Thursday, August 30, 2018

Heart disease in the American South: echoes of the Civil War?

He displayed an extraordinary ability to absorb the conflicting wills of a divided people and reflect back to them an unbending faith in a unified future. 

Although historian Doris Kearns Goodwin was describing President Abraham Lincoln when she wrote these words in a recent Harvard Business Review article, they could have been said of a statesman of a later era. The longtime Republican "maverick" Senator John McCain, who passed away on August 25, implored Americans in a farewell letter to "not despair of our present difficulties," but to instead "give each other the benefit of the presumption that we all love our country, we will get through these challenging times. We will come through them stronger than before, we always do."

I had the privilege of meeting Senator McCain in 2014 at a Smithsonian Associates event for Thirteen Soldiers, a book he co-authored with Mark Salter that included the stories of soldiers serving in each of America's thirteen major conflicts, from the Revolutionary War to the current wars in Afghanistan and Iraq. I had seen McCain speak on television countless times, but experiencing his outsized, generous, wisecracking personality in the flesh was something else entirely. And I hope he's right about "our present difficulties."

Outside the John Brown House in Chambersburg, PA

While I have long been fascinated by the American Civil War era, when these United States (as opposed to the United States) were more divided than they have been before or since, I gain no pleasure from watching the ceaseless warring of present-day political factions who have seemingly lost the ability to compromise for the public good.

Mount Hebron Cemetery, Winchester, VA

Along with the end of slavery, another positive outcome of the the Civil War was advances in medicine. In 2004 and 2013, I taught a class at Georgetown University School of Medicine called "Civil War Medicine In the Modern Age," and I have enjoyed attending the National Museum of Civil War Medicine's scholarly Annual Conference, which includes educational talks and entertaining trips to nearby historical sites.

Just north of the Mason-Dixon line

Although the Civil War ended more than 150 years ago, its health effects have echoed through the ages. They echo in the hundreds of thousands of soldiers and civilians who perished prematurely from battles or disease; the hundreds of thousands more who were permanently disabled or disfigured by wounds; and - as reported in the Washington Post in 2016 - in the legacy of increased mortality from heart disease concentrated in the South:

To Richard Steckel, an Ohio State University economist, that striking pattern raises a seemingly outlandish, but utterly serious question: Could the heavy toll of heart disease in the American South today have been triggered, in part, by the region's rapid rise out poverty since the 1950s? In a new paper, Steckel argues that decades of poverty caused by the Civil War shaped people's organs and physiology in a way that left them particularly unsuited for a cushy life. The current health disparities in the South, Steckel says, developed as Southerners encountered more prosperous lifestyle than their bodies were prepared for, including more food and less manual labor.

Monterey Pass Battlefield Park, Franklin County, PA

Steckel's hypothesis is intriguing, but even if correct, it is only part of the story. Surely poor diet, physical inactivity, and unrelieved stress caused by a century of segregation and continuing discrimination against African Americans also had a lot to do with the sky-high heart disease rates. And it doesn't help that most of these states have not expanded their Medicaid programs to extend health insurance coverage to those who are most likely to benefit. But that's something to write about another day.


I took all of the photos in this blog post on various Civil War-themed summer trips. This is what I do when I'm not seeing patients, editing articles, blogging, or teaching medical students about health policy.