Historical Slavery and Modern-Day Stroke Mortality in the United States Stroke Belt
2018; Lippincott Williams & Wilkins; Volume: 49; Issue: 2 Linguagem: Inglês
10.1161/strokeaha.117.020169
ISSN1524-4628
AutoresCharles Esenwa, Daudet Ilunga Tshiswaka, Mulugeta Gebregziabher, Bruce Ovbiagele,
Tópico(s)Acute Ischemic Stroke Management
ResumoHomeStrokeVol. 49, No. 2Historical Slavery and Modern-Day Stroke Mortality in the United States Stroke Belt Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessArticle CommentaryPDF/EPUBHistorical Slavery and Modern-Day Stroke Mortality in the United States Stroke Belt Charles Esenwa, MD, MS, Daudet Ilunga Tshiswaka, PhD, Mulugeta Gebregziabher, PhD and Bruce Ovbiagele, MD, MS Charles EsenwaCharles Esenwa From the Department of Neurology, Montefiore Medical Center, New York, NY (C.E.); Department of Public Health, University of West Florida, Pensacola (D.I.T.); Departments of Public Health (M.G.) and Neurology (B.O.), Medical University of South Carolina, Charleston. , Daudet Ilunga TshiswakaDaudet Ilunga Tshiswaka From the Department of Neurology, Montefiore Medical Center, New York, NY (C.E.); Department of Public Health, University of West Florida, Pensacola (D.I.T.); Departments of Public Health (M.G.) and Neurology (B.O.), Medical University of South Carolina, Charleston. , Mulugeta GebregziabherMulugeta Gebregziabher From the Department of Neurology, Montefiore Medical Center, New York, NY (C.E.); Department of Public Health, University of West Florida, Pensacola (D.I.T.); Departments of Public Health (M.G.) and Neurology (B.O.), Medical University of South Carolina, Charleston. and Bruce OvbiageleBruce Ovbiagele From the Department of Neurology, Montefiore Medical Center, New York, NY (C.E.); Department of Public Health, University of West Florida, Pensacola (D.I.T.); Departments of Public Health (M.G.) and Neurology (B.O.), Medical University of South Carolina, Charleston. Originally published15 Jan 2018https://doi.org/10.1161/STROKEAHA.117.020169Stroke. 2018;49:465–469Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2018: Previous Version 1 In the United States, stroke incidence and related mortality have declined in the past half century.1,2 This drop is largely because of better recognition and control of modifiable cardiovascular disease risk factors.3,4 There remain significant racial disparities however, and studies and surveillance programs consistently show higher rates of stroke and stroke-related mortality in native born blacks when compared with non-Hispanic whites (NHW).5–9 Nowhere is this racial disparity more evident than in the stroke belt, an area in the Southeastern United States with disproportionately high rates of stroke.10–12 Although a higher prevalence of cardiovascular disease risk factors, specifically hypertension, diabetes mellitus, obesity, and cigarette smoking, account for much of the excess stroke risk, it remains unclear why these cardiovascular comorbidities, and other lifestyle-related risk factors, cluster in this region of the United States, particularly in blacks.13–15 Multiple explanations have been proposed, but the medical community has yet to offer a fully satisfactory explanation for what is driving stroke mortality in the ≈700 hot spot counties of the stroke belt.16 A clue is that these counties also have higher proportions of black residents and unemployment, as well as lower educational status, median income, and healthcare use.16While often ignored in the medical literature, a history of slavery, and ongoing social segregation, racial discrimination, and economic inequality, provide a historical precedent for the phenotype of poor cardiovascular health observed in several predominantly black communities. Although many reports depict the racial disparities and skew in stroke risk factors in this region of the United States, a PubMed search using the words slavery, slave, stroke, stroke belt, and cardiovascular disease returned no relevant articles. Our goal is to review the historical evidence and test the strength of association between historical slavery and modern-day stroke mortality in the Southeastern United States.Historical EvidenceThe socioeconomic chasm between blacks and NHW originated early in US history. In the late 1700s, the highest density of African slaves was localized to the coastal states of Maryland, Virginia, and South Carolina. Detailed county-level census data taken in 1860, just before the start of the American Civil War and the passing of the Emancipation Proclamation by Abraham Lincoln, show the forced redistribution and settlement of enslaved blacks to the south and west, an area that mirrors today's stroke belt (Figure in the online-only Data Supplement). Although the practice of slavery was outlawed in 1863, blacks mostly living in the Southeastern United