End “race norming” in healthcare.

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Over the past year, the global pandemic has highlighted the vast racial disparities in medical treatment in the U.S. Many of its elements are more subtle; difficult to see if you don’t experience it first-hand. But some are more blatant – like racial correction factors. In medicine, equations and algorithms can often be used to diagnose or screen patients. Racial correction factors are when physicians adjust the measurements or risk calculations for patients based on their race. Despite the fact that race is a social construct, many medical providers hold on to the idea of race as a biological variable. This has a severe, sometimes fatal impact on people of color.

One of the most commonly used and widely discussed racial correction factors exists with estimated glomerular filtration rates (eGFR) in the kidneys, which assesses the level of kidney functioning. Medical providers measure eGFR by using a mathematical calculation that compares the creatinine measured in a person’s blood, with their size, age, sex, and race (Kaiser Permanente). Many medical institutions utilize a racial correction factor of approximately 1.2 for Black people (Nature).

“With the correction, Black patients’ estimated kidney function is about 16-21% higher (depending upon the equation used) than all other races in this country”, according to Dr. Vanessa Grubbs, nephrologist and author of Hundreds of Interlaced Fingers: A Kidney Doctor’s Search for the Perfect Match.

Medical providers use eGFR values to deduce what stage of chronic kidney disease a patient is at (National Kidney Foundation). The lower the eGFR value, the lower the kidney functioning, and the higher stage of kidney disease a patient is diagnosed with (Kidney). The correction factors that inflate Black patient’s eGFR measurements, could potentially have them diagnosed with an incorrect stage of kidney disease and delay needed treatment.

“This means that Black patients—even though they reach end-stage kidney disease nearly 4x faster than White patients—are referred later to nephrology specialty care and transplant evaluation”, recounts Grubbs. “I would not have referred one of my patients to kidney transplant at least a year later had I believed the race correction was indeed correct. And he lost kidney function faster than expected,” she adds. Grubbs recommends that patient’s request cyastain C blood tests to estimate their kidney functioning without the inclusion of race.

Another commonly used correction factors exists in in the use of spirometers in pulmonology. Spirometers directly measure the amount of air you can inhale and exhale, and the rate at which you exhale (Mayo Clinic). Medical providers use this tool to assess the strength of lungs and to diagnose for respiratory conditions such as chronic obstructive pulmonary disease (COPD) (Mayo Clinic). Spirometers measure two main values: FEV1 (how much air you can force out of your lungs in 1 second) and FVC (greatest amount of air you can breath out after brething in very deeply) (Healthline). Provider diagnose certain respiratory conditions such as by comparing patient’s FEV1, FCV and FEV1/FCV ratio to predicted normal values.

“So every age group has a different measurement of what normal means. At the same time, differences in gender, and race, at this moment is still added as part of the metrics,” explains Dr. Panagis Galiatsatos, MD, MHS pulmonologist and Assistant Professor, Division of Pulmonary & Critical Care Medicine at Johns Hopkins School of Medicine.

Many spirometers have a built-in racial correction factor that automatically assumes a 10-15% smaller lung capacity for Black patients and a 4-6% smaller lung capacity for Asian patients when computing measurements (NIH). Medical providers typically diagnose COPD when a patient’s FEV1/FVC ratio is less than 70% of an estimated normal value (NIH). The lower adjusted values for Black and Asian patients could potentially lead to these patients not being diagnosed as having COPD when measured as having similar spirometry values or physical symptoms as white patients who are diagnosed with COPD.

“There’s a great number of studies that show fewer diagnoses of COPD in Black/African-America patients, even though they have much more symptoms,” explains Galiatsatos. “Spirometry is used for diagnostic purposes. So if you can’t diagnose [COPD], because you have this racial bias, then you’re going to delay these patients from getting the interventions that they need” he adds. He recommends patients ask medical providers to look at their flow volume curve results, which is not influenced by race when looking for an assessment or diagnosis.

The idea that Black people have different medical needs stems back from the times of slavery and was built from racist scientific ideas.

During slavery, people believed that Black folks had inferior lung capacities to white people. In 1832, Thomas Jefferson referenced differences in lung function between slaves and colonizers (Google Books). In the 1800s, physician (and slave owner) Samuel Cartwright used the spirometer to compare the lung capacities of enslaved Africans to the slaveholding white masters (NIH). He concluded that enslaved Africans had inferior lungs.

The racial correction factor for eGFR, however, was introduced later in the 1990s because Black people were observed to have higher creatinine levels in their blood (Nature). Researchers concluded that Black people’s higher creatinine levels were due to Black people having higher muscle mass than white people (Scientific American). This study failed to truly consider other explanations for why the Black patients had higher creatinine levels. This idea of all Black people being stronger than other people is reminiscent of stereotypes used to justify the animalization and enslaving of Black people for profit (NIH)

“There is no real science behind it,” believes Grubbs. “Most doctors still do it because they don’t know why race was included in the first place and are just following along blindly. Others still do it because they are upholding White supremacy ideology that Black people are inherently different than all other humans.”.

Racial correction factors for eGFR are especially harmful because Black people are 3-4 times as likely to develop kidney failure compared to white people (NIH). 32% of kidney failures occur in Black people, despite only making up 13% of the population (NIH). In addition, Black people are three times as likely to die from asthma and Black men are 50% more likely to get lung cancer than white men (Lavaca Medical Center). Black and Asian people are both at a higher risk for being hospitalized for asthma compared to white people (NIH). It’s devastating to imagine how many people of color were delayed or denied life-saving treatment because of an outdated correction factor.

The movement to end the use of racial correction factors is picking up across medical institutions across the country (STAT News). Vanderbilt, University of Washington, and the University of California, San Francisco have moved to end the use of race-based correction factors in their medical institutions (VanderbiltUWUCSF). Students like Noor Chadha at the joint UCSF Medicine and UC Berkeley program created a report titled Towards the Abolition of Biological Race in Medicine which examines the many explicit racist issues, including racial correction factors, in modern medicine.

We need to abolish racial correction factors to ensure that all people can equally get a chance to get life-saving medical treatments.

Key Takeaways

  • Many healthcare providers still utilize racial correction factors that require Black and Asian people to have lower kidney function and lower lung capacity to get diagnosed and get needed treatment.

  • Many racial correction factors are rooted in racist scientific ideas.

  • Many institutions are now making a push to remove racial correction factors.

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