Kidney Disease in African Americans

Kidney Disease in African AmericansKidney disease in African Americans

Kidney disease in African Americans is one the most dramatically different occurrences of a disease, and results in significant suffering and death.  Generally kidney disease is the result of diabetes and high blood pressure, and given the increased number of both of these in African Americans, there is a six to twelve-fold increased occurrence compared to whites.  Additionally, there is a 17-fold greater rate of high blood pressure as a cause of kidney failure in African Americans.  If you have high blood pressure or diabetes, or both, your risk for kidney failure resulting in needing dialysis is MUCH higher if you are African American.

Having diabetes and high blood pressure that is controlled on medications almost erases this increased risk. This is why it is critical that if you have high blood pressure, you should take medication to bring it down. If you have diabetes, you should make sure your blood sugars are controlled because if you don’t, your risk for needing dialysis is very high.

Kidney disease in African Americans

Risk for Requiring Dialysis is High

While African Americans are 13 percent of the general population, we make up 35 percent of all patients on chronic dialysis.  Diabetes as the leading cause of kidney failure and high blood pressure is the second most common cause.

Not having medical insurance or access to medical facilities and the increased number of people with high blood pressure contribute greatly to kidney disease in African Americans.  Well designed studies have failed to fully account for the excess proportion of kidney disease in Blacks.  Anatomically, despite equivalent age, blood pressure, and other factors, African Americans tend to have reduced kidney blood flow. Despite similar dietary salt intake, the kidney’s processing of bodily fluids are somewhat different in African Americans compared to whites.

A Possible Genetic Cause?

The Tsetse Fly transmits the African Sleeping Sickness. By International Atomic Energy Agency

Some of the increased risk for kidney disease in African Americans is attributed to a genetic variant (APOL1) found in more than 30% of African Americans and largely absent in white Americans.  It is thought that this gene offered protection from African Sleeping Sickness (a frequently deadly disease known in medical circles as African trypanosomiasis) that was carried by the Tsetse fly. Basically, having this gene gave protection from the African Sleeping Sickness and was beneficial in African regions where the tsetse fly lived.

Scientists believe that the increased risk for kidney disease seen in African Americans is equal to the increased occurrence of the same gene that offered protection from the deadly African Sleeping Sickness.

Obesity Can Lead to Kidney Problems Too

In addition to these genetic differences, researchers also suspect that increased obesity in African Americans is driving up kidney disease.  They found that as your BMI (Body Mass Index is calculated based on your weight and height) gets higher, the risk for kidney problems increases.

With all of the kidney disease in the African American community, there is one last bit of curious news.  African Americans have a better survival rate on dialysis than white Americans.  This paradox of improved survival in African Americans after initiation of dialysis has puzzled researchers.  Researchers at the Wake Forest School of Medicine suggest that the improved survival may also be due to the very gene that causes the problem . . . the APOL1 gene.  In this case the APOL1 gene gives protection against hardening of the arteries while on dialysis.

Kidney Disease in African AmericansHere’s What You Need To Do . . .

Kidney disease in African Americans can be a confusing topic to understand and there is a lot to consider.  The most important points are:

  1. If you have high blood pressure, take your medicine and watch your salt intake so that your pressure stays normal. That will allow your kidneys to stay normal.
  2. If you have diabetes, take your medicine and watch your diet so that your blood sugars stay normal.
  3. Watch your weight because the bigger you are, the higher your chance for kidney disease.

 

Atrial Fibrillation in African Americans

Atrial Fibrillation In African Americans

Atrial Fibrillation in African Americans

Atrial fibrillation in African Americans effects one in nine before the age of 80 and is the most prevalent arrhythmia in the US and is associated with significant bad outcomes that include stroke, heart failure, and increased death.  Surprisingly, studies also confirm a decreased atrial fibrillation incidence in African Americans (41% lower risk of being diagnosed than European Americans) but a greatly increased occurrence of stroke and sudden death in African Americans with atrial fibrillation. So compared to whites, African Americans are less likely to get atrial fibrillation, more commonly called “A Fib”, but if they get it, are more likely to have complications.

“Racial Paradox?”

Some have suggested that the decreased incidence of atrial fibrillation in African Americans is actually under-diagnosis, but others have called it a “racial paradox” where despite atrial fibrillation being a result of increased high blood pressure, diabetes, over-weight, heart failure, and heart attacks, all of which are higher in African Americans, the incidence of atrial fibrillation is surprisingly lower.

Atrial Fibrillation In African AmericansAfrican Americans were also less likely to be aware they have A Fib, and much less likely to be treated with blood thinners like warfarin (Coumadin, Jantoven) that prevent the heart attacks and strokes that having A Fib causes.   Even more surprising was this decreased use of warfarin in African Americans was regardless of whether the person had insurance or made more money.   It is truly stunning that a medication to prevent strokes is used LESS in a group of people who are prone to have MORE strokes and this was found in a study by Meschia and colleagues who looked at over 30,000 patients:

“We also found that among those who were aware that they had AF (atrial fibrillation) and who had confirmation of the diagnosis of AF, (African Americans) were about one quarter as likely to be treated with warfarin as whites. In striking contrast, risk of stroke as stratified by the CHADS2 score was not a predictor of warfarin use. The fact that risk of future stroke did not significantly alter the likelihood of warfarin use would seem to reflect an evidence-practice gap.”

