Support health equity by ending America’s amputation epidemic

As we recognize National Minority Health Month, a time designated to examine the systemic inequities in our nation’s health care system, we must take a close look at the imbalances that have been exposed even further because of the COVID-19 pandemic. Once hidden to the unaffected, it’s now clear to all that communities of color — including the Black community — have suffered from harmful barriers to comprehensive care, underinvestment, and a severe trust deficit due to discriminatory practices.

Throw in social determinants of health — many of which are linked to slavery, segregation, and structural racism — and it’s little wonder that Black Americans are unduly affected by the pandemic. Not only are we more likely to be infected by SARS-CoV-2, but we are also more likely to die from it and are less likely to have access to the groundbreaking vaccines approved for use in the U.S.

While I’m glad more people are talking about health care equity, I’m worried that other major disparities may get overlooked in the nation’s fight to end the pandemic.

Case in point: the amputation epidemic. In my work as an interventional cardiologist, I’ve found that too few people have heard of peripheral artery disease (PAD) until it’s too late to save their limbs. Like COVID-19 and other diseases, Black people tragically face the highest risks and the more dire consequences. According to recently-published research in the Journal of the American College of Cardiology, Black Americans living in rural areas face disproportionately high mortality rates due to heart disease, diabetes, hypertension, and stroke — all risk factors for PAD.

Peripheral artery disease, often associated with diabetes, leads to reduced blood flow in the lower limbs. As a result, the circulation decreases and less oxygen is delivered to the extremities, which can result in amputation if not properly treated. PAD is entirely manageable and amputations can be easily prevented if the disease is diagnosed early. In fact, research shows that the vast majority (some 85 percent) of the roughly 200,000 annual non-traumatic amputations that take place across America can actually be prevented with access to routine screening. Amputation as a primary treatment for PAD misallocates resources and wastes taxpayer dollars. It also creates tremendous financial, physical and psychological burdens for the patient and patient’s family.

While an estimated 20 million Americans live with PAD today, the disease is only diagnosed and treated in about 13 percent of all cases. Unfortunately, too few Americans — particularly in communities of color — have access to the simple, painless diagnostic tests used to identify PAD. Moreover, the effects of these disparities are particularly acute for Black Americans: this vulnerable population is about three times more likely to suffer from severe complications that require surgical amputations than white Americans.

In fact, if you map the rates of annual amputations across this country, it would look eerily similar to the population density of people who were enslaved at the outset of the Civil War. Not coincidentally, these areas also have the lowest rates of limb-preserving procedures (called revascularization). This generational scar has resulted in racial and ethnic disparities that are as disabling and deadly as most cancers.

Where I practice in Mississippi, you can count the number of PAD specialists in the whole state on one hand, despite the fact that we sit dead-center in America’s “Diabetes Belt” and represent ground zero for the ongoing amputation epidemic.

The impact of systemic racism isn’t just felt in the South: a major Health Affairs study found that the lowest-income neighborhoods in California, which unfortunately are home to a disproportionately high number of BIPOC individuals, had amputation rates 10 times higher than the most well-off communities.

It is long overdue for health equity to take center stage.

Awareness about PAD and the severe disparities that patients of different racial groups face is the first step towards ending the amputation epidemic. I have invested significant time in educating people about managing the disease at church groups, football games, and even in the parking lots of busy grocery stores. By helping people understand the risks of PAD and encouraging at-risk individuals to get screened, we decreased the amputation rate by 88 percent in my community. The success of our practice demonstrates what is possible when structural changes, including increased education and greater access to PAD screening, are put in place.

Recognizing these inequities, I applaud leaders in Congress who are working to end the amputation epidemic. Rep. Donald Payne, Jr. (D-N.J.), chair of the Congressional PAD Caucus, recently reintroduced the bipartisan Amputation Reduction and Compassion (ARC) Act (H.R. 2631) with several of his colleagues in the U.S. House.

This bill would establish a PAD education program to support, develop, and implement educational initiatives that inform health care professionals and the public about the existence of peripheral artery disease and methods to reduce amputations, particularly with respect to at-risk populations. This patient-centered policy would drastically expand access to the non-invasive tests needed to diagnose PAD and address the devastating disparities that communities of color face when it comes to peripheral artery disease.

The ARC Act alone will not solve systemic racism in America’s health care system. But it will help hundreds of thousands of Americans by saving their limbs while promoting health equity where it is long overdue.

Foluso A. Fakorede, MD, is an interventional cardiologist and CEO of Cardiovascular Solutions of Central Mississippi in Cleveland, Miss.