Published On May 20, 2021
It is now possible to imagine a world recovered from COVID-19. In that future, how will medicine have changed? These 10 essays explore the technical, social and political ripples of the pandemic.
In the summer of 2020, physicians from Massachusetts General Hospital made their way to the State House in protest of the police killings of George Floyd and Breonna Taylor. As we look at the past year, we remember that it held a reckoning with what many have called “twin pandemics”: COVID-19 and systemic racism. COVID-19 was new but it laid bare the longstanding, stark realities of racial injustice in our country.
In the medical field, this has partly meant revisiting fundamental questions about race and ethnicity. We commonly use race clinically, but our latest insights from population genetics have demonstrated convincingly that race is a poor proxy for genetic difference; studies have repeatedly shown that greater genetic variation exists within racial groups than between them. Race is a pervasive social construct, but biologically and medically it is less useful. Categories like “Black” or “white” are exceedingly unlikely to represent meaningful genetic differences between individual patients.
Medicine is still behind the curve in updating its practices to reflect this understanding. Our tools often use race as a proxy for true biological difference. Concerningly, many of these tools even use such variables in a way that can direct care or attention disproportionately toward white patients compared with patients of color. Calculators that predict lower chances of successful vaginal births for Black women may deter them from attempting such births. Risk scores that predict lower rates of fracture in Black patients could delay therapy for osteoporosis.
This year, critique of these practices gained new ground. Academic scholarship shed light on the widespread and often harmful practice of “race correction” in medical algorithms. Traction on this issue reached the federal level, and the chairman of the House Ways and Means Committee asked professional medical societies to account for their use, and many have assembled task forces.
In March, the American Society of Nephrology and National Kidney Foundation task force announced its official recommendation to end race adjustment in the widely used algorithm for kidney function called the estimated glomerular filtration rate (eGFR). The Maternal Fetal Medicine Unit Network also announced the development of a new tool for predicting successful vaginal birth after cesarean without race correction. This debate even reached the NFL, where a concussion lawsuit cast new light on a race correction used to interpret neurocognitive testing in football players. Different curves for Black and white players effectively lowered the chance of Black players earning concussion settlements compared with white players.
As medicine moves increasingly toward computerized models of risk assessment, the creation of best practices for the use of race becomes ever more urgent. It is crucial to understand that this does not suggest the adoption of race-blind medicine. Racism continues to have pernicious effects on health outcomes. But in the decade ahead, we must do the difficult work of recognizing those effects and addressing their causes, rather than defaulting to building these inequities into predictive tools. Once we see racism as the risk factor for poor health outcomes instead of race, our interventions can be designed to address root causes rather than risk perpetuating inequities.
Darshali Vyas // clinical fellow in Medicine at MGH.
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