- Many ageing diabetics develop a circulation condition called peripheral artery disease (PAD), which can affect wound healing.
- In the worst cases it requires amputation. A disproportionate share of PAD amputations are being done on Black bodies.
- Dr. Foluso Fakorede, who practices in the Mississippi Delta, aims to change that.
- He’s pressing lawmakers to implement a screening test for people over age 60 – especially smokers, diabetics, and people with hypertension and high cholesterol.
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Linda Amos had to get one of her ten toes cut off last year, but it could’ve been much worse if she’d never met Dr. Foluso Fakorede.
Amos and Fakorede live in the Mississippi Delta, America’s diabetes capital.
Living in the area, which has the lowest number of doctors per capita in the US, and even fewer cardiologists (like Fakorede), Amos is at high risk for a disease that could, if left untreated, lead to a major amputation.
It’s a circulation issue that she shares with roughly 6% of Mississippians, and it’s especially common among older adults like her. Nationwide, Black patients like Amos are three times more likely than others to get a leg or a foot chopped off.
Fakorede’s clinic does something unique to combat this silent threat lurking in the Delta: taking the time and care to remove Amos’s socks and examine her feet on every visit, just like the clinic does for every patient who walks through its doors.
As a result of Fakorede’s efforts, many patients, including Amos, are holding on to their feet, legs, and lives.
“I do know people who’ve had limbs amputated,” she said. “It’s really sad, and a lot of us are Black, you know? A lot of African Americans are losing limbs.”
Where Amos lives, limb loss is a serious threat for ageing adults because of a common condition called peripheral artery disease, or PAD. In 2019, researchers estimated that more than 5% of adults over the age of 25 around the world have PAD, with The Lancet classing it a pandemic. But most people don’t know about it. Essentially, it’s like a heart attack for legs – a big, problematic clog that often goes unnoticed until it’s too late to treat.
“It’s not something that you get overwhelming symptoms of, and so you might never know unless someone says, ‘Oh, I see certain things here,'” Amos said.
It started with a pedicure wound that wouldn’t heal
Amos’ own PAD issues flared up after a seemingly routine pedicure.
“I, like a lot of other ladies, love pedicures,” she said.
But when her manicurist clipped just a little too close to the skin, what started out as a tiny puncture wound just wouldn’t heal right.
Typically when someone gets a cut, the body moves into a swift repair mode. Underneath the surface of the skin, blood vessels dilate, rushing fresh, oxygen-rich blood into the area to repair the wound.
But for Amos, who’s lived with Type 2 diabetes for 47 years, that didn’t happen. A buildup of plaque, calcium, and fatty cells in her legs blocked the flow of oxygen to her wound, much like what happens to the heart during a heart attack, or to the brain during a stroke.
Fortunately, her unique reaction was spotted by Fakorede, who swiftly moved to amputate her toe, thereby saving her leg. If they’d met earlier, he said, it might not have even come to that.
Linda’s story is not unheard-of in the Delta
About three years earlier, Amos had met Fakorede at a local health fair.
“Dr Fakorede is very sensitive,” she said. “I mean, the last thing he wants you to do is lose a limb.”
Fakorede calls PAD “the most prevalent, the most chronic, the most costly, the most deadly, and the most morbid debilitating condition that most Americans have never heard of.”
He’s frustrated that the burden of the most severe cases falls so heavily on his clinic in rural Mississippi, where in addition to diabetes, high blood pressure rates, high cholesterol, and nicotine use all put people at greater risk of developing PAD. But doctors still don’t tend to screen for it, or ask their patients the kinds of questions that could lead to an early diagnosis, despite many acknowledging it as an epidemic in the US.
Amos says part of the problem is poor eating habits in the Mississippi Delta. (“Folks here love to eat sweets, and fatty food and, you know, all the things that we probably shouldn’t want to eat,” she said.)
But bad food can’t fully explain the issue of why people in Mississippi have so many missing limbs.
Many PAD cases in Mississippi are never diagnosed or treated early, in part because patients aren’t taught how to look out for signs of trouble.
“There’s been a disinvestment in these societies and communities, and so that is in play as well, in terms of their outcomes,” Fakorede said. “They are doomed to start with.”
The doctor aims to change that by caring for his patients with compassion, “just like a family member,” he said.
In addition to taking socks off and examining feet, he’s educating patients about how the disease works and how to fight it in a non-judgmental, accessible way.
In the process of doing so, he’s provided some of the first compelling evidence that such simple, preventive care not only saves limbs, it saves lives. Now he’s trying to get Congress to make simple, early assessments part of the norm for ageing diabetes patients, in the same way cancer screenings like mammograms are now a routine part of healthcare.
A quiet killer that targets Black limbs
Only about 30% of people with PAD in the US overall know they have it. But a diagnosis doesn’t appear to be the defining factor that determines whether you face an amputation or not. Overwhelmingly, white Americans who have undiagnosed PAD are far more likely than Black Americans to escape amputations.
