The Black American Amputation Epidemic

The doctor put up billboards in the Mississippi Delta.

Amputation Prevention Institute, they read.

He could save their limbs, if it wasn’t too late.

The Black American Amputation Epidemic

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IT WAS A FRIDAY EVENING in the hospital after a particularly grueling week when Dr. Foluso Fakorede, the only cardiologist in Bolivar County, Mississippi, walked into Room 336. Henry Dotstry lay on a cot, his gray curls puffed on a pillow. Fakorede smelled the circumstances — a rancid whiff, like dead mice. He asked a nurse to undress the wound on Dotstry’s left foot, then slipped on nitrile gloves to examine the damage. Dotstry’s calf had swelled to nearly the size of his thigh. The tops of his toes were dark; his sole was yellow, oozing. Fakorede’s gut clenched. Fuck, he thought. It’s rotten.

Fakorede, who’d been asked to consult on the case, peeled off his gloves and read over Dotstry’s chart: He was 67, never smoked. His ultrasound results showed that the circulation in his legs was poor. Uncontrolled diabetes, it seemed, had constricted the blood flow to his foot, and without it, the infection would not heal. A surgeon had typed up his recommendation. It began: “Mr. Dotstry has limited options.”

Fakorede scanned the room. He has quick, piercing eyes, a shaved head and, at 38, the frame of an amateur bodybuilder. Dotstry was still. His mouth arched downward, and faint eyebrows sat high above his lids, giving him a look of disbelief. Next to his cot stood a flesh-colored prosthetic, balancing in a black sneaker.

Fakorede explained that he wasn’t the kind of doctor who cuts. He was there because he could test circulation, get blood flowing, try to prevent any amputation that wasn’t necessary. He hated that doctors hadn’t screened Dotstry earlier — when he’d had the stroke or lost his leg. “Your legs are twins,” he said. “What happens in one happens in the other.”

Dotstry needed an immediate angiogram, an imaging test that would show blockages in his arteries. He also needed a revascularization procedure to clean them out, with a thin catheter that shaves plaque and tiny balloons to widen blood vessels. His foot was decaying, fast. Though Fakorede ran an outpatient practice nearby, when doctors consulted him on inpatients at Bolivar Medical Center, the local hospital, he expected to use its facilities.

He asked his nurse to schedule the procedures. But by the time he had driven home to his ranch house on the northern edge of town, he hadn’t received an answer. Nor had he when he woke up on Saturday at 3:30 a.m., as he did every morning. By sunrise, he was restless at his kitchen counter, texting the hospital’s radiology director, explaining the need for an intervention on Monday, Martin Luther King Jr. Day. Within a few hours, he got a response: “I don’t have the staff or the supplies. I’m sorry.”

Now Fakorede was mad, walking briskly into his office, dialing friends on speaker phone, pacing around his conference room. He’d been raised in Nigeria, moved to New Jersey as a teenager and had come to practice in Mississippi five years earlier. He’d grown obsessed with legs, infuriated by the toll of amputations on African Americans. His billboards on Highway 61, running up the Delta, announced his ambitions: “Amputation Prevention Institute.”

Nobody knew it in January, but within months, the new coronavirus would sweep the United States, killing tens of thousands of people, a disproportionately high number of them black and diabetic. They were at a disadvantage, put at risk by an array of factors, from unequal health care access to racist biases to cuts in public health funding. These elements have long driven disparities, particularly across the South. One of the clearest ways to see them is by tracking who suffers diabetic amputations, which are, by one measure, the most preventable surgery in the country.

Look closely enough, and those seemingly intractable barriers are made up of crucial decisions, which layer onto one another: A panel of experts decides not to endorse screening for vascular disease in the legs; so the law allows insurance providers not to cover the tests. The federal government forgives the student loans of some doctors in underserved areas, but not certain specialists; so the physicians most critical to treating diabetic complications are in short supply. Policies written by hospitals, insurers and the government don’t require surgeons to consider limb-saving options before applying a blade; amputations increase, particularly among the poor.

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 underinsured 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.

Henry Dotstry, Dr. Foluso Fakorede’s patient. (Ruddy Roye for ProPublica)

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, nonhealing 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 cellphone 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.

AVERAGE ANNUAL AMPUTATIONS, 2007–9

0–5
5–8
8–10
10–13
13+

The average number of amputations for peripheral artery disease per 10,000 patients per year. Source: Dartmouth Atlas of Healthcare

ENSLAVED POPULATION IN 1860

0%
0–10%
10–30%
30–50%
50%+

The percentage of the population enslaved in 1860. Source: IPUMS NHGIS, University of Minnesota

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.

A highway in the Mississippi Delta. (Andrea Morales for ProPublica)

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 in his clinic with a patient. (Ruddy Roye for ProPublica)

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.

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. (Andrea Morales for ProPublica)

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.

Luvenia Stokes. (Ruddy Roye for ProPublica)

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.

Nationwide, more than half of patients do not get an angiogram before amputation; in the Delta, Fakorede found that the vast majority of the amputees he treated had never had one. Now, he was determined to make sure that no one else lost a limb before getting the test. This wasn’t a controversial view: The professional guidelines for vascular specialists — both surgeons and cardiologists — recommend imaging of the arteries before cutting, though many surgeons argue that in emergencies, noninvasive tests like ultrasounds are enough. Marie Gerhard-Herman, an associate professor of medicine at Harvard Medical School and a cardiologist at Brigham and Women’s Hospital, chaired the committee on guidelines for the American College of Cardiology and the American Heart Association. She told me that angiography before amputation “was a view that some of us thought was so obvious that it didn’t need to be stated.” She added: “But then I saw that there were pockets of the country where no one was getting angiograms, and it seemed to be along racial and socioeconomic lines. It made me sick to my stomach.”

Stokes wasn’t at immediate risk of losing her left leg when she met Fakorede, but pain prevented her from walking. She had a severe form of the disease, and Fakorede booked her for an angiogram and revascularization. He inserted a wire into her arteries and cleaned out the clogged vessels, letting oxygen-rich blood rush to her remaining foot. While she was recovering in Fakorede’s lab, she thought about her neighbors who had the same problems. “I really don’t like what’s happening to us,” she said to me. “They’re not doing the tests on us to see if they can save us. They’re just cutting us off.”

A wooden ramp and concrete steps outside Stokes’ trailer. (Ruddy Roye for ProPublica)

Patients didn’t know about vascular disease, or why their legs throbbed or their feet blackened, so Fakorede went to church. The sales rep, Hampton, introduced him to pastors, and several times each month, he stood before a pulpit. He told the crowds that what was happening was an injustice, that they didn’t need to accept it. He told them to get screened, and if any surgeon wanted to cut off their limbs, to get a second opinion. In the lofty Pilgrim Rest Baptist Church, in Greenville, he asked the congregation, “How many of you know someone or know of someone who’s had an amputation?” Almost everyone raised their hands.

At first, Fakorede took a confrontational approach with colleagues. Some seemed skeptical that he could “prevent” amputations; it’s a tall claim for a complex condition. Once, when a doctor had disregarded his advice, he’d logged it in the electronic health record, so the oversight would be on display for anyone who looked up his patient’s chart. Fakorede could fume when people questioned his authority; self-confidence carried him, but it sometimes blinded him to his missteps. Over time, though, Fakorede tried to rein in the arrogance. “You peel off a layer that may be comprised of: I’m from up North, I know it all, you should be thankful we’re here to provide services that you probably wouldn’t get before.” He picked up some Southern manners. Fakorede began texting doctors with photos of their patients’ feet along with X-rays of their arteries, before his intervention and afterward. Referrals picked up, and within a year, he’d seen more than 500 patients.

But Bolivar Medical Center, he learned, was turning away people who couldn’t pay a portion of their revascularization bill upfront. Several former employees told me the same. “It’s a for-profit hospital, it’s no secret, it’s the name of the game,” Fakorede said. “But a for-profit hospital is the only game in town in one of the most underserved areas. So what happens when a patient comes in and can’t afford a procedure that’s limb salvage? They eventually lose their limbs. They’ll present back to the emergency room with a rotten foot.” And a surgeon would have no choice but to amputate. (A hospital spokeswoman said that last year, it gave $25 million in charity care, uncompensated care and uninsured discounts. Asked if it turned away patients who couldn’t pay for revascularization, she did not respond directly: “We are dedicated to providing care to all people regardless of their ability to pay.”)

The practice was discriminatory, he reasoned, and also financially backward. At $237 billion in medical costs each year, diabetes is the most expensive chronic disease in the country; one of every four health care dollars is spent on a person with the condition. Left untreated, the costs pile on. Medicare spends more than $54,000 a year for an amputee, including follow-ups, wound care and hospitalizations; the government program is the country’s largest payer. Then come the uncounted tolls: lost jobs, a dependence on disability checks, relatives who sacrifice wages to help with cooking and bathing and driving.

By the time Carolyn Williams came to see Fakorede, in 2016, she’d been uninsured with diabetes for 20 years; she’d worked at a housing nonprofit and for a food assistance program, but neither had offered coverage. At the age of 36, she’d needed a triple bypass surgery, and at 44, she had three toes amputated. Untreated leg pain left her needing a wheelchair; she pulled out of Delta State University, where she was pursuing a degree in social work. Fakorede reconstituted blood flow in her legs and got her walking. But the diabetes was already destroying her kidneys. She joined the government’s disability rolls. She also went on dialysis, at a yearly cost to Medicare of $90,000.

On the days when Fakorede wanted to give up and leave, he drove to an Emmett Till memorial in Money, Mississippi. After 14-year-old Till was mutilated and murdered, in 1955, his mother had insisted on opening his casket. “Let the people see what I’ve seen,” she said, and his image brought national outrage to racist violence in the South. Fakorede thought often about how that decision sparked the Civil Rights movement. He thought about it as he exhibited his photos of rotten feet and limbless bodies, his own proof of what he considered a modern atrocity. He didn’t want to live by Bolivar Medical’s policies. He decided that in order to treat as many people as possible, irrespective of income or insurance, he needed to build a lab of his own.


THIS JANUARY, THAT LAB was now Dotstry’s best shot. The hospital’s consulting surgeon expected to amputate his leg below the knee. He had written that because Dotstry’s kidneys were impaired, the contrast dye in an angiogram would be dangerous. But Fakorede could replace the dye with a colorless gas, which wouldn’t jeopardize Dotstry’s health.

It would have made the most sense to perform the procedure at the hospital; Dotstry had been admitted and was occupying a bed. But after Fakorede opened his outpatient lab and hired away two techs and a nurse, a spokeswoman said the hospital stopped doing certain interventions. She told me it shouldn’t have surprised Fakorede that they couldn’t schedule Dotstry’s case, and that if he had been unable to treat a patient in his lab, the hospital could have worked with him to find another. Fakorede told me he’d never received such a message. When a doctor asks him to treat an inpatient with an acute condition, his responsibility, as he sees it, is to do it in the hospital. “If I don’t have a hospital that wants to coordinate,” he asked, “what do I do?”

Fakorede prepares for a procedure. (Ruddy Roye for ProPublica)

The answer, at least this time, was to get his patient out of there. He called Dotstry’s doctor and convinced her to discharge him for the intervention. Then, at noon on Saturday, Fakorede walked back into Room 336. Dotstry’s sister, Judy, was standing by his bed. She wore tall leather boots over acid-washed jeans, with a thick, black wig in a braid down her back.

Fakorede handed over his card. “I called the hospital to see if we can do this case on Monday,” he said, “and they said no.”