A Higher Risk for Death

The risk for death in the presence of atrial fibrillation (A Fib) in the first four months after diagnosis was very high with heart disease, heart failure and stroke accounting for the most of the deaths, the study also found.  The risk for hospitalization in African Americans from atrial fibrillation doubled as did the risk for recurrent stroke, and related dementia from repeated “little strokes” (multi-infarct dementia).

What is the Best Medication for A Fib?

So the medical evidence would suggest that African Americans should receive MORE treatment with blood thinning medications like warfarin and other newer medications like dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis) . . . and in fact they receive LESS.

Some of the complaints about warfarin is the need to have relatively frequent blood tests to confirm the “thin-ness” of your blood.  The newer medications to replace warafarin do not need blood tests.

Keep in mind that African Americans have an increased risk for complications from bleeding on some of these newer medications like dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis), so although it can be more inconvenient with frequent blood draws, warfarin may be best for now until more information is available. There is also significant evidence that there are warfarin dosing differences between European Americans and African Americans that need to be anticipated and considered.

What You Need to Know . . .

While this topic may seem a little confusing, here are the main points:

  1. If you have atrial fibrillation (A Fib), you are at a much greater risk for stroke or another major event.
  2. Being on a blood thinner, like warfarin, can significantly decrease your risk for stroke (or another event).
  3. Being on a blood thinner increases your risk for bleeding . . . but not as much as it decreases your risk for stroke. So while you risk a bleed, your risk for stroke is much higher.
  4. The newer “blood thinners” do not require as many lab tests as warfarin, but they also may not be as safe in African Americans (this is controversial and not clear).

Here is a video on anticoagulation and warfarin:

Lactose Intolerance in African Americans

Lactose Intolerance in African Americans

Lactose Intolerance in African AmericansThree out of four African Americans are lactose intolerant.  Lactose intolerance means that if you drink milk, or eat yogurt, or have cheese in large amounts, you will get bloated and later have loose gassy stool.  If you are not near a toilet (of your choice), this can be an embarrassing problem.  The stomach’s reaction to not being able to digest lactose (a sugar in dairy products) is to simply flush it through its system.   For a majority, lactose intolerance in African Americans simply leads to the avoidance of milk and milk-related products like yogurt and cheeses.

The significantly decreased intake of milk and dairy products in the African American diet presents a potential increased health risk as “moderate evidence shows that the intake of milk and milk products is associated with a reduced risk of cardiovascular disease, type 2 diabetes, and lower blood pressure in adults”.  Constance Brown-Riggs in her article “Nutrition and Health Disparities: The role of Dairy in Improving Minority Health Outcomes” has recommendations for African Americans to consume three to four servings of low-fat dairy daily.

If only one serving of dairy causes stomach upset and loose stool . . . what will three servings cause?  That question is what many African Americans ask themselves, and the answer has been very clear.  African Americans drink significantly less milk and eat substantially less cheese and yogurt when compared to the rest of the American population.

The decreased dairy consumption leads to decreased intake of essential nutrients that are found in milk and cheeses. Studies show that African Americans’ intake of the required nutrients calcium, vitamin D, and potassium were all lower than white and Hispanic Americans.  And it has been well known in medical circles that African Americans have significantly lower vitamin D levels in their blood.

A Genetic Link for Lactose Intolerance??

Lactose Intolerance in African AmericansThe choice for African Americans to avoid milk and related products is not voluntary.  Lactose intolerance in African Americans may be due to a genetic design.  Research has shown that the proportion of people that are lactose intolerant can be tied to their region of genetic origin.  Put simply, regions where dairy herds could be raised safely and efficiently produced people that could digest lactose. Harsher climates in African and Asia restricted the availability of milk, and produced people with much more lactose intolerance, a study at Cornell University found.  Researchers found a wide range of lactose intolerances with as low as 2 percent of the population of Denmark descendants as unable to have dairy products compared to nearly 100 percent of the people with Zambian African origin.  Their survey “found that lactose intolerance decreases with increasing latitude and increases with rising temperature”.

Lactose Intolerance in African Americans
Red = Lactose Intolerant, Green = Lactose Tolerant, Brown = 50/50

Newer information has revealed that maybe there are not as many purely lactose intolerant African Americans as previously thought.  Nutritionists have advised that adding milk to a larger meal helps with successful digestion.  Some find that having smaller amounts of dairy over time improves digestion and decreases symptoms.

Lactose Intolerance Solutions

Lactose Intolerance in African AmericansOthers advise to simply take a lactose enzyme supplement (Lactaid, for example), and the problem is solved because milk, yogurt, or cheese is then easily broken down normally and naturally . . . while the dairy products again provide improved nutrient supplementation.

Other ways of replacing the missing nutrients resulting from low dairy consumption has become fairly easy due to multiple milk equivalents including soy, almond, coconut, and other ‘milks’ that can be used as part of a healthy breakfast.  All have been ‘fortified’ with calcium and vitamin D if needed.  Oatmeal and/or whole grain cereals with milk equivalents can make a fast and nutritionally efficient meal.

