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EDITORIAL COMMENT |
Rush-Presbyterian-St. Luke’s Medical Center and Cook County Hospital, Chicago, Illinois
Studies consistently show that persons of lower socioeconomic status (SES) fare poorly on a wide variety of indices of health and well-being (1, 2). It is time to identify the reasons for this and, ultimately, do something about it. Although a number of these "next-step" studies exist, they have focused on traditional risk factors as explanatory variables and have found that accounting for them may reduce, but not eliminate, the disparity (3, 4). Thus, the search to explain this differential should continue.
The previous article by Reiff and colleagues (5) is an excellent example of an important direction in next-step studies, where the focus is on stress as an explanatory factor. Its aim was to study the relationship between stress and blood pressure in a population of ethnic minority residents living in the inner city of Harlem, half of whom had a family income of $11,000 or less. Their description of this population provides a window into the severity of the stressors in the lives of these people. Half were unemployed, one fourth had been homeless at some point in their lives, and half of the men and 20% of the women had witnessed someone being injured seriously or killed violently. The researchers showed that each of these stressors or traumas was strongly and independently associated with elevated blood pressure, after accounting for traditional risk factors such as overweight, physical inactivity, and depression.
One of us (A.H.) has spent his career treating patients from the inner city of Chicago at Cook County Hospital. The stories told by these patients are similar to those of the Harlem residents and reveal an intricate web of struggles, violence, and pain. For example, one man in his 40s with high blood pressure complained of impotence after years in prison for a conviction for rape. He is passionate that he did not commit the rape, feels a deep and painful shame at being convicted, but readily admits having committed even more violent acts. There is the elderly former nursing home aide struggling to control hypertension and heart failure who, in her 50s, began raising her young grandson after his mother died of a drug overdose and his father was killed in a drug-related incident. She raised him using physical force, saw him through his subsequent gang banging, and visited him during his multiple placements in structured living arrangements. Now, although he is "rehabilitated" in the eyes of the social service workers, she worries as she watches him flirt with the violence that was once habitual. One 65-year-old man with severe heart disease hides from his classmates in stress-reduction meetings every time he becomes overwhelmed with memories of racist workplace abuse. There is the woman who comes to stress-reduction meetings with the single, simple hope that she will receive "some sense of survival."
Prison, violence, chronic abuse, loss of the means to subsist—these stressors are clearly more powerful than those we are used to seeing in middle-class populations. Because of their sheer strength and ubiquitousness, it is possible that their link to health is stronger than that observed for traditional risk factors. This is precisely what was observed by Reiff and colleagues (5).
The readers of Psychosomatic Medicine have considerable experience and technical expertise in stress research, which can, and should, be brought to bear on investigations of stress and health in disadvantaged populations. But we should not simply "cut" our familiar stress constructs from middle-class populations and "paste" them into studies of more disadvantaged groups. Reiff and colleagues (5) hypothesized, as have others (6), that negative emotions mediate the relationship between SES and health. But, despite the considerable attention they paid to depression, they found that it was unrelated to high blood pressure. This suggests that the powerful environmental stressors (which were related to high blood pressure) influenced it through some other mechanism.
We should take a fresh look at the nature and breadth of psychosocial stress in disadvantaged populations. Stress emerges from a perception of threat when demands exceed resources (7). Articles such as the one by Reiff et al. (5) provide us with some insight into the daily demands faced by inner city residents. More of these articles are needed. Moreover, we know almost nothing about the resources brought to bear to meet these demands. Some have suggested that poverty is associated with social conflict (8) or low social capital (9), and that this could explain at least a part of the differential in health. However, our anecdotal observations suggest that considerable cohesiveness often exists in inner city communities where it is not uncommon for residents to unite to protect their street blocks. Inner city residents seem to be more inclined to take advantage of opportunities for daily social intercourse (eg, chatting with neighbors, store clerks) which may "lighten their load" through the experience of positive emotions. Faith and spirituality may provide perceptions of control in the face of an uncontrollable environment. Without such cushions, the SES differential may be even greater than that which we currently observe.
It is not easy to conduct research on disadvantaged populations. They tend to distrust research and researchers, making them difficult to enroll and retain in studies. This distrust, of course, is largely justified considering past incidents such as Tuskegee (10) where the health of unsuspecting people was put in jeopardy by injecting them with the syphilis virus. Many of us would like to forget about such incidents, but they are kept alive in ethnic minority families by stories that are passed on informally from generation to generation. This became obvious in one of our research meetings when the topic of Tuskegee came up. Each of the eight African American research assistants had been told about Tuskegee, and warned about research, by elder family members while they were growing up. To counteract such distrust, it is essential that we take the time to earn trust and show respect for cultural and subcultural norms. We must seek first to understand, before being understood (11). We must develop reciprocal relationships where each side–the participant and the researcher—gives, and each side takes.
Equally challenging is finding ways to fend off researcher frustration when faced with the realization that many of the problems have roots in social policy. In America, we believe that anyone who works hard will be rewarded. The problem with this, of course, is that different starting points limit the ability to achieve similar outcomes.
Our "discovery" that heart disease is an equal opportunity killer of women as well as men led to a burgeoning of interest in women’s health as well as the funding of the Women’s Health Initiative, the largest clinical trial ever conducted by the National Institutes of Health. It is our hope that our discovery of the socioeconomic differential in health and disease will lead to a similar burgeoning of interest in the health of disadvantaged groups. The readers of Psychosomatic Medicine are well placed to become leaders in identifying the pathways that link psychosocial stress to health and disease in this group, and to find creative, culturally sensitive, and multilevel ways to improve it. We look forward to seeing them take the next steps.
REFERENCES
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