THE RECENT controversy over a JAMA (prestigious Journal of the American Medical Association) podcast—along with “racial inequities in medicine…Black Americans contracting the coronavirus and dying from it at higher rates thanks to decades of medical racism,” according to the Washington Post —prompts an update of Mary Carpenter’s post on racism in U.S. medicine from last year.
JAMA and other “elite medical journals have routinely excluded, minimized and mishandled issue of race,” according to complaints following the podcast, which serves “to perpetuate and entrench health inequities that have long harmed and shortened the lives of people of color.”
Medical researchers told Statnews about being “explicitly told” to remove the word racism from their work. In an egregious example of racism, last August’s Journal of the American Heart Association included an article arguing that educational programs intended to increase diversity would produce poorer clinicians.
In the podcast, one JAMA editor questioned using the term racism at all because it “involves feelings among people,” and JAMA’s promotional tweet for the podcast made the unacceptable statement that no physician is racist.
Among racist practices receiving new attention with Covid-19 is placing blame on genetic rather than social factors for higher rates of Covid-19 deaths and hospitalizations —which fails to pinpoint structural racism as a cause. A more specific example, the dearth of images using dark skin in dermatology medical literature can impede the assessment of rashes on the toes and elsewhere linked to Covid-19—leading to incorrect and life-threatening diagnoses.
The standard kidney assessment adjusts for the dated racist assumption that black people have higher muscle mass and thus better kidney function. The test results—deeming the kidneys of many black patients in better shape than they are—can delay treatment or eligibility for transplant, often placing patients so low on wait lists that they die before having the chance to receive a new kidney.
More difficult to address are the racist medical practices that stem from “implicit bias,” which includes a range of beliefs, especially affecting evaluation of pain. At least one life-threatening consequence of treating black patients differently is the three and a half times greater likelihood of healthy black children dying during surgery compared with white children.
While high rates of adult black patients’ deaths during surgery are often traced to overlapping health conditions or risks, black children with no underlying conditions still had a higher rate of death and complications after both elective and emergency procedures than their white peers.
Among outdated racist practices and beliefs from the past that persist today, commercial spirometers used to diagnose and monitor respiratory illness have a “race correction” built into the software to control for blacks’ “lack of lung capacity,” as described by Thomas Jefferson.
The spirometer’s designer, Louisiana physician Samuel Cartwright, estimated blacks’ lung deficiency at 20% and suggested treatment using forced labor to “vitalize” the blood. (Cartwright also described a disease of the mind called drapetomania that caused enslaved people to run away from their enslavers.)
While the proportion of images using dark skin in dermatology textbooks ranges from 4 to 18%, the one exception is sexually transmitted diseases—with images using black skin appearing twice as often for infections that are sexually transmitted, compared to 28% of images using black skin for infectious diseases in general.
The dermatology bias creates a painful reminder of the Tuskegee researchers who withheld diagnosis and failed for decades to treat black men with syphilis. Black skin was also the object of racist experimentation in the 1900s by Georgia physician Thomas Hamilton, who created blisters and then cut into the skin of one slave while attempting to prove that black skin was thicker than white skin.
While areas of medical bias, such as textbook images, may take longer to correct, objective measurements involving the spirometer and kidney tests could be easy to change. The kidney function test that measures “estimated glomerular filtration rate” (eGFR)—the ability of the kidneys to filter waste from the blood—includes a variable of race (along with age, gender and levels of the waste product creatinine) that allows for only two groups, black and not black, with points added to raise the scores for those in the black group.
Individual medical institutes have started adjusting for muscle mass instead of race, but some physicians argue that any role of muscle mass is medically unfounded and call for eliminating this variable entirely. The National Kidney Foundation has affirmed that “race modifiers should not be” part of kidney function assessments, and that current equations should be replaced by those that are “accurate, inclusive, and standardized.”
Looking at implicit bias in medical practice, studies of medical students repeatedly find widespread beliefs that “black people’s nerve endings are less sensitive than white people’s… their skin is thicker.. their blood coagulates more quickly,” writes University of Washington health researcher Janice Sabin.
Implicit bias has the most impact in medically ambiguous situations. For pain that has no clear cause, such as traumatic injury, providers rely more heavily on their personal judgment. In addition, the media often exposes medical providers to stereotypes and images, that, for example, associate black people with substance abuse and drug-seeking behavior.
A meta-analysis of research over 20 years that included many sources of pain found that black patients were 22% less likely than white patients to receive any pain medication—with the greatest disparities for conditions like backache, migraine and abdominal pain.
Many people find it easier to recognize pain in faces like their own—making it easier for white medical providers to assess pain in white faces. “We are in the midst of an Implicit Revolution,” writes Sabin, “bringing new insights into how our minds work…we operate at the unconscious level much more than we ever imagined.”
Exercises like taking the “Implicit Association Test” can help medical providers recognize and acknowledge their biases. And learning about disparities in pain management can help clinicians improve their practices. But some experts put their greatest hope in finding more objective measures—for pain, a blood test using biomarkers could measure intensity.
In White Fragility, Robin DiAngelo explores the evolution of racism in American medicine. Early in U.S. history, “tension between the noble ideology of equality and the cruel reality of…enslavement…had to be reconciled. Jefferson and others turned to science…Race science…legitimized racism and privileged the status of those defined as white.”
She explains, “The idea of race as a biological construct makes it easy to believe that many of the divisions we see in society are natural. But race, like gender, is socially constructed. Under the skin, there is no biological race.”
Mary Carpenter regularly reports on topical issues in health and medicine.