An American Story of a Health System Dilemma: The Slave Health Deficit and Post-Traumatic Slavery Stress Disorder (PTSSD)

PMCID: PMC12446405

PMID: 40721709

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The purpose of this discussion is to enhance understanding of the historical foundations of current racial and ethnic health disparities. A pivotal narrative within American history will be examined with a focus on centuries of chronic emotional and physical trauma experienced by individuals of Black ancestry. The descendants of enslaved Black individuals continue to experience the enduring ethno-historic trauma rooted in slavery, further exacerbated by the persistent legacy of systemic oppression and the sustained transmission of racialized ideologies of inferiority. These intersecting factors have resulted in profound and multifaceted social, physical, and psychological consequences [1]. This paper will also explore the intricate dynamics between the lasting effects of slavery and contemporary health inequities while introducing the concept of racialized social determinants of health (rSDOH) in the United States. Historically, targeted discriminatory policies created cycles of disadvantage, resulting in disproportionate concentrations of affected populations in contexts marked by poverty, inadequate education, and poor health outcomes. Current evidence indicates that Black Americans face some of the worst health outcomes among racial groups resulting in excess premature deaths, characterized by elevated rates of infant and maternal mortality, as well as reduced life expectancies. According to the Center for Disease Control (2023), the age-adjusted death rates reveal profound racial health disparities: overall rates are 750.5 deaths per 100,000 US population, with American Indian/Alaska Native populations experiencing the highest rates 1,277.7 for males; 920.3 for females. Black Americans follow closely with 1,151.6 for males; 753.6 for females, while in descending order, White, Hispanic, and Asian populations exhibit significantly lower rates [2]. This paper will explore some of the root causes for these health disparities within the American healthcare system.
Part I provides an overview of critical topics, including the origins of humanity, the employment of pseudoscientific theories that supported concepts of White supremacy and Black inferiority, as well as the weaponization of Christian doctrine that reinforced false scientific beliefs justifying the institution of slavery of indigenous populations. To comprehend the impact of ethno-historical trauma on contemporary health disparities, particularly among Black Americans, this section examines historical events and erroneous notions of human hierarchy. A key historic event discussed include the Transatlantic Slave Trade—often termed the Black Holocaust [3] which lasted several centuries. These factors have led to significant intergenerational trauma for African slaves and their descendants, manifesting as increased chronic diseases and premature deaths within today's Black population. Part II presents an analysis of the inequitable healthcare received by Black Americans during and after slavery, revealing contemporary health disparities characterized as the “slave health deficit” [4–9], a term that depicts the origin of current Black health disparities stemming from slavery. This discussion will acknowledge the role of Western physicians and scientists who propagated false racial concepts that supported Black inferiority and contributed to today’s slave health deficits. A clear definition of White supremacy will be proposed to understand how this ideology has perpetuated systemic racial and ethnic inequities in contemporary American society. Part III introduces the hypothesis of post-traumatic slavery stress disorder (PTSSD) [8, 10], which posits that intergenerational trauma from slavery results in persistent toxic stress, as measured by allostatic load, thereby contributing to adverse health outcomes in Black Americans. Current evidence will be presented to underscore colorism [11] as a discriminatory factor supporting the PTSSD hypothesis, particularly through an analysis of differential toxic stress across racial and ethnic groups via comparative mortality and cardiovascular risk assessments. This discussion will also highlight the significant roles of the National Medical Association (NMA), W. Montague Cobb Health Institute, and NAACP in addressing these health inequities. Moreover, recent data will illustrate the significant human toll of poor health outcomes and mortality, especially for Black Americans, alongside the substantial economic burden associated with ongoing health disparities in the United States.
The genetic and paleontological scientific evidence for common origins of humanity is found on the African Continent. This was revealed with the successful unraveling of the human genome in 2001. Early Western scientific concepts of the origin of modern humans, or Homo sapiens, did not perceive all racial groups, other than Africans, being originated on the African Continent, but rather proposed a multi-regional theory, suggesting humans found on other Continents where more evolved, falsely concluding that only Africans evolved from apes. However, the palaeontologic and genetic evidence shows that approximately 270,000 years ago all modern humans began to evolve on the African Continent [12]. Approximately 70,000 years ago, groups of these early modern humans began migrating out of Africa, eventually populating every continent [12]. However, many early Western scientists refused to accept the evidence of the single region theory because it did not coincide with their false belief of a human hierarchy with the White race at the top. We now know modern humans are remarkably genetically similar—approximately 99.9% of our DNA is identical across all people with more genetic diversity within different racial groups than between racial groups with the greatest diversity found in the African populations. This means that the variation we observed in phenotypical traits such as skin color, hair type, and various physical features accounted for only 0.1% of our genetic makeup. Using a perspective that considers the origins of the human genome originating on the African Continent, it can be argued that the human genome is logically classified as the “African Human Genome.” Furthermore, this underscores an important point: that race, as we often discuss it today, is not a strict biological category. Instead, it is largely a social construct shaped by historical and cultural factors as well as indigenous societal biases. In essence, we can say that we are part of a single human race, with diverse ethnicities that have evolved from our shared ancestry in Africa, but false concepts of human hierarchy have created misconceptions and false beliefs of superior and inferior races amongst our human family. This discussion hopes to achieve a better understanding of our common origins and fosters a sense of unity among all people, despite the many differences that exist in appearances and cultures.
The racist concepts of White supremacy became rooted in American society as highlighted by the French philosopher Alexis de Tocqueville, with his personal observation of American society witnessed during his American journey from 1831–1832. Tocqueville’s Democracy in America journal on page 332 he writes [13], “Among these widely differing families of men, the first that attracts attention, the superior in intelligence, in power, and in enjoyment, is the white, or European, the MAN pre-eminently so called; below him appear the Negro and the Indian.………. we should almost say that the European is to the other races of mankind what man himself is to the lower animals: he makes them subservient to his use, and when he cannot subdue, he destroys them.”
The concept of White supremacy and pseudoscience has shaped our current understanding of humanity. If we take a step back in history, we find that many Western scientists, such as J.F. Blumenbach, played pivotal roles in promoting these flawed theories. In his 1781 work, On the Natural Variety of Mankind, Blumenbach suggested that the Caucasian skull represented the “most beautiful form” compared with the lesser extreme, the Ethiopians and Mongolians [5, 7, 14]. He even suggested that the white skin color must be the original skin color of humans. This idea not only positioned White individuals at the pinnacle of humanity but also set a dangerous narrative regarding people of color. There were individuals such as Carl von Linnaeus, considered Father of Biological Classification and Theophrastus Bombastus von Hohenheim—better known as Paracelsus—who contributed to the pseudoscientific belief that people of diverse races were somehow inferior to Caucasians. Linnaeus categorized humans into different “varieties,” each with its own set of traits that inherently framed non-White individuals as less civilized or intellectually capable. Paracelsus took that even further, proposing that Africans and other non-Christian groups descended from different, lesser ancestors, distancing them from the biblical Adam and Eve. Adding to this legacy of pseudoscience was Georges Cuvier (1769–1832), a prominent French naturalist and paleontologist, whose teachings influenced many American scholars [7, 14], such as Louis Agassiz, a professor of Medicine at Harvard University, and a key figure in American science, adopted similar views, promoting the idea of racial hierarchies based on perceived differences in intellect and moral character [14].
Another noted American physician who contributed to these false beliefs was Josiah Clark Nott, a graduate of the University of Pennsylvania School of Medicine, who founded the University of Alabama [5, 7, 14]. He not only practiced medicine but also owned slaves. He used his scientific standing to justify slavery itself, claiming “the negro achieves his greatest perfection, physical and moral, and greatest longevity, in a state of slavery.” Some scientists, such as Samuel George Morton (1799–1851) who taught at the University of Pennsylvania, promoted false disciplines of craniology and phrenology, which measured skull shapes and capacities, to argue larger skull capacities placed Whites at the top hierarchy and relegated Blacks to an inferior status—almost akin to apes on the evolutionary ladder [7, 14]. The belief in polygenesis or multi-regional theory of human origin—the idea that different races had separate geographical origins—was steadfastly adopted by most early Western scientists, although, this was directly contradicted by the scientifically supported view of monogenesis, which posits that all human beings share a common African ancestry. The early proponents of White supremacy refused to accept the evidence that points to Africa as the cradle of humanity from which all people evolved and those that did accept the single regional theory of human origin, continued to falsely postulate that human intellect and creativity only occurred after the populations migrated out of Africa.
The origins of White supremacy cannot be fully understood without considering the significant influence of Christianity. Numerous proponents of scientific racism have historically linked their unfounded claims of White superiority to various Christian beliefs and doctrines. For example, Johann Friedrich Blumenbach classified a skull discovered near the Caucasus Mountains in southeastern Europe as the epitome of beauty among human skulls, asserting its superiority over other racial forms, thus the origin of the name Caucasian to classify Whites [5, 7, 14]. After inspecting three mummies from ancient Egyptian catacombs, American scientist Samuel Morton concluded that Caucasians and Negroes were already distinct species three thousand years ago. Since the Bible indicated that Noah's Ark had washed up on Mount Ararat located in eastern Turkey, only a thousand years ago before this, Morton claimed that Noah’s sons could not possibly account for every race on earth. This association prompted some to assert that the biblical figures of Adam and Eve, as portrayed in Christian theology, were exclusively ancestors of Europeans, thereby excluding other racial groups from this narrative. Joshua Nott and other American scientists turned from their naturalists’ beliefs to their bible and deducted that Blacks were the children of Ham, son of Noah, who, along with his progeny, was “marked” and condemned to be servant to his brothers for having viewed his father’s nakedness [15].