Judy inhaled. “What now?”

Fakorede laid out the plan for a Monday morning angiogram in his own procedure room. He would open up as many vessels as he could. If he could get circulation to Dotstry’s foot, he might be able to save it. He wasn’t sure about the toes.

When Dotstry had suffered his stroke several years back, Judy had become his caregiver. She’d stopped taking jobs in home care and supported her brother without pay — shuttling him to doctors’ appointments, controlling his sugars, managing his medications. After his amputation, she’d helped him learn to walk again. In place of a salary, she’d drawn disability for an old work injury; she’d been electrocuted while operating a machine, and the nerves in her arm were damaged, making her hands tremble. But she couldn’t stay unemployed forever. This past fall, she had gone back to work, cleaning the local post office.

After Fakorede left, Judy looked over at her brother, who sat slumped over the side of the cot, a blue gown slipping off his bony shoulders. Their father had been a sharecropper, and Dotstry had dropped out of elementary school to help on the farm, harvesting soybeans, rice and cotton. Of 10 kids, he was the oldest boy, and he took care of the others, bringing in cash and cooking them dinner. They almost never saw a doctor. Instead, they’d relied on cod liver oil, or tea from hog hoofs, parched over a fire.

Dotstry had spent his career driving tractors, hauling crops and plowing fields, but he wasn’t insured and still rarely saw doctors. At 60, when he was diagnosed with Type 2 and prescribed insulin, he didn’t know how to manage the medicine properly; he had never learned to read. Insulin pumps were too expensive — more than $6,000. His blood sugar levels often dropped, and he sometimes passed out or fell on the job. Little by little, his employer cut back his duties. In 2015, he had a stroke; diabetes had raised his risk. A year later, his right foot blackened and was amputated at the ankle. The infection kept spreading, and soon, his lower leg went. He could no longer work.

Two of his sisters had died after complications of diabetes. Judy had stood over their beds like she was now standing over Dotstry’s. He’s still here, she reminded herself.

Dotstry with his niece Shequita, his girlfriend and his sister Judy. (Ruddy Roye for ProPublica)

She pulled out her phone and called another brother. “They gonna amputate his foot, cause it’s bad,” she said. “Toe’s rotted.”

Dotstry looked up from the bed. “No!” he shouted. “They can’t take that off. Why?”

“Why you think your foot look like that? Why you think it smells? It stinks!” she said. Dotstry reached down to unwind the gauze. Judy wondered why he hadn’t told her that his foot was infected sooner. She lowered her voice. “You were doing pretty good. If you wasn’t, I could have tried to get back in there and do something.”

Her daughter, Shequita, ran into the room, huffing. She was loud and pissed off. “Whose foot is that?” she shrieked. She kneeled by the cot and helped Dotstry scoot up onto his pillow, stretching out his legs. He was usually a prankster, a hard-headed contrarian, the uncle who’d picked her up and spun her around like an airplane. She was thrown off by how quiet he’d become.

“Your daughter wants to know if you want to come stay with her, if you want to come to Texas,” Shequita told him.

Dotstry knew the offer was on the table, but he hadn’t yet accepted. A few days earlier, a tornado had torn the roof from his trailer, and he was, for the moment, without a home.

“She said it’s a lot better doctors up there,” Shequita continued, “and if she gotta stop working to take care of you, she can do that.” She gripped her hands around the frame of the bed and leaned over it, locking her eyes with his. “I need you to be thinking hard about this, sir. This ain’t you. I need you to get back to you.”

“He ain’t gotta go to Texas,” Judy interrupted.

Shequita shot back: “You gonna take care of him?”

Judy was silent. She knew that she couldn’t, not like before. She needed her paycheck for home repairs; a flood had warped her wooden floors. But Dotstry’s daughter was younger, and Judy thought that if she quit her job at Walmart, she’d get restless. Besides, Dotstry knew no one in Texas. She pictured him in a wheelchair, staring off, confused about where he was. Judy figured if he went, he’d go on and die.

She crossed her arms. “He’ll be all right if they don’t have to amputate that leg,” she said.

Shequita looked at her mother. She walked over to where she stood, by a shaded window, and threw her arms around her neck. Then, she left the room. Judy hoisted herself up onto the foot of her brother’s cot. She swung her legs up so that she faced him, and she laid herself down.


ABOUT EVERY FIVE YEARS, the doctors and researchers who make up the U.S. Preventive Services Task Force reassess their screening guidelines. In 2018, the members returned to peripheral artery disease and the blood flow tests that Fakorede had asked local primary care doctors to conduct. Once again, the panel declined to endorse them, saying there was not enough evidence that the tests benefited the average asymptomatic American.

In their statement, they acknowledged that public commenters had raised concerns that the disease “is disproportionately higher among racial/ethnic minorities and low-socioeconomic populations” and that this recommendation “could perpetuate disparities in treatment and outcomes.” In response, the panel said it needed better evidence. But as the National Institutes of Health has found, minorities in America make up less than 10% of patients in clinical trials.

Dr. Joshua Beckman, the director of vascular medicine at Vanderbilt University Medical Center, was an expert reviewer of the evidence base for the task force, and its final report struck him as irresponsible. It hardly noted the advantages of treatment after screening; the benefits were right there in the data that he saw. The panel discounted the strongest study, a randomized control trial, which demonstrated that vascular screening, for men ages 65 to 74, reduced mortality and hospital days. (The study bundled peripheral artery disease screening with two other tests, but in Beckman’s eyes, the outcomes remained significant.) He was confused about why the task force had published its evaluation of screening the general public, when it was clear that the condition affects specific populations. Several American and European professional society guidelines recommended screening people with a higher risk. “You wouldn’t test a 25-year-old for breast cancer,” he told me. “Screening is targeted for the group of women who are likely to get it.”

Dr. Alex Krist, the chair of the task force, repeated the group’s position in an email that the data was not strong enough to endorse screening, even for at-risk patients. “The Task Force does not do its own research, so we can’t fix these research gaps, but we can — and did — ring the alarm bell to raise awareness of this vital issue among researchers and funders.”

Fakorede performs a revascularization procedure with an assistant. (Ruddy Roye for ProPublica)

Vascular surgeons who have spent their careers studying limb salvage have come to see preventive care as perhaps more important than their own last-ditch efforts to open blood vessels. Dr. Philip Goodney, a vascular surgeon and researcher at Dartmouth and White River Junction VA Medical Center, made a name for himself with research that showed how the regions of the country with the lowest levels of revascularization, like the Delta, also had the highest rates of amputation. But revascularizations aren’t silver bullets; patients still must manage their health to keep vessels open. Now, Goodney believes his energy is better spent studying preventive measures earlier in the disease’s progression, like blood sugar testing, foot checks and vascular screening. Many patients have mild or moderate disease, and they can be treated with medicine, counseled to quit nicotine, exercise and watch their diet. “We need to build a health system that supports people when they are at risk, when they are doing better and when they can keep the risk from coming back,” he told me. “And where there’s a hot spot, that’s where we need to focus.”

Fakorede scrolled through the task force’s statement. “You want more data? Really? Who has the highest amputation rates in America?” he asked. “That’s your data.” He had taken to the national stage, speaking at conferences about what he’d witnessed in Bolivar. On behalf of the Association of Black Cardiologists, he testified before Congress, convincing U.S. Rep. Donald M. Payne Jr., a Democrat from New Jersey, along with U.S. Rep. Gus Bilirakis, a Republican from Florida, to start a Congressional Peripheral Artery Disease Caucus. The group is pushing for the task force to reevaluate the evidence on screening at-risk patients, for federal insurers to start an amputation prevention program and for Medicare to ensure that no amputation is allowed before evaluating arteries. Other groups are advocating for legislation that would require hospitals to publicly report their amputation rates.

In Bolivar, Fakorede had seen more than 10,000 cardiovascular patients from around the Delta. Dr. DeGail Hadley, a primary care provider in town, told me that before Fakorede arrived, he wasn’t sure what was best to do for patients with rotting feet. “It was always a process of transferring the patients to Jackson or Memphis, which can be difficult.” Both cities were two hours away. Now, Fakorede was performing about 500 angiograms annually in town. Last year, he published a paper in Cath Lab Digest describing an 88% decrease in major amputations at Bolivar Medical Center, from 56 to seven. (Fakorede did not provide me with all of his sources.) The hospital has different internal figures, which also reflect a significant decrease. Between 2014 and 2017, the hospital recorded that major amputations had fallen 75% — from 24 to six.

Fakorede couldn’t catch everyone in time, and he was haunted by the patients who got to him too late. A week before he’d met Dotstry, Sandra Wade had come in with an open sore on her right big toe. She came from a family of diabetics. Her mother had died after a diabetic coma. Her cousin had just lost a leg. Her oldest sister, who’d raised her, had given up on walking when a tired, burning, itching sensation consumed her legs. Now, Wade felt it, too.

Sandra Wade. (Ruddy Roye for ProPublica)

“I don’t want to give up like that,” Wade had said, reclining in a cot in Fakorede’s pre-procedure room. “I want my toes. I don’t want to lose not one limb. I choose life.” She elongated her O’s. She was 55 and had a high, gentle voice, a wide smile and big, curled lashes under loose, curled hair. She had spent most of her career in food service and retail, recently managing a Family Dollar, but after diabetes took her eyesight, she’d had to quit. She wondered if the sodas and chips that had fueled her at the store had accelerated her disease. Or if she’d focused so much on her son, who was developmentally disabled, that she’d neglected herself. She didn’t like to offload blame onto her genes. “Somebody’s gotta try to change the cycle,” she’d said. “I really want to be the one.”

Fakorede inserted an IV into the top of her leg. He opened up each of her blocked arteries, one at a time, until he got to the most important one, which ran along her inner calf. It was supposed to supply blood to her open wound, and she needed it to heal. Without it, she’d likely lose her toe. If she didn’t control her sugars, she could lose her lower leg next. Fakorede was hopeful as he slid a wire through the vessel in her knee, and into that crucial artery in her calf. But then, about a third of the way down, it stopped. It was as if the vessel itself had evaporated.


UNDER A CRISP, WIDE SKY, on Martin Luther King Jr. Day, churches around town were opening their doors for services. Fakorede’s office was scheduled to be closed, but he’d called in his nurses and radiology technicians, even those out hunting deer, to staff Dotstry’s case.

“What’s up, young man?” Fakorede greeted Dotstry, who was slowly fading into his Ambien, and he handed Judy a diagram of a leg. “The prayer is that we can find this many vessels to open up,” he said, pointing to the paper. “As soon as I’m done, I’ll let you know what I find.”

In the procedure room, he put on his camouflage-patterned lead apron, and with an assistant, he inserted an IV near Dotstry’s waist. He wound a wire across Dotstry’s iliac artery, into the top of his left leg. The femoral artery was open, even though it had hardened around the edges, a common complication of diabetes. They shot a gas down the arteries in Dotstry’s lower leg so the X-ray could capture its flow. Fakorede looped his thumbs into the top of his vest, waiting for the image. Other than a small obstruction, circulation to the toes was good. “They don’t need to whack off the knee,” he said, staring at the screen. Dotstry would lose one toe.

After they’d cleaned out the plaque, Fakorede called Judy into the lab and pulled up the X-rays. Dotstry snored in the background. The doctor showed Judy a playback of the blood moving through the vessels. She could tell that his foot had enough flow. She folded over, running her palms along her thighs. “Y’all have done a miracle, Jesus.”