States remained bound by codes and laws that restricted their civil rights and civil liberties for another 100 years. The lawful discrimination based on race by the federal and state governments ended with the passage of the Civil Rights Act of 1964. Just before the passage of the Civil Rights Act, Dr Max Seham, in the article Discrimination Against Negroes in Hospitals, wrote; "There is no question that if the same care was available to Negroes in Mississippi and other Southern states as in Minnesota and other Northern states, Negro morbidity and mortality rates could be sharply reduced. Factors responsible for this difference are poverty, lack of Negro doctors and of doctors for Negroes and the exclusion of Negroes from first-class 'white' hospitals."17 Today, native born blacks living in the Southeastern United States have a 2× to 4× higher risk of stroke compared with NHW, suggesting that institutional racism and economic oppression continue to affect the lives of blacks in this region of the United States.18In 1968, the US Department of Justice issued The National Advisory Commission on Civil Disorders Report, which concluded that "Our nation is moving toward two societies, one black, one white – separate and unequal."19 The statement is proven to be true today when disparities between blacks and NHW pervade every aspect of American society. Average income for blacks is nearly half that of NHW, and blacks have on average one thirteenth the individual wealth of NHW.20 Disparities in race consistently show up in measures of poverty, unemployment, access to jobs, level of education, and healthcare access—lingering effects of the centuries of oppression experienced by blacks during slavery and under the guise of separate but equal Jim Crowism.21 It should, therefore, come as no surprise that racial disparities in cardiovascular disease, and more specifically stroke, are at least in part a result of a legacy of slavery.Epidemiological AssociationTo provide objective evidence that slavery has contributed to the geographic and racial disparities in stroke mortality seen in the Southeastern United States, we analyzed county-level slavery and slave density patterns in the year 1860 and compared them to stroke mortality rates for years 2011 to 2013.Materials and MethodsThe study area included 2017 counties, 1134 of which were slave counties and 883 nonslave counties in 1860. We chose this year because of the availability of detailed slave population density data recorded by the US census. These data also show the final distribution of slavery just before it was outlawed by executive order in 1863. Presence of slavery and slave population density, defined as number of slaves per 100 residents, on a county level was obtained from The US Coast Survey map, Census Office, Department of the Interior, published on September 9, 1861.22 Of the slave counties, there were 1110 with observations for slave density. Geographic territories that were not yet considered US counties in 1860 were excluded (Figure 1). Stroke mortality was obtained from the Centers of Disease Control and Prevention, National Vitals Statistics System, for years 2011 to 2013 (Figure 2). Age-adjusted mortality from all stroke types was included with an age cutoff of ≥35 years. This age cutoff was preset by the Centers of Disease Control. Cartographic manipulations and displays were done in Environmental Systems Research Institute ArcGIS 10.4.1. ArcGIS user interface was used to enter county-level slave density and stroke mortality into geographic information systems shape files representing US counties from 1860 and 2011, respectively. The 2 layers were merged to create a single map with merged county territories with slave density and stroke mortality overlapping for each territory.Download figureDownload PowerPointFigure 1. County-level slave population density in the year 1860. Map of US counties in 1860 with heat map of slave density (percent slaves per 100 county inhabitants). Counties in white did not have slaves or were nonslave counties. Areas in gray were excluded from final analysis because they were not yet considered states or were recently admitted states that were considered free of slaves. Data derived from map showing the distribution of the slave population of the southern states of the United States. Compiled from the census of 1860 by E. Hergesheimer, Engraved by Th. Leonhardt, in Library of Congress, Geography, and Map Division.Download figureDownload PowerPointFigure 2. All-race stroke mortality for the years 2011 to 2013. Map of county-level stroke mortality rates for all stroke subtypes for years 2011 to 2013. Data are age adjusted and only includes those aged ≥35 years. Data derived from the Centers of Disease Control and Prevention, National Vitals Statistics System.We used t test and Wilcoxon