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 Darrell Cager Sr., 64, had diabetes. So his youngest daughter urged
him to seek care. The next day, he collapsed and died in his New
Orleans home.
The daughter soon learned the cause: acute respiratory distress from
COVID-19. His death certificate noted diabetes as an underlying
condition. Brumfield, who lives in Texas and also has type 2
diabetes, is “terrified” she could be next.
“I'm thinking, Lord, this could happen to me,” she said of her
father's death in late March.
She has good reason to fear. As U.S. outbreaks surge, a new
government study shows that nearly 40% of people who have died with
COVID-19 had diabetes. Among deaths of those under 65, half had the
chronic condition. The U.S. Centers for Disease Control and
Prevention analyzed more than 10,000 deaths in 15 states and New
York City from February to May. Jonathan Wortham, a CDC
epidemiologist who led the study, called the findings “extremely
striking,” with serious implications for those with diabetes and
their loved ones.
A separate Reuters survey of states found a similarly high rate of
diabetes among people dying from COVID-19 in 12 states and the
District of Columbia. Ten states, including California, Arizona and
Michigan, said they weren’t yet reporting diabetes and other
underlying conditions, and the rest did not respond - rendering an
incomplete picture for policymakers and clinicians struggling to
protect those most at-risk.
America’s mortality rates from diabetes have been climbing since
2009 and exceed most other industrialized nations. Blacks and
Latinos suffer from diabetes at higher rates than whites and have
disproportionately suffered from COVID-19.
“Diabetes was already a slow-moving pandemic. Now COVID-19 has
crashed through like a fast-moving wave,” said Elbert Huang, a
professor of medicine and director of the University of Chicago’s
Center for Chronic Disease Research and Policy.
Keeping diabetes under control - among the best defenses against
COVID-19 - has become difficult as the pandemic disrupts medical
care, exercise and healthy eating routines.
The high price of insulin has also forced some people to keep
working - risking virus exposure - to afford the essential medicine.
And as the country grapples with an economic crisis, millions of
Americans have lost their jobs and their employer-sponsored health
insurance.
Much of this could have been anticipated and addressed with a more
comprehensive, national response, said A. Enrique Caballero, a
Harvard Medical School endocrinologist and diabetes researcher. Top
health officials should have done more to emphasize the threat to
people with diabetes and assuage their fears of hospital visits, he
said, while also focusing more on helping patients manage their
condition at home.
Policymakers had ample warning that COVID-19 posed a high risk for
diabetes patients. In 2003, during the coronavirus outbreak known as
SARS, or Severe Acute Respiratory Syndrome, more than 20% of people
who died had diabetes. In 2009, during the H1N1 flu pandemic,
patients with diabetes faced triple the risk of hospitalization.
Most recently in 2012, when the coronavirus Middle East Respiratory
Syndrome, or MERS, emerged, one study found 60% of patients who
entered intensive care or died had diabetes.
The COVID-19 pandemic, however, has unearthed previously unknown
complications because it has lasted longer and infected many more
people than earlier coronavirus epidemics, said Charles S. Dela
Cruz, a Yale University physician-scientist and Director of the
Center of Pulmonary Infection Research and Treatment.
Doctors warn that the coronavirus pandemic may indirectly lead to a
spike in diabetes-related complications - more emergency-room
visits, amputations, vision loss, kidney disease and dialysis.
“My fear is we will see a tsunami of problems once this is over,”
said Andrew Boulton, president of the International Diabetes
Federation and a medical professor at the University of Manchester
in England.
‘ONE BIG PUZZLE’
Researchers have scrambled for months to unravel the connections
between diabetes and the coronavirus, uncovering an array of
vulnerabilities.
The virus targets the heart, lung and kidneys, organs already
weakened in many diabetes patients. COVID-19 also kills more people
who are elderly, obese or have high blood pressure, many of whom
also have diabetes, studies show.
On the microscopic level, high glucose and lipid counts in diabetes
patients can trigger a “cytokine storm,” when the immune system
overreacts, attacking the body. Damaged endothelial cells, which
provide a protective lining in blood vessels, can lead to
inflammation as white blood cells rush to attack the virus and may
cause lethal clots to form, emerging research suggests.
“It’s all one big puzzle,” said Yale’s Dela Cruz. “It’s all
interrelated.”