Dotstry would need aggressive wound care, help controlling his sugars and a month in rehab following his toe amputation. In the meantime, Judy and her daughter would have to learn to manage his antibiotics and find him an apartment. He’d still be able to tinker with his cars, as he did most afternoons. And as far as Judy was concerned, he wasn’t moving to Texas.

Fakorede scrubbed out. He sat at his desk to update Dotstry’s doctors. He called an infectious disease specialist, 35 miles south, to check on whether he could see Dotstry the following morning. Then, he dialed the hospital and asked for one of the nurses. He explained what he’d found: that Dotstry didn’t need a leg amputation.

“Oh, great,” the nurse replied. “The surgeon was calling and asking about that. He called and tried to schedule one.”

Fakorede had been typing up notes at the same time, but now he stopped. “He was trying to schedule it when?” he asked.

“He was trying to schedule it today.”


ABOUT THE REPORTING

For this story, Lizzie Presser spent over a month in Mississippi, in December and January, speaking with dozens of patients and shadowing doctors, in clinic and in procedures. She interviewed over a dozen medical professionals whose work has intersected with Fakorede’s, including nurses, limb-salvage specialists, primary care providers and the hospital’s consulting surgeon, Dr. Roger Blake, who corroborated all facts related to his treatment plan for Henry Dotstry. She asked Bolivar Medical Center if it believed it provided Dotstry with adequate care. Even with Dotstry’s permission, the hospital declined to comment on his case, citing patient privacy.

The scenes in the story are informed by her own observations and interviews with the subjects to fill in details, including their thoughts at the time.

To put her observed reporting into national context, she reviewed the salient medical research and interviewed more than a dozen experts in all corners of the health care system, from those who treat diabetic patients to those who inform and set policies around care.

Lizzie Presser covers health, inequality and how policy is experienced for ProPublica.

Benjamin Hardy contributed research to this story. Maps by Lena Groeger. Design and production by Jillian KumagaiAgnes Chang, and David Sleight.

Source: The Black American Amputation Epidemic

How COVID-19 Hollowed Out a Generation of Young Black Men — ProPublica

How COVID-19 Hollowed Out a Generation of Young Black Men

They were pillars of their communities and families, and they are not replaceable. To understand why COVID-19 killed so many young Black men, you need to know the legend of John Henry.

The Rev. Dr. Kejuane Artez Bates was a big man with big responsibilities. The arrival of the novel coronavirus in Vidalia, Louisiana, was another burden on a body already breaking under the load. Bates was in his 10th year with the Vidalia Police Department, assigned as a resource officer to the upper elementary school. But with classrooms indefinitely closed, he was back on patrol duty and, like most people in those early days of the pandemic, unprotected by a mask. On Friday, March 20, he was coughing and his nose was bleeding. The next day, he couldn’t get out of bed.

Bates was only 36, too young to be at risk for COVID-19, or so the conventional wisdom went. He attributed his malaise to allergies and pushed forward with his second full-time job, as head pastor of Forest Aid Baptist Church, working on his Sunday sermon between naps. Online church was a new concept to his parishioners, and during the next morning’s service, he had to keep reminding them to mute their phones. As he preached about Daniel in the lion’s den — we will be tested, but if we continue to have faith, we will come through — he grimaced from the effort. That night he was burning up with fever. Five days later he was on a ventilator; five days after that, he died.

While COVID-19 has killed 1 out of every 800 African Americans, a toll that overwhelms the imagination, even more stunning is the deadly efficiency with which it has targeted young Black men like Bates. One study using data through July found that Black people ages 35 to 44 were dying at nine times the rate of white people the same age, though the gap slightly narrowed later in the year. And in an analysis for ProPublica this summer using the only reliable data at the time accounting for age, race and gender, from Michigan and Georgia, Harvard researcher Tamara Rushovich found that the disparity was greatest in Black men. It was a phenomenon Enrique Neblett Jr. noticed when he kept seeing online memorials for men his age. “I’ll be 45 this year,” said the University of Michigan professor, who studies racism and health. “I wasn’t seeing 60- and 70-year-old men. We absolutely need to be asking what is going on here?”

To help illuminate this gap in knowledge and gain a deeper understanding of why America has lost so many young Black men to COVID-19, ProPublica spent months gathering their stories, starting with hundreds of news articles, obituaries and medical examiners’ reports, then interviewing the relatives and friends of nearly two dozen men, along with researchers who specialize in Black men’s health. Our efforts led us to a little-known body of research that takes its name from one of the most enduring symbols of Black American resilience.

In interviews about the young men who died from the virus, a portrait emerged of a modern John Henry: hard-working, ambitious, optimistic and persistent, trying to lift others along with themselves. They were the very people communities would have turned to first to help recover from the pandemic: entrepreneurs who were also employers; confidants like coaches, pastors and barbers; family men forced into a sandwich generation younger than their white counterparts, because their parents got sick earlier and they had to care for them while raising kids of their own.

They were ordinary men. Time and again, it was their fight that was remarkable.

Kejuane Bates and his daughter, Madison.
Kejuane Bates and his daughter, Madison. (Courtesy of Chelsea Bates)

Bates, the only child of a single mother who supported him as a teacher’s aide, made it to Alcorn State University on football and choir scholarships. When his mother got sick with breast cancer, he had to drop out; after she died, he was almost destitute. Over the years, he built himself into multiple men at once, each a pillar to many others: the pastor whose flock depended on his counsel; the mentor known to school kids as Uncle Officer Bates; the assistant football coach and band director; the adoring father to 5-year-old Madison — his “heartbeat,” he called her. Recently he and his wife, Chelsea, a second grade teacher, had launched One Love Travel, organizing excursion packages and cruises as part of their long-term plan to build generational wealth.

He carried the stress of his efforts in his blood vessels, in his kidneys, in the extra pounds that accumulated with each passing year; he had diabetes and hypertension and at 6-foot-6, he was more than 100 pounds overweight. His official cause of death, on April 1, was COVID-19-related pneumonia and acute respiratory distress syndrome.

But Chelsea knows that the virus, no matter how powerful, didn’t kill her husband on its own. It was the years of working nonstop, taking care of other people more than himself, that wore his body down. And when the virus attacked, he couldn’t fight back.


 

In the summer of 1978, the social epidemiologist Sherman James, then a 34-year-old researcher at the University of North Carolina at Chapel Hill, met the man who would shape his life’s work. At 70, John Martin was a retired farmer who suffered from debilitating osteoarthritis and hypertension. He had peptic ulcers so severe that doctors had to remove 40% of his stomach. Recounting his story in his backyard rocking chair, his cane resting on his lap, the old man had no doubt why his health was so bad: “I worked too hard.”

Born in 1907, Martin grew up in a family of sharecroppers who were only paid half of what their labor in the tobacco fields earned. Throughout the South at the time, most Black farmers lived at the economic mercy of landowners who were employers, landlords and vendors all at once. Martin watched as the system ruthlessly exploited his father; after one particularly harsh winter spent hungry, Martin vowed he would be different. Borrowing $3,725 in 1941, he purchased 75 acres. He had 40 years to settle the mortgage but accomplished the near-impossible: He paid it off in five. “That’s the reason my legs [are] all out of whack today,” he told James.

James listened, spellbound, until Martin’s wife called out, “John Henry, it’s time for lunch.” At that moment, something clicked. Holy cow, James remembers thinking. “It was just like the ancestors were speaking to me.” The power of Martin’s story wasn’t simply that it echoed the legend of John Henry; it also echoed the life experiences of most of the working-class African American men James knew.

Five years out of graduate school, James was among a small group of researchers focusing on one of the most enduring public health problems in the United States: why health outcomes for Black men are so poor. Black men live shorter lives than all other Americans — 71.5 years versus 76.1 years for white men — and have for generations. Black men’s life expectancy didn’t reach 65, the eligibility age for Medicare, until 1995, 30 years after the federal health program for the elderly became law; white men were living into their mid-60s by 1950. The shorter lifespans reflect a broader disparity: Black people have much higher rates of hypertension, obesity, diabetes and strokes than white people do, and they develop those chronic conditions up to 10 years earlier. The gap persisted this year when the Brookings Institution examined COVID-19 deaths by race; in each age category, Black people were dying at roughly the same rate as white people more than a decade older.

For generations, public health experts mostly ignored the disparities. When they did pay attention, they invariably blamed the victims — their “unhealthy” behaviors and diets, their genes, the under-resourced neighborhoods they “chose” to live in and the low-paying jobs they “chose” to work. Their chronic illnesses were seen as failures of personal responsibility. Their shorter life expectancy was written off to addiction and the myth of “black-on-black” violence. Many of those arguments were legacies of the slave and Jim Crow eras, when the white medical and science establishment promoted the idea of innate Black inferiority and criminality to rationalize systems built on servitude and segregation.

Pondering the lessons of John Henry Martin, James began to see what many of his colleagues had been missing. It wasn’t just living in poverty that wore down Black men’s bodies, he hypothesized, but the struggle to break out of poverty. It wasn’t just inequality that made them sick, but the effort to be equal in a system that was fundamentally unjust. “It’s this striving to make something of themselves … to live their lives with dignity and purpose and to be successful against extraordinary circumstances,” James said. “They’re trying to make a way out of no way. It’s the Black American story.”

Sherman James Explains the Theory of John Henryism

Joe Singer, Nadia Sussman, Derrick Dent (special to ProPublica)

America has changed profoundly since Martin’s day. Yet the machinery of racial inequality continues to be omnipresent. It’s in the hospitals where Black newborns have significantly lower mortality if they’re cared for by Black doctors rather than white ones. In the redlined neighborhoods where poverty and pollution are concentrated — but not affordable housing or grocery stores or reliable internet. It’s in the crumbling, exploitative economies that force parents to risk their lives working long hours for low pay without sick leave. In mass incarceration and voter suppression. In the innumerable hurdles, one piled upon another, that make Black Americans’ climb up the socioeconomic ladder more daunting than ever, their successes more fragile and their setbacks more consequential.

“Everyone thinks about racism as something that is personally mediated, like someone insulting me,” said Linda Sprague Martinez, a professor at Boston University’s School of Social Work who conducts community health research with adolescents and young adults. “But the way in which it’s really pervasive is how it disrupts life chances and opportunity. … These are systems that are designed for you to fail, essentially, and for you to be erased and to be maintained in a certain position in our society.”

Challenging such a relentless machine, through “high-effort coping,” James concluded, requires three categories of personal traits that are major themes of the John Henry legend: tenacity, mental and physical vigor and a commitment to hard work. To measure them, he developed the John Henryism scale, with scores determined by how strongly people identify with 12 statements, including: “Once I make up my mind to do something, I stay with it until the job is completely done,” and, “It’s not always easy, but I usually find a way to do what really needs to be done.”

To score high in John Henryism, you don’t have to be Black or male or economically disadvantaged. But over the years, James and other researchers have found that Black people, especially those who are poor and working-class, do score high and tend to suffer greater cardiovascular risks, perhaps because the innumerable hurdles in their paths require greater effort to overcome. “The stress,” James said, “is going to be far more overwhelming than it has a human right to be.”

Elliott Robbins, special to ProPublica

Stress is a physiological reaction, hard-wired in the body, that helps protect it against external threats. At the first sign of danger, the brain sounds an alarm, setting off a torrent of neurological and hormonal signals that whoosh into the blood, stimulating the body to fight or give flight. The heart beats faster and breathing quickens; blood vessels dilate, so more oxygen reaches the brain and muscles. The immune system’s inflammatory response is activated to promote quick healing. When the threat passes, hormone levels return to normal, blood glucose ebbs and heart rate and blood pressure go back to baseline. At least, that’s how the human body is designed to work.

