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Are you on the right blood pressure medicine? 

High Blood Pressure in African Americans

When it comes to the treatment of high blood pressure in African Americans, there are a number of important differences. For reasons that are not entirely clear, many African Americans patients respond differently from white patients based on the hypertension medication used.

Evidence from studies suggests that African Americans do very well with thiazide diuretics (a “water”pill) and they should be used often for the treatment of high blood pressure (hypertension).  Thiazide-type diuretics (chlorthalidone) was better at reducing blood pressure and preventing cardiovascular events like a heart attack or stroke than an ACE (lisinopril) in African Americans as found in the “Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack” (ALLHAT) trial.

right blood pressure medicineBest Stroke Prevention in African Americans

For ideal blood pressure control, the thiazide-type diuretic dose should be equivalent to chlorthalidone 12.5 to 25 mg/day or hydrochlorothiazide 25 to 50 mg/day because lower doses have not been found to be as effective.  Overall, calcium channel blockers (amlodipine) have also shown great effect in African Americans as an initial choice, and are more effective in decreasing strokes than water pills. right blood pressure medicineThus an African American male would be best served by amlodipine first line given the stroke prevention potential, and a African American female better served with a thiazide diuretic initially to get to goal more efficiently.

ACE Inhibitors are not preferred

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blocker (ARB) medications are less effective in African Americans for blood pressure control and are sometimes associated with worse outcomes.  A large study of over 400,000 patients done at the New York University School of Medicine compared outcomes in African Americans and white Americans with three distinct groups:

right blood pressure medicineTheir study  showed that ACE inhibitors were associated with a significant increase in stroke, heart failure, and combined cardiovascular disease when compared with calcium channel blockers or thiazide diuretics in African Americans. The worse outcomes with angiotensin-converting enzyme (ACE) inhibitors were similar to that of B-blockers in this population.

 

Because ACE inhibitors are commonly listed as “first-line” medications for hypertension control in national and international guidelines and recommendations, it should be noted that this principally is based on their response in white populations.  Based on these large African American-inclusive studies and a number of considerations (including cost, co-morbid conditions and disease propensities), the National Institute for Health and Clinical Excellence clinical practice guideline suggests calcium channel blocker therapy initially in African Americans, and substitute a thiazide-like diuretic in the event of edema or intolerance “or if there is evidence of heart failure, or a high risk of heart failure.”

Putting all of these risks aside (imagine that??), ACE inhibitor blood pressure response in African Americans is usually less when compared to calcium channel blockers, thiazide diuretics, or even B-blockers. Researchers suspect that the low blood pressure response is related to “high sodium intake in salt-sensitive” patients, but others have suggested that hypertension in African Americans may just be different.

More Side Effects in African Americans

African Americans have a greater risk of ACE-related cough, and a higher rate of stopping due to cough compared to other racial groups. African Americans were also more prone to develop ACE-related full allergic reactions.

High Blood Pressure in African Americans

When considering all of these issues with ACE’s and ARB’s in African Americans, it should be noted that they are essential for preventing kidney disease in people with diabetes, and certain other kidney related problems.  So if you don’t know why your on an ACE or ARB, call your physician and ask.  The renal-sparing benefits of the ACE and ARB medications is still very valid when used to slow renal/kidney function decline (particularly in kidney disease due to high blood pressure), and they should still be used for kidney protection in African American patients with diabetes and similar conditions.

Please don’t just stop your medications based on this article, check with your provider to get your particular and specific advice. Use this article as a starting point for your discussion. Some providers are aware of these differences, and others may not be fully aware.

African Americans, Vitamins & Heart Health

African Americans also tend to be more deficient in potassium and magnesium and that can negatively impact your heart health.  Vitamin D and vitamin C deficiencies have also been connected to poor heart issues.    Consider Sequence Multivitamins for African Americans as a multivitamin that replaces what you need.

Sequence Multivitamins for African Americans
Sequence Multivitamins for African Americans — “Because our needs are different”

Strokes in African Americans

 Strokes in African Americans

Most strokes in African Americans occur due to high blood pressure and a much higher number of African Americans have uncontrolled blood pressure.  A quarter of all strokes occur in the presence of atrial fibrillation (a fib) and while representing 13 percent of the US population, African Americans experience almost twice that percentage of all strokes (26%).

