Angela Glover Blackwell Speaker 1: (00:05)
Welcome to the Radical Imagination podcast, where we dive into the stories and solutions that are fueling change. I'm your host, Angela Glover Blackwell. In today's episode, we examine some of the structural inequities within our healthcare system and how they impact adequate access to treatments for Black and Brown Americans. We meet a doctor working tirelessly to save people's limbs in the Mississippi Delta. And we look into the global access to medicines movement that is reimagining the U.S patent system known for fueling drug prices. Well before COVID-19 embedded itself into our lives, Black Americans, particularly in the South already experienced inadequate access to healthcare. In the Mississippi Delta, one of the poorest regions in the country, Black people were already twice as likely to die from diabetes and live three years less on average than their White counterparts. When Dr. Foluso Fakorede arrived in Bolivar County, Mississippi black patients were undergoing limb amputations at alarming rates, and there were no diabetes specialists to be found within a hundred miles. Dr. Fakorede took matters into his own hands and began putting billboards along major highways, that read Amputation Prevention Institute. Then earlier this year, the pandemic hit.
Media clip: (01:32)
You have to start taking seriously what you can do now that if and when the infections will come and they will come. Nationwide, six new States reported their first cases today. States are reporting disproportionately large numbers of African American deaths. I will take every action that our experts tell us will protect Mississippi's most vulnerable citizens.
Angela Glover Blackwell : (01:57)
The Corona virus would sweep the country, taking a disproportionate number of black lives and exacerbating inequities that already existed for a deeper look into these disparities and how they are manifested through often preventable amputations in the South. We're joined by Dr. Foluso Fakorede. He's also the founder of Cardiovascular Solutions of central Mississippi. Dr. Fakorede, welcome to Radical Imagination.
Dr. Foluso Fakorede: (02:23)
Thank you for having me.
Angela Glover Blackwell : (02:24)
I want to first talk a little bit about underserved communities. One of the things I noticed is that when you arrived in Mississippi in 2015, there was only one black interventional cardiologists in the entire state. I also noticed that in 2015 in the Delta, the state had the nation's lowest number of positions per capita, and it had not expanded Medicaid to include the working poor. And so you have opened up a conversation about racial disparities, race discrimination. When you got there, you talked about what was not happening in terms of treatment. It also looks like there were very few physicians there, period, to be able to provide treatment
Dr. Foluso Fakorede: (03:06)
Correct. There were no incentivize programs took for a physician to come here independently, unless you are recruited. And so if I were interested in coming to Mississippi to serve a community that looks like me and I wanted to do that independently unrecruited, it was going to be hard.
Angela Glover Blackwell : (03:32)
Bolivar County, Mississippi. That is exactly where you located. And I'd love for people to get a sense of what that place is like.
Dr. Foluso Fakorede: (03:40)
Bolivar County is split in the middle in terms of a racial divide. It's 50% African American, 50% Caucasian. You have a farming industry. Um, the number one employer is the hospital, the healthcare industry.
Angela Glover Blackwell : (03:55)
And when you arrived in Mississippi, what were some of the issues that you came across? What were you seeing in terms of the patients there?
Dr. Foluso Fakorede: (04:02)
One of the troubling trends that I noticed was that peripheral artery disease, which is a mouthful. It's an epidemic that affects 21 million people here in the United States. And what peripheral disease does, it leads to the narrowing of blood vessels to your lower extremities and decreases blood supply. And most of these patients have very vague or atypical symptoms. And so if it's not caught on time, it claims their limbs, their lives and their livelihoods. And I also noticed that Mississippi had a 37% African American population. The rates of peripheral arterial disease and amputations were three to nine times higher than other regions where the socioeconomic strata were different. And so people at risk for amputation here where people over the age of 60 or people who've had diabetes, high blood pressure, high cholesterol, all these patients have chronic conditions. And so I was infuriated by the struggles of what we call affordable healthcare in the United States, especially here in the South. There are 200,000 amputations that are performed each year and 130,000 of these amputation are performed on diabetics. Majority of these patients undergo an amputation without giving an option for a limb preserving procedure. And you have the option to unclog that artery. But the odds of undergoing an amputation is decreased by 90%, if that is offered to you.
