What Racism Does to the Body
Medical Science Is Solving a Mystery for a Physician Who Wondered for Years What Was Happening to Her Patients
By TED HARTZELL
BENTON HARBOR, Mich. – For years Dr. Pat Rush kept confronting a troubling mystery: Why did so many patients she was seeing have multiple chronic illnesses, or seem suddenly to develop a profound illness?
She even got an MBA degree, thinking that health care management might provide the answer. It didn’t.
In the course of 25 years she had treated thousands of patients at the huge Cook County Hospital in Chicago (including its emergency room), in managed care and as a medical professor in that city. The evidence was clear that social determinants of health (SDoH)—such factors as poverty or prosperity, one’s access or lack of access to nutritious food, educational attainment and level of employment—all these and more played a huge role. In other words, a person’s ZIP code was a big determinant of health.
But something else, something deeper, seemed to be at work. And, if so, what were its underlying biological mechanisms? As she walked the halls of Cook County Hospital and saw patients, including many African Americans, she knew these people were poor and were coming to Cook County because they had no insurance. But she thought, “There is something else going on here.”
A Microcosm of American’s Racial Chasm
Rush, an internal medicine physician, helped an audience understand what medical researchers have been discovering in recent years about the biological underpinnings of that once-mysterious “something else” that had so perplexed her. She spoke in April 2018 to doctors, nurses, social workers, others in the healing professions and to lay people in the first presentation of a three-year speaker series, “Community Grand Rounds: Healing the Trauma of Racism.”
The joint project by the Lakeland Health system in southwest Michigan and the Todman Family Foundation is bringing in nationally recognized experts to share what the emerging fields of epigenetics and social genomics are discovering about the biological effects of living in conditions of trauma, including chronic stress.
The chronic stress of racism has particular relevance for the Lakeland Health system. It is headquartered in the prosperous and mostly white city of St. Joseph, literally across the river from Benton Harbor, a predominantly poor and African-American city. The area is also polarized along the line of health outcomes. In certain ZIP codes in the Benton Harbor area black people are dying at far greater rates—up to two-and-a-half times higher—than the average for Michigan, and chronic diseases are far more prevalent.
A 2016 study of the population served by Lakeland Health showed that blacks have higher rates of psychological distress, obesity and diabetes. Their greater rates of premature death are due to such conditions as hypertension, cardiovascular disease and stroke. Indeed, “being black” is among the risk factors for death in Berrien County, according to Lynn Todman (a PhD in urban and regional planning), who is Lakeland’s Executive Director for Population Health and whose foundation is sponsoring the series.
Rush’s own journey to find an answer to what she suspected was an underlying biological mechanism to the illnesses of many of her patients proved a helpful framework for her presentation. “I wondered: ‘What are we missing here?’ ” She doubted that medical science as conventionally practiced could get to the root of the problem
Rush did know this much from talking with patients over the years: that long-term stress and chronic illness were somehow linked. So, in 2000, after a quarter century as a physician, she did something “completely crazy.” She quit her job as vice president and assistant professor at Rush University Medical Center to open a solo primary care storefront practice. “I wanted to have more time to talk to my patients.”
A Revolution in Thought
The change proved revolutionary, the now-retired Rush said of what she discovered in detailed interviews of more than 500 patients in her practice from 2001 to 2008.
What did she find? After dispensing early in her storefront practice with patient medical history questionnaires that proved of little value, Rush took a different approach. The form that a new patient now filled out contained the statement: “Growing up for me was”—followed by check-off boxes for either “Mostly OK” or “Pretty stressful.”
“My mind was blown,” Rush said. She found that her under-age-50 patients who answered “Mostly OK” had only minor complaints and were in good health. The 50-and-over patients in the “Mostly OK” category were also generally in good shape but showed more wear and tear from longer lives.
But all of her patients under age 50 who answered “Pretty stressful” about their growing-up years had complex chronic illness. They included such conditions as rheumatoid arthritis, Crohn’s disease and ulcerative colitis, multiple sclerosis, end-stage kidney disease on dialysis, massive obesity, breast cancer in young women, and more chronic illnesses.
