Although the consequences of hypertension are universal, blacks (African-Americans or indigenous Africans) have been the subject of a differential approach to causation, outcome, and treatment. Blacks have a greater propensity to salt sensitivity and suppressed plasma renin suggesting a predisposition to sodium retention. Target organ damage is more frequent and blood pressure is more difficult to control. We explore potential underlying causes, both genetic and environmental, particularly in the South African population, and propose a more physiological approach to the treatment of resistant hypertension in blacks.