This conflation of scientific inquiry with religious doctrine raises pertinent questions about its historical roots. A significant catalyst for this intertwining can be traced to the Christian Doctrine of Discovery, articulated in the mid-fifteenth century [16]. This doctrine, also referred to as the Doctrine of Domination, emerged during a period dominated by the exploration and colonization efforts of European powers, primarily Portugal and Spain, accompanied by a monolithic Christian Church prior to the Reformation. Pope Nicholas V issued the Doctrine of Discovery in 1452, which sanctioned the invasion and subjugation of non-Christian peoples and territories on the African Continent [16]. The decree explicitly stated that European Christians were permitted to “invade, search out, capture, vanquish, and subdue all Saracens (Muslims), and pagans whatsoever, and other enemies of Christ wheresoever placed.” Furthermore, it justified the appropriation of their possessions and the enslavement of individuals perpetually, all for the purpose of profit and the purported conversion to Christianity. This papal sanction suggested that the superior status of European Christians could be conferred upon the conquered populations through the introduction of Christianity, thus framing the appropriation of land and resources as a morally justified act. The Church subsequently issued various iterations of this Doctrine of Domination. In 1493, Pope Alexander VI issued the papal bull interCaetera that divided newly discovered lands between Spain and Portugal. This new doctrine provided moral and legal justification for Christopher Columbus’s return voyages to the New World in the Americas [16]. This effectively facilitated the establishment of Christian missions and contributed to the genocidal practices inflicted upon indigenous populations. White supremacy weaponized Christian doctrines to justify a racist social system constructed during the age of exploration, and played a crucial role in legitimizing acts of domination, exploitation, enslavement, and profoundly influenced societal attitudes toward race and superiority that persist in various forms today. This resulted in a social system with racist policies that guaranteed Blacks and Native Americans would be perpetual second-class citizens in America.
The topic of the Black Holocaust and the Transatlantic Slave Trade is a deeply painful and significant part of American history that continues to resonate today. It is crucial to acknowledge how false notions of White supremacy were used as a justification for the horrific treatment of both Native Americans and enslaved Africans over centuries. The Transatlantic Slave Trade with the enslavement of Africans in the Americas and Caribbean is referred to as the Black Holocaust. The Black Holocaust transpired over several centuries, and entailed a total death toll estimated between 6 to 150 million lives lost during and after the Transatlantic Slave Trade [3]. The United Nation estimates 17 million deaths while the World Future Fund estimates 60 million died during this span of time [3]. The first period: —the Pre-transatlantic Slave Round-Up, countless African men, women, and children were captured, forcibly taken to the western shores of Africa, and subjected to brutal conditions in dungeons. It has been estimated that between 6 to 10 million Black souls perished before they even set their feet on a slave ship. The second period, the Transatlantic Voyage, entailed the harrowing journey across the Atlantic, where enslaved individuals were crammed into ships under inhumane conditions. As many as 800 people were crammed together in the cargo holds of ships resulting in death rates reaching 20%. This means that 1.2 to 2.4 million souls lost their lives during the Transatlantic crossing because of the unsanitary and inhumane conditions they faced. Finally, the third period, the Post-transatlantic Voyage Break-in Period, in which the horrible living conditions and poor treatment did not end upon arrival. Within just 3 years, death rates for these new arrivals could soar to 30% or even 50%, as they faced the daunting challenge of acclimating to harsh new environments [5, 14]. It is notable that physicians were intimately involved in all three periods and served on slave ships to protect the cargo of slaves. Slave ship physicians’ salaries were reported to be second only to the captain of the ship, and a lucrative job for physicians was on plantations treating slaves.
In 2000 and 2002, authors W. Michael Byrd, MD, MPH and Linda Clayton, MD, MPH, in their extensively documented books, titled, An American Health Dilemma, Vol I and II [5, 14], revealed the significant impact of the pseudoscience of White supremacy on the poor health of American slave descendants. The authors documented statistics showing how the health of Blacks in America has been the worst compared to other racial groups, dating back to slavery, and highlighted the term, “slave health deficit,” a term coined by medical historians Dr. Todd L. Savitt and Dr. James O. Clayton, to describe the severe health disparities experienced by enslaved Africans in the United States [4–9]. Deficit refers to the negative health outcomes that result from unhealthy living and working conditions during and after slavery. Among the ten leading causes of death in the US, such as heart disease, cancer, stroke, diabetes, unintentional injuries, infant mortality, and maternal mortality, African slave descendants suffer the highest chronic disease and death rates. These racial health disparities can be less, depending on individual social and economic status, but race and ethnicity remain persistent independent risk factors for poor health outcomes. US health data clearly reveal Blacks have poor access to quality health care, and once they have accessed the health system, Blacks commonly are treated differently because of discriminatory institutional policies, as well as healthcare provider conscious or unconscious biases, which have been documented in many scientific publications on this subject [17–20].
Slavery has been a part of human history for centuries, but the system established in the Americas and the Caribbean was particularly harsh and dehumanizing. Enslaved individuals were treated as valuable property, and as such, plantations hired physicians, often referred to as slave doctors, to meet their needs. Unfortunately, these medical practitioners adhered to the same biases and misguided beliefs as their European counterparts, viewing Black individuals through a lens of perceived inferiority. They often failed to connect the health issues faced by enslaved people to the brutal conditions and environments imposed upon them. The disadvantaged status of slaves created a large pool of individuals for medical experimentation, which allowed physicians to refine their treatments and techniques on enslaved bodies before applying them to their White patients. A notorious example is J. Marion Sims (1813–1883) who is often referred to as the “Father of Gynecology.” Sims conducted numerous surgical procedures on enslaved women without anesthesia, operating under the false belief that Black individuals possessed a greater tolerance for pain [5, 7, 15, 17]. This misconception has persisted through the years, with contemporary studies demonstrating that Black patients frequently receive inadequate pain relief compared with their White counterparts [17, 20]. Decades of unethical treatment and experimentation including the Tuskegee Syphilis study as documented by author, Harriett Washington in her book, Medical Apartheid [15], has created a significant distrust of the US health system for Blacks and other populations. This distrust further hinders the ability to effectively address the barriers of eliminating health disparities in these most affected populations.
Samuel A. Cartwright (1793–1863) was a graduate of the University of Pennsylvania School of Medicine who theorized that Blacks should medically be treated differently owing to their “nonhuman” biological peculiarities [6, 14, 21, 22]. Cartwright later became a professor of Medicine at the University of Louisiana. In 1851, he published a review article in a New Orleans medical journal called DeBow’s review titled “Diseases and Peculiarities of the Negro Race [19].” He coined the names of mental diseases that he attributed specifically to Blacks. He suggested that slaves who ran away from the brutality experienced on plantations suffered from a mental disease, Drapetomania, defined as runaway madness, and Dysesthesia Aethiopica, defined as uppity, rebelliousness or rascality. He prescribed treatment for drapetomania with condescension and brief periods of play time as though they were children. However, for those slaves that had dysesthesia aethiopica and continued to rebel, he prescribed whippings as punishment to “beat the devil out of them” and therefore prevent them from absconding.
During the early twentieth century, there were 7 medical schools designated for Black students; however, following the 1910 Flexner Report, a significant reduction occurred, leading to the closure of most of these institutions, leaving only Howard and Meharry Medical Schools operational [5, 23]. The ramifications of this action, combined with the limited financial resources available to the Black population and inadequate educational opportunities at historically Black colleges and universities (HBCUs), have contributed to a persistent shortage of Black physicians. According to recent data, while Black individuals make up approximately 13.7% of the overall US population, they account for only 5.7% of practicing physicians. Access to medical care for Black individuals was further hindered by the stark realities of segregated healthcare facilities. In many cases, hospitals that accepted Black patients maintained segregated wards, where they were typically treated by White physicians who often had exclusive admission privileges due to the organized medical community’s institutional racism, notably within the American Medical Association (AMA). The AMA's longstanding refusal to accept Black physicians severely restricted their ability to practice medicine and provide care within hospital settings. In 1893, John Hopkins University Hospital in Baltimore, Maryland opened with rigidly segregated classes, hospitals, and medical staff and remained segregated well into the 1960 s [5]. The desegregation of medical institutions, catalyzed by the Civil Rights Movement of the 1960 s, began to dismantle these barriers. Despite these advancements, the legacies of segregation and discrimination continue to resonate within healthcare systems today, leading to enduring health disparities.
The intellectual landscape of the nineteenth century further complicated the status of African Americans, as prominent academic figures propagated notions of racial inferiority. For example, Nathaniel Shaler at Harvard University espoused theories that positioned Black individuals as evolutionary inferiors, even justifying the violence of lynching as a misguided but noble attempt to protect societal values [15]. Similarly, Joseph LeConte’s writings at Harvard and later the University of California, reinforced the idea that slavery served a developmental purpose for the so-called “negro,” advocating for the denial of citizenship and voting rights in service of a paternalistic notion of protection and guidance. The post-slavery era and the Jim Crow period created a complex interplay of legal, educational, and healthcare inequities that profoundly affected African American communities, echoing through generations, and impacting contemporary structures. The historical context provided by White academic elites and the ingrained false assumptions that Blacks exhibited traits and tendencies due to their inferior status [24], only served to justify and sustain these inequities, contributing to the systemic challenges faced by Black Americans in the present day.
Post-traumatic stress disorder (PTSD) is a psychiatric disorder that occurs in individuals who have experienced or witnessed a traumatic event, series of events or set of circumstances. Some researchers have linked the psychological residual effects of slavery with PTSD dysfunctional behaviors [25–29]. Clinical psychologist, Dr. Joy DeGruy introduced the concept of collective multigenerational trauma associated with centuries of pre and post slavery experiences in America and coined the term post-traumatic slavery syndrome (PTSS) [29]. This multigenerational trauma resulted in destructive behaviors that she described in 3 categories, vacant or low self-esteem, ever present anger, and racist socialization or internalized racism. Further research outlines how the impact of slavery and the oppression of African American people and their culture served as significant trauma to African Americans, which was carried forward through successive generations; providing an explanation of their current anxiety-related conditions, poor health, and maladaptive behaviors [26, 30]. These traumas resulted not only from the dehumanization experienced during slavery but post slavery Jim Crow Laws, terror of lynchings, and the intentional riots and massacres directed by Whites at economically successful Black communities, such as the New York City Draft Riots (1863), Colfax, Louisiana (1873), Wilmington, North Carolina (1898), Atlanta, Georgia (1906), Chicago, Illinois (1919), Elaine, Arkansas (1919), Tulsa, Oklahoma (1921), and Rosewood, Florida (1923), as well as and many other massacres [31, 32].
