Black Man in a White Coat (10 page)

We all nodded in agreement and approval, as if our leader had preached a medical gospel. I had gone through my first day of hands-on medicine in months, and been reminded of what I enjoyed about it: the data of vital signs and lab tests; the intricacies of the human body seen through the physical exam; synthesizing these findings into a treatment plan. But mixed with these thoughts about process and analysis came concerns about the people we'd seen.

Would Pearl lose weight, take medicines, and stave off the complications of diabetes and hypertension that struck her brother? Would the man with recurrent bronchitis quit smoking? And Tina? Could we get her blood pressure under control? Would she be able to get surgery?

After saying our good-byes to the doctors in the gravel parking lot, Sharon and I got into Mike's car for the drive back to Durham. We took in our dilapidated surroundings one more time. “Being here really does make you appreciate what you have,” Sharon said.

“Amen to that,” Mike replied.

But as the single-lane road became a two-lane highway and then a three-lane interstate, we gradually put the day's patients behind us.

*   *   *

Two years earlier, during my first year of medical school, I sat nervously in an exam room at the student health clinic. A nurse had just left the room. She had confirmed the high blood pressure readings that a classmate had discovered a few days before during our weekly introduction to medicine course. Dr. Katz, a small-framed, middle-aged man with short brown hair and large glasses, entered the room and scanned the nurse's notes before asking me the same questions I would ask Tina two years later. My answers were simple: Other than mild scoliosis, I didn't have any health problems. I didn't smoke, drink, or use drugs.

“Do you have a family history of high blood pressure?”

I nodded. About twice a month after Sunday church, my mom would drive to my grandmother's second-story, one-bedroom apartment off Georgia Avenue in Northeast Washington, D.C. One afternoon, when I was about ten or eleven, my grandmother had cooked salty ham, and this led to a heated discussion with my mom about how my grandmother had not been taking her blood pressure medication or cutting back on high-salt foods as her doctor had recommended. My grandmother argued that the medication made her go to the bathroom all night, and, in her usual blunt style, announced that she had no plans to stop enjoying the foods she'd eaten her whole life. Frustrated, my mom backed off, realizing that there was nothing more that she could do. That was the last time I remember them talking about her high blood pressure.

On the other side of my family, I didn't yet know about my dad's hypertension, because he'd avoided doctors for more than three decades. When he was finally diagnosed, he wound up requiring three different medications to control his blood pressure. But I did know that his older brother, who died from a stroke when I was fourteen, had hypertension. Like my grandmother, he apparently had not followed medical advice either.

Despite this family history, I had not expected to find myself in this position, certainly not in my early twenties. “How's your diet?” he asked.

Terrible, I admitted. I'd grown up eating whatever was placed in front of me—and then seeking out more. My mom worked long daytime hours and my dad worked nights, and healthy homemade meals were the exception rather than the rule. Ready-made processed meals, fast food, and buffet restaurant trips were dietary staples. Every so often, my mom would go on a Weight Watchers diet and eat healthier foods, but that didn't impact me. Since I was very tall and skinny throughout childhood (I stood six-five and weighed 160 pounds at age sixteen), what harm could come from two foot-long steak subs, an extra-large pepperoni pizza, or a half-dozen hot dogs?

This eating pattern only worsened in college, as I tried to add weight to keep from getting pushed around during basketball games. Even with an extra thirty pounds, I still fell within the normal weight range for my height, so I saw no reason to cut back. This approach to food continued upon my arrival at Duke, where each day brought dinner at a regularly rotating group of fast-food spots. Just as in college, I rarely drank more than a glass of water daily, and I could go several days without eating a fruit or vegetable (not counting French fries and potato chips). However, with a myopic focus on weight as my barometer for wellness, I'd chosen to ignore basic nutritional facts and believe that I was perfectly healthy.

Dr. Katz performed a basic physical exam that he said was normal. He then sent me downstairs to the lab, where a pimply-faced young phlebotomist took two tubes of blood from my arm and sent me to the adjacent bathroom to collect a urine sample.

