Heart disease is the leading cause of death for all Americans. But Black Americans, particularly Black women, have the worst outcomes when it comes to cardiovascular health, says Dr. Deborah Crabbe of the Lewis Katz School of Medicine at Temple University. Deaths from heart disease are higher in Black Americans than in their white counterparts, and heart disease develops at a younger age in African Americans. Nearly 48% of African American women and 44% of African American men have some form of heart disease.
Crabbe, whose passion is women’s health, has spent 20 years studying cardiovascular health disparities in communities of color and serving local North Philadelphia residents at Temple University Hospital. Recently, she and Dr. Sabrina Islam were approved for a $35,000 award from the Edna Kynett Foundation to start a pilot program that provides mentorship and research training experience to female medical trainees and medical trainees of color focused on racial/sex-specific cardiovascular disease disparities in COVID-19.
“COVID-19, it’s a national awakening [because] the preponderance of deaths are happening in communities of color,” said Crabbe. “And there’s an observation that these outcomes are poor because the preponderance of risk factors tend to be more clustered at a higher amount in the African American community.”
Why are Black Americans dying of COVID at higher rates?
On average, Black Americans have died from COVID-19 at almost three times the rate of white Americans, according to Yale University researchers. And though the high incidence among Black people of underlying health conditions, such as poor cardiovascular health, has contributed to high infection rates, a researcher at the University of Michigan believes these diseases are symptoms of a more insidious chronic stress response to growing up, developing, and aging in a racist society. She calls this process weathering.
“Weathering itself, that word, is a contronym, and it means sort of opposite things,” said Arline Geronimus, associate director of the Population Studies Center at the University of Michigan. “You can be weathered by the storm, as in experience erosion — how your body systems through stress-mediated wear and tear become eroded — but you can also weather the recession, meaning come safely through.”
Black Americans have a collective culture that emphasizes enduring through adversity. Perhaps you remember Michelle Obama’s story about her father, who she says never missed a day of work despite having MS and trouble walking. But that push to be resilient also leads to a host of health issues.
You might know about the body’s “fight or flight” response: Your blood travels to your muscles and your heart; your blood pressure rises. Geronimus said that while that’s OK to experience for about three minutes once in a while, the kind of stress Black people experience under structural racism is happening chronically, for a sustained amount of time.
“And when this happens over years, these systems just get completely worn out,” Geronimus noted. “Your immune system gets dysregulated and weakened, so you start doing weird things in your body like having autoimmune diseases like lupus and MS. You can’t fight off infections as easily because of the weakness of your immune system.”
Geronimus said there’s a common misconception that high-fat and high-sugar diets cause heart disease. But when you look at the chronic stress response that’s triggered from living in a racist society, it causes blood pressure go up, it makes your heart pound, it brings sugars and fats out of their storage spaces in your body so that it can send them to your muscles.
“Again, if that’s for three minutes, it’s wonderful if you had it because it saved your life,” Geronimus said. “But if it’s all the time, then your blood pressure goes up and it becomes hypertension. … Your heart can get enlarged from all the pumping and overdoing things. Your arteries get hardened, and they get plaque.”
So all the diseases that, on average, Black people die from more, and at younger ages than white Americans, are things that weathering contributes to. Stressors for Black people come in all kinds of forms and often involve some kind of sustained cognitive and emotional engagement with something.
“That could be something as big as social injustice,” Geronimus said, “but it could also be fighting with your landlord to turn the heat on in your apartment… and you have to take forever doing that and they are not responding. All of that also causes these stress responses.”
‘We need to have a diverse workforce’
Dr. Islam, a cardiologist at Temple Heart and Vascular Institute and a professor of medicine, has spent over 10 years studying cardiovascular health inequity. Prior to moving to Philadelphia, she worked closely with a community of patients in Baltimore and said she expected the two cities to be very similar.
In terms of health outcomes, majority Black sections of North Philadelphia rank among the worst in the city for length of life and cardiovascular health. But what stood out to her about patients there, Islam said, was the sense of community among residents and their reliance and trust in the local networks of health care available in the area.
“I’m often impressed at how reliant they are on our health care institutions,” said Islam. “But a lot of those important resources that are necessary in the community for cardiovascular health are severely lacking here, like access to healthy food and having a safe space to exercise or recuperate after cardiovascular events.”
Islam said it’s common for her patients’ cardiovascular health to quickly deteriorate after surviving from a major cardiovascular episode because exercise or physical rehab is not accessible. And that means they’ll continue to have worse outcomes.
Both Islam and Crabbe acknowledged that the health disparity issue must account for structural racism, which means beginning with diversifying the medical workforce.
According to the American College of Cardiology, even though African Americans make up 13% of the population, fewer than 3% of cardiologists were African American as of 2015. The Temple University funds from the Edna Kynett Foundation will be leveraged to try to change those low numbers.
“We are going to help young people develop the important dossiers that they need in order to be competitive and to learn about cardiovascular medicine,” said Crabbe. “The [funding] will allow us to help them get involved in some research, allow them to interact with other members of our team, and to interact with other cardiologists.”
The selected medical trainees will contribute to the project’s COVID-19 research activities, and the award will also create leadership and mentorship opportunities for female fellows in cardiovascular medicine, in recognition of their unique under-representation in the field of academic cardiology.
According to Crabbe, women make up 51% of medical students, but are not represented in cardiovascular health at those same levels. Dr. Islam will be responsible for providing leadership in executing the Women in Cardiology curriculum and mentorship to the medical trainees, and will serve as course director for a citywide diversity in cardiovascular medicine conference.
“When we are all in alignment, it’s an exciting time to be in health care, where we understand that this is a problem,” said Islam. “I hope that we can just move forward together when tackling how people are trained, how we interact with our patients, and how they move forward with their lives.”
The award will support a citywide conference on diversifying the cardiovascular medicine workforce and will be conducted virtually to the four academic medical centers in the greater Philadelphia area.
For Crabbe, opening up the cardiovascular workforce isn’t just about race and gender, but it also takes into consideration diversity of thought and ideas. She said that with all the medical problems facing various marginalized communities, we can’t afford to leave out anyone from the table because you don’t know where the next best solution will come from.
“To me, COVID-19 is the racial disparity problem of the 21st century,” said Crabbe. “We need to have a diverse workforce… People relate to other people who are like them. That doesn’t mean that they can’t relate to others who are not like them but it does mean that there’s a connection that can be made.”
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