Angela Glover Blackwell : (05:47)
Let's hear about it through the example of one of your patients, Henry Docstreet.
Dr. Foluso Fakorede: (05:53)
Mr. Docstreet was a diabetic. He lived in a very poor area here in Mississippi. He had seen a primary care provider, but unfortunately the awareness of primary care providers for peripheral arterial disease is also low. And so in a rural area where all these providers are overburdened with a high patient volume and limited time to assess a patient in depth, you do lose a lot of these patients to what we call "the amputation lottery". And in his case, he presents to our hospital here with poor circulation in his limbs. And some of the challenges that I face within the hospital, who was that, you know, you have a for profit hospital system, that is set in their ways in terms of their policies. They are losing economically by performing an amputation within the hospital system. The surgeon might benefit, but the hospital loses money. And so luckily I had had that in mind when I built my clinic to have an outpatient setting where I could bring a patient, any patient independent of your insurance status, independent of your grace, your color, your sex, and you can come into my lab and I can perform a procedure, open up your arteries and hopefully restore and preserve that limb.
Dr. Foluso Fakorede: (07:13)
So it's not only a limb saving procedure, it's a lifesaving procedure. And that's what happened to Mr. Docstreet. We were able to save his legs before they got amputated.
Angela Glover Blackwell : (07:37)
Mississippi's history during the time of slavery is important here. The state became a cotton growing powerhouse by the 19th century, all the while with more than 80% of the people living along the Delta being enslaved. And I know that you have been able to depict what is going on, looking at two maps. Describe those maps so that people get a sense that this is not just happening. This is part of systemic racism.
Dr. Foluso Fakorede: (08:05)
Yes. So if you look at the maps over in slave population, you would notice a couple of trends. If you look at what I call the "Black census scope of America" and you overlay heart attack rates, and you overlay amputation rates, which has peripheral arterial disease, and you overlay patients who have the lowest access to limb and life saving procedures, it all follows that map. And then you sprinkle in there, the number of physicians and specialists available. And there is not one endocrinologist who are diabetes specialists within a hundred mile radius of where I currently practice. We have a medical crisis that Dr. Martin Luther King had diagnosed early since the 1960s. And we have not, in spite of all the technological advances, and all the fact that we have decreased cardiovascular deaths in certain regions of the country by 32%, there are still underserved areas like the Black South that have not seen those numbers and those benefits and that in itself is inequity.
Angela Glover Blackwell : (09:16)
It certainly is. And I want to go back and dig into when you made the decision that you absolutely had to start your own practice.
Dr. Foluso Fakorede: (09:26)
Um, I hate being told no. And I was told by certain people in this town that I will not be successful without their help. And I had a plan to come here to be nimble and pivot to the needs of a community. By seeing if I can build a physician led comprehensive, cardiovascular, amputation prevention center. Not knowing how to achieve that was the interesting journey. One literally had to figure out how to fund a practice. And so I had to borrow money from friends. I had to sell my house and I sold my car. You know, the way some banks work - and I realized this in rural areas - it's not necessarily about your credit score the end of the day. It's about if you're from here. Number one. So if you, if you are from the town and two, it depends on, you know, the, what you look like in terms of your race.
Dr. Foluso Fakorede: (10:25)
Uh, the, I, I think at the end of the day, I can, I had a perfect credit. I am an interventional cardiologist, and that should mean that this guy can be a huge money maker in the town. So that was not a concern. But however, there, for some reason, four banks said no, and I wasn't willing to go to fifth. And so I had to adapt. And lastly, there was not a grant or loan forgiveness program because I came unsolicited and unrecruited. I had to also figure out how to pay off my loans while trying to take care of my community.
