When Deborah Crabbe was a 12-year-old growing up in the Bronx, she faced a dilemma: She knew she wanted to work with less fortunate communities — she was a child of the 60s who grew up hearing about the plight of African American people, and Dr. King inspired her. “I always imagined I would work on solving problems that plague people of color,” she says.
But should she become an educator, like her second-grade teacher, Mrs. Spires, who let her know she could do great things in her life, and Mrs. Wallace, another grade school teacher whom she kept in touch with for years? Or should she be a doctor, like the inspiring characters she watched on shows like Marcus Welby, MD?
Her parents, both nurses, helped her see a path to bridging that gap: “My mother told me, ‘If you’re a doctor, you can also teach,’” Crabbe says. Her decision was made.
Ultimately, she went on to medical school at Howard University, a residency at Robert Wood Johnson Medical School, and specialty training at Temple Health, which at the time was one of the top-ranked heart failure transplant programs in the country. Since 1998, she has been a faculty member, practicing cardiologist and researcher at Temple and an activist and advocate on behalf of the community she serves.
Driving to work along Broad Street for nearly three decades, Crabbe has seen Philly change before her eyes. But to her dismay, one fact has remained unchanged: Heart disease is the number one cause of death among African American and Hispanic women in North Philadelphia. According to the Centers for Disease Control, over 60 million women (44 percent) in the United States are living with some form of heart disease, making it the leading cause of death for women. In 2021, it was responsible for the deaths of 310,661 women — or about 1 in every 5 female deaths.
Crabbe is determined to make strides to change that. In a recent interview, she shared her multidimensional plans for cultivating better heart health in Philly — and her call to action to funders, physicians, and citizens just like you.
This interview has been edited and condensed for clarity.
Why are women more likely to die from heart disease than men?
There’s not just one answer. First of all, for years and years and years women were understudied. The rationale was that it didn’t make sense to involve “confounders” like pregnancy, so a lot of the research was confined to one sex. And so pregnant women and women in general have been left out of research studies. That persisted until about the early 1990s, when the late Dr. Bernadine Healy became the director of NIH [National Institutes of Health]. When she realized this huge disparity, she changed NIH policy, mandating that researchers had to do sex-specific reporting and had to include women in studies. And they had to give a reason as to why women were not included in studies.
“These disparities are not going to go away without a lot of multidisciplinary, connected support and partnerships. And the most important piece is the patients themselves.” – Dr. Deborah Crabbe
Despite that, we’re still grossly underrepresented in clinical trials. So part of the problem is that the knowledge base, particularly for cardiovascular disease, is limited, and the innovation is limited.
The other problem is that we’re undertreated. For instance, Temple is involved in a national study called Rebirth that specifically addresses women who have a condition called peripartum cardiomyopathy. It’s a condition that happens during pregnancy, usually the last month of pregnancy or the first five months postpartum. Most women recover, but there’s a select portion of them who will get very very sick, and the chances that their heart function will recover diminishes. These women can get so sick that they end up needing transplants. It’s devastating.
And right now the only therapy we have specific to this is a conventional heart failure medicine that we treat all patients with. We don’t have a specific treatment that addresses the pathophysiology of this condition. And that’s what the Temple trial is looking at. But more and more studies like this need to be done in order to give us really specific therapies that address conditions that uniquely affect women.
And then the last part, I think, is that women are undereducated about health. When, in the 90s, the American Heart Association started the first-ever polling looking at cardiovascular disease awareness — in other words, the percentage of women in the country who recognize that heart disease was their number-one healthcare threat — they realized there were huge disparities. Women didn’t recognize it. And there were particularly huge disparities in recognizing it among African American and Latinx women. And the tragedy of that is that these are the women who are highest at risk.
Over the years, with campaigns like Go Red For Women and The Heart Truth, there was some uptick in the number of women recognizing heart disease as the number one killer. Then, just before the pandemic, there was a study showing that the gains that we’d been making in heart health awareness are beginning to diminish, and the groups that it’s affecting are the minority groups.
And those studies don’t include my patient population, which is the sickest of the sick, who have very poor health literacy. They don’t understand why they’re on the meds that they’re on, and we don’t have enough studies addressing their unique situations to help us innovate in this space.
So what steps have you taken to address these challenges?
I changed the way I practiced. I spent more time during patient visits educating as much as I could. But it became very clear that even that was insufficient.
So I started to look for opportunities to expand that on another level. First, we started by developing a series of programs for primary care physicians, because primary care physicians weren’t particularly attuned to some of these issues and how they impact the delivery of care. They also didn’t know a lot about heart health and the sex-specific differences between men and women in presentation, treatment, outcomes. I did a series of programs that helped address that, and we started to see a bit of a narrowing of the physician educational deficit, nationally, in the medical literature.
