Mississippi Today

‘These people were never given the chance to catch up’: Inside the diabetes belt of rural Mississippi

Published

5 months ago

December 20, 2023

Melvin Jones, a 64-year-old native of Cleveland, was in his 30s when he was diagnosed with diabetes. He knew he was at an increased risk because of his family history.

In 2013, at 54 years old, Jones had two toes on his right foot removed and would later lose the big toe on his left foot. He didn't know it then, but he had peripheral artery disease, or PAD, a condition where plaque builds up in peripheral arteries – those that do not supply blood to the heart or brain – and restricts circulation. Without treatment, a patient will continue to need further amputations and will die young.

One doctor told Jones he would likely need to amputate his entire foot – but Jones, whose condition made him retire early from his job at Baxter Pharmaceuticals, was resolved not to let that happen.

“I thought ‘I don't want that,' and me and the doctor were through,” Jones said. “It would have changed my life. I already can't drive my truck no more.”

But many diabetics in rural Mississippi don't have access to the care Jones went on to receive to avoid further amputations. Diabetes and the cardiovascular problems it causes are often asymptomatic at first, or symptoms are obscure. A lack of specialists coupled with some of the lowest social determinants in the country leave regions like the Delta prone to late detection of diabetes and a high rate of amputations.

Now, Jones goes to cardiologist Dr. Foluso Fakorede's Cleveland clinic, Cardiovascular Solutions of Central Mississippi, for regular wound care from a nurse practitioner who travels to the clinic every Thursday from Oxford.

His life is different now, but he's thankful he can still move around and hasn't had to undergo a major amputation, which, for legs, is characterized as any cut above the ankle joint.

Mississippi is the only state with every county represented in what is called the “diabetes belt” of the U.S., which spans an upward arc from the deep South to Appalachian states, according to the Centers for Disease Control and Prevention.

Fakorede said academic institutions should be investing in the region through medical research, but it's not an attractive market.

“I'll make the argument that it should be,” he said. “Because these people were never given the chance to catch up. And now we've left them to suffer in isolation and in pain.”

With 14.8% of its adults diagnosed with the disease, Mississippi is second only to West Virginia in prevalence.

Uncontrolled diabetes, which runs rampant in rural and underserved areas, can lead to blindness, kidney failure, high blood pressure, high cholesterol, heart attacks, strokes and gangrene.

Mississippi, one of 10 states that has not expanded Medicaid, is the fifth highest uninsured state. In Bolivar County and several other Delta counties, at least one in five residents have medical debt in collections.

About one in three diabetics over the age of 50 will develop PAD, which often goes undiagnosed and untreated in medical care deserts like the Delta.

When it is caught, doctors often have an “amputation-first” mentality, which results in the loss of limbs and early mortality – despite the fact that a procedure exists to clean out the arteries of a PAD patient and restore blood flow to extremities.

Within five years of an amputation, diabetics stand a good chance of being dead. Nationally, Black patients are four times more likely to suffer diabetes-related amputations than white patients.

“It's a death sentence,” Fakorede said, “and it's very often preventable.”

The procedure capable of decreasing a PAD patient's odds of amputation by 90% is called an angiogram, an invasive diagnostic imaging test that detects arterial blockages. Revascularization is the therapeutic procedure that cleans out those arterial blockages.

Jones received five angiograms and revascularization procedures in both his legs over the course of the last two years.

The number of angiograms a diabetic patient with PAD will need depends on a number of risk factors such as age, race, hypertension, heart conditions and habits such as diet and tobacco use.

In the U.S., more than half of patients never receive an angiogram or revascularization procedure before a major amputation.

At his Delta clinic, Fakorede, the only cardiologist in Bolivar County, estimates that the number of amputees who never had an angiogram is close to 90%.

Dr. Foluso Fakorede follows up with patient Joann Moore at Cardiovascular Solutions of Central Mississippi in Cleveland, Miss., Wednesday, Nov. 29, 2023. Credit: Eric J. Shelton/Mississippi Today

Fakorede, who was born in Nigeria and spent his teenage and young adult life in New Jersey, struggled to justify moving to Mississippi and opening his own clinic. He knew nothing about the place and had never operated his own business. But when he saw how great the need was in the Delta for a procedure he was skilled at, he knew his mind was made up.

“You walk through Walmart or Kroger here,” Fakorede said, “and I promise you you'll see someone who has had a limb taken off or a dialysis catheter around their neck.”