Many of their vulnerabilities can be traced to high blood sugar,
which can weaken the immune system or damage vital organs. COVID-19
appears not only to thrive in a high-sugar environment but to
exacerbate it. Recent evidence suggests the virus may trigger new
cases of diabetes.
David Thrasher, a pulmonologist in Montgomery, Alabama, said up to
half of COVID-19 patients in his local hospital ICU have diabetes.
“They are often my most challenging patients,” he said, and the
immune system response may be a big reason why.
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‘DIABETES BELT’
The pandemic has ripped through several southern states with some of the
nation’s highest diabetes rates. A Reuters examination of state data found that
nearly 40% of COVID-19 deaths were people with diabetes in Alabama, Louisiana,
Mississippi, North Carolina, South Carolina and West Virginia. Much of this area
lies within what the CDC calls the “diabetes belt.”
Alabama has the highest percentage of adults with diabetes at 13.2%, or more
than 550,000 people, CDC data show. Diabetes patients accounted for 38% of the
state’s COVID-related deaths through June, officials said. Karen Landers,
Alabama’s assistant state health officer, said she is particularly heartbroken
at the deaths of diabetes patients in their 30s and 40s.
Medical professionals in these states say they struggle to keep patients’
diabetes under control when regular in-person appointments are canceled or
limited because of the pandemic.
Sarah Hunter Frazer, a nurse practitioner at the Medical Outreach Ministries
clinic for low-income residents in Montgomery, Alabama, said diabetes is common
among her COVID-19 patients. With clinic visits on hold, she stays in touch by
phone or video chat. If a problem persists, she insists on an outdoors,
face-to-face meeting. “We meet them under a shade tree behind the clinic,”
Frazer said.
In similar fashion, doctors at the University of North Carolina stepped up their
use of telemedicine to reach at-risk rural patients. Despite those efforts, John
Buse, a physician and director of the university’s diabetes center, said he’s
certain some foot ulcers and dangerously high blood sugars are being missed
because people avoid health facilities for fear of the virus.
‘UNDER CONTROL’
Many diabetes patients with severe or deadly cases of COVID-19 were in good
health before contracting the virus.
Clark Osojnicki, 56, of Stillwater, Minnesota, had heard early warnings about
the risks of the coronavirus for people with diabetes, said his wife, Kris
Osojnicki. But the couple didn’t think the admonitions applied to him because
his glucose levels were in a healthy range.
“He was incredibly active,” she said.
On a Sunday in mid-March, Osojnicki jogged alongside his border collie, Sonic,
on an agility course for dogs inside a suburban Minneapolis gym. Three days
later, Osojnicki developed a fever, then body aches, a cough and shortness of
breath. He was soon in the hospital, on a ventilator. Clark, a financial systems
analyst, died April 6 from a blood clot in the lungs.
Osojnicki is among 255 recorded deaths in Minnesota of people with COVID-19 and
diabetes mentioned on their death certificate as of mid-July, according to state
data. The records describe people who died as young as 34.
WORKING FOR INSULIN
For years, the skyrocketing cost of insulin has fueled much of the national
outrage over drug prices. Early in the pandemic, the American Diabetes
Association asked states to eliminate out-of-pocket costs for insulin and other
glucose-lowering medications through state-regulated insurance plans.
But no state has fully followed that advice, the ADA said. Vermont suspended
deductibles for preventive medications, like insulin, starting in July. Other
states ordered insurers to make prescription refills more available but didn’t
address cost.
Robert Washington, 68, knew his diabetes put him at risk from COVID-19. When his
employer, Gila River’s Lone Butte Casino in Chandler, Arizona, reopened in May,
he decided to keep working as a security guard so he could afford insulin.
Washington’s supervisors had assured him he could patrol alone in a golf cart,
said his daughter, Lina. But once back at work, he was stationed at the
entrance, where long lines of gamblers waited, most without masks, Robert told
his daughter.
“He was terrified at what he saw,” Lina said.
He tested positive for the virus in late May and was admitted to the hospital
days later. He died from complications of COVID-19 on June 11, his daughter
said.
A week after Washington’s death, the casino again closed as COVID-19 cases
exploded in the state. The casino did not respond to a request for comment.
“It’s hard to accept he is gone. I have to stop myself from wanting to call
him,” said Lina, a sports anchor and reporter at a Sacramento, California, TV
station. “A lot of these deaths were in some way preventable.”
(Reporting by Chad Terhune, Deborah J. Nelson and Robin Respaut; Editing by
Brian Thevenot)
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