May 6, 2022
When we talk about health equity, we often hear about overcoming both implicit and explicit bias, which implies that if we could only change individual and collective behavior, we could improve health outcomes. But what is left out of these discussions is the important factor of structural racism, the ways that our health care system was built to generate the racial health inequities we see today. Surprising to some clinicians is that structural racism is even built into the tools that we use on an everyday basis, everything from lab values to pulse oximeters. Join this discussion with our guest host Adriene Thornton, health equity manager and her guest, Siman Nuurali, change management consultant as they discuss how racism is built into the tools of health care and what we can do to change this going forward.
Transcript
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the Kid Experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas, and practical tips will surprise, challenge, and perhaps change how you care for kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. When we talk about health equity, we often talk about overcoming bias, both implicit and explicit bias, which implies that if we could only change our behavior, then we could improve health outcomes for all of our patients. What’s left out of these discussions is the important factor of structural racism, the ways that our health care system were explicitly designed to create the racial health inequities we see today. What’s surprising to some of us is that those structures built the racism right into the tools that we use on an everyday basis. Everything from lab values to pulse exhibitors. Join this health equity actions discussion with guest host, Adriene Thornton and her guest Siman Nuurali as they discuss how racism is built into the tools of healthcare and what we can do to change this going forward.
Adriene Thornton: I am Adriene Thornton. I am the manager of health equity, and I am so excited to be bringing you my next guest. She is absolutely fabulous. She used to work for me and she left to be a change management consultant, which is befitting because she is an amazing change management practitioner and will still be borrowing her from time to time to help with health equity. So I want to welcome Siman Nuurali.
Siman Nuurali: Thank you so much, Adriene. I should just take you with me and have you do all my introductions anytime in your office.
Adriene Thornton: Just let me know when you need me. I’m usually available.
Siman Nuurali: That’s awesome. Thank you. Thanks for having me. I’m really glad to be here.
Adriene Thornton: I wanted to bring you on because oftentimes when we talk about health disparities and health equity, people immediately think of implicit bias or explicit bias and behavior change. They think it’s more related to how the medical professionals treat the patients based on their own biases, which that is a large part of it, but there is so much more involved in health equity, especially when you’re looking at structural racism. And what I’m finding is that when we have those conversations, a lot of people have no clue what structural racism in health care looks like. Tell us about what you found out about lab values and the structural racism in healthcare related to that.
Siman Nuurali: The thing about structural racism is that it’s built into the system, which is why it takes a lot more than just equity, inclusion, diversity, inclusion training and education, or behavior change like you talked about because it is directly built into the infrastructure of the society. So it’s built into government legislative agendas, policy. It’s built into tools, the tools that we used. It’s built into the way that we determine quality of housing and all of these things have an impact on the patient’s health. And so what I found out was a lot of the diagnostic tools that we use have something called a race correction factor, which is where basically depending on what tool it is, it’ll assign a certain number, either going up or going down if the person is Black. And what that does is it disqualifies the person either from reaching the threshold for advanced care or specialty care, or it rules them out completely of interventions like transplants.
And so it was this really earth shattering thing that I sort of stumbled onto. And actually after that talk, I had a lot of clinicians reach out and similar to you, similar to me did not know that a lot of these biases were built into the tools that they were in very good faith using to treat their patients. And so all the education in the world, all of the behavior change in the world is not going to, by itself, that is still important, I do want to make it clear that that’s still important, but by itself is not going to be useful in getting rid of this systemic racism that we’re talking about. It’s going to have to be a multi-pronged approach where we’re coming at it from each and every direction that it exists in so that we can dismantle it.
Adriene Thornton: What I think about as we move more into algorithms that are created from machine learning to guide and enhance and direct health care is going to be more important than ever for us to have accurate information that we’re utilizing to build these algorithms. Because if we are weeding people out based on erroneous data, then we’re going to see more chronic disease. We’re going to see more health care issues. We’re going to see less accessibility of health care for people who need it the most. And that is one of the things that is most concerning because as organizations really embrace diversity and inclusion and work really hard to accurately capture their race, ethnicity, and language data, we don’t want to capture more of that data and then on the back end have a deleterious effect on people because of it. And so I think it’s really important for people to be aware that this even exists because as we are doing more of this machine learning, we need to make sure the information we’re feeding the machine is accurate and that it’s going to benefit everyone.
