Changing a community to fight high blood pressure

Can a city lower its own blood pressure?

I was inspired to ask that question while seated with a number of medical and health policy luminaries at a recent gala marking the 40th anniversary of the Philip R. Lee Institute for Health Policy Studies at UC San Francisco.

Among the many health policy stalwarts seated at my table was Dr.
Claiborne Johnston, Director of the Clinical and Translational Science Institute and the Associate Vice Chancellor of Research at UCSF. Dr. Johnston is a neurologist and an expert on strokes. I asked him: “If a community wanted to reduce its stroke incidence, particularly among its poor and vulnerable population, what would the community do?” He answered immediately, “Screen and treat the population for high blood pressure.”

That got me thinking. Could Richmond begin a Health Ambassadorship Program where we train and employ some of our at risk youth to do blood pressure screening at city events like city council meetings? They could offer the same at churches and community centers. Eventually some of these ambassadors could enter into Emergency Medical Technician training as a pathway out of poverty.

If the city could set an example by providing public blood pressure screening, perhaps we could help the community focus more attention on improving public health. The majority of the diseases found in Richmond are more severe and come earlier in our poor communities and communities of color. The term health inequities refers to this unfair health disadvantage. Heart disease and stroke are very much health inequity issues and improving blood pressure control would improve outcomes in each.

Successfully controlling blood pressure, though, is exceedingly difficult to do. The brain, through a complex set of neuro-hormonal signals, initiates and orchestrates an exquisite symphony resulting in the appropriate blood pressure for the level of threat or challenge faced by an individual at any given time. When the brain perceives the threat going up, blood pressure goes up too.

Modern medicine has shown that lowering blood pressure to 135/85 or below improves health outcome. But rather than reducing the level of threat in the social environment and increase the support for individuals in the community, our therapies are aimed at severing the neuro-hormonal influence the brain has over blood pressure control. In essence, cutting off the brain-body connection. Modern medicine takes a normal physiological response (elevated blood pressure) to a chronically threatening environment and reframes it as a disease within the individual patient.

But this medicated response only triggers an escalating battle between the physician, using drugs, and the brain, which tries desperately to get around the effect of the medication.

The doctor, aware that a lower blood pressure is healthier for the patient over the long-term, typically prescribes a beta-blocker counteracting the effects of the adrenaline system, thereby decreasing the rate and strength of the heart’s contraction, and lowering the blood pressure. The brain, still aware that the social environment is threatening, counters by having the kidneys hold on to more fluid — driving the blood pressure back up.

The doctor responds with a diuretic. The brain, not to be outdone by the doctor, increases the hormone angiotensin, leading to blood vessel constriction and again driving up blood pressure. But the doctor has a medication for this too: She gives an ACE inhibitor and perhaps nitrates. At this point the patient’s blood pressure may be controlled, providing that he or she can afford and can keep up with the three or four (or more) medications needed to “control” their blood pressure and any potential side effects.

Could a city attempt to do more than just screen and treat its hypertensive population? Could we lower blood pressure by enriching the social environment of those most in need in ways that reduced the threat level and increased the level of support?

Fear of physical harm is a concern of many community residents. We know Richmond’s Office of Neighborhood Safety and our Police Department, which embraces a community policing strategy, have helped lower crime. What more could an organized community do to improve security? How can we facilitate community engagement that will allow our collective wisdom to help answer such questions? Richmond already has quite a few programs and projects aimed at preventing violent crime and promoting public safety. How might a public health perspective help move us toward safer and more secure communities?

There is also the physical violence that takes place in our homes and that is often denied. Can our community’s collective wisdom also help us heal this wound?

Our schools could be excellent intervention points for blood pressure screening and for learning skills like meditation, yoga, and non-violent conflict resolution. Some of these skills are already being taught. Yoga and meditation training and practice have been shown to decrease stress levels while simultaneously improving self-control. These are valuable skills especially for those subjected to overly challenging environments. Students can also learn how to take blood pressure and can be asked to screen their parents and other family members. They can also teach their family members meditation and other stress reduction skills. Issues of bullying behavior, which can have tragic consequences, can also be addressed at the school level.

Another major area of community stress is widespread economic insecurity. Significantly improving the economic circumstances of Richmond’s poor and vulnerable may be beyond the scope of what we can expect from an initial intervention aimed at enriching Richmond’s social environment, but the city could help provide a minimum level of support by guaranteeing food security.
Richmond has excellent growing conditions for many fruits and vegetables. The city has access to considerable land. There is considerable farming knowledge in the community. There are many idle hands in Richmond.

As part of the city’s overall commitment to lowering stress levels, especially for our poor and vulnerable population, the city could lead a community wide process with the aim of guaranteeing food security to all of Richmond’s residents and at the same time educating the community about healthy food and beverage choices.

Most processed food is high in sugar and salt, both of which have been tied to elevated blood pressure. Sugar sweetened drinks appear to be particularly worrisome since the rapidly absorbed fructose leads to elevations in uric acid which interferes with the nitric oxide system we have in our blood vessels. The nitric oxide ordinarily causes blood vessel dilatation, leading to a fall in blood pressure. The city could help to counter this by promoting tap water and non-processed food.

These are just some of my suggestions on how Richmond might lower its incidence of high blood pressure, heart disease and stroke. Join the conversation. Let me hear from you. I can be contacted at

Jeff Ritterman, M.D. is Vice President of the San Francisco Bay Chapter of Physicians for Social Responsibility. He is a former member of the Richmond City Council.

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