Abdullah Ibish, MD
Cummings C, Almallouhi E, Al Kasab S, Spiotta AM, Holmstedt CA. Blacks Are Less Likely to Present With Strokes During the COVID-19 Pandemic: Observations From the Buckle of the Stroke Belt. Stroke. 2020.
In the midst of the COVID-19 pandemic and a national climate of social unrest following the aftermath of the George Floyd killing, the authors highlight a particular racial disparity as it pertains to predominantly Black communities. In their study of South Carolina patients from March 2019 to February 2020, the authors demonstrated a lower percentage of Black patients presenting with strokes during the pandemic for unclear reasons. We know from data from the REGARDS study (Reasons for Geographic And Racial differences in stroke), standard vascular risk factors alone were higher amongst Black persons, however only accounting for up to 40% of stroke incidences amongst White and Black patients.1 The remaining 60% of other stroke incidences remained unclear.
Moreover, recent studies have highlighted disproportionate cases of COVID-19 morbidity and mortality as it relates to minority communities, particularly Black patients.2,3 In this study, the investigators evaluated retrospective data, utilizing both pre- and post-COVID-19 pandemic stroke cases of over 5852 patients spanning March 2019 to February 2020 in South Carolina. This analysis included over 27 centers via a comprehensive tele-stroke network in South Carolina and assessed a myriad of different baseline characteristics as highlighted in their Table 1. Between the two groups (pre- and post-COVID-19 pandemic), there was a higher percentage of patients receiving intravenous tPA during the pandemic (15.5% versus 12.5% p=0.0037), and the number of thrombectomies per week was lower during the pandemic. Notably, however, there was a lower percentage of Black patients presenting via tele-stroke consultations during the pandemic (13.9% vs 29% prior to COVID-19 pandemic, p<0.001).
A strength of the study was assessing pre- and post-COVID-19 pandemic tele-stroke consult volume, corroborating trends of what we are seeing across many other stroke centers. An interesting finding was the higher rate of tPA in the midst of the pandemic, possibly due to shorter arrival time to hospitals.
With regards to the social determinants of health, one limitation of the study was the generalizability of the patient population. In particular, South Carolina has a higher proportion of Black residents, many of whom live below the poverty line, and a lower life expectancy, and further research suggests that, on average, families need an income of about twice the federal poverty threshold to meet their most basic needs. Indeed, these basic needs are pre-requisites to obtaining access to quality healthcare and, in particular, access to stroke neurological care, an even more limited resource in many rural centers. Another limitation was the lack of non-Black demographic representations, including Whites, Hispanics, and/or other underrepresented peoples in their Table 1 in South Carolina.
In summary, we know that, tragically, Black persons have been disproportionally affected during our COVID-19 pandemic, suffering a higher incidence of infection with increased mortality rates. Failure to seek medical care (particularly stroke care) may be due to a host of non-medical factors, including education, transportation, and access to appropriate resources.
Now, the killings of several unarmed Black persons brings national attention to the Black community. As society is rallying in many ways around the social injustice that has plagued and continues to plague the Black community at large, we must be receptive to the possibility of a relationship between social injustices and stroke disparities.
What role, if any, this may have on the impact of addressing the disparities in stroke outcomes has yet to be known. With the national spotlight, this study and current events may be an opportunity for healthcare providers and, in particular, stroke neurologists to become increasingly aware of social determinants of health and reflect on our own practice as it pertains to providing excellent cerebrovascular care in communities of color.
1. Howard G, Cushman M, Kissela BM, et al. Traditional risk factors as the underlying cause of racial disparities in stroke: lessons from the half-full (empty?) glass. Stroke. 2011;42:3369-75.
2. Cw Y. COVID-19 and African Americans. JAMA. 2020;323:1891–1892.
3. Reyes CHN, Gutowski C, et al. Chicago’s coronavirus disparity: Black Chicagoans are dying at nearly six times the rate of white residents, data show. https://www.chicagotribune.com/coronavirus/ct-coronavirus-chicago-coronavirus-deaths-demographics-lightfoot-20200406-77nlylhiavgjzb2wa4ckivh7mu-story.html. Chicago Tribune. Accessed May 9, 2020.