On Disparities in Healthcare

It’s been 20 years since I led a study evaluating gender disparities at leading medical institutions in the U.S. and Canada. Our research was among the first to show that women were vastly undertreated than their male counterparts despite having a similar degree of coronary disease. Over the past decade, I’ve also had the privilege of serving as a Trustee for The AstraZeneca Foundation’s Connections in Cardiovascular Care, where we’ve funded more than $20 million in innovative, non-pharmaceutical based community projects to marginalized communities. However, systemic discrimination continues to pervade our country’s healthcare system and should be classified as a health risk.  Upon medical school graduation, reciting the Hippocratic Oath is a rite of passage. One of its core tenets reads that a physician is “to treat the ill to the best of one’s ability”. This statement is meant to encompass ALL people: of all races, religions, genders and sexual orientations. Unfortunately, research has shown that this important oath has not been upheld properly.  It’s time for the medical community to recognize this and make systemic changes.

It takes activists and community leaders working together alongside dedicated professionals to help reduce health care disparities.  Progress can be achieved through greater awareness in the medical community, and educational initiatives in the patient population.  Such an initiative might include a series of educational messages featuring BIPOC (actors or medical professionals or patients) on media-based platforms that are promoted by prestigious organizations such as the American Heart Association. The goal of these messages would be to increase knowledge and relevance of heart disease risk factors, such as hypertension in underserved communities.  Another goal would be to ensure that heart healthy foods are readily available in all communities, focusing on those with food insecurity.  One such successful program is the Sankofa Community Development Corporation in New Orleans, LA which educates high-school age youth and their families about heart healthy lifestyles, nutrition and techniques for growing fruits and vegetables. 

A third goal would be to integrate healthy nutrition with measures to increasing physical activity to help reduce the high rates of obesity in underserved communities.  An example of one such successful program is the “Partnering for Youth Cardio-Fit Project,” which provides free-after school programs to enhance physical fitness and overall well-being. The fourth goal would be to offer programs that help to reduce chronic stress that in itself, remains a significant health issue in these communities.   This might include yoga, meditation, tai chi, dance instruction and spirituality exercises. For example, in my Baltimore community, there are a number of local wellness advocates who provide free access to yoga and meditation. 

Right now, there is considerable unconscious (and conscious) bias that arises when medical professionals see a patient that is part of the BIPOC community. For example, when a Black patient discusses their health concerns, medical professionals (on average) are less likely to take their concerns as seriously as they might a White patient. This shows that these problems must be solved NOT ONLY with community outreach, but also with a revised curriculum for medical professionals. Physicians, nurses, PAs, etc. must all be trained in unconscious bias and learn how to recognize how these biases affect patients in real time. In addition, medical schools need to revise their curriculum to include case studies that showcase conditions in multiple races (since diseases may manifest themselves differently depending on the racial makeup of a patient). For example, @brownskinmatters is an awesome instagram account that does this for dermatological conditions.

The bottom line is that as health care professionals, we need to do better and treat all of our patients as if they were our family members, regardless of race, religion, gender or sexual orientation.  

Michael Miller, MD is a cardiologist and Professor of Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine in Baltimore, Maryland.  His latest book,  “Heal Your Heart: The Positive Emotions Prescription to Prevent & Reverse Heart Disease” is published by Penguin Random House, USA.

In Honor of Dr. Elijah Saunders

In celebration of the Juneteenth holiday, I would like to pay homage to Dr. Elijah Saunders, a world renowned cardiologist who was one of my heroes and a hero to countless medical students, physicians and patients alike. Dr. Saunders was the first BIPOC cardiologist in the state of Maryland who practiced for nearly 50 years until his passing in 2015 at the age of 80. He was the consummate physician who gave patients his all, all of the time. His area of expertise was hypertension for which he was not only a stalwart who took care of thousands in the black community, but he was also a Doctor’s Doctor because we constantly sought his advise and looked up to him as a leader in the medical field.

I met Dr. Saunders 30 years ago where he was a professor at the University of Maryland School of Medicine and head of the Hypertension Division. Soon after, his pioneering work found that black patients responded better to certain blood pressure medications, helping to pave the way for identifying more effective blood pressure treatments in underserved and marginalized communities throughout the world.

He was a brilliant physician and had the innate ability to inspire curiosity in others, regardless of their background. He always made himself accessible — from patients to junior residents to senior staff members.

Medicine today as we know it was shaped by his enormous contributions.

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland.

COVID-19 Complications: Reducing Your Risk

Over the past month, hospitalization rates have fallen in many part of the U.S., including the State of Maryland (my home). Yet while infection rates remain high (~20,000 new cases each day), most COVID-19 positive cases (~9 of out of every 10) exhibit a range of symptoms between none and mild-moderate (low-grade fever, cough, weakness and fatigue) that can be treated at home. 

Should you become infected with COVID-19, here are some suggestions that might help to reduce your risk of a COVID-19 complication.

Stay well hydrated:  With a cough and fever of 100.5ºF (38ºC), fluid loss can be significant: ~16 oz (475 mL) daily on top of normal fluid requirements (~64 oz/ 1.9 L per day).  Because severe dehydration can land you in the hospital, the goal is to stay well hydrated throughout the day.  To do this, drink 8 oz of water hourly over 10-hours each day until the fever subsides.  