She realized that she—“and every other doctor, too”—had been seeing such patients for their entire medical careers, but didn’t realize what they had been seeing. She simply had not been trained to listen for such stories.
Many patients in her storefront practice told Rush painful stories of growing up, including sexual and other abuse, losing a parent, living in poverty, going into foster care, and tales of cruel discrimination because of their race, ethnicity or gender identity. The patients who were victims of chronic discrimination also talked about never feeling safe or accepted, always feeling judged and having other people expect them to fail.
A ‘Pathway’ to Chronic Illness
Rush came to the conclusion that she had detected a clear and consistent pattern, “the pathway to severe chronic illness.” It works this way: Trauma, adversity or neglect, usually starting in early childhood, grade school or middle school, causes overwhelming psychological distress. To “calm their brain,” traumatized people use unhealthy coping mechanisms like smoking, taking drugs, gambling and physically harming themselves.
The downward “pathway” continues with disturbed sleep. It is here that “the body really goes off the rails,” Rush said. She discovered that her traumatized patients were sleeping only three or four hours a night—and then maybe not continuously, but “a little bit here, a little bit there.” Some patients were too terrified to turn off the lights, or they slept with the TV on to help them feel that someone was in the room with them.
Robbed of the restorative power of deep sleep, and with their minds constantly returning to their painful experiences, these patients began developing physical dysregulation and multiple, chronic diseases. Rush believes that the consistent pattern of extreme stress at a young age, profound sleep disorder and emotional distress represents a common pathway leading to many chronic physical illnesses.
When the Medical History Should Begin
The interviews in her solo practice revealed that about 25 percent of her patients with complex chronic illness had suffered a severe, prolonged illness as a child or young adolescent. For each patient, the problem had typically appeared to resolve itself, but five to 25 years later the person would develop a new and unexplained serious illness. Although Rush has found no reports in the medical literature, she theorizes that for such a patient the initial illness appeared to heal, while in reality the person still had an underlying neurologic disruption with inflammation that had profoundly reordered the person’s physiology. Then, later in life, a new major stressor triggered the person’s underlying (but hidden) physiologic instability, producing a new disease.
Rush realized that a person’s true medical history should begin with questions about the time period long before the period evaluated by the conventional medical history. The typical approach is to date the patient’s medical history from his or her first interaction with the medical system. To be most effective, however, medical professionals need to ask what happened to a person before then. What was happening from the period beginning during their mother’s pregnancy and extending to early adulthood? What traumas and chronic stresses did the patient endure during those growing-up years?
A ‘New Model’ to Explain Chronic Illness
Researchers today are finding answers to the question that troubled Rush when she opened her solo practice. They are coming up with a more comprehensive understanding of the interplay between the body’s nervous, immune and endocrine systems in translating trauma and stress into physical illness.
While living conditions (SDoH)—or one’s ZIP code—and unequal treatment by health care professionals are important factors in health, Rush said overwhelming scientific evidence has added a “new model” in the last 20 years. “The big problem, really,” is the role played by traumatic life experiences and severe adversity, which can ultimately disrupt this body-mind network and cause a host of chronic illnesses.
The research consensus as of 2018 is that trauma triggers a neurologic dysregulation, abnormal endocrine signaling and inflammation. The end result is organ damage. (In a follow-up communication to her presentation, Rush said there is “an explosion of scientific interest” in what is called neuro-inflammation, with currently more than 14,000 articles on the subject, and more than 2,500 published in 2017 alone.)
“The researchers agree that trauma and dysregulation are the root of disease, and also the most effective place for treatment,” Rush said.
A ‘Shocking’ Study
“Science tells us that this disruption starts in childhood,” Rush said. As an example, she cited a Harvard Division of Systems Biology study reported in 2017 in the British medical journal The Lancet. She called the findings “shocking.” She showed her audience an illustration from that article demonstrating a chain of biological events starting with stress activating the brain’s amygdala, where its “fear center” is found, and leading to increased bone marrow activity and, ultimately, heart attacks due to inflammation of the arteries.