But I also knew I needed to do more in the community. It just so happened that I had the opportunity to be connected with a faith-based organization in North Philadelphia called Triumph Baptist — it’s a mega-church, with about 8,000 members, many of whom seek their care in North Philadelphia at Temple. And so I pursued them. I’d go out and have community sessions on a regular basis. I would get between 75 and 100 women on a Saturday morning at my sessions! It became so clear that there was a huge need.
When the pandemic hit, it severely impacted us, as it did with everyone. But one day I was sitting on my couch, watching the terrible things unfolding on TV and realizing Oh my goodness, if they’re saying that cardiovascular risk factors are going to result in poorer Covid outcomes, what’s going to happen to North Philadelphia? And I started to think about how the general public doesn’t understand how the medical community solves these kinds of problems.
One of the ways we solve problems is through research. And unfortunately there’s a huge mistrust of research and the research enterprise by people of color.
I applied for and got two grants to work with the community and really get them engaged in research, research education, research protections, and trying to get them engaged in solutions. These disparities are not going to go away without a lot of multidisciplinary, connected support and partnerships. And the most important piece is the patients themselves.
Now we’re working with the Latinx community, and we’re finding huge gaps there as well. The hope is that we will be able to get them involved and able to understand the importance of research and how it can change policy, can impact their lives and their healthcare, and can give them a seat at the table.
You have to knock down misinformation through credible sources. I’ve been in the community for a long time and I’m a credible source. Most people are willing to engage in conversations with those of us, like my co-lead Heather Gardiner, who are trusted sources. Most of them come to us not realizing that there’s vasts amount of evidence and research backing up the efficacy and the effectiveness of the drugs that we prescribe. They don’t understand the research protections, the whole process and how long and arduous it is. Opening their eyes and getting their voice heard are two of the most important things we can do.
Beyond health literacy, how much does environment play a role in cardiovascular health and disease?
The problems in North Philadelphia are multifold. One of them is the social determinants of health, the environment. Since I’ve been coming up Broad Street for 25 years, I’ve seen more building, more housing, more businesses develop. This is good, because if local people can get employed, then you’ll increase the standard of living. And if you improve education, there’s a relationship between your educational attainment and your risk for heart disease.
If we want people who live in North Philadelphia to have a reduction in cardiovascular disease mortality like we’ve seen in other populations in the U..S, we absolutely have to get serious about properly managing these comorbidities and these social determinants. There is plenty of space for innovation, and I think that it will be cost-effective as well. If you reduce mortality, you’re going to save dollars. And you’re going to have more productive people in the society who can contribute.
But there’s also the issue of funding and resources. Most doctors don’t have access to the available resources that the government has. In my humble opinion, those resources are not well managed.
Another one of your initiatives focused on achieving more diversity in the cardiovascular field. Tell me more about that.
For North Philadelphia to really see advances, you need to have more diverse people working in these underserved communities. The next generation is also going to need to be leaders to be able to handle and solve some of these problems. So we came up with a project that helps support minorities with career development. For example, while the American Heart Association was holding their citywide conference in Philadelphia, we held one that invited minority folks to come hear panel sessions, yes, but also meet with me and other people in healthcare to talk about what it’s really like to work in the field. I was so moved that one mom and her two teen daughters took a bus all the way from Newark, NJ, just to be there. They were such bright girls, and mom stayed for all of the presentations too. People want this information.
As we head into American Heart Month in February, is there a note you want to leave me on?
My mom is 99-and-a-half, and she stopped going to her ob/gyn at around 90 — they told her don’t come back! But the reality is that some women, when they’re done having their babies, stop going to their ob/gyn, and many of those women were utilizing their ob/gyn as a primary care doctor. So I encourage women to get a primary care physician. There’s also a push now to have a cardi-obstetric program, to try to help women with cardiovascular diseases get better recognized and better care, should they get pregnant.
But age-appropriate screening is important throughout the lifespan. If you’re over 20, you should have had a cholesterol check at least once. If you’re going to have a baby, you have to have a pre-screening risk factor assessment. If you’re a woman around menopause, you should also be getting screened. We now know that a year after menopause, we can see a change in cardiovascular disease risk factors, particularly cholesterol. The protective effects of estrogen start to attenuate after menopause. The longer you’re postmenopausal, that increases your risk for having heart disease, as does age. So there are times during the lifespan of a woman where screening makes sense. And certainly, if you have a family history, clearly you should come into the [healthcare] system sooner.
But one of the things that does not get attention enough in general is the fact that in North Philadelphia, the premature cardiovascular disease mortality rate is the highest in the city. And I have yet to hear an organized plan about how we plan to tackle that problem. And to be perfectly honest, it’s a disgrace. It’s a United States disgrace and we are better than that and we can fix this. This can get fixed.
This piece is part of a year-long editorial series looking at innovations to address inequities in women’s healthcare, sponsored by Independence Blue Cross.
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Photo by Marek Studzinski for Unsplash.