Hypertension in Blacks: Physiological, Psychosocial, Theoretical, and Therapeutic Challenges

Blacks constitute only 12% of the U.S. population, but a variety of factors expose this group to the greatest health risk. Members of this group, chiefly descendants of African slaves, are unfavorably represented in all the major demographic topologies: one-third live in poverty, a value threefold higher than whites; one-half live in urban communities typified by poverty, inadequate and overcrowded schools, overcrowded housing, unemployment, constant exposure to a pervasive drug subculture and periodic street violence, and in general a high level of stress. Life expectancy is rising for the general population, but falling for blacks. Although indistinguishable from whites in causes of death by chronic diseases, blacks are distinguished by increased severity and greater prevalence of such diseases. Of the estimated 60 million hypertensive cases reported, blacks represent 25% (almost twofold higher than representation in the general population). Not only are blacks more likely to develop hypertension, but the disorder develops earlier, is often more severe, and is more likely to be fatal at an earlier age. Stroke is 50% greater in blacks compared with whites; ventricular hypertrophy is 30% greater in blacks; death in middle-aged blacks is sixfold greater; and kidney failure or end-stage renal disease in blacks is threefold higher than whites. End-stage renal disease is also more pervasive in blacks with diabetes and hypertension and is generally less prevalent in diabetic whites than diabetic blacks. Socioeconomic and psychosocial factors, plus inadequate scientific knowledge, preclude black hypertensives from getting early and aggressive therapy; consequently the majority of black hypertensives go untreated or are treated unsuccessfully. These facts prompted the recent observation that while the treatment of hypertension is improving considerably in the general population and while the morbidity and mortality from hypertension-related diseases are rapidly declining in the general population, treatment proposals (and programs) and morbidity and mortality rates remain impoverished in black communities (31).