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More Research Is Needed to Understand How Racism Contributes to Stroke Disparities, Neurologists Say

Article In Brief

Two neurologists contennd that stroke disparities are only partially explained by differences in the prevalence of traditional stroke risk factors between Black and White patients. They discuss the framework for understanding the effects of racism on stroke risk and where the field needs to go from here.

Black Americans are twice as likely to have a stroke and 40 percent more likely to die from one as compared with White Americans, according to the Centers for Disease Control and Prevention. Although decades of research have highlighted racial stroke disparities, there is a dearth of evidence on why they exist.

Now two prominent stroke neurologists are calling on the field to investigate how racism may impact vascular health. In an opinion article published online on August 21st in JAMA Neurology, Bruce Ovbiagele, MD, FAAN, and Olajide A. Williams, MD, note that stroke disparities are only partially explained by differences in the prevalence of traditional stroke risk factors between Black and White patients.

Dr. Ovbiagele, professor of neurology at the University of California San Francisco Weill Institute for Neurosciences, and Dr. Williams, professor and chief of staff of the department of neurology at the Columbia University Vagelos College of Physicians and Surgeons, recently spoke with Neurology Today about a framework for understanding the effects of racism on stroke risk and where the field needs to go from here.

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“I think grooming more researchers of all stripes; it doesnt have to be just people of color, who are interested in health inequities, to consider studying the issue of racism, would also be very important. We need more training programs to help people develop their careers in stroke disparities research. We need all hands-on deck if we are actually going to successfully tackle this issue.”—DR. BRUCE OVBIAGELE

What motivated you to publish this piece?

Dr. Ovbiagele: While stroke disparities have been well documented, we haven't fully resolved what all the explanations or solutions are. This is an issue that has been pervasive for five decades. As you saw from the article, we can only explain about half of what seems to be contributing to Black-White disparity in terms of stroke outcomes.

Dr. Williams: I think the nation is sensitized, the world is sensitized, given the events of George Floyd in addition to the devastating disparities that were illuminated by COVID-19. Bruce and I have been working within the world of health disparities for decades, but it's amazing just how few Americans understand the severity of these disparities and how they impact all of us. I think COVID really showed the interconnectedness of all of us in society, whether you are the cleaning person going into a patient's room, or whether you are the physician walking into it, or a nurse, or a nursing aide. If one of those people in that chain has COVID, everyone is at risk. It shows we have to take care of the least among us. We thought we should take advantage of this moment by expanding the knowledge of the academic community on this topic.

In your Viewpoint article, you highlight three levels for understanding racism: institutionalized, personally mediated, and internalized. Could you explain how each type of racism may impact Black Americans at risk for stroke?

Dr. Williams: Institutionalized racism is the codification of discrimination and bias into the structures of societies. These structural biases are driven by individual-level biases. For example, if I put a group of biased individuals on the governance committee of a particular organization, those individuals will translate their bias into policies and procedures. And then there is internalized racism, which is the effect of chronic racism on an individual. Chronic discrimination, chronic dehumanization, chronic marginalization causes the individual on the receiving end to ask, what is my worth? Before you know it, that individual will start internalizing the worth that society has placed on him. Once you internalize racism, it can be self-destructive.

What happens across these different levels is the systematic denial of opportunities such as access to health care. There is also the denial of diversity within health care by discriminating against people of color seeking admission into the medical field. This was highlighted by the Flexner Report [on medical education in the United States and Canada, originally published in 2010].

So structurally, you're being denied access, denied opportunities, and denied the ability to improve diversity within medicine. Personally, you're experiencing daily discrimination. Bruce and I included the Everyday Discrimination Scale in our paper to highlight the daily injustices experienced by people of color as a result of personally mediated racism. That in itself can be quite traumatic; it can generate anxiety, it can generate chronic stress responses, which in turn can lead to higher levels of inflammation, hypertension, etc. Couple that with decreased access to get these things fixed; couple that with decreased motivation to get these things addressed because you don't value yourself. Now you're dealing with a perfect storm that may lead to strokes and earlier mortality among people of color.

How may racism impact the evaluation, diagnosis, and treatment of people who are Black?

Dr. Ovbiagele: What we do know is that on the surface, at least, there are clearly differences in the timeliness and appropriateness of care that is delivered to Black people either at risk for stroke or who have experienced stroke. Can you categorically say that is due to racism? It is very hard to say. But that is what we are trying to call people to look into. If we don't have clear evidence pointing in one direction, it would be hard to design interventions or solutions to address it.

Dr. Williams: The 2013 Institute of Medicine report, Unequal Treatment, reviewed examples of implicit biases in medicine and showed quite tangibly that due to implicit bias, Black individuals may not receive the same level of pain treatment as White individuals. They showed that Black individuals may not get appropriate referrals for cardiac catherization compared to White individuals. We need much more rigorous research into this area in order to best determine where our resources should be focused.