A ‘new’ problem is that African Americans consistently eat fewer breakfasts, and therefore the “opportunity” to have milk, yogurt, cheese, or milk equivalents has substantially decreased.

Making a point of having the required serving of calcium and vitamin D in the form of a dairy (or dairy-like) product is the next nutritional priority of African Americans seeking a long and healthy life.

 

Diet Differences in African Americans

Diet Differences in African Americans

There are a number of important diet differences in African Americans that need to be considered prior to offering advice regarding improvements or adjustments.  To tell someone to “eat better” without first knowing their current diet is a waste of everyone’s time.

Some of the basic foundations of African Americans’ diet stem from slavery days, but there are also more recent adaptations that have slowly weaved into the fabric of the African American diet.   Some of the changes were economic and others more convenience and culture-related.  To sum up the African American diet by only referring to slave influences is to ignore one and a half centuries of added impacts that made the African American diet what it is today.   Food availability, storage, financial independence, health literacy, and a sense of history and heritage all contribute to the ever changing components of the widening African American diet.

More Cultures Adding Diet Changes

With the ever changing make-up of African Americans, their diet is equally changing. More Africans, Caribbeans, and mixed races folds in a number of cultural nuances that need to be considered.  Even within the African American community, the diets vary greatly. Some sub-cultures eat more rice while others prefer pasta.  Some avoid pork for religious reasons, while other avoid beef due to poor digestion or its increasing cost.

These considerations aside, the basics of the African American diet mirror an American diet.  The “average” meal will have meat, starch, and vegetables in varying proportions.

Adding Meat to Your Vegetables??

African Americans more frequently will have their vegetables cooked rather than fresh.  Because of the scarcity of meat as a main course in slavery days, seasoning these cooked vegetable dishes with fatty cuts of low preference meat (whether smoked or not) quickly became a mainstay in the African American diet.  Having the lean cuts reserved exclusively for the more affluent, African Americans became accustomed to other cuts of meat (ham hocks, neck bones, and ox tails, etc.).

Now that the scarcity of meat is much less of a logistical problem, the ‘habit’ or custom of adding meats to vegetables is now merely a standard way to cook them. String beans, collard/mustard/turnip greens almost always have a smoked (and/or salted) cut of meat in the pot.  Because of a growing aversion to pork products in some circles, a significant number of African Americans use smoked turkey to season cooked vegetables and beans.

African Americas Do Eat More Chicken

The breakdown in terms of specific meats preferred by African Americans show a predominance of chicken and turkey, as well as relatively more fish and pork, but less beef than white or Hispanic American diets.

Diet Differences in African Americans

Overall, African Americans eat less grains, fewer eggs, less vegetables, and much less milk, but they consume significantly more meat and fruits.  By increasing the amount of vegetables, particularly fresh uncooked in the form of salads, more nutritional balance can be brought to the African American diet fairly easily. The increased consumption of fish and poultry (both chicken and turkey) already represents a beneficial existing tradition.

Diet Differences in African Americans

Although African Americans eat relatively fewer vegetables, there are also distinct differences within this category with an increased consumption of fresh green beans, fresh cabbage, and fresh greens when compared with other vegetables.

African Americans Prepare More Meals “From Scratch”

African Americans prepare more meals “from scratch” when compared to majority populations.  This diet difference in African American home cooking leads to comparatively more purchases of cooking items including spices, seasonings, oils, and preparation items including baking powder, flour, extracts, and sugars in multiple forms.

Diet Differences in African AmericansThe more “home cooking” done in African American kitchens leads to less consumption of pre-processed or ready-to-eat foods which is considerably beneficial.  Conventionally, when people think of processed and ready-to-eat foods, they generally equate them with poor nutritional quality and lower socio-economic status.  Poti, Mendez, and colleagues looked at the nutritional value of “processed foods” and found they have “higher saturated fat, sugar, and sodium content” when compared to lesser processed foods.  Because of the higher proportion of African Americans that are poor, many assumed that they too consume more ready-to-eat foods, but studies reveal that, in fact, African Americans buy less overall ready-to-eat and/or highly processed foods when compared to European Americans.

More Sugary Sweetened Drinks

By PepsiCo, designed by Edward F. Boyd – Downloaded from https://www.usatoday.com/money/books/reviews/2007-01-22-pepsi-book_x.htm?csp=34, Fair use, https://en.wikipedia.org/w/index.php?curid=11103395

One glaring exception in the purchasing of pre-processed foods was African Americans’ tendency to purchase a much higher proportion of pre-processed sugary beverages when compared to white Americans, and a much lower volume of milk and dairy purchases.  Marketing campaigns targeting African Americans like the one to the right from the 1940’s is just one of many that drove up the consumption of surgery beverages.

Other exceptions include a significantly higher consumption of bacon and sausages.  Finally, there was also an increased purchasing of processed sweeteners including sugar, syrups, jams and jellies in African American consumers.