How is this past traumatic history related to the poor health outcomes for African Americans today? Recent compelling evidence suggests that these psychologically adaptive behaviors can lead to significant physical health consequences and chronic diseases later in life. I suggest we can expand this concept with the hypothesis of post-traumatic slavery stress disorder (PTSSD) [8, 10], which arises from the need to address the profound health effects of racism and the ethno-historical trauma experienced by descendants of American slaves. This hypothesis posits that “racism and the ethno-historical multigenerational trauma produced from the legacy of slavery in the United States, produces chronic physiological stress, measured as allostatic load, which significantly increases the risk for a variety of chronic diseases such as heart disease, hypertension, diabetes, infections, and cancer.” Collectively, these factors contribute to notable health disparities or slave health deficits, leading to early deaths within the US Black population. The trauma experienced over generations has had lasting effects—both psychologically and physiologically—on the descendants of enslaved Africans in the United States. This chronic form of stress manifests through complex mechanisms involving epigenetics, with research indicating that the traumatic experiences of past generations can influence the health outcomes of current generations [33, 34].
A critical component of this discussion is the concept of the allostasis which is defined as the physiological process by which the body achieves stability through change, adapting to various stressors encountered in the environment. In contrast, allostatic load refers to the cumulative physiological burden or wear and tear placed on the body because of repeated or prolonged activation of stress response systems, often termed chronic toxic stress. The allostatic load can be assessed through various biomarkers, including stress hormones and neurotransmitters. Daily exposure to racism contributes to this toxic stress, leading to an overproduction of biomarkers such as cortisol and epinephrine, and resulting in a decline in immune functions, for example, the suppression of immunoglobulin A (IgA). Furthermore, shortened telomere length associated with chronic stress has been linked to cell damage and decreased life expectancy [35]. Research supports the notion that Black individuals in the US have higher levels of stress biomarkers compared with their counterparts of other ethnicities, as well as a higher overall allostatic loads. A pivotal study published in the American Journal of Public Health in 2006 highlighted that Black individuals, particularly Black women, exhibit significantly elevated allostatic loads compared with White individuals, with even higher allostatic loads than their low-income White peers [36].
In addition, Adverse Childhood Experiences (ACEs)—stressful incidents encountered during childhood, such as parental incarceration or various forms of abuse—play a crucial role leading to diseases later in life. Higher ACE scores are consistently correlated with the emergence of chronic physical and mental illnesses later in life [37]. These experiences are believed to affect individuals through a combination of dysfunctional behaviors and altered stress-related biomarkers, impacting various bodily systems and the immune response. The prevalence of ACEs among Black children is striking. National statistics indicate that 61% of Black children faced at least one ACE, in contrast to 51% of Hispanic children, 40% of White Children, and 23% of Asian children [38]. The unique American cultural experience for Black individuals subjects them to various forms of racism—structural, personally mediated, and internalized [39–41]—leading to a heightened risk for PTSSD, which in turn contributes to chronic disease and premature mortality.
The concept of post-traumatic slavery stress disorder encapsulates the multifaceted impacts of historical trauma on the health of African American populations, emphasizing the need for a holistic understanding of the intersection between racism, psychological trauma, and physical health. Considerable information has been published in books and articles describing the relationship between stress and racism and its impact on health [21, 29, 40, 41]. It is imperative that we consider these factors when addressing the health disparities faced by Black individuals in the United States today.
Chronic toxic stress as measured by the allostatic load is relevant across diverse human populations, though its impact and implications can vary widely among different racial demographic groups. The relationship between chronic toxic stress and health disparities is particularly evident in racial demographic statistics regarding beginning-of-life and end-of-life outcomes, as illustrated in Table 2. This data indicates African Americans experience the highest rates of infant and maternal mortality along with the shortest life expectancies. This is followed by American Indians/Alaska Natives (AI/AN), Whites, Hispanics, and Asians respectively. These findings suggest racial and ethnic groups suffer adverse health consequences that are contingent upon the duration and intensity of chronic stress because of their experiences with systemic oppression in the context of White supremacy.
The socio-cultural framework of American society, underpinned by a doctrine of racial superiority, has created a toxic environment that adversely affects the health of both subordinate and dominant groups suggesting that current American culture can be bad for our health and wellbeing. This observation may partially explain the “immigrant health paradox” where immigrants are healthier compared to their native-born peers of similar demographics and socioeconomic profile. However, this paradox disappears as immigrants stay longer in the host country [42].
The relationship between melanin content in a population and the prevalence of health disparities is a multifaceted and underreported issue that merits thoughtful examination. Observations indicate that populations historically subjected to systemic discrimination and dehumanization, notably US Blacks and Native Americans, along with certain Hispanic sub-populations such as Puerto Ricans and Asians with South Asian ancestry, present higher rates of health disparities and cardiovascular disease risk than other populations with less African ancestry. White supremacy has led to a form of discrimination based upon one’s skin color referred to as colorism [11], which is prejudice or discrimination against individuals with dark skin tones. This observation makes it fair to say, that there is a direct correlation between the amount of melanin in a population and the severity of their health disparities.
This observation is confirmed when utilizing the Atherosclerotic Cardiovascular Disease (ASCVD) 10-year risk estimator (CV risk estimator) adopted by both the American Heart Association (AHA) and the American College of Cardiology (ACC) [43], which includes race and ethnicity as risk factors. When I introduced this health risk tool into my clinical practice, I encountered a 50-year-old African American male patient with the following cardiovascular (CV) risk profile: His blood pressure was recorded at 160/90, with a total cholesterol of 230, LDL cholesterol of 110, and HDL cholesterol of 45. Notably, he was a nonsmoker, had diabetes, and was currently on treatment for hypertension. His estimated 10-year CV risk was calculated at 25.1%, which was significantly above the optimal CV risk of 3.9%. In a striking comparison, when I then adjusted the ethnicity in his profile to identify him as a White male or categorized him as “Other Ethnicity,” with the same CV risk profile, the risk decreased to 15.1%. Moreover, this template revealed that a hypothetical 50-year-old Black female with the same risk profile, presented the highest cardiovascular risk of 27.2%, whereas a 50-year-old White female with a CV risk of 7.7% presented the lowest risk. Table 1 reveals for both the 40-year-old and 50-year-old, the Black female CV risk is greatest, followed by Black male > White male, and > White female. This increased CV risk for 40-year-old and 50-year-old Black female is supported by studies showing Black females have higher allostatic loads than Black males and as well as all other races and ethnicities [36].

Important to note, the ACC/AHA 10-year CV risk assessment tool may underestimate cardiovascular risk for certain “other” ethnicities, particularly American Indians, some Asian Americans of South Asian ancestry, and specific Hispanic groups, such as Puerto Ricans. Conversely, for individuals of East Asian ancestry and Mexican Americans—who generally have less African ancestry—risk assessments may be overestimated. These findings reinforce the literature indicating that Blacks, especially Black females, experience greater allostatic loads of chronic toxic stress, compared with all other races and ethnic groups [36]. These data suggest an urgent need to further investigate and address the root causes of these disparities. The interplay of race, ethnicity, and health should be critical areas for ongoing research and intervention within clinical practice.
When we look at cardiovascular (CV) risk, it is fascinating how disparities really pop out—especially for populations with significant African ancestry or those who have faced long-standing second-class status owing to systemic racism. These groups tend to have higher CV risks, sometimes just behind those of African Americans. This interesting observation seems to reveal a direct connection between melanin levels and colorism-based health disparities. This raises the following question: How much of this risk is tied to lived experiences, such as racism and discrimination? Now that we can measure levels of a person’s perceived racism, we have found that racism can make us sick [40, 41]. The ACC/AHA 10-year ASCVD risk estimator, which uses race and ethnicity as variables, may reflect the cardiovascular risk associated with heightened allostatic loads resulting from chronic stressors linked to discriminatory practices endemic in American society. While there have been advancements toward developing a CV risk calculator that does not incorporate race as a factor, but utilizes other social determinants, it is essential to note that the ACC/AHA algorithm has been validated as a reliable predictive tool across diverse populations, specifically for both Black and White cohorts.
The efficacy of the ACC/AHA 10-year CV risk tool has been corroborated through rigorous evaluation in several large Black cohorts, such as the Jackson Heart Study (JHS) and the Multiethnic Study of Atherosclerosis (MESA), demonstrating its predictive capabilities in these Black populations [44]. The observed disparities in cardiovascular (CV) risk highlight populations with significant African ancestry or those who have endured prolonged periods of racism and socioeconomic disenfranchisement exhibit increased CV risks, often second only to African Americans. I believe these observations shed light on how race and historical context can influence health outcomes and underscores the necessity of considering both biological and historical sociocultural factors in the assessment of cardiovascular risk. This aligns with research demonstrating a direct correlation between melanin concentration and the extent of health disparities within various populations with higher levels of African ancestry.
Throughout the twentieth century and into the twenty-first century, African Americans consistently faced higher mortality rates due to a significant number of leading causes of death. This persistent inequity extends beyond health and infiltrates economic, educational, and judicial systems, perpetuating cycles of disadvantage. However, the impact of these disparities is stark when we look at beginning-of-life and end-of-life data by examining key metrics such as infant mortality rates (IMRs), maternal mortality rates (MMRs), and overall life expectancy (LE). Data shows that in 1850, life expectancy was approximately 25.5 years for Whites and 21.4 years for Blacks. By 1900, Whites had an average life expectancy of 47 years, compared with 33 years for Blacks (Table 2). Fast forward to 2000, and while both groups saw improvements—White life expectancy reaching 77.6 years and Black life expectancy rising to 71.8 years—a gap of 5.8 years remains (Table 2). Additionally, maternal, and infant mortality rates consistently demonstrate that Black women and their infants experience the highest rates of morbidity and mortality compared with all other ethnic groups. A recent analysis published in June 2023 by the Journal of the American Medical Association (JAMA), highlighted that between 1999 and 2019, while overall maternal mortality rates saw some improvements, those for Black, American Indian, and Alaskan Native women significantly increased [45]. Although infant mortality rates improved during this period, they remained the highest for Black and American Indigenous infants (Table 2) [46, 47]. The ongoing health disparities faced by African Americans and other historically marginalized populations, highlight the entrenched nature of racialized inequities within the US healthcare system.

