How race-adjusted algorithms amplify structural inequities
By: Esther-Joelle Asare
While our understanding of race and human genetics has evolved over the past several years, there still exists a grey area regarding the implementation of scientifically-validated guidelines for the use of race in medicine. In an attempt to individualize risk assessment and guide clinical decisions, certain diagnostic algorithms tend to adjust their outputs based on a patient’s race or ethnicity. The harsh reality is that many of the screening assessments used in today’s healthcare system are magnifying the carefully concealed biases that prevent marginalized groups from receiving appropriate treatment for their ailments. With this in mind, it is extremely important to adopt a multicultural approach to examine how modern medicine sits at the intersection between deeply rooted racial disparities and present-day clinical practice.
Painting the Picture
Grey’s Anatomy, a contemporary medical drama set in Seattle's fictional Grey-Sloan Memorial Hospital, addressed this issue in one of its recent episodes. No stranger to using their storylines as a form of activism and advocacy, Grey’s Anatomy tackled some of the racist undertones of common medical practices in Episode 2 of Season 18: Some Kind of Tomorrow. Dr. Winston Ndugu ends up with a new patient, Rashida Flowers, a black woman who has developed kidney disease as a complication of diabetes. With a clotting disorder that makes dialysis difficult, her only choice is a kidney transplant. Unfortunately, Rashida does not qualify for the transplant due to her estimated glomerular filtration rate (eGFR) results, although her poor renal function should make her a prime candidate. Confused and dismayed, Dr. Ndugu cites patients with nearly-identical health profiles whose eGFR results differ only in the fact that they are white, mirroring the real-world consequences of race-based medicine.
An eGFR test is a routine procedure used to calculate renal function based on the amount of creatinine (a waste product that is filtered out of the body by the kidneys) present in the blood. This standard medical practice falls short in its dependence on race, which has the potential to skew the results. According to the National Kidney Foundation, “race was originally included in eGFR calculations because clinical trials demonstrated that people who self-identify as Black/African American can have, on average, higher levels of creatinine in their blood. It was thought the reason why was due to differences in muscle mass, diet, and the way the kidneys eliminate creatinine. Since a patient’s race is not always used when laboratory tests are ordered, laboratories used different eGFR calculations for African American and non-African American and included both numbers in their lab results” (National Kidney Foundation, 2021). Unfortunately, the eGFR test is not an isolated incident or a one-off example of biased care. Racist ideology has been sneaking its way into medicine for years.
The Implications of “Coloured” Care
In Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms, the New England Journal of Medicine recently compiled a non-exhaustive list of 13 race-adjusted algorithms based on their potential to perpetuate or amplify race-based health disparities. From the Vaginal Birth after Cesarean (VBAC) Risk Calculator which utilizes correction factors subtracted from the estimated success rate for any person identified as Black or Hispanic, to the National Cancer Institute’s Breast Cancer Risk Assessment Tool which returns lower risk estimates for women who are African American, Hispanic/Latina, or Asian American, it is apparent that these structural inequities bleed into many areas of clinical practice including cardiology, obstetrics, nephrology, and urology (Vyas et al., 2020).
These algorithms disregard the fact that race is not a biological concept, but rather, a social construct and therefore, it is not a valid factor for these assessments. That is not to say that race has no part in healthcare at all. In fact, a completely ‘colour blind’ approach to medicine is damaging as well. It is to say, however, that race should only be considered based on tangible evidence rather than presumptuous conventions. Even so, the fact remains that, as is, these tests remain a standard for healthcare professionals around the world, oftentimes preventing people of colour from accessing the standard of care that is effortlessly afforded to their white counterparts.
Continuing the Conversation
Though we live in a world where white people’s lives are often awarded higher value than those of people of colour, the burden of advocating for suitable care should never be placed on vulnerable patients. As long as healthcare workers remain complicit, innocent people will continue to face the consequences of systematic discrimination. It is up to our healthcare professionals to follow through on their commitment to help and not to harm, to be a voice to the voiceless, and to become the picture of what antiracist allyship looks like in medicine. It is conversations like these that will help us to dismantle the structures that prevent all people from receiving the care they deserve.
Race and EGFR: What is the controversy? National Kidney Foundation. (2021, October 15).
Retrieved November 19, 2021, from https://www.kidney.org/atoz/content/race-and-egfr-what-controversy.
Scientific American. (2020, December 1). Take racism out of medical algorithms. Scientific
American. Retrieved November 19, 2021, from https://www.scientificamerican.com/article/take-racism-out-of-medical-algorithms/.
Vyas, D. A., Eisenstein, L. G., & Jones, D. S. (2020, June 17). Hidden in plain sight -
Reconsidering the use of race correction in clinical algorithms. New England Journal of Medicine. Retrieved November 19, 2021, from https://www.nejm.org/doi/full/10.1056/NEJMms2004740