How the Wealth Gap Exacerbates Amputations in Black Communities

Dr. Bill Releford
January 25, 2022

A UCLA study published in the August issue of Health Affairs found a high amputation rate in California neighborhoods with a greater concentration of households below the federal poverty line. Further, most of the amputees were observed to be Black minorities. This study is but one of many that bring to light the ever-existent wealth gap between Blacks and Whites in America and its impact on amputations in Black communities.

History Of the Black-White Wealth Gap

Wealth is the difference between what families own – for instance, their houses, cars, savings – and debts such as student loans, mortgages, and what they owe on credit cards. Currently, Black households have a small fraction of the wealth of white households. A study found that the median wealth of Black households with defined-benefit pensions was $40,400 in 2019 which is 15.5 percent of the $258,900 in median wealth for white families. Also, white households are much more likely to inherit wealth from their parents and grandparents, and their inheritances are much larger than those of Black households.

The current racial wealth gap is a by-product of American slavery and the violent economic dispossession that followed. It emanates from centuries of federal and state policies starting with the slavery of Africans, Jim Crow South, to the current institutionalized racism characterized by poor education, healthcare, and housing. All these have disadvantaged the African Americans’ ability to build, maintain, and pass wealth and can constitute increased health risks.

Amputation Epidemic in Black and African American Communities

African Americans with peripheral artery disease (PAD) are two to four times more likely to undergo amputations than white patients. Reasons for this disparity are numerous and include differences in socioeconomic status (SES), insurance coverage, and lack of access to quality health care.

Low Socioeconomic Status and Amputations

Many argue that race could be a marker for SES and ultimately for healthcare access, as a reason for racial disparity in vascular outcomes. Low SES is linked with a higher prevalence of hypertension, diabetes, smoking, and physical inactivity – all of which are linked to amputations.  

A case study was conducted to establish the impact of racial disparity and low SES on limb loss in patients with PAD. They found that low SES increases the risk of amputation. This is mainly because Blacks living in poor neighborhoods cannot afford quality healthcare and the health centers in their localities are ill-equipped to offer preventive care.

A cross-sectional study found that primary amputation was performed with a higher frequency on low-income non-white patients who had lower extremity ischemia and were not covered by private insurance. Ischemia is a serious form of PAD and constitutes severe blockage in the arteries of the lower extremities leading to amputation.

Black people in the lower SES groups have a lower 2-year amputation-free survival rate than whites after the first minor amputation. This is compounded by inequities in the care of these patients even after a limb-threatening situation has been identified. Ideally, they should all have undergone a continuous assessment of blood supply to the foot and have had equal follow-up after minor amputation. Instead, patients with low income are more likely to die or undergo a subsequent major amputation.

Low income can be associated with the prevalence of PAD. There’s however little research addressing the impact of socioeconomic status on PAD outcomes or the correlation between race, SES, and lower extremity amputations.

Lack of Access to Quality Care

Beyond race and ethnicity, socioeconomic factors such as income and insurance serve as proxies for access to care. A recent study found that factors like healthcare access, household density, and pervasive discrimination are the driving forces for disparities in healthcare.

Low-income minority patients mostly get their care from hospitals with fewer resources. Most of these patients have Medicaid as their primary insurance, or are uninsured and will more likely seek care in emergency departments and community health care centers with limited vascular surgery and angiography capacity.

The coverage expansion under the Affordable Care Act (ACA) is a step forward towards universal coverage. However, most of the coverage options are costly meaning that access to affordable healthcare is still a challenge for many minorities – particularly African Americans.

Research found that persons with low income, Medicaid, and Medicare were more commonly admitted to facilities performing low numbers of lower extremity revascularization (LER) procedures and these patients had higher odds of undergoing major amputation than LER. Further studies also co-relate an increased risk of major amputations for patients with Medicare or Medicaid and those without insurance.

A case study was conducted between 1995 and 2003 at three Chicago hospitals to determine the cause of variations in lower extremity amputations. They discovered a higher rate of primary and repeat amputations for African American patients at ill-equipped institutions than at well-equipped hospitals.

Patients need a full team of medical specialists to optimally care for them and prevent lower extremity amputations. Unfortunately, this level of access is often unavailable or unattainable for patients living below the federal poverty line. Unless the wealth gap is closed, we may continue to see the disparities that disproportionately affect Black and African American people.