Strokes are Worse in Blacks

And when a stroke occurs, African Americans have them earlier in life and present with more severe and disabling conditions.    The “Cardiovascular Quality and Outcomes” group concluded that “compared with other race/ethnicity groups, (African American) patients were less likely to receive IV tissue-type plasminogen activator <3 hours, early antithrombotics, antithrombotics at discharge, and lipid-lowering medication prescribed at discharge,” a study looking at over 200,000 patients showed.

Not surprisingly, with these prescriptive deficiencies in play, data analysis also showed a persistently increased re-hospitalization rate in African Americans at both 30 days and one year for all causes.  African Americans also have a 2.4 times higher rate of recurrent strokes than white Americans, and the highest death rate of any racial group.
Stroke patients overseen by neurologists were almost 4 times more likely to receive IV clot dissolving medicine than those seen by non-neurologists for all races and ethnicities (study from the Baylor College of Medicine ), but unfortunately African Americans were half as likely as whites to be seen by a neurologist when presenting with a stroke.

Aspirin to reduce Strokes in African Americans

Aspirin use is decreased among African Americans as compared to whites while the indications for aspirin use are actually higher in African Americans. More African Americans should be taking aspirin because it reduces the risk of stroke, heart disease, and colon cancer. And this was proven at the low dose of 81 mg.  The risk for gastrointestinal bleed is much lower than the risk of stroke, heart attack, etc.
African Americans over age 40 should be taking aspirin to help with the increased incidence of colon cancer, heart disease, and strokes.

Overall, prevention experts (USPSTF ) recommend referring adults who have stroke risk factors and are obese to intense behavioral counseling to promote a healthy diet and more physical activity. That means going to your doctor and having a detailed conversation about what you do . . . and what you eat.  For example, by decreasing your intake of salt and fried foods, lowering the blood pressure and getting proper exercise, strokes in African Americans can greatly decrease.

Take a look at this video that explains why you need to start your medicine, keep taking it, and come in to make sure it is doing what it’s supposed to be doing. Take care.

Heart Failure in African Americans

Heart failure in African Americans

Heart failure in African-Americans occurs more often and is more deadly.  African Americans have a significantly higher risk and earlier onset of heart failure and heart-related death compared to all other populations in the United States.  In fact, African Americans are two and a half times more likely to die from heart failure than Whites, and it occurs at an earlier age.  Much of the added occurrence of heart failure can be attributed to poor blood pressure control and being on the right medications to better control your blood pressure (take a look at my article “Are you on the right blood pressure medicine?”).  But there are also other causes to know.

The “heart failure” name is not the best (in my opinion) to describe the situation with the heart because it gives an impression of impending and unavoidable “failure” of the heart.  In reality, people are admitted to hospitals across the nation with the diagnosis of “heart failure” and then are given medications that readily reverses the “failure.” The term “congestive” heart failure is also used and reflects the situation of too much fluid for the heart to process. The “congestion” in the heart effects its proper function like the congestion in your nose when you have a cold.  In congestive heart failure, “water pills” and other medications are given and the “extra” fluid is flushed (urinated) out.

Heart Failure in African AmericansThe problem with heart failure is complicated, but for our purposes can be considered a combination of

  1. too much fluid in the body
  2. too much heart muscle (from high blood pressure)
  3. abnormal squeezing (or relaxation) of the heart muscles

The occurrence of heart failure, although not as ominous as it sounds in the short term, is a sign of a serious heart condition that can bring premature death.  Like many other health conditions, heart failure occurs more frequently in African Americans.  The major drivers to this racial disparity is a higher incidence of obesity, high blood pressure, diabetes, physical inactivity, and smoking.  To see if you are at risk, let’s review each risk factor.

Obesity

A significant number of African Americans are obese by a number of standards.  A strict criteria starts obesity at a BMI (Body Mass Index) of 30. Your body mass index tries to predict an ideal weight based on your height.  Look at the chart below and find your height on the left and then tract across to your weight.  If you are in the red, many will say you are  “obese.”

Heart Failure in African Americans

You and I both know that African Americans culturally prefer being “meatier” and many African Americans in the red areas are completely happy with their weight and size.  Others have suggested a different (more racially appropriate) chart be used for African Americans and other racial groups, but there is not widespread acceptance.

High Blood Pressure

Heart Failure in African AmericansHigh blood pressure (also called hypertension) that is untreated is the biggest risk for having heart failure in African Americans.  Having your blood pressure controlled to less than 130 over less than 80 is a huge step in the right direction. And being on the correct medicines for the treatment of high blood pressure and watching how salt impacts your health is important as well.

