Even as the overall mortality rate from strokes has fallen, the racial disparity in the toll has remained what Dr. John McBurney calls stubbornly high.
McBurney sees that disparity daily as medical director of the Bon Secours St. Francis Stroke Program. The program is based in Greenville, South Carolina, one of eight southeastern states identified by the Centers for Disease Control and Prevention and other health agencies as the Stroke Belt for their high incidence of strokes.
Julius Hudson is flanked by his sister, Roberta Robinson, left, and wife, Amanda, outside of St. Francis Downtown hospital in Greenville, South Carolina, where he was recovering from a stroke. Hudson exercises and doesn't smoke. His physician, Dr. John McBurney, is investigating the reasons for the higher than average incidence of stroke among African Americans.
"What we can see is that while there has been progress made for all racial and ethnic groups in the difference in the mortality rates — and that has been validated as a good proxy for the overall incidence of stroke — the disparity has not closed," McBurney says.
He has in recent years undertaken his own exploration of this lingering disparity and how to address it. His conclusions include that while providing quality treatment for stroke victims is vital, the roots of stroke disparities are much deeper than what medical care can address.
McBurney is strongly supportive of his system's investments in programs that address the social determinants of health. And he is working with other organizations to provide early health-related interventions in the communities his program serves.
Statistics cited by the CDC show age-adjusted death rates for stroke declined steadily and dramatically from 1950, when the rate was 88.8 per 100,000 Americans, to 1996, when the rate was 26.5. The rate has fluctuated in more recent years, as Americans have become more sedentary and overweight. In 2018, it was 37.1 per 100,000 people.
Even as the overall picture has brightened in the last 70 years, the strikingly higher incidence of stroke deaths among Black Americans as compared to the population at large hasn't changed. For non-Hispanic Black Americans, the rate in 2018 was 53 per 100,000, while for white Americans it was 36 and for Hispanic Americans it was 32. Those numbers translate to a likelihood of death by stroke almost 50% higher for Blacks than whites and about 65% higher for Blacks than Hispanics.
Julius Hudson, left, is a patient in the Bon Secours St. Francis Stroke Program directed by Dr. John McBurney, right. Despite a rigidly healthy lifestyle, Hudson suffered a series of strokes in early 2021. McBurney is working with organizations to promote vigorous exercise in children and adolescents, establishing patterns that could reduce stroke risks later in life.
McBurney points to studies that suggest the disparities are rooted in lingering trauma that goes back to slavery and has left its imprint on the genes of generations of Black Americans.
For example, a study published in 1996 in The New England Journal of Medicine found Southern-born Black men and women both died from cardiovascular disease at a rate substantially higher than that of their counterparts born in the Northeast or in the Caribbean. "The observed differences in mortality from cardiovascular disease according to birthplace may be due to genetic or environmental influences" or both, the authors said.
A study published in the journal Stroke in 2018 used county-level census data to compare stroke statistics between people of different races and birthplaces. It concluded that "a history of slavery may be a previously unacknowledged driver of current-day stroke mortality, particularly in blacks, and provide insights into the causes of present-day racial disparities seen in the Southeastern United States."
Stroke victim stunned
One of McBurney's patients is Julius Hudson, a 54-year-old Black resident of Greenville who is recovering from three strokes he suffered in late February and early March. He has a full-time corporate job and runs his own private security business on the side. He is long married with three adult children.
When Hudson got into competitive bodybuilding at 19, he adopted a low-fat, high-protein diet that he has stayed with since. He thought his strict diet and workout regimen would keep him healthy.
"My mind still can't understand how this happened," Hudson says. "One minute you walk around thinking you're Superman. The next minute you can barely lift a bottle of water. It comes out of nowhere."
By July, Hudson says he felt like "I'm probably a good 60% back, maybe a little bit higher."
Hudson's care through the Bon Secours St. Francis Stroke Program has included medication to treat a constricted carotid artery in the back of his head that has restricted oxygen and blood flow to his brain and physical therapy to address the muscle weakness, particularly on his left side, from the strokes.
McBurney points out that Hudson's lifestyle does not include any of the known risk factors for cardiovascular disease or stroke, such as smoking and lack of exercise.
"Julius lives an exemplary life," McBurney says. "He certainly strives to be the best person he can be and he is inspirational in so many ways. And yet, here he is, in his early 50s, and he's had a series of strokes."
Patients such as Hudson inspire McBurney to find ways to address the underlying problems that are at the root of stroke's unequal toll. "To me, as a medical director of a comprehensive stroke center, I look at where the problem is and it seems obvious that the biggest problem confronting the stroke care community is just the excess of stroke among African Americans," he says.
McBurney was in the middle of his career in 2012 when, he says, he "became increasingly convinced that as a neurologist, I was seeing disease too late, too far downstream."
He decided to do an integrative neurology fellowship at the University of Arizona. "This sparked a period of intense intellectual growth," he says. "I learned about diets, the effects of stress, the role of herbal medicine, and epigenetics, among many other topics."
In 2018, he came to Bon Secours St. Francis as medical director of its comprehensive stroke center. He stays up on studies and literature on stroke disparities. One of the texts that has been key in developing his interest is Health Disparities in the United States: Social Class, Race, Ethnicity, and the Social Determinants of Health by Dr. Donald A. Barr, a professor in the Stanford University School of Medicine.
That book examines the limitations of medical care in addressing race-based disparities in health outcomes and it makes the case for the importance to overall health of social determinants of health including safe housing and economy security, McBurney says.
"What we're seeing, I think, is that access to care is only a part of this," he says. "We fool ourselves when we focus exclusively on that and not the social determinants of health."
McBurney's observations so far in his studies of stroke patients at Bon Secours St. Francis mirror what earlier and wider studies have shown about their harsher impact on people of color. For example, statistically, African-American patients in his program typically present with stroke 10 years younger than whites despite not being more obese or having more incidences of diabetes.
In 2020, McBurney co-edited a textbook called Integrative Neurology that presents evidence-based integrative approaches to the prevention and treatment of neurological disease.
McBurney advocates an integrative care strategy that takes account of the body, mind and spirit of patients as well as all aspects of their lifestyles. It relies on evidence-based therapies, both conventional and alternative, including medication, diet, exercise and acupuncture.
In addition to providing integrative care to the patients in his program, McBurney is working with organizations on early intervention strategies.
"We're talking about problems that begin in childhood and then progress in adolescence and become symptomatic in young adulthood," McBurney says. "So, whatever we do, we have to target programs and support that benefit children and adolescents."
The COVID-19 pandemic has slowed progress on some of his collaborations. One that he hopes to begin soon is with Momentum Bike Clubs, which works with youths aged 10 to 18 to promote vigorous exercise and healthy peer and mentor relationships. Another of his plans is to help bring the Hip Hop Stroke program to schools and churches in and around Greenville. The interactive program uses hip-hop music to teach fourth- through sixth-grade children about stroke including how to recognize symptoms and what to do.
McBurney says he takes pride in the efforts his system, which is part of Bon Secours Mercy Health, is undertaking to address social issues that contribute to health. One of those efforts is to partner with the nonprofit Piedmont Health Foundation to improve nutrition programs in Greenville schools. Another is a program called Well Walkers in which the community is invited to make use of an indoor walking track and earn rewards such as T-shirts for meeting their distance goals.
McBurney says he has hope that continued study and early interventions can change the trajectory for Black Americans when it comes to stroke prevention and outcomes. "I believe that we can make substantial inroads, but I think that what we have to really get down to is understanding the root causes," he says.
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