Dave Chappelle once joked, “What kills black people more than anything…more than police or terrorism? Salt…regular ol’ table salt.” According to the most recent CDC data, there’s truth beyond the punchline. In the U.S. there are more African-Americans living with hypertension than any other ethnicity. As our most underestimated threat, hypertension is the leading risk factor for three of the top 10 causes of death in the U.S., including cardiovascular disease, kidney failure, and stroke. The disproportionate effect on people of color spans over 25 years, which should make hypertension a national public health concern of the same caliber as the opioid epidemic. However, this issue has yet to reach critical mass…not even within Black culture. For public health minds, physicians, federal budget committee members, but most importantly — the black community, this raises an unsettling but necessary question:
At what point will hypertension risk among Black people become a top priority?
If you’re anything like my family — we simply called it the pressure. The pressure was why Gammie took that little pill once a day (which she pronounced, “Thighs-ide”). It was why Pop-pop walked a few loops around the neighborhood, and why all the flavorful ham hock-containing meals I loved as a kid were gradually substituted with turkey legs. But the days of the pressure being viewed as an older person’s disease are long gone. In fact, hypertension (high blood pressure) among people less than 45 years old has grown exponentially, and with it, a concomitant increase in the number of deaths due to stroke in persons under age 65. While the DASH diet became our first line of defense, hypertension went and got a black belt. Now African-American men and women have double the risk of a first stroke compared to that of their white counterparts, and among all ethnicities, are most likely to die due to stroke.
Make no mistake, hypertension is the Kawhi Leonard of chronic illnesses: an expressionless, stealthy assassin that can annihilate opponents through a series of small, unsuspected chess moves.
Because of this, researchers have spent considerable time and energy trying to better understand the condition.
We know the spectrum of the disease (impairment of normal function for vital organs, such as the heart and the kidneys, while also decreasing vision and sensation over time).
We also know who it commonly affects: Black men (top of the risk totem pole, less likely to have it under control, more likely to go without a formal diagnosis, and once diagnosed, have higher rates of treatment failure).
We even know the trends; comparative studies show that black people have an earlier disease onset. And yet, the ethnic disparity gap among people with hypertension — that is the difference between Black Americans with hypertension and white counterparts — hasn’t contracted in two decades.
With the risk of hypertension and its downstream complications outpacing every other ethnicity, a collective sense of urgency should be the response, right? Instead, it’s as though our disease burden defaults to insignificance — simply because the condition is viewed as easily managed. But this is far from “easy”, especially given the amount of Black folks that enter my ED with blood pressures that are through the roof, or worse, presenting with red flag symptoms (i.e. numbness, weakness, chest pain, slurred speech, vision changes, altered mental status). Nothing about hypertension is synonymous with ease, or simplicity, or even harmlessness. And when I think about the tipping point — one name comes to mind: John Singleton.
April 29th, 2019 (exactly one month ago) – A new notification surfaced on my phone: “Director/Producer John Singleton dies at 51.”
I sat on the edge of my bed, still in scrubs from the night before, feeling the complete weight of the news as though it were a wrapped in 10-oz. Everlast gloves and thrown by Deontay Wilder. I knew something wasn’t right. Singleton was poised to join the ranks of Dick Gregory, Ruby Dee and Ossie Davis…in due time. He would be our generation’s Harry, Sidney, and Melvin, a fixed laureate at every Academy Awards to the point where my unborn children could pick him out in the audience. But that narrative was cut short. John didn’t die from a freak accident. He didn’t die from some act of brutality or violence. John died of a hemorrhagic stroke — a brain bleed caused by dangerously high blood pressure — at 51 YEARS OLD. How was it that the curator of “coming-of-age” masterpieces like Boyz n the Hood, Poetic Justice, Higher Learning, and Baby Boy could succumb to a “controllable condition” like high blood pressure?
A closer look at John Singleton reveals a man who was downright gifted at delivering critical messages to our generation using a medium that traditionally shared our stories through a clouded prism. In each of his projects, Singleton was able to set a national public health agenda and shift the conversation within our respective communities; this is a skill that most trained public health advocates struggle to perfect. Consider the impact that movies like Boyz or Poetic Justice had on gun violence. Or that of Higher Learning on the optics of policing and hate crimes as a public health concern. Or even the prevalence of intimate partner violence emphasized in Baby Boy. These were not just captivating stories, they were 120-minute health awareness campaigns with unforgettable plots and dope soundtracks.
Singleton hand-delivered characters that felt like our own family members, leaving a lasting impression on viewers. But by the numbers, about half of these beloved characters would suffer from high blood pressure today; and they wouldn’t die at the hands of rival gang members or white supremacists — but rather complications of uncontrolled blood pressure. Naturally, this is a brilliant allegory for our own risk burden, and even Singleton’s risk of stroke. Now, the same cohort of young black men that first saw themselves portrayed through characters like Tre, Furious, Lucky, Malik, and Jody are in the crosshairs of a different, more stealthy killer — hypertension.
In his abrupt departure, we are forced to reexamine hypertension as a premier medical concern, and ultimately answer why we ever lost sight of it in the first place. It boils down to poor public perception of the hazard, and unsuccessful adoption of interventions that work. Even the fixed ethnic disparity gap among people with hypertension suggests a systemic failure in addressing social determinants of health. Familiar hurdles such as lack of education, lack of access to appropriate health services, inconsistent support for lifestyle modification, and environmental barriers to lifestyle improvement continue to pose significant challenges for intervention strategists. In plain terms, we understand some of these social determinants, the problem is that we don’t have enough translational research, and what seems to work effectively lacks adequate resources to test at scale.
Most hypertension interventions are hospital or clinic-based and target “easily changed” or modifiable risk factors (i.e. smoking cessation, weight control, and dietary adjustment). However newer approaches focus on screening and prevention by entering cultural meeting hubs like churches, salons, and barbershops to expand the catchment area. In fact, the barbershop-based intervention model has become a widely-championed vehicle for hypertension awareness that disrupts conventional modes of access to care services.
Now the reason why these interventions work is the same reason why health motifs in John Singleton’s movies are so resonant; they are diaspora-approved and hinge on community adoption. Everything from the practitioners conducting the intervention down to the content being shared has passed the cultural eye test. To appropriately elevate hypertension to a national public health concern, the next step must position culturally-informed interventions (that have demonstrated efficacy, scalability, and adoption) as the gold standard. But until all parties involved — medical, public health, and the at-large Black community — acknowledge and push for federal dollars to support efforts like these, we will continue to be the proverbial dog chasing its own tail.
In the final scene of Singleton’s 1991 classic Boyz n the Hood, Tre and Doughboy (played by Cuba Gooding Jr. and O’Shea Jackson Sr.) mourn their brother Ricky. The lens centers on Dough as he delivers one of the most powerful monologues in contemporary film history. “Either they don’t know, don’t show, or don’t really care about what’s going on in the hood.” There’s bone-chilling irony in that remark, as it perfectly encapsulates America’s underwhelming response to hypertension as a national health crisis affecting the Black community. The death of John Singleton does not absolve Black folk — we too have operated with a certain nonchalance surrounding the issue. So what will it take to elevate the pressure to a top priority? Hopefully nothing more than this loss. But in running this dialogue up the flagpole, we honor John’s legacy the right way; and in the process, we’ll tip the scales in favor of interventions that save lives.