Article In Brief
Experts discuss how systemic racism has an impact on neurologic disorders and access to care for black Americans.
Systemic racism and white supremacy is hazardous to the health of black Americans—including their neurologic health. That, experts told Neurology Today, is the outcome of inequity, combined with discrimination, abuse and mistrust, and with perhaps the most pernicious and inescapable health effect of racism: the inescapable, ongoing, daily stress of being black in America.
“Several studies have shown clear biological links for poor health outcomes associated with racism, even after controlling for other factors that you think experiences of racism might serve as a proxy for, such as access to care,” said April Thames, PhD, associate professor of psychology and director of the social neuroscience in health psychology lab at the University of Southern California. There, Dr. Thames has developed a translational neuroscience research program focused on the impact of chronic disease, substance abuse, socioeconomic disadvantage, and lifetime stress/adversity and resiliency on neurological, cognitive, and mental health outcomes.
In a study published in Psychoneuroen-docrinology in 2019, Dr. Thames and co-author Steven Cole, PhD, professor of medicine and psychiatry and biobehavioral sciences in the David Geffen School of Medicine at UCLA, described what they call “conserved transcriptional response to adversity” (CTRA). In CTRA, genes that promote inflammation are turned on while genes that promote an antiviral response, which protects against infection and pathogens, tend to have their expression decreased.
“In our study, we found that black individuals had a significantly higher conserved transcriptional response to adversity,” Dr. Thames said. “Even after controlling for factors like education, environment and other forms of psychosocial stress, perceived discrimination explained more than 50 percent of total race-related differences in pro-inflammatory transcription factor activity.”
Dr. Thames said that CTRA could be a significant mechanism putting black Americans at increased risk for many chronic and degenerative medical conditions, including neurologic conditions ranging from sleep disorders to dementia and stroke.
Evidence of Neurologic Disparities
There's significant literature to support this theory. For example, regarding dementia and cognitive impairment, a 2017 study in the Journal of Alzheimer's Disease by researchers at the University of Wisconsin found that while lifetime stress is associated with poor cognitive health across the board, black Americans report more stressful events—60 percent more than whites—and those events are associated with greater cognitive detriment.
The disparities are evident in studies regarding stroke. Stress and depression are well-known risk factors for stroke. In a 2014 study in Stroke, researchers at the University of Minnesota reported that each additional point on the depression, stress, and hostility scales was associated with significantly increased stroke risk. And the 2015 “Social Determinants of Risk and Outcomes for Cardiovascular Disease: Scientific Statement from the American Heart Association,” published in Circulation, linked experiences of racism to both blood pressure and cardiovascular reactivity.
With regard to sleep disorders, reports of lifetime experiences of discrimination were positively associated with self-reported insufficient sleep in a survey of over 7,000 adults reported in 2012 in Behavioral Sleep Medicine, and a 2016 analysis of the scientific literature in Sleep Medicine demonstrated “consistent evidence that discrimination is associated with poorer sleep outcomes.”
Indeed, since the early 1990s, researchers have been investigating the role of racism in “allostatic load”—the physiological consequences of chronic exposure to fluctuating or heightened neural or neuroendocrine response resulting from repeated or prolonged chronic stress.
Arline Geronimus, ScD, professor in the department of health behavior and health education and research professor in the Population Studies Center at the Institute for Social Research at the University of Michigan, coined the term “weathering” in a 2006 paper in American Journal of Public Health to describe an accelerated aging phenomenon experienced by people of color exposed to chronic toxic stress related to racism and socioeconomic disadvantage.
A June 10 editorial in the New England Journal of Medicine summed up the health crisis: “Discrimination and racism as social determinants of health act through biologic transduction pathways to promote subclinical cerebrovascular disease, accelerate aging, and impede vascular and renal function, producing disproportionate burdens of disease on black Americans and other minority populations,” wrote Michele K. Evans, MD, and colleagues.
