The Black American Amputation Epidemic Pt III
“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.”
Dr. Fakorede tested them, he found peripheral artery disease, in which clogged arteries in the legs limit the flow of blood. Cont.
This is what uncontrolled diabetes does to your body: Without enough insulin, or when your cells can’t use it properly, sugar courses through your bloodstream. Plaque builds up faster in your vessels’ walls, slowing the blood moving to your eyes and ankles and toes. Blindness can follow, or dead tissue. Many can’t feel the pain of blood-starved limbs; the condition destroys nerves. If arteries close in the neck, it can cause a stroke. If they close in the heart, a heart attack. And if they close in the legs, gangrene.
Within a month, Bolivar Medical Center had credentialed Fakorede, allowing him to consult on cases and do procedures in the hospital. His most complicated patients came in through the emergency room. Some arrived without any inkling that they had gangrene. One had maggots burrowing in sores. Another showed up after noticing his dog eating the dead flesh off the tips of his toes. Fakorede took a photo to add to his collection. “It was a public health crisis,” he told me. “And no one was talking about amputations and the fact that what was happening was criminal.”
On weekends, Fakorede had been driving back to his five-bedroom home in Tennessee, but in August of 2015, he decided to go all-in on Bolivar County. He sold his house and black Mercedes G-Wagon, and applied for funding to build a practice in the Delta: Cardiovascular Solutions of Central Mississippi. He pitched himself as a heart guy and a plumber, removing buildup in the arteries. Four banks denied him loans, so he borrowed money from friends. He gave himself a two-year window to reduce amputations and publish his outcomes.
The Delta was once a cotton empire:
The Delta flood plain runs 7,000 square miles along the northwestern edge of the state, with sweet-smelling, clay-like soil cordoned between bluffs and the banks of the Mississippi River. By the 19th century, the primeval forests had been transformed into a cotton empire; at the start of the Civil War, more than 80% of people in many Delta counties were enslaved. Sharecropping emerged after emancipation, and black farmers cultivated small plots in return for a portion of their crop. They lived on credit — for food and feed and clothing — until the harvest, but even then, their earnings rarely covered their expenses.
For decades, African Americans in the South struggled to find and afford health care. The American Medical Association excluded black doctors, as did its constituent societies. Some hospitals admitted black patients through back doors and housed them in hot, crowded basements. Many required them to bring their own sheets and spoons, or even nurses. Before federal law mandated emergency services for all, hospitals regularly turned away African Americans, some in their final moments of life.
Fakorede was drawn to Bolivar County, in part, because of its history. He’d run out of gas there when he was first scouting the region, and later that evening, he’d Googled its background. For a brief moment, Bolivar was the center of a movement for public health care, driven by the conviction that racial equality was not possible without justice in health. In 1964, when a group of physician activists traveled to the Delta, Robert Smith, a black doctor from Jackson, saw rocketing rates of intestinal parasites and maternal death. “I understood for the first time what it truly meant to be black in Mississippi,” he told a magazine. Under President Lyndon B. Johnson’s War on Poverty, a Boston doctor secured funding to open a community health center in Bolivar, which he grew with the help of Smith. Clinicians worked with residents to take on housing, sanitation, exercise and nutrition. Its success spawned a national project of more than a thousand Federally Qualified Health Centers for the underserved. But funding shrank under President Richard Nixon, and the centers’ initiatives were scaled back to basic primary care.
By the time Fakorede moved to the Delta, in 2015, the state had the nation’s lowest number of physicians per capita. It had not expanded Medicaid to include the working poor. Across the country, 15% of African Americans were still uninsured, compared with 9% of white Americans. That year, Jennifer Smith, a professor at Florida A&M University College of Law, wrote in the National Lawyers Guild Review what Fakorede saw firsthand: “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 has shifted from legally sanctioned segregation to inferior or non-existent medical facilities due to market forces.”
Fakorede understood that to reach patients, he needed referrals, so he met primary care providers at hospitals and clinics. He asked them to screen for vascular disease, measuring blood pressure at the ankle and the arm. Many didn’t have the time; given the shortage of local physicians, some were seeing up to 70 patients a day. Others didn’t know much about peripheral artery disease or why it was important to diagnose. Some were offended by Fakorede’s requests. Michael Montesi, a family doctor, was grateful for the help, but he found it brash for the new doctor in town to start telling the veterans what to do. He recalled thinking, “Where were you the first 12 years of my practice, when I needed a cardiologist, when I needed an OB-GYN, when I needed a surgeon, when I had to do an amputation in the ER, or deliver a baby that was 23 weeks and watch the baby die because there was nobody there that could take care of him?”
The brushoffs disturbed Fakorede, but when he dug deeper, he realized that the doctors weren’t only overwhelmed; they had no guaranteed payment for this vascular screening. The Affordable Care Act mandates that insurers cover all primary care screenings that are recommended by the U.S. Preventive Services Task Force, an independent panel of preventive care experts. The group, though, had not recommended testing anybody without symptoms, even the people most likely to develop vascular disease — older adults with diabetes, for example, or smokers. (Up to 50% of people who have the disease are believed to be asymptomatic.) As specialists, cardiologists are reimbursed if they screen patients with risk factors. But by the time patients got to Fakorede, the disease was sometimes too far along to treat. Many already had a nonhealing wound, what’s known as “end stage” peripheral artery disease, the last step before an amputation.
When Luvenia Stokes came to Fakorede, she had already lost her right leg at the age of 48. Like many Delta residents, she grew up in a food desert, and without money for fresh produce, she’d developed diabetes at a young age. She said that a pedicurist nicked her toe, and the small cut developed an infection. Without good blood flow, it began bubbling with pus. Stokes told Fakorede that no doctor had performed an angiogram to get a good look at the circulation or a revascularization to clean out the arteries. A surgeon removed her second toe. Without cleared vessels, though, the infection spread. Within weeks, a new surgeon removed her leg.
Stokes lived in a single-wide trailer with her mother. Her wheelchair could not fit in the doorways, so she inched through sideways with a walker. Because she could hardly exercise, she gained 48 pounds in two years. The amputation hadn’t treated her vascular disease, and a stabbing pain soon engulfed her remaining leg, “like something is clawing down on you,” she said. When she finally made it to Fakorede, she told him that one doctor had prescribed neuropathy medication and another had diagnosed her with arthritis. “I’m not letting them get that other leg,” Fakorede told her. Stokes’ grandmother, Annie, who lives in a nearby trailer, had lost both her legs, above the knee, to diabetes. Her cousin Elmore had lost his right leg, too.
General surgeons have a financial incentive to amputate; they don’t get paid to operate if they recommend saving a limb. And many hospitals don’t direct doctors to order angiograms, the most reliable imaging to show if and precisely where blood flow is blocked, giving the clearest picture of whether an amputation is necessary and how much needs to be cut. Insurers don’t require the imaging, either. (A spokesperson for America’s Health Insurance Plans, a leading industry trade association, said, “This is not an area where there is likely to be unnecessary surgery.”) To Fakorede, this was like removing a woman’s breast after she felt a lump, without first ordering a mammogram.