Studies show high blood pressure, also called hypertension, affects Black adults — particularly women — earlier and more dramatically than their white peers. | stock.adobe.com
Untreated, high blood pressure can lead to disabling, potentially fatal illnesses including heart disease, stroke, dementia, kidney disease, sexual dysfunction, vision loss.
High blood pressure. And structural racism. Researchers say they are two of the biggest factors responsible for the gap in poor heart and brain health between Black and white adults in the United States. And they are inextricably linked.
Studies have shown high blood pressure affects Black adults — particularly women — earlier and more dramatically than their white peers. By 55, research has found that three of four Black adults have developed the condition, versus about half of white men and 40% of white women.
Untreated, high blood pressure can lead to a range of disabling and potentially fatal chronic illnesses, including heart disease, stroke, dementia, kidney disease, sexual dysfunction and loss of vision.
Behind these elevated risks, researchers say, is a complex web of negative influences stemming from the multigenerational impacts of structural racism.
Chandra Jackson, a research investigator and epidemiologist with the National Institute of Environmental Health Sciences, describes structural racism as the “totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, wages, benefits, credit, media, health care and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values and the maldistribution of health promoting or harming resources.”
One way that plays out can be seen by looking at the decades of discriminatory lending, called redlining, that kept Black families segregated in neighborhoods with fewer resources and greater chronic exposure to environmental hazards, such as unclean drinking water and noise and air pollution, Jackson says.
These neighborhoods tend to lack quality healthcare facilities and providers, grocery stores that sell healthy and affordable foods or open spaces where adults can exercise and kids can play, she says. Discriminatory employment and educational systems result in higher levels of poverty that create financial strain, housing and food insecurity, strained relationships and less access to good health insurance.
All of this adds to stress that could be associated with increased blood pressure, according to Augustine Kang, an investigator at Brown University School of Public Health in Rhode Island, who says, “All these factors set up the perfect storm for disease.”
Black men and women report higher levels of stress than white men and women. But studies show Black women, who experience the compounding effects of race and gender discrimination, pay a particularly high price with their health starting early in life. Black women have a shorter life expectancy than white women, in part due to higher rates of heart disease.
Stress also makes it harder to manage heart and brain health risk factors such as high blood pressure once they take hold.
Kang led a study that found Black women with high blood pressure who experienced high levels of stress were substantially less likely to take medication or practice blood pressure-lowering behaviors such as exercising or eating a healthy diet.
“Lifestyle factors are incredibly important in managing blood pressure,” he says. “There are social and environmental factors that present an added barrier to diet and physical activity, which accounts for a lot of the health disparities we see today.”
A program at Kaiser Permanente in California targeting high blood pressure eliminated differences in control among Black and white adults and used electronic health records to track blood pressure, increased doctor-patient messaging outside of office visits and lowered the price of blood pressure medication to make it more affordable and accessible.
“In well-organized health systems, we’re doing a better job of monitoring and controlling blood pressure,” says Dr. John Ayanian, director of the Institute for Healthcare Policy and Innovation at the University of Michigan in Ann Arbor. “But the U.S. has a fragmented health care system.”
Ayanian led a study showing disparities in blood pressure among Black and white Medicare Advantage enrollees persisted in every region across the nation except the West, where the Kaiser health plans eliminated those differences. His research also showed Black adults were disproportionately enrolled in lower-performing health plans nationwide.
Asking people to improve their diet when they don’t have access to healthy foods, to exercise when they don’t have access to safe or affordable spaces, to take blood pressure medications when they can’t afford them won’t elminitate health inequities, says Dr. Monika Safford, founder and co-director of the Cornell Center for Health Equity in New York City and chief of general internal medicine at Weill Cornell Medical College.
“We can’t leave it up to individuals,” Safford says. “It’s not their fault. The system is set up to fail them. The system is not fair, equal and equitable.”