By Rob Stein
Washington Post Staff Writer
Sunday, May 1, 2005
When Sandi Stokes waits for lunch at the sandwich shop near her office in downtown Washington, she notices the counter worker often assumes the white person next to her was there first.
Brenda Person frequently finds that when she goes shopping near her home in Silver Spring, clerks seem to ignore her and instead help a white customer.
Peggy Geigher, a District resident, says restaurant hostesses often seem to seat her near the bathroom, even when better tables are available.
Many African Americans tell stories such as these -- seemingly minor examples of subtle discrimination they experience routinely.
"It happens all the time," said Person, 56, a mother of two daughters. "It's part of day-to-day experiences, unfortunately. But you are never prepared for it -- it makes you feel like you're out of rhythm with the rest of the world, and like there's no justice."
Some medical researchers have begun to suspect that such incidents take a physical toll as well and may play a role in why black people tend to have much poorer health than white people. Over time, chronic, low-level stress from such incidents may increase the risk for a host of ills, including heart disease and cancer, according to the theory.
The hypothesis remains far from proven and is highly controversial. Skeptics say it is very difficult to rule out other factors, such as diet, lifestyle, personal perceptions and cultural differences. But support for the theory has been slowly accumulating in recent years, including a new study released yesterday linking such experiences to the early stages of heart disease. Some researchers say it is among the strongest pieces of evidence so far.
"Exposure to this kind of discrimination has real health implications for African Americans," said Tene T. Lewis, a health psychologist at Rush University Medical Center in Chicago who presented the findings at an American Heart Association meeting in Washington. "We need to figure out how it's happening and why it's happening and how we can prevent it from happening."
Health experts have known for decades that blacks and other racial minorities are at far greater risk than whites for many health problems, tend to suffer more complications when they get sick and are less likely to recover. Most of the differences can be explained because blacks tend to be poorer and have less access to high-quality health care, experts say. But even when socioeconomic factors such as income and education are accounted for, blacks still tend to fare worse, leading some to suspect that stress from insidious, persistent discrimination may play a role.
Studies have linked discrimination to higher rates of depression, and a small number have found associations with risk factors for physical disease, such as high blood pressure. The new study is the largest, most detailed to date to examine the relationship between discrimination and the early stages of a physical ailment.
Lewis and her colleagues studied 181 black women ages 45 to 58 in Chicago and Pittsburgh who are participating in a large, ongoing project, called the Study of Women's Health Across the Nation (SWAN), that is examining a host of health issues among middle-age women.
As part of the SWAN project, every year between 1996 and 2001 the women answered a questionnaire designed to measure encounters with subtle racial discrimination. The questionnaire asked each woman if, in her "day-to-day life," she had had one of 10 experiences, including: "You are treated with less courtesy than other people"; "You receive poorer service than other people at restaurants or stores"; and "People ignore you or act as if you are not there."
"We're not talking overt incidents. It's not racism in the form of being chased down the street because you have brown skin or being called a name," Lewis said. "We're talking about subtleties -- everyday insults that build up over time."
The women's scores over the years were averaged on a four-point scale, and in 2001 the participants underwent an examination known as a CT scan to measure coronary artery calcification -- buildup of calcium inside arteries that supply blood to the heart. It is considered an early stage of heart disease -- the nation's leading cause of death.
The more discrimination the women reported, the more likely they were to have calcification, the researchers found. After accounting for age, geographic location and education, the researchers found that for every unit of increase in perceived discrimination, the odds of having calcification nearly tripled. The chances of having calcification remained 2 1/2 times higher even after the researchers took into consideration such factors as high blood pressure, cholesterol, smoking, age and body weight.
"It's a strong association," Lewis said in a telephone interview before her presentation.
Although the study involved only women, it is likely the findings also would hold true for men, and possibly for other ethnic groups, as well, Lewis said. "We're seeing a real risk factor here."
Other research has suggested that chronic stress may increase the risk of heart disease by raising levels of stress hormones, such as cortisol, as well as boosting levels of inflammation in the body, Lewis said.
"We believe it's the accumulated burden of this subtle racial discrimination that's having this effect," Lewis said. "It's not just having this experience once or twice but having it over and over again throughout a person's life."
Other researchers agreed, noting that stress can also suppress the immune system.
"I think the findings clearly indicate that racism matters a lot," said David R. Williams, an expert on racial disparities in health at the University of Michigan at Ann Arbor. "A lot of people dismiss reports of discrimination as just something that's in people's minds. What these data suggest is these minor incivilities and minor incidents of discrimination are actually consequential for physiologic function, and adversely affect health."
Norman Anderson, the chief executive officer of the American Psychological Association who has done research in this area, called the research "groundbreaking."
"It's one of the first to link exposure to discrimination to a specific disease process," Anderson said.
But other researchers were skeptical, saying the researchers had failed, for example, to differentiate whether the women had actually experienced discrimination or just thought they had.
"It's almost meaningless," said Sally Satel, a resident scholar at the American Enterprise Institute who is a vocal critic of such research. "If someone is rude to you, you don't know if it's discrimination or your perception. People who are already high-strung and hypervigilant may bring that kind of interpretation to the situation and are probably the kind of people who would be at high risk for heart problems."
Jennifer H. Mieres, director of nuclear cardiology at North Shore University Hospital in Manhasset, N.Y., said the researchers had not fully ruled out the possibility that the results could be explained by other factors.
"While discrimination may be a factor here, I have a hard time seeing a direct link," said Mieres, a national spokesperson for the American Heart Association.
But Mieres called the study "thought-provoking" and worth following up.
Peter Bach, a senior adviser at the Centers for Medicare and Medicaid Services who has done work in this area, said he also was skeptical but agreed that the hypothesis warrants further careful examination.
"This is an incredibly important area of research," Bach said. "It's going to be a very hard problem to fully disentangle because of the difficulty in assigning causality in something that is a patient's interpretation of their experience over a very long period of time. But it's a very important area to pursue in a scientifically valid way."
For their part, Stokes, Person and Geigher said they were uncertain whether their experiences were adversely affecting their health, although they would not rule it out.
"At the very least," Stokes said, "I'm caught off guard every time it happens, but I've learned that you can't allow people to ruin your life. So I just deal with it. I don't walk around with a chip on my shoulder. It is my belief every person is unique, so I try to give everyone I encounter the benefit of the doubt."