Doctors on the front line talk about why the coronavirus is ravaging black people
Manage hypertension, control your weight and beware ‘the sugar’
It’s been more than a month since the first stay-at-home orders were issued in a handful of California counties to help stop the spread of the coronavirus which, at the time, affected about 4,200 Americans. Some public health experts were warning then that the disease would strike African Americans, who suffer from significant economic and health disparities, particularly hard.
Now, with more than 800,000 cases of COVID-19 reported nationwide, including over 44,000 dead, more than 90% of Americans are under orders to stay at home. And within the general pandemic, a particularly horrific statistic has emerged. African Americans, who are around 13% of the U.S. population, comprise a third of all coronavirus infections.
Louisiana is among the hardest-hit states, with coronavirus cases topping 25,000. The overall population is one-third African American, but black people make up 56% of the almost 1,500 people who have died.
Doctors in the New Orleans metropolitan area see how the coronavirus exploits the vulnerabilities they had long been treating in black and brown people — especially “sugar diabetes.” While 80% of those infected have mild to moderate symptoms, “what we do see is that the two big risk factors that increase a person’s risk for hospitalization from COVID are diabetes and obesity,” said Victoria A. Smith, associate medical director at St. Charles Parish Hospital and for primary care in the River Region, both part of the nonprofit Ochsner Health.
These are among the health issues “that we need to address in the African American community head-on,” said Marc J. Labat, an emergency medicine doctor at St. Charles Parish Hospital.
Smith and Labat spoke with The Undefeated about the choices African American communities face as they battle COVID-19, and what the fight looks like on the front lines.
This interview has been edited for length and clarity.
Before the coronavirus struck, what kinds of patients did you treat, and how was their health?
Smith: We are really working on folks who have chronic health conditions like hypertension and diabetes. We’re working to ensure that those folks who have those conditions have them as controlled as possible. If your hypertension is not controlled, you have a higher risk of cardiovascular disease. Or having kidney failure if your diabetes is not controlled. You have a high risk of lots of problems — a decreased immune system. Neurologic impact.
I’ve spent a lot of time talking with people about how to get them more active. To be doing at least 150 minutes a week of physical activity. And sometimes just talking to people like, ‘OK, can we start with five minutes a day and build from there.’ This is a place where the food is really good and not always so good for you. I’ve found that it’s easy to prescribe the medications for diabetes, but the more important part of the job is working with people on lifestyle changes.
I have a pretty large geriatric population, so a lot of my patients are probably 70s or older. A lot of things we would talk about was maybe walking in their neighborhood or things they could do in their home. A lot was just really educating people about proper nutrition and what are the healthier opportunities.
Labat: One of the benefits of going into emergency medicine is we pretty much see everything from fractures to gynecologic emergencies to heart attacks, sepsis, motor vehicle accidents, gunshot wounds. If you have diabetes disproportionately, if you have hypertension, coronary artery disease or obesity, of course these preexisting conditions are going to lead to further complications and a higher degree of emergencies. And we know that many of those conditions have a higher prevalence in the African American community.
When did each of you start seeing coronavirus patients? And when you first learned about it, did you have any sort of existential worry, like this is going to be really bad for black people?
Smith: Our first documented case in Louisiana was March 9. Watching this in Washington state, and California and New York, I have to say I did not really believe that we didn’t have any cases in Louisiana. Now that I look back on it, and Marc can probably attest to this, there were a lot of people that I was seeing in, say, late January, February who had what I would consider typical flu symptoms, and they didn’t have the flu. I think a lot of that was coronavirus.
As I shared with you, I have a large elderly population, so I was really very concerned. I mean, we’re seeing it in all ages, but in terms of more serious hospitalization and death, seeing a lot more in the elderly population.
Labat: To reiterate what Victoria said, looking back, there were certain patients that I saw in February, even before Mardi Gras, who had pretty significant clinical complications of what we would normally call just an average viral syndrome that didn’t add up. They were much sicker than your average cold, and their flu tests were coming back negative.
It became much more prevalent and obvious in the middle of March. I’ve had about two decades of experience firsthand with medicine, and during that time, we’ve seen the SARS outbreak in Tokyo. We’ve seen other potential pandemics, Ebola, MERS and each of these, fortunately, did not expand throughout the world to create a crisis that we are seeing with coronavirus. When I saw my first 10 or 20 patients, I knew that we were dealing with a different beast. We now know that this virus is contagious even during an asymptomatic period prior to the onset of symptoms for a patient. This obviously creates a challenge because it spreads much more easily than other viruses.
I don’t want anyone to get the idea that this only affects elderly patients. I’ve seen 36-year-olds with significantly low oxygen levels requiring oxygen supplementation. I’ve seen 40-year-olds pass away from this virus.
Of course, there’s a higher incidence of morbidity and mortality the older you get, but the reality of this virus is that it does not discriminate.
Even with some of the health challenges you mentioned, are there some conditions that make African Americans especially susceptible to the most extreme outcomes of the virus?
Labat: This virus obviously affects people who have significant comorbid conditions more than those who do not. I can tell you, clinically, it loves to particularly affect people that are obese. The reality of the matter is that we know that African Americans are 50% more likely to be obese than their non-Hispanic white counterparts.
That relates to certain educational disparities, as far as what’s healthy food and what’s not. There are obviously socioeconomic differences. And there’s some cultural differences also. All of those are things we need to evaluate as an African American community.