In the end, Fakorede said the Delta proved to be far more similar to his hometown in Nigeria than he thought. They are regions that, for the majority of residents, reflect nothing of their country's wealth – despite the rich resources they provide that contribute to that wealth.

“That is actually what made me stay – that similarity,” he said.

In the Delta, Fakorede explained, there are a number of socioeconomic factors that contribute to what he calls “the perfect storm” and leave people at a greater risk of chronic and life-threatening conditions.

Studies have shown that the body's inflammatory response to chronic stressors like poverty, food deserts and unemployment – all of which pervade the Delta – can accelerate diseases like PAD.

Fakorede believes that a large part of the problem is inadequate screening measures. The United States Preventive Services Taskforce, or USPSTF, is the governing body that doctors look to for recommendations on who to screen for which conditions.

The USPSTF has not endorsed a screening for PAD, despite the fact that the five-year mortality for undiagnosed or untreated PAD patients is higher than that of breast cancer and prostate cancer, and studies have shown minorities are disproportionately affected.

“That is atrocious,” Fakorede said. “These patients have existed for decades. We know that this disease is destroying them because it's taking them out of the workforce. It's taking them out of their homes. They're ending up in caskets early on.”

Meanwhile, Ozempic shortages are sweeping the nation as doctors prescribe the FDA-approved, weekly Type 2 diabetes medication to patients without diabetes for weight loss.

In Mississippi, nurse practitioner KC Arnold, director of the Ocean Springs Diabetes Center, witnesses the shortage daily.

“Every single day I'm getting a call: ‘hey, my pharmacy can't get this,'” Arnold said. “In all my years of helping people with diabetes, this has been the biggest challenge for me to help people get what they need.”

Arnold's facility is nurse practitioner owned and run – a rarity in Mississippi, where restrictive and expensive collaboration agreements limit the freedom with which nurse practitioners can operate.

Ozempic has a weight-loss version called Wegovy, but it isn't covered by Medicare, so doctors will sometimes prescribe Ozempic in its place. The Mississippi Board of Nursing has guidelines that prohibit nurse practitioners from prescribing the weight loss drugs off label. But that rule doesn't apply to doctors.

Arnold says she supports insurance companies covering a drug that addresses obesity. But until that happens, doctors shouldn't be prescribing Ozempic to patients for weight loss.

“I can't get the medicine for my patients with Type 2 diabetes,” she said. “Insurance needs to change to help people with weight – I'm all for that – but right now my patients with diabetes need medicine they're not getting.”

And the drug isn't just prescribed to people with diagnosed obesity. Chelsea Handler, a comedian and host of the 2023 Critics Choice Awards, joked that “everyone's on Ozempic” in Hollywood.

Many insurance companies don't cover drugs prescribed off label, but those who can afford it are paying premiums out of pocket.

“You know who ain't getting it?” Fakorede said. “We ain't getting it here in the Delta. There are people who are not even diabetic who are getting it in the Upper East Side in New York. Socioeconomic status matters.”

Dr. Foluso Fakorede takes a call from a professional in wound care while at Cardiovascular Solutions of Central Mississippi in Cleveland, Miss., Wednesday, Nov. 29, 2023. Credit: Eric J. Shelton/Mississippi Today

Mississippi's alarming rate of diabetes plays a significant role in another of the state's abysmal health statistics: leading the country in infant and maternal mortality.

Pregnancy tends to highlight the socioeconomic disparities of diabetes since some women receive Medicaid coverage for the first time during pregnancy, according to maternal-fetal specialist Dr. Sarah Novotny.

“Often, pregnancy is the first time women have access to health care insurance,” Novotny, who serves as division director of maternal-fetal medicine at University of Mississippi Medical Center, said. “So, a lot of times patients are coming into pregnancy with very poorly controlled diabetes because they didn't have access to pre-pregnancy care.”

In pregnancy, diabetes can be separated into two categories: women who already had diabetes, whether it be Type 1 or Type 2, and then became pregnant, versus those who developed gestational diabetes during pregnancy.

Women who have preexisting diabetes and become pregnant are at risk of developing vascular problems, high blood pressure, renal problems and retinopathy. Gestational diabetes doesn't carry the same risks for the mother. Both conditions carry increased risks such as abnormal growth and birth defects for babies.

Women who develop gestational diabetes carry a 50% risk of developing Type 2 diabetes later in life.