Angela Glover Blackwell : (10:56)
Very familiar story. One thing that you might know is that people who are African American are three times as likely to start a small business as people who are white, and yet they have very little access to financing and resources and what they need in order to go forward. The racism that you have seen there in the Mississippi Delta is rampant across the country and shows up every place. One of the places that has really lifted its head is around the Coronavirus. Do you remember what you felt the moment you heard about the novel coronavirus?
Dr. Foluso Fakorede: (11:29)
I was scared, not scared for myself, but I was scared for the people here. COVID-19, it's a pandemic that basically exposed the epidemic of health inequities. If you think about it, um, it targets minorities, it targets diabetes, it targets high blood pressure. It targets obese patients. That sounds familiar, right? It's all the risk factors for cardiovascular disease. And so when you add all these things together, they are at a disadvantage. And when they end up on a ventilator, over 90% of them are dead. So the death rates from high blood pressure were already up 72% in rural areas, pre-COVID. Amputation reads were as high as 50% compared to other regions pre-COVID. And so this hit rural hospitals hard because you had poor cardiovascular outcomes, access to PPE was a problem in terms of their protective equipment. And some of them are just doomed to fail. So as the community doomed to become sicker and more vulnerable.
Angela Glover Blackwell : (12:32)
And it sounds like it directly impacted your work, that what you had built in response to amputations suddenly became very important in response to the pandemic. How did the pandemic impact the need for your work and the expertise that you were bringing to the Delta?
Dr. Foluso Fakorede: (12:48)
Uh, most patients with COVID-19 have a higher risk of forming clots in their lower extremities or in their vasculature system. And so we instituted protocols whereby we put them on blood thinners early on in the hospital. Quite honestly, tele-medicine was a challenge here because half of my patients lack the internet bandwidth that most people have and do not have smartphones. So I literally had to bring patients in who I considered at risk and my staff and I had to use cautionary measures. And we brought them into physically inspect the wound sites, their dialysis sites, and to check their pulses frequently. Medicine encompasses the power of mankind to do good, to heal and to be humanistic. So that is, that is what we do.
Angela Glover Blackwell : (13:34)
And it seems that you have taken that commitment to do whatever it is that has to be done into the policy making realm. You become involved in policymaking to try to make change at the very top. Is there anything in the works that could help address some of these pressing issues when it comes to racial disparities in healthcare that you're trying to move forward?
Dr. Foluso Fakorede: (13:54)
Yes, there is. We took this advocacy fight to the Congressional Hill and testified in September, 2018 on behalf of the Association of Black Cardiology to help raise awareness. And then the next steps which we're currently working through is to introduce legislation, to address the evils of unnecessary amputation that lies in the failure to perform early screening. We evaluate the US preventative service task force evidence on vascular screening of at risk patients. We need to promote crosstalk with cardiovascular societies that have endorsed at risk screening already in their guidelines and with the failure to provide treatment of at risk patients. And we have a firm resolution to disallow payments for non-emergent amputation, unless an anatomical testing has been done in months prior to such an amputation. And we think if this is a national policy, there'll be more African Americans, more Native Americans, more Hispanics who will be saved from undergoing an amputation.
Angela Glover Blackwell : (14:57)
So you finally opened your practice with the goal of reducing amputations along the Delta. What results have you been able to see over the past few years?
Dr. Foluso Fakorede: (15:06)
Five years later, we have successfully decreased amputation rates by 88%.
Angela Glover Blackwell : (15:12)
Dr. Fakorede, your work has just been so important and I am impressed that you have gone to a place where there is such enormous need, and you have found a way to be able to make a difference in people's lives. Um, I think people who do that actually bring a super power. What's your superpower?
Dr. Foluso Fakorede: (15:33)
God is my superpower, but at my will is greater than my skills. Um, it's something that I always tell my students, your purpose here is to serve others.
