hazards. Poor people smoke more, exercise less and are more likely to be victims of accidents and violence. “There’s a whole boatload of things that are in the environments where they’re more likely to grow up,” Lurie says. “HIV, crime, that kind of stuff. There’s a lot of extra dying going on from trauma.”
Anyone living in a poverty-stricken neighborhood has health disadvantages, says Dr. Roshan Bastani, director of the Healthy and At Risk Population Program at UCLA’s Jonsson Cancer Center. “It’s where you live, what kind of work you do, what kind of food you eat, access to physical activity, where you go for health care,” she says. “It’s kind of a vicious cycle that gets worse and worse.”
About 25% of African Americans live in poverty, compared with about 8% of whites, according to the U.S. Census Bureau’s most recent report, and about 20% of blacks are uninsured, compared with about 8% of whites.
And those African Americans who are poor are more likely to live in disadvantaged neighborhoods than are poor whites, according to a March 1998 report in the International Journal of Urban and Regional Research. Only 6% of poor whites live in high poverty areas, while 34% of poor blacks live in such areas, where risks of violence are higher and access to fresh, healthy foods and safe places to exercise are lower.
Vance Pierre, 45, of Inglewood says he encountered more than a few risks in his youth, including getting run over by a car. As a teen, he and his friends thought it was fun to jump in front of oncoming cars to make them swerve. “I’d be drinking like a 40-ounce, and I’d say, ‘Hey, watch this,’ ” he says. “A couple of times I couldn’t get out of the street in time.” His father died of alcoholism, and today Pierre says he doesn’t drink anymore. He also knows the benefits of eating fruits and vegetables, and sometimes will make a meal of all vegetables. But more often, he says, it’s convenient to eat out at places like McDonald’s or Popeyes Chicken & Biscuits.
Still, all the socioeconomic factors together don’t fully explain racial disparities. Researchers S.L. Isaacs and S.A Schroeder, in a study reported in the Sept. 9, 2004, New England Journal of Medicine, found that people earning $15,000 a year or less from 1972 to 1989 were three times more likely to die prematurely than those earning $70,000 or more. But at the lowest levels of income, less than $10,000 a year, black men still had a 21% greater risk of death within the study period than whites.
And in a Feb. 9, 1990, study in the Journal of the American Medical Assn., researchers compared black and white death rates per 100,000 people 35 to 54 years old and found the black rate 2.3 times higher. When they adjusted the data for known risk factors such as smoking, alcohol intake and diabetes, the gap narrowed to 1.9 times, and when they adjusted further for income, it narrowed to 1.4 times. How people live, die and get sick depends on economic class as well as race, but all of the adjustments combined didn’t completely explain the black-white mortality gap, leaving about a third of the problem unexplained, the researchers found.
The reasons behind that final third remain a mystery. “Life expectancy for everyone is increasing, but the disparities are not getting better,” says Lurie of Rand.
Seeking to explain that gap, researchers have grown increasingly interested in the theory, based on a growing body of evidence linking stress to poor physical health, that racial discrimination can result in unremitting stress. That additional, ongoing stress might explain some of the still mysterious gap.
For a black man, a stress response to discrimination can be triggered by something as subjective as feeling suspicious eyes on him in a department store. “That can be annoying,” says Michael Johnson, 38, of Inglewood. “You know you’ve got money in your pocket to pay, and somebody is following you around. We’ve all felt that. But you get so used to it, you’re numb to it.”
In one of the first studies to examine the effect of discrimination on lifestyle behaviors, researchers looked at 3,300 adults, black and white, from a range of income groups, ages 18 to 30, and followed them for 15 years. The study, published in the Aug. 13 American Journal of Epidemiology Advanced Access, found that 38% of whites reported feeling discriminated against in housing, education or work, while 89% of blacks reported such feelings of discrimination.
Regardless of income or race, all who felt discrimination were more likely to have unhealthy behaviors, including smoking, drinking and use of marijuana. “When people feel they’re treated unfairly,” says Dr. Luisa Borrell, professor of epidemiology at Columbia University Mailman School of Public Health and author of the study, “they’re going to find a way to cope with that unfair treatment.”
Stress of racism
People feel and respond to discrimination in similar ways, though the experience of discrimination is more common to blacks. Among blacks, it’s more commonly felt among men, the researchers found.
Mays was lead author on a paper published in the 2007 Annual Review of Psychology that examined studies looking at the responses of the brain and body to race-based discrimination. Experiences of racial discrimination can set the brain up for what’s known as the fight or flight response. While that biological response can be life-saving, too much of it sets people up for heart disease, diabetes, obesity and infection.
If it happens over and over again, in large doses of vulgar taunts or small doses of perceived slights, parts of the brain become overwhelmed. Two things can happen. The brain can shut down the release of chemicals and people respond with a kind of numbness. Under production of cortisol can result in depression and is linked to asthma, allergies, and rheumatoid arthritis. Or it can fail to shut down, leaving the body at a continuous state of heightened alert.
“Let’s say something occurs where you follow me around in a store,” Mays says. “I think that’s racist. My blood pressure goes up. I get upset. Then I go to a different store. Someone appears to start following me. I am primed from a previous experience and I feel it again. We call it a micro-assault.”
According to research into stress, such emotionally packed memories are held in a part of the brain called the amygdala, which regulates fear responses through the release of hormones such as cortisol. “Amygdala-driven stress responses are fight-or-flight based, tailored to survive now, ask questions later,” says Billi Gordon, a postdoctoral researcher at the UCLA center. The chemical release happens quickly, aiming for a quick, life-saving response. There isn’t even enough time to consult the cortex, the logical part of the brain.
