Listen: How Racism Kills Black Americans

The health effects of discrimination are usually less obvious than murder.

After the killing of George Floyd, some leaders have suggested that racism should be declared a public-health crisis. Sherman James, a professor emeritus at Duke University, has made this case for decades. He’s studied the connection between health and discrimination since the 1970s, and he coined the concept of “John Henryism” through years of research in social epidemiology.

He joins staff writer James Hamblin and executive producer Katherine Wells on the podcast Social Distance:

Listen to the episode here:

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What follows is an edited and condensed transcript of their conversation.

James Hamblin: One of the things that we’re hearing right now is the idea that racism is a public-health issue. And I felt like, for you, that has been a defining theme of your work for many years, and for other people, this is kind of a moment where they’re realizing it for the first time.

Sherman James: My first position right out of graduate school was in the school of public health at the University of North Carolina at Chapel Hill. And that department had a long-standing interest in racial differences in cardiovascular disease, particularly high blood pressure. The faculty there became interested in finding black psychologists to sort of help work on the social aspects of this incredible epidemic of high blood pressure, particularly in southern blacks.

I’m a southerner. I grew up in South Carolina. And I was intrigued by this. I didn’t really know any epidemiology at the time, but I was intrigued. So I went there with the idea that I would focus on trying to understand why these racial differences existed to the great detriment, really, of the black population.

Katherine Wells: What were the hypotheses? I mean, did it feel like a mystery at the time?

James: Very much so. The reigning hypothesis was genetic, that something about African genes that perhaps interacted with poor diets to make African Americans, particularly working-class southern African Americans, especially vulnerable to high blood pressure. And that’s not unreasonable, but, as far as I know, they haven’t yet identified what those “African genes” are.

But there was also very keen interest in the role of stress and racial discrimination, because several of the senior faculty members were immigrants from South Africa. In fact, the department chairman was an immigrant from South Africa. So, he in particular had a lot of experience with how social, economic, and political marginalization—maybe it would be more accurate to say domination—make black people especially vulnerable to stress-related diseases. So there was a very receptive intellectual environment for someone like me. But I didn’t really have a good idea about what I was going to do. It was a gigantic leap of faith on my part and on their part that this naturally worked out.

Wells: So what did you set out to do? How do you even start to look at a question like that?

James: Well, quite by accident, I hit upon this notion of “John Henryism.” We received a big grant from the National Institutes of Health in the late 1970s to do some work on high blood pressure in black and white populations in eastern North Carolina. And we made a decision that we wanted to focus specifically on African American men, because that’s the group that really is at greatest risk for developing these disorders, very early in adult life. So I thought, okay, to lay the groundwork for intervention they wanted to conduct in this part of the state, I would go and interview some African American men who have high blood pressure. And I guess.

Wells: Seems reasonable.

James: Yeah, get their story. So I made appointments and drove out. And the very first person that I met was a man by the name of John Martin. A retired farmer. I think he was maybe 74 at the time. So he agreed to meet with me. And I drove up one hot July, muggy afternoon and sat and began to chat with him. And he told me this amazing story about his early childhood and how he was born into this very impoverished family. His father was a sharecropper, presumably his grandfather was a sharecropper as well, and he made reference to his grandfather, probably talking about someone who was born into slavery.

So, born into deep poverty. And as a young man, he decided that he was not going to live his life impoverished in the same way that his father did, working very hard and giving up half of his income to the man who owned the land. It was really serfdom, if you will. It was really slavery by another name. So with the encouragement of his wife, who grew up in a land-owning family … She strongly encouraged him to buy some land in debt. And he did. But he was very, very concerned about being vulnerable economically in the same way that his dad had been. He was able to get a 40-year mortgage from a bank. And he decided that he didn’t want to be in debt for 40 years, and he wanted to pay it off as quickly as possible. And he vowed that he was paid off in one year.

He didn’t want to be obligated. So he worked night and day. He was in the fields often seven days a week—14, 16 hours a day. He actually paid off that mortgage in five years.

Wells: Wow.

James: And then he said: “I think maybe that’s the reason why my legs are all out of whack as it is, because I think I pushed myself too hard in the fields.” So I should have said that, in addition to having that high blood pressure, he also had a debilitating case of osteoarthritis. He could barely walk. And he had had a case of a peptic ulcer disease sometime in his 50s that was so severe that 40 percent of his stomach had to be removed. So he had these three major diseases, at the root of which is inflammation and presumably chronic psychological stress. So I thought, Oh, that’s really very interesting.

I was just blown away by the fact they could pay off this property—about 75 acres—in five years. So after about an hour and a half or so, his wife came in. And she said, “John Henry, it’s time for lunch, and bring your guest with you.” And I said, “Your name is John Henry? And he said, “Yes, my name is John Henry Martin.”

