COVID-19 put a lens on societal disparities in the US. Dr Keith C Ferdinand (Tulane University School of Medicine, New Orleans, LA, US) offers his viewpoint on the pandemic’s impact on African Americans in New Orleans and beyond. He shares his experiences during Hurricane Katrina and its parallels with COVID-19 in a discussion with Dr Harriette Van Spall (McMaster University, Hamilton, CA)
Keith C Ferdinand, MD, is Professor of Medicine at the Tulane University School of Medicine and the Tulane Heart and Vascular Institute in New Orleans, Louisiana.
Recorded remotley from Luisiana and Hamilton, 2020.
[Van Spall] The COVID-19 pandemic has put a lens on healthcare disparities in the US. The US was ranked as number one in pandemic preparedness prior to the COVID-19 pandemic but has had some of the worst outcomes to date. There have been race-based variations in mortality across the US. In Louisiana, blacks form 32% of the population and account for over 70% of the deaths. In Chicago, this pattern is seen again, with blacks accounting for 30% of the population and representing 70% of COVID related deaths. The infection rate in a predominantly black county is about three times that of a similar county comprised of primarily white Americans. I'm Harriette Van Spall, cardiologist and associate professor of medicine for McMaster University in Canada. And I'm honoured and delighted to have with me today, Dr. Keith Ferdinand, who has a lifelong history of tackling race-based inequities in care through his research, advocacy and clinical work in New Orleans, Louisiana. He holds the Gerald S. Berenson Endowed Chair in Preventive Cardiology and is professor of medicine at the Tulane University School of Medicine. Welcome, Dr. Ferdinand.
[Ferdinand] My pleasure, thank you.
[Van Spall] In the JACC article that you recently authored, you referred to the higher COVID-19 mortality rates in black Americans as a sentinel event. I wonder if you could start by telling us what you mean by this?
[Ferdinand] In the United States, the Joint Commission, who are looking into the quality of care in hospitals, has what they call sentinel events. These are specific things, such as the wrong site surgery, operating on the wrong patient, patient falls or other injuries. And what it means is that the quality of care in that institution may be substandard and pushes the Joint Commission to look further into the quality of care because those sentinel events are markers that something may be deeply troubling in the care that's being given. If you look at what's happened now with the COVID-19 pandemic, black versus white, rich versus poor and I consider them sentinel events because they're bringing to the forefront some long-standing disparities in outcomes, specifically in cardiovascular disease, but also seen in cancer, infant mortality and even childbirth related deaths. And this sentinel event, the COVID-19 pandemic, is also an opportunity for us to do better as a society.
[Van Spall] How do we know that the differences in mortality seen during this COVID-19 pandemic are not explained solely by baseline differences in cardiovascular risk factors and in differences in cardiovascular disease? Because these are associated with a higher mortality rate in COVID-19 illness.
[Ferdinand] Clearly there are differences in cardiovascular risk, African Americans have higher rates of hypertension, obesity, diabetes and asthma, all of these are associated with increased mortality with COVID-19, but if you look at the statistics that you so well articulated, the mortality risk of COVID-19 infections in the African-American community is 1.5, 2 or even 3 times that seen versus whites in various locations. Those underlying comorbid conditions, while increased in American blacks, are not usually considered to be 2, 3 or 4 times higher than the general population. So that clearly is a part of it, but we know the social determinants of health. Where you live, where you work and how you live have a great impact on cardiovascular risk. So, I don't think it's just simply higher rates of hypertension, diabetes, asthma and obesity, that's clearly part of the problem, but in my paper, I use the term, and I'm from New Orleans, it's a toxic gumbo of comorbid conditions and environmental factors.
[Van Spall] Thank you for that. How do you see the social determinants of health as weighing in on the current situation? Can you comment about disparities in education, housing, nutrition, population density, between black and white Americans?