Managing diabetes before conception would go a long way in mitigating the state's maternal and fetal mortality and morbidity rates, according to Novotny. But at the very least, recognizing and diagnosing diabetes during pregnancy can serve as an opportunity for previously uninsured or underinsured women to improve their quality of life.

In the last three decades, despite all the technological and medical advancements that have been made, diabetics in minority populations have seen worse outcomes.

Turning those statistics around would mean prioritizing tackling inequities in health care and recognizing places like the Delta as meccas for research, according to Fakorede.

“We need to be collaborators,” he said. “We need to be hope dealers. We need to be disruptive in terms of using our positive thinking to address some of the systemic inequities that have plagued these people and this region for decades.”

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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On this day in 1862

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12 hours ago

May 13, 2024

Staff Editor

MAY 13, 1862

During the Civil War, Robert Smalls and other Black Americans who were enslaved commandeered an armed Confederate ship in Charleston. Wearing a straw hat to cover his face, Smalls disguised himself as a Confederate captain. His wife, Hannah, and members of other families joined them.

Smalls sailed safely through Confederate territory by using hand signals contained in the captain's code book, and when he and the 17 Black passengers landed in Union territory, they went from slavery to freedom. He became a hero in the North, helped convince Union leaders to permit Black soldiers to fight and became part of the war effort.

After the war ended, he returned to his native Beaufort, South Carolina, where he bought his former slaveholder's home (and allowed his widow to live there until her death). He served five terms in Congress, one of more than a dozen Black Americans to serve during Reconstruction. He also authored legislation that enabled South Carolina to have one of the nation's first free and compulsory public school systems and bought a building to use as a school for Black children.

After Reconstruction ended, however, white lawmakers passed laws to disenfranchise Black voters.

“My race needs no special defense for the past history of them and this country,” he said. “All they need is an equal chance in the battle of life.”

He survived slavery, the Civil War, Reconstruction and the beginnings of Jim Crow. He died in 1915, the same year Hollywood's racist epic film, “Birth of a Nation”, was released.

A century later, his hometown of Beaufort opened the Reconstruction Era National Monument, which features a bust of Smalls — the only known statue in the South of any of the pioneering congressmen of Reconstruction. In 2004, the U.S. named a ship after Smalls. It was the first Army ship named after a Black American. A highway into Beaufort now bears his name.

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Mississippi Today

Lawmakers move to limit jail detentions during civil commitment

Published

15 hours ago

May 13, 2024

Staff Editor

mississippitoday.org – Kate Royals – 2024-05-13 05:00:00

This article was produced for ProPublica's Local Reporting Network in partnership with Mississippi Today. Sign up for Dispatches to get stories like this one as soon as they are published.

Mississippi lawmakers have overhauled the state's civil commitment laws after Mississippi Today and ProPublica reported that hundreds of people in the state are jailed without criminal charges every year as they wait for court-ordered mental health treatment.

Right now, anyone going through the civil commitment process can be jailed if county officials decide they have no other place to hold them. House Bill 1640, which Gov. Tate Reeves signed Wednesday, would limit the practice. It says people can be jailed as they go through the civil commitment process only if they are “actively violent” and for a maximum of 48 hours. It requires the mental health professional who recommends commitment to document why less-restrictive treatment is not an option. And before paperwork can be filed to initiate the commitment process, a staffer with a local community mental health center must assess the person's condition.

Supporters described the law, which goes into effect July 1, as a step forward in limiting jail detentions. Those praising it included county officials who handle commitments, associations representing sheriffs and county supervisors, and the state Department of Mental Health.

“This new process puts the person first,” said Adam Moore, a spokesperson for the Department of Mental Health, which provides training, along with some funding and services related to the commitment process. “It connects someone in need of mental health services with a mental health professional as the first step in the process, before the chancery court or law enforcement becomes involved.”

But some officials involved in the commitment process said that unless the state expands the number of treatment beds, the effect of the legislation will be limited. “Just because you've got a diversion program doesn't mean you have anywhere to divert them to,” said Jamie Aultman, who handles commitments as chancery clerk in Lamar County, just west of Hattiesburg.

Although every state allows people to be involuntarily committed, most don't jail people during the process unless they face criminal charges, and some prohibit the practice. Even among the few states that do jail people without charges, Mississippi is unique in how regularly it does so and for how long. Under Mississippi law, people going through the commitment process can be jailed if there is “no reasonable alternative.” State psychiatric hospitals usually have a waiting list, and short-term crisis units are often full or turn people away. Officials in many counties see jail as the only place to hold people as they await publicly funded treatment.

