The purpose of this paper is to investigate and analyze institutional factors that may have a direct

or indirect causal relationship to the high levels of heart disease mortality rates among middle age

African American males. The African American population has been exposed to state sponsored violence,

oppression and in some cases out right murder (wrongful convictions, imposed death penalty) since the

days of slavery. Such vile social behavior can cause lasting psychological and physiological impacts.

Heart disease mortality rates among African American males has been significantly higher than

any other racial/ethnic population in the United States for more than three decades. Heart disease can be

caused by many factors. After investigating the health impacts of racial stress and institutional

contributors in relation to the prevalence of heart disease mortality incidences among this particular

subset of the population; this research will attempt to highlight the direct or indirect causal relationship

between racial stresses imposed by institutional racism that is erroneously supported by United States

public policies.

Possible Causal Relationships:

Could iatrophobia be a contributing factor in the trend of abnormally high heart disease mortality

rates among middle age African American males? Certainly. Could that iatrophobia be directly related to

the institutional racism and torture imposed by the unethical medical practices, from slavery up until

recent decades, perpetrated against the African American community?

What is iatrophobia? Iatrophobia is a fear of doctors or medical treatment. It is said to be sourced

from the seeds of distrust sown in African American communities by the unethical and predatory medical

practices imposed upon them throughout American history. In Medical Apartheid by Harriet Washington

one story referenced is the story of Dr. James Marion Sims, an early American surgeon who specialized

in gynecology. Sims routinely experimented on his female slaves without anesthesia. Back then,

researchers believed African Americans were sub-human creatures who didn’t feel pain: “Each naked…

slave woman had to be forcibly restrained by the other physicians through her shrieks of agony as Sims

determinedly sliced, then sutured her genitalia. The other doctors fled when they could bear the scene no

longer1.” Breakthroughs he uncovered, during this barbaric research, secured his seat as president of the

American Medical Association.

The Tuskegee Syphilis Study began in 1929 as a cooperative study involving the Public Health

Service, the Julius Rosenwald Fund, and state and local health departments in six Southern states. It

evolved into a study of possible differences in the effects of the disease on Caucasians and African

Americans. During the study a number of African Americans in Tuskegee (Macon County), Alabama,

with Syphilis were left untreated but were observed, studied and compared to a control group which did

not have the disease. Researchers wanted to observe how the disease progressed differently in blacks in

its late stages and to examine its devastating effects with postmortem dissection. The study continued

until the 1970's when its existence was revealed to the public, resulting in Department of Health

Education and Welfare and Congressional hearings on the ethics of medical experiments on human

subjects2.

The study involved approximately 600 black men- 399 with syphilis, 201 which did not have the

disease. The study was conducted without informed consent. A media leak exposing the study ignited a

public outcry. As a result, an Ad Hoc Advisory Panel was appointed to review the study. It consisted of

nine members from the medical, law, religion, labor, education, health administration and public affairs

fields. These nine members concluded that the study participants had “agreed freely” to be examined and

treated but there was no evidence that the researchers had ever informed the patients of the study or its

purpose. In fact, the men had been misled and had not been given all of the facts required to provide

informed consent3.

Stress as a contributor to health disparities and heart disease: The relationship between stress,

heart disease and sudden death has been recognized since antiquity. The incidence of heart attacks and

1 Ekundayo, Bukola. "Medical Apartheid." Colorlines. March 2, 2007. Accessed April 05, 2016. http://www.colorlines.com/.2 "U.S. Public Health Service Syphilis Study at Tuskegee." Center for Disease Control. December 22, 2015. Accessed April 5, 2016. http://www.cdc.gov/tuskegee/timeline.htm.3 "U.S. Public Health Service Syphilis Study at Tuskegee." Center for Disease Control. December 22, 2015. Accessed April 5, 2016. http://www.cdc.gov/tuskegee/timeline.htm

sudden death have been shown to

increase significantly following the

acute stress of… any severe stressor

that evokes “fight or flight’ responses.

Coronary heart disease is also much

more common in individuals subjected

to chronic stress and recent research

has focused on how to identify and

prevent this growing problem4.

How does racism contribute to health disparities? African Americans are more geographically

segregated from whites than any other minority group in the United States. Racial segregation has been

found to be a predictor of poor health outcomes and a partial explanation for racial disparities in health.

Income and wealth are significant and independent predictors of having a chronic condition. Individuals

in the lowest socioeconomic strata are much more likely to be negatively affected by health issues than

are those in higher strata. A metro Atlanta heart disease study found that stressful racism and race-related

discrimination at work are associated with increased blood pressure and increased hypertension5.

In a Pitt County, North Carolina Study, comparisons of African American men by socioeconomic

status found that, compared with men who had high socioeconomic status in childhood and adulthood, the

odds of hypertension were seven times as great for low childhood/low adulthood, four times as great for

low childhood/high adulthood men, and six times as great for high childhood/low adulthood men. The

study concluded that both childhood and adulthood access to wealth are protective against premature

hypertension among African American men. The number of US-based studies is increasing but, to date,

these studies have focused largely on White Americans. The paucity of research on life-course…

4 "Stress and Heart Disease." The American Institute of Stress. Accessed April 05, 2016. http://www.stress.org/stress-and-heart-disease/.5 Centers for Disease Control and Prevention. A Closer Look at African American Menand High Blood Pressure Control: A Review of Psychosocial Factors and Systems-LevelInterventions. Atlanta: U.S. Department of Health and Human Services; 2010.

Cardiovascular Disease risk in US racial and ethnic minorities represents a significant gap in the

literature6.

An additional area for further research is the presence of hypertension in middle class African

American men. Although education and income appear to serve as protective factors against hypertension

for African American women, it is the opposite for African American men. Moreover, African American

men who fall into the second-highest income bracket have the highest rate of hypertension. It is theorized

that the stress of maintaining a higher economic standard is more prevalent in this group as a result of the

threat of discrimination, as well as the lack of a safety net for wealthier African American individuals

who may not have relatives or other support systems to provide assistance should they have an economic

crisis7.

Institutional oppression: War on Drugs and mandatory minimum sentencing as possible

institutional contributors to increased heart disease mortality rates among African American males. The

birth of mass incarceration can be traced to a similar political dynamic to that of Jim Crow. Michelle

Alexander, the author of The New Jim Crow, describes the evolution of the racial environment from the

old Jim Crow laws to the new, similar predatory policies that took their place. Alexander shows that, by

targeting black men through the War on Drugs and decimating communities of color, the current U.S.

criminal justice system functions as a contemporary system of racial control. As a result of these policies,

African American males have disproportionately been affected more than any other racial/ethnic

population in the United States. Leading to a startling reality, where 1 in 3 African American males born

today will end up in prison at some point in his life8. African Americans have been made criminals by the

6 James, Sherman A., John Van Hoewyk, Robert F. Belli, David S. Strogatz, David R. Williams, and Trevillore E. Raghunathan. "Life-Course Socioeconomic Position and Hypertension in African American Men: The Pitt County Study." American Journal of Public Health. May 6, 1996. Accessed April 05, 2016. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470586/.7 Centers for Disease Control and Prevention. A Closer Look at African American Menand High Blood Pressure Control: A Review of Psychosocial Factors and Systems-LevelInterventions.P32-37. Atlanta: U.S. Department of Health and Human Services; 2010.8 "Criminal Justice Fact Sheet." National Association for the Advancement of Colored People. 2009. Accessed April 05, 2016. http://www.naacp.org/pages/criminal-justice-fact-sheet.

War on Drugs to a degree that dwarfs its effect on other racial and ethnic groups, especially whites. And

the process of making them criminals has produced racial stigma.

Mass incarceration, like Jim Crow, was born of racial opportunism— an effort by white elites to

exploit the racial hostilities, resentments, and insecurities of poor and working-class whites. Moreover,

racial hostility and racial violence have not altogether disappeared, given that complaints of racial slurs

and brutality by the police and prison guards are fairly common. Racial violence has been rationalized,

legitimated, and channeled through our criminal justice system; it is expressed as police brutality, solitary

confinement, and the discriminatory and arbitrary imposition of the death penalty9.

The psychological and physiological impacts of institutional racism on African American male

youth is disturbing. Throughout the black community, there is widespread awareness that low income

African American youth have few, if any, realistic options, and therefore dealing drugs can be an

irresistible temptation. Suburban white youth may deal drugs to their friends and acquaintances as a form

of recreation and extra cash, but for ghetto youth, drug sales— though rarely lucrative—are often a means

of survival, a means of helping to feed and clothe themselves and their families. The fact that this

“career” path leads almost inevitably to jail is often understood as an unfortunate fact of life, part of what

it means to be black in America10. Because of a system that has been created to ensure their failure. How

does that feel? How does it feel to not believe in your future or yourself? All because of government

policies that support institutional racism instead of eliminating it.