Diabetes

Heart Failure in African AmericansType 2 Diabetes is the most common type in African Americans and occurs with an 80 percent greater chance.  Getting control of blood sugars with medications and diet adjustments is critical to avoiding poor control that could lead to heart failure. Shooting for a HbA1c near 7.0 or below is an indication of good control.  There are other important differences in the medical care of diabetes in African Americans and you can review them HERE.

Physical Activity

A lack of physical activity is bad for your health and that alone can be a risk factor for heart failure.  Studies have consistently shown that physical activity reduces risks of heart disease, stroke, and heart failure.  By walking, running, biking, dancing and more you can make great progress in decreasing the risk for heart failure.  Set a schedule, track your steps, and get started making the rest of your life more health drama-free. If you swim use this waterproof Fitbit to track your performance.

Smoking

Heart Failure in African AmericansA recent study found that “cigarette smoking sharply increases the risk of heart failure in black men and women.”  The study that looked at thousands of African Americans (both smokers and non-smokers) and found that:

  • smokers had a larger heart size (which is associated with heart failure)
  • smokers had a lower heart muscle strength (which is associated with heart failure)
  • smokers had a greater risk for needing to be hospitalized for heart failure

All of this is in addition to the increased risk for diabetes due to smoking (See “Heavy Smokers at Higher Risk for Diabetes”) and the increased cancer and circulation problems.

Let’s get real . . .

Heart failure is real and touches almost ever African American family.  We all know family members with diabetes, high blood pressure, kidney disease, and smokers.  They are on the road to heart failure and because they are related to us . . . we are at risk too.

It’s time to get serious about preventing it.

Heart Failure in African Americans

Establishing Trust When Patients Distrust Doctors

Distrust DoctorsDistrust Doctors ??

Multiple studies over an extended period of time confirm what most doctors and providers already knew, African Americans are more likely to distrust doctors and other healthcare providers than patients of other racial or ethnic groups.

What many of us did not know was why.  As providers, we spent many years training to help others.  Medicine is a service profession. Why would anyone suspect our intentions, question our motives, or assign us collectively as untrustworthy?  The answer lies in the historical experience African Americans had with America’s doctors, hospitals, and researchers.

A History of Abuse

While the Tuskegee Syphilis Study is a ‘classic example’ of abuse based purely on race, unfortunately the American experience has many more examples of why African Americans mistrust the medical community.

From African American’s earliest days in this country, abuse based on race was commonplace.  Slaves were frequently used as subjects for dissection, surgical experimentation, and medical testing. J. Marion Sims, MD, the so-called father of modern gynecology perfected many of his surgical techniques on slave girls without anesthesia. Stories of doctors kidnapping and killing southern blacks for experimentation consistently appear in literature throughout American history.

Distrust DoctorsAs Vanesa Northington Gamble, MD, PhD put in her article “Under the Shadow of Tuskegee: African Americans and Health Care” tales of ‘medical student’ grave robbers, recount the exploitation of southern blacks as their deceased family members would be stolen and sent to northern medical schools for anatomy dissection.  Dr. Gable writes:

“These historical examples clearly demonstrate that African Americans’ distrust of the medical profession has a longer history than the public revelations of the Tuskegee Syphilis Study. There is a collective memory among African Americans about their exploitation by the medical establishment.”

Racial Differences in Trust

Chanita Hughes Halbert published a study in JAMA in 2006 looking at racial differences in trust in healthcare providers. Her study of almost one thousand white American and African American patients found that “compared with whites, African Americans were most likely to report low trust in health care providers.”

“Trust has been described as an expectation that medical care providers (physicians, nurses, and others) will act in ways that demonstrate that the patient’s interests are a priority. Trust is a multidimensional construct that includes perceptions of the health care provider’s technical ability, interpersonal skills, and the extent to which the patient perceives that his or her welfare is placed above other considerations. Trust is an important determinant of adherence to treatment and screening recommendations and the length and quality of relationships with health care providers.”

Fortunately, the level of trust a patient has for any specific provider is not stagnant, it can be earned.  Increased exposure to providers in general, and to the same provider in specific, has been shown to improve trust.