Idaho lawmakers recently dealt with a similar issue. There, some people deemed “dangerously mentally ill” have been imprisoned for months at a time; this spring, lawmakers funded the construction of a facility to house them.

Nearly every county in Mississippi reported jailing someone going through the commitment process at least once in the year ending in June 2023, according to the state Department of Mental Health. In just 19 of the state's 82 counties, people awaiting treatment were jailed without criminal charges at least 2,000 times from 2019 to 2022, according to a review of jail dockets by Mississippi Today and ProPublica. (Those figures, which included counties that provided jail dockets identifying civil commitment bookings, include detentions for both mental illness and substance abuse; the legislation addresses only the commitment process for mental illness.)

Sheriffs have decried the practice, saying jails aren't equipped to handle people with severe mental illness. Since 2006, at least 17 people have died after being held in jail during the civil commitment process; nine were suicides.

The bill's sponsors said Mississippi Today and ProPublica's reporting prompted them to act. “The deficiencies have been outlined and they're being corrected,” said state Rep. Kevin Felsher, R-Biloxi, a co-author of the bill.

An affidavit of someone who was committed and held in a Mississippi jail for mental health issues. Credit: Obtained by Mississippi Today and ProPublica. Highlighting by ProPublica.

Under current law, anyone can walk into a county office and fill out an affidavit alleging that someone, often a family member, is so seriously mentally ill that they must be forced into treatment. A judge or special master issues an order directing sheriff's deputies to take the person into custody for evaluations, a court hearing and sometimes inpatient treatment. Those screenings take place after the person is in custody — and often while they are in jail.

The legislation adds several steps to the civil commitment process in order to weed out unnecessary commitments. When someone seeks to file paperwork to commit another person, a county official will direct them to the local community mental health center. There, a mental health professional will try to interview the person alleged to be mentally ill and others who are familiar with their condition. Staff can recommend commitment or other services, including intervention by mental health professionals who will travel to the patient or inpatient treatment at a crisis stabilization unit.

As a chancery clerk in northeastern Mississippi's Lee County, Bill Benson has long dealt with people seeking to file commitment affidavits.

He said first requiring a screening by a mental health professional is a good move. “I'm an accountant. I'm not going to try and make a determination” about whether someone needs to be committed, he said. He generally allows people to file commitment papers so he can “let the judge make that call.”

The bill says that if the community mental health center recommends commitment after the initial screening, someone can't be jailed while awaiting treatment unless all other options have been exhausted and a judge specifically orders the person to be jailed. The legislation also says people can be held in jail for only 24 hours unless the community mental health center requests an additional 24-hour hold and a judge agrees. Roughly two-thirds of the people jailed over four years were held longer than 48 hours, according to Mississippi Today and ProPublica's analysis.

However, the bill does not address the underlying reason that many people are jailed as they await a treatment bed. “I'm not certain there are enough beds and personnel available to take everybody,” Benson said. “I think everyone will attempt to comply, but there are going to be some instances where somebody's going to have to be housed in the jail.”

Nor does the legislation say anything about how the provisions will be enforced. House Public Health Chair Sam Creekmore, R-New Albany, the primary sponsor of the bill, said the Department of Mental Health will “police this.” He also said he hopes the law's new reporting requirements for community mental health centers will encourage county supervisors to monitor compliance.

Moore, at the Department of Mental Health, said the agency won't enforce the law, although it will educate county officials, who are responsible for housing people going through civil commitment until they are transferred to a state hospital. “We sincerely hope all stakeholders will abide by the new processes and restrictions,” Moore said. “But DMH does not have oversight over county courts or law enforcement.”

Several mental health experts and advocates for people with mental illness say the law doesn't go far enough to ban a practice that many contend is unconstitutional. For that reason, representatives of Disability Rights Mississippi have said they're planning to sue the state and several counties.

“The basic flaw remains,” said Dr. Paul Appelbaum, a professor of psychiatry at Columbia University and former president of the American Psychiatric Association. “There is no justification for putting someone who needs hospital-level care in jail, not even for 24 hours.”

Agnel Philip of ProPublica and Isabelle Taft, formerly of Mississippi Today, contributed reporting.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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