But overexposure to cortisol and other stress hormones can cause the gears to malfunction. “Your body’s over-producing, always working hard to bring itself back down to the normal level,” said Roland J. Thorpe Jr., a professor at the Johns Hopkins Bloomberg School of Public Health and founding director of the Program for Research on Men’s Health at the Hopkins Center for Health Disparities Solutions. The constant strain “resets the normal,” he said. As blood pressure remains high and inflammation becomes chronic, the inner linings of blood vessels start to thicken and stiffen, which forces the heart to work harder, which dysregulates other organs until they, too, begin to fail. “Your body starts to wear down,” Thorpe said — a phenomenon known as weathering.

The cumulative effects of stress begin in the womb, when cortisol released into a pregnant woman’s bloodstream crosses the placenta; it is one of the reasons a disproportionate number of Black babies are born too early and too small. Then, exposure to adverse childhood experiences — anything from abuse and neglect to poverty and hunger — continues the toxic stream; too much exposure to cortisol at a critical stage in development can rewire the neurological system’s fight-or-flight response, essentially causing the brain’s stress switch to break. The more stress a youngster endures, the more likely he or she is to have academic, behavioral and health problems from depression to obesity.

Weathering isn’t specific to race, but it is believed to take a particular toll on Black people because of the unique, unrelenting stress caused by racism that wears away the body and the spirit, “just like you have siding on the house, and the rain or the sun beats on it, and eventually it starts to fade,” said Dr. Jerome Adams, the U.S. surgeon general under the Trump administration. Shawnita Sealy-Jefferson, a social epidemiologist at Ohio State University, says the human body isn’t designed to withstand such biological and emotional assaults: “It’s the same thing as if you revved the engine of your car all day, every day. Sooner or later, the car is going to break down.”

The effects of stress can be seen at the cellular level. Researchers have found that in Black people, telomeres — repeated sequences of DNA that protect the ends of chromosomes by forming a cap, much like the plastic tip on a shoelace — become shortened at a faster rate, a sign of premature aging. In a 2018 study examining changes in seven biomarkers in cardiac patients over a 30-year period, researchers found that Black patients weathered at an average of about six years faster than whites. And it was the extraordinarily high rates of hypertension in the Black community that prompted scientists to look at the impact of stress in the first place. By age 55, about 76% of Black men and women develop high blood pressure, versus 54% of white men and 40% of white women, which increases the risk of heart attacks and strokes.

Sustained stress has strong links to obesity, which Black children and adults have at much higher rates than whites. Some of this is physiological: The interplay between cortisol and glucose is complex and insidious, triggering metabolic changes that can lead to diabetes and other chronic diseases. Some of it is psychological and behavioral: Stress is strongly associated with depression and other mental health disorders. “The way that people deal with stress is by strategies that make us feel better,” such as comfort eating, said Thomas LaVeist, dean of Tulane University School of Public Health and Tropical Medicine. Stress and anxiety cause sleeplessness, which itself is correlated with weight gain. The result is often a cascade of health problems — hypertension, cardiovascular disease, metabolic syndrome — that strike early and feed off of each other.

Because Black Americans experience many forms of stress, often at once, researchers have more questions than answers about the specific role John Henryism plays in these outcomes. The study of Black men’s health remains an under-examined frontier, with little in the way of funding or will because “Black men are not viewed as sympathetic,” said LaVeist, and because so few go into the health research professions. He and Thorpe, the Johns Hopkins professor, co-founded the Black Men’s Health Project, the first large-scale national study focused solely on Black men’s needs, with a goal sample size of 5,000. They hope to learn how stressors like segregation and adverse early life experiences impact health outcomes.

If this segregated body of emerging knowledge were to grow and infiltrate the mainstream medical and research communities, James can only imagine how beneficial that would be. Health professionals could build deeper relationships with their patients by better understanding the sources of stress that wreak havoc on their cardiovascular systems. They could test for high blood pressure, diabetes and cholesterol levels more frequently and at younger ages. “Until we can have a society that is more just racially,” James said, “we do need to find these intermediate steps.”

As ProPublica examined the lives lost to COVID-19, themes emerged in the pressure points faced by many young Black men. The wearing down typically begins when they are boys and must become little John Henrys to navigate white spaces or push through the adverse experiences endemic to Black communities. It continues when they grow into men, as most need to navigate the public’s projections of danger with unwavering vigilance. The more they succeed, the more responsibility they feel to lift their families and communities with them, and with that, comes more stress.

As James listened to the stories ProPublica was gathering, he instantly recognized the cycle of striving and succumbing that he has been writing about for 40 years. “They could have done so much more had the struggle not been so intense,” James said. “They were cut down too soon.”

Elliott Robbins, special to ProPublica

Thomas Fields Jr. was barely a year old when his father first went to prison. The loss altered the trajectory of his life in ways that many children wouldn’t have been able to overcome. His mother, just 17 when he was born, moved with him from the suburbs of Washington, D.C., to Detroit, where her own mother had recently relocated. The city was in freefall: manufacturing jobs were disappearing; crime was surging; middle-class and white flight was stripping away the city’s tax base, eroding vital services and causing schools to fail. Just waiting at the wrong bus stop could get you robbed or shot.

“When you’re a young male living in Detroit, if you live past 18, it’s like you’re 50 years old,” Fields, then 31, said on a Facebook Live chat last year. “I swear that’s how it feels.”

Mitigating childhood adversity requires deep wells of resilience; researchers say one of the best ways to build those reserves is having a nurturing caregiver. In this, young Thomas was exceptionally lucky. His mother worked two jobs and still managed to watch him like a hawk; she told him constantly that she loved him. His grandmothers looked after him after school and during summer breaks. His father, Thomas Sr., did his best to be involved from behind bars, urging him to not make the same mistakes. “I wanted this Thomas Fields to break the mold,” he said.

Thomas Fields Jr. standing in Times Square.
Thomas Fields Jr. (Courtesy of Fields’ family)

To do that, Thomas became a little John Henry. He got decent grades, stayed out of trouble and taught himself to cook — healthy food, not the junk so many of his peers ate. After high school, he attended Grambling State University in Louisiana for a couple of years, then joined the U.S. Navy, where he went from being a talented amateur chef to a trained professional. He also became a father. When there were setbacks, he was already planning his next move. It’s a strategy that Black adolescents absorb like the air they breathe and the water they drink, Sprague Martinez said. “The mentality is: ‘Even if this system is not designed to work for me … I’m going to win this game. I haven’t gotten the prize yet? I must not be working hard enough.’”

High-effort coping can confer mental health benefits even for children raised in the direst of circumstances. Dosha DJay Joi endured the kind of trauma that dooms many children — beatings, neglect, sexual abuse. Born in Chicago, he spent much of his adolescence in group homes in the Wisconsin system. For years he was afraid to talk about the abuse and scared to tell his birth mother he was queer. He learned to channel himself into education and advocacy, helping other LGBTQ and foster kids; he especially wanted to make sure children remained connected with their siblings. He was inspired to study social work because of what he’d been through, said his mother, Kecha Kitchens. “Then a family member got sick, and he didn’t like how the nurses were treating the other patients in the nursing home, so he wanted to become a nurse.”

Dosha Joi wearing a red shirt.
Dosha Joi. (Courtesy of Kecha Kitchens)

By the age of 28, Joi had a bachelor’s degree in human services, he had trained as a substance abuse counselor and he was working toward his nursing degree. He served as a court-appointed special advocate for kids aging out of foster care and lobbied lawmakers in the Wisconsin capitol and Washington D.C., forming a special bond with Rep. Gwen Moore, who represents Milwaukee in Congress. But the years of hardship took an enormous physical toll; Joi suffered from hypertension, heart and lung problems and at his heaviest, he weighed more than 500 pounds. When COVID-19 arrived in the Midwest, he was particularly vulnerable. He died on May 14.

For young John Henrys, the psychological benefits of high-effort coping seem to be complicated by what’s happening inside the body. “Typically when you study resilience in any group, and [subjects are] doing well by our typical metrics” — going to college, getting a good job, not taking drugs — “we say, ‘Woo-hoo,’” University of Georgia researcher Gene Brody said. “Logically, we thought this would transfer to have health benefits.” But for Black young adults trying to climb the economic ladder, they found just the opposite. “When you look under the skin, doing blood draws and using other kinds of measures, they look like their health is starting to suffer.”

In more than 25 years spent tracking the health of Black families in rural Georgia, Brody and his colleagues found that adolescents identified by their teachers as being success-oriented already had higher “allostatic loads” — science jargon for wear-and-tear on the body — at age 19 than their peers. By age 25, those from more disadvantaged backgrounds who scored high on the John Henryism scale were more likely to have metabolic syndrome, a cluster of conditions that are precursors to diabetes and heart disease, than people from less disadvantaged backgrounds. Brody and his colleagues have dubbed this phenomenon “skin-deep resilience.” The same effects are not found for young white strivers.

In his late 20s, Fields was diagnosed with such a severe case of diabetes that his military career came to a screeching halt. When he returned to Detroit last year, he was a little brawnier, with more tattoos. “Diabetes was something that he was going to beat, because he wasn’t going to lose to anything,” said the Rev. Torion Bridges, one of his best friends for 20 years. He became a personal chef and motivational speaker, started a podcast and wrote a cookbook. He helped out his mom, who had multiple sclerosis. And he took a job as a “school culture facilitator,” working with kids who had discipline problems, at Paul Robeson Malcolm X Academy, the pioneering Afrocentric public school he had attended. He was especially good with troubled boys who didn’t have a father at home, said principal Jeffrey Robinson, his onetime homeroom teacher, later his boss. “He could identify with the feeling of the loss.”

In March, Fields and his mother caught the coronavirus at the same time.

She recovered. He did not.

Elliott Robbins, special to ProPublica

To navigate life as a Black man is to be constantly vigilant. The ubiquity of racism means that everyday interactions, while driving or shopping or birdwatching, can have potentially dangerous outcomes. So John Henrys live in a heightened state of awareness, continually adjusting. It might mean placing family photos near the front door to quickly prove your son belongs should police ever respond. It often means being able to “strategically assimilate” — to assume a public identity aimed at neutralizing stereotypes of blackness and defusing irrational white fears. This, W.E.B. DuBois explained more than a century ago, is “double-consciousness, this sense of always looking at one’s self through the eyes of others, of measuring one’s soul by the tape of a world that looks on in amused contempt and pity.”

New York Times columnist Brent Staples would whistle Vivaldi in graduate school to signal that he was too cultured to be threatening. Darrell Hudson, who researches health disparities at Washington University in St. Louis, scans the closet each day before teaching class to select what he calls his “Non- Threatening Black Guy Uniform.”

“What’s not appreciated fully, I think, is how much energy it takes,” said Derek M. Griffith, professor and director of the Center for Research on Men’s Health at Vanderbilt University. “All of these different things that you have to do to modulate your body and so forth, all that additional attention that you have to pay to that, is a burden that most people don’t have to bear. It is a cause of weathering that we don’t fully appreciate.”

2014 study found that vigilance was positively associated with the prevalence of hypertension for Blacks but not whites. The more vigilant Black people were, the more the disparity grew. And researchers have found that Black people who are on guard against anticipated discrimination have higher blood pressures while they sleep. “When you experience racism or discrimination and it could cost your life, it’s good to be vigilant; but a prolonged and heightened state of vigilance is not good,” the University of Michigan’s Neblett said. “It can kill you in the end.”

