In the mid-1970s, a 39-year-old Black sharecropper's son walked into Sherman James's North Carolina field office and told him a story he could not stop turning over. The man, James called him John Henry Martin in his later talks, had been born in 1907 to a tenant family in eastern North Carolina, taught himself to read at 40, and by 50 owned 75 acres outright. He had also developed hypertension, severe arthritis, and a peptic ulcer that perforated. He told James, plainly, that nothing was going to stop him. He had outworked every obstacle in his way. James, then an epidemiologist at UNC Chapel Hill, walked out of that interview with a question that would absorb the next four decades of his career: what does it cost a body to refuse, on principle, to be defeated?
The answer, published in the Journal of Behavioral Medicine in 1983 (James, Hartnett, and Kalsbeek, vol. 6, pp. 259-278), was the construct he named John Henryism. James and his coauthors developed a 12-item scale capturing three themes: efficacious mental and physical vigor, a strong commitment to hard work, and a single-minded determination to succeed. Then they surveyed 132 working-class Black men aged 17 to 60 in the rural southeast. The first finding was that scoring high on John Henryism (JH) in the context of low education was associated with elevated diastolic blood pressure. The men working hardest, with the least to work with, had the highest pressures. The men working hardest with more education did not.
That is the hypothesis. High-effort active coping, deployed against chronic structural stressors that the coper does not actually have the resources to overcome, exacts a measurable cardiovascular toll. James wasn't romanticizing the folk hero. He was naming the wear. John Henry, the steel-driving man, beat the steam drill and then died with the hammer in his hand. The legend is not a victory story. It is a coroner's report.
What happened after 1983 is the part nobody tells you. James spent the next decade replicating and refining. By the 1994 review he authored in Culture, Medicine and Psychiatry (vol. 18, pp. 163-182), the JH-by-SES interaction had been tested in Pitt County, in Edgecombe County, in samples of Black men, Black women, Black college students, white workers. The findings were not unanimous, but they kept clustering in the predicted direction for low-resource Black respondents. By the 2000s, the scale was being deployed in cohorts James never started: CARDIA, the National Survey of American Life, the Pitt County follow-ups, and eventually the Jackson Heart Study, the largest single-site investigation of cardiovascular disease in Black Americans ever assembled.
Subramanyam and colleagues, including James himself, published the Jackson Heart analysis in Social Science and Medicine in 2013 (PMID 23906131). Among Jackson men, low income paired with high John Henryism scores was associated with a hypertension prevalence ratio of 1.12, while low income paired with low JH scores actually inverted the relationship (PR 0.85). The authors called it modest support for the hypothesis in men, and the modesty is worth sitting with. They were not claiming John Henryism explains the Black-white blood pressure gap. They were saying the construct, 30 years after James named it, still predicted who was sick in a sample of 5,000 Black Mississippians.
Then the picture got more complicated, in the way real science always does. Fernander and colleagues, working with urban Black adults in south Florida, reported in the Journal of the National Medical Association in 2004 (PMID 14977286) that JH actually predicted higher blood pressure in better-educated Black men, the opposite of James's rural finding. The 2018 systematic review in the Journal of Urban Health by Felix and colleagues (PMID 30506136) pulled 21 studies on JH and cardiovascular outcomes in women and found a mess: 3 supportive, 4 null, 3 in the opposite direction on the core SES interaction. Robinson and Thomas Tobin's 2021 paper in the Journal of Health and Social Behavior (PMID 34100655) found that high John Henryism was associated with worse allostatic load (the cumulative biological wear-and-tear index) but also with 20 percent lower depressive symptoms. So which is it. Resource or risk.
Both. That's the synthesis the literature actually supports. John Henryism is a coping strategy with a real psychological payoff, lower depression, higher sense of efficacy, that is paid for somewhere else in the body, in cortisol, in nighttime blood pressure that doesn't dip, in arterial stiffness, in the cumulative biological reading the allostatic load index is built to capture. It is not a defect in Black people. It is a rational response to an environment that punishes giving up and underpays the trying. The cost shows up later, on a different ledger, often in the cardiology clinic.