Physician Bias

In the “Medscape Internist Lifestyle Report 2017“, Carol Peckham looked at internist’s admitted explicit biases “toward specific types or groups of patients” and found wide differences between racial groups in bias for a number of influences.  The study further examined if the physician bias actually impacted care delivery, and almost one in five providers (18%) admitted that their bias did impact the quality of their care.

Generally these biases are positive toward white American patients and negative toward African American patients as a study by Oliver et al demonstrated at the University of Virginia. They found providers explicitly preferred white Americans to African Americans with “significantly higher feelings of warmth toward white people” and also found that white American patients were “more medically cooperative than African Americans”.  This study found no significant difference in the quality of care between the racial groups.

“physicians demonstrated implicit pro-white bias, reported an explicit preference for white people, had beliefs that blacks were less medically cooperative than whites, and believed that subconscious biases could influence their clinical decision making.”

Unconscious Bias

Biases that effect medical care can be consciously counteracted, and admitting the existence of biases is the critical first step in canceling its effect on medical care. Having a doctor who professes to treating “everyone the same” will undoubtedly provide inferior care to patients that are different.

A study done at Johns Hopkins by Lisa Cooper and colleagues found that primary care physicians who hold unconscious racial biases tend to dominate conversations with African-American patients during routine visits, paying less attention to patients’ social and emotional needs, and making these patients feel less involved in decision making related to their health. These patients also reported reduced trust in their doctors, less respectful treatment, and a lower likelihood of recommending the physician to a friend.

Because there are a limited number of physicians to provide care to African Americans, many patients simply “put up” with biases and unequal treatment . . . with others avoiding healthcare altogether until they they arrive in Emergency Departments with very advanced disease.

Patient Centered Care Improves Quality

Patient centered care can positively improve care, specifically for African Americans.  Although this seems obvious, spending time with patients is an easy approach to establishing trust. Fiscella and colleagues measured patient trust against the time spent with a patient and found a one-to-one correlation: the more time spent led to more perceived trust on the part of the patient. Making suggestions about diet changes requires a trusting relationship that involves a non-judgmental regard for the current diet.

Many delays in diagnosis and treatment are simply an outgrowth of the lack of trust. You will not accept someones advice if you don’t trust them.

Find a physician you trust.

Kidney Disease in African Americans

Kidney disease in African Americans

Kidney disease in African Americans is one the most dramatically different occurrences of a disease, and results in significant suffering and death.  Generally kidney disease is the result of diabetes and high blood pressure, and given the increased number of both of these in African Americans, there is a six to twelve-fold increased occurrence compared to whites.  Additionally, there is a 17-fold greater rate of high blood pressure as a cause of kidney failure in African Americans.  If you have high blood pressure or diabetes, or both, your risk for kidney failure resulting in needing dialysis is MUCH higher if you are African American.
Having diabetes and high blood pressure that is controlled on medications almost erases this increased risk. This is why it is critical that if you have high blood pressure, you should take medication to bring it down. If you have diabetes, you should make sure your blood sugars are controlled because if you don’t, your risk for needing dialysis is very high.
Kidney disease in African Americans

Risk for Requiring Dialysis is High

While African Americans are 13 percent of the general population, we make up 35 percent of all patients on chronic dialysis.  Diabetes as the leading cause of kidney failure and high blood pressure is the second most common cause.
Not having medical insurance or access to medical facilities and the increased number of people with high blood pressure contribute greatly to kidney disease in African Americans.  Having high blood pressure but being on the wrong medications can contribute as well.

Well designed studies have failed to fully account for the excess proportion of kidney disease in Blacks.  Anatomically, despite equivalent age, blood pressure, and other factors, African Americans tend to have reduced kidney blood flow. Despite similar dietary salt intake, the kidney’s processing of bodily fluids are somewhat different in African Americans compared to whites.  Reducing salt in your diet can greatly improve health.

A Possible Genetic Cause?

The Tsetse Fly transmits the African Sleeping Sickness. By International Atomic Energy Agency

Some of the increased risk for kidney disease in African Americans is attributed to a genetic variant (APOL1) found in more than 30% of African Americans and largely absent in white Americans.  It is thought that this gene offered protection from African Sleeping Sickness (a frequently deadly disease known in medical circles as African trypanosomiasis) that was carried by the Tsetse fly. Basically, having this gene gave protection from the African Sleeping Sickness and was beneficial in African regions where the tsetse fly lived.
Scientists believe that the increased risk for kidney disease seen in African Americans is equal to the increased occurrence of the same gene that offered protection from the deadly African Sleeping Sickness.