“The US has a long history of structural and institutionalized racism that creates systematic differences in the quality of life for people who are in racial and ethnic minorities and those who are not,” said Roy H. Hamilton, MD, MS, FAAN, associate professor of neurology and vice chair of inclusion and diversity at the University of Pennsylvania and senior author of “Reducing Neurodisparity: Recommendations of the 2017 AAN Diversity Leadership Program,” published in Neurology in February 2019.
“Frequently discussed factors include environmental racism, which can include unsafe home environments, lack of access to nutrition and green spaces and opportunities for healthy physical activity. There are disparities in access to care, including neurologic care, as well as differences in how people are treated even if they are able to obtain care,” Dr. Hamilton said. “For example, we know that black patients experiencing a stroke are one quarter less likely to be given thrombolysis, the treatment we know is most likely to be effective, than white patients. But beyond all of this, evidence suggests that the stress of the experience of racism may have its own physical impact. It's about access and unequal treatment, but it's also about much more than that. The fact that individuals have to live with these stressors their entire lives produces adverse health consequences. Discrimination has a directly toxic impact on health in general and neurologic health in particular.”
The Imperative for Neurologists
What's the imperative for neurologists, departments of neurology, and the AAN in addressing the neurotoxicity of racism and adopt a stance of anti-racism?
“I think a variety of things need to happen,” said Dr. Hamilton. “We need all clinicians to become aware of how systemic and pervasive racism is and how it is lived by our patients, but I also think they need to grasp the foundational concept that race isn't an intrinsic biological distinction between people that has social implications. Instead, it is a deeply ingrained social construct that as a consequence has massive downstream health effects. This social construct causes the impacts the minority patients are experiencing. We have to think of inequities in neurology as an end result of racism, and we all have to act accordingly to combat that root cause, rather than acting as though there are inherent biologic differences between races that are the principle drivers of different incidences of disease and different health outcomes.”
Anti-Racism in Neurology
Altaf Saadi, MD MSc, a neurologist at Massachusetts General Hospital and instructor in neurology at Harvard Medical School, published research in Neurology in 2017 documenting that black patients are nearly 30 percent less likely to be treated by an outpatient neurologist than whites. Dr. Saadi is now shifting her research to community-based and policy solutions.
“In one study, we found that mistrust of researchers impacted stroke knowledge in minority elderly involved in a community intervention trial. We need to address mistrust by partnering with trusted community organizations to conduct our research,” she said.
“We are also working to create more structured training for our trainees to understand how these issues manifest for our patients. Racism and its impact on health is a complex issue to take on, requiring a multi-pronged approach that spans the individual, local community, state and national levels. We need to pursue solutions at all of these levels as neurologists.”
Dr. Saadi praised the AAN's most recent statement on systemic racism and inequities in society, issued by AAN President James C. Stevens, MD, FAAN; Jeffrey C. McClean, II, MD, FAAN, chair of the Academy's Equity, Diversity, and Inclusion Joint Coordinating Council; and AAN CEO Mary E. Post, MBA.
It read in part: “We cannot be indispensable if we remain silent in the face of an issue that so profoundly impacts so many of our members. We cannot promote the best care for our patients or enhance the careers of our members if we ignore the pervasive inequities that are often insurmountable barriers to both. In the face of these historic and systemic issues, it is not enough to not be a racist organization. We must speak out and lead in order to ensure change. To achieve our Vision and Mission, we must be an anti-racist organization.”
The AAN's Board of Directors also approved the creation of an AAN Special Commission to recommend specific actions by July 15, 2020, to implement the position statement throughout the organization.
“I really appreciate that the Academy stepped forward to name the problem, without being afraid of using words like racism,” Dr. Saadi said.
“This affects our specialty as much as any other. But we need to move from naming the problem to actively addressing it. As a junior faculty member trying to build a career around health disparities and community partnered research, I need the financial support to do so. Our funding mechanisms and priorities need to shift to embrace this research that is less common and pursued in neurology and work to solve, rather than just document, that problems exist. We already know that they do.”