Angela Glover Blackwell : (15:42)
Dr. Fakorede thank you for speaking with us.
Dr. Foluso Fakorede: (15:45)
Thank you for the privilege of invitation.
Angela Glover Blackwell : (15:47)
Dr. Foluso Fakorede is the founder of Cardiovascular Solutions of Central Mississippi. Coming up on Radical Imagination, we look into the access to medicines movement, and effort to make drugs more affordable to low income communities. By reimagining the way the patent system works, stay with us more when we come back.
Angela Glover Blackwell : (16:35)
And we're back. Now, we turn to a movement that's trying to help black and other vulnerable communities access the medicines they need by re-imagining the U.S patent system. Patents are what protect the time and money invested by the pharmaceutical industry to develop a drug and bring it to market. But the same patent system is subject to very little accountability, and it can fuel the higher price of medicines that are essential for many who cannot afford them. To talk more about this. We're joined by Priti Krishtel. She is a lawyer activist and the cofounder of I-MAK, a team of patent detectives who are trying to change the patent system for medicines. Priti. Welcome to radical imagination.
Priti Krishtel: (17:21)
Thanks so much for having me today.
Angela Glover Blackwell : (17:24)
Just say what a patent is, particularly in the context of medicines.
Priti Krishtel: (17:28)
Absolutely. So patents are rights that the government gives to inventors in order to reward them with a time limited monopoly for inventing something. But what we're seeing in our country and all over the world is that drug makers are filing more and more patents on each medicine. We've been able to show through our research that they're filing right now on the bestselling drugs in America, over 125 patents. The patent system was supposed to be for invention, not to be used as a defensive business practice. So we've seen that the system is actually just being gamed now.
Angela Glover Blackwell : (18:09)
Would you place this as a root cause of the high cost of medicines?
Priti Krishtel: (18:13)
Absolutely. It's the root source of where we get our power to price is our patents. And so the way I think about this is that patents are just one part of this larger medicine system. And that system includes everything from where public research dollars go to, which diseases are prioritized for R & D, to what people end up paying at the pharmacy. And all of those levers work together to create the system that we have right now, which is designed first and foremost to serve commercial interest. You know, one in four Americans today is reporting that they are struggling to afford their medications.
Angela Glover Blackwell : (18:55)
That is a shocking number.
Priti Krishtel: (18:57)
The latest data is showing that 34 million Americans lost a loved one in the last five years because they couldn't afford their meds. And this is twice as likely for people of color. And those numbers are higher in Black and Brown communities. So I think that our policy makers really need to be going into the next year, thinking about what solutions are we going to find to this problem that are going to be impactful and actually bring drug prices down for families who are waiting for relief.
Angela Glover Blackwell : (19:30)
Talk more about why it is so important for people to understand the extent to which patent decisions impact their lives, especially the lives in black communities that are often most affected.
Priti Krishtel: (19:42)
You know, right now people are seeing the world, I think through the eyes of black families who are witnessing the killing of their loved ones and they're really being moved by it. I wish that people could also see the world through the eyes of black families whose loved ones are, you know, with diabetes are three times more likely to lose a limb to amputations or who are losing loved ones because they can't afford medicines that they need to stay alive. This is also the systemic taking of people's lives. And it doesn't have to be this way. If you look at insulin, for example, for diabetes, Humalog. It's price increased at 20 times the rate of inflation since 1996 and the drug maker was able to hike prices in this way because it gets its monopoly power from its patents. Now there are 61 patents filed on Humalog, which takes its years of monopoly, which is supposed to be 20 years under the law. And now it's almost 46 years. So if we had curved this type of patent abuse, we could have had cheaper drugs earlier. And on the flip side of that Black and Brown communities, we know that COVID is disproportionately affecting people with underlying health conditions like diabetes. And thankfully in the last couple of months, we're seeing public pressure at work. We've seen the price of Humalog come down, but this is a systemic problem. And we can't pressure every drug maker to do the right thing on every drug. So we need systemic solutions.