Cortisol readies the body for the immediate danger, taking resources away from the some of the body’s longer-term resources, such as control of the immune system, while increasing blood pressure and blood sugar levels. That’s fine for the short term, but if it happens again and again, over a lifetime, the continual assaults of racism can result in a greater vulnerability to infection from a weakened immune system. In the long run, it places the body at increased risk for inflammatory diseases such as cardiovascular disease and possibly obesity and diabetes as a result of repeated changes to the regulation of glucose, says Barnes.
Over time, the disruption of cortisol control can get even worse. At first, the release of the hormone acts as an anti-inflammatory agent in the body. But if the body continually overloads with cortisol, the protective system shuts down and then actually reverses, increasing inflammation, which is linked to high blood pressure, cardiovascular disease and possibly diabetes.
“One of the most dangerous things that can happen to the body is when the cortisol signal is compromised or no longer working. It remains in a heightened state,” Gordon says.
Mays believes, and argued in the recent paper, that scientists know enough about people’s reactions to racial discrimination and also the body’s response to stress to link the two. “The literature is building,” she says.
“It’s downward synergy,” Gordon says. “Each time you have a micro-assault, it accumulates and each one changes the person’s sense of self-worth. You are constantly feeling a little bit different. Over a long period of time, it’s like the water that undermines the sea wall.”
One of the foremost researchers on the health effects of stress, Dr. Bruce McEwen, head of the Harold & Milliken Hatch Laboratory of Neuroendocrinology at Rockefeller University, has written in his book, “The End of Stress as We Know It”: “Stress hormones acting on the hippocampus can engrave important experiences into our long-term memory, but excessive or chronically elevated levels of these same hormones can damage the very part of the brain that shuts them off.”
No single ‘X factor’
Whether that process can be directly linked to experiences of discrimination is unproven. But Robert Sapolsky, professor of neuroscience at Stanford University School of Medicine, whose early work with McEwen helped chart the effect of stress on the brain, sees it as a plausible theory.
“To my knowledge, no one has looked at the relationship between being an outgroup [racial or otherwise] and things like cortisol levels, but it makes perfect sense. It’s a corrosive, permeating experience of lack of control — the very definition of chronic psychosocial stressor,” he says. “That’s a sure pathway to poor health.”
Mays and her colleagues, and others studying the causes of racial disparities, believe this may be happening in great numbers to minorities in the United States, and in the greatest numbers to African American men.
“This may be the explanatory variable,” Mays says. “For African Americans, it may not be just diet, or that you don’t walk enough.”
Studies keep pouring out showing racial disparities in health. A recent one in the September 2007 Annals of Epidemiology found that even in the so-called stroke belt of Southern states, where all races and both genders suffer the highest rates of stroke in the country, African American men are stricken at the highest of the high rates.
The study’s lead author, Dr. George Howard, chairman of the department of biostatistics at the University of Alabama at Birmingham, is not ready to finger discrimination as the primary cause.
“It’s a whole toxic cocktail of bad things, but if I had to pick one, it would be socioeconomic status,” he says. “It’s clear that racism plays a role, but I don’t think it’s the 800-pound gorilla.”
No one factor, including the possible biological toll taken by the accumulated insults of racism, will rise to the level of 800-pound gorilla. Attacking the problem, Lurie says, means looking beyond medicine to every aspect of society. “Ultimately, to make a real difference in life expectancy and health disparities, you have to simultaneously attack social and nonmedical determinants,” she says.
Statisticians have been taking note of the corrosive effect of race on health status for more than a century. But it’s only since 2000, when President Clinton proposed and Congress allocated $150 million to establish the National Center on Minority Health and Health Disparities, that understanding the complex reasons and working to correct the gap have become a national priority.
The center supports basic, clinical and population research on health disparities and has funded more than 100 universities and academic institutions, including UCLA, as well as hospitals and community health centers to help establish programs examining health disparities. It provides loans to doctoral students doing health disparities research, so far contributing to the efforts of more than 1,000 professionals.
In March 2002, the Institute of Medicine released a report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” that for the first time mapped out the scope and depth of racial disparities in health.
Poverty creates a vicious cycle, one that tennis coach and stroke survivor Davis, born into a large family in Compton, has escaped. His sons, in their Ladera Heights home with weekly backyard barbecues and plenty of sidewalk space for running and skateboarding, are protected from poverty’s worst health consequences.
These days, Davis takes his medication. He says he’s trying to eat better, but Carrie rolls her eyes, setting off a good-natured marital debate about actual quantities of sausages consumed versus vegetables. And he’s still trying to figure out what kinds of exercise to add to his professional routine that can be sometimes rigorous, other times little more than throwing balls back to students.
As long as there is racial discrimination, scientists say, there is the potential for added stress that just may prove to be the mysterious variable in the shortened lives of black men.
But when it comes to the health of their sons, the Davises, like so many parents, worry most about the boys’ love for junk food, bacon and red meat.
Be sure to check out the California Newsreel video series UnNatural Causes: is inequality making us sick?, particularly the second episode When the Bough Breaks, which deals with higher infant mortality among blacks. Neonatologists James Collins and Richard David believe that African American women are at increased risk during pregnancy, not because of something innate to their biology, but because of the cumulative impact of racism they experience over their lifetime – an impact that can outweigh even the benefits of higher social and class status.