And so the wheels started turning. John Henry Martin. The legend of John Henry, the steel-driving man who went up against this mechanical steam drill and refused to be defeated by it. He emerged victorious because he just went all-out, mobilized all of his energy—psychological and physical—to defeat this mechanical steam drill in this contest. He won, but then immediately after victory, dropped dead from complete exhaustion. Well, John Henry Martin also went up against a machine. The machine was the sharecropping system. And he was determined to be successful. He was successful, but he paid a very high price.

That planted this idea in my mind: John Henryism. Maybe this whole phenomenon that the life of John Henry Martin represented was something that could be called John Henryism. There’s a lot of cardiovascular disease in my family. And so I realize that John Henry Martin’s story was really the story of my people. It was the story, really, of African Americans writ large, being faced with the machine—the machine that I have in recent years come to call structural racism, where the social and economic order is arrayed against you. It’s designed to keep you subordinated. It’s designed to prevent you from being successful. And if you resist those forces of subjugation, if you refuse to acquiesce and you go against it and you become determined to be successful in the face of these enormous odds, you might very well be successful. But there will be a price to pay.

The physiological wear and tear that results from that kind of long-term struggle will manifest itself in high blood pressure and so on. And because African Americans are overrepresented in low-wage jobs, in physically demanding jobs, in jobs that offer inadequate levels of economic security. And so the wear and tear that results from that, I think, contributes really quite importantly to the epidemic of cardiometabolic diseases in the African American population.

Wells: I’m curious: Did that finding surprise you?

James: Well, it didn’t surprise me. I think it surprised a lot of other people. I think it surprised non–African Americans. The John Henryism hypothesis went up against a very powerful counter-narrative, which was that the problem is really genetic and diet.

Hamblin: To that point, you’ve since subsequently shown that this effect plays out in other populations as well, in other countries that there are effects of disenfranchisement or domination. That would undermine any idea that it had to do with a particular group’s genes.

James: That’s correct. There are two published studies on European populations. So this is not something that is unique to African Americans. I think it really taps into the human condition. Any population that is immersed in very, very trying economic circumstances and members therein struggle against those circumstances try to overcome them—that’s the group in that society that’s going to be on a faster trajectory to develop these cardiovascular diseases.

Hamblin: It sounds like it also is dependent on exactly how rigged the machine is. If you could get together and just vote, that’s going to have a different effect than if it seems like the same protests have to happen decade after decade, and there is disenfranchisement and voter suppression and gerrymandering and all these things that make the machine that much harder to beat.

James: I think that’s exactly right, Jim. If there is a silver lining in this terrible situation that all of us are going through now, it is that I think white Americans increasingly see the necessity of changing the system, of making the political and economic machinery of the country less deadly to people of color, and particularly African Americans. And for me, that’s something of a shift, which is not to say that you didn’t have a similar kind of alliance across racial lines occurring in the 1960s. As a matter of fact, I doubt very seriously if the changes in social policies that resulted from the civil-rights movement of the 1960s, that those structural changes that took place would have taken place without this cross-racial alliance. And particularly the involvement of young whites along with young blacks. I think the same thing is true now.

Wells: So I’m going to ask you about solutions, but I want to be clear that I’m not asking you for, like, false hope. I’m just curious, from an epidemiological perspective, are there case studies or examples where you’ve seen where these metrics of high blood pressure and cardiovascular disease actually move in response to social changes or certain types of interventions. Like, what actually works? Are there examples of places where you feel those health metrics respond positively?

James: Yes. So the modern civil-rights movement began in 1955 to ’56 with the Montgomery bus boycott and the coming on the scene of Martin Luther King Jr. That was obviously a very intense, protracted, and in some respects, deadly struggle to bring down the oppressive system of Jim Crow. That resulted in the passage of the Civil Rights Act of 1964, the Voting Rights Act of 1965, and then a few years later, following the assassination of Martin Luther King Jr., the passage of the Fair Housing Act of 1968. But critically, it was the Civil Rights Act and the Voting Rights Act that really changed the landscape for black folks, particularly southern blacks, and resulted in the desegregation of southern hospitals. So now southern blacks have access to higher-quality medical care that they have been denied forever. So now they have more access to the health-care system because of the change in these public policies.

Well, so epidemiologists looked at the black-white differences in mortality from heart disease and stroke, 1955 to 1964. That 10-year period. And they found enormous differences in terms of mortality from stroke and heart disease in the black population, particularly the southern black population, compared to whites. Now, if you compare those mortality statistics during that 10-year period with 1965 as the baseline year through 1975, what you found was that during that 10-year period, there was a remarkable reduction in the death rates from heart disease and stroke in the black population.

Wells: It can happen that quickly, even in individuals who had experienced decades of discrimination?

James: See, that’s the beauty of it. That is the beauty of it. In record time. I mean in epidemiological time, it would be almost instantaneous.