Racism in health care made headlines last month when it was revealed that a prominent algorithm, used widely in hospitals across the U.S. to manage and allocate health care, has been systematically relegating black patients to decreased access and poorer quality of care. While some scientists are shocked that an algorithm that set out to be “color blind” has led to racial inequity, blatant examples of race-based medicine leading to unequal treatment are commonplace.
Take the case of kidney function. In nearly all hospitals and clinics across the country, calculations of kidney function are “adjusted up” by African American race. A black patient will be estimated to have higher kidney function, a.k.a. glomerular filtration rate (GFR), when compared to non-black patients with otherwise similar characteristics. Overestimation of kidney function can lead to devastating consequences, delayed referrals for specialty care and transplant evaluation, and improper counseling and treatment. Against a backdrop of statistics demonstrating that African Americans are more than three times as likely to develop end-stage kidney disease (which requires transplant or dialysis for survival) and wait twice as long for transplants, such scenarios are especially disturbing.
How did this come to be? In the early 1990s, scientists performed a series of studies and observed that African American participants had higher GFRs on average when compared to whites with the same level of a common blood test called creatinine. The researchers suspected that the correlation was likely due to a higher average muscle mass in their African American participants (creatinine is a breakdown product of muscle). However, when they derived the GFR equation, they chose to include race as a proxy for muscle mass.
The use of this “race correction factor” is fundamentally flawed and unscientific. Race is a social construct, not a biological one. There is more genetic variation between individuals of the same race than between populations of different races. Furthermore, the implicit acceptance of GFR race correction reinforces antiquated colonial myths that there is something fundamentally different between races. These are the same fallacious narratives that have been invoked throughout history to justify horrendous acts such as slavery and indigenous genocide, on the “scientific” basis that the persecuted race was biologically inferior to whites.
We must do better. As a primary care doctor, my heart breaks to see how the use of race-based medicine creates inequitable outcomes for my African American patients. I refuse to allow these harmful practices to continue. That’s why I joined with other family doctors, specialists and the clinical laboratory to eliminate race-based reporting of GFR at San Francisco General Hospital, following the lead of Beth Israel Deaconess Medical Center in Boston. Beyond GFR, we must also eliminate other instances of race-based medicine, such as in lung function tests and cardiovascular risk assessment tools.
To be clear, rejecting race-based medicine does not mean denying race matters for people’s health. It does. However, the ways in which race impact health are mediated by racism, not because of any biological basis of race. The key is learning to identify, prioritize and combat racism’s impact on people’s health, while rejecting race-based medicine.
It is clear that discriminatory algorithms run rampant throughout medicine. Many times, the most insidious examples are baked right into the “science” of research and health care delivery. We must educate ourselves and root out these manifestations of race-based medicine. We invite hospitals, clinics, public health departments, researchers and patients from across the country to join us in eliminating race-based GFR as one of many necessary steps towards health justice and the abolition of all forms of race-based medicine.
Referenced article: https://science.sciencemag.org/content/366/6464/447
Dr. Juliana E. Morris is a family doctor in San Francisco and Oakland and a clinical instructor at UC San Francisco and San Francisco General Hospital. Dr. Vanessa Grubbs is a nephrologist and author of “Hundreds of Interlaced Fingers: A Kidney Doctor’s Search for the Perfect Match.” Dr. Monica Hahn is a family doctor at UC San Francisco. Dr. Stephen Richmond is a family medicine resident at UC San Francisco and San Francisco General Hospital. The views expressed are those of the authors and do not necessarily represent the views of UCSF.