While there is far more diet differences in African Americans to cover, the best way to advise a patient on their diet is to first know their specific diet . . . don’t generalize . . . interview.  Find out what, exactly, they eat, and then devise an alternative plan with suitable substitutions.  Very few people will be able to completely change their diet, and providers should not expect this because it is unrealistic.  But we should be able to give helpful advise based on a detailed interview.

Check out this great video on cooking oils and the dangers of reusing oils !!

Strokes in African Americans

Strokes in African AmericansStrokes in African Americans

Most strokes in African Americans occur due to high blood pressure and a much higher number of African Americans have uncontrolled blood pressure.  A quarter of all strokes occur in the presence of atrial fibrillation (a fib) and while representing 13 percent of the US population, African Americans experience almost twice that percentage of all strokes (26%).

Strokes are Worse in Blacks

And when a stroke occurs, African Americans have them earlier in life and present with more severe and disabling conditions.    The “Cardiovascular Quality and Outcomes” group concluded that “compared with other race/ethnicity groups, (African American) patients were less likely to receive IV tissue-type plasminogen activator <3 hours, early antithrombotics, antithrombotics at discharge, and lipid-lowering medication prescribed at discharge,” a study looking at over 200,000 patients showed.

Not surprisingly, with these prescriptive deficiencies in play, data analysis also showed a persistently increased re-hospitalization rate in African Americans at both 30 days and one year for all causes.  African Americans also have a 2.4 times higher rate of recurrent strokes than white Americans, and the highest death rate of any racial group.
Stroke patients overseen by neurologists were almost 4 times more likely to receive IV clot dissolving medicine than those seen by non-neurologists for all races and ethnicities (study from the Baylor College of Medicine ), but unfortunately African Americans were half as likely as whites to be seen by a neurologist when presenting with a stroke.

Aspirin to reduce Strokes in African Americans

Aspirin use is decreased among African Americans as compared to whites while the indications for aspirin use are actually higher in African Americans. More African Americans should be taking aspirin because it reduces the risk of stroke, heart disease, and colon cancer. And this was proven at the low dose of 81 mg.  The risk for gastrointestinal bleed is much lower than the risk of stroke, heart attack, etc.
African Americans over age 40 should be taking aspirin to help with the increased incidence of colon cancer, heart disease, and strokes.

Overall, prevention experts (USPSTF ) recommend referring adults who have stroke risk factors and are obese to intense behavioral counseling to promote a healthy diet and more physical activity. That means going to your doctor and having a detailed conversation about what you do . . . and what you eat.  For example, by decreasing your intake of salt and fried foods, lowering the blood pressure and getting proper exercise, strokes in African Americans can greatly decrease.

Take a look at this video that explains why you need to start your medicine, keep taking it, and come in to make sure it is doing what it’s supposed to be doing. Take care.

Establishing Trust When Patients Distrust Doctors

Distrust DoctorsDistrust Doctors ??

Multiple studies over an extended period of time confirm what most doctors and providers already knew, African Americans are more likely to distrust doctors and other healthcare providers than patients of other ethnic groups.

What many of us did not know was why.  As providers, we spent many years training to help others.  Medicine is a service profession. Why would anyone suspect our intentions, question our motives, or assign us collectively as untrustworthy?  The answer lies in the historical experience African Americans had with America’s doctors, hospitals, and researchers.

A History of Abuse

While the Tuskegee Syphilis Study is a ‘classic example’ of abuse based purely on race, unfortunately the American experience has many more examples of why African Americans mistrust the medical community.

From African American’s earliest days in this country, abuse based on race was commonplace.  Slaves were frequently used as subjects for dissection, surgical experimentation, and medical testing. J. Marion Sims, MD, the so-called father of modern gynecology perfected many of his surgical techniques on slave girls without anesthesia. Stories of doctors kidnapping and killing southern blacks for experimentation consistently appear in literature throughout American history.

Distrust DoctorsAs Vanesa Northington Gamble, MD, PhD put in her article “Under the Shadow of Tuskegee: African Americans and Health Care” tales of ‘medical student’ grave robbers, recount the exploitation of southern blacks as their deceased family members would be stolen and sent to northern medical schools for anatomy dissection.  Dr. Gable writes:

“These historical examples clearly demonstrate that African Americans’ distrust of the medical profession has a longer history than the public revelations of the Tuskegee Syphilis Study. There is a collective memory among African Americans about their exploitation by the medical establishment.”

Racial Differences in Trust

Chanita Hughes Halbert published a study in JAMA in 2006 looking at racial differences in trust in healthcare providers. Her study of almost one thousand white American and African American patients found that “compared with whites, African Americans were most likely to report low trust in health care providers.”

“Trust has been described as an expectation that medical care providers (physicians, nurses, and others) will act in ways that demonstrate that the patient’s interests are a priority. Trust is a multidimensional construct that includes perceptions of the health care provider’s technical ability, interpersonal skills, and the extent to which the patient perceives that his or her welfare is placed above other considerations. Trust is an important determinant of adherence to treatment and screening recommendations and the length and quality of relationships with health care providers.”

Fortunately, the level of trust a patient has for any specific provider is not stagnant, it can be earned.  Increased exposure to providers in general, and to the same provider in specific, has been shown to improve trust.