Beginning-of-life and end-of-life mortalities and impact from COVID-19[45–49]
The COVID-19 pandemic has had profound and far-reaching impacts across the United States, with data from the Centers for Disease Control and Prevention (CDC) highlighting significant disparities among different racial and ethnic groups. The statistics reveal a concerning trend: Black, American Indian/Alaskan Native (AI/AN), and Hispanic populations faced disproportionately higher rates of COVID-19 infection and mortality compared with their White counterparts. In 2020, COVID-19 emerged as the third leading cause of death in the US, accounting for approximately 11% of all fatalities that year. According to CDC statistics reported by APM Research Lab [48], in December 2020, the cumulative COVID-19 mortality rates/100,000 by race and ethnicity, revealed Indigenous and Black individuals bore the brunt of this crisis, with death rates of 133 for Indigenous and 123.7 for Blacks. This was higher than death rates for Pacific Islanders (90.4), Hispanics (86.7), Whites (75.7), and Asians (51.6).
Furthermore, the pandemic contributed to a notable decline in life expectancy across the nation. The National Center for Health Statistics (NCHS) reported a decrease of 1.5 years in life expectancy for the total US population, dropping from 78.8 years in 2019 to 77.3 years in 2020 [49]. This decline is the most substantial 1-year reduction observed since World War II, bringing life expectancy to its lowest point since 2003. However, as depicted in Table 2, the impact was not uniformly distributed across racial and ethnic groups. Hispanics and non-Hispanic Blacks experienced a significant decline of 3.0 years in life expectancy in contrast to Whites with a decline in life expectancy of 1.2 years and later obtained data for AI/AN and Asians showed a decline in life expectancy of 4.7 years and 2.1 years respectfully as shown in Table 2. These disparities underscore the longstanding issues that historically marginalized populations face, particularly during crises. The often-used phrase, “When White folks catch a cold, Black folks catch pneumonia,” captures the essence of this reality. During catastrophic events such as pandemics, wars, or natural disasters such as seen with Hurricane Katrina, marginalized communities frequently find themselves at a disadvantage, facing significant healthcare disruptions, economic instability, structural racism, and increased social isolation.
A recent study sponsored by the National Institute of Health (NIH) and published in JAMA in 2023 highlighted the significant burden of health disparities affecting the Black population in the United States. Over a 22-year period, from 1999–2020, the data reveal that this group experienced more than 1.63 million excess deaths compared with their White counterparts, along with more than 80 million excess years of potential life lost [50]. In a related finding, another study published in May 2023 by JAMA, addressed the economic implications of these health disparities. It is estimated that in 2018 alone, the cost of racial and ethnic health disparities to the US economy was a staggering $451 billion—a substantial 41% increase from estimates provided in 2014. Notably, a significant portion of this economic burden fell predominantly on the Black/African American population, accounting for 69% of the costs attributed to premature mortality [51].
The enduring pre and post slavery framework of racial hierarchy and the consequent discrimination against specific racial groups have led to the concept of racialized social determinants of health (rSDOH). Social determinants of health (SDOH) are non-medical factors that critically influence health outcomes, including the conditions of one’s birth, growth, work, and aging. In contrast, racialized social determinants of health (rSDOH) arise from systemic targeted racial discrimination through policies that disproportionately disadvantage the targeted racial groups. Historical practices such as Jim Crow laws, redlining, and segregated healthcare facilities have perpetuated these inequities, creating cycles of economic disadvantage leading to greater levels of poverty, particularly for Black and Native American communities. Recent data from the Kaiser Family Foundation (KFF-2023) reveal significant disparities in poverty rates among different racial groups in the United States, with American Indian/Alaskan Native individuals at 24.2%, Black individuals at 20.6%, Hispanic individuals at 16.6%, Asian/Pacific Islander individuals at 10.0%, and White individuals at 9.5% [52]. These statistics highlight the disproportionate levels of poverty with resultant barriers, faced by Black and Native American populations, to accessing educational opportunities, accumulating generational wealth [53], receiving quality healthcare with poor health outcomes [17, 54, 55], and avoiding premature mortality [50]. Effective policy formulation must not only acknowledge the impact of rSDOH but also work to dismantle barriers hindering equitable health outcomes for these populations.
Leadership within the NMA, particularly figures such as past presidents W. Montague Cobb (1964) and John L.S. Holloman (1966), strongly advocated for health and social equity. These leaders recognized that the broader social environment had serious health implications, especially considering the frequent lynchings. During the late nineteenth and early twentieth centuries, over 4,700 lynchings of mostly Blacks by Whites were documented, causing physical and emotional terror within the Black communities, and was identified as glaring life ending health disparities [56, 57]. In the early years of its founding, the NMA collaborated with other Black organizations such as the National Association for the Advancement of Colored People (NAACP), to end lynchings against Blacks throughout America. In fact, the NMA changed its planned national meeting from Memphis, Tennessee to Philadelphia to protest the lynching of Ell Persons on May 22, 1917 [56, 57]. These groups advocated enacting anti-lynching laws but were always blocked by racist members of the US Congress.
Although health disparities are believed to be caused primarily by poor social and economic conditions, referred to as social determinants of health (SDOH), the role of racism in medicine was rarely mentioned or minimized as a cause of these disparities. However, many members of the NMA believed that racism played a significant role in contributing to persistent health inequities, leading to health disparities. In the late 1990 s, because of NMA health policy advocacy, working with the Congressional Black Caucus (CBC), the United States Congress funded the Institute of Medicine (IOM) and National Academy of Science report published in 2002, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare [17]. This landmark report documented structural racism and healthcare provider biases that contributed to health disparities, especially in Black populations. Since then, hundreds of scientific publications have independently confirmed that racism, race, and ethnicity are independent variables and significant contributors to racial health disparities, specifically, the slave health deficit.
W.E.B. Du Bois, in his seminal work “The Souls of Black Folk,” articulates a profound concept known as “double consciousness” [58]. This phenomenon describes the dual awareness that African Americans possess: they see themselves through the lens of a prejudiced White society while simultaneously striving to maintain their own unique Black identity. This internal conflict is deeply rooted in the legacy of slavery, where survival often necessitated the internalization of damaging beliefs perpetuated by a system of White supremacy, leading to entrenched forms of internalized racism [39, 55]. African slave descendants understood that revealing their true selves could result in severe repercussions, including, loss of income and acceptance. During slavery and Jim Crow, repercussions were more severe, such as whippings or even death, in the form of lynching.
Medical Health Reparations [6, 59, 60]—to repair and restore quality health status for the US Black populations we need adequate funding of Black health institutions such as HBCUs, mental health centers, and research focused on the epigenetic and intergenerational traumas of communities with inherited deficits.
Critical consciousness [61, 62]—to recognize how systems of privilege and oppression contribute to trauma disproportionately affecting marginalized communities.
Cultural humility [63, 64]—learning to acknowledge the significance of cultural differences of others and engage in self-reflection to address one’s own biases.
Radical healing [65]—to learn and address the root causes of trauma, particularly identity-based wounds stemming from racism and other forms of discrimination.
Restorative justice [66]- to repair harm, restore relationships, and rebuild communities affected by trauma and conflict, empowering individuals, and promoting healing.
Community Resilience Programs [67]—to collectively support culturally anchored stress-reduction initiatives such as faith-based wellness and historical healing circles.

Sections

"[{\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR1\", \"CR2\"], \"section\": \"Introduction\", \"text\": \"The purpose of this discussion is to enhance understanding of the historical foundations of current racial and ethnic health disparities. A pivotal narrative within American history will be examined with a focus on centuries of chronic emotional and physical trauma experienced by individuals of Black ancestry. The descendants of enslaved Black individuals continue to experience the enduring ethno-historic trauma rooted in slavery, further exacerbated by the persistent legacy of systemic oppression and the sustained transmission of racialized ideologies of inferiority. These intersecting factors have resulted in profound and multifaceted social, physical, and psychological consequences [1]. This paper will also explore the intricate dynamics between the lasting effects of slavery and contemporary health inequities while introducing the concept of racialized social determinants of health (rSDOH) in the United States. Historically, targeted discriminatory policies created cycles of disadvantage, resulting in disproportionate concentrations of affected populations in contexts marked by poverty, inadequate education, and poor health outcomes. Current evidence indicates that Black Americans face some of the worst health outcomes among racial groups resulting in excess premature deaths, characterized by elevated rates of infant and maternal mortality, as well as reduced life expectancies. According to the Center for Disease Control (2023), the age-adjusted death rates reveal profound racial health disparities: overall rates are 750.5 deaths per 100,000 US population, with American Indian/Alaska Native populations experiencing the highest rates 1,277.7 for males; 920.3 for females. Black Americans follow closely with 1,151.6 for males; 753.6 for females, while in descending order, White, Hispanic, and Asian populations exhibit significantly lower rates [2]. This paper will explore some of the root causes for these health disparities within the American healthcare system.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR3\", \"CR4\", \"CR9\", \"CR8\", \"CR10\", \"CR11\"], \"section\": \"Introduction\", \"text\": \"Part I provides an overview of critical topics, including the origins of humanity, the employment of pseudoscientific theories that supported concepts of White supremacy and Black inferiority, as well as the weaponization of Christian doctrine that reinforced false scientific beliefs justifying the institution of slavery of indigenous populations. To comprehend the impact of ethno-historical trauma on contemporary health disparities, particularly among Black Americans, this section examines historical events and erroneous notions of human hierarchy. A key historic event discussed include the Transatlantic Slave Trade\\u2014often termed the Black Holocaust [3] which lasted several centuries. These factors have led to significant intergenerational trauma for African slaves and their descendants, manifesting as increased chronic diseases and premature deaths within today's Black population. Part II presents an analysis of the inequitable healthcare received by Black Americans during and after slavery, revealing contemporary health disparities characterized as the \\u201cslave health deficit\\u201d [4\\u20139], a term that depicts the origin of current Black health disparities stemming from slavery. This discussion will acknowledge the role of Western physicians and scientists who propagated false racial concepts that supported Black inferiority and contributed to today\\u2019s slave health deficits. A clear definition of White supremacy will be proposed to understand how this ideology has perpetuated systemic racial and ethnic inequities in contemporary American society. Part III introduces the hypothesis of post-traumatic slavery stress disorder (PTSSD) [8, 10], which posits that intergenerational trauma from slavery results in persistent toxic stress, as measured by allostatic load, thereby contributing to adverse health outcomes in Black Americans. Current evidence will be presented to underscore colorism [11] as a discriminatory factor supporting the PTSSD hypothesis, particularly through an analysis of differential toxic stress across racial and ethnic groups via comparative mortality and cardiovascular risk assessments. This discussion will also highlight the significant roles of the National Medical Association (NMA), W. Montague Cobb Health Institute, and NAACP in addressing these health inequities. Moreover, recent data will illustrate the significant human toll of poor health outcomes and mortality, especially for Black Americans, alongside the substantial economic burden associated with ongoing health disparities in the United States.