The Black American Amputation Epidemic Pt II
“This story represents a view of how our population in poverty areas of the south are being decimated with removal of limbs to take care of diabetes disease instead of finding solutions to the problem. Some information provided could cause a sickening feeling to some but graphic dialogue is necessary.”
Despite the great scientific strides in diabetes care, the rate of amputations across the country grew by 50% between 2009 and 2015. Diabetics undergo 130,000 amputations each year, often in low-income and under insured neighborhoods. Black patients lose limbs at a rate triple that of others. It is the cardinal sin of the American health system in a single surgery: save on preventive care, pay big on the backend, and let the chronically sick and underprivileged feel the extreme consequences.
Dr. Foluso Fakorede with the patient.
Fakorede grabbed his car keys and headed to the hospital. He walked straight to the lab. As he suspected, it had all the supplies that he needed. Why won’t they give me staff? he wondered. They wouldn’t do that to a surgeon.
He has little tolerance for this kind of transgression. He is militaristic, to an extreme. To him, non healing wounds are like heart attacks. “Time is muscle,” he repeats. He calls huddles when nurses forget to check a patient’s ankles: “If you haven’t assessed both legs, I don’t want to walk into that room.” He considers each of his procedures an act of war. When people stand in his way, he sends a barrage of text messages, punctuated by exclamation marks. And he uses his cell phone to collect evidence that the system is working against his patients, and his efforts.
He pulled out his iPhone and photographed the hospital’s wires and catheters, IVs and port protectors. He shot the images over to the hospital’s radiology director. Fakorede’s private practice was closed for the holiday weekend. He calculated that he had only a few days to carry out some plan before Dotstry’s remaining leg was amputated.
Two maps explain why Fakorede has stayed in the Mississippi Delta. One shows America’s amputations from vascular disease. The second shows the enslaved population before the Civil War; he saw it at a plantation museum and was stunned by how closely they tracked. On his phone, he pulls up the images, showing doctors, or history buffs, or anyone who will listen. “Look familiar?” he asks, toggling between the maps. He watches the realization set in that amputations are a form of racial oppression, dating back to slavery.
Fakorede was initially tempted to move to the Delta while practicing in Tennessee. He befriended a medical device sales rep named Maurice Hampton who had grown up in the Mississippi region. Hampton talked about how black families were leery of local hospitals and how few black doctors in the Delta specialized in vascular work. “It’s the norm to go to Walmart and see an amputation or a permacath in the neck,” he’d told Fakorede. “If you don’t see one, then you didn’t stay but two minutes.”
Then, a little over a year into his Tennessee job, Fakorede found himself at loose ends. He’d raised concerns that he was being billed for expenses that weren’t his and asked for an audit; though the audit later found that the clinic where he worked had claimed over $314,000 in improper expenses, he was quickly terminated. Fakorede sued the clinic for retaliation under the False Claims Act and lost. (The clinic’s lawyer said his client had no comment, but there were “numerous” reasons for Fakorede’s departure.) In the spring of 2015, he had a mortgage, a quarter of a million dollars in student debt and four months of severance pay. He also had an impulse to understand the Delta.
Fakorede spent four days driving through its long, flat stretches of farmland dotted with small towns and shotgun houses. The wood-slat homes and bumpy roads reminded him of his grandparents’ village in the Nigerian state of Ondo, where he’d spent summers as a kid. He drove scores of miles on the Mississippi highways without seeing a single grocery store; fast-food chains lit the busiest intersections. He was startled by the markers of disease — the missing limbs and rolling wheelchairs, the hand-built plywood ramps with metal rails. He thought of amputees like “an hourglass,” he said, “that was turned the day they had their amputation.” Mortality rates rise after the surgeries, in part, because many stop walking. Exercise improves circulation and controls blood sugar and weight. The less activity a person does, the higher the risk of heart attacks and strokes. Within five years, these patients were likely to be dead.
Fakorede weighed taking a lucrative job up north, near his parents, who had both been diagnosed with diabetes. He had professional connections there; he’d gone to Rutgers Robert Wood Johnson Medical School and done a residency at NewYork-Presbyterian Weill Cornell Medical Center. But the South, he felt, needed him. About 30 million people in America had diabetes, and Mississippi had some of the highest rates. The vast majority had Type 2; their bodies resisted insulin or their pancreas didn’t produce enough, making their blood sugar levels rise. Genetics played a role in the condition, but so did obesity and nutrition access: high-fat meals, sugary foods and not enough fiber, along with little exercise. Poverty can double the odds of developing diabetes, and it also dictates the chances of an amputation. One major study mapped diabetic amputations across California, and it found that the lowest-income neighborhoods had amputation rates 10 times higher than the richest.
The Delta was Mississippi’s poorest region, with the worst health outcomes. Fakorede had spent years studying health disparities: African Americans develop chronic diseases a decade earlier than their white counterparts; they are twice as likely to die from diabetes; they live, on average, three years fewer. In the Delta, Fakorede could treat patients who looked like him; he could find only one other black interventional cardiologist in the entire state. A growing body of evidence had shown how racial biases throughout the medical system meant worse results for African Americans. And he knew the research — black patients were more responsive to, and more trustful of, black doctors. He decided after his trip that he’d start a temporary practice in Mississippi, and he rented an apartment deep in the Delta.
He fantasized about building a cardiovascular institute and recruiting a multidisciplinary team, from electrophysiologists to podiatrists. But as he researched what it would take, he found a major barrier. Medical specialists with student debt, who graduate owing a median of $200,000, generally could not benefit from federal loan forgiveness programs unless they got jobs at nonprofit or public facilities. Only a few types of private practice providers — primary care, dentists, psychiatrists — qualified for national loan forgiveness. The Delta needed many other physicians. Though Bolivar County was at the center of a diabetes epidemic, there wasn’t a single diabetes specialist, an endocrinologist, within 100 miles.
Fakorede leased a windowless space in the Cleveland Medical Mall, a former shopping center that had been converted to doctors’ offices. People came to him with heart complaints, but he also asked them to remove their socks. Their legs alarmed him. Their toes were black and their pulses weak. Their calves were cold and hairless. Some had wounds but didn’t know it; diabetes had numbed their feet. Many had been misdiagnosed with arthritis or gout, but when Fakorede tested them, he found peripheral artery disease, in which clogged arteries in the legs limit the flow of blood.
We continue our story on Part III as Dr. Fakorede continues his fight for those who need the help most.