Siman Nuurali: Right. We should not and absolutely must not actually disqualify the collection of race, ethnicity, and language data, because that is actually what helps us pinpoint disparities. That’s what helps us figure out gaps in the system. That’s what helps us assign resources to where they’re needed. The conversation that we’re having is to not take that information into account during your medical treatment or the determination of medical treatment for your patients. Because people can say, “Well, what if we just made it blind? What if we didn’t know anybody’s race?” All the people that are like, “Well, I’m not racist. I don’t see color.” So make it blind. There was actually a study where insurance companies had used this analytic algorithm to try to determine future cost of a particular patient based on how they were accessing the system and it was completely blind. There was no race information.
And in this particular study, because white people disproportionately accessed the system for primary care and for specialized care, it actually ended up assigning more resources to white patients than it did for Black patients because it determined that Black patients did not need as much care because they were not accessing the system as well. But they left out the whole conversation of why that is. They left out the reasoning behind why is it that Black people don’t access the system in the same way that white people do. And it has to do with access issues. It has to do with insurance coverage. We hear about psychosocial determinants of health, all of that prevents Black people and people of color in general from accessing the system the way that they should. And what that does is it makes it seem like they’re a healthier population when the exact opposite is true.
Adriene Thornton: Can you share with us some of the lab values and information that you discovered during your research that specifically relate to people of color and how it negatively impacts our health care outcomes?
Siman Nuurali: I think the most commonly known one or the one that I found a lot of people are familiar with is the EGFR. EGFR is estimated glomerular filtration rate. And it is this marker that is used to help diagnose kidney disease, both the existence of the kidney disease, but also at what stage that kidney disease has increased too. And so in EGFR there is a race correction factor that is placed in there. And what that does is it actually reduces the threshold. So it reduces the threshold for white patients and raises the threshold for Black patients. And so the point at which kidney disease would be diagnosed prompting the patient to get specialized care, white patients are able to reach that and Black patients are not. They need I think something like three points higher for them to meet the threshold.
And so there was a study that was done that showed if we got rid of the race correction factor, and there is a way, there’s alternative tests that you can use that doesn’t take that into account. But if you got rid of it, the study showed that one in three Black patients would be reclassified as having a more severe stage of chronic kidney disease than they originally were. Now, when you take into account that Black people account for 35% of kidney disease diagnosis nationally, you would drastically cut down kidney disease in the Black population to about 10 to 15%, which is not something to celebrate, but the disparity is just so large that it’s kind of mind boggling. I think that’s the most well known one.
Another one is the pulse oximeter that we use to try to determine a patient’s oxygen saturation. When this device was approved by the FDA in the late 80s, what happened was it was tested on a hundred percent white patients, so white skin tones. But then what ended up happening is because it was never tested on Black skin or Black skin tone or darker skin tone folks, they found out that the infrared doesn’t go through Black skin the way that it goes through white skin. And so what this device does is it corrects for that by overestimating oxygen saturation in Black patients, in patients of color.
And there was a research that was done at the Hypoxia Lab at UCSF, University of California and in San Francisco. And what they did was they tested the use of the pulse oximeter and then in the same patient drew labs and did arterial blood gasses, and the arterial blood gasses had an oxygen saturation that was actually lower than what the pulse oximeter was showing by several points, which as we know can be the difference between somebody on [inaudible 00:10:35], or somebody on oxygen or does somebody need elevated assistance for their respiratory condition? And so there’s all these different tests that exist that just is mind blowing that they exist. But the frustration is, what are clinicians supposed to use? These are the tests and values that they’ve been designated all the way from medical school by boards across the nation. And so it just becomes a really frustrating problem to deal with.
Adriene Thornton: We know that Black people and brown people and people of color disproportionately have higher rates of hypertension and heart disease. Hypertension directly related to kidney function. And I talked about with Dr. Zeke a study that was done many, many years ago that showed the first line drug that was used to control hypertension for everyone caused more kidney failure in Black people than it did white people. You add that to the fact that the tests we’re using to test for kidney failure is erroneously saying, “Oh, you’re not in kidney failure, but maybe you are.” That is a problem.
And then also what you’re talking about with the pulse oximeter, one thing Dr. Zeke and I talked about where our whole presentation was on Black people and brown people and people of color participating in clinical trials. And the importance of that. The pulse oximeter is a great example of what happens when we are not a part of the clinical trials. This is the one time where it’s not really the environmental impact that makes it different, but it’s the melanin in our skin. We definitely need to be a part of those clinical trials.
Siman Nuurali: Which is going to be a significant challenge to overcome because traditionally, what has the health care system done for Black people? It’s the amount of distrust, specifically as it regards clinical trials, experimentation sort of over the last couple of centuries makes it so that people of color rightfully so do not trust the system, do not trust the system that has been put in place to care for them because there has been so much harm done in the past and continues to be done now. That harm hasn’t gone away. So even if people of color where to say, “Well, that was in the past and things are different now.” Things are not different now. And so that makes it harder to get folks to come in to agree to be part of clinical trials, which then obviously impacts the ability of those studies or those trials to be able to say, “Hey, this impacts different patient populations in this particular way.”