The following day, I returned to see Dr. Katz to get the results. He wasted no words: “Your creatinine is 1.6.”

I took a deep breath. Serum creatinine is the baseline test used to assess kidney function. The upper limit of normal at Duke's lab was 1.3. Something was wrong with my kidneys.

I searched his face for reassurance, but he looked down at the lab report before speaking. He had more bad news.

“There were also traces of protein in your urine,” he said.

A detectable level of protein in the urine, known as proteinuria, is another sign of kidney disease. My face fell into my hands. Worst-case scenarios flashed through my mind.

Sensing my distress, Dr. Katz tried to calm me down. Even though he spoke for several minutes, I made out only the bare outline of what he said. Something about restricting sodium intake and supplementing basketball with other aerobic exercises, such as jogging or swimming. At the end, he told me to check my blood pressure weekly and return in a few months for repeat tests.

The day before, Dr. Katz had said that my heart and lungs sounded normal. But as I stepped outside the clinic into the crowded parking lot, my heart pounded as if it were going to explode from my chest. My shirt was soaked with sweat. I could barely breathe. Although I had never experienced one before, I knew I was having a panic attack.

During the ensuing sleepless night, my mind flooded with images of my grandmother. Around the age of seventy, her memory began to fail rather abruptly—likely from vascular dementia, the result of decades' worth of mismanaged hypertension. At age seventy-three, she suffered a massive stroke and was later found to have heart failure, which was also related to her hypertension. In those few years, she'd been reduced from the spirited person I'd loved so much to someone barely recognizable: crippled on one side, needing aides to clean her, babbling about places from her childhood and people long dead. Was that my future too?

From that point forward, hypertension became my obsession. For weeks, I spent hours in the medical library reading everything I could about it. Hypertension is the prototypical disease when it comes to black health disparities. It's about 50 percent more common in black people than in whites, afflicting nearly two out of every five adults. It also strikes black people at a younger age, and blacks are less likely to have their blood pressure adequately controlled. Consequently, hypertension tends to run a more aggressive course in black people, increasing the risk of several other diseases that are also more common in blacks (e.g., stroke, kidney failure).

The reasons offered as to why black Americans suffer so severely from hypertension are as diverse as the fields represented. The psychologically oriented journals cite the stress of American racism. Evolutionary scientists theorize that among African slaves, the ones best able to retain water survived the harsh Atlantic journey, passing on their genes, which later proved problematic in the modern world. Public-health writers comment on the various inequities in our health care system and cultural differences in dietary and physical activity patterns.

Regardless of the cause, or causes, I wanted answers, a fix for my problem. Armed with data from several research studies, I set about changing my life. I started regular grocery shopping for the first time, being sure to eat fresh fruits and vegetables on a daily basis. I replaced soda with water. I supplemented basketball with running on a treadmill and stretching exercises. Within three months, my weight was unchanged, but my blood pressure had dropped to a normal 120/80. From then on, I knew it would be my blood pressure, and not my weight, that would define how healthy I was.

Later on in medical school when the time came to choose a research project, I jumped at the chance to work in a behavioral medicine lab led by Duke psychologist James Blumenthal that studied lifestyle-based approaches to treating hypertension and heart disease. There, I saw patients, both black and white, reduce their blood pressure through eating better, exercising more, and learning basic stress management techniques. This experience reinforced my own commitment to live a healthier lifestyle.

When I saw Pearl and Tina at the rural health clinic, I was not just another medical student seeing black patients with poorly controlled blood pressure. I stood before them face-to-face with my family's past and perhaps my own future.

Despite our similar health struggles, I quickly recognized the many advantages that I had over Tina, Pearl, and so many others. For starters, I understood the language of medicine. Terms like glomerular filtration rate, thiazide diuretics, and calcium channel blockers were part of my growing medical vocabulary. The patients at this clinic had limited formal education. Tina had a high school diploma; Pearl hadn't gotten past tenth grade.