Physician Bias

In the “Medscape Internist Lifestyle Report 2017“, Carol Peckham looked at internist’s admitted explicit biases “toward specific types or groups of patients” and found wide differences between racial groups in bias for a number of influences.  The study further examined if the physician bias actually impacted care delivery, and almost one in five providers (18%) admitted that their bias did impact the quality of their care.

Generally these biases are positive toward white American patients and negative toward African American patients as a study by Oliver et al demonstrated at the University of Virginia. They found providers explicitly preferred white Americans to African Americans with “significantly higher feelings of warmth toward white people” and also found that white American patients were “more medically cooperative than African Americans”.  This study found no significant difference in the quality of care between the racial groups.

“physicians demonstrated implicit pro-white bias, reported an explicit preference for white people, had beliefs that blacks were less medically cooperative than whites, and believed that subconscious biases could influence their clinical decision making.”

Unconscious Bias

Biases that effect medical care can be consciously counteracted, and admitting the existence of biases is the critical first step in canceling its effect on medical care. Having a doctor who professes to treating “everyone the same” will undoubtedly provide inferior care to patients that are different.

A study done at Johns Hopkins by Lisa Cooper and colleagues found that primary care physicians who hold unconscious racial biases tend to dominate conversations with African-American patients during routine visits, paying less attention to patients’ social and emotional needs, and making these patients feel less involved in decision making related to their health. These patients also reported reduced trust in their doctors, less respectful treatment, and a lower likelihood of recommending the physician to a friend.

Because there are a limited number of physicians to provide care to African Americans, many patients simply “put up” with biases and unequal treatment . . . with others avoiding healthcare altogether until they they arrive in Emergency Departments with very advanced disease.

Patient Centered Care Improves Quality

Patient centered care can positively improve care, specifically for African Americans.

Although this seems obvious, spending time with patients is an easy approach to establishing trust. Fiscella and colleagues measured patient trust against the time spent with a patient and found a one-to-one correlation: the more time spent led to more perceived trust on the part of the patient. Making suggestions about diet changes requires a trusting relationship that involves a non-judgmental regard for the current diet.

Many delays in diagnosis and treatment are simply an outgrowth of the lack of trust. You will not accept someones advice if you don’t trust them.

Find a physician you trust.

 

Are you on the right blood pressure medicine? 

High Blood Pressure in African AmericansHigh Blood Pressure in African Americans

When it comes to the treatment of high blood pressure in African Americans, there are a number of important differences. For reasons that are not entirely clear, many African Americans patients respond differently from white patients based on the hypertension medication used.

Evidence from studies suggests that African Americans do very well with thiazide diuretics (a “water”pill) and they should be used often for the treatment of high blood pressure (hypertension).  Thiazide-type diuretics (chlorthalidone) was better at reducing blood pressure and preventing cardiovascular events like a heart attack or stroke than an ACE (lisinopril), or an alpha-adrenergic blocker (doxazosin) in African Americans as found in the “Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack” (ALLHAT) trial.

right blood pressure medicineBest Stroke Prevention in African Americans

For ideal blood pressure control, the thiazide-type diuretic dose should be equivalent to chlorthalidone 12.5 to 25 mg/day or hydrochlorothiazide 25 to 50 mg/day because lower doses have not been found to be as effective.  Overall, calcium channel blockers (amlodipine) have also shown great effect in African Americans as an initial choice, and are more effective in decreasing strokes than water pills. right blood pressure medicineThus an African American male would be best served by amlodipine first line given the stroke prophylaxis, and a African American female better served with a thiazide diuretic initially to get to goal more efficiently.

ACE Inhibitors are not preferred

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blocker (ARB) medications are less effective in African Americans for blood pressure control and are associated with worse outcomes.  A large study of over 400,000 patients done at the New York University School of Medicine compared outcomes in African Americans and European Americans with three distinct groups:

right blood pressure medicineTheir study  showed that ACE inhibitors were associated with a significant increase in stroke, heart failure, and combined cardiovascular disease when compared with calcium channel blockers or thiazide diuretics in African Americans. The worse outcomes with angiotensin-converting enzyme (ACE) inhibitors were similar to that of B-blockers in this population.

Because ACE inhibitors are commonly listed as “first-line” medications for hypertension control in national and international guidelines and recommendations, it should be noted that this principally is based on their response in white populations.  Based on these large African American-inclusive studies and a number of considerations (including cost, co-morbid conditions and disease propensities), the National Institute for Health and Clinical Excellence clinical practice guideline suggests calcium channel blocker therapy initially in African Americans, and substitute a thiazide-like diuretic in the event of edema or intolerance “or if there is evidence of heart failure, or a high risk of heart failure.”

Putting all of these risks aside (imagine that??), ACE inhibitor blood pressure response in African Americans is usually less when compared to calcium channel blockers, thiazide diuretics, or even B-blockers. Researchers suspect that the low blood pressure response is related to “high sodium intake in salt-sensitive” patients, but others have suggested that hypertension in African Americans may just be different.

More Side Effects in African Americans

African Americans have a greater risk of ACE-related cough, and a higher rate of stopping due to cough compared to other racial groups. African Americans were also more prone to develop ACE-related full allergic reactions.