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR12\", \"CR12\"], \"section\": \"Origins of Humanity\", \"text\": \"The genetic and paleontological scientific evidence for common origins of humanity is found on the African Continent. This was revealed with the successful unraveling of the human genome in 2001. Early Western scientific concepts of the origin of modern humans, or Homo sapiens, did not perceive all racial groups, other than Africans, being originated on the African Continent, but rather proposed a multi-regional theory, suggesting humans found on other Continents where more evolved, falsely concluding that only Africans evolved from apes. However, the palaeontologic and genetic evidence shows that approximately 270,000 years ago all modern humans began to evolve on the African Continent [12]. Approximately 70,000 years ago, groups of these early modern humans began migrating out of Africa, eventually populating every continent [12]. However, many early Western scientists refused to accept the evidence of the single region theory because it did not coincide with their false belief of a human hierarchy with the White race at the top. We now know modern humans are remarkably genetically similar\\u2014approximately 99.9% of our DNA is identical across all people with more genetic diversity within different racial groups than between racial groups with the greatest diversity found in the African populations. This means that the variation we observed in phenotypical traits such as skin color, hair type, and various physical features accounted for only 0.1% of our genetic makeup. Using a perspective that considers the origins of the human genome originating on the African Continent, it can be argued that the human genome is logically classified as the \\u201cAfrican Human Genome.\\u201d Furthermore, this underscores an important point: that race, as we often discuss it today, is not a strict biological category. Instead, it is largely a social construct shaped by historical and cultural factors as well as indigenous societal biases. In essence, we can say that we are part of a single human race, with diverse ethnicities that have evolved from our shared ancestry in Africa, but false concepts of human hierarchy have created misconceptions and false beliefs of superior and inferior races amongst our human family. This discussion hopes to achieve a better understanding of our common origins and fosters a sense of unity among all people, despite the many differences that exist in appearances and cultures.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR13\"], \"section\": \"Concepts of White Supremacy, Pseudoscience, Slavery, and Christianity\", \"text\": \"The racist concepts of White supremacy became rooted in American society as highlighted by the French philosopher Alexis de Tocqueville, with his personal observation of American society witnessed during his American journey from 1831\\u20131832. Tocqueville\\u2019s Democracy in America journal on page 332 he writes [13], \\u201cAmong these widely differing families of men, the first that attracts attention, the superior in intelligence, in power, and in enjoyment, is the white, or European, the MAN pre-eminently so called; below him appear the Negro and the Indian.\\u2026\\u2026\\u2026. we should almost say that the European is to the other races of mankind what man himself is to the lower animals: he makes them subservient to his use, and when he cannot subdue, he destroys them.\\u201d\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR5\", \"CR7\", \"CR14\", \"CR7\", \"CR14\", \"CR14\"], \"section\": \"Concepts of White Supremacy, Pseudoscience, Slavery, and Christianity\", \"text\": \"The concept of White supremacy and pseudoscience has shaped our current understanding of humanity. If we take a step back in history, we find that many Western scientists, such as J.F. Blumenbach, played pivotal roles in promoting these flawed theories. In his 1781 work, On the Natural Variety of Mankind, Blumenbach suggested that the Caucasian skull represented the \\u201cmost beautiful form\\u201d compared with the lesser extreme, the Ethiopians and Mongolians [5, 7, 14]. He even suggested that the white skin color must be the original skin color of humans. This idea not only positioned White individuals at the pinnacle of humanity but also set a dangerous narrative regarding people of color. There were individuals such as Carl von Linnaeus, considered Father of Biological Classification and Theophrastus Bombastus von Hohenheim\\u2014better known as Paracelsus\\u2014who contributed to the pseudoscientific belief that people of diverse races were somehow inferior to Caucasians. Linnaeus categorized humans into different \\u201cvarieties,\\u201d each with its own set of traits that inherently framed non-White individuals as less civilized or intellectually capable. Paracelsus took that even further, proposing that Africans and other non-Christian groups descended from different, lesser ancestors, distancing them from the biblical Adam and Eve. Adding to this legacy of pseudoscience was Georges Cuvier (1769\\u20131832), a prominent French naturalist and paleontologist, whose teachings influenced many American scholars [7, 14], such as Louis Agassiz, a professor of Medicine at Harvard University, and a key figure in American science, adopted similar views, promoting the idea of racial hierarchies based on perceived differences in intellect and moral character [14].\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR5\", \"CR7\", \"CR14\", \"CR7\", \"CR14\"], \"section\": \"Concepts of White Supremacy, Pseudoscience, Slavery, and Christianity\", \"text\": \"Another noted American physician who contributed to these false beliefs was Josiah Clark Nott, a graduate of the University of Pennsylvania School of Medicine, who founded the University of Alabama [5, 7, 14]. He not only practiced medicine but also owned slaves. He used his scientific standing to justify slavery itself, claiming \\u201cthe negro achieves his greatest perfection, physical and moral, and greatest longevity, in a state of slavery.\\u201d Some scientists, such as Samuel George Morton (1799\\u20131851) who taught at the University of Pennsylvania, promoted false disciplines of craniology and phrenology, which measured skull shapes and capacities, to argue larger skull capacities placed Whites at the top hierarchy and relegated Blacks to an inferior status\\u2014almost akin to apes on the evolutionary ladder [7, 14]. The belief in polygenesis or multi-regional theory of human origin\\u2014the idea that different races had separate geographical origins\\u2014was steadfastly adopted by most early Western scientists, although, this was directly contradicted by the scientifically supported view of monogenesis, which posits that all human beings share a common African ancestry. The early proponents of White supremacy refused to accept the evidence that points to Africa as the cradle of humanity from which all people evolved and those that did accept the single regional theory of human origin, continued to falsely postulate that human intellect and creativity only occurred after the populations migrated out of Africa.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR5\", \"CR7\", \"CR14\", \"CR15\"], \"section\": \"Concepts of White Supremacy, Pseudoscience, Slavery, and Christianity\", \"text\": \"The origins of White supremacy cannot be fully understood without considering the significant influence of Christianity. Numerous proponents of scientific racism have historically linked their unfounded claims of White superiority to various Christian beliefs and doctrines. For example, Johann Friedrich Blumenbach classified a skull discovered near the Caucasus Mountains in southeastern Europe as the epitome of beauty among human skulls, asserting its superiority over other racial forms, thus the origin of the name Caucasian to classify Whites [5, 7, 14]. After inspecting three mummies from ancient Egyptian catacombs, American scientist Samuel Morton concluded that Caucasians and Negroes were already distinct species three thousand years ago. Since the Bible indicated that Noah's Ark had washed up on Mount Ararat located in eastern Turkey, only a thousand years ago before this, Morton claimed that Noah\\u2019s sons could not possibly account for every race on earth. This association prompted some to assert that the biblical figures of Adam and Eve, as portrayed in Christian theology, were exclusively ancestors of Europeans, thereby excluding other racial groups from this narrative. Joshua Nott and other American scientists turned from their naturalists\\u2019 beliefs to their bible and deducted that Blacks were the children of Ham, son of Noah, who, along with his progeny, was \\u201cmarked\\u201d and condemned to be servant to his brothers for having viewed his father\\u2019s nakedness [15].\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR16\", \"CR16\", \"CR16\"], \"section\": \"Concepts of White Supremacy, Pseudoscience, Slavery, and Christianity\", \"text\": \"This conflation of scientific inquiry with religious doctrine raises pertinent questions about its historical roots. A significant catalyst for this intertwining can be traced to the Christian Doctrine of Discovery, articulated in the mid-fifteenth century [16]. This doctrine, also referred to as the Doctrine of Domination, emerged during a period dominated by the exploration and colonization efforts of European powers, primarily Portugal and Spain, accompanied by a monolithic Christian Church prior to the Reformation. Pope Nicholas V issued the Doctrine of Discovery in 1452, which sanctioned the invasion and subjugation of non-Christian peoples and territories on the African Continent [16]. The decree explicitly stated that European Christians were permitted to \\u201cinvade, search out, capture, vanquish, and subdue all Saracens (Muslims), and pagans whatsoever, and other enemies of Christ wheresoever placed.\\u201d Furthermore, it justified the appropriation of their possessions and the enslavement of individuals perpetually, all for the purpose of profit and the purported conversion to Christianity. This papal sanction suggested that the superior status of European Christians could be conferred upon the conquered populations through the introduction of Christianity, thus framing the appropriation of land and resources as a morally justified act. The Church subsequently issued various iterations of this Doctrine of Domination. In 1493, Pope Alexander VI issued the papal bull interCaetera that divided newly discovered lands between Spain and Portugal. This new doctrine provided moral and legal justification for Christopher Columbus\\u2019s return voyages to the New World in the Americas [16]. This effectively facilitated the establishment of Christian missions and contributed to the genocidal practices inflicted upon indigenous populations. White supremacy weaponized Christian doctrines to justify a racist social system constructed during the age of exploration, and played a crucial role in legitimizing acts of domination, exploitation, enslavement, and profoundly influenced societal attitudes toward race and superiority that persist in various forms today. This resulted in a social system with racist policies that guaranteed Blacks and Native Americans would be perpetual second-class citizens in America.