Which brings us to the part that should embarrass medicine. Open any current major cardiology textbook to the section on hypertension in Black patients. You will find discussions of salt sensitivity, of nocturnal non-dipping, of resistant hypertension, of the disastrous 2013 JNC8 guidance that nudged clinicians toward thiazides and CCBs first-line for Black patients. You will not find John Henryism. You will not find Sherman James. Cuffee and colleagues, publishing in Health Education and Behavior in 2020 (PMID 31592686), surveyed 787 Black hypertensive patients at an Alabama safety-net hospital and found that higher JH scores predicted lower trust in providers and worse medication adherence. The clinicians treating these patients had, in all likelihood, never been taught the construct that was actively shaping their patients' relationship to the prescription pad.
This is not a small gap. The American Heart Association's most recent scientific statements acknowledge psychosocial stress as a cardiovascular risk factor. They cite chronic stress, discrimination, neighborhood disadvantage. They very rarely cite the 40-year program of research on the specific coping style that interacts with those exposures in Black Americans. The Jackson Heart Study lives on the AHA's published flagship cohort list. The JH analyses from Jackson are sitting right there in PubMed. The translation step, from epidemiology to clinic, has not been taken.
What that means for you, if you are Black and reading this with a cuff in the bathroom drawer, is that the framework your doctor is using to explain your numbers is probably incomplete. You may be told to lose weight, cut salt, take your lisinopril. You may not be asked whether you sleep through the night. Whether you can ever stop working in your head. Whether anyone in your life has ever told you, out loud, that you are allowed to fail at something. Those are not soft questions. In the cardiovascular literature they are increasingly recognized as predictors of whether the medication you were just prescribed will actually bring your numbers down.
So here is what to do this week, concretely.
First, ask for a 24-hour ambulatory blood pressure monitor, the cuff that fires every 20 to 30 minutes for a full day and night. Office BP readings miss nocturnal non-dipping, the failure of pressure to drop 10 to 20 percent during sleep, which is more common in Black adults and is a stronger predictor of cardiovascular events than daytime readings. The 2017 ACC/AHA hypertension guidelines explicitly endorse out-of-office monitoring to confirm diagnosis and assess control. If your insurance balks, home BP monitoring with a validated upper-arm cuff (the AMA's validatedbp.org maintains a current list) for two weeks of twice-daily readings is the accepted fallback.
Second, take the John Henryism Active Coping Scale yourself. It is 12 items, public, validated, free. Items include statements like "Once I make up my mind to do something, I stay with it until the job is completely done" and "When things don't go the way I want them to, that just makes me work even harder." Score yourself 1 to 5 on each. A total above 45 puts you in the high-JH range James originally identified. The scale is not a diagnosis. It is a mirror. Use it to notice what you already know about how you cope.
Third, if your blood pressure is uncontrolled or you score high on JH and low on what James would have called "successful coping resources" (savings, paid time off, a partner who can carry the load when you can't), the evidence base for stress-reduction interventions in Black hypertensives is real and specific. Schneider and colleagues' work on Transcendental Meditation in Black adults with coronary heart disease, published in Circulation: Cardiovascular Quality and Outcomes in 2012, showed a 48 percent reduction in mortality, MI, and stroke at 5 years. Mindfulness-based stress reduction has weaker but supportive cardiovascular outcomes data. These are not woo. They are the only behavioral interventions with hard endpoint data in this specific population. Pick one and do it daily for 90 days before deciding it doesn't work.
Fourth, find a clinician who will actually engage with this. The Association of Black Cardiologists maintains a member directory at abcardio.org searchable by zip code. A Black cardiologist is not a guarantee of cultural fluency, but the base rate of "has read Sherman James" is meaningfully higher. If you cannot get to one, bring the 1983 paper to your appointment. Print the abstract. Hand it to your doctor. Ask whether your treatment plan accounts for the construct.
Fifth, and this is the one nobody prescribes, practice resting on purpose. Not collapsing after the work is done. Resting while the work is still undone, by choice, as a discipline. Sherman James, when he gives talks now, often closes by saying that the most radical thing a Black American can do in this country is decide that some battles are not theirs to win. The body keeps score. It has been keeping score since 1983, and the score is in the literature, and the literature is sitting in PubMed, waiting for the clinic to catch up.
John Henry beat the steam drill. Then he died. The point of the story was never the hammer.
