We’ve seen it time and time again in the news – stories of patients being treated differently, not believed by doctors, or significantly harmed by illnesses simply because of their ethnic background. Consider even this year how during COVID-19 people of color were described as “bearing the burden” of the viral pandemic. But what is the cause of this? Why, despite our knowledge, do we continue to marginalize this population within the healthcare sphere? According to Consumer Reports, the issue is medical algorithms. By using standard medical algorithms, especially those that were formed decades ago, patients are getting hurt.
ForeSee Medical describes medical algorithms as computational, formulaic, or statistical tools used in healthcare for decision-making. For example:
A medical treatment algorithm can assist in standardizing the selection of patient care plans, with algorithm automation intended to reduce the possibility of errors. Computerized health diagnostic testing algorithms can provide timely clinical decision support at the point of care, and improve adherence to evidence-based guidelines for value based care.
But what happens when those algorithms inherently harm patients?
When a patient in his 50s, Eli, visited Dr. Vanessa Grubbs, he was experiencing some health difficulties. Eli has membranous nephropathy, a kidney disorder in which glomeruli, blood vessels in the kidney, become swollen and thick. As a result, the glomeruli are unable to effectively filter waste out of the blood. Patients experience organ damage as the disease progresses.
Dr. Grubbs treated Eli for five years. During this time, the man became more and more ill. Another issue arose when it became time to seek an organ transplant. Doctors decide who can get onto the kidney transplant list by using glomerular filtration rate (GFR), which evaluates how quickly the kidneys are able to filter blood. If patients have a GFR of 20 or lower, they are able to join the list. GFR is measured via a blood test, which tests for creatinine. However, the final medical algorithm takes a patient’s age, sex, and race into account.
20 if not African-American. 24 if African-American. Those were the numbers returned back to Dr. Grubbs. But she refused to accept these results, refused to believe that Eli was somehow healthier and not in need of a kidney simply because of his race. So she ordered a new test. Though it was more invasive, it didn’t take race into account. And what do you know? 20. Eli was able to join the kidney transplant list.
Of course, not all doctors are as intensive or caring as Dr. Grubbs. However, the deeper issue is the racial aspect built into medical algorithms. In terms of kidney function, as in Eli’s case, the algorithm was developed nearly 21 years ago. An article published in Annals of Internal Medicine in 1999 explores why algorithms should be adjusted based on race. In some cases, you may see these referred to as “race corrections.” Doctors use these algorithms to determine test results, decide whether a patient should receive a certain treatment, or even decide what tests to run. But is this appropriate and fair?
Most likely, the answer is no. Some doctors may solely use algorithms to make medical choices and recommendations, despite the fact that these decisions should embrace a number of factors. Race corrections are now prevalent in cardiology, pulmonology, nephrology, obstetrics and gynecology, and other medical areas. Some people believe that race corrections solidify another harmful viewpoint. Grubbs shares:
“We’ve really never stopped doing these Black-white comparisons and just assuming that Black people are inherently different.”
Tuskegee Syphilis Study
This viewpoint of racial differences has been imbedded in our medical system for years. For example, the Tuskegee Syphilis Study began in 1932. According to the CDC, syphilis became an enormous concern in 1926, with around 35% of the total sexually active population contracting it. In 1932, the study enrolled 600 Black men. Of these, 399 had syphilis; the remaining 201 did not. The CDC explains:
The study was conducted without the benefit of patients’ informed consent. Researchers told the men they were being treated for “bad blood,” a local term used to describe several ailments, including syphilis, anemia, and fatigue.
However, no patients were given cures for their syphilis, despite the fact that penicillin was widely offered as a treatment in 1947. Researchers told the men that the study would last for around 6 months. But the Tuskegee Syphilis Study actually lasted until 1972: a total of 40 years! It is difficult to argue with the idea that these men were not treated, and just observed to understand disease progression, because of their race.
Even before the Tuskegee Syphilis Study, medical science was used to subjugate Black individuals. Prior to the Civil War, Samuel Cartwright used a spirometer to claim that Black people were deficient and inferior based on lung capacity. Although this sounds ridiculous in our contemporary time period, this perceived difference in lung capacity was used in eugenics arguments. In 1974, this racial correction was implemented into a clinical algorithm in the pulmonology sphere.
The Dangers of Contemporary Medical Algorithms
Black patients are less likely to be referred to specialists when needed, as race corrections make it seem as though they are not suffering as severely from illnesses. Other medical algorithms use race to prevent Black patients from receiving care. For example, calculating the risk on having a vaginal birth following a C-section generally positions it as less risky for white women. However, it becomes “riskier” for Black and Latinx patients. Yet National Vital Statistics Reports shares that Black women are more likely than other groups to get a C-section. As a result, their continuing medical procedures are now shaped by that risk, making doctors less willing to perform certain procedures moving forward.
Additionally, Black patients are less likely to be tested for conditions like kidney stones. Why? Because calculations and medical algorithms say that these are less likely. But this ignores the danger we put patients in if they are experiencing an issue that an algorithm suggests could not be true. Nephrologist Nwamaka Eneanya shares that the system needs to be changed to optimize patient outcomes. She explains:
“No one is saying to throw away science. We just want to make sure that we are not causing harm to our patients.”
Further, Eneanya urges Black individuals to take control over their own care and make sure to ask questions:
“Ask your doctor, ‘What does this mean for my current care? If I am unable to receive certain specialty referrals or treatments, are there alternative measurements of [organ function] that do not include race?'”
Whether or not medical algorithms should be adjusted in still somewhat of a controversial discussion. In regards to GFR, for example, many hospitals and medical practices are beginning to take race out of the medical algorithm. This is spurred by activists, who insist that race should not play such a large role in medical algorithms. Others, like Dr. Neil Howe, argue two things:
- Race corrections help craft the most accurate algorithms.
- Removing race corrections could cause worse patient outcomes. For example, if a patient’s condition looks more dire than it is, simply because of a non-adjusted algorithm, patients can be overmedicated or prevented from joining clinical trials.
Admittedly, race does play a role in health outcomes. Across the nation, Black individuals have higher rates of asthma, stroke, and diabetes. But these conditions can also be related to environmental and lifestyle factors. So as the medical sphere continues to debate the role of race in medical algorithms, it is important to ask a question: should race be the first factor we attribute to health, or should we place a heightened importance on what else is going on?