“What predicted who was going to have a heart attack or not five years later” in the Harvard study was found in the answer to the question: “Was their brain calm, or was their brain constantly hyped up?” Rush said. “And if the brain was hyped up, then what they found was increased activation in the immune system (leading to inflammation), and that’s what caused the blockage in the blood vessels. And now we know that this is also the start of hypertension, and most likely also diabetes.”
She said a recent study in the Journal of the American Medical Association shows that hypertension among black males starts as early as age 8. “That tells us that black boys are living in fear.”
The new model of the interconnected nature of how the brain and body respond to stress also involves a deeper understanding of how the various parts of the brain work. Dr. Rush talked about how, for traumatized people, the part of the brain concerned with sheer survival is hypervigilant, shortchanging the areas of the brain that regulate the emotional state and rational thinking.
“If we want our children to do well … be healthy … if we want our schools to be calm and organized, we have to work on the bottom (of the brain), which is that people need to feel safe. They need to feel loved before they can think clearly.”
To the people in her audience, many of whom are on the front lines of health care in a racially segregated area, Rush noted the damage done by chronic, everyday discrimination. Sustaining such discrimination adds up to a major trauma itself. The discrimination goes far beyond such matters as denial of a job or of entry to a college. Among the symptoms of chronic discrimination are: being treated with less courtesy or respect, receiving poorer service, being threatened or harassed, encountering people who act as if they’re afraid of you or think you’re not honest, unwarranted traffic stops by the police and so on. The daily indignities pile up and over time exact a toll on mind and body.
More than 750 studies demonstrate that a person’s experience of everyday discrimination can contribute to premature birth, low birth weight, poor birth outcomes, higher rates of diabetes and obesity and other illnesses, she said. On July 10, Dr. David Williams, a Harvard professor of public health, will give the Community Grand Rounds presentation. Williams was the researcher who developed the concept of everyday discrimination into a helpful research tool.
Nearly two decades after she left the medical college to start her solo practice on a deep-seated hunch, Rush said there are now more than 20 researchers at the university working on the trauma-informed model of medicine. “This is what all physicians, nurses and social workers need to move toward.”
Next Step: ‘Courageous Action’
Dr. Rush began her presentation in April 2018 by saying “This is fundamentally a conversation about hope.” And she ended on a hopeful note.
Today there is cause for hope because “the researchers agree trauma and dysregulation are the root of disease, and also the most effective place for treatment.” Society can, therefore, address the root causes by helping relieve people’s fear and giving them the basics for healthy lives.
“So I’m calling on us all to take courageous action,” she said. “What we really need to do is to look at primary prevention, and we know now what that means. That means taking care of our children, taking care of young families, especially mothers that need the resources during pregnancy and in the first three years of the child’s life.
“My scientific conclusions are that discrimination and racism are a major cause of disease and health inequity. We know what the physiologic mechanism is. Twenty years ago when I started (her own clinic), I did not know. But now we know it’s from toxic, unrelenting stress. And it’s time for us to take action in our community. We need to eliminate the root causes, we need to heal the trauma of racism. We need to face every type of discrimination, and every group that has been discriminated (against) needs our support. We need to provide real support for at-risk families.
“In our culture and our community, trauma is all around us. We need a different and deeper approach.”
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A Revelation that Changed Dr. Rush’s Approach
Dr. Pat Rush called it a “lightbulb moment.”
One day, not long after she had opened her solo storefront practice, she was talking with a woman patient in her 30s who had lupus. “I asked her, ‘When did you first notice a problem.’” The woman said she noticed it when she was 14.
“What happened when you were 14?”
“My grandmother died.”
“Oh, I’m so sorry,” Rush said.
The woman then added: “Both my parents were already dead, and I was 14. I had an 11-year-old brother, and we had to move into foster care.”
This exchange proved revelatory. “This has got to be related,” Rush thought. That is when she dispensed with the elaborate questionnaires and decided to draw outpatients’ stories by asking them how their lives were growing up.
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