rank-sum test to compare the differences in stroke mortality rates by presence of county-level slavery for all races and stratified by race. Poisson regression was used to generate incidence rate ratios (IRR) for stroke mortality stratified by race. IRRs were used evaluate the relationship between slave density and stroke mortality only in counties with history of slavery. A Spearman correlation was performed between density of slavery and mean stroke mortality. Given that all data were publicly available, Institutional Review Board review was not needed. All analyses were done using SAS software version 9.4, and data were analyzed by authors C. Esenwa and M. Gebregziabher.ResultsWhen including all counties, presence of county-level slavery was strongly associated with an increased all-race stroke mortality rate (per 100 000) when compared with nonslave counties (mean difference, 15.0; 95% confidence interval [CI], 14.1–16.0; P<0.001). When stroke mortality was stratified by race, stroke mortality in slave counties was higher than in nonslave counties, in NHW (mean difference, 12.5; 95% CI, 10.5–12.4; P<0.001) and to a much greater degree in blacks (mean difference, 31.8; 95% CI, 28.4–35.4; P<0.001), but not in Hispanics (mean difference, −3.4; 95% CI, −6.5 to −0.3; P<0.001), where a slight negative association was found (Table 1). When excluding nonslave counties, and limiting the analysis to the 1134 counties with a history of slavery, a 1% increase in slave density was associated with a 0.09% increase (per 100 000) in all-race stroke mortality (IRR, 1.0009; 95% CI, 1.0007–1.0012; P<0.001). When stratified by race, a 1% increase in slave density was associated with a 0.07% decrease (per 100 000) in white race stroke mortality (IRR, 0.9993; 95% CI, 0.9990–0.9996; P<0.001) and a 0.82% increase (per 100 000) in black race stroke mortality (IRR, 1.0082; 95% CI, 1.0080–1.0085; P<0.001; Table 2; Table in the online-only Data Supplement).Table 1. Mean Stroke Mortality Rates in Counties With a History of Slavery vs Those Without a History of SlaveryRaceSlave CountiesNonslave CountiesMean Difference95% CIP ValueAll88.173.115.014.1 to 16.0<0.001Non-Hispanic white84.872.312.510.5 to 12.4<0.001Black97.065.231.828.4 to 35.4<0.001Hispanic32.335.7−3.4−6.5 to −0.3<0.001County-level stroke mortality defined as number of cases (per 100 000 people) for years 2011 to 2013 stratified by race, in counties with a history of slavery vs those without a history of slavery in 1860. P values adjusted for unequal variances via Satterthwaite approximation. CI indicates confidence interval.Table 2. Effect of County-Level Slave Density on Stroke MortalityRaceIRRSE95% CIP ValueAll1.00090.00011.0007–1.0009<0.001Non-Hispanic white0.99930.00010.9990–0.9996<0.001Black1.00820.00011.0080–1.0085<0.001Hispanic0.99070.00040.9899–0.9916<0.001Effect of a 1-unit change in slave density in 1860 on county-level stroke mortality estimated by Poisson regression IRR (age adjusted, per 100 000 people) for years 2011 to 2013. Only counties with a history of slavery were included. CI indicates confidence interval; and IRR, incidence rate ratios.DiscussionHistory suggests that a legacy of slavery is contributing to present-day racial disparities in US health. By comparing historical slave density patterns to current-day stroke mortality rates, we found that the presence of county-level slavery in 1860 affects current-day stroke mortality rates in blacks ≈3-fold more than NHW. To determine whether this relationship was dose dependent, we limited our analysis to counties with a history of slavery in 1860 and compared the number of slaves per county to present-day stroke mortality for that respective territory. We found a strong and highly significant dose response of slave density in 1860, on stroke mortality in 2011 to 2013, for blacks but not NHW.Our analyses confirm that a history of slavery is associated with current-day stroke mortality, particularly in blacks. The effect of slavery on stroke mortality among NHW was surprising but not necessarily unexpected. After the Civil Rights Act of 1964 and the healthcare reforms that afforded blacks equal access to medical care, black infant mortality rates in the most affected states, dropped immediately and precipitously.23 Infant mortality rates in NHW also decreased albeit at a much lower rate, suggesting that there may have been spill-over effects of segregation to vulnerable NHW in these communities. During the same period, stroke rates in southern states dropped in blacks and NHW, in a pattern similar to infant mortality.24 Unlike blacks and NHW, stroke mortality in Hispanics was inversely related with slavery. This suggests that the causes of stroke disparities in native US blacks are likely distinct from those observed in native Hispanics, where stroke mortality may be more