Being Black Can Cost an Arm and a Leg
COVID-19 is not the only epidemic plaguing America’s Black community today.
The respected medical journal, The Lancet, has reported, “The epidemic of amputations among Black communities across the USA is a brutal reminder of the enduring complications of [diabetes] among underserved populations…” Other prestigious publications have characterized this epidemic as an indictment of our health care system.
Diabetes is one of the most common causes of amputation because it leads to peripheral artery disease, or PAD. PAD in the legs is the narrowing or blockage of the vessels that carry blood from the heart. With the decrease of blood flow, the feet and legs are at a significant risk of gangrene.
Diabetics undergo 130,000 amputations each year in the United States, with these patients most often being low-income and underinsured.
Numerous studies have shown that Black folk have their legs amputated at a much higher rate than whites with the same health problems. Some studies have shown that Black folk with diabetes receive amputations at nearly three times the rate of white patients, particularly in the rural South. Others claim that the disparity is four times greater. These disparities exist even when the data is controlled for the fact that diabetes is more prevalent among African Americans.
Dr. Foluso Fakorede, a cardiologist in Bolivar County, Miss., who specializes in cardiovascular management, has been waging a campaign to bring awareness to the fact that failure to provide caring treatment for Black and poor people with PAD results in amputations that could have been prevented.
Dr. Fakorede reports that on one occasion, he examined the left foot of a Black patient with uncontrolled diabetes and found that the tops of his toes were dark, his sole was yellow and oozing, as the foot was literally rotting due to diabetes constricting the blood flow to his foot and preventing an infection from healing. Upon examining the patient’s chart, Dr. Fakorede found that a consulted surgeon had begun his written recommendation by stating casually that the patient had “limited options” other than amputation below the knee.
This patient recently had lost his right leg below the knee, and it seems that the surgeon had little concern that another amputation would place the patient a wheelchair for the rest of his life.
Looking further into this patient’s records, Dr. Fakorede discovered that no screening had been done on this patient at the time of his first amputation to determine if his left leg was at risk and if intervention might help improve the health of the remaining limb.
Realizing the lack of interest in avoiding preventable diabetic amputations in Mississippi, Dr. Fakorede created the Amputation Prevention Institute. He even put up a billboard on the side of a highway alerting people to the fact that amputations could be preventable and alternate courses of treatment could be pursued. He also has tried to convince physicians to perform more thorough evaluations of PAD patients before cutting off their legs.
With proper attention, Dr. Fakorede saved the leg of the man with the rotting foot and he only lost one toe.
About 37 million people in America have diabetes, and Mississippi has one of the highest rates in the country. The vast majority have Type 2 diabetes and their bodies resist insulin or their pancreas does not produce enough, thus making their blood sugar levels rise and their arteries become constricted.
Genetics plays a role in the condition, but it also has been reported that poverty can double the odds of developing diabetes and dictating a higher risk of amputation. Black people who live in food deserts, where there is a lack of availability of nutritious food, tend to consume high-fat meals, sugary foods and do not get enough fiber. And when you add to that a lack of opportunity to engage in adequate exercise, the risk of diabetes increases exponentially because obesity is also a significant contributing factor.
These disadvantages combine with an array of public policies, from insufficient access to health care to racist biases resulting in cuts in public health funding. Policy decisions like these maintain disparities, particularly in the South, that result in diabetic amputations, which are, by one measure, the most preventable surgery in the country.
African Americans in the South have always had difficulty finding and affording adequate health care. In past years, major Southern hospitals admitted Black patients through back doors and housed them in basements. Many hospitals required them to bring their own sheets and eating utensils. Before federal law mandated emergency services for all, these hospitals routinely turned away African Americans in need of medical attention, even if it meant a death sentence.
These problems are systemic and built into the culture of America. Jennifer Smith, a professor at Florida A&M University College of Law, wrote in the National Lawyers Guild Review: “While the roots of unequal and inequitable health care for African Americans date back to the days of slavery, the modern mechanisms of discrimination in health care have shifted from legally sanctioned segregation to inferior or non-existent medical facilities due to market forces.”
Even though Title VI of the Civil Rights Act of 1964 protects individuals from discrimination in various areas of health care and services, disparities persist in the provision of health care because caring treatment comes from a compassionate heart, not a code of law.
And then there is the profit motive. There is more of a financial incentive to amputate than not. Because policies set out by hospitals, insurers and the government don’t require surgeons to consider limb-saving options before cutting, the amputation epidemic continues, particularly among the poor and people of color. A procedure known as an angiogram can inform a physician as to whether there is sufficient blood flow in a leg to warrant an intervention that could save it. It was through the use of an angiogram that Dr. Fakorede was able to save the leg of his patient with the rotting foot. But an amputation pays more than an angiogram. It is reported that nationwide, half of the amputees do not get an angiogram before losing their leg to surgery.
The tragedy of an unnecessary amputation does not end with the loss of a leg. Mortality rates rise after these amputations, partly because many amputees stop walking. Exercise is essential to good circulation, and it helps to control blood sugar and weight. The less active an individual is, the greater their risk of heart attack and stroke. Being placed in a wheelchair can take years off one’s life.
Dr. Marie Gerhard-Herman, an associate professor of medicine at Harvard Medical School and a cardiologist at Brigham and Women’s Hospital, told a reporter that it made her “sick to her stomach” that, in certain parts of the country, patients were not getting angiograms prior to amputation and those decisions appeared to be made along racial and socioeconomic lines.
America constantly touts its world-class health care. But that level of care is not for us. And unless we begin to strongly demand that adequate health care is our due, it will never be for us.
Oscar H. Blayton is a former Marine Corps combat pilot and human rights activist who practices law in Virginia. His earlier commentaries may be found at https://oblayton1.medium.com/