The other thing it also does is it continues the narrative of the information that we have. It continues the narrative that “Oh, Black people don’t like vaccines or don’t like flu shots.” And what does that do? The provider then says, “Well, this is a Black patient. They’re not going to agree to the flu shots so I’m not going to do my due diligence.” And again, don’t want to be unfair, not saying that everybody does that, but that narrative is perpetuated throughout the entire system. And so that patient gets put in the position constantly over and over again of having to say, “This system doesn’t work for me. Why do I bother going into it?” Earlier when you talked about diabetes and hypertension in Black patient populations, that actually is less likely to make them qualify for transplants, for kidney transplants, even though there’s more Black patients on dialysis than white patients.
And because we’re not addressing diabetes, we’re not addressing hypertension in Black patient populations, it has a domino effect. So we tend to think that this one space that the patient is in is the only one I need to worry about. No, there’s repercussions everywhere. It’s a domino effect. It decreases the pool of candidates for those transplants and whatever that small pool is is cut down even more when transplant surgeons are like, “Well, because of comorbidities, this patient is less likely to survive or have a good prognosis. We’re not going to waste them organ on them.” So it’s just this really, really severe ramifications in perpetuating that narrative.
Adriene Thornton: In your research, did you find anything that you can give to health care professionals? Because when we talk about this, the next question from people is, “Well, what do I do? How do I not let these structurally built racist systems negatively impact my work and my patients and their health outcomes?”
Siman Nuurali: One is we absolutely should take systemic racism personally in the sense that we’re all collectively responsible for it, including us because we function and exist within that same framework. And also not to take it personally in the sense that when we talk about systemic racism, nobody is calling you a racist. We’re not saying you’re actively contributing to a Black patient’s death or deterioration. That’s not what’s being said. 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. And so thinking of it as we all know, race is not sort of a biologic construct, it’s social construct. And so it’s this thing that we created to differentiate different people, but it doesn’t really particularly mean anything.
And people have different ways of identifying themselves, but that is only surface level. If I’m Black, my internal systems are not different from somebody who’s comparable age or demographic, or what have you. And so thinking of it that way and acknowledging that we are not immune. Health care specifically because we think of our profession as “Well, we’re taking care of patients, we’re healing them. How could I possibly be racist? How could I possibly harm this patient when I’m there to heal them?” But again, because it’s in the system, it’s in the walls like. You know what I mean? It’s in the building.
Adriene Thornton: It’s in the water.
Siman Nuurali: It’s in the water. It’s everywhere. You cannot get away from it. And so simply being aware, just the fact that I’m going into a room that has a Black child that has asthma and if I use this pulse ox, I need to be aware that potentially his oxygen saturation might be lower than what’s actually showing up on that machine. That when I do a PFT or I do spirometry that there’s a race correction factor built into the machine that automatically cracks that. I need to be able to do more than just that. I need to be able to look at additional tests, whether that’s actively examining the patient or relying on other values, that is something that we need to do. So just being aware of the inadequacies of the tools we’ve been given to take care of patients.
And I think finally and most importantly is just understanding and acknowledging and accepting that across the board Black people are less likely to be adequately diagnosed, treated, for their chronic conditions to be managed properly. And this is because of, again, structural racism, historical racism, and this assumption that the Black body by itself is thought of in an abstract way as being built to survive or to tolerate things that would otherwise harm a white patient. So things like having thicker skin, being able to endure pain more, being able to endure adverse environmental changes, whether that’s weather or what have you. Getting rid of those assumptions because those assumptions are rooted in racism, are rooted in slavery, and looking at that patient the way that you would look at any other patient and especially being sensitive to the fact that in addition to looking at them the same as other patients, they might be more vulnerable and adjusting your thinking and adjusting your behavior to take that into account. We have quite a bit of work to do in this area, but I think those are some of the things that I would recommend.
Adriene Thornton: I think it’s really important for us to continue to have these conversations and share this information with people so that they can start the work of improving and making changes to processes so that everyone has better health outcome. Health equity doesn’t just improve the health of the population with the biggest disparity. When you improve the disparity for one, you improve health for all.
And so I want to thank you again for coming today and talking to us. I know this was brief. We could talk for hours on end about health equity and health disparities and just continue to educate and inform our audience and give them the information they need. Thank you so much for coming today.
Siman Nuurali: Oh goodness, thank you so much for having me. It’s just been such a privilege and absolutely anytime I would love to come back. Thank you, Adriene.
Dr. Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Lexi Dingman is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.