strongly affected by lifestyle changes because of immigration patterns to the Southwestern United States.A major limitation to our study was missing data on stroke mortality for Hispanics and blacks. For Hispanics, we did not have county-level stroke mortality data for the majority of the Southeastern United States. In blacks, most of the stroke mortality data for the Southeastern counties were present but not for the rest of country. Nonetheless, for our main analysis of slave density and stroke mortality in blacks, we had nearly complete data for the counties analyzed. We purposefully did not include mediators or confounders in our analysis because our study was an ecological study without information on individuals. We do acknowledge, however, that there may be lasting downstream socioeconomic effects from the American Civil War, or other previously unidentified environmental factors, that could account for the association between presence of slavery and the increased stroke risk in NHW that would presumably be independent of slavery. Our sources of slave density and stroke mortality were obtained from the US census bureau and the Centers of Disease Control, respectively, published 150 years apart, strengthening our causal theory and making selection bias unlikely. Furthermore, the strong dose effect seen in blacks, combined with the minimal and negative effect of slave density in NHW, give the observed association biological plausibility.ConclusionsOverall, our review and analyses show that a history of slavery may be a previously unacknowledged driver of current-day stroke mortality, particularly in blacks, and provide insights into the causes of present-day racial disparities seen in the Southeastern United States. It is likely that poverty, lack of geographical access to care, migration patterns, and a complex web of other socioeconomic factors, some of which left over from the era of slavery, are interacting to affect stroke mortality in this part of the United States. We propose that on the institutional level these factors include racial segregation, economic oppression, educational inequality, and unequal access to healthcare. Then, there are biopsychosocial mediators, such as epigenetics, environmental, cultural, and social risks. Most proximal are disease-specific processes that lead directly to physiological precursors of stroke (Figure 3).Download figureDownload PowerPointFigure 3. Hypothesized mediators in the association between slavery and stroke mortality in blacks. Variables denoted by rectangles are hypothesized mediators. Variables in ovals are hypothesized effect measure modifiers.A great amount of progress has been made in the past half century in the prevention of stroke by targeting immediate stroke risk factors, but racial disparities in stroke rates continue to be astounding and could be in part because of the lasting effects of slavery. Centuries of racial inequality continue to affect the cardiovascular health of blacks through disparities in economic standing, social inequality, and limited access to appropriate healthcare. Social injustice is the fabric on which such social gradients of health persist. In other words, the disparity associated with stroke mortality will likely persist in regions where racial inequality is systemic. Indeed, recent analyses project substantial future widening of stroke prevalence in the United States for blacks compared with NHW.25 The medical community must, therefore, continue to be involved in raising awareness of health-related disparities and be active in denouncing all forms of segregation for the sake of not only our generation but also those to come.AcknowledgmentsWe thank Harriet A. Washington for her trusted input and edits to this article.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.117.020169/-/DC1.Correspondence to Charles Esenwa, MD, MS, Stern Stroke Center, 3316 Rochambeau Ave, 4th Floor, Bronx, NY 10467. 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Feinstein M, Hsue P, Benjamin L, Bloomfield G, Currier J, Freiberg M, Grinspoon S, Levin J, Longenecker C and Post W (2019) Characteristics, Prevention, and Management of Cardiovascular Disease in People Living With HIV: A Scientific Statement From the American Heart Association, Circulation, 140:2, (e98-e124), Online publication date: 9-Jul-2019. February 2018Vol 49, Issue 2 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.117.020169PMID: 29335332 Manuscript receivedNovember 17, 2017Manuscript acceptedDecember 6, 2017Originally publishedJanuary 15, 2018Manuscript revisedNovember 29, 2017 KeywordsstrokemortalityAfrican Americansslaverycardiovascular diseasesPDF download Advertisement SubjectsCerebrovascular Disease/StrokeEpidemiologyMortality/SurvivalRace and EthnicityRisk Factors
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