THE RADICAL EFFECTS OF DISCRIMINATION:
What Every Doctor Should Know Jeff Ritterman, MD Several months ago, I was seeing medical patients in my office. Covid19 had not yet changed all of our lives. My focus was on diabetes, hypertension, heart disease, and the other concerns that bring folks to see their primary care doctors. A new patient walked into my office. He was a forty-five year old Black school teacher with elevated blood pressure. He was new to the area and had not been to a doctor for several years. He was not on any medication. The remainder of his history and physical exam were normal, as were his routine lab tests. He was not overweight. He exercised regularly, followed a healthy diet, and had a loving wife and family. I suggested home blood pressure monitoring to make sure that he was not just suffering from white coat hypertension. He returned to the clinic two weeks later with consistently high ambulatory blood pressure readings. I suggested that he begin taking an anti-hypertensive. When he returned again with elevated blood pressure readings, I added a second antihypertensive medication. This seemed to work for a time, but soon his home blood pressure readings were again high. I added a third medicine. The process repeated itself over the ensuing weeks. We finally achieved blood pressure control after adding a fourth medication. Sexual dysfunction, dry mouth, leg swelling, cough, and other unpleasant effects may well occur given the medicines which he is taking. But these same medications may be saving his life. This scenario repeats itself in doctors’ offices all over the country. Why is blood pressure so difficult to control? Why does it stay elevated? Blood pressure is not like temperature which is guarded around a set point of 98.6 degrees. All of our biochemical reactions do better at that temperature. Blood pressure is designed to increase when there is a need and to decrease when we are resting. It’s never a good idea to take the blood pressure of a sleeping patient, as it can be very low. After all, we are horizontal when we sleep, and we have no need for muscle exertion. But when a saber tooth tiger walks into the room our blood pressure rises immediately, allowing us to run for our lives. The cascade of stress hormones and nerve firings that occur during stress prepares us to respond with “fight or flight.” Our heart increases both the rate of beating and the force of contrac28
SAN FRANCISCO MARIN MEDICINE
NOVEMBER/DECEMBER 2020
tion, supplying our exercising muscles with the oxygen and the nutrients that are needed. Blood vessels contract to the areas of the body that don’t participate in the stress response and open to those areas that need the extra blood flow. It’s not a time for digestion or sexual arousal. It’s a time for maximal physical effort. What is the saber-toothed tiger in my patient’s life? It turns out that being mistreated by others and the fear of mistreatment are sadly significant threats.1,2 Scientists call this “everyday discrimination.” Examples include the feeling of being treated with less courtesy than others and the feeling that people act as if one is dishonest. These everyday slights have been called “microaggressions.” They are part of the Black experience in America for many of our patients. In addition to causing blood pressure elevations, these microaggressions can lead to depression, other mental health problems, and even early death. Clearly “micro” is a misnomer. When our patients fear an attack coming, they get prepared to run or to fight. Hypervigilance is needed. This is an automatic physiological response. The fight or flight response can be lifesaving when we are running from the tiger, but it can wear us down when the response is chronically elicited. Scientists call this “weathering.” It results in excess morbidity and premature death. Maintaining a hypervigilant state is not healthy, but is certainly understandable when fearing repeated attacks. The vigilance required to avoid these microaggressions is of such a degree that it continues even during sleep. The normal dip in blood pressure that occurs during sleep does not occur in patients who have experienced discrimination during the day. The lack of nocturnal blood pressure dipping is closely related to cardiovascular morbidity and mortality. White patients who are discriminated against will also suffer this lack of blood pressure dipping, but discrimination is much more common in our Black patients. The microaggressions suffered during the day keep our patients on guard even while they sleep. There is no respite, no safe place. While there are competing theories for the high rate of hypertension in Blacks, at least part of the explanation must be the daily stresses suffered due to aggression, both micro and macro. There is a terrible mismatch between the body’s stress WWW.SFMMS.ORG
