The excess of hypertension among blacks has been recognized since early in this century and explains a substantial portion of the black health disadvantage. In a cohort study begun in the 1970s, hypertension accounted for 20% of all-cause mortality among blacks, compared to 10% among whites. National data on trends in hypertension (140/90 mm Hg or treatment) prevalence from 1960 to 1990 suggest a decline from 44% to 32%, although differences in survey technique likely account for this pattern. During this period the prevalence ratio of black:white remained constant at 1.5, suggesting that secular trends in causal factors, if any, effected both groups equally. Recent data demonstrate a gradient in risk across the African diaspora, with standardized prevalences of 14% in West Africa and 26% in the Caribbean, compared to 33% in the US. This pattern parallels the gradient in known risk factors, with obesity alone accounting for a third of the excess in the US compared to Africa. Why the black excess of hypertension in the US? Despite widespread speculation, unique characteristics of hypertension among blacks have yet to be established. Consistent evidence demonstrates a similar impact of the known risk factors in all population groups. Epidemiologic evidence likewise suggests that a similar risk of complications exists with blood pressure elevation among blacks and whites, level for level. Although the genetic epidemiology of hypertension is still in its infancy, no clear cross-population differences are yet apparent. Pathophysiologic traits that are known to be part of the causal etiologic pathway have not been shown to vary across groups. Unique features of this condition among blacks are likely to be restricted to the different mixes and intensities of risk factors. In the absence of evidence to support the hypothesis, it is perhaps surprising that credence continues to be given to the notion of black exceptionalism. Am J