Obesity Can Lead to Kidney Problems Too

In addition to these genetic differences, researchers also suspect that increased obesity in African Americans is driving up kidney disease.  They found that as your BMI (Body Mass Index is calculated based on your weight and height) gets higher, the risk for kidney problems increases.

With all of the kidney disease in the African American community, there is one last bit of curious news.  African Americans have a better survival rate on dialysis than white Americans.  This paradox of improved survival in African Americans after initiation of dialysis has puzzled researchers.  Researchers at the Wake Forest School of Medicine suggest that the improved survival may also be due to the very gene that causes the problem . . . the APOL1 gene.  In this case the APOL1 gene gives protection against hardening of the arteries while on dialysis.

Kidney Disease in African AmericansHere’s What You Need To Do . . .

Kidney disease in African Americans can be a confusing topic to understand and there is a lot to consider.  The most important points are:

  1. If you have high blood pressure, take your medicine and watch your salt intake so that your pressure stays normal. That will allow your kidneys to stay normal.
  2. If you have diabetes, take your medicine and watch your diet so that your blood sugars stay normal.
  3. Watch your weight because the bigger you are, the higher your chance for kidney disease.


Atrial Fibrillation in African Americans

Atrial Fibrillation in African Americans

Atrial fibrillation in African Americans, also called “A Fib”, effects one in nine before the age of 80 and is the most prevalent arrhythmia in the US and is associated with significant bad outcomes that include stroke, heart failure, and increased death.  Surprisingly, studies also confirm a decreased atrial fibrillation incidence in African Americans (41% lower risk of being diagnosed than European Americans) but a greatly increased occurrence of stroke and sudden death in African Americans with atrial fibrillation. So compared to whites, African Americans are less likely to get atrial fibrillation, more commonly called “A Fib”, but if they get it, are more likely to have complications. This is just one of many “important differences” that exist in the care of African Americans.

“Racial Paradox?”

Some have suggested that the decreased incidence of atrial fibrillation in African Americans is actually under-diagnosis, but others have called it a “racial paradox” where despite atrial fibrillation being a result of increased high blood pressure, diabetes, over-weight, heart failure, and heart attacks, all of which are higher in African Americans, the incidence of atrial fibrillation is surprisingly lower.

Atrial Fibrillation In African AmericansAfrican Americans were also less likely to be aware they have A Fib, and much less likely to be treated with blood thinners like warfarin (Coumadin, Jantoven) that prevent the heart attacks and strokes that having A Fib causes.   Even more surprising was this decreased use of warfarin in African Americans was regardless of whether the person had insurance or made more money.   It is truly stunning that a medication to prevent strokes is used LESS in a group of people who are prone to have MORE strokes and this was found in a study by Meschia and colleagues who looked at over 30,000 patients:

“We also found that among those who were aware that they had AF (atrial fibrillation) and who had confirmation of the diagnosis of AF, (African Americans) were about one quarter as likely to be treated with warfarin as whites. In striking contrast, risk of stroke as stratified by the CHADS2 score was not a predictor of warfarin use. The fact that risk of future stroke did not significantly alter the likelihood of warfarin use would seem to reflect an evidence-practice gap.”

A Higher Risk for Death

The risk for death in the presence of atrial fibrillation (A Fib) in the first four months after diagnosis was very high with heart disease, heart failure and stroke accounting for the most of the deaths, the study also found.  The risk for hospitalization in African Americans from atrial fibrillation doubled as did the risk for recurrent stroke, and related dementia from repeated “little strokes” (multi-infarct dementia).

What is the Best Medication for A Fib?

So the medical evidence would suggest that African Americans should receive MORE treatment with blood thinning medications like warfarin and other newer medications like dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis) . . . and in fact they receive LESS.

Some of the complaints about warfarin is the need to have relatively frequent blood tests to confirm the “thin-ness” of your blood.  These tests called “PT / INR” shoots for an INR between 2.0 and 3.0.  Less than 2.0 means your blood is “too thick” and more than 3.0 means it is “too thin.”  The newer medications to replace warfarin do not need blood tests.

Keep in mind that African Americans have an increased risk for complications from bleeding on some of these newer medications like dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis), so although it can be more inconvenient with frequent blood draws, warfarin may be best for now until more information is available. There is also significant evidence that there are warfarin dosing differences between European Americans and African Americans that need to be anticipated and considered.

