Dr Keith Ferdinand, a prominent cardiologist and lifelong New Orleans resident, has long been outspoken on the issue of inequities in health care for minority communities. The disparities in morbidity and mortality between White populations and populations of color are driven not by biology or genetics but by social determinants that are structural, socioeconomic, and deeply rooted, he says.
The body of evidence that supports the impact of social determinants of health has expanded many times over since the COVID-19 pandemic began. At the Obesity Medicine Association's Virtual Spring Summit, opening on Friday, April 23, 2021, Dr Ferdinand will talk about the combined impact of COVID-19 and obesity on Black communities.
Dr Ferdinand gave Patient Care Online a short preview and answered our question on how he would challenge primary care providers to incorporate the harsh lessons the pandemic is teaching.
The White-Black Death Gap
“There is a long, persistent, and unacceptable gap in mortality between Black and White Americans, with life expectancy shorter for both Black men and women than for White Americans.
I call this the White- Black Death Gap, and it is primarily driven by disparities in cardiovascular disease.
The prominent disparity in years of life expectancy lost as a result of COVID-19—2.7 years lost for Blacks vs 0.8 years for the general population—means that the White-Black difference in life expectancy will not only persist but will widen as more Black lives are lost to COVID-19 compared to the population at large.”
Keith C Ferdinand, MD, holds the Gerald S Berenson endowed chair in preventive cardiology and is professor of medicine at the Tulane University School of Medicine and the Tulane Heart and Vascular Institute in New Orleans.
The following transcript has been edited lightly for clarity.
Patient Care Online: Good morning, Dr. Ferdinand.
Keith Ferdinand, MD: How are you?
PCO: So, it's been painfully clear since the beginning of the COVID-19 pandemic, that mortality among African Americans has trended higher than among other racial and ethnic groups. In fact, I think it's been almost one year since your editorial appeared in the Journal of the American College of Cardiology, where you identified African American COVID-19 mortality as a sentinel event. I don't know if it's possible to summarize the experience of a year in a short interview but what does the medical community know today that it didn't know in April 2020 about COVID-19 infection and risk in the African American community?
Ferdinand: Well, let's go back a year. I'm here in New Orleans, which was one of the epicenters. Mardi Gras was February 25, 2020. It was a glorious day I was out there with the second line bands. And then about March 9, we had our first case, and we think it was the 300 000 visitors who came in and that someone probably internationally brought COVID-19. So along with Seattle, New York, New Orleans was one of the epicenters. I think what we've learned is that certain populations, including African Americans, Hispanic, LatinX populations have high rates, but it's not genetic. It's the social determinants of health. Those essential workers early on, the grocery clerks, the transit operators, the delivery persons who are being exposed with people were sneezing and coughing and breathing on them. And at that time, there was no personal protective equipment. There were no barriers that were up at that time. The other thing that we learned is that persons who live in socially stressed environments, multigenerational homes, not having access to early testing, were more prone to become more sick, have more hospitalization. And once you have hospitalization, of course, you have an increase in deaths. It's had a profound effect on longevity, and I would like to bring that point out.
PCO: So as an underlying condition or comorbidity, obesity increases the risk of severe COVID-19, almost geometrically anyway, and it has earned a spot as one of the most dangerous comorbidities. By some estimates, about half of the African American community suffers from obesity, which is an added factor that can spark the inflammatory storm that we see often. Could you talk a little bit about the link between inflammation and severe COVID-19 infection?
Ferdinand: Well, we know the most powerful risk factor for being hospitalized and dying is age. And in fact, 80% of deaths are related to persons who are 65 years and older whereas if you look in some of the cohorts in the African American population, you see the mean age is about 60, about 5 years younger than would be expected and perhaps the strongest driver in that population is obesity. Obesity, of course causes mechanical obstruction of ventilation and difficulty being placed in the prone position which we found was optimal for respiration. But also, obesity is related to an inflammatory state. Cytokines which are released with infection with coronavirus are also baseline higher in persons with obesity; we know there are high levels of C-reactive protein, interleukin-6. So now you have a condition where the inflammatory state is already heightened. You add a virus which causes an increase in cytokines, and that kind of up regulates the inflammatory state and makes it even more a problem in terms of persons who become ill, with increased hospitalization and unfortunately increased death.
PCO: So, you're a clinician who has lived and worked in the community that you care for probably for most of your career. And I sense you provide probably a little bit more than cardiovascular care and you community. So, we talked to an audience of primary care clinicians, IMs, GPs, Doctor of Osteopathic, and their primary job is to promote wellness and to prevent morbidity and mortality. How would you challenge them, in what will we hope one day be a post COVID-19 health care world, to use what this crisis has shown us more starkly than ever before about healthcare inequalities?
Ferdinand: Remember, I’d like to revisit longevity, but let's talk about various risk factors. As a cardiologist, I have to deal with those risk factors—hypertension, diabetes, high cholesterol, obesity, but it is the primary care providers, they're the frontline workers who are going to control the epidemic of cardiovascular disease we see related to and unrelated to COVID-19. And in fact, if you look at some of the best ways to reduce the burden of heart disease and stroke, it's control of risk factors. And the providers, primary providers, whether they be internist, primary care doctors, family medicine, doctors, nurse practitioners, physician assistants, clinical pharmacists, they actually do a better job and treat more patients for control of cardiovascular risk factors than the cardiologist. Unfortunately, so many of our younger cardiologists are now enthralled with doing procedures and putting in devices and that's important for the individual patient. But if you look at the public health burden of cardiovascular disease, it is primarily controlled by primary care providers.
PCO: And that's where they need to be laser focusing attention as we as we go forward.
I have one other pandemic related question and that is related to telemedicine. I'm wondering how you and your patients fared, needing to deploy telemedicine practically overnight, and whether there have been some unexpected benefits to the use of telemedicine?
Ferdinand: Well, that's one of the hidden gems of the COVID-19 pandemic. It allowed us to learn the benefits of telemedicine. I did a lot of virtual visits. And one of the important things was that for the control of risk factors, you probably can do much of that virtually. The patient needs to have a valid blood pressure device. And I suggest you go to validatebp.org, to get a valid blood pressure device. And their means now some of them relatively inexpensively can Bluetooth to an app and the physician can see their blood pressure; there are even Bluetooth scales. Patients know how to do their temperatures. If they have blood drawn—and many of my patients were afraid to come into the hospital setting—they can do it in an outpatient lab. And then we can electronically access those results. So, you then can see the patient over the Internet to talk to them about their symptoms. They can tell you their vitals and you can make assessments in terms of medications. They can go to the local pharmacy and pick them up and never come into an inpatient hospital or clinic setting.
PCO: So, it's probably here to stay as an as an element of healthcare in your estimation.
Ferdinand: The thing we need to overcome is the literacy gap related to IT literacy. Some of my older patients really had difficulty accessing how to do the virtual visits, they had smartphones, but they use them to call grandkids—they never used them to access the Internet. So, we need to build into that some education.
PCO: I want to thank you very much for your time today and all the best in New Orleans.