It Is Not About Biology
The serum creatinine level is a standard blood test used as part of an equation to determine how well a person’s kidneys function. Creatinine itself is a protein produced by muscles that the kidney filters out of the blood and excretes in the urine. Creatinine levels vary with things like age, weight, and sex and therefore by themselves don’t tell us much about kidney function. But when the serum creatinine level is plugged into an algorithm that includes these other factors, you get something called the estimated glomerular filtration rate (eGFR), which does reflect kidney function. Low GFR means the kidneys are having trouble and can signal kidney disease.
How does race factor into this? For any age and sex the algorithm for GFR tells us that Black people have a higher—that is more normal—level than a white person. In other words, In other words, race is put into the algorithm too. For example, a 50 year old Black man and a 50 year old white man could have exactly the same serum creatinine level (let’s say 1.0) but the equation says that the GFR for the Black man is higher than for the white man.
What is going on here? Remember that this isn’t a direct measure of kidney function but rather an algorithm that uses a blood test and several demographic factors to estimate kidney function. What is the justification for the algorithm giving a higher GFR for Blacks than whites? The rationale commonly given is based on the fact that great muscle mass is associated with higher serum creatinine levels and Black people are said, on average, to have greater muscle mass than white people. The algorithm therefore is programmed to adjust for this supposed artifact that increases serum creatinine level in one group compared to the next.
The problem is that the evidence that Black people have greater muscle mass than white people seems to be missing. As explained in a recent landmark article in the New England Journal of Medicine, “Explanations that have been given for this finding include the notion that black [sic] people release more creatinine into their blood at baseline, in part because they are reportedly more muscular. Analyses have cast doubt on this claim, but the ‘race-corrected’ eGFR remains the standard.” Now being under the impression that the GFR is higher in one person than another can mean that the person with the lower GFR gets attention for her kidney disease first, including priority for dialysis and kidney transplant. Indeed, as the article points out, Black people in the U.S. have longer waiting times for kidney transplants than white people.
The authors of the New England Journal of Medicine article actually find a number of instances in which algorithms change medical decision-making based on race and they note that “By embedding race into the basic data and decisions of health care, these algorithms propagate race-based medicine Many of these race-adjusted algorithms guide decisions in ways that may direct more attention or resources to white patients than to members of racial and ethnic minorities.” These race-adjusted algorithms, they find, occur in cardiology, obstetrics and urology, in addition to the one explained above in kidney medicine (i.e. nephrology).
No One Thinks They Are Racist
Perhaps we are inclined to think of racism as overt, conscious hatred of another group. We suspect that most readers of this Critica commentary do not hold such blatant prejudice.s Most white physicians are also not about to acknowledge that they don’t like Black patients or think they are inferior in some ways to white patients. A physician who publicly expressed such thoughts would appropriately be shunned by colleagues and effectively barred from practicing medicine, at least in most parts of the U.S.
So we use this example of creatine and the GFR to illustrate a more insidious but still very harmful form of racism that exists in medicine. Scores of medical students have been taught about the GFR algorithm without thinking twice about the racial aspect of how it is calculated. When Critica President Jack Gorman was in medical school, the guidelines for writing up and presenting a case on rounds called for identifying the patient by age, sex, and race, e.g. “this 29-year-old Black man sustained a right humerus (arm) fracture as a passenger in a car crash.” One professor bravely asserted that in a case like this–and, he argued, most cases–the patient’s race had no bearing on the diagnosis or clinical management of the patient, so why mention it. The students and other professors were shocked. Isn’t it the case, they insisted, that some diseases are more common in one race than in another? When asked to name them, the students could actually come up with very few and for those few there was actually no need to state the person’s race; everyone knows that someone with sickle anemia is going to be black. Before long, race was taken out of those guidelines, but the story again highlights how racial bias exists in medicine without anyone actually realizing it.
The fact is that race is a social construct, not a biological one. All humans originated in Africa and therefore we all share most of our genes in common with each other. A white person of Italian heritage and a white person of Eastern European heritage are likely to be more genetically different than either is with a Black person.