Leslie Lamar Parker, at a maternity photo shoot before the birth of his son Chance.
Leslie Lamar Parker, at a maternity photo shoot before the birth of his son Chance. (Courtesy of Whitney Parker)

Leslie Lamar Parker grew up in the Minneapolis suburbs, in a state that was 84% white. Like many John Henrys in this story, he was large — tall and wide — in a way that made him stand out to cruel classmates and clueless teachers. Bigness can be perilous for Black boys, who are often seen as older, stronger and less innocent than their white counterparts, stereotypes that underlie higher rates of school discipline and police violence. Parker learned to play the class clown and questioned authority. “School couldn’t hold his attention, not because he wasn’t smart. He wouldn’t go,” his mother, Tyuon Brazell, said. Because he wasn’t on track to graduate, she did what other parents might not and suggested he drop out his junior year. That’s when he started to thrive, earning his GED, graduating from college and becoming an IT specialist in his old school district, where he mentored students of color, ordering them lunch from DoorDash and supervising the tech club. “That was really important to him,” said his wife, Whitney, “making sure they didn’t fail any other brown kids like they failed him.”

One key to his coping was overcorrecting for how he might be perceived. Strangers would approach him to say how lovely it was to see him with his son and daughter, a microaggression masquerading as a compliment. He was so sensitive to stereotypes about absent Black fathers, his wife said, he was “a present parent on steroids.” To walk through the world as a Black man is to be simultaneously hypervisible and invisible, under surveillance yet never really seen. So he turned his wardrobe into a “conversation starter,” an expression of his irreverent personality but also armor against snap judgments about his imposingness. He carried a Spongebob SquarePants backpack to work and often wore a pro-wrestling or superhero T-shirt during off hours.

Parker was constantly scanning the horizon for threats against his family and his kids at school, wondering whether there was something more that he could do for them. He projected a cool demeanor, his argumentative wit camouflaging worries that his mother knew kept his head in overdrive. “I kept telling him: ‘Son, you need to rest. You don’t have to do everything in a day.’” He was diagnosed with high blood pressure at just 27 and worried it, and the extra pounds, would keep him from seeing his two children grow up. He died in May from COVID-19 at the age of 31.

The effort it takes for Black people to navigate mostly white spaces — to get an education, earn a living, take out a loan, raise a child — can be caustic. Their credentials are questioned; expertise doubted. On college campuses, Black students are often asked if they’re on a sports scholarship or if they’re really students. Research shows that a person doesn’t need to be the target of a racist incident for his body to be affected. Watching videos of police killing Black people or even just anticipating a racist experience can trigger the fight-or-flight response. Incidents build up in memories and transform into chronic stressors; ruminating on them can activate the body’s biological stress reaction. This happens over and over again, often many times a day, until the cortisol pump essentially breaks.

Joshua Bush.
Joshua Bush. (Courtesy of LaKita Bush)

Joshua Bush, who died in April of COVID-19, slammed up against racial stereotypes in his work as a nurse in South Carolina. There were funny looks from people who didn’t expect to see a Black man when he arrived at job interviews and white patients who refused to let him touch them. He told them, “That is your choice, but you’re missing out on great help,” his mother, Linda, recalled. He and his wife, LaKita, saw the health care industry as their route to upward mobility. She worked in hospital administration; at 30, he was studying to become a registered nurse, working as an LPN.

Bush also suffered from a rare enzyme abnormality that caused severe muscle cramps from overexertion, and because of it, trips to the emergency room weren’t uncommon. He’d come to accept that the first image doctors and nurses saw — someone Black and overweight — influenced their bedside manner. They treated him like he had no medical knowledge and lectured him about diabetes, though it had nothing to do with why he was seeking care. His experience informed the way he cared for his own patients, part of his “fight against the system,” his wife said. At the same time, she could see her husband’s stress “all over his body.”

Elliott Robbins, special to ProPublica

Lifting as we climb, onward and upward we go. Words that started as a call-to-action at the rise of the Jim Crow South have become an enduring part of the African American experience — and can serve as a unique form of stress. The proverb was born of Black suffragist Mary Eliza Church Terrell’s belief that it was incumbent upon the growing Black middle and upper class to use their position to fight racial discrimination and help others rise through education, work and community activism. It is why Thomas Fields was told as a boy that he was “duty-bound” to give back to the community once he got an education. Why Dosha Joi advocated for young people in the system “because someone helped bring out the sunshine in me.”

“You’re socialized to say it’s not just about you. It’s really about what you’re going to do for your broader community and for your family,” Washington University’s Hudson explained. “People take it very seriously, trying to light a path for those behind them — even when they’re not necessarily in the most stable situation themselves. … But they’re lifting as they climb. That’s taxing. That’s a visceral stress.”

In the Brookhaven, Mississippi, of Eugene Thompson’s youth, Black business owners understood that Brookway Boulevard — at least the stretch that ran through downtown — was for white businesses. The election of Barack Obama was a turning point; Thompson figured if a Black man could become president of the United States, surely he could rent a modest space on “the Boulevard.” Publicly, his goal was to grow his client base by cutting white people’s hair, too. His family knew his aspirations were grander. “He wanted to do something in Brookhaven to help Black people to get off their knees,” his mother, Odell Edwards, said. “We are on our knees.”

It’s not easy earning a living in Mississippi, where the single most common job is working as a cashier and the $7.25 minimum wage hasn’t budged in a decade. Cutting hair came naturally for Thompson, who started on himself at 12. He attended a local beauty academy before he could afford to go to barber school and over the years took the same methodical approach to growing his business — buying secondhand equipment, doing the construction himself, all without bank loans, mentoring or government support.

Eugene Thompson in a barber shop.
Eugene Thompson. (Courtesy of Odell Edwards)

But Thompson’s real ambition was to start his own school. “He always tried to encourage the boys in the community, or people who had been in prison and couldn’t find a job — ’I can teach you how to cut hair and you can have your own business,’” his younger sister, Dedra Edwards, said. After three years spent earning his teaching credential, Thompson opened his TaperNation Barber Academy for students last fall. Then he realized graduates needed places to work, so he launched his next project: renovating a second shop nearby where other barbers and hair stylists could rent chairs.

“It was running him ragged,” Odell said.

At 46, Thompson was severely overweight and suffered from lifelong respiratory problems as well as anxiety and sleeplessness. High blood pressure and diabetes ran in his family, but Thompson’s true health status was unclear — like more than 15% of Black people in Mississippi, he wasn’t insured and avoided going to the doctor except in an emergency. When he started feeling symptoms of COVID-19 in late March, he shrugged them off at first; he’d been having heart palpitations and panic attacks, which his family attributed to stress from work.

After he died in early April, leaving behind six children, TaperNation had to shut down. “You have to have a barber’s instructor license to keep it going, and no one else in the family has one,” his sister said. “We had to sell almost everything.”

Recent disasters — Hurricane Katrina, the Great Recession — have shown that Black communities aren’t just more vulnerable than white populations to economic and social dislocations; they recover more slowly. The impacts of the pandemic are likely to be magnified because so many deaths have occurred among Black people under age 60, the peak earning years when people raise families, start businesses, amass social capital and create lasting legacies. In addition to the lives it took, COVID-19 has robbed wealth that John Henrys were only beginning to accrue and toppled what they had begun to build for themselves and those around them.

In many cases, they were the structural beams, holding everything up. “These are people who help pay bills for people who aren’t their biological family members,” said Sealy-Jefferson, the Ohio State social epidemiologist. “They bring food when somebody dies. They watch kids when a single mother has to work.” Some of the biggest losses are intangible, she said: “social support, emotional support, resource sharing, encouragement, storytelling, role modeling— all of these things that are vital for African Americans in particular, given our history in this country.”

Fields couldn’t comfort students reeling from a crisis that has killed more than 1,600 of their loved ones and neighbors. “It’s a tremendous loss,” said Robinson, his principal. Bates’ wife, Chelsea, was too bereaved to go back to work when school resumed, which meant living off of her husband’s death benefits and savings; she focused on trying to help Madison process a grief she’s too young to understand. “Sometimes she lays on the floor and kicks and screams that she wants her daddy, that she misses daddy and why did he have to leave?” she said. “I tell her, I’m sorry, I wish that mama could do something to bring him back. I really do.”

Elliott Robbins, special to ProPublica

Weekday mornings have been quiet without Kendall Pierre Sr. puttering around the house before sunrise so he could open his barbershop by 5 a.m. That’s when workers from nearby chemical plants would stop in for a cut or shave after their graveyard shifts. Sundays are different without his sermons at Mt. Zion Baptist Church, in the little town of Ama, Louisiana, followed by a family breakfast his son always looked forward to. “My grandmother would come. Some of my aunties and cousins. He would put Aunt Jemima batter in the waffle iron and say: ‘See? This is better than Waffle House!’”

Since his dad died in May of COVID-19, Kendall Pierre Jr., a 20-year-old student at Louisiana State University, has felt an overwhelming absence and, at the same time, his father’s equally consuming presence. “I can still hear him,” he said.

Clockwise from left, Kendall Pierre Sr., sons Kaden and Kendall Jr., wife Sabrina and daughter Tayler.
Clockwise from left, Kendall Pierre Sr., sons Kaden and Kendall Jr., wife Sabrina and daughter Tayler. (Courtesy of Sabrina Pierre)

Don’t drive with your hoodie on.

Work twice as hard.

Real men don’t wear slippers in public; put on some shoes.

The only child of a single mother, 45-year-old Pierre Sr. took his role as father figure seriously. To nieces and nephews, he was Uncle Dad. To his sons’ basketball teams, he was Coach Kendall with the pep talks.

If a task has begun, never leave it until it’s done.

Be the labor great or small, do it well or not at all.

When players couldn’t afford uniforms or travel for tournaments, he would pay. “Their parents would send them with all they could, which was sometimes only $5,” Pierre Jr. said. They could count on him for food, deodorant, even a haircut. “He would bring his clippers to make sure all the players looked nice.”

When the killing of George Floyd roiled the country, Pierre Jr. had no doubt about how his father would have reacted. He would have talked to officials at the sheriff’s office, school board administrators, government leaders. He would have organized community meetings at the church.

We’re living in troubled times.

His son thought about that when his friend texted him about organizing a Black Lives Matter protest. “Since my dad passed, I’ve had this newfound courage, and this urge to act on things … to just do things outside of my comfort zone,” he said.

On a Saturday morning in June, 400 people joined in the 2.6-mile march from Westbank Bridge Park to St. Charles Parish Courthouse. A local reporter covered it and interviewed Pierre Jr. for a story. “If we don’t speak about systemic racism and police brutality, no change will ever happen,” he said. “I feel like it’s something that I have to do and be a part of something bigger than just me.”

He knows his father would have been proud. His mother was. But she worries, too. Her husband didn’t make enough time for doctor’s appointments to monitor his Type 2 diabetes, nor did he get much sleep. “I would tell him, ‘Kendall, you need to rest,’” recalled Sabrina, his wife of 24 years and a registered nurse. “He would say he could rest when he’s dead and gone.”

She knows how much goes into taking care of yourself as a Black man and thinks about that every time her sons walk out the door; her daughter, too. “Lord, I pray for them. … I tell them: ‘Put the seat belt on, drive the speed limit. Make sure you don’t get any tickets.’ I don’t want them to get stopped by a cop.” Her husband’s stature in the community conferred a kind of protection. “Because of my husband and who he was, people would be looking out for my sons. We don’t have that anymore.”