“It’s called statistical discrimination,” Fakorede said. “The perception of the therapy that I’m going to administer to a patient, based on the colour of their skin.”
Every year, more than 50,000 diabetic Americans will go through a major amputation procedure. One 2018 study which surveyed all lower extremity amputations across the US over a seven year period found fewer than one in five patients who were admitted with limb ischemia (severe blockages to the extremities) were Black, but more than one in four undergoing amputation were Black.
It’s expensive, often costing over $US100,000 in taxpayer dollars to amputate one limb, and Fakorede says a simple screening tool called the ankle-brachial index could turn the tide of this trend.
The index is a blood pressure reading that compares the pressure and blood flow rate in a person’s ankle to their arm. It takes just a few minutes to perform in an exam room, but many doctors don’t do it because it’s not a recommended screening procedure, even for at-risk patients.
Many cardiologists argue that it’s common sense this screening tool should be performed on anyone over the age of 60, and those over the age of 50 if they smoke or have diabetes. But in a place like Mississippi, where there are just a couple hundred cardiologists, most general practitioners and family doctors haven’t been clued in. Worse, surgeons make thousands of dollars each time they cut off a body part, disincentivizing them from changing the screening-free system.
That’s why Fakorede is speaking out to journalists, Congresspeople, and anyone in central Mississippi who’ll listen to him at a local health fair.
“Those patterns and practices devalue and dehumanize people, and especially their bodies,” Fakorede said.
They also don’t work.
“When you chop my leg, and that is clogged up, what does that mean? The process has not stopped,” he says. “The process is still ongoing in other arteries, so they die of heart attacks, strokes, because that process was not addressed appropriately.”
The five-year death rate for patients who have had below-the-knee amputation ranges from 40 to 82%.
Amos may be one toe down, but she’s still got both feet and legs, and both she and Dr. Fakorede want to keep it that way.
“I probably need to exercise more, but I walk, I walk a lot,” Amos said, adding she now watches what she eats “seriously,” too, and uses an insulin pump to monitor her blood sugar levels at home. Less cake, more high-fibre cereal, she said.
Fakorede wants more patients to realise that by keeping an eye on blood sugar levels and monitoring circulation in their legs, amputations are often avoidable.
It’s what he’s seen in his practice, where he touts a 87.5% reduction in major amputations. At his clinic, 80% of patients are Black, and just 7% have commercial insurance. Consistently, since 2016, fewer than 10 of his patients have suffered a major amputation every year.
Fakorede’s patients appreciate that he is a Black doctor
Amos said that Fakorede is her only Black doctor, but that’s not why she recommends him to her friends.
Still, she’s not colorblind about the situation they’re in.
“I could be wrong, but I don’t think a Caucasian doctor would consider this a mission the way Fakorede does, in terms of getting people educated about peripheral artery disease,” she said.
A Nigerian via way of New Jersey, Fakorede isn’t shy about the fact that he’s on a mission in the American South.
“As a kid who grew up in Africa, in Nigeria, who came to America at a young age, the reason why we came to America was for opportunity,” he said.
He’s still frustrated by how little of it some Americans have.
Not everyone has appreciated how Dr. Fakorede is speaking out inequities in the US healthcare system.
“In some hospitals in Mississippi, it’s their revenue stream, these amputations,” US Congressman Donald Payne, a Democrat from New Jersey, said.
As a diabetic who’s had circulation issues in his own legs and had trouble with slow-healing wounds in his feet, Payne knows PAD firsthand.
“I have all the symptoms that potentially would lead me to have an amputation. I am a 25-year diabetic, I have neuropathy in my legs,” he said. “I’m fighting for everyone in this country to have the same quality of healthcare that I have.”
Payne said he is “probably” going to author a bill for PAD screenings during the first 2021 legislative session, along with his PAD caucus counterpart, Florida Republican Congressman Gus Bilirakis.
Fakorede’s hope is that the US Preventive Service Task Force, the agency that makes screening recommendations to doctors across the US, will recommend ankle-brachial screenings for at-risk, ageing patients. Any doctor could do it.
Fakorede also wants more doctors to perform angiograms on PAD patients before surgeries, to evaluate how severe a blockage really is before they cut someone’s limbs off (most don’t).
PAD early warning signs are easy to find
Fakorede says many of the early warning signs of PAD are easy to spot, just by giving loving care and attention to patients, and having them, in turn, learn to love on themselves.
Have a person take their socks off, feel the temperature of their skin. Notice abnormal nail growth.
With Fakorede’s help, Amos has developed her own daily PAD screening routine she can do at home.
Every morning in the shower, she checks her legs and feels her feet, a kind of diagnostic massage.
“Feeling warm versus cold with my feet, you know, just making sure there’s no irregularities around the toes, and things like that,” she said.
Fakorede says in the US, this may be some of the best preventative care a Black woman in the Mississippi Delta can get.
“You will die a decade earlier than your white counterpart, and you are twice as likely to die from diabetes,” he said.
“Guess what? You have to take ownership of your health, you have to take ownership of your lifestyle and dietary changes, because that is the only out you have.”
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