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR3\", \"CR3\", \"CR5\", \"CR14\"], \"section\": \"The Black Holocaust and the Transatlantic Slave Trade\", \"text\": \"The topic of the Black Holocaust and the Transatlantic Slave Trade is a deeply painful and significant part of American history that continues to resonate today. It is crucial to acknowledge how false notions of White supremacy were used as a justification for the horrific treatment of both Native Americans and enslaved Africans over centuries. The Transatlantic Slave Trade with the enslavement of Africans in the Americas and Caribbean is referred to as the Black Holocaust. The Black Holocaust transpired over several centuries, and entailed a total death toll estimated between 6 to 150 million lives lost during and after the Transatlantic Slave Trade [3]. The United Nation estimates 17 million deaths while the World Future Fund estimates 60 million died during this span of time [3]. The first period: \\u2014the Pre-transatlantic Slave Round-Up, countless African men, women, and children were captured, forcibly taken to the western shores of Africa, and subjected to brutal conditions in dungeons. It has been estimated that between 6 to 10 million Black souls perished before they even set their feet on a slave ship. The second period, the Transatlantic Voyage, entailed the harrowing journey across the Atlantic, where enslaved individuals were crammed into ships under inhumane conditions. As many as 800 people were crammed together in the cargo holds of ships resulting in death rates reaching 20%. This means that 1.2 to 2.4 million souls lost their lives during the Transatlantic crossing because of the unsanitary and inhumane conditions they faced. Finally, the third period, the Post-transatlantic Voyage Break-in Period, in which the horrible living conditions and poor treatment did not end upon arrival. Within just 3 years, death rates for these new arrivals could soar to 30% or even 50%, as they faced the daunting challenge of acclimating to harsh new environments [5, 14]. It is notable that physicians were intimately involved in all three periods and served on slave ships to protect the cargo of slaves. Slave ship physicians\\u2019 salaries were reported to be second only to the captain of the ship, and a lucrative job for physicians was on plantations treating slaves.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR5\", \"CR14\", \"CR4\", \"CR9\", \"CR17\", \"CR20\"], \"section\": \"The Black Holocaust and the Transatlantic Slave Trade\", \"text\": \"In 2000 and 2002, authors W. Michael Byrd, MD, MPH and Linda Clayton, MD, MPH, in their extensively documented books, titled, An American Health Dilemma, Vol I and II [5, 14], revealed the significant impact of the pseudoscience of White supremacy on the poor health of American slave descendants. The authors documented statistics showing how the health of Blacks in America has been the worst compared to other racial groups, dating back to slavery, and highlighted the term, \\u201cslave health deficit,\\u201d a term coined by medical historians Dr. Todd L. Savitt and Dr. James O. Clayton, to describe the severe health disparities experienced by enslaved Africans in the United States [4\\u20139]. Deficit refers to the negative health outcomes that result from unhealthy living and working conditions during and after slavery. Among the ten leading causes of death in the US, such as heart disease, cancer, stroke, diabetes, unintentional injuries, infant mortality, and maternal mortality, African slave descendants suffer the highest chronic disease and death rates. These racial health disparities can be less, depending on individual social and economic status, but race and ethnicity remain persistent independent risk factors for poor health outcomes. US health data clearly reveal Blacks have poor access to quality health care, and once they have accessed the health system, Blacks commonly are treated differently because of discriminatory institutional policies, as well as healthcare provider conscious or unconscious biases, which have been documented in many scientific publications on this subject [17\\u201320].\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR5\", \"CR7\", \"CR15\", \"CR17\", \"CR17\", \"CR20\", \"CR15\"], \"section\": \"Healthcare and Slavery in America\", \"text\": \"Slavery has been a part of human history for centuries, but the system established in the Americas and the Caribbean was particularly harsh and dehumanizing. Enslaved individuals were treated as valuable property, and as such, plantations hired physicians, often referred to as slave doctors, to meet their needs. Unfortunately, these medical practitioners adhered to the same biases and misguided beliefs as their European counterparts, viewing Black individuals through a lens of perceived inferiority. They often failed to connect the health issues faced by enslaved people to the brutal conditions and environments imposed upon them. The disadvantaged status of slaves created a large pool of individuals for medical experimentation, which allowed physicians to refine their treatments and techniques on enslaved bodies before applying them to their White patients. A notorious example is J. Marion Sims (1813\\u20131883) who is often referred to as the \\u201cFather of Gynecology.\\u201d Sims conducted numerous surgical procedures on enslaved women without anesthesia, operating under the false belief that Black individuals possessed a greater tolerance for pain [5, 7, 15, 17]. This misconception has persisted through the years, with contemporary studies demonstrating that Black patients frequently receive inadequate pain relief compared with their White counterparts [17, 20]. Decades of unethical treatment and experimentation including the Tuskegee Syphilis study as documented by author, Harriett Washington in her book, Medical Apartheid [15], has created a significant distrust of the US health system for Blacks and other populations. This distrust further hinders the ability to effectively address the barriers of eliminating health disparities in these most affected populations.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR6\", \"CR14\", \"CR21\", \"CR22\", \"CR19\"], \"section\": \"Healthcare and Slavery in America\", \"text\": \"Samuel A. Cartwright (1793\\u20131863) was a graduate of the University of Pennsylvania School of Medicine who theorized that Blacks should medically be treated differently owing to their \\u201cnonhuman\\u201d biological peculiarities [6, 14, 21, 22]. Cartwright later became a professor of Medicine at the University of Louisiana. In 1851, he published a review article in a New Orleans medical journal called DeBow\\u2019s review titled \\u201cDiseases and Peculiarities of the Negro Race [19].\\u201d He coined the names of mental diseases that he attributed specifically to Blacks. He suggested that slaves who ran away from the brutality experienced on plantations suffered from a mental disease, Drapetomania, defined as runaway madness, and Dysesthesia Aethiopica, defined as uppity, rebelliousness or rascality. He prescribed treatment for drapetomania with condescension and brief periods of play time as though they were children. However, for those slaves that had dysesthesia aethiopica and continued to rebel, he prescribed whippings as punishment to \\u201cbeat the devil out of them\\u201d and therefore prevent them from absconding.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR5\", \"CR23\", \"CR5\"], \"section\": \"Post Slavery and Jim Crow\", \"text\": \"During the early twentieth century, there were 7 medical schools designated for Black students; however, following the 1910 Flexner Report, a significant reduction occurred, leading to the closure of most of these institutions, leaving only Howard and Meharry Medical Schools operational [5, 23]. The ramifications of this action, combined with the limited financial resources available to the Black population and inadequate educational opportunities at historically Black colleges and universities (HBCUs), have contributed to a persistent shortage of Black physicians. According to recent data, while Black individuals make up approximately 13.7% of the overall US population, they account for only 5.7% of practicing physicians. Access to medical care for Black individuals was further hindered by the stark realities of segregated healthcare facilities. In many cases, hospitals that accepted Black patients maintained segregated wards, where they were typically treated by White physicians who often had exclusive admission privileges due to the organized medical community\\u2019s institutional racism, notably within the American Medical Association (AMA). The AMA's longstanding refusal to accept Black physicians severely restricted their ability to practice medicine and provide care within hospital settings. In 1893, John Hopkins University Hospital in Baltimore, Maryland opened with rigidly segregated classes, hospitals, and medical staff and remained segregated well into the 1960\\u2009s [5]. The desegregation of medical institutions, catalyzed by the Civil Rights Movement of the 1960\\u2009s, began to dismantle these barriers. Despite these advancements, the legacies of segregation and discrimination continue to resonate within healthcare systems today, leading to enduring health disparities.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR15\", \"CR24\"], \"section\": \"Post Slavery and Jim Crow\", \"text\": \"The intellectual landscape of the nineteenth century further complicated the status of African Americans, as prominent academic figures propagated notions of racial inferiority. For example, Nathaniel Shaler at Harvard University espoused theories that positioned Black individuals as evolutionary inferiors, even justifying the violence of lynching as a misguided but noble attempt to protect societal values [15]. Similarly, Joseph LeConte\\u2019s writings at Harvard and later the University of California, reinforced the idea that slavery served a developmental purpose for the so-called \\u201cnegro,\\u201d advocating for the denial of citizenship and voting rights in service of a paternalistic notion of protection and guidance. The post-slavery era and the Jim Crow period created a complex interplay of legal, educational, and healthcare inequities that profoundly affected African American communities, echoing through generations, and impacting contemporary structures. The historical context provided by White academic elites and the ingrained false assumptions that Blacks exhibited traits and tendencies due to their inferior status [24], only served to justify and sustain these inequities, contributing to the systemic challenges faced by Black Americans in the present day.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR25\", \"CR29\", \"CR29\", \"CR26\", \"CR30\", \"CR31\", \"CR32\"], \"section\": \"Post-Traumatic Slavery Stress Disorder (PTSSD)\", \"text\": \"Post-traumatic stress disorder (PTSD) is a psychiatric disorder that occurs in individuals who have experienced or witnessed a traumatic event, series of events or set of circumstances. Some researchers have linked the psychological residual effects of slavery with PTSD dysfunctional behaviors [25\\u201329]. Clinical psychologist, Dr. Joy DeGruy introduced the concept of collective multigenerational trauma associated with centuries of pre and post slavery experiences in America and coined the term post-traumatic slavery syndrome (PTSS) [29]. This multigenerational trauma resulted in destructive behaviors that she described in 3 categories, vacant or low self-esteem, ever present anger, and racist socialization or internalized racism. Further research outlines how the impact of slavery and the oppression of African American people and their culture served as significant trauma to African Americans, which was carried forward through successive generations; providing an explanation of their current anxiety-related conditions, poor health, and maladaptive behaviors [26, 30]. These traumas resulted not only from the dehumanization experienced during slavery but post slavery Jim Crow Laws, terror of lynchings, and the intentional riots and massacres directed by Whites at economically successful Black communities, such as the New York City Draft Riots (1863), Colfax, Louisiana (1873), Wilmington, North Carolina (1898), Atlanta, Georgia (1906), Chicago, Illinois (1919), Elaine, Arkansas (1919), Tulsa, Oklahoma (1921), and Rosewood, Florida (1923), as well as and many other massacres [31, 32].\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR8\", \"CR10\", \"CR33\", \"CR34\"], \"section\": \"Post-Traumatic Slavery Stress Disorder (PTSSD)\", \"text\": \"How is this past traumatic history related to the poor health outcomes for African Americans today? Recent compelling evidence suggests that these psychologically adaptive behaviors can lead to significant physical health consequences and chronic diseases later in life. I suggest we can expand this concept with the hypothesis of post-traumatic slavery stress disorder (PTSSD) [8, 10], which arises from the need to address the profound health effects of racism and the ethno-historical trauma experienced by descendants of American slaves. This hypothesis posits that \\u201cracism and the ethno-historical multigenerational trauma produced from the legacy of slavery in the United States, produces chronic physiological stress, measured as allostatic load, which significantly increases the risk for a variety of chronic diseases such as heart disease, hypertension, diabetes, infections, and cancer.