Adopting a stance of anti-racism, as the Academy has committed itself to do, requires a significant level of education, Dr. Hamilton said. “Many physicians are just now becoming more fully aware of the scope and magnitude of structural racism in our society and its impact on health. As a neurologist, one needs to lean into knowing more about this, just as one is obligated to know about other health conditions that lead to profoundly negative health consequences.”
Ima Ebong, MD, an assistant professor of neurology and clinical neurophysiology at the University of Kentucky and a participant in the AAN's 2019 Diversity Leadership program, is in the process of developing proposals for neurology residency curriculum components on racism and social justice.
“That's one thing we don't teach in neurology residency,” Dr. Ebong said. “We need to make sure that there are lectures dedicated to racial disparities in neurology and in medicine in general. I've been researching different texts, journals and podcasts that I would like to incorporate into our residency curriculum. Examples of these include Medical Apartheid: The Dark History of Medical Experimentation on Black Americans by Harriett A. Washington, The Immortal Life of Henrietta Lacks by Rebecca Skloot, Levels of racism: A theoretic framework and gardener's tale by Camara P. Jones, and Just Medicine: A Cure for Racial Inequality in American Health Care by Dayna Bowen Matthew. It's important that trainees learn to be neurologists who can competently care for all segments of the population.”
She also suggests that AAN could publish a regular edition of Continuum regarding neurological health disparities. “Physicians tend to be more motivated to change their practice if there is CME credit involved,” she said. “Racial disparities in neurologic disease shouldn't be a topic for a one-time special issue, but should be on the regular rotation for Continuum just like neuromuscular disease, vascular disease or epilepsy.”
The AAN, neurologic subspecialty societies, and departments of neurology across the country should also commit to representative leadership, said Allison Willis, MD, MS, associate professor of neurology and of epidemiology, director of the Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, and co-director of the Resource Center for Minority Aging Research at the University of Pennsylvania Perelman School of Medicine.
“If I'm not seeing diverse leadership, persons of color in all types of leadership roles, then I wonder to what extent an organization is truly focused on making meaningful cultural change,” she said. “And I also want to see people who are not of color doing meaningful work on diversity initiatives. These cultural expectations—that persons of color also can and should lead, that persons who are not of color also can and should participate in diversity and anti-racism efforts, because diversity adds real value—come from the top down. Are top officials willing to train, support and uplift people of color in leadership roles?”
Dr. Willis praised the AAN's efforts to date on this front, such as the Diversity Leadership Program and the Medical Student Diversity Scholarship, as well as efforts to improve gender diversity on the editorial board for Neurology.
“I'm really looking forward to seeing how those efforts are able to produce more chairs and vice chairs of color in neurological departments and leading the AAN. That has to be the ultimate goal of these training programs: to provide the training, one-on-one mentoring, sponsorship and connections that will allow talented and deserving people of color to also lead, excel and thrive in those positions.”
“But you do not have to be in a leadership role at the AAN or in an academic medical center's department of neurology to take an anti-racist role in neurology,” Dr. Willis said. “No matter where you are, you can call out instances of micro- or macro-aggression and racism. You know it when you hear it, a presumptive comment about a patient being drug seeking or having a functional disorder that is not yet supported by the clinical and laboratory evidence, mocking of a patient because of an accent, cultural belief. Even more common, and also visible, palpable, is the lower amount of attention to detail when taking the history, effort toward tracking down corroborative information, enthusiasm for solving a neurological puzzle, response to calls for help—simply put, the care that is received by persons of color.
“When you see this happening, stand up and speak up. Doing so signals that this is no longer an acceptable culture or mentality. Take note of your own unintentional tendencies to dismiss or provide less effective care to persons from underserved groups. That is power that anybody has, to call out what is wrong and to actively fight their own implicit bias.”