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“There arent enough Black neurologists, certainly not enough Black stroke neurologists to do the volume of work required. Because this is a societal problem, its critically important for us to mobilize not just people of color, but allies who feel passionate about this injustice to join hands and help with the research and solutions.”—DR. OLAJIDE A. WILLIAMS

Dr. Ovbiagele: Specifically, for stroke, as noted in the American Stroke Association “Racial-Ethnic Disparities in Stroke Care” statement in 2011. Black individuals have longer waiting times in the emergency department and are less likely to receive tPA or carotid revascularization procedures than White individuals.

You call for more funding and research into “stroke interventions and the role of racism in stroke outcomes.” What types of funded projects would you like to see?

Dr. Williams: I think the vascular effects of racism need to be better studied. For example, we now know the effects of rumination on blood pressure. We know that among people who are exposed to a racist event—such as when police pull someone over, grab him/her out of their car, and handcuff that person because he/she is Black—blood pressure surges due to the acute stress response at that moment. But these events are not isolated experiences, and so the cycle repeats itself. Moreover, the events are also replayed in your mind in the form of recurrent nightmares, the post-traumatic stress disorder of that experience. So not only is the experience continuing to happen in the real world, you're also being assaulted by the memory of the experience over and over again. All this causes vascular effects and inflammatory responses.

Dr. Ovbiagele: We need more representation of people of color but especially African-Americans in trials... I think we need to incorporate measures of discrimination and racism into trials as well. I would like to see those as endpoints in trials. I think those are the things that could be done almost immediately, and it would be wonderful to get the NIH to encourage that. I think grooming more researchers of all stripes; it doesn't have to be just people of color, who are interested in health inequities, to consider studying the issue of racism, would also be very important. We need more training programs to help people develop their careers in stroke disparities research. We need all hands-on deck if we are actually going to successfully tackle this issue.

Dr. Williams: There aren't enough Black neurologists, certainly not enough Black stroke neurologists to do the volume of work required. Because this is a societal problem, it's critically important for us to mobilize not just people of color, but allies who feel passionate about this injustice to join hands and help with the research and solutions.

How would you like the field of stroke neurology to respond to your Viewpoint?

Dr. Ovbiagele: Advocacy with nongovernmental organizations, professional organizations like the American Academy of Neurology, the American Neurological Association, the American Stroke Association, as well as major funders like the NIH. And, also not to just make this an American issue...this is a call to motivate a global cohort of people to address potentially racism-contributing stroke disparities in their countries.

Dr. Williams: There have been many acts of racism in medicine against the Black community, such as [the Tuskegee Study of Untreated Syphilis in the Negro Male] that have really drowned the confidence that people of color have with the health care system. They need truth and reconciliation. They need to be told that it's not in their minds; it's not in their heads. This is real, and it happened, and it is still happening. There needs to be acknowledgment before there is that recovery.

How can individual neurologists mitigate the effects of racism on health?

Dr. Williams: It all begins with the individual. I would say, listen, learn, and become an ally.

Dr. Ovbiagele: Undergo implicit bias and cultural sensitivity awareness training. Look at your own practice and routinely examine whether there are racial differences in care and outcomes among the stroke patients you see and address them. Lend your voice to support studies and programs aiming to eliminate this prominent and long-standing health disparity in our country. In “Forecasting the Future of Stroke in the United States” (Stroke. 2013;44:2361-2375), it's been projected that racial/ethnic disparities in stroke will likely worsen with time, without new concerted efforts, so there is no time like the present to strongly address this issue.

Drs. Williams and Ovbiagele reported no relevant disclosures.

Link Up for More Information

• Williams O Ovbiagele. Viewpoint: Stroking out while Black—The complex role of racism https://jamanetwork.com/journals/jamaneurology/article-abstract/2769834#:~:text=Internalized%20racism%20and%20the%20resulting,in%20addition%20to%20cardiovascular%20disease. JAMA Neurol 2020; Epub 2020 Aug 21.
    • Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care https://www.nap.edu/catalog/12875/unequal-treatment-confronting-racial-and-ethnic-disparities-in-health-care. 2003, https://doi.org/10.17226/12875.
      • Williams DR, Yu Y, Jackson JS, et al. Racial difference in physical and mental health: Socioeconomic status, stress, and discrimination https://journals.sagepub.com/doi/10.1177/135910539700200305. J Health Psychology 1997;2(3):335–351.
        • Cruz-Flores S, Rabinstein A, Biller J, et al; for the American Heart Association Stroke Council. Racial-ethnic disparities in stroke care: The American Experience-A statement for healthcare professionals from the American Heart Association/American Stroke Association https://www.ahajournals.org/doi/10.1161/STR.0b013e3182213e24?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed. Stroke 2011;42:2091–2116.
        • Glynn LM, Christenfeld N, Gerin W. Recreating cardiovascular responses with rumination: The effects of a delay between harassment and its recall https://www.sciencedirect.com/science/article/abs/pii/S0167876007000979. Int J Psychophysiol 2007;66(2):135–140.