\\u201d Collectively, these factors contribute to notable health disparities or slave health deficits, leading to early deaths within the US Black population. The trauma experienced over generations has had lasting effects\\u2014both psychologically and physiologically\\u2014on the descendants of enslaved Africans in the United States. This chronic form of stress manifests through complex mechanisms involving epigenetics, with research indicating that the traumatic experiences of past generations can influence the health outcomes of current generations [33, 34].\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR35\", \"CR36\"], \"section\": \"Post-Traumatic Slavery Stress Disorder (PTSSD)\", \"text\": \"A critical component of this discussion is the concept of the allostasis which is defined as the physiological process by which the body achieves stability through change, adapting to various stressors encountered in the environment. In contrast, allostatic load refers to the cumulative physiological burden or wear and tear placed on the body because of repeated or prolonged activation of stress response systems, often termed chronic toxic stress. The allostatic load can be assessed through various biomarkers, including stress hormones and neurotransmitters. Daily exposure to racism contributes to this toxic stress, leading to an overproduction of biomarkers such as cortisol and epinephrine, and resulting in a decline in immune functions, for example, the suppression of immunoglobulin A (IgA). Furthermore, shortened telomere length associated with chronic stress has been linked to cell damage and decreased life expectancy [35]. Research supports the notion that Black individuals in the US have higher levels of stress biomarkers compared with their counterparts of other ethnicities, as well as a higher overall allostatic loads. A pivotal study published in the American Journal of Public Health in 2006 highlighted that Black individuals, particularly Black women, exhibit significantly elevated allostatic loads compared with White individuals, with even higher allostatic loads than their low-income White peers [36].\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR37\", \"CR38\", \"CR39\", \"CR41\"], \"section\": \"Post-Traumatic Slavery Stress Disorder (PTSSD)\", \"text\": \"In addition, Adverse Childhood Experiences (ACEs)\\u2014stressful incidents encountered during childhood, such as parental incarceration or various forms of abuse\\u2014play a crucial role leading to diseases later in life. Higher ACE scores are consistently correlated with the emergence of chronic physical and mental illnesses later in life [37]. These experiences are believed to affect individuals through a combination of dysfunctional behaviors and altered stress-related biomarkers, impacting various bodily systems and the immune response. The prevalence of ACEs among Black children is striking. National statistics indicate that 61% of Black children faced at least one ACE, in contrast to 51% of Hispanic children, 40% of White Children, and 23% of Asian children [38]. The unique American cultural experience for Black individuals subjects them to various forms of racism\\u2014structural, personally mediated, and internalized [39\\u201341]\\u2014leading to a heightened risk for PTSSD, which in turn contributes to chronic disease and premature mortality.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR21\", \"CR29\", \"CR40\", \"CR41\"], \"section\": \"Post-Traumatic Slavery Stress Disorder (PTSSD)\", \"text\": \"The concept of post-traumatic slavery stress disorder encapsulates the multifaceted impacts of historical trauma on the health of African American populations, emphasizing the need for a holistic understanding of the intersection between racism, psychological trauma, and physical health. Considerable information has been published in books and articles describing the relationship between stress and racism and its impact on health [21, 29, 40, 41]. It is imperative that we consider these factors when addressing the health disparities faced by Black individuals in the United States today.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"Tab2\"], \"section\": \"The Differing Effects of Chronic Toxic Stress Between Ethnic Populations in the United States\", \"text\": \"Chronic toxic stress as measured by the allostatic load is relevant across diverse human populations, though its impact and implications can vary widely among different racial demographic groups. The relationship between chronic toxic stress and health disparities is particularly evident in racial demographic statistics regarding beginning-of-life and end-of-life outcomes, as illustrated in Table\\u00a02. This data indicates African Americans experience the highest rates of infant and maternal mortality along with the shortest life expectancies. This is followed by American Indians/Alaska Natives (AI/AN), Whites, Hispanics, and Asians respectively. These findings suggest racial and ethnic groups suffer adverse health consequences that are contingent upon the duration and intensity of chronic stress because of their experiences with systemic oppression in the context of White supremacy.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR42\"], \"section\": \"The Differing Effects of Chronic Toxic Stress Between Ethnic Populations in the United States\", \"text\": \"The socio-cultural framework of American society, underpinned by a doctrine of racial superiority, has created a toxic environment that adversely affects the health of both subordinate and dominant groups suggesting that current American culture can be bad for our health and wellbeing. This observation may partially explain the \\u201cimmigrant health paradox\\u201d where immigrants are healthier compared to their native-born peers of similar demographics and socioeconomic profile. However, this paradox disappears as immigrants stay longer in the host country [42].\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR11\"], \"section\": \"Amount of Melanin in a Population and the Severity of Health Disparities\", \"text\": \"The relationship between melanin content in a population and the prevalence of health disparities is a multifaceted and underreported issue that merits thoughtful examination. Observations indicate that populations historically subjected to systemic discrimination and dehumanization, notably US Blacks and Native Americans, along with certain Hispanic sub-populations such as Puerto Ricans and Asians with South Asian ancestry, present higher rates of health disparities and cardiovascular disease risk than other populations with less African ancestry. White supremacy has led to a form of discrimination based upon one\\u2019s skin color referred to as colorism [11], which is prejudice or discrimination against individuals with dark skin tones. This observation makes it fair to say, that there is a direct correlation between the amount of melanin in a population and the severity of their health disparities.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR43\", \"Tab1\", \"CR36\"], \"section\": \"Amount of Melanin in a Population and the Severity of Health Disparities\", \"text\": \"This observation is confirmed when utilizing the Atherosclerotic Cardiovascular Disease (ASCVD) 10-year risk estimator (CV risk estimator) adopted by both the American Heart Association (AHA) and the American College of Cardiology (ACC) [43], which includes race and ethnicity as risk factors. When I introduced this health risk tool into my clinical practice, I encountered a 50-year-old African American male patient with the following cardiovascular (CV) risk profile: His blood pressure was recorded at 160/90, with a total cholesterol of 230, LDL cholesterol of 110, and HDL cholesterol of 45. Notably, he was a nonsmoker, had diabetes, and was currently on treatment for hypertension. His estimated 10-year CV risk was calculated at 25.1%, which was significantly above the optimal CV risk of 3.9%. In a striking comparison, when I then adjusted the ethnicity in his profile to identify him as a White male or categorized him as \\u201cOther Ethnicity,\\u201d with the same CV risk profile, the risk decreased to 15.1%. Moreover, this template revealed that a hypothetical 50-year-old Black female with the same risk profile, presented the highest cardiovascular risk of 27.2%, whereas a 50-year-old White female with a CV risk of 7.7% presented the lowest risk. Table 1 reveals for both the 40-year-old and 50-year-old, the Black female CV risk is greatest, followed by Black male\\u2009>\\u2009White male, and\\u2009>\\u2009White female. This increased CV risk for 40-year-old and 50-year-old Black female is supported by studies showing Black females have higher allostatic loads than Black males and as well as all other races and ethnicities [36].\\n\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR36\"], \"section\": \"Amount of Melanin in a Population and the Severity of Health Disparities\", \"text\": \"Important to note, the ACC/AHA 10-year CV risk assessment tool may underestimate cardiovascular risk for certain \\u201cother\\u201d ethnicities, particularly American Indians, some Asian Americans of South Asian ancestry, and specific Hispanic groups, such as Puerto Ricans. Conversely, for individuals of East Asian ancestry and Mexican Americans\\u2014who generally have less African ancestry\\u2014risk assessments may be overestimated. These findings reinforce the literature indicating that Blacks, especially Black females, experience greater allostatic loads of chronic toxic stress, compared with all other races and ethnic groups [36]. These data suggest an urgent need to further investigate and address the root causes of these disparities. The interplay of race, ethnicity, and health should be critical areas for ongoing research and intervention within clinical practice.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR40\", \"CR41\"], \"section\": \"Amount of Melanin in a Population and the Severity of Health Disparities\", \"text\": \"When we look at cardiovascular (CV) risk, it is fascinating how disparities really pop out\\u2014especially for populations with significant African ancestry or those who have faced long-standing second-class status owing to systemic racism. These groups tend to have higher CV risks, sometimes just behind those of African Americans. This interesting observation seems to reveal a direct connection between melanin levels and colorism-based health disparities. This raises the following question: How much of this risk is tied to lived experiences, such as racism and discrimination? Now that we can measure levels of a person\\u2019s perceived racism, we have found that racism can make us sick [40, 41]. The ACC/AHA 10-year ASCVD risk estimator, which uses race and ethnicity as variables, may reflect the cardiovascular risk associated with heightened allostatic loads resulting from chronic stressors linked to discriminatory practices endemic in American society. While there have been advancements toward developing a CV risk calculator that does not incorporate race as a factor, but utilizes other social determinants, it is essential to note that the ACC/AHA algorithm has been validated as a reliable predictive tool across diverse populations, specifically for both Black and White cohorts.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR44\"], \"section\": \"Amount of Melanin in a Population and the Severity of Health Disparities\", \"text\": \"The efficacy of the ACC/AHA 10-year CV risk tool has been corroborated through rigorous evaluation in several large Black cohorts, such as the Jackson Heart Study (JHS) and the Multiethnic Study of Atherosclerosis (MESA), demonstrating its predictive capabilities in these Black populations [44]. The observed disparities in cardiovascular (CV) risk highlight populations with significant African ancestry or those who have endured prolonged periods of racism and socioeconomic disenfranchisement exhibit increased CV risks, often second only to African Americans. I believe these observations shed light on how race and historical context can influence health outcomes and underscores the necessity of considering both biological and historical sociocultural factors in the assessment of cardiovascular risk. This aligns with research demonstrating a direct correlation between melanin concentration and the extent of health disparities within various populations with higher levels of African ancestry.