[Ferdinand] All of the social determinants now come into play, even health literacy, understanding the disease process itself. There's a lot of mythology that is very found high in the black community regarding COVID-19. For instance, and this is going to sound odd, but I have heard personally, personal communication, "Blacks don't get COVID-19. "COVID-19 can be washed away with hot water, "gargling with hot water." Things which have no basis in biology or science, but because of low literacy, especially now with the internet, this miss information can be spread like wildfire. But let's go beyond that, in the United States, there's an imbalance in insurance status. Many blacks are uninsured or underinsured, don't have an identifiable source of primary care, so even when they become ill, there's no one person that they can call or turn to. There's a fear of mistrust of conventional medical care, so many patients may delay presentation to the hospital until they're in a terminal event. There is living conditions where you have multi-generational families, social distancing becomes very difficult. So now, the child, who may be an essential worker, a grocery clerk or working in sanitation, comes home and brings the infection to an older person who lives in the same household. There's even differences in testing, something simple as drive through testing for the diagnosis of COVID-19 in the United States, while it sounds to be a very convenient way of doing testing for diagnosis, actually will under diagnose those persons who live in crowded inner cities where many don't own a car and use public transportation, may, well, it be the subway in New York City, or the conventional bus in New Orleans, as their main means of transportation. Many of the testing sites when they were first rolled out were only for persons who had automobiles and it's somewhat remind me of Hurricane Katrina. The people who were left on those rooftops to die, were people who did not have a car. On Sunday, August 29th, in 2005, the mayor said, "We have a mandatory evacuation." Well, 40% of the people in New Orleans, which is a predominant African American city, did not own cars, where could they go? They even drowned at a very high levels from the flood waters or were left to perish for two to three days, unattended by federal help.
[Van Spall] Those are powerful observations and highlight that directives given by federal or state authorities are only as effective as the means that people can access and the means that people can afford. Tell us about the book you wrote about Hurricane Katrina and how you see the similarities as having played out during the COVID-19 pandemic.
[Ferdinand] Hurricane Katrina affected the New Orleans area very greatly, you're looking at a small city where 1,500 people died from the flood and perhaps 100s more died from the sequelae, which I think may also happen with COVID-19. Where people who have delayed care or have had no care for their hypertension, diabetes and cholesterol, may now present with strokes, heart attack and heart failure. Overcoming Katrina, African American Voices was an oral history that I did with a historian and what we did was allow people to give their stories. My own personal story, I'm a child of the Lower Ninth Ward, the African American community that was so heavily damaged by Hurricane Katrina. In 1965, I was one of those people on a roof with my mother and father. My paternal grandfather died next door. When I was sent out into the flood waters to try to rescue him and for many decades, I was haunted by the fact that I was unable to save my grandfather. So, I know, personally, the type of pain that people live in those neighbourhoods and the type of suffering that can happen, whether it be a pandemic or a flood.
[Van Spall] Those are powerful experiences that have undoubtedly shaped your viewpoint and your career. Tell us how those experiences in your family and neighbourhood inspired you to pursue the career that you subsequently embarked on and how you have transformed the pain and frustration of those early experiences into being the impactful advocate and researcher that you currently are. I think it's a story that merits us delving into. It's a source of inspiration to me and many others.
[Ferdinand] Presently, I'm a professor of medicine and as you noted, the Endowed Chair in Preventive Cardiology at Tulane University, one of our well-known academic major centers, but for 30 years, I actually had, along with my wife who was a PhD in nursing at cardiovascular center in the Ninth Ward. When I developed my skills as a cardiologist, I wanted to apply them directly to my community. Our community center was washed out, on August 29th, 2005, by Hurricane Katrina and I then moved into academic medicine. The problem that we have in the United States is that these disparities are not new. The Heckler Report, from 1985, was actually published and showed that there were disparities in cardiovascular disease and mortality. As long as 1985, the Institute of Medicine, in another major work sponsored by the federal government, called Unequal Treatment. In the year 2002, also playing out these disparities. This is not a side story for America, this is part of the healthcare fabric and it's one of the reasons why, despite the fact that we spend more per dollar on individual's care, when you look at longevity, the United States among developed societies, we are approximately 16th. And it's not because Americans are somehow inherently prone to die earlier, it's because of these disparities. People who have identified sources of care, who live in stable environments have a life expectancy equal to that of Western Europe, Canada or Japan. It's because we have these long-standing disparities, mainly in cardiovascular disease, but as I mentioned, other conditions also, it affects the median life expectancy in the United States. So, for me and I think for most people who understand public health, this is not a side story, it is important to look at this as part of the fabric of the American healthcare landscape.