What You Need to Know . . .

While this topic may seem a little confusing, here are the main points:

  1. If you have atrial fibrillation (A Fib), you are at a much greater risk for stroke or another major event.
  2. Being on a blood thinner, like warfarin, can significantly decrease your risk for stroke (or another event).
  3. Being on a blood thinner increases your risk for bleeding . . . but not as much as it decreases your risk for stroke. So while you risk a bleed, your risk for stroke is much higher.
  4. The newer “blood thinners” do not require as many lab tests as warfarin, but they also may not be as safe in African Americans (this is controversial and not clear).

Here is a video on anticoagulation and warfarin:

 

Elizabeth Clarke, Master Teacher

Elizabeth Clarke, Master Teacher

While cleaning a closet I found this article from the Plain Dealer about my 6th grade teacher Elizabeth Clarke.  Mrs. Clarke was legendary in many ways. As the teacher of more than a generation of successful African Americans in Cleveland, her success with students was no accident.  As a teacher at Miles Standish Elementary School in the Glenville neighborhood where I grew up, she taught many of my family and friends including two of my brothers and my wife.  She also has taught a who’s who of African American success stories in Cleveland including TV personality Leon Bibb, prominent attorney Inajo Davis Chappell, Judge Ray Headen, former Mayor Mike White, and many others.

Elizabeth Clarke, Master Teacher
Miles Standish Elementary School (Currently Michael White Elementary School)

Mrs. Clarke demanded success and expected it of all of her students.  She was incredibly strict and ruled by intimidation and ridicule . . . which in my case was the perfect motivation. We were told we were better than the other students in the school and we needed to act like it, we were in “Mrs. Clarke’s class.”   Even within the class, she had her favorite students and everyone knew their status. I was one of her favorites as was Inajo, Ray, Miles Roach and others. My brothers and others were not so lucky.

The basics plus more . . .

Mrs. Clarke insisted we learn the educational basics of elementary school as fast as we could. Simply learning the multiplication tables was unacceptable, we needed to learn and recite them in lightning speed. Stuttering, or breathing for that matter, meant we had to see her exasperation and start again from the beginning. I can still recount those tables in my head when needed.

Diagramming Sentences

We also had to learn to diagram sentences which apparently had been a long abandoned approach to grammar, but not in Mrs. Clarke’s class.  We all strove for her complimentary comments on our homework: “Very Excellently Done!” I’ve embedded a video of diagramming sentences for those of you unfamiliar.

“What does Africa mean to me?”

Most important in her class was to learn a deep appreciation for the continent of Africa.  As the PD article describes, she won a paid excursion to Africa as a Master Teacher and continued to go whenever she could. Because of her stern nature, she didn’t smile much, but when she did, Africa was likely the topic of discussion. Annually, she would put together a student performance that educated students at other schools about the rich culture, values, and contributions of our African heritage. Like everything else, that performance had to be perfect every time . . .and it was. We were also the children of Africa and needed to represent that continent impeccably.

Elizabeth Clarke, Master Teacher
Mrs. Clarke’s students would chant “What does Africa mean to me?” between giving education facts about the great continent.

47 years later, here I am writing about a truly masterful teacher who made an indelible mark in the lives of many. Her approaches to teaching would surely not be allowed today. Her deviation from the standard 6th grade curriculum, blatantly “having favorite students”, discounting other students as not as good, and using fear as a primary motivation to learn, would all draw stern criticism from today’s educational leaders.

But the fact remains that Elizabeth Clarke, the Master Teacher, set a path for our success that was deliberate and incredibly impactful. She laid the foundations for learning and the expectation for excellence that many of us carry to this day. There may have been other students that needed a different method for learning, or a more loving approach, but that was never her intention. She unapologetically demanded superiority of her students and accepted nothing less.

For my life, and the lives of a few others, Mrs. Clarke was exactly what we needed to build our self-confidence, to gain appreciation for our heritage, and to carry and exemplify that pride and expectation of more, to the next generation.

For that, we say “Very excellently done, Mrs. Clarke.”

Elizabeth Clarke Master Teacher
Plain Dealer Article by Margaret Bernstein from February 16th, 1992.

