Echoes of Tuskegee: The Socioeconomic Cycle of Heart Disease

Being poor and uneducated remains a health risk to large segments of first-world societies.

Herman Shaw, 94, climbs aboard a tour bus in Tuskegee, Ala., in 1997 to embark on a visit to Washington, D.C. [AP Photo]

Herman Shaw, the valedictorian of his high school class, had dreams of going to college and becoming an engineer. But the impoverished conditions in rural Alabama not only kept him from college, but replaced his dreams with a sharecropper's plow and a place in a forty-year government-funded study on a sexually transmitted disease.

This young black scholar in early twentieth century, segregationist America became an unwitting participant in the United States Public Health Service's (USPHS) "Study of Untreated Syphilis in the Negro Male," better known as the Tuskegee Experiment. And Mr. Shaw wasn't alone; six hundred black men, of whom 399 were syphilitics and 201 utilized as controls, were unaware that the "bad blood" the federal doctors offering free care had diagnosed was actually syphilis.

The Experiment, which began in 1932, consisted of doctors making quarterly visits to the men in order to observe the progression of the disease. They also sought to ensure that in their absence the Tuskegee men did not receive treatment for syphilis by any physician, program, or organization. With promises of hot meals and free health care, the doctors kept the indigent, under-educated men returning to undergo invasive medical tests for decades. If the men began to decline to be seen or resisted continuing the study, the USPHS resorted to bribery: it promised to pay for all medical and burial expenses, a persuasive measure due to the low socioeconomic status of the men.

In July of 1972, The New York Times ran an article, titled "Syphilis Victims in U.S. Study Went Untreated for 40 Years; SYPHILIS VICTIMS GOT NO THERAPY," that garnered national attention and effectively brought the study to a conclusion. In 1973, the Department of Health, Education, and Welfare issued a final report on the Tuskegee Experiment stating it was "ethically unjustified," that there was "no evidence of consent," and that "a person should not be subjected to avoidable risk of death or physical harm." And finally, in 1997, President Bill Clinton issued a formal apology to the Tuskegee men and their families, offering reparations, free health care, and the establishment of bioethics scholarship programs for minority students.

AP97051605211.jpgShaw with President Clinton and Vice President Al Gore during Clinton's 1997 apology to the black men whose syphilis went untreated by government doctors. [AP Photo]

If Herman Shaw was in high school today, he wouldn't have to worry about government experiments. Instead, as a poor, black agrarian, the largest threat to his health would be developing cardiovascular health disease. It wouldn't be a result of poor diet, tobacco use, or hereditary predispositions. What would make him more susceptible to the disease is the confluence of his income, occupation, and level of education.

Research clearly shows people with a lower socioeconomic status (SES) -- a metric based on education, income, and occupation -- develop heart disease at a rate that is 50 percent higher than those with a better status. Moreover, even when high-risk behaviors, such as smoking and obesity, are eliminated, those with lower SES still disproportionately suffer and die from heart disease, especially in the larger minority communities.

In other words, poverty is a risk factor for heart diseae. Its existence as such is the result of a complex mesh of educational failings, increasing income inequality, and limited access to preventative health care. And trends indicate that poverty will remain an issue for years to come, which means that heart disease, already the leading cause of death for Americans, will continue to be an issue.

Since 2000, the poverty rate has increased by four percent, meaning there are almost twenty million more people in poverty. For black Americans, the rate increased to nearly 26 percent, and is over 28 percent for Hispanics. And in 2010, 1 in 3 high school students dropped out, making them twice as likely to end up in poverty. Additionally, the income inequality gap is quickly growing, and that increases the ranks of those in the lower SES.

Because SES is a relative measurement, research indicates that the disproportionate ratio of heart disease is a first world problem. That is, one's socioeconomic status is dependent upon the nation's average education, income, and occupation levels. The more disparity that exists, the more heart disease impacts those on the lower end of the spectrum. Where poverty is rampant in a country, heart disease does not adversely affect one group over another. But in countries with high GDP and per capita rates, the stratification of the classes can be seen in the increasing rates of heart disease in those with lower SES.

The reason for this is not entirely clear, but most likely is the result of a number of factors. Communities of people in the lower SES have less access to healthcare and are less likely to visit doctors until in crisis. Though there are doctors physically located in many disadvantaged areas, recent studies show that one in three doctors are not taking new Medicaid patients due to the low reimbursement rates. For those uninsured, walk-in visits are cost-prohibitive.

Moreover, as the population increases and lives longer, there won't be enough doctors to deliver care, especially in areas with low SES. In 2014, the doctor shortage is expected to be 60,000 and that number will more than double by 2025.

Low income and levels of education also contribute to many not knowing how to construct a proper diet, or being unable to afford healthy alternatives when processed foods are more budget-friendly. Many poorer areas are in so-called food deserts -- areas with little or no fresh, affordable foods available.

And many doctors warn not to discount stress as a major, if not primary, factor in the prevalence of heart disease in these communities. Those with lower SES often work jobs that pay less and are physically demanding. Their communities tend to be less safe, and the school systems less equipped to break the cycle of poverty with education. This causes a perpetuation from generation to generation of lower SES, and thus, heart disease.

Just as in Tuskegee, the very act of being poor and uneducated presents a health risk to large segments of our society.

In an overdue twist of fate, however, Herman Shaw's intellect and dedication to learning led him from Macon County, Alabama to a place harder to be admitted to than college: a speaker's podium at the White House. When President Clinton apologized on behalf of the country at a ceremony in the East Room, the six surviving members of the Tuskegee Experiment voted ninety-five year old Herman Shaw to be their speaker.

Whether Tuskegee or today's poor, Mr. Shaw's words at the ceremony are fitting: "In order for America to reach its full potential, we must truly be one America, black, red, white together, trusting each other [and] caring for each other..."