Zipporah Osei and Mollie Simon contributed reporting.

Art Direction by Lisa Larson-Walker.


About the Art

Elliott Jamal Robbins, 32, is an artist who works in a variety of media, including drawing, printmaking, sculpture and video/animation. He has exhibited artworks in group and solo exhibitions in New York, Chicago, Miami, Berlin and the Netherlands. This is how he described his thinking behind the art in this story:

For me, the story of John Henry presents problems. Namely, its focus on the physical attributes of the man and celebrating the labor that killed him. In the original tale, John Henry is almost Christlike in his willingness, if not gleeful, in sacrificing his own body. In my own work, I’m always more drawn to the mundane scene. Rather than consider the figure of John Henry as a type or didactic prop to expound the ills of systemic racism, I decided to focus a narrative as though from the point of view of the subject, and we witness his day-to-day experiences as he does.

Beginning on the bus, we are reminded of this as the site where African Americans fought for the basic human right to sit where they chose. From one mode of transportation to another, the horseback rider recalls the notion of the American west, which most often represents a connection to the land, and freedom. In contrasting the horse from the rider, we see that while one figure experiences a kind of liberation, another body is at work which propels this motion. This relationship between horse and rider is a corollary for the relationship between John Henry and the train, a mechanical achievement that would bring with it the promises of cross country travel, commerce and economic prosperity.

The story of John Henry is a means of making visible the unseen labor, exploitation and oppression of nation building. In this way I want to consider the real impact of systemic racism on those experiencing it daily, as well as decentralize the notion of racial violence from images of murdered black men and women. Instead, I want to consider how violence is enacted everyday, and its key actors are those who participate in systems which are propped up by the degradation of others.

Clarification, Dec. 24, 2020: This story was updated to clarify a figure on Black infant mortality.

RACIAL JUSTICE

ProPublica is a nonprofit newsroom that investigates abuses of power.

Source: How COVID-19 Hollowed Out a Generation of Young Black Men — ProPublica

The Effect of the Coronavirus on America’s Black Communities | The New Yorker

The old African-American aphorism “When white America catches a cold, black America gets pneumonia” has a new, morbid twist: when white America catches the novel coronavirus, black Americans die.

Thousands of white Americans have also died from the virus, but the pace at which African-Americans are dying has transformed this public-health crisis into an object lesson in racial and class inequality. According to a Reuters report, African-Americans are more likely to die of covid-19 than any other group in the U.S. It is still early in the course of the pandemic, and the demographic data is incomplete, but the partial view is enough to prompt a sober reflection on this bitter harvest of American racism.

The small city of Albany, Georgia, two hundred miles south of Atlanta, was the site of a heroic civil-rights standoff between the city’s black residents and its white police chief in the early nineteen-sixties. Today, more than twelve hundred people in the county have confirmed covid-19 cases, and at least seventy-eight people have died. According to earlier reports, eighty-one per cent of the dead are African-American.

In Michigan, African-Americans make up fourteen per cent of the state’s population, but, currently, they account for thirty-three per cent of its reported infections and forty per cent of its deaths. Twenty-six per cent of the state’s infections and twenty-five per cent of deaths are in Detroit, a city that is seventy-nine per cent African-American. covid-19 is also ravaging the city’s suburbs that have large black populations.

The virus has shaken African-Americans in Chicago, who account for fifty-two per cent of the city’s confirmed cases and a startling seventy-two per cent of deaths—far outpacing their proportion of the city’s population.

As many have already noted, this macabre roll call reflects the fact that African-Americans are more likely to have preëxisting health conditions that make the coronavirus particularly deadly. This is certainly true. These conditions—diabetes, asthma, heart disease, and obesity—are critical factors, and they point to the persistence of racial discrimination, which has long heightened black vulnerability to premature death, as the scholar Ruthie Wilson Gilmore has said for years. Racism in the shadow of American slavery has diminished almost all of the life chances of African-Americans. Black people are poorer, more likely to be underemployed, condemned to substandard housing, and given inferior health care because of their race. These factors explain why African-Americans are sixty per cent more likely to have been diagnosed with diabetes than white Americans, and why black women are sixty per cent more likely to have high blood pressure than white women. Such health disparities are as much markers of racial inequality as mass incarceration or housing discrimination.

It is easy to simply point to the prevalence of these health conditions among African-Americans as the most important explanation for their rising death rates. But it is also important to acknowledge that black vulnerability is especially heightened by the continued ineptitude of the federal government in response to the coronavirus. The mounting carnage in Trump’s America did not have to happen to the extent that it has. covid-19 testing remains maddeningly inconsistent and unavailable, with access breaking down along the predictable lines. In Philadelphia, a scientist at Drexel University found that, in Zip Codes with a “lower proportion of minorities and higher incomes,” a higher number of tests were administered. In Zip Codes with a higher number of unemployed and uninsured residents, there were fewer tests. Taken together, testing in higher-income neighborhoods is six times greater than it is in poorer neighborhoods.

Inconsistent testing, in combination with steadfast denials from the White House about the threat of the virus, exacerbated the appalling lack of preparation for this catastrophe. With more early coördination, hospitals might have procured the necessary equipment and staffed up properly, potentially avoiding the onslaught that has occurred. The consequences are devastating. In the Detroit area, where the disease is surging, about fifteen hundred hospital workers, including five hundred nurses at Beaumont Health, Michigan’s largest hospital system, are off of the job with symptoms of covid-19. Early in the crisis, at New York City’s Mount Sinai Hospital, nurses were reduced to wearing garbage bags for their protection. Across the country, health-care providers are being asked to ration face masks and shields, dramatically raising the potential of their own infection, and thereby increasing the strain on the already overextended hospitals.

The early wave of disproportionate black deaths was hastened by Trumpian malfeasance, but the deaths to come are the predictable outcome of decades of disinvestment and institutional neglect. In mid-March, Toni Preckwinkle, the president of the Cook County Board in Illinois, which encompasses Chicago, lamented the covid-19 crisis and proclaimed that “we are all in this together,” but, weeks later, she closed the emergency room of the public Provident Hospital in the predominantly black South Side. Preckwinkle claimed that the closure would last for a month and was a response to a single health-care worker becoming infected with the virus. Leave aside the fact that nurses, doctors, and other health-care workers have been testing positive for covid-19 across the country, and their facilities have not been shuttered. It is a decision that simply could not have been made, in the midst of a historic pandemic, in any of the city’s wealthy, white neighborhoods on the North Side.

Meanwhile, in Cook County Jail, three hundred and twenty-three inmates and a hundred and ninety-six correctional officers have tested positive for covid-19. Not only have officials not closed the county jail as a result but they also have yet to release a significant number of jailed people, even though the facility has the highest density of covid-19 cases in Chicago. These are the kinds of decisions that explain why there is a thirty-year difference in life expectancy—in the same city—between the black neighborhood of Englewood and the white neighborhood of Streeterville. They are also just the latest examples of the ways that racism is the ultimate result of the decisions that government officials make, regardless of their intentions. Preckwinkle is African-American, and the chairperson of the Cook County Democratic Party, but her decisions regarding Provident Hospital and Cook County Jail will still deeply wound African-Americans across Chicago.

The rapidity with which the pandemic has consumed black communities is shocking, but it also provides an unvarnished look into the dynamics of race and class that existed long before it emerged. The most futile conversation in the U.S. is the argument about whether race or class is the main impediment to African-American social mobility. In reality, they cannot be separated from each other. African-Americans are suffering through this crisis not only because of racism but also because of how racial discrimination has tied them to the bottom of the U.S. class hierarchy . . .

Read More: The Effect of the Coronavirus on America’s Black Communities | The New Yorker

Opinion | My Mother’s Death Will Have Everything and Nothing to Do With Covid-19 – The New York Times

My Mother Is Busy Getting Ready to Die

No insurance. 64 years old. Alone, along with all the other black people at the bottom of the pandemic.

By 

Dr. Manigault-Bryant is an associate professor of Africana studies at Williams College.

My mother is dying a painful death, and it has everything and nothing to do with Covid-19.

In a piece for The Atlantic detailing the ways in which the coronavirus seems to be hitting black people the hardest, Ibram X. Kendi wrote: “Sometimes racial data tell us something we don’t know. Other times we need racial data to confirm something we already seem to know.” My mother is a living example of what we already know about race, class and suffering.

She is not in an elder-care facility, nor a hospital. She has not been, and most likely will not be, tested for the virus or receive a diagnosis of having it.

Still, hers is the body of all the black people at the bottom of the pandemic. No insurance, though not for lack of trying. Medicaid applications denied for reasons we don’t understand. Inconsistent care at a local public clinic meant hard-to-come-by appointments and checkups only at moments deemed most critical. It wasn’t enough.

Now, she’s dying from end-stage liver disease and kidney failure, diagnosed too late to save her. This has nothing to do with Covid-19.

She is not even that old (64, and thus Medicare ineligible), but FaceTime tells no lies, and she is wasting away before us. What’s worse, even as I’m exactly four hours and three minutes away — geographically closer than I’ve been in over a decade — I can’t be near her, touch her, cook for her, kiss her or tell her all of the things that I don’t yet know I need to say. This has everything to do with Covid-19.
On the occasion she’s strong enough to answer the phone, holding the phone for FaceTime proves too much. Calls come too late, even as time is too short. The grandchildren who live close by cannot get close to her — the idea of transmitting anything to her, as she’s so obviously immune-compromised, is terrifying. The underlying conditions would amplify an already-certain death. This has everything to do with Covid-19.

My brother, who lives exactly six minutes and 24 seconds away from Mommy, risks seeing her because someone needs to make sure she’s still breathing. That check-in is thus essential. He scrubs himself clean after work with all manner of chemicals — he’s a waste management truck driver, an essential employee. This is an effort to protect her. He’s close to her. This is an effort to protect us. This has everything to do with Covid-19.

He tries to get her to eat something other than her single meal of applesauce and Vienna sausages. This has nothing to do with Covid-19.

It’s officially power-of-attorney and health-proxy time. Getting my mother to the lawyer — a four-minute drive — is a thing. My brother and I spend hours strategizing transportation. The errand feels like it takes an eternity. This has everything to do with Covid-19.

Like so many, countless others, my family and I are going to be left with the unsettling weight of her death. My mother is going to die soon, and it will most likely be alone. I am afraid. I am one of many grieving, forever-changed faces. No repast. No low-country songs sung graveside. No sending up our timber for her. We cannot grieve properly. Lots of regret. This has everything to do with Covid-19.

When the pandemic is over, we still won’t know how to deal with this. We’re not ready for this kind of grief. Death is so utter, so absolute, yet so much right now is uncertain. My mother is dying a painful death, and it has everything and nothing to do with Covid-19.

LeRhonda S. Manigault-Bryant (@DoctorRMB) is associate professor of Africana studies at Williams College and the author of “Talking to the Dead: Religion, Music, and Lived Memory Among Gullah/Geechee Women.”

 

Confinement and Disease from Slavery to the COVID-19 Pandemic – AAIHS

 

Confinement and Disease from Slavery to the COVID-19 Pandemic

Apartment building in Chicago, 1941, (Russell Lee: Library of Congress)

As many college students as well as others have moved back home during the current pandemic people’s houses are feeling more cramped than ever. The conditions of small living spaces feel even more confining as communities are tasked with staying inside as much as possible with orders to shelter in place still intact in some locations. These conditions have left many feeling restless, bored, agitated and sad as they try to carve out private space and a sense of normalcy in such an uncertain time. The feelings of confinement ordinary people are facing contrasts starkly with the views of celebrity housing available through live streams, photos, and videos on social media. Gal Gadot and several other celebrities, for example, released a video of them singing John Lennon’s “Imagine.” The video was posted to Gadot’s Instagram with the caption “We are in this together, we will get through it together. Let’s imagine together. Sing with us. All love to you, from me and my dear friends.” Immediately, people on Instagram and Twitter noted the emptiness of these gestures coming from wealthy celebrities without the addition of material action.

