The Amputation Epidemic
The COVID-19 pandemic and its effect on communities of color have highlighted racial health disparities in America and renewed a sense of urgency to an ongoing issue. However, it’s just the latest in a long series of unequal health outcomes that must be called what they really are: injustices perpetuated at all levels of a healthcare system that has, for too long, treated Blacks with seemingly less regard and fewer options than white Americans.
We know that chronic health conditions such as cardiovascular disease, hypertension, and diabetes affect Black Americans at rates higher than other populations. And unfortunately, Blacks are not only more likely to have these diseases but also to suffer worse outcomes – a fact that was made painfully obvious in a recent ProPublica article, The Black American Amputation Epidemic. The article detailed the work of Dr. Foluso Fakorede, the only cardiologist in Bolivar County, Mississippi, as he fights to provide interventions that can save Black Mississippi Delta residents with diabetes from losing a limb.
It’s a story that should be familiar by now – if not in the details, at least in the concept. By shadowing Dr. Fakorede and learning of the all the barriers he has to overcome to make sure his patients don’t needlessly lose a leg when amputation could have been prevented, author Lizzie Presser reveals a series of ingrained, systemic barriers that almost seem implemented to ensure inequitable care and worse outcomes for Blacks. As Ms. Presser sums it up:
“Look closely enough, and those seemingly intractable barriers are made up of crucial decisions, which layer onto one another: A panel of experts decides not to endorse screening for vascular disease in the legs; so the law allows insurance providers not to cover the tests. The federal government forgives the student loans of some doctors in underserved areas, but not certain specialists; so the physicians most critical to treating diabetic complications are in short supply. Policies written by hospitals, insurers and the government don’t require surgeons to consider limb-saving options before applying a blade; amputations increase, particularly among the poor.”
Some of these are decades-old issues that have their roots in generations of segregation and exclusion. A professor at Florida A&M University College of Law, wrote in the National Lawyers Guild Review that, “While the roots of unequal and inequitable healthcare for African Americans date back to the days of slavery, the modern mechanisms of discrimination in healthcare has shifted from legally sanctioned segregation to inferior or non-existent medical facilities due to market forces.”
Compounding this is a healthcare system that does not properly incentivize doctors to perform preventive care: surgeons have a financial incentive to amputate; they don’t get paid to operate if they recommend saving a limb. Many patients are not given angiograms, the most reliable imaging to show a blockage and insurers don’t require imaging. According to Dr. Marie Gerhard-Herman, Associate Professor of Medicine at Harvard Medical School and the Chair of the Committee on guidelines for the American College of Cardiology and the American Heart Association, “There are pockets across the nation, where no one was getting angiograms, and it seemed to run along racial and socioeconomic lines”.
I do not want to diminish the seriousness or severity of diabetes in any population, and there are a confluence of factors (increasing obesity levels, rising costs of insurance and care, leading people to delay critical doctor visits) that are leading to poor outcomes for White patients, too. Despite strides in diabetic care, amputations grew by 50% between 2009 and 2015, and 55% of diabetes patients who have a lower extremity amputation will require amputation of the second leg within 2- 3 years. Still, African Americans are up to four times more likely than white Americans to suffer an amputation due to diabetes and twice as likely to die from it.
As a Black man in America, I – unfortunately but predictably – have shared some of these experiences firsthand and seen them play out in my own family.
In 2005, my mother, the retired Director of Social Services for Suffolk County on Long Island, New York moved to Alabama. Shortly after her move, she began experiencing issues with her balance and other potentially neurologic symptoms. For nearly five years, she visited multiple area doctors and specialists, even seeking treatment from a University hospital with national rankings attesting to its quality of care.
During this period, she received multiple misdiagnoses, including: general balance disorder, polymyositis, polymyalgia rheumatica, and untreated Lyme disease. In each instance, she was sent away with medications and other treatments, many of which further exacerbated her condition. Eventually, doctors told her they didn’t really know what she had, but asked if she’d like to participate in a study.
It’s difficult not to draw conclusions: here we have an extremely articulate and well-spoken woman with a generous private health care plan, seeing top-tier physicians, and she still isn’t being given adequate care or appropriate consideration. I could not continue to let my mother suffer: I recommended she come back to New York and see a specialist on Long Island. Within a week and a half, her condition was diagnosed as Progressive Supranuclear Palsy, and an appropriate treatment protocol was prescribed. Again, it’s hard to wonder, in her case and with Dr. Fakorede’s patients, how much the color of her skin affected her treatment and outcome.
Of course, anecdotal information is not science. However, what was observed by the young doctor in Mississippi is a microcosm of the healthcare landscape in many areas across the nation. The ailments most associated with racial health disparities seem to have proven preventive treatments – cost-effective ones that promote better outcomes and prevent tragic complications – that are just not offered to certain populations. This is not a new story, but hopefully the visibility brought by the Covid-19 pandemic and the ongoing push for racial justice in America will prompt new efforts to address and overcome these persistent issues.