High Blood Pressure in African AmericansWhen considering all of these issues with ACE’s and ARB’s in African Americans, it should be noted that they are essential for preventing kidney disease in people with diabetes, and certain other kidney related problems.  So if you don’t know why your on an ACE or ARB, call your physician and ask.  The renal-sparing benefits of the ACE and ARB medications is still very valid when used to slow renal function decline (particularly in hypertensive renal disease), and they should still be used for kidney protection in African American patients with diabetes and similar conditions.

High Blood Pressure in African AmericansSo don’t just stop your medications based on this article, please check with your provider. Use this article as a starting point for your discussion. Some providers are aware of these differences, and others may not be fully aware.

The key is to have a doctor you trust that knows about these differences.

High Blood Pressure in African Americans

The Tuskegee Syphilis Study

Tuskegee Syphilis StudyThe Tuskegee Syphilis Study (originally called “Tuskegee Study of Untreated Syphilis in the Negro Male”) was originally formed to record the natural history of syphilis with the hope of justifying the funding of public treatment programs for African Americans. The study, which began in 1932, included 600 African American men, 399 with syphilis and 201 without. While the study was originally slated to last 6 months, it was extended for over 40 years. Central to the study was the patient’s lack of informed consent.  None of the patients were told they had syphilis, instead they were told they had “bad blood” that required monitoring.  In exchange for taking part in the study, the men received free medical exams, free meals, and burial insurance.  Many physicians, including African Americans, and national physician societies, fully supported the study.

Betrayed Trust & Conspiracy

Tuskegee Syphilis StudyDuring the study, researchers not only allowed the disease to progress, but actively blocked the men from receiving curable treatment, not just from the study physicians, but also from other community physicians.   The researchers implemented a coordinated effort . . . a verified conspiracy, with area physicians and hospitals to actively block treatment if they presented elsewhere for care. Needless to say, the study required the widespread communication of personal health information across an entire region and involving hundreds of people.  The names and a stigmatizing diagnosis were circulated widely, and in a way that the patient would not know. The fact that nearly 400 African American men were denied effective treatment for syphilis without their knowledge or consent so that researchers could document the natural history of the disease, stands as a singular event that largely validates the mistrust African Americans have against the medical establishment.

Tuskegee Syphilis Study40 Years Later . . .

It wasn’t until 1972, when a news article reported the study, that a government review panel finally halted it. The Tuskegee Health Benefit Program was established as a settlement for the class action suit brought against the United States. The US agreed to pay all medical and burial expenses for the subjects involved, with added support for their families. During the course of the study, 40 wives contracted the disease and 19 children were born with congenital syphilis.  Many credit the Tuskegee Syphilis Study as the main reason informed consent regulations exist today.  For many African Americans, the study is the perfect example for why to not trust public health, medical research, or healthcare.

The Apology

In 1996, a formal apology was issued by the US government and the survivors were invited to the Oval Office by President Clinton.

Tuskegee Syphilis Study

Some argue that with time the Tuskegee Syphilis Study is merely a distant historical event for most African Americans.  A study done at Johns Hopkins looked at awareness of the Tuskegee Syphilis Study and found an overwhelming number of African Americans (81%) were aware of the study and outcomes, while only 28 percent of European Americans had knowledge of the study. With widespread knowledge of this government-sanctioned and funded study within the African American community, mentioning the study as a way to stimulate discussion, and build trust, is a preferable approach to ignoring its existence.

Historical Reasons for African American Distrust of Doctors

Historical Reasons for African American Distrust of Doctors

Stephen Kenny, University of Liverpool

The history of human experimentation is as old as the practice of medicine and in the modern era has always targeted disadvantaged, marginalized, institutionalized, stigmatized and vulnerable populations: prisoners, the condemned, orphans, the mentally ill, students, the poor, women, the disabled, children, peoples of color, indigenous peoples and the enslaved.

Human subject research is evident wherever physicians, technicians, pharmaceutical companies (and others) are trialling new practices and implementing the latest diagnostic and therapeutic agents and procedures. And the American South in the days of slavery was no different – and for those looking for easy targets, black slave bodies were easy to come by.

Black bodies in the slave south

There is a rich and rapidly expanding scholarly literature examining the history of human subject research, including studies of the burgeoning bio-medical economy in the US in the 20th century. The Tuskegee experiment and other episodes of medical racism all feature prominently.

The history of the acquisition and exploitation of slave bodies for medical education and research in the US, first explored in depth by historians James Breeden and Todd Savitt, focused primarily on medical schools and the traffic in slave bodies in Virginia. Savitt’s work drew attention to professional medicine’s use of slaves in classroom and bedside demonstrations, in operating amphitheatres, and experimental facilities.

Slave Village
By Wesleyan Juvenile Offering – https://archive.org/details/wesleyanjuvenil07socigoog, Public Domain, https://commons.wikimedia.org/w/index.php?curid=44910848

Savitt argued that African Americans were easy targets for ambitious and entrepreneurial white physicians in the slave south. Slaves, as human commodities, were readily transformed into a medical resource, easily accessible as empirical test subjects, “voiceless” and rendered “medically incompetent” through the combined power and authority of the enslaver and their employee, the white physician. Savitt suggested that “outright experimentation upon living humans may have occurred more openly and perhaps more often owing to the nature of slave society,” and also that “the situation may have been (and probably was) worse in the Deep South.”