The pandemic has drawn to a head the inequalities in housing and wealth defining the contemporary US. The nation’s majority have been left scrambling to make rent for their tiny apartments while watching the wealthy squirrel away in large open concept mansions with lush lawns and huge pools.

For Black communities, these contradictions are nothing new, as forced immobility and confinement have defined their historical and contemporary experiences with regard to the matters of space. As West Africans were rendered slaves, one of their primary spatial experiences was confinement, first in slave castles like El Mina in modern Ghana and then aboard the thousands of slave ships that traversed the Atlantic across five centuries. Africans crossed the ocean packed in and chained together with little room to move.

The carceral space aboard the slave ship  put captives in a position of increased vulnerability to diseases and illness. Despite slave trader’s efforts to bring only “healthy” Africans across the sea many ships suffered numerous casualties due to yellow fever, smallpox, scurvy, malaria, flux, and several other diseases. Sowande’ Mustakeem has noted that the isolation caused by the sea voyage along with the cramped and unsanitary conditions captives were held in created unique and devastating encounters with disease. The spread of disease was further aggravated by the violent treatment of captives aboard these ships as well as poor nutrition. As people’s bodies attempted to heal from physical and psychological injuries as well as illness, they faced an environment that only further deteriorated their capacities to fight infection.

In the North American context, despite variation in housing circumstances across different regions and time, the enslaved were forced to live in confining spaces. Whether awaiting sale in a dingy and overcrowded slave pen in Richmond, living in overcrowded gender-segregated barracks in Charleston, or making lives in a drafty and inadequately sized cabin on a rural sugar plantation in New Orleans’ hinterland, slaves experienced the quotidian violence of tight living irrespective of other differences in their social conditions and labor. This contrasts sharply with white slave owners who demonstrated their power with sprawling homes on sprawling estates. Consider for example, Thomas Jefferson’s Albemarle County, Virginia mansion, Monticello in contrast to the small and poorly insulated log cabin structures in which the people he enslaved lived. The contrasts between Black and white space also had another dimension related to mobility. Especially in the wake of the Jacksonian era, white people moved freely, while enslaved people’s movements were legally regulated and violently circumscribed. Even free Black people, especially after Nat Turner’s bloody 1831 rebellion, were strictly delimited in their abilities to move freely. Confinement and immobility were twinned conditions for slaves. As Katherine McKittrick analyzesHarriet Ann Jacobs, spent seven years in her grandmother’s garret or attic space, unable to fully stand upright in nine-foot-long, seven-foot-wide, three-foot-tall space. She hid in this space, carving it as a “loophole of retreat” in order to evade the violence of her master and eventually to escape. For Jacobs freedom required a subtle reworking of the confinement enforced on Black life and Black geographies.

This lack of mobility and confinement continued after slavery as part of its afterlives along with the related condition of predisposition to contagious disease and premature death. In Chicago between the World Wars, Black migrant communities were forced into the West and Southside by legally sanctioned segregation, policing, and vigilante violence. Black families rented small apartments called kitchenettes at exorbitant rates, and as St. Clair Drake and Horace Cayton characterized  in their influential study, lived in cramped poorly heated and congested conditions. As Rashad Shabazz argues, in the spaces of kitchenettes, Black Chicagoans experienced an expression of carceral power in their ordinary lives, manifest in the arrangement of their housing. He writes “by creating close associations between people the kitchenette made privacy of any kind impossible, shaming its residents by putting all actions under the forced gaze of others in the room.”1 This kind of housing arrangement is psychologically wearing, as Richard Wright’s Native Son disturbingly and dramatically fictionalizes. Many Black Chicagoans, across generations, experienced life-long emotional states like the frustration, restlessness, and captivity some people stuck in their homes due to the pandemic currently are experiencing for the first time.

This confining geography extending out from kitchenette also had deadly effects. In 1918 and 1919 the Spanish Flu pandemic caused mass death and tremendous social upheaval that anticipated and rehearsed what Black communities are currently experiencing with COVID-19. Prisoners today are among the most vulnerable to COVID-19—the highest number of cases tied to a location is a prison in Ohio where 80% of the prisoners have tested positive. This resonates with the history of the Spanish Flu in Chicago. As one Chicago Defender writer noted, “Chicago police stations are doing more to breed disease than any other agency supposed to be working for the good of Chicago.”2 The journalist went on to note the way Chicago jails “huddle prisoners together” without medical examinations and how this led to the spread of the deadly flu.3 The carcerality of the kitchenette also made its residents vulnerable. Shabazz notes that Black Chicagoans had higher rates of mental illness, disease, and death all of which were influenced by their crowded and run-down living conditions. These kinds of vulnerabilities tied to spatial confinement are ongoing in Chicago where 50% of the deaths from COVID are Black, and where segregation and carcerality continue to define the landscape.”4

Blackness’s tie to tight spatial control and confinement,extending between living spaces and formal carceral institutions, and from slavery to the present, puts Black people at greater risk for disease and infection exacerbated by the mental health effects of confinement. This greater vulnerability tied to spatial confinement, overcrowding, and other effects of our nation’s anti-Black geography buttresses the spatial advantages white communities enjoyed historically and which they continue to enjoy. White slave owners profited from the confinement and forced vulnerability of their slaves. White landowners in Chicago profited from overcharging their Black tenants for poor quality housing. The risk of death, disease, and mental illbeing that Black people live with exists to produce white safety and comfort, guaranteed in exclusive geographies away from lead paint, rusty water, over-policing, and gratuitous violence. In order to mitigate the unequal deadly effects of COVID-19  and to prevent the future of devastating conditions disproportionately affecting Black people, we must reimagine the American landscape outside this history defined by the twinned and reinforcing structures of Black immobility and confinement.

  1. Rashad Shabaz, Spacializing Blacknes: Architectures of Confinement and Black Masculinity in Chicago. (Chicago: University of Illinois Press, 2015), 50. 
  2. “Spanish Plague Raging in Chicago: All Places of Public Assemblage Ordered Closed by Health Officials,” Chicago Defender (Chicago, IL), Oct. 19, 1918. 
  3. Ibid. 
  4. The Color of Caronavirus: COVID-19 Deaths by Race and Ethnicity in the US.” APM Research LAB, May 5th, 2020. https://www.apmresearchlab.org/covid/deaths-by-race. 

Source: Confinement and Disease from Slavery to the COVID-19 Pandemic – AAIHS

‘The Father of Environmental Justice’ Isn’t Surprised by COVID-19 Health Disparities – Texas Monthly

As the coronavirus keeps large swaths of Texas shut down, from the economy to the education system and social life, it has become common to note that the disease “doesn’t discriminate.” But Robert Bullard, a professor and former dean at Texas Southern University’s Barbara Jordan–Mickey Leland School of Public Affairs, has spent the past four decades researching the opposite: how natural disasters and crises wreak havoc on society unequally. Low-income communities of color often have far fewer resources to address disaster and, as a result, face far greater risks than whiter, wealthier neighborhoods in times of crisis.

Indeed, across the nation, evidence suggests that people of color are dying at higher rates from COVID-19 than are white people. Though Texas’s Department of State Health Services has so far reported incomplete racial data, some counties are following the national trend. In Harris County, for example, 40 percent of those who died from COVID-19 were black, though black people account for only 20 percent of the county’s population.

A number of factors could be responsible for the disparity. In Texas, black and Latino communities have higher rates of preexisting conditions that make the coronavirus deadly, like asthma and high blood pressure. When it comes to health care, black, Hispanic, and Native Americans in the state are more likely to be uninsured than white residents, according to data from the Kaiser Family Foundation. Testing for COVID-19 is also far from equally accessible: in the city of Dallas, testing is concentrated in high-income areas. And people of color might also be more likely to be employed in sectors that preclude social distancing: black and Latino workers are the least likely to report being able to work from home, according to the U.S. Bureau of Labor Statistics.

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While COVID-19 is a new phenomenon, racial disparities in health outcomes are not. In the seventies, Bullard’s research in Houston demonstrated that toxin-releasing facilities like waste and sewage plants were disproportionately placed in the city’s black neighborhoods, leading to a higher concentration of health problems. To this day, the pattern holds true.

Bullard’s work catalyzed the American environmental justice movement, which argues that environmental problems disproportionately affect communities of color and the poor, and that race and class should be accounted for in their potential solutions. Texas Monthly spoke with Bullard about how the pandemic intersects with environmental issues and why people of color are more vulnerable to the disease.

[This interview has been lightly edited for length and clarity.]

Texas Monthly: In your book The Wrong Complexion for Protection you write, “When societal resources are distributed unequally by class and race, it should be no surprise that population health is distributed along those lines as well.” Were you at all surprised by the racial disparities many counties are reporting with COVID-19?

Robert Bullard: No. When it comes to who gets in line first, and who has priority [for resources like health care], a lot of that is predetermined by the power structures, politically and economic. Oftentimes privilege aligns with race, with white people getting the first and the best protection. And so it’s not surprising when you look at how structural and institutional racism has given privileges for some and disadvantaged others. And when you have poverty, lack of access to health care, [high rates of] uninsured, many who have no private automobiles and are dependent on the buses and public transportation, and neighborhoods in pollution sacrifice zones—and then you pile on top of that the stress of racism—you’re going to get people who are vulnerable. It’s not rocket science. These social determinants of health have been known for many years.

And so the coronavirus is basically taking advantage of those vulnerabilities, and you’re seeing it play out in the deaths. And that’s more than sad. It’s unacceptable.

TM: The coronavirus seems to be a public health disaster that’s layering on top of existing disparities in environmental and social determinants of health. How do you see these things as interconnected, and how are environmental vulnerabilities making the coronavirus worse in certain communities?

RB: We know that if communities are saturated with all kinds of polluting facilities—landfills, incinerators, petrochemical plants and refineries, and coal power plants—and the air quality is bad, you’ll find high rates of ill health: asthma, respiratory illnesses, and other kinds of diseases that are elevated among people of color and poor people, like diabetes and hypertension.

We’re not even dealing with the coronavirus yet: we’re talking about studies that have shown that areas that have high concentration of polluting facilities also have high concentration of health disparities.

So when you apply that to this virus that appears to be attacking the respiratory system … and the cardiovascular system, it’s already hard to breathe in some of these neighborhoods. The coronavirus will make it even harder. It will kill you.

The idea is that if a community is located physically on the wrong side of the levee, the wrong side of the river, on the wrong side of the tracks, it receives less protection than those who are on the right side. Communities of color are disproportionately more vulnerable.

You tell me your zip code, and I can tell you how healthy you are. And so when you talk about trying to map out those social, economic, and racial vulnerabilities, and then overlay health, you can see that there’s a big disparity. You can go from one census tract or one zip code to another, and life expectancy changes by more than fifteen or twenty years by just crossing that line.

TM: Has Texas’s response failed to acknowledge preexisting health disparities?

RB: Texas has the second lowest percentage of testing but that doesn’t surprise me. What surprises me is that it doesn’t have the worst.

