Working on the issues of race and medicine at the local level are Imogene Drakes, the director of laboratory services at Brattleboro Memorial Hospital; Dr. Rebecca Jones, a dermatologist in private practice; and Dr. George Terwilliger, chief medical officer and emergency medicine physician at Grace Cottage.
Courtesy photos (Drakes and Terwilliger); Randolph T. Holhut/Commons file photo (Jones)
Working on the issues of race and medicine at the local level are Imogene Drakes, the director of laboratory services at Brattleboro Memorial Hospital; Dr. Rebecca Jones, a dermatologist in private practice; and Dr. George Terwilliger, chief medical officer and emergency medicine physician at Grace Cottage.

The color of medicine

Local hospitals work on eliminating racial disparities in the delivery of health care as a Windham County NAACP group targets race-based presumptions in the medical milieu

BRATTLEBORO-Medically, the only two ways in which white patients and Black patients differ are skin color and hair type.

That's it. Everything else is a social, not a racial, construct.

Yet it is not widely known, at least among the white population, that there is medicine for them and then there's medicine for African Americans and other people of color.

The medical establishment has now acknowledged that there is a problem. And, in Windham County, both Brattleboro Memorial Hospital and Grace Cottage Hospital are taking steps to fix it.

Established medical procedures that have factored race into account "have resulted in some unintended consequences," said Dr. George Terwilliