It has been a tough past few months as 2020 continues to prove itself an immovable force. We are in the middle of a global pandemic that has forced us to acknowledge just how much we are all interconnected, followed by the elephant in the room that is racism and the division that plagues this country. Black Americans are being murdered while jogging. They are being strangled in broad daylight on suspicion of using a counterfeit $20 bill to buy cigarettes. They are being lynched. The grotesque debate of black lives mattering reignites after each senseless police murder, and as a result, our livelihood continues to be politicized.
Stressors are high in the black community, and I can’t help but wonder what this means for the collective health of Black people. I have decided to write this blog to shed light on the well-documented adverse health effects of the stress brought about by racial discrimination.
All stress is not created equal. In fact, acute (short-term) stress is absolutely necessary. It is a defensive mechanism that enhances protection and performance under conditions involving a threat or challenge. During an episode of stress, chemicals like epinephrine, norepinephrine and cortisol are released, which enhance cognitive and physical performance through stimulating effects on brain, musculo-skeletal, and cardiovascular function. This response is commonly referred to as the fight or flight response. The fight-or-flight response is nature’s fundamental survival mechanism, and served to be extremely evolutionary adaptive for our ancestors who may have had to avoid being chased down by lions, or eaten by wolves.
Although modern humans no longer experience those threats, acute stress is still beneficial. In today’s climate, episodes of acute stress help us meet our daily challenges and motivate us to reach our goals. Stress may serve to help us accomplish tasks more efficiently. Researchers even believe that acute stress provides health benefits such as a heightened immune system. For example, one study showed that individuals who experience moderate levels of stress before surgery were able to recover faster than individuals who had low or high levels.
Typically, the body returns back to normal stress levels after the stressor ceases to exist. However, when the stressor does not subdue in the short-term, people may develop a chronic (long-term) stress response. Chronic stress causes the body to go into overdrive, and adversely affects almost every organ system. Chronic stress increases one’s risk of diabetes, cardiac disease, and gastrointestinal disorders. It also suppresses the immune system. It can cause reproductive dysfunction in men and women (I will expand on this later). Newer evidence even shows that chronic stress causes faster aging of DNA by shortening telomere length.
To understand stress and stress reactions in the context of health disparities, one must consider the role of social structures. Many stressful experiences occur within these constructs. Prime examples include socio-economic status, race, and gender as they are often related to a person’s designated place within social structures.
While some factors, such as socioeconomic status are widely understood to affect health outcomes, we are still learning the dire effects of psychological stress on health and health disparities. The figure above shows how psychological stress can act independently and interactively to result in differential health status between groups. Racial discrimination is defined as a class or type of avoidant racism that is reflected in behaviors, thoughts, policies, and strategies that have the intended or accidental purpose or effect of maintaining distance or minimizing contact between dominant racial group and non-dominant racial group members (Carter, Forsyth, Mazzula, et al., 2005). It includes routine experiences with disrespect and treatment connoting that one is inferior or unintelligent. Exposure to racial discrimination causes poor health outcomes that begin at a young age and are extended across a lifetime. Dr. Dayna Long, a pediatrician at UCSF, has found that more than 20% of mostly Black and Hispanic/Latino children in Oakland have experienced racial discrimination by their 12th birthday. This perceived racial discrimination comes with a cost. A UCSF study found that racial discrimination experienced by African-American children and young adults may exacerbate a type of asthma known to be resistant to standard treatment. Documents such as Institute of Medicine’s Unequal Treatment report (Smedley, Stith, & Nelson, 2003) and the Surgeon Generals’s Mental Health: Culture, Race, and Ethnicity report (USDHHS, 2001) point to racism and discrimination as major contributing factors in the findings of health and mental health disparities regardless of economic resources.
The widespread use of the term “stress” in popular culture has made this word a very ambiguous term to describe the ways in which the body copes with psychosocial, environmental and physical challenges. Rather than referring to everything dealing with responses to environmental and psychosocial situations as stress, scientists provided a new formulation using two new terms, “allostasis” and “allostatic load”. Allostasis refers to an organism’s ability to respond to physical and psychological stressors through various physiologic processes. It is a concept used for understanding the prolonged effects of stress on morbidity and mortality.
Allostasis provides a framework for scientists, epidemiologists, and health disparity researchers to examine the mechanisms of the mediating effect of multi-system biology linking stressors to adverse health outcomes. Allostatic load (AL) is defined as the biological burden of chronic or repeated challenges that the individual experiences as stressful. AL refers to the wear and tear that the body experiences due to repeated cycles of allostasis as well as the inefficient turning on or shutting off of these responses. The accumulation of AL leads to neural, endocrine, and immune stress mediators that adversely affects various organ systems, leading to disease. The flowchart above illustrates the allostatic challenges that lead to the deterioration of mental and physical health. This study concluded that allostatic load partially explains higher mortality among blacks, independent of social economic status and health behaviors.
To further account for the early health deterioration seen among Blacks in the US compared to other groups, a public health researcher named Arline Geronimus proposed the “weathering hypothesis” in 1992. This hypothesis posits that the stressors that impact people of color such as discrimination and political marginalization leads to general health vulnerability and a higher susceptibility for chronic disease. Initially her hypothesis was met with resistance as naysayers insisted that black communities had worse outcomes due to unhealthy life choices, and immutable genetic differences. However, now we know that racism contributes to health disparities that persist independent of wealth, lifestyle, and education. The everyday stress of being marginalized in America leads to weathering. The constant feelings of frustration, fear, and anger lead to a chronic stress response that has adverse health effects on the body. Various studies conducted with racially diverse samples have found that the incidence and frequency of racial discrimination tend to be high for people of Color and that exposure to such incidents of racism is associated with lower levels of physical health and psychological well-being (Klonoff & Landrine, 1999; Landrine & Klonoff, 1996; Pak, Dion, & Dion, 1991; Sanders-Thompson, 1996; Schneider, Hitlan, & Radhakrishnan, 2000; Utsey, Chae, Brown, & Kelly, 2002).
Perhaps the most pressing example of weathering is seen when discussing the disparities in infant mortality rates across race and ethnicity. Black babies in the United States die at just over two times the rate of white babies in the first year of their life. There is a growing consensus that racial discrimination experienced by black mothers during their lifetime makes them less likely to have successful pregnancies. Stress hormones are the highest during a normal full-term labor. It is hypothesized that due to African-American women having to endure a more stressful life at the hands of racial discrimination, they endure premature births at an alarming rate. One study compared childbirth outcomes of wealthy, educated Black women against white women with less income and education and found black women have worse outcomes than white women with fewer resources. The results of this study point to the chilling truth that racism begins to adversely affect the health of black people while they are still in their mother’s womb. Essentially, racism is killing black children before they are even conceived regardless of the socioeconomic status of their mother.
The average person makes 35,000 decisions everyday, and each decision requires time and energy and depletes our willpower. As a black man, I am forced to make even more. Systemic racism impacts my daily decision-making on both macro and micro levels. I am constantly questioning; can I live here? Can I eat there? Am I safe here? Can I vacation here? How can I increase my chances of surviving this routine traffic stop? This type of stress is dehumanizing and compounding, and it comes with a cost.
Decision fatigue refers to the deteriorating quality of decisions made by an individual after a long session of decision-making. The more choices you make throughout the day, the harder each one becomes, and eventually, your brain begins to search for shortcuts. This leads to impulsivity, reckless decision-making, or simply doing nothing.
In the scope of health disparities, decision fatigue leads to overeating, alcohol and drug abuse, sexually impulsive behavior, unwanted pregnancy, and smoking. It is clear that racial discrimination alone may contribute to decision fatigue. Low socioeconomic status and its associated disparities seem to compound the experience of racial discrimination pertaining to decision fatigue. When socioeconomic status is added into the mix an additional decision needs to be made, “Food, medicine, or rent?” and you only get to choose two.
Racial health disparities cannot be solely explained by structural social and economic disadvantages. Even when all of those things are equal, black people still exhibit worse health outcomes and the cause is not genetic. It is clear that racism, not race, is a tangible entity that operates as a chronic stressor, which in turn exacerbates health disparities across many diseases. Racism does not have to be as blatant as the actions of Derek Chauvin to take the lives of black people in this country. It can also be a silent killer that hacks away at the health of its victims for years until the camel’s back eventually breaks. The cure for this silent killer is not the doctor’s office. Instead, the cure is in fixing the systematic issues that give legs to discriminatory policies and practices. It is imperative that the psychological and emotional experience of racism not be overlooked, even if there is considerable effort in our society to hide racism and to keep targets silent. Racism is a public health emergency, and it is time that we address it as such.