African American Healthcare Negatively Impacted by Bias-Driven Data

Hospitals across this nation use protocols and algorithms aimed at improving outcomes in their patients, but because of nuanced differences in the care of African Americans, those protocols have now been shown to negatively impact African American healthcare. A recent article in Science, “Dissecting racial bias in an algorithm used to manage the health of populations” reviewed outcomes data and found that “Black patients assigned the same level of risk by the algorithm are sicker than White patients.” Essentially the computer “assumes” that African Americans are healthier than they are because of their decreased use of certain medical care services.

African American Healthcare By Greg Hall

The predictive model uses, among other things, cost of care as a marker for health.  Because of bias in providers, less interventions are ordered and completed, less referrals to specialty providers, and less orders for a number of counseling opportunities.  African American patients, across the population have less successful follow up with physicians, fewer prescriptions filled and refilled, and more missed appointments.  These combine to produce an outcome that mathematically would suggest better health, but instead bias on both the patient and providers’ part is driving worse outcomes.

African American Healthcare By Greg Hall

Large hospital and hospital systems spend a significant amount of money trying to save money. There are a  number of “risk-prediction tools” that are used to target “high risk” patients that would get more attention, added studies, longer stays, increased follow up, and more.  Knowing the significant health disparities impacting African Americans, one would assume that added attention would improve these rock-bottom outcomes, but the “predictive model” does the exact opposite and suggests less interventions.

The study also found a difference in healthcare-related spending with African Americans having “fewer inpatient surgical and outpatient specialist costs, and more costs related to emergency visits and dialysis.”

The take-home message is bias on almost everyone’s part (provider, social worker, discharge planner, patient, hospital, etc.) negatively impacts African American health and healthcare outcomes.  Systems and algorithms designed to improve outcomes and save money are actually driving up cost and decreasing quality outcomes in African Americans.  Bias-driven outcomes can easily be tracked, considered and corrected.

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In addition to bias, there are other African American healthcare differences that impact hypertension, diabetes, stroke, diet counseling and more. These differences, by and large, are also being ignored by hospital systems, medical schools and providers.

The good news is the first textbook addressing the patient-centered clinical care of African Americans was recently released.

 

 

Love Your Kids, Not Your Guns

Love kids not guns

It’s silly that I have to write an article about something so obvious: Love your kids, not your guns.  I’ve wrongly stayed neutral about gun control because so many of my patients have and love guns.  And frankly, I didn’t want to alienate them.  I’ve said to myself, if they want to have assault weapons and an arsenal in the basement of their home, who am I to say what they do . . . . or what they have? Some people collect stamps and other people collect guns.  Collecting stamps never impacted so many other lives as collecting guns. The people that collect stamps really get into it.  They travel to foreign lands just to personally buy incredibly valuable stamps, and many I’m told, can never stop.  Their stamp collection is never complete.  Many of my friends and patients with guns have the same “story” where they collect various guns of different fashions and capacities . . . and their collections seem boundless as well.  Up to one third of adults engage in some form of “collecting” and for many Americans, guns are their passion.

357 Million Guns

Americans, by far, own the most guns per capita in the world, with over one gun per person. But gun ownership is highly concentrated with only about a third of Americans admitting to owning one.  And these numbers are decreasing from numbers in the 1970’s where the majority of Americans had guns. Among these “normal” gun owners is a small subset of “gun super-owners” who have huge collections that can result in well over one hundred guns.  Once they collect the usual hand guns and rifles for hunting or home protection, they migrate into bigger and more impressive gun collections that have the capacity for wide-spread devastation.  They buy rapid fire machine guns, grenades, silencers, and more.  They are not planning to attack anyone, but if someone attacks them . . . there’s going to be trouble.   This small number of law-abiding collectors do not want their ability, or access, to guns and ammunition impeded by laws that restrict what they can “collect.”

Why have all of these guns?

When admiring their gun collection, some “super owners” confess to imagining jumping into action at a moment’s notice.  They fantasize about heroic acts that will finally validate their collection.  Do I have enough guns to fight off an invasion of aliens like in the movie “Independence Day?”   What if aliens attack us?  Who will protect us?  The neighbor “gun super-owner” will come to our rescue. That’s silly.  Aliens won’t attack. Love kids not gunsWhat about some virus that “goes bad” and turns half of the world into the “Walking Dead” or zombies like in “World War Z”?  Then I’d bet you wish you had rapid fire assault machine guns to kill all of those “walkers”!   But how much ammunition would you need? Would it run out? Love kids not gunsWait.  That’s silly.  You couldn’t store enough ammunition for that.  The zombies would eventually get us. What about some sort of invasion of the Russians (or whoever), and somehow the United States military would “break down” and then we would need to defend our homes and community from “the enemy?” Then we’d be happy we had military grade guns and ammunition to defend our freedom. That’s silly too.  They would just drop a bomb.