Power and opportunism

When an elite white enslaver-physician, Charlestonian Elias S. Bennett, published notes recalling the case of a truly extraordinary tumour afflicting a young female slave on the family’s James Island plantation, his narrative revealed much about the opportunities for human subject research under American slavery.

Bennett recalled an unnamed female patient-subject who had developed “a small tumour the size of a ten cent piece” behind her right ear when she was just four weeks old. In 1817, when Bennett was training to become a doctor and “anxious to perform an operation”, he, together with a fellow physician-apprentice, made a disastrously crude surgical attempt to explore and remove this growth.

In an era prior to anaesthesia and asepsis, this type of surgical intervention was extremely dangerous – especially when undertaken by two unsupervised medical apprentices – who took liberty of an opportunity presented by an extremely vulnerable enslaved child. As Bennett remembered, the child suffered a great deal of “inflammation” as a result, and only “by very close attention” did she recover “in six to eight weeks” – the plantation/labour camp’s seclusion providing perfect cover for what would prove to be a major medical blunder.

‘Unknown enslaved sufferer’. Waring Historical Library, Charleston

Bennett’s crude interference with the tumour, which may have been in a lymph node, was the cause of a severe inflammatory reaction and sudden excessive growth of the lesion. In 1821, when the child was six, Bennett described the tumour as being about the size of an ostrich egg, while in the years immediately prior to her death, his narrative reported that the tumour increased to an enormous, indeed “extraordinary” size. The case report concludes with an post-mortem analysis, or, as Bennett noted in a ghoulish tone, “an imperfect outline of the results furnished by the examination of the tumour, when I obtained the head, or at least so much of it as remained.”

The remains of the enslaved girl’s skull became a pathological specimen in the University of Maryland’s medical museum collection.

Dark medicine: cash for ‘negros’

All of the key training, networks and power bases of southern medicine —apprenticeships, private practice, colleges, hospitals, journals, and societies —operated through slavery’s ruthless traffic and exploitation of black bodies. White medical students, as a matter of course, expected education and training based on the observation, dissection and experimental treatment of black bodies.

White doctors, including those in remote rural locations, routinely sent reports of experiments on slave subjects to medical journals and trafficked black bodies to medical colleges. Medical museums openly solicited black body parts and medical societies relied on black bodies. Students too wrote graduating theses based on the medical manipulation of black “subjects” and “specimens”.

Lucinda. Waring Historical Library, Charleston

Under slavery, there was also an extensive network of specialist “negro hospitals”. The grimmest of slavery’s institutions, these hospitals were often sites of risky medical research and were closely linked to “negro traders” anxious to patch up their “stock” for sale. Large numbers of individual doctors routinely advertised in southern newspapers that they would pay cash for black people suffering from chronic disease. The fate of these trafficked medical subjects, of course, assumed the very worst possibilities.

Slaves were generally unable to prevent treatments chosen by their owners and physicians could take enormous risks with the lives of these patients. Those risks were all the greater when doctors were also the owners of the enslaved patients. The opportunities presented by the system of chattel slavery meant that white doctors had at hand an easily accessible population upon which they could execute experimental research programs and develop new tools, techniques and medicines.

White racist attitudes, the enormous traffic in human chattel, and the slave regime rationalised and normalised the use and abuse of black bodies. Human subject research under American slavery was ultimately nothing unusual. In the context of a society defined by dehumanisation, impoverishment, violent punishment, incarceration, a vigorous trade in human property, racialisation and sexual interference, it should come as no surprise that human experimentation and the exploitation of enslaved bodies was a frequent, widespread and indeed commonplace feature of medical encounters between physicians and slaves. That was the culture of American slavery and every day slave patients faced appalling dangers.

Click here to read more articles in The Conversation’s series On Human Experiments.

Stephen Kenny, Lecturer in 19th and 20th-century North American History, University of Liverpool

This article was originally published on The Conversation. Read the original article.

Grassroots politics led to the 14th Amendment and black citizenship

How black grassroots politics led to the 14th Amendment and black citizenship

Frederick Knight, Morehouse College

In 2008, the United States elected its first African-American president. But in the last year of Obama’s final term, the paradox and tragedy of race is as apparent now as any time in recent American history. A poll released earlier this month indicates a growing pessimism about race relations in the U.S., an attitude triggered by the deaths of black people at the hands of law enforcement officers and subsequent attacks on police in Baton Rouge and Dallas.

As the nation seeks to understand the recent violence, and as the Black Lives Matter Movement claims the mantle of black leadership, now is an important time to remember an earlier period of race-based violence and civil rights struggles.

150 years of black ‘citizenship’

A critical period in the history of civil rights in the United States began 150 years ago and led to the ratification of the 14th Amendment to the Constitution in 1868. For nearly a century after, the federal government failed to enforce the 14th Amendment’s provisions. Yet, the 14th Amendment is arguably the Constitution’s most important because it defined the meaning of citizenship and established the rights of citizens to “due process of law” and “equal protection of the laws.”

