Addressing health care disparities is often focused on changing health care providers’ behaviors and helping them overcome biases that are implicit (unconscious, outside of a person’s awareness) and explicit (conscious, a person is aware of their actions and words) when treating patients of color. Everyone is susceptible to bias, and more work needs to be done to overcome individual and collective preconceptions to improve health outcomes for Black and brown people. However, there is another important part of this conversation that also needs to be addressed: structural racism in health care, including some common tests and tools used to treat patients.
In the Talking Pediatrics podcast Health Equity Actions: When Racial Bias is Built Into Our Medical Tools, guest host Adriene Thornton dives into this complex area of health equity with Siman Nuurali, a change management consultant at Children’s Minnesota. Thornton is the manager of health equity at Children’s Minnesota.
Structural racism in health care tools and treatments
The definition of structural racism is broad because it’s about the ways racism was built into systems like housing, education, employment, earnings, public policies, criminal justice, health care, and the list goes on. What surprises many clinicians is that structural racism is even built into the medical tools they use every day, including lab values and pulse oximeters, contributing to the racial health inequities we see today.
The race correction factor
Race correction is the use of a patient’s race in a scientific equation that can influence how they are treated. For example, the eGFR equations used to measure kidney function adjust for several variables, including the patient’s age, sex and race. Indicating a patient is Black in the eGFR test raises the threshold for the patient to receive specialized care. Removing race from the eGFR test showed one in three Black patients would be reclassified as having more severe stage chronic kidney disease than when race was included in the test, according to multiple studies.
Some medical professionals and researchers point out: the problem with using race as a factor in determining medical treatment is that race isn’t a biological category; it’s a social category. Ancestry is a biological category, but it can be very difficult to determine ancestry by appearance alone, which further complicates the use of the race correction factor for health care choices.
The challenges of removing racial bias
Those who study health equity and racial bias like Nuurali and Thornton have found many health care practitioners are surprised to learn about the biases that are built into the tools they use in good faith to treat their patients.
For example, there is racial bias with the commonly used pulse oximeter, a device used to measure blood oxygen levels. A 2020 study showed pulse oximeters can be less accurate for people with darker skin pigmentation. This device was originally developed in the late 1980s with tests only of white people. Later tests showed that the infrared light of the pulse oximeter doesn’t penetrate Black skin as effectively as it does white skin, resulting in overestimated oxygen saturation levels in patients of color. The FDA issued a warning about this finding in 2021.
Despite all the work done in organizations to educate on equity, inclusion and diversity, Nuurali and Thornton point to the need for a multi-pronged approach to dismantle systemic racism. “We should not and absolutely must not disqualify the collection of race, ethnicity and language data because that is what helps us pinpoint disparities. That’s what helps us figure out gaps in the system,” said Nuurali. “The conversation that we’re having is to NOT take that information into account during the determination of medical treatment for your patients.”
Looking to the future
As technology continues to evolve, algorithms and machine learning tools used to enhance and direct health care must gather patient information that takes into account data applicable for assessing all patients. Additionally, health care practitioners need to be aware of the inadequacies of the tools they have and look to additional tests and sources of information when assessing patients.
Race information cannot be eliminated from health care entirely, nor should it be. It’s one more piece of information a health care practitioner should take into account when treating a person of color. Consider across the board, Black people are less likely to be adequately diagnosed and treated properly for their chronic conditions. Many Black people distrust the health care system and clinical trials after generations of abuse by the medical community. It’s important to acknowledge these factors when treating patients of color to dismantle the racial bias narrative that Black people care less about managing their health.
“We absolutely should take systemic racism personally in the sense that we’re all collectively responsible for it,” said Nuurali. “And, also not take it personally in the sense that when we talk about systemic racism, nobody is calling you a racist. What we’re saying is you need to be aware of the system. You need to be aware of the shortcomings of the system so you can adjust your behavior, so you can adjust the solutions that you would come up with for your patients.”
Listen to the podcast
Listen to Health Equity Actions: When Racial Bias is Built Into Our Medical Tools or read the full transcript.