Existing Race-Based Predictions Can Perpetuate Racism in Nephrology
As in all systems, racism permeates and persists in healthcare. In a recent journal article, corresponding author Sushrut S. Waikar, MD, MPH, a nephrologist at Boston Medical Center, reviewed specifically how racism has infiltrated his specialty of nephrology and, in keeping, in other areas of medicine and clinical decision-making.
Waikar notes that when it comes to this particular research, he and his co-writer use the definition of racism as "a belief that race is a fundamental determinant of human traits and capacities" as well as systems built on that belief. The article asserts that clinical and research decisions are determined by insufficient beliefs about race and biological fact, which perpetuate a non-scientific ideology about the impact ethnicity can have on health outcomes.
In a discussion with HealthCity, Waikar talks about his article in the Journal of the American Society of Nephrology, citing specific examples of how racism can impact medical decisions. He also discusses what nephrology, as well as the healthcare system, can do to practice antiracism.
HealthCity: Your perspective outlines that racism permeates many clinical and research decisions in nephrology, which perpetuates a non-scientific ideology about the impact that race and ethnicity can have on health outcomes. Can you please explain?
Sushrut S. Waikar, MD, MPH: I don't think it's necessarily overt racism but, rather, concepts that have been around for decades, which were ultimately racist in origin. For example, we assume that such a thing as race exists, but scholars in biology, sociology, and anthropology have made it clear that race is a social construct. Ancestry does impact biology, but categorizing people into "races" is ultimately rooted in bigotry and prejudice. People of the "Black race" can include a huge range of individuals with distinct ancestries.
This is not to say that we should ignore race, however. People who are classified as "Black" are subject to housing discrimination and police violence more often than people who are classified as "white." But to classify as Black and white in medicine can be problematic. Instead of using race to describe inequalities, in medicine, we have used race for some aspects of clinical decision-making.
For example: Doctors use prediction equations to help determine how likely it is that their patient has a certain condition or disease. Many of these equations use race as a factor in that equation. Although this may improve the ability to predict risk in certain patients, there is a drawback, which is that we are using a social construct rather than a biological fact.
Let’s take the example of kidney stones. Black patients seem to have a lower risk of kidney stones — at least according to certain studies. We don't know why that is or whether that's true — i.e., were the small studies good enough to trust? And can they be applied to the entire population of “Black” people — a population comprising a large group of individuals who are incredibly diverse in terms of ancestry? What if the reason they are less likely to have kidney stones is not due to some biological difference but, rather, because of dietary patterns in the patients that were not studied? Or, more concerning, what if the difference between Black and white patients in the studies were due to differences in access to medical care, such as a doctor not listening to a Black patient's concerns and ordering the appropriate diagnostic test? These differences would misleadingly show a lower apparent risk of kidney stones.
Using small studies involving limited numbers of patients without access to detailed socioeconomic and dietary data may invalidate the prediction equation developed from those data.
By perpetuating the use of race in such prediction equations, we could be preserving a legacy of racism for generations.
HC: Where does nephrology stand among other medical specialties on testing by race?
SW: Unfortunately, we are not alone. Race is used in equations to predict, for example, whether a child has a urinary tract infection, whether someone is likely to die of heart failure, whether a woman is likely to have a successful vaginal birth after a prior C-section; and whether they are likely to have a hip fracture and require preventative medications.
HC: Based on your experience, what changes need to happen for there to be more equity in care?
SW: I find it gratifying to see that these discussions about racism in medicine are being held so vigorously around the country. In healthcare, we need to be more cautious about assuming that differences in small groups of individuals are based on a biologically-assumed construct of race. We need to always consider where patients live, what they eat, and the social and economic stressors they face.
This interview has been edited and condensed.