The Radical Effects of Discrimination: What Every Doctor Should Know

THE RADICAL EFFECTS OF DISCRIMINATION:

What Every Doctor Should Know

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 contrac-

Jeff Ritterman, MD

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

response and the everyday experience of stress. My patient can hardly strike out or run away when he experiences everyday discrimination. Indeed, the experience is often subliminal. Patients are routinely asked to minimize it. Hormones churn and nerves fire. Blood pressure and heart rate both increase, but running and fighting are not acceptable responses. So patients suffer quietly, but not without weathering the stressful physiological storm.

These storms take their toll. They are part of the reason for the Black-white health gap. Experiences of racial discrimination and also the internalization of negative racial bias work together to accelerate the biological aging of Black men. Researchers have studied aging using the length of telomeres, the region at the ends of chromosomes which protect our DNA. The shorter the telomeres, the greater the physiological age of the patient. Microaggressions shorten telomeres. Patients age more quickly than they would otherwise.3

If smoking causes lung cancer, the most intelligent therapy is prevention. Don’t smoke. If microaggressions and even more overt aggressions are causing excess morbidity and mortality, we need to identify and remove the aggressive behavior. We can prescribe meditation and other therapies to soften the blow of these microaggressions, but a far more effective and just response would be to address and challenge the racism which is at the root of the problem. There is no medicine to shield one against racism.

“Everyday discrimination” is meted out hierarchically. Not all of our patients are treated the same. It is not a hierarchy of talent, or skill, or kindness, or empathy, or compassion. It is a hierarchy of caste! Every doctor could benefit from reading Isabel Wilkerson’s new book, “Caste: The Origins of Our Discontents.”4 Wilkerson, who won a Pulitzer Prize for her first book, “The Warmth of Other Suns,” has written what will likely become a classic. She compares and contrasts the US caste system (white over Black), the Indian caste system (everyone over the untouchable Dalits), and the Nazi Germany caste system, (Aryan over Jew). Wilkerson defines caste this way: “Caste is the granting or withholding of respect, status, honor, attention, privileges, resources, benefit of the doubt, and human kindness to someone on the basis of their perceived rank or standing in the hierarchy.”5

This remarkable book helps us to see how race is used in the US to subordinate an entire people based on an arbitrary physical trait and to strip them of their individuality and their humanity. It is swimming in these polluted waters of our caste system that drives up my patient’s blood pressure and makes life unhealthier for all of us.

It’s also the caste system that has allowed some in medicine to betray our most sacred oath of “Do No Harm.” Dr. James Marion Sims, “Father of Gynecology,” practiced and perfected his surgeries on black enslaved women and did so without giving them anesthesia despite its availability. The women had to be forcibly held down as they screamed out while Dr. Sims sliced and sutured their genitalia. Dr. Sims was no rogue doctor. He was elected president of the American Medical Association in 1876.

There is much in the history of medicine and the history of our country that we must learn and face in order to move forward. In Wilkerson’s words: “You cannot solve anything that you do not admit exists, which could be why some people do not want to talk about it: it might get solved.”6

Wilkerson gives us a way forward; “radical empathy.” This, like medicine itself, is a moral mission. We do our very best work when we are motivated by our loftiest ideals. Wilkerson explains: “Each time a person reaches across caste and makes a connection it helps break the back of caste…multiplied by millions in a given day it becomes the flap of the butterfly wing that shifts the air and builds to a hurricane across an ocean.”7

Let’s shift the air together!

Jeff Ritterman, MD, retired as chief of cardiology at Kaiser Richmond in 2010, where he had worked since 1981. Dr. Ritterman currently serves as Vice President of the Board of Directors of the San Francisco Bay Area chapter of Physicians for Social Responsibility. Dr. Ritterman served on the City Council of Richmond, CA. Due to his efforts, Richmond’s tobacco prevention ordinances are now models for the state.

References

1 Tomfohr L, Cooper DC, MillsPJ, et al. Everyday Discrimination and

Nocturnal Blood Pressure Dipping in Black and White Americans.

Psychosom Med 2010 Apr, 72 (3) 266-272. Online Feb 2, 2010 doi 10.1097/Psy.0b013e3181d0d8b2 2 Nadal KL, Griffin KE, Wong Y, et al. The impact of racial microaggressions on mental health: counseling implications for clients of color. 3 Chae DH, Nuru-Jeter AM, Adler NE, et al. Discrimination, Racial Bias, and Telomere Length in African-American Men. Am J Prev Med. 2014 Feb; 46(2): 103-111 4 Wilkerson, I. Caste. New York, NY. Random House 2020. 5 Caste p. 70 6 Caste p. 385 7 Caste p. 386