Black History Month
By L. Ebony Boulware, M.D., M.P.H.
Chief, Division of General Internal Medicine, Department of Medicine
Director, Duke Clinical and Translational Science Institute
Duke University School of Medicine
Recent events compel us to reckon, yet again, with the ongoing legacy of systemic racism in the U.S. The merciless murders of George Floyd, Ahmaud Arbery, Breonna Taylor, and countless other Black individuals through police violence reflect an epidemic of brutality that manifests ongoing and profound racially mediated structural social inequities in the U.S. Compounding this, the recent higher COVID-19 death rates among Black and Hispanic communities have made it clear that race-based structural inequities are directly tied to poor health and further threaten the lives of Black and other minoritized individuals.1 These intersecting realities have brought many in the fields of science and medicine to consider how race and racism are harmfully operationalized through many aspects of our collective experiences.
I have spent my career investigating race disparities in kidney failure, a condition for which Black Americans have two to threefold greater risk compared to others. Black Americans’ increased risk of kidney failure is compounded by significant race-based inequities in their health care, including 1) suboptimal prevention, 2) delayed recognition and treatment for kidney disease risk factors, 3) lack of access to health care, 4) poor referrals for evidence-based health care, 5) poorer quality dialysis treatment, and 6) lower rates of kidney transplantation.
In 1999, researchers developed the Modification of Diet in Renal Disease (MDRD) equation to estimate kidney function.2 Investigators hypothesized the existence of a biological difference in kidney function among Black individuals compared to individuals from all other racial and ethnic population groups, based on conventional wisdom and bolstered by weak evidence suggesting differences in Black individuals’ muscle mass compared to others. Despite the lack of a well-substantiated biological rationale for purported racial differences in kidney function, investigators placed a “correction factor” in the form of a coefficient into the equation. The coefficient systematically estimates all Blacks to have 21% better kidney function than non-Blacks.
Many have recently questioned the use of race-based equations in kidney care and are examining the equations’ potentially harmful contribution to kidney health racial inequities. Two national organizations have developed a task force to consider whether racialized equations should be removed from kidney care altogether. Meanwhile, several U.S. health care systems seeking to embrace anti-racist practices in medicine have independently decided to eliminate the use of these algorithms from their workflows.
The growing evidence suggests that racialized medical algorithms may contribute to numerous inequities in the medical treatment of Black individuals who are already at increased risk of kidney failure. This has generated recognition that faulty assumptions in science and medicine about race may indeed have negative and systemically racist effects on health care delivery for large populations of Black individuals who suffer inequities in kidney health and kidney care.
How can the scientific and medical community respond to the emerging recognition that our assumptions about race may lead to harm for the very individuals we seek to help? Many believe a fundamental rethinking of how we conceptualize race in the context of research and medical practice is in order. Several key concepts are essential to starting this process.
- We must fully accept race as a non-biological construct based in harmful social ideology through which systemically racist policies and practices are justified.
- We must further recognize that unsubstantiated assumptions regarding the biological nature of race have contaminated our scientific and medical reasoning in both subtle and profound ways with harmful results.
- We must actively interrogate hypotheses, study designs, inferences, and medical practices that embrace race-based thinking.
- We must seek to completely disavow ourselves from potentially racist assumptions.
- We must also seek to overturn longstanding pedagogy in science, medical school, and professional training that perpetuate racist thinking.
- We must shine a bright light on race and racism as essential contributors to generations of poor health and health inequities for Black and other minoritized individuals.
- We must continually seek to illustrate how race and racism affect individuals’ and communities’ health.
By using our scientific and medical capabilities to generate and disseminate evidence on the precise mechanisms through which structural racism contributes to health inequities, we can target and dismantle harmful policies and practices. We must follow these initial steps with collective ongoing advocacy in our fields and engagement in our communities to ensure that the health of all individuals is promoted through equitable policies and practices.
Ultimately, it will only be through our careful and humble consideration of the legacy of race and racism in science and medicine that we will be able to meaningfully contribute to discoveries and changes in care necessary to eliminate health inequities across society.
Dr. Boulware also helped NIMHD celebrate Black History Month by presenting at the NIMHD Director’s Seminar Series (DSS) on February 4, 2021. Learn more about her presentation at the DSS website.
- Williams A, Blanco A. How the coronavirus exposed health 12 disparities in communities of color. Updated May 26, 2020. 13 Accessed July 15, 2020. 14 https://www.washingtonpost.com/graphics/2020/investigati15 ons/coronavirus-race-data-map/
- Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999 Mar 16;130(6):461-70. doi: 10.7326/0003-4819-130-6-199903160-00002. PMID: 10075613