But while the social construct of race tells us very little about biology and medicine, it does tell us a great deal about the ways in which racism affects health. Today in the U.S., Black people are more likely to have high blood pressure, heart disease, asthma, and diabetes than white people. That turns out to have less to do with biology than it does with what are now called social determinants of health, things like poverty, living in crowded and segregated neighborhoods, poor availability of healthy food, and less access to healthcare. For instance, one study showed that Black people living in highly segregated neighborhoods have higher rates of hypertension than those living in more integrated neighborhoods. Moreover, when people moved from high segregated to less segregated neighborhoods, their blood pressure improved. Obviously, changing where you live does not change your genes, but it can lead to less stress, better healthcare, and healthier lifestyle because of cleaner air and more fruits and vegetables in local markets.
The Black American experience with healthcare has often been told in terms of the infamous Tuskegee experiments, in which poor Black men with syphilis were deliberately not given treatment, without their knowledge, so that investigators could study the course of the disease. The study lasted from 1932 until 1972, even though penicillin, which effectively treats syphilis, was introduced in the late 1940s. Some of the men enrolled in the study died of syphilis. The scandal that arose when this egregious breach of medical ethics was finally disclosed led to reforms in medical research, but also created a lingering effect in the Black community that government and organized medicine cannot be trusted.
As horrible as the Tuskegee experiments were, they are only part of the picture of Black people receiving substandard medical care in the U.S. Study after study has shown that Black Americans simply do not get the same quality of healthcare as white Americans, leading to shorter lifespans. As just one example, newborn mortality is three times higher in the US for Black than white babies. One telling study showed that death among Black newborns is reduced when the physicians caring for them are themselves Black. Another example is a study that looked at insulin pump utilization among children with diabetes. Instead of repeated injections, insulin pumps provide a regular administration of insulin that is coordinated with blood sugar levels. It is sadly unsurprising that Black children with diabetes are substantially less likely to have insulin pumps. In the study, this did not seem due to socioeconomic differences according to the study authors. Thus, a likely explanation is racial discrimination. Examples like this abound.
This again is not a biological phenomenon but rather racism built into the U.S. healthcare system. So deep is the problem that although study after has documented the problem, most healthcare professionals are probably not aware of it. They do not consider themselves racist and therefore fail to see that a legacy of discrimination and inequities have denied Black people the quality healthcare that whites get.
Another Pandemic Dilemma
Black Americans have less trust that science is acting for the public good than white Americans. Their mistrust of the healthcare system is causing a crisis right now in developing a COVID-19 vaccine. Although Black Americans are disproportionately affected by the pandemic, they are reluctant to volunteer for vaccine clinical trials. Without their involvement, it would be unclear whether the vaccine is effective and safe among Black people. There is consequently an urgent need for Black people to volunteer for vaccine clinical trials and to accept vaccination when it becomes available, but long-standing mistrust of the healthcare system borne of more than a century of racial discrimination stands in the way.
There are now many suggestions for rooting out structural racism in the healthcare system, but still nothing that could be called comprehensive or well-funded. Various national accrediting bodies have called for health disparities curricula for residents training in internal medicine, but a recent study showed that the majority of programs do not have them. As physician Fola May put it in an op ed piece last June, “It is the responsibility of medical school and academic institutions to produce ‘woke’ doctors. Institution leaders are obligated to play an active role in identifying platforms to discuss race and locating the resources needed to provide training for all students and faculty on racial injustice, overt and implicit bias, and cultural competency.” Studies show, May writes, that the “medical education system…is ridden with structures that promulgate bias, especially against Black students.” This takes the form of disparities in grading and awarding honors.
Critica thrives on well-conducted research studies and usually recommends that for every perceived problem in health and science, rigorous research is needed to provide data that will guide solutions. Racism in medicine is a problem, however, that does not need more empirical research. We already know it exists. Major medical and scientific societies like the American Public Health Association have stated this explicitly. We agree with the conclusions of four University of California, San Francisco scholars, two of whom are Black and two are white, that what is needed is a complete reckoning by every healthcare professional and institution of its own contributions to structural racism. They write:
“We believe our health professions colleagues, societies, and systems need to go beyond declarations—that each must review its own history, structures, workforce, and policies in an approach dedicated to truth and reconciliation and that we must all proactively engage in the battle against structural racism and health inequities to bring about a new era of antiracism in medicine.”
These are sentiments with which we fully agree.
 Nolen LT, Beckman AL, Sandoe E: How foundational moments in Medicaid’s history reinforced rather than eliminated racial health disparities. Health Affairs Blog, September 1, 2020