The Adverse Childhood Experiences Study is an ongoing research collaboration between CDC

offices in California and Georgia linking childhood trauma to long-term health and social consequences.

Child maltreatment affects children now and later, and the costs to our country are significant: Children

who experience maltreatment are also at increased risk for adverse health effects and certain chronic

diseases as adults, including heart disease11.

9 Alexander, M. The New Jim Crow: Mass Incarceration in the Age of Colorblindness.P114-119.10 Alexander, M. The New Jim Crow: Mass Incarceration in the Age of Colorblindness.11 "Child Maltreatment: Risk and Protective Factors." Centers for Disease Control and Prevention. 2015. Accessed April 05, 2016. http://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html.

Data:

From 1999–2004, death rates increased continually, as shown in the graph below. They were substantially

higher among African American men than among white men throughout the period.

In one large study, level of exposure to discrimination among African American men was found to be

related to differences in blood pressure level after controlling for such factors as age, marital status, and

alcohol consumption. But the relationship differed on the basis of the men’s socioeconomic status. Blood

pressure levels were also higher among those who reported no incidents of racial discrimination, as well

as among those who reported the highest levels of exposure (three or more situations), compared with

more moderate levels of exposure (one or two situations)12.

Death rates from

hypertensive disease increased from

1999–2004 among African

American men and comparison

groups: white men and African

American women. In each year,

death rates for African American

men were more than twice those of

white men. Rates for African American

men and white men increased in each

year of the period. African American

men experienced the largest rate

increase, (3.2 deaths per 100,000

population)13.

12 Centers for Disease Control and Prevention. A Closer Look at African American Menand High Blood Pressure Control: A Review of Psychosocial Factors and Systems-LevelInterventions.P30. Atlanta: U.S. Department of Health and Human Services; 2010.13 Centers for Disease Control and Prevention. A Closer Look at African American Menand High Blood Pressure Control: A Review of Psychosocial Factors and Systems-Level

Illness-related deaths accounted for 50% of all inmate deaths in local jails in 2013. Heart disease

continued to be the leading cause of illness-related inmate deaths in local jails in 2013. From 2001 to

2013, male prisoners were twice as likely as female prisoners to die of cancer, heart disease, and liver

disease, which were the leading causes of death in state prisons14. Deaths from heart disease in state

prisons (26%) accounted for more than a quarter of all prisoner deaths.

Every year during a study done by the University of Alabama, 4 in 1,000 black men died from

heart disease, on average, compared to 1.9 of 1,000 white men, the researchers found. Among women, 2

in 1,000 blacks died of heart disease each year, compared to 1 in 1,000 whites15. "The sad fact is, we

really don't see an awful lot of movement in terms of that long-standing disparity. It's pretty much where

we were the last time we looked at it," Dr. Monika Safford, from the University of Alabama at

Birmingham commented in a Reuters Health interview.

Conclusion

Interventions.P22. Atlanta: U.S. Department of Health and Human Services; 2010.14 Noonan, Margaret, Harley Rohloff, and Scott Ginder. "Mortality in Local Jails and State Prisons, 2000–2013 - Statistical Tables." Bureau of Justice Statistics (BJS). August 2015. Accessed April 05, 2016. http://www.bjs.gov/content/pub/pdf/mljsp0013st.pdf.15 Pittman, Genevra. "Heart Attack Deaths Higher in Blacks than in Whites." NBC News. November 6, 2012. Accessed April 05, 2016. http://vitals.nbcnews.com/_news/2012/11/06/14975601-heart-attack-deaths-higher-in-blacks-than-in-whites?lite.

There is strong evidence linking platelet activation, autonomic activity, and inflammatory

markers to both depression and heart disease.16 The direct association between depression and heart

disease, is among the best-documented of all comorbidities, so why has the correlation between the

effects of institutional racism and heart disease yet to be made? Surely, racism never imposes feelings of

euphoria or causes a chemical release of endorphins in person the racism is focused on.

Therefore, if racism causes depression, depression causes heart disease and heart disease is the

cause of death for a disproportionate amount of African American males, then indirectly the United States

government is at the very least culpable in this medical crisis. It is time the medical community and the

government join forces to eliminate institutional racism as a way to battle heart disease mortality rates in

African American males. There must be a way for all Americans to have equal access to ethical medical

treatment under the law. Every American is entitled to live without fear of discrimination. That includes

the African American male population.

16 Glassman, Alexander H. "Depression and Cardiovascular Comorbidity." Dialogues in Clinical Neuroscience. March 9, 2007. Accessed April 05, 2016. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181839/.

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