Angela Glover Blackwell : (21:36)
I'm wondering whether the diseases that impact black families aren't prioritized because of this sort of hierarchy of human value, that places very little value on black life, or is it because the economic return on those drugs is not as great?
Priti Krishtel: (21:56)
You know, it's so interesting, Angela, in this moment, there is a distinctly racialized dimension to who gets hurt the most in a system like that. Diseases that disproportionately affect Black and Brown people, like chagas, sickle cell, neglected and tropical diseases -- all of these are chronically underfunded. So when you look across that whole system, based on the very limited data that we have right now, it looks like white scientists are far more likely to receive funding from the NIH then Black scientists, Black inventors get less than 1% of all patents that are granted. And of course, Black patients are underrepresented in clinical trials. So all of this across the whole system is holding us back from culturally responsive research and innovation. And that's a big problem.
Angela Glover Blackwell : (22:51)
Well, in 2006, you co-founded I-MAK. Could you talk more about the work you and your team have been doing to expose and challenge the manipulation that fuels high drug prices?
Priti Krishtel: (23:03)
We realized that one of the ways we were going to get medicine to people was to challenge unjust patents. We started winning cases all over the world, and that litigation work actually unlocked $50 billion for countries who can now put millions of people on treatment. And since that time, our team has now worked in 50 countries on everything from Avian flu to hepatitis C. Our real challenge has been that we started working in the U.S a few years ago, and it's been our biggest challenge because the system here for medicines is really a black box. There's very little oversight or public participation. So we're working right now to unlock the box. And that means we're taking on some very entrenched old school ideas about what economic growth should look like and who should have a seat at that table.
Angela Glover Blackwell : (23:57)
That's really interesting. So the team I hear that you all sometimes are referred to as patent detectives. That's right. What does that work like being a patent detective?
Priti Krishtel: (24:07)
So we have an incredible team patent lawyers who came from private sector, law firms or scientists who came over from the pharmaceutical industry. And what we'll do take a moment like this with COVID. We will get under the hood, uh, to look at the actual patents for all of the treatments and vaccines that are emerging and see what the real story is that is told by those patents. What are companies trying to do? Where are they trying to protect their turf? Where are they playing games? And through that, we're able to release these investigations.
Angela Glover Blackwell : (24:45)
So here we are with the worst pandemic that most people alive today have ever seen, and we see Black and Brown and Native Indigenous people dying and unprecedented numbers. And this suffering is likely to continue. I'm wondering how could COVID-19 make Black, Brown, Asian, and Native access to medicines, and then a vaccine in the future, more difficult.
Priti Krishtel: (25:14)
The whole world right now is watching the race to find a cure vaccine for COVID. And people assume that once we find it, that everyone's going to get it. And it's not true, history shows us that it's not true. You know, some people are going to get it first and some people aren't going to get it at all. So our job right now is to make sure that Black and Brown communities who are hardest hit by COVID aren't structurally excluded from accessing this medicine. And when I think of this question, you know, I always think about the story of polio from nearly a century ago, because after a vaccine was made available and they said, okay, well, polio is under control. Polio, still persisted in poor communities for a decade. So we have to make sure we're writing a different story for COVID. It can't be quote "under control" if it's still persisting in low income communities of color.
Angela Glover Blackwell : (26:11)
I'm wondering if there are things that you think advocates for health equity ought to be doing now to try to head off this disaster that could be looming right in front of us.
Speaker 3: (26:22)
This is really the new hunger games. You know, we're seeing it in even our own country buying up. Most of the world's supply of the latest drug that just came out for COVID. Um, this is how it's gonna play out, right? High income countries and populations are poised to win at the expense of lower income countries, populations. And so what our movement is really asking people to do is to call on governments not to fall into the nationalism trap. Because if we do, we are looking at countless more deaths that we could have prevented worldwide and a much longer road out of this pandemic than we ever imagined.