Stay well nourished: The antiquated adage “feed a cold, starve a fever” has no place in the treatment of COVID-19 (or any other infection for that matter).  This is because fever raises metabolic rate resulting leading to higher caloric requirements. You may need to force yourself to eat if you’ve lost your sense of taste and smell (one of the signs of coronarvirus).  Recommendations include increased protein intake from plant-based sources such as chia seeds, lentils, almonds and Ezekiel bread to name a few (see other top foods in “Heal Your Heart”).   Also try to consume foods enriched in Vitamin C (such as broccoli, grapefruit, strawberries), zinc (such as hempseeds, oysters, shitake mushrooms) and cook with anti-inflammatory spices (such as garlic, ginger, turmeric) and foods (such as salmon, sardines, herring).

Stay less stressed:  Like with other infections and illnesses, emotional stress complicates COVID-19 recovery efforts.  To more effectively combat this infection, (beyond adequate hydration and nutrition), aim for 7-8 hours of uninterrupted sleep (see my blog “Want to sleep like a baby”), consider meditation, magnesium containing foods and stay socially connected with friends and loved ones until circumstances permit physical connections to be reinstated.

Practice breathing exercises: Check out this informative video from Dr. Jonathan Bayuk on useful breathing exercises (and his other recommendations) that may help to limit COVID-19 related lung complications.

Get Sunlight:  As low Vitamin D levels may play a role in COVID-19 complications, aim for 15-20 minutes of sunlight daily. For more info, also refer to my blog “COVID-19 Diet : What We Know”.

What about taking a blood thinner? A major advance in reducing the need for a ventilator and improving hospital survival rates has been the use of blood thinners (or anticoagulants).  This is because COVID-19 has a tendency to promote blood clots that can form in vascular regions including the legs, lung and brain.  At this time however, there are no recommendations to take a blood thinner (including aspirin), unless you are hospitalized with COVID-19 (or have a non-COVID reason to be on this group of medications).   

Michael Miller, MD is Professor of Medicine, Epidemiology & Public Health and a cardiologist at the University of Maryland School of Medicine in Baltimore, Maryland.  His recent book,  “Heal Your Heart: The Positive Emotions Prescription to Prevent & Reverse Heart Disease” is published by Penguin Random House, USA.

Does COVID-19 Weaken Over Time?

Earlier this week, the prominent and influential Italian physician Dr. Matteo Bassetti was criticized by the World Health Organization (WHO) for suggesting that COVID-19 was weakening. This was based upon his observation that his recently hospitalized patients with coronavirus were not as sick compared to just a month earlier. While the WHO argues that there is no scientific data to support this conclusion, the epidemiology appears to suggest otherwise. That is, when we review the COVID-19 experience in the U.S. a clear pattern emerges. As shown in the 2 graphs below (i.e., relative decline in the steepness of the curves; data from COVID Worldmeter), despite the high daily case rate over the past 4-6 weeks (~20,000-25,000 new cases in the U.S. per day), the rate of death is lower over this same time period (~2000 to ~1000 in the U.S. per day) with a continued downward trend.

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So what factors may be accounting for the improvement in U.S. mortality rates in recent weeks?

Below are several possibilities:

1. Adherence to social distancing measures: Wearing masks, especially when indoors and in public places as well as maintaining social distance (~6 feet apart) will help to limit significant viral infectivity so should you encounter an asymptomatic person who is infected with the virus, the likelihood of being infected with a large viral load (resulting in pneumonia and/or disease requiring hospitalization) is reduced. While we do expect a surge in infection rates in upcoming weeks resulting from laxity of social distancing during the recent large gathering protests, it remains to be seen to what extent hospitalization rates will also rise. If the virus is inherently weakening (see #3 below), we may not see such an increase.

2. Better treatments in place: Compared to the initial phase of infectivity, therapies are emerging which may help hospitalized patients reduce viral complication rates, shorten duration of illness and potentially improve survival. Promising therapies to date include Remdesivir , convalescent plasma, and intravenous immunoglobulin therapy.

3. COVID-19 is weakening: While there is no scientific proof at this time that COVID-19 has weakened, clear evidence exists that life-threatening infection rates, have been largely reduced (or virtually eliminated) in China, Japan, Europe and the U.S. Unfortunately, in other areas of the world where COVID-19 transmission has only more recently become widespread, such as in Brazil and Mexico, virulent viral activity is quite robust.

While things are looking a little brighter in some parts of the world with respect to COVID-19, there is still no room for complacency until vaccination become available. Therefore, effective social practice measures must remain a top priority to maintain our safety and keep this virus at bay.

This post is dedicated to Dr. Glenn Barquet, an outstanding physician and colleague whose life was cut way too short due to COVID-19.

Michael Miller, MD is Professor of Medicine, Epidemiology & Public Health and a cardiologist at the University of Maryland School of Medicine in Baltimore, Maryland.  His recent book,  “Heal Your Heart: The Positive Emotions Prescription to Prevent & Reverse Heart Disease” is published by Penguin Random House, USA.