Stroking Out While Black—The Complex Role of Racism | Cerebrovascular Disease | JAMA Neurology | JAMA Network

America is in the midst of a racist revolution, specifically systemic racism built into the American way of life.

Physicians have been aware of this fact for over one hundred years.  People of color have been aware of and subject to the laws of systemic racism for centuries.

Just this week the JAMA Neurology published an academic article about "Stroking Out While Black-The Complex Role of Racism."

The killing of George Floyd, an unarmed 46-year-old Black man by a White police officer in Minneapolis, led to widespread protests against police brutality. Beginning with a focus on law enforcement reforms, the protests grew in diversity and objective, evolving into a broader call to end institutionalized racism. For the first time in history, a diverse, global coalition came together to protest injustice in the societal treatment of Black lives. Perhaps it was the collision of George Floyd’s horrific death with the disproportionate and egregiously high death rates and coronavirus disease 2019 infection rates within communities of color in the US that fueled this movement. Of note, precursors of change, such as the diversity, inclusion, and equity initiatives being spawned in all major sectors (economic, education, health), hold out hope for meaningful progress. This Viewpoint highlights the complex role of racism in stroke and suggests a framework for understanding its effects.

The same may be said for the systemic disparity in health care for people of color, African American, Latino, and Native Americans.  Each group has its own issues regarding health and wellness.

Native Americans in particular are isolated often in remote areas with a paucity of health institutions, although served by the Indian Health Service.  The incidence of infectious disease, chronic illness, especially diabetes, obesity, and hypertension is much higher than in white populations.

Levels of Racism Theoretical Framework

The Levels of Racism framework delineates 3 interacting levels of racism to guide the development of interventions aimed at reducing racial differences in health outcomes.1 These include institutionalized or structural racism, personally mediated racism, and internalized racism.1 Institutionalized racism occurs when access to goods, services, and opportunities is influenced by race.1 It is also referred to as structural racism owing to its codification in organizational practice and policy, to the extent that it becomes the normative behavior—a cultural disease—without the presence of a specific transgressor. Personally mediated racism is prejudice arising from conditioned assumptions about a person’s intentions and abilities, based on race, causing implicit and explicit bias.1 Internalized racism is a by-product of structural racism and personally mediated racism, reflecting the total capitulation of the individual’s self-worth and self-esteem. It occurs when people accept racist beliefs about their own abilities and human value.1

Social Determinants of Health

Social determinants of health are the conditions in which we are born, live, learn, work, and play and their impact on our health. Differences in social determinants are linked to wealth status and drive the powerful association between a person’s zip code and life expectancy. But these conditions, operating across the socioecological spectrum of human life, are not only influenced by socioeconomic status but also by levels of racism. They include upstream factors related to health outcomes, such as housing conditions, school quality, environmental conditions, employment opportunities, access to healthy foods, and access to quality health care, all of which may be influenced by racial inequities and moderate the downstream biological processes responsible for health outcomes.

Stroke Disparities

A 2003 Institute of Medicine report,2 entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” provided a compelling body of research highlighting health care injustices associated with greater mortality among Black patients. These included lower quality of health services and a lower likelihood to receive appropriate medical procedures among Black vs White US citizens.2 Poorer stroke outcomes for Black Americans compared with their White counterparts have persisted for more than 50 years. For example, Black individuals are twice as likely to die of stroke than White individuals, and this disparity is not entirely explained by differences in the prevalence of traditional risk factors (as defined by the Framingham Stroke Risk Function). Indeed, data from Reasons for Geographic and Racial Differences in Stroke (REGARDS) showed that only 40% of the Black-White incidence disparity is attributable to differences in the prevalence of traditional stroke risk factors and that the source of the outstanding 60% remains unclear.3 The REGARDS investigators suggest that this excess disparity may be driven by differences in risk factor control, the differential impact of risk factors by race and nontraditional risk factors, such as for physical inactivity, diet, and psychosocial factors, including depression and discrimination.3 Others have gone a step further by tracing stroke disparities to historical slavery, racism, and segregation.4 This active legacy of slavery manifests itself in the structural inequities of American society. They cause chronic repetitive, socially structured stressors shown to elicit physiological responses associated with cardiovascular disease and premature death. Indeed, a growing body of research regarding these physical consequences of social inequality referred to as the “weathering hypothesis,” shows that its physiological responses can be measured using markers of allostatic load.

Structural Racism and Stroke

Social determinants of health are riddled with race-based inequity due to the role of racial discrimination in resource allocation that have lingered since the US government’s redlining policies. These inequities are not only remnants of slavery and de jure segregation, but also related to the widespread de facto segregation in the US today. Evidence from US Census data suggests that, while the US has become more diverse, segregation has not appreciably improved since the era of Jim Crow. The separate social worlds between Black and White individuals are driven in part by income, preference, the absence of integrated experiences to help break the cycle of preference, and discriminatory practices, such as racial steering in which real estate brokers “steer” prospective homebuyers toward or away from certain neighborhoods based on their race. Consequently, Black individuals are concentrated in neighborhoods excluded from mainstream resources. It is why the variability of school quality across neighborhoods correlates with their racial composition. Such area deprivation, captured by economic, educational, and other environmental inequalities, is associated with worse mortality. Although beyond the purview of neurologists, these conditions may be drivers of stroke risk factors, such as smoking, obesity, hypertension, and type 2 diabetes.

Personally Mediated Racism and Stroke

This form of racism influences the decision-making of policymakers and members of governing bodies responsible for resource development and allocation, contributing to structural racism and its indirect effects on health. But personally mediated racism is also directly toxic to the health of those who experience it. It can be captured and quantified by validated scales, such as the Everyday Discrimination Scale,6 a measure of subjective experiences of discrimination. Examples of daily race-based indignities are itemized on this measure and range from microaggressions (eg, being treated as if you may be dishonest or as if people may be afraid of you, or receiving poorer service than others) to profiling and police brutality. While many of the experiences described in the measure appear minor, their sheer volume and chronicity have harmful consequences, including hypertension, higher levels of inflammation, and premature mortality.6 Moreover, even the recall of these experiences, a feature of rumination, produces adverse blood pressure responses comparable with those that occurred when the person was exposed.7

Internalized Racism and Stroke

Internalized racism and the resulting self-devaluation, self-rejection, engagement in risky health practices, and hopelessness1 has been linked to nontraditional stroke risk factors. These include depression, anxiety disorders, and several maladaptive behaviors in addition to cardiovascular disease.

The hydra-headed disadvantage of being deprived and a Black individual supports the need to include racism as a distinct construct of health disparities. Beyond social determinants of health, the insidious and paroxysmal health effects of racism directed at Black people, and which begins early in life, maybe underestimated, potentially explaining some of the excess Black-White stroke disparities observed. We call for increased funding and research that expands the use of an “equity lens” in the design and evaluation of stroke interventions and the role of racism in stroke outcomes. Promising areas of study include an examination of racism’s vascular effects on stroke risk and on differences in blood pressure control.

Stroking Out While Black—The Complex Role of Racism | Cerebrovascular Disease | JAMA Neurology | JAMA Network