[Van Spall] As a Canadian, I see these disparities not only as interwoven into your healthcare system, but also interwoven into your history. There appears to be a history of institutionalised racism across sectors and services. Tell me how you see the future, what are the changes that you think need to be enacted, not only in the healthcare system, but also in the socioeconomic fabric of the United States of America, for these disparities to be effectively tackled?
[Ferdinand] I appreciate the opportunity to articulate what I see as a fundamental problem of American healthcare and environment in the United States. Not only in the Deep South where you have an historical legacy of slavery, but let's look at the Upper Midwest where you have these meat factories, which are being the place where you have African Americans and immigrants who are packing meat, or processing meat, working shoulder-to-shoulder and have high mortality related to COVID-19. So the working conditions, although they are employed, are substandard, housing, education, healthcare, working condition, transportation, all of these play a part in these disparities that we see in cardiovascular disease and now related to mortality with COVID-19. What I would like to see is for us, as Americans, to be honest about these disparities. This is not social science, we're talking about mortality and death, related not only to COVID-19, but also to hypertension, the rates of uncontrolled blood pressure, diabetes and a wide range of conditions. It's unnecessary and it is not driven primarily by genetics, it's mainly driven by how we care for people, or don't care for people, where they live and the conditions under which they work.
[Van Spall] Are you concerned about the lifting of lockdowns and social distancing measures across the United States? There seems to be a balance between maintaining the health of the population and facilitating a return to work and there are several strategies employed to manage this balance. What are your thoughts on the lifting of social distancing measures across the US at the current time?
[Ferdinand] I'm not an economist, but I do know that if we lift the restrictions too quickly and too broadly, that some of the infections related to coronavirus will increase. I also know that those persons who can't work from home, who are essential workers, who must go to environments where they're not protected from getting an infection with coronavirus, will have, then, an upsurge in infection. And we're going to see the disparities, which have been manifest over the last several weeks, to continue or even grow. It is important for us to recognise that although we as humans are always looking for the bright side, sometimes, we have to face the reality of what we are looking at. And that is a novel virus, which none of us have immunity for, that affects people who cannot have social distancing in their workplace, who cannot have social distancing even in their place of living, who are going to be affected disproportionately because of underlying comorbid conditions. So I'll go back to the phrase that I used early in our discussion, that toxic gumbo of comorbid conditions and environmental factors will predict that if we lift these restrictions too quickly and too arbitrarily, we're going to see an increase again in not only infections, but disparate mortality related to COVID-19.
[Van Spall] As a healthcare provider, do you have access in your institution to the resources required to care for people with infection? Do you have a community outreach programme to enhance testing capacity within the larger community that you serve?
[Ferdinand] Louisiana was affected greatly by the coronavirus pandemic. Tulane University, LSU and OSHA institutions have all done well combating the acute illnesses, there actually have, now, become some efforts to do outreach directly into the community for early diagnosis. And we're going to need, of course, contact tracing where we can find out patients who need to remove or distance themselves from others so that the infections related to coronavirus don't continue to spread. We are doing better, we are seeing some downtrends, now, in the infection rate in the New Orleans area, but as I just mentioned, those are going to happen uptick and those mortalities are going to manifest themselves again if we become overly ambitious removing some of the social distancing and constraints. Fortunately, the mayor here in New Orleans is not being bullied by some of the business owners who want to rush back to work and, "Pass a good time," as we say in New Orleans. It is not yet time for us to remove these restrictions and if we don't heed what's been beneficial, we're going to repeat some of the downsides of the COVID-19 pandemic.
[Van Spall] Dr. Ferdinand, let me take this opportunity to thank you so much for your time. I'm so delighted that you could share your insights and expertise with us, and I hope our paths cross again soon. Thank you so much.
[Ferdinand] It's my pleasure, let's stay in touch.
[Van Spall] Absolutely, it would be my honour to. Thank you, Sir.