This virus does not does not look at your race, or your color. It looks at vulnerability. You can try and look at geographic areas the virus is hitting and not look at race. But then if you put race back in, you will see that there is a discernible pattern. Oftentimes, lax enforcement of environmental law means that communities on the frontline suffer. And that goes hand in hand with lax civil rights enforcement. Texas has the highest rates of uninsurance in the nation, and it has resisted expanding Medicaid, for example. So these policies have created vulnerabilities and it disadvantages communities.

If you talk to people in those neighborhoods on the streets, they can tell you without mapping that they’re most likely to get flooded. Most likely to get polluted. Most likely to suffer from extended unemployment. Or they don’t have the benefit of working from home or a safety net for sick days and paid leave. The medical folks call it comorbidity. Folks on the frontline have always known that’s how things are connected. It’s the cumulative impact of all these things coming at you at one time.

TM: What sort of public policies do you think that Texas, or the United States more generally, should implement to close these racial disparities?

RB: There are some obvious things that need to happen like strengthening people’s access to health care and health insurance. In the last few weeks, we’ve seen attempts to weaken both access to health care and environmental standards with federal rollbacks of specific provisions of the Clean Air Act and tailpipe pollution, and even today with mercury emissions.

So for many of us who have been advocates of environmental justice and health equity, that’s the wrong direction. Other states have taken the high road, and expanded Medicare and access to health insurance. And we should also acknowledge that climate change will make it even more difficult in the future for Texans with hotter days and more bad air-quality days. There will be more outbreaks [because of climate change], as health professionals and scientists have said. We can’t wait to address these issues. We need a real emergency plan for disasters, especially as our population is growing in Texas, to make our cities and rural areas more resilient.

TM: Low income communities are also more likely to live in environmentally vulnerable areas, particularly those at risk of flooding. Do you have concerns about hurricane season coming up and how that might put a double strain on some communities?

RB: The communities that are hit hardest and take the longest to recover, those are the same communities that I’m worried about. On June 1, if we have an active hurricane season in communities that are already suffering from COVID-19, how can you shelter in place when you have to evacuate? Where do people go? If you go to a shelter, it’s going to be hard to social distance. So you’re talking about disasters compounding. That should be worrisome for FEMA and the state government. I’m hoping there is planning for that, so that we don’t get caught flat-footed. I would hope that the smartest people in government are working on the areas that have historically had these severe weather events.

People are stressed about the virus, and people who live on the Gulf Coast, April and May is when they start getting stressed about hurricane season. How are we going to respond to another Harvey or Imelda? In many cases, community groups are the first line of defense. People aren’t going to wait on the government for [immediate aid], because if we do, it will be too late. It’s important to lift up organizations and institutions that have built up that trust in communities. We have to make sure that these organizations are funded and positioned in a way that can address what’s happening.

Why African-Americans may be especially vulnerable to COVID-19

African-Americans are more likely to die from the disease than white Americans

two people wearing masks
African-Americans have increased exposure to COVID-19, in part, because they disproportionately have jobs in the service sector. Here, a man is shown with his ride share driver at a train station in Joliet, Ill., on April 6.CHARLES REX ARBOGAST/AP PHOTO

COVID-19 was called the great equalizer. Nobody was immune; anybody could succumb. But the virus’ spread across the United States is exposing racial fault lines, with early data showing that African-Americans are more likely to die from the disease than white Americans.

The data are still piecemeal, with only some states and counties breaking down COVID-19 cases and outcomes by race. But even without nationwide data, the numbers are stark. Where race data are known — for only 3,300 of 13,000 COVID-19 deaths — African-Americans account for 42 percent of the deaths, the Associated Press reported April 9. Those data also suggest the disparity could be highest in the South. For instance, in both Louisiana and Mississippi, African-Americans account for over 65 percent of known COVID-19 deaths.

Other regions are seeing disparities as well. For instance, in Illinois, where the bulk of infections are in the Chicago area, 28 percent of the 16,422 confirmed cases as of April 9 were African-Americans, but African-Americans accounted for nearly 43 percent of the state’s 528 deaths.

Other data find similar trends. A study published online April 8 in the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report looked at hospitalizations for COVID-19 across 14 states from March 1 to 30. Race data, which were available for 580 of 1,482 patients, revealed that African-Americans accounted for 33 percent of the hospitalizations, but only 18 percent of the total population surveyed.

Here are three reasons why African-Americans may be especially vulnerable to the new coronavirus.

1. African-Americans are more likely to be exposed to COVID-19.

SARS-CoV-2, the coronavirus that causes COVID-19, is highly contagious, even before symptoms appear (SN: 3/13/20). So to curb the virus’ spread and limit person-to-person transmission, states have been issuing stay-at-home orders. But many individuals are considered part of the critical workforce by the U.S. Department of Homeland Security and must continue to work. That includes caregivers, cashiers, sanitation workers, farm workers and public transit employees, jobs often filled by African-Americans.

For instance, almost 30 percent of employed African-Americans work in the education and health services industry and 10 percent in retail, according to 2019 data from the U.S. Bureau of Labor Statistics. African-Americans are less likely than employed people in general to work in professional and business services — the sorts of jobs more amenable to telecommuting.

Additionally, a disproportionately high percentage of African-Americans may live in places that could increase their risk of exposure. Census data from January 2020 show that only 44 percent of African-Americans own their own home compared with almost 74 percent of white people. Consider a family living in a crowded inner-city apartment, says epidemiologist Martina Anto-Ocrah of the University of Rochester Medical Center in New York. “Can you possibly take an elevator alone? No.”

African-Americans’ risk of higher exposure to COVID-19 has historical roots — including legal segregation in schools and housing, discrimination in the labor market and redlining, the practice of denying home loans to those living in predominantly African-American neighborhoods. Those forces have contributed to a persistent racial wealth gap, with African-Americans continuing to struggle to move into neighborhoods with the sorts of socioeconomic opportunities that allow white families to better avoid exposure to COVID-19.

“All the ingredients are in place for there to be a sharp racial and class inequality to this [pandemic],” says Robert Sampson, a sociologist at Harvard University.

2. African-Americans have a higher incidence of underlying health conditions.

Among those at highest risk of getting severely ill with COVID-19 are patients with other serious health problems, such as hypertension, diabetes and heart disease (SN: 3/20/20). Over 40 percent of African-Americans have high blood pressure, among the highest rates in the world, according to the American Heart Association. By comparison, about a third of white Americans have high blood pressure. Similarly, African-Americans tend to have higher rates of diabetes.

Part of that heightened risk has to do with African-Americans’ disproportionate exposure to air pollution. Such pollution has been linked to chronic health problems, including asthma, obesity and cardiovascular disease (SN: 9/19/17). In an April 2019 study in the Proceedings of the National Academy of Sciences, Sampson and fellow Harvard sociologist Robert Manduca showed that poor African-American neighborhoods have higher levels of lead, air pollution and violence than poor white neighborhoods (SN: 4/12/19).

 

 

 

Researchers are still sorting out how neighborhood stressors contribute to poor health. But even if the causes aren’t always clear, research suggests that helping people move to better neighborhoods can improve health. For instance, a 2017 study in JAMA Internal Medicine showed that for African-American adults, moving out of racially segregated neighborhoods was linked to a drop in blood pressure (SN: 5/15/17).

3. African-Americans have less access to medical care and often distrust caregivers.

Inequities in access to health care, including inadequate health insurance, discrimination fears and distance from clinics and hospitals, make it harder for many African-Americans to access the sort of preventive care that keeps chronic diseases in check.

According to a December 2019 report from The Century Foundation, a nonpartisan think tank based in New York City and Washington, D.C., African-Americans are still more likely to be uninsured than white Americans. And African-Americans who are insured spend a greater fraction of their income on premiums and out-of-pocket costs, about 20 percent, than the average American, who spends about 11 percent.

Census data show that about 20 percent of African-Americans live in poverty compared with 10 percent of white Americans. As a result, African-Americans have been disproportionately hurt by some states’ decisions not to expand Medicaid as part of the Affordable Care Act. Expanded Medicaid has been linked to a reduced likelihood of deaths from cardiovascular disease (SN: 6/7/19) and a reduction in the racial health gap between white and black babies (SN: 4/23/19).

Lack of preventive care means that African-Americans are more likely than other racial groups in the United States to be hospitalized or rehospitalized for asthma, diabetes, heart failure and postsurgery complications, researchers reported in 2016 in the Annual Review of Public Health.

African-Americans can also face hidden biases to care. For instance, an algorithm used to determine which patients should receive access to certain health care programs inadvertently prioritized white patients over African-American patients (SN: 10/24/19), researchers reported in October 2019 in Science. That disparity arose because the algorithm used health care spending as a proxy for need, but African-Americans often spend less on health care because they are less likely to go to a doctor. In part that may be because African-Americans have a long-standing distrust of the medical establishment due to events such as the Tuskegee experiment (SN: 3/1/75), in which hundreds of African-American men with syphilis were denied treatment for decades.

“These long-standing structural forms of discrimination that African-Americans have faced in the [United States] are manifesting in what we’re seeing with COVID right now,” says epidemiologist Kiarri Kershaw of the Northwestern University Feinberg School of Medicine in Chicago.

Even so, more can be done to identify communities that might be especially vulnerable to COVID-19 and improve their odds of coping with the pandemic, Sampson says. For example, “look at a map of incarceration, lead risk and violence in Chicago [and] you’ll basically see a map of COVID deaths,” he says. Those kinds of proxies could provide a road map to identifying at-risk communities and targeting resources to them, such as greater access to COVID-19 testing, distribution of masks and mobile clinics to provide care.

INCREASING PUBLIC POWER TO INCREASE COMPETITION: A FOUNDATION FOR AN INCLUSIVE ECONOMY

INCREASING PUBLIC POWER TO INCREASE COMPETITION:  A FOUNDATION FOR AN INCLUSIVE ECONOMY

ISSUE BRIEF BY WILLIAM DARITY JR., DARRICK HAMILTON, AND RAKEEN MABUD
MAY 2019

Executive Summary

The United States needs an economy grounded in justice and morality, where everyone, free of undue resource constraints, can prosper. To achieve this, citizens ought to have universal access to undeniable economic rights, such as the right to employment, medical and health care, high quality education, sound banking and financial services, or a meaningful endowment at birth (Paul, Darity, Hamilton 2018). Currently, our system provides these rights primarily through the “free market” by private providers, but these private companies often fail to meet the following criteria:

•   Quantity: Are goods adequately supplied?
•   Quality: Are the goods high quality?
•   Access: Do people have adequate access to these goods?

Because of the failure of America’s markets-first approach to policy, the federal government should intervene by introducing public options that provide these essential goods and services in direct competition with private firms. Doing so will set “floors” on wages and quality and “ceilings” on price for private actors who are intent on providing important economic rights at a cost. In employment, this might mean providing a federal jobs guarantee (FJG); in financial services, this could mean access to bank accounts and safe, nonpredatory loans. Throughout this issue brief, we explore what public options might look like in employment, health, housing, education, and financial services. We argue that in these sectors, public options are necessary to combat high-cost, low-quality provision by private actors and ensure universal and better quality access to all Americans.

Full Report here.   https://rooseveltinstitute.org/wp-content/uploads/2019/04/RI_Increasing-Public-Power-to-Increase-Competition-brief-201905.pdf

CREATIVE COMMONS COPYRIGHT 2019 | ROOSEVELTINSTITUTE.ORG

The report features the work of OUR COMMON GROUND Voices, Drs. William “Sandy” Darity and Darrick Hamilton

Darity Hamilton

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