Smith: Ochsner Health is a major academic institution, and we have a center for outcomes research that is really looking at health care disparities. Just like everywhere else, we’ve seen a disproportionate number of infected patients be African American because of some of the risk factors, as Marc has talked about. Obesity then increases that risk of ICU [intensive care unit] admission.
Labat: I think we need to touch on other reasons why there are disparities. One of the things that we hear frequently is that there is somewhat of an underlying mistrust within the African American community with regard to health care. We have to ask why that exists.
I’ll give you an example: My father, who is a retired general surgeon, told me a story where when he was a young child, he had a large laceration to his leg after a fall. His dad picked him up and put him in the car. He was bleeding – in his eyes as a young child, bleeding profusely. They arrived to the hospital and presented to the emergency room, and they were turned away because of his skin color.
I grew up in a family of doctors [father, sister, a mother with a doctorate in biology] that taught me to look beyond racial differences or socioeconomic differences. But there’s an underlying historical issue at play that can be passed down from generation to generation. What we need to do is really proactively have people of color that are physicians to be able to break down that barrier.
Smith: I think definitely representation is important. I’m the first physician in my family. I didn’t necessarily see African American physicians growing up. What I believe is as important as representation is just really caring about a person’s life.
I was interviewing an endocrinologist last week and she deals with a lot of patients who were not doing what she asked them to do. Then she realized the fact that somebody was coming to see her meant they were really trying, and she needed to figure out how to just get somebody to take one step.
What are you telling patients about how they should navigate, right now, in our hardest-hit communities?
Smith: In America, there’s this rugged individualism and you’ve got to keep going even if you’re sick. But you could be infecting other people, and now that infection could be truly deadly. That’s also showing that many people don’t have paid sick leave.
There’s a lot of learning for us, but my advice to my patients is to do their best to practice social distancing and make sure they’re really meticulous about hand hygiene. From a practical perspective, multiple people may be living in a home with one or two people infected. But then, those people have to be doing as much as possible to still try to maintain distance. The whole family can be quarantining or staying out of circulation until it’s passed through that household. Even with those challenges, there are still ways to stay safe and decrease the infectivity.
Labat: In the emergency room, we usually see patients who are presenting with the active infection. There is a preventative approach that I feel is necessary, even from an emergency medicine standpoint, when we see these patients.
I take a considerable amount of time to educate the patient on self-quarantining, recommending that they remove themselves from a home if at all possible if there are elderly parents or relatives living with them. And if that is not possible, really instructing them on how to separate themselves from family members completely for the duration of the illness.
We know throughout this country, there is definitely a disproportionate number of African Americans who live in densely populated urban communities. And if you are living in a densely populated community, of course you are more likely to be exposed to this virus.
It’s a challenge, but we need to educate the public. We know that for every one person that is infected, they subsequently infect at least two to 2½ other people. This is a virus that our immune systems have never seen before. That’s why we call it a novel virus. So if you combine the fact that our immune systems do not have the armor and weapons to combat the disease, combined with its highly contagious characteristics, that is much more the reason why we need to educate about social distancing, hand hygiene and really removing yourselves from patients that are not yet infected.
When do people need to go to the emergency room?
Smith: When you’re looking at being more in that 20% than that 80% [with mild symptoms], and a lot of that is around the respiratory system. The shortness of breath. Being more easily winded either at rest or with activity. That’s something we are telling people and really encouraging, please monitor that.
Labat: I tell people you’re going to have a fever. You’re going to have a little bit of shortness of breath and a cough. These symptoms are going to last for several weeks, possibly. The key is to explain what we want the patient to return for: significant shortness of breath. Shortness of breath with exertion. Significant chest pain.
I can honestly say that it is probably routine for me to see at least 15 patients a shift that either have a new diagnosis or a return visit because of complications because of COVID. Just clinically, 80-90% of my patients have coronavirus or complications of coronavirus.
What do you want black communities to work on when we get to the other side of this pandemic?
Labat: I think it’s important to recognize that every day is a new day and it’s not too late to change our behaviors. We need to increase efforts to eat healthy. We need to encourage patients to take the medications they need to treat diabetes and hypertension. At the same time, understand it is a combination of efforts to really control these types of conditions that can lead to severe complications from this virus. And it’s not too late to make this change.
Smith: And we’re not done with this. We’re in it for the long haul. I really echo what Marc said. Even pre-COVID, I had great respect for diabetes because of the damage that it does to all parts of the body. And now, in the times of COVID, here’s another challenge that is created for a person whose diabetes is not controlled. I feel like I am a kind of crusader about diabetes and it has strengthened that passion about why this is such a dread disease. I really want to help all patients, no matter their race, ethnicity, whatever, to either never develop diabetes, or once they have it to really work with them to control it.
And then with obesity, really seeing how much that impacts, in particular, this disease. We know it can shorten people’s life spans, but this is so direct. It just gives me even more of a passion personally because I’ve definitely been stress overeating during this time. But then also with patients to work harder to help people make those small changes that can lead to sustained weight loss.
I guess the bigger thing is to help people to realize this is not going away quickly, so not to be hysterical or panicked, but that there is a lot that we can do. Social distancing, the importance of washing our hands on a regular basis. I’m even more passionate about some of the basics of infection prevention.
Labat: We are a resilient city, we withstood Katrina. It’s funny how two of the largest metropolitan areas with regard to the number of coronavirus cases per capita are New York City and New Orleans, which have both endured major catastrophes.
It’s important to recognize that we are resilient people, and we will overcome this.