These “gun super-owners” are collectors.

They are not mass murderers.  They are also not saviors from some potential apocalyptic attack.  They are collectors that are simply obsessed with guns.  But their well-meaning obsession puts highly destructive weapons within the reach of other people who shouldn’t have them.  The gun collectors, like the stamp collectors, think they pose no threat.  But they do, and they have. That basement arsenal can be accessed by children, grandchildren, friends, neighbors, or simple criminals who would have no other access to these weapons except for your less-than-secure home security system. Are you ready to take responsibility for your guns no matter where they go, or what they do? The usual approach of “guns don’t kill people, people kill people” can no longer apply.  Over-prescribing opioids by doctors has been rightfully blamed for some of the opioid epidemic.  If the pills had not been in the medicine cabinet, the kids wouldn’t have experimented, and the addiction could have been avoided in some.   A massive campaign has begun to decrease the amount of opioids that are readily available . . . and no one has objected.  Where are the “pain pills don’t kill people, abusing pain pills kills people” objectors? They simply do not exist because its a silly argument. Gun super-owners mean well, but their right to bear arms (or collect arms) shouldn’t extend into our ability to educate our children in an environment free of military-style attacks. Assault weapons have no place in a civilized society. Love your kids, not your guns. Love kids not guns

The Tuskegee Syphilis Study

Tuskegee Syphilis StudyThe Tuskegee Syphilis Study (originally called “Tuskegee Study of Untreated Syphilis in the Negro Male”) was originally formed to record the natural history of syphilis with the hope of justifying the funding of public treatment programs for African Americans. The study, which began in 1932, included 600 African American men, 399 with syphilis and 201 without. While the study was originally slated to last 6 months, it was extended for over 40 years. Central to the study was the patient’s lack of informed consent.  None of the patients were told they had syphilis, instead they were told they had “bad blood” that required monitoring.  In exchange for taking part in the study, the men received free medical exams, free meals, and burial insurance.  Many physicians, including African Americans, and national physician societies, fully supported the study.

Betrayed Trust & Conspiracy

Tuskegee Syphilis StudyDuring the study, researchers not only allowed the disease to progress, but actively blocked the men from receiving curable treatment, not just from the study physicians, but also from other community physicians.   The researchers implemented a coordinated effort . . . a verified conspiracy, with area physicians and hospitals to actively block treatment if they presented elsewhere for care. Needless to say, the study required the widespread communication of personal health information across an entire region and involving hundreds of people.  The names and a stigmatizing diagnosis were circulated widely, and in a way that the patient would not know. The fact that nearly 400 African American men were denied effective treatment for syphilis without their knowledge or consent so that researchers could document the natural history of the disease, stands as a singular event that largely validates the mistrust African Americans have against the medical establishment.

Tuskegee Syphilis Study40 Years Later . . .

It wasn’t until 1972, when a news article reported the study, that a government review panel finally halted it. The Tuskegee Health Benefit Program was established as a settlement for the class action suit brought against the United States. The US agreed to pay all medical and burial expenses for the subjects involved, with added support for their families. During the course of the study, 40 wives contracted the disease and 19 children were born with congenital syphilis.  Many credit the Tuskegee Syphilis Study as the main reason informed consent regulations exist today.  For many African Americans, the study is the perfect example for why to not trust public health, medical research, or healthcare.

The Apology

In 1996, a formal apology was issued by the US government and the survivors were invited to the Oval Office by President Clinton.

Tuskegee Syphilis Study

Some argue that with time the Tuskegee Syphilis Study is merely a distant historical event for most African Americans.  A study done at Johns Hopkins looked at awareness of the Tuskegee Syphilis Study and found an overwhelming number of African Americans (81%) were aware of the study and outcomes, while only 28 percent of European Americans had knowledge of the study. With widespread knowledge of this government-sanctioned and funded study within the African American community, mentioning the study as a way to stimulate discussion, and build trust, is a preferable approach to ignoring its existence.