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"Tab2\", \"Tab2\", \"CR45\", \"Tab2\", \"CR46\", \"CR47\"], \"section\": \"Impact of the Slave Health Deficit on the Beginning-of-Life and End-of-Life\", \"text\": \"Throughout the twentieth century and into the twenty-first century, African Americans consistently faced higher mortality rates due to a significant number of leading causes of death. This persistent inequity extends beyond health and infiltrates economic, educational, and judicial systems, perpetuating cycles of disadvantage. However, the impact of these disparities is stark when we look at beginning-of-life and end-of-life data by examining key metrics such as infant mortality rates (IMRs), maternal mortality rates (MMRs), and overall life expectancy (LE). Data shows that in 1850, life expectancy was approximately 25.5 years for Whites and 21.4 years for Blacks. By 1900, Whites had an average life expectancy of 47 years, compared with 33 years for Blacks (Table\\u00a02). Fast forward to 2000, and while both groups saw improvements\\u2014White life expectancy reaching 77.6 years and Black life expectancy rising to 71.8 years\\u2014a gap of 5.8 years remains (Table\\u00a02). Additionally, maternal, and infant mortality rates consistently demonstrate that Black women and their infants experience the highest rates of morbidity and mortality compared with all other ethnic groups. A recent analysis published in June 2023 by the Journal of the American Medical Association (JAMA), highlighted that between 1999 and 2019, while overall maternal mortality rates saw some improvements, those for Black, American Indian, and Alaskan Native women significantly increased [45]. Although infant mortality rates improved during this period, they remained the highest for Black and American Indigenous infants (Table\\u00a02) [46, 47]. The ongoing health disparities faced by African Americans and other historically marginalized populations, highlight the entrenched nature of racialized inequities within the US healthcare system.\\n\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR45\", \"CR49\"], \"section\": \"\", \"text\": \"Beginning-of-life and end-of-life mortalities and impact from COVID-19[45\\u201349]\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR48\"], \"section\": \"Impact of the COVID-19 Pandemic\", \"text\": \"The COVID-19 pandemic has had profound and far-reaching impacts across the United States, with data from the Centers for Disease Control and Prevention (CDC) highlighting significant disparities among different racial and ethnic groups. The statistics reveal a concerning trend: Black, American Indian/Alaskan Native (AI/AN), and Hispanic populations faced disproportionately higher rates of COVID-19 infection and mortality compared with their White counterparts. In 2020, COVID-19 emerged as the third leading cause of death in the US, accounting for approximately 11% of all fatalities that year. According to CDC statistics reported by APM Research Lab [48], in December 2020, the cumulative COVID-19 mortality rates/100,000 by race and ethnicity, revealed Indigenous and Black individuals bore the brunt of this crisis, with death rates of 133 for Indigenous and 123.7 for Blacks. This was higher than death rates for Pacific Islanders (90.4), Hispanics (86.7), Whites (75.7), and Asians (51.6).\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR49\", \"Tab2\", \"Tab2\"], \"section\": \"Impact of the COVID-19 Pandemic\", \"text\": \"Furthermore, the pandemic contributed to a notable decline in life expectancy across the nation. The National Center for Health Statistics (NCHS) reported a decrease of 1.5 years in life expectancy for the total US population, dropping from 78.8 years in 2019 to 77.3 years in 2020 [49]. This decline is the most substantial 1-year reduction observed since World War II, bringing life expectancy to its lowest point since 2003. However, as depicted in Table\\u00a02, the impact was not uniformly distributed across racial and ethnic groups. Hispanics and non-Hispanic Blacks experienced a significant decline of 3.0 years in life expectancy in contrast to Whites with a decline in life expectancy of 1.2 years and later obtained data for AI/AN and Asians showed a decline in life expectancy of 4.7 years and 2.1 years respectfully as shown in Table\\u00a02. These disparities underscore the longstanding issues that historically marginalized populations face, particularly during crises. The often-used phrase, \\u201cWhen White folks catch a cold, Black folks catch pneumonia,\\u201d captures the essence of this reality. During catastrophic events such as pandemics, wars, or natural disasters such as seen with Hurricane Katrina, marginalized communities frequently find themselves at a disadvantage, facing significant healthcare disruptions, economic instability, structural racism, and increased social isolation.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR50\", \"CR51\"], \"section\": \"The Cost of US Health Inequities\", \"text\": \"A recent study sponsored by the National Institute of Health (NIH) and published in JAMA in 2023 highlighted the significant burden of health disparities affecting the Black population in the United States. Over a 22-year period, from 1999\\u20132020, the data reveal that this group experienced more than 1.63 million excess deaths compared with their White counterparts, along with more than 80 million excess years of potential life lost [50]. In a related finding, another study published in May 2023 by JAMA, addressed the economic implications of these health disparities. It is estimated that in 2018 alone, the cost of racial and ethnic health disparities to the US economy was a staggering $451 billion\\u2014a substantial 41% increase from estimates provided in 2014. Notably, a significant portion of this economic burden fell predominantly on the Black/African American population, accounting for 69% of the costs attributed to premature mortality [51].\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR52\", \"CR53\", \"CR17\", \"CR54\", \"CR55\", \"CR50\"], \"section\": \"Social Determinants of Health (SDOH) Barriers to Achieving Health Equity\", \"text\": \"The enduring pre and post slavery framework of racial hierarchy and the consequent discrimination against specific racial groups have led to the concept of racialized social determinants of health (rSDOH). Social determinants of health (SDOH) are non-medical factors that critically influence health outcomes, including the conditions of one\\u2019s birth, growth, work, and aging. In contrast, racialized social determinants of health (rSDOH) arise from systemic targeted racial discrimination through policies that disproportionately disadvantage the targeted racial groups. Historical practices such as Jim Crow laws, redlining, and segregated healthcare facilities have perpetuated these inequities, creating cycles of economic disadvantage leading to greater levels of poverty, particularly for Black and Native American communities. Recent data from the Kaiser Family Foundation (KFF-2023) reveal significant disparities in poverty rates among different racial groups in the United States, with American Indian/Alaskan Native individuals at 24.2%, Black individuals at 20.6%, Hispanic individuals at 16.6%, Asian/Pacific Islander individuals at 10.0%, and White individuals at 9.5% [52]. These statistics highlight the disproportionate levels of poverty with resultant barriers, faced by Black and Native American populations, to accessing educational opportunities, accumulating generational wealth [53], receiving quality healthcare with poor health outcomes [17, 54, 55], and avoiding premature mortality [50]. Effective policy formulation must not only acknowledge the impact of rSDOH but also work to dismantle barriers hindering equitable health outcomes for these populations.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR56\", \"CR57\", \"CR56\", \"CR57\"], \"section\": \"The Role of the National Medical Association (NMA) and Health Equity\", \"text\": \"Leadership within the NMA, particularly figures such as past presidents W. Montague Cobb (1964) and John L.S. Holloman (1966), strongly advocated for health and social equity. These leaders recognized that the broader social environment had serious health implications, especially considering the frequent lynchings. During the late nineteenth and early twentieth centuries, over 4,700 lynchings of mostly Blacks by Whites were documented, causing physical and emotional terror within the Black communities, and was identified as glaring life ending health disparities [56, 57]. In the early years of its founding, the NMA collaborated with other Black organizations such as the National Association for the Advancement of Colored People (NAACP), to end lynchings against Blacks throughout America. In fact, the NMA changed its planned national meeting from Memphis, Tennessee to Philadelphia to protest the lynching of Ell Persons on May 22, 1917 [56, 57]. These groups advocated enacting anti-lynching laws but were always blocked by racist members of the US Congress.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR17\"], \"section\": \"The Role of the National Medical Association (NMA) and Health Equity\", \"text\": \"Although health disparities are believed to be caused primarily by poor social and economic conditions, referred to as social determinants of health (SDOH), the role of racism in medicine was rarely mentioned or minimized as a cause of these disparities. However, many members of the NMA believed that racism played a significant role in contributing to persistent health inequities, leading to health disparities. In the late 1990\\u2009s, because of NMA health policy advocacy, working with the Congressional Black Caucus (CBC), the United States Congress funded the Institute of Medicine (IOM) and National Academy of Science report published in 2002, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare [17]. This landmark report documented structural racism and healthcare provider biases that contributed to health disparities, especially in Black populations. Since then, hundreds of scientific publications have independently confirmed that racism, race, and ethnicity are independent variables and significant contributors to racial health disparities, specifically, the slave health deficit.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR58\", \"CR39\", \"CR55\"], \"section\": \"Remedies\\u2014Remove the Mask\", \"text\": \"W.E.B. Du Bois, in his seminal work \\u201cThe Souls of Black Folk,\\u201d articulates a profound concept known as \\u201cdouble consciousness\\u201d [58]. This phenomenon describes the dual awareness that African Americans possess: they see themselves through the lens of a prejudiced White society while simultaneously striving to maintain their own unique Black identity. This internal conflict is deeply rooted in the legacy of slavery, where survival often necessitated the internalization of damaging beliefs perpetuated by a system of White supremacy, leading to entrenched forms of internalized racism [39, 55]. African slave descendants understood that revealing their true selves could result in severe repercussions, including, loss of income and acceptance. During slavery and Jim Crow, repercussions were more severe, such as whippings or even death, in the form of lynching.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR6\", \"CR59\", \"CR60\"], \"section\": \"\", \"text\": \"Medical Health Reparations [6, 59, 60]\\u2014to repair and restore quality health status for the US Black populations we need adequate funding of Black health institutions such as HBCUs, mental health centers, and research focused on the epigenetic and intergenerational traumas of communities with inherited deficits.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR61\", \"CR62\"], \"section\": \"\", \"text\": \"Critical consciousness [61, 62]\\u2014to recognize how systems of privilege and oppression contribute to trauma disproportionately affecting marginalized communities.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR63\", \"CR64\"], \"section\": \"\", \"text\": \"Cultural humility [63, 64]\\u2014learning to acknowledge the significance of cultural differences of others and engage in self-reflection to address one\\u2019s own biases.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR65\"], \"section\": \"\", \"text\": \"Radical healing [65]\\u2014to learn and address the root causes of trauma, particularly identity-based wounds stemming from racism and other forms of discrimination.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR66\"], \"section\": \"\", \"text\": \"Restorative justice [66]- to repair harm, restore relationships, and rebuild communities affected by trauma and conflict, empowering individuals, and promoting healing.\"}, {\"pmc\": \"PMC12446405\", \"pmid\": \"40721709\", \"reference_ids\": [\"CR67\"], \"section\": \"\", \"text\": \"Community Resilience Programs [67]\\u2014to collectively support culturally anchored stress-reduction initiatives such as faith-based wellness and historical healing circles.\"}]"

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PMC Articles

An American Story of a Health System Dilemma: The Slave Health Deficit and Post-Traumatic Slavery Stress Disorder (PTSSD)

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