The 14th Amendment was the result of local struggles and national debates on the political status of African-Americans in the wake of slavery and the Civil War. The 600,000 people sacrificed during the Civil War, and the 13th Amendment that abolished slavery, were not enough to guarantee equal treatment and protection of African-Americans by local governments.

In late 1865, a U.S. military official filed a report that made it into the hands of congressional leadership. The report highlighted how the state of Mississippi had enacted laws limiting the rights of freedmen and women. In the report, submitted on Nov. 28, Lieutenant Eldridge wrote that a Mississippi law barred African-Americans from leasing land, “testifying in cases of whites,” “doing any independent business” and appealing court cases past the county level.

The Mississippi law did give African-Americans the right to marry, to sue and to own property. But the ultimate goal of the state’s “Black Codes” and those passed in other states like Alabama and South Carolina was to limit the movement and gain control over the labor of freedmen and women. In the state of Mississippi and in other southern states, black and white people were to live under different laws.

Senator Lyman Trumbull from Illinois.
Wikimedia Commons

With the failure of white Southerners to recognize African-Americans as citizens, Senator Lyman Trumbull of Illinois led a congressional response and wrote the Civil Rights Bill. It passed Congress but was vetoed by President Andrew Johnson. Congress mustered the votes to override the veto and passed the bill into law in April of 1866. Its principal objective was to make explicit the citizenship rights of African-Americans, and in effect prevent racial discrimination. More specifically, the law guaranteed black people protection by the government.

In a message delivered on April 4, 1866, Trumbull responded to President Johnson’s veto message. Drawing on the ideas of political theorists and the opinion of military officials, Trumbull argued that the federal government was responsible for providing protection to all citizens regardless of race. The law, Trumbull argued, would make binding policies that had already been undertaken by the military in the post-Civil War South.

The United States military had filled the vacuum created by the collapse of the Confederacy. One of their roles was to administer justice and adjudicate disputes. Within this context, Major General Sickles, based in South Carolina, ordered in late 1865 to early 1866 that the government’s role was to “secure the same equal justice and personal liberty to the freedmen as to other inhabitants.”

Black grassroots politics and the contest for equal rights

Leading up to the civil rights debate at the federal level, African-Americans in the North and South organized grassroots movements to secure their rights as citizens.

Pennsylvania Equal Rights League leader Octavius Catto.
Library of Congress

For example, the Pennsylvania Equal Rights League emerged in the wake of the Civil War. Led by William Forten, Octavio Catto and other prominent black Philadelphians, they pressed the state legislature for black male voting rights and an end to segregation on Philadelphia’s streetcar lines.

African-Americans in the South held political conventions to define their new roles in the U.S. as citizens. Freedmen held a convention in Augusta, Georgia, in January of 1866 to define what they meant by citizenship rights. They resolved they had the right to protection, to land, to serve on juries, to individual and collective property ownership, to pensions for military service and to universal male suffrage. This meeting also launched the Georgia Equal Rights Association to realize this vision.

Yet, the Civil War had not fully come to an end. Violence broke out in the streets of New Orleans and Memphis. As African-Americans flocked to Memphis looking for a refuge from rural poverty and exercising their new rights to move about freely, the white press of Memphis reacted by painting blacks as “lawless.”

The “Massacre in Memphis” erupted on May 1, 1866, leaving nearly 50 black people dead and another 70 to 80 wounded. White rioters went after black women in particular, perpetrating rape as a form of terror. On July 30, mob violence led by Confederate veterans and the police in New Orleans left over 40 African-Americans dead. The 1866 massacres and Johnson’s earlier veto of the Civil Rights Bill pushed Congress to pass the 14th Amendment and send it to the states for ratification.

White Americans attacked black men and women in the Memphis Riot of 1866.
WikimediaCommons/Alfred Rudolph Waud

The process was not without its imperfections. Men and women, blacks and whites had joined common cause before the Civil War to promote women’s rights and an end to slavery. But throughout the push for civil rights in 1866, rhetoric used by politicians, military officials and equal rights organizations called for the rights of “men.” This would ultimately translate into a focus on black male suffrage, which was embedded in the 14th Amendment. The specific rights of women were put on hold.

As a result of this compromise, fissures grew in the interracial coalition of men and women who had fought for equal rights before the war. The unraveling of this coalition was emblematic of a larger process.

Soon after, in the face of corruption scandals and an economic crisis, the federal government lost its will to defend African-Americans and failed to protect their civil rights. Through a long, complicated and contested process, white vigilante groups, local and state governments, and even the Supreme Court rolled back the political gains of the 1860s.

The political struggles of 1866, the ratification of the 14th Amendment and the aftermath demonstrate the intertwined nature of grassroots and national politics. It also shows how fragile political coalitions can be. Ultimately, it reveals that political progress is neither linear nor inevitable – that forces of reaction, regression and retrenchment meet every forward movement.

The Conversation

Frederick Knight, Associate Professor of History, Morehouse College

This article was originally published on The Conversation. Read the original article.