Angela Glover Blackwell : (27:12)
Specifically. What are some of the solutions your organization is proposing to change the way the patent system works in favor of people, as opposed to in favor of the drug industry.
Priti Krishtel: (27:22)
We have a set of reforms to reimagine the patent system called RAISE. That's spelled RAISE, and these reforms would do five things: First, raise the bar on what it takes to get a patent, so monopolies can't be misused to hike, drug prices out of reach. Second. Amend incentives so the system balances public needs with economic growth. Third, increase significantly public participation. Right now, the patent system is a black box, and that has to change. Fourth, standing. We want to make sure that people who are most affected have the right to go to court. And right now drug companies have the right to challenge unjust patents in court, but we don't have that same right of legal standing. And finally, and to me, one of the most important things: we need better oversight mechanisms, the Inspector General, members of Congress. We need all of them to start paying serious attention to the patent system and its impact on Americans, especially those who are most vulnerable.
Angela Glover Blackwell : (28:30)
I want to go back into a couple of them that might not be immediately understood. The first one I want to focus on is standing for justice. You talked about the fact that drug companies can challenge a patent, but patients or would-be patients or the general public cannot. Say more about that. And I'm curious in the litigation that you've done, who you've been representing.
Priti Krishtel: (28:51)
Most of the time, if not every time, when we've brought these cases, we have represented patient networks or communities of low income patients that want legal representation within the patent system. In 2017, we actually filed patent cases on a hugely expensive hepatitis C drug and the patent office essentially just closed the door in our face. Public participation in the patent system is not something that happens because the system is seen as a driver for economic growth.
Angela Glover Blackwell : (29:25)
I was thinking the same thing that so often health is so personal that people don't think about it as long as their health is good and it's not until they or a family member or somebody they know happens to have something that people might get energized around the unfairness that they see is that family struggles to try to take care of the health of that family member. But COVID really does have the potential to link us in a way that we have not been linked together around health. And so I'm wondering if you really do see a way that treated properly by all the activists who have been activated by COVID-19. If they began to really see this as an opportunity to restructure healthcare entirely, if this just might be an opportunity for breakthrough.
Speaker 3: (30:13)
I can see that very clearly from where I sit, I see more and more advocates reaching out who have never done this work before, who are saying, how do we fight for change? Because this system is not set up right now to keep the most people alive, especially those in marginalized communities. You know, for us this whole scale recreation of the system and the rooting out of structural issues, it starts with re-imagining how we do medicines. Because in doing that, we're literally ensuring that the people who are most vulnerable can access the medicines, they need to keep them alive. And in addressing the patent system, we're dismantling that root source of power. That's currently wired to drive inequity and rewiring it to actually work for people.
Priti Krishtel: (31:09)
I think we need to take profit out of healthcare altogether. It's really important to remember that this system for medicines really evolved over the last century, but it's been accelerated in the last 40 years. So if you take something like the patent system, we didn't use to operate this way, where we had hundreds of patents being filed on one medicine. That was born out of it, a very specific economic ideology about 40 years ago, and it has become normalized. And yes, I absolutely think we need to start advocating for a new ideology that maximizes the wellbeing of everyone.
Angela Glover Blackwell : (31:54)
Priti, it's so inspiring to listen to you, to see how you are able to get into a very specific area like patents and connect the two and begin to use movement to create change. I think people who work in the world that way, bring a superpower. What's your superpower?
Priti Krishtel: (32:13)
Hmmm. I have been told that my superpower is creating containers that allow people who have never come together to be in dialogue and deepen their understanding of each other's lives. So I'm hoping to bring that into this process as we move into the next chapter.
Angela Glover Blackwell : (32:36)
Priti, thank you for speaking with us.
Priti Krishtel: (32:38)
Thank you, Angela
Angela Glover Blackwell : (32:41)
Priti Krishtel is a lawyer, activist and the cofounder of I-MAK.