Should the medical world reconsider the use of race in medical algorithms?

“The 360” shows you diverse perspectives on the day’s top stories and debates.

What’s happening

The Doris Duke Charitable Foundation awarded more than $10 million in grant money to five medical organizations last month to study and address the “potentially dangerous” consequences of race misuse in medical algorithms. The foundation cited the important role that medical and professional research societies play in advancing health equity and closing the gaps of racial disparities in health care.

“Societies can have an impact on education to update medical knowledge on misconceptions about race in medicine, on increasing the diversity of the medical workforce, on the diversification in clinical trials to ensure that research findings are applicable to the diversity of patients affected by specific diseases, and down to clinical research to illuminate how the consideration of race and ethnicity in medical tools (such as algorithms and diagnostics) impacts health outcomes,” Sindy Escobar-Alvarez, the program director for medical research at Doris Duke, said in a statement to Yahoo News.

The grants come as the medical industry is increasingly scrutinizing centuries of medical practice that used race as an identifier in diagnoses including kidney disease, pediatric care, obstetrics and transplant allocation. Race in medical algorithms was integrated and argued to be necessary to predict a risk of disease in clinical practice to determine care.

Dr. Joseph Wright, chief health equity officer for the University of Maryland Medical System, told Yahoo News that the medical practice is “historic in nature,” steeped in historical biases, racism and assumptions, used by physicians for several hundred years to assist in evaluating diagnoses and treatment of patients. The practices often use Black/non-Black classification as one of the predictors.

“Many of the assumptions are rooted in pseudoscience or unscientific assumptions,” Wright said. “For instance, pulmonary function tests — and this goes back several hundred years to Thomas Jefferson — who just asserts out of the air that there are lung capacity differences between the enslaved and the enslavers. That hypothesis, ungrounded in any kind of science, has lived on. Now, when you go to the doctor and you need to assess the status of your lung function, the very machine that is used is race-normed. Someone takes a look and says, 'Oh, well, I think this patient is X. Let me dial this in.'”

Why there’s debate

A research article published by Science Advances in May points out that within the medical community, there is an argument that including race in certain algorithms can perpetuate inequities across different racial groups since race is a social construct and not a “biological feature.” The assumptions on how race can affect patient outcomes are also often unknown and can be potentially harmful, especially to people of color.

“It’s not the race assignment, but the actual bias that people experience that contributes to the differential and deleterious outcome,” Wright — who was recently named the first chief health equity officer and senior vice president of equity initiatives for the American Academy of Pediatrics, one of the grantees — continued. “Race has a huge impact on people’s differential lived experiences that definitely impacts their health outcomes. I would contend that we need to be more scrutinous about the impact of race as a social construct on health.”

Following the death of George Floyd in May 2020, coupled with the inequities in health care for people of color that the COVID pandemic exposed that same year, discussions of race were propelled into the forefront of conversations in academic health circles.

“We have a great deal more scrutiny on what the drivers are for health disparities and among them are these race-based algorithms and the unfounded and unscientific premise that race is somehow a biological variable that can be just included in the scientific algorithms around which we practice medicine,” said Wright.

What’s next

The clinical community, including the Duke foundation’s five grantees, is laying out the road map to reconsidering the nuances of how the race factor can be used to serve patients with equitable care and avoid discrimination. One approach includes working with industries whose job is to consider the impact of race and racism, such as social scientists, economists and geneticists.

“The medical societies need to dig deeply into all of their policies, training and the teaching materials that include references to race and race-based approaches,” Wright stated, adding that the American Academy of Pediatrics has “a very thick compendium of policies and practices that frankly need to be scrubbed from stem to stern that there’s no other way to do this. It has to be a whole policy approach.”

Perspectives

Social drivers of health are important factors

“Race norming is wrong when we are calculating somebody’s pulmonary function test. But you cannot ignore, for instance, the impact of redlining with regard to where people of color live and what they’re exposed to that may impact their lung function.” — Dr. Joseph Wright to Yahoo News

Categorizing based on race is a ‘historical, imperial, and erroneous enterprise’

“Medical professionals published pseudoscientific racial rankings, baldly motivated by economic gain, White supremacy, and racist colonial agendas. Bolstered by the authority of Western biomedicine, dehumanizing conclusions about racial inferiority were widely adopted in medical scholarship and served as foundations for racial adjustments. Race was thereby operationalized as an immutable, physiological trait despite lack of evidence of a genetic basis.” — Madeleine Kane, Dr. Rachel Bervell, Dr. Angela Y. Zhang and Dr. Jennifer Tsai, AMA Journal of Ethics

Using race in the pharmacogenetics field is useful to advance personalized medicine for individual patient care

“There is a strong social component to race, but there is also a genetic component. And genetic variants have biological consequences. So, in addition to social factors, our research studies need to account for as much genetic variation as possible. One way we do this is making sure our studies include participants from diverse genetic ancestries, and we often use race to approximate ancestry.” — Akinyemi Oni-Orisan, UCSF Magazine

Social inequalities can affect cognitive testing

“If you look at the history of cognitive testing, for example, what we’ve seen is that it’s the most socially disadvantaged groups that get the lowest scores. These disparities are not inherent. They are caused by inequalities — in income, education, stress, etc. — that can advantage some groups over others, starting in early childhood. So what we need to do is unpack that social experience and measure it systematically so that we can understand the true factors that predict somebody’s baseline cognitive function.” — Katherine Possin,UCSF Magazine

An initiative by organizations to reconsider race to calculate kidney function may hinder Black patients’ ability to receive the right care

“Some institutions omit Black race in computation of eGFR [estimated glomerular filtration rate, which measures how well your kidneys work], thus assigning the value for non-Black persons to Black persons. However, the accuracy of this approach as compared with measured GFR has not been evaluated; it could lead to underestimates of measured GFR, with effects on clinical decision making and public health. This is particularly important given that Black Americans already bear a disproportionate burden of kidney failure. Systematic differences in GFR-based care could exacerbate health disparities.” — New England Journal of Medicine

Doctors run the risk of underdiagnosing when you eliminate race from the equation

“Cystic fibrosis is underdiagnosed in populations of African ancestry because it is thought of as a ‘White’ disease. Rheumatologic conditions are underdiagnosed in non-White and non-Asian populations. Some researchers caution that there are few good alternatives that do not use race when compared with the current equations that do use race.” — Richard E. Neal and Michelle Morse, National Library of Medicine

Eliminating race in diagnoses and prognoses could worsen existing inequities

“Diagnostic models that do not take race into account would increase systemic inequities and discrimination. I found similar results for prognostic models intended to compensate for individual circumstances. For example, excluding race from algorithms that predict the future survival of patients with kidney failure would fail to identify those with underlying circumstances that make them more vulnerable.” — Anirban Basu, the Conversation

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