At Duke, I had access to three campus gyms along with several nearby grocery stores and restaurants that served healthy items. Tina and Pearl were constrained by fewer exercise and healthy-food options where they lived. And while I had no money to my name, my social status as a medical student placed me in daily contact with physicians and other medical professionals who could help me navigate the best practices and expose me to the latest medical advances. Tina and Pearl were from families and communities cut off from these advantages.

A 2005
New York Times
article vividly illustrates this dramatic influence of social class as it follows the journey of three New Yorkers—one rich, one middle class, and one working class—who each suffer heart attacks around the same time. In describing their uneven recoveries, in which the wealthy person is left better off, the middle-class man fighting through a setback, and the working-class woman struggling with increasingly complex medical and social problems, the author observed: “class informed everything … from the emergency care each received, the households they returned to, and the jobs they hoped to resume. It shaped their understanding of their illness, the support they got from their families, their relationships with their doctors. It helped define their ability to change their lives and shaped their odds of getting better.”

I saw a similar contrast between me and the women at the rural clinic. As a Duke student, I had health insurance. I didn't have to think about seeing the doctor or filling a prescription; everything was covered. For each clinic visit, I'd see Dr. Katz and enjoy the benefits of a stable doctor-patient relationship. Tina and Pearl had to go to a monthly free clinic where doctors rotated each month; this meant they had to “start over” with the hopes that the next doctor would be as caring and competent as the previous one. While Tina's initial blood pressure pill was cheap, Dr. Watson worried that her blood pressure was so high that she would likely need a second or even third medicine that could each cost in excess of $50 or more every month.

So while Tina, Pearl, and I were all black and hypertensive, the similarities ended there.

Given these glaring differences, it should come as no surprise that the poor and uninsured as a group have worse health outcomes and higher death rates than people with health insurance. A 2002 Institute of Medicine report noted that in one study over a seventeen-year period, adults who lacked health insurance at the outset of the study had a 25 percent greater chance of dying than did those who had private health insurance. A major 2001 study found that a lack of health insurance is associated with an increased risk of decline in health for adults over age fifty. Diagnoses are delayed, and chronic conditions are poorly managed. Both factors result in a dizzying array of medical complications on the way toward a premature death.

As with so many societal problems, blacks as a group suffer to the largest extent, being nearly twice as likely as white Americans to live without health insurance. And while obtaining health insurance alone does not fix the health problems of the poor, it makes a real difference. A 2007 study found that previously uninsured adults, in particular those with cardiovascular disease or diabetes, reported improved health over a seven-year follow-up period after obtaining Medicare coverage at age sixty-five.

Back in the late-1990s, Tina was one of approximately forty million uninsured Americans, a tally that climbed closer to fifty million over the ensuing decade. Though I'd heard snippets about the uninsured in college during the fight over the failed 1993 Clinton health plan, I had ignorantly allowed myself to assume that they lacked health coverage because they didn't work, and that they ultimately received medical care as part of our social welfare system. Because of my growing interest in the topic, I later learned that more than 70 percent of people who are uninsured are either working or, in the case of stay-at-home spouses, live under the same roof with a working person, and that having health coverage could be the deciding factor in whether a person sought health care, or if they could even receive services.

But I didn't know any of that when I met Tina. During the previous year of clinical rotations, we had a week or two devoted to an overview of the U.S. health care system. Although I vaguely recall some mention of how the United States lacked universal health coverage in comparison to Canada and Western Europe, the discussions seemed focused more on how managed care organizations potentially threatened our future autonomy and incomes. Or maybe the instructors had tried to teach us about the uninsured but I had simply tuned that part out, dwelling instead on topics related to my own self-interest. In the hospital setting, where most of our rotations took place, I rarely knew whether the patients had insurance or not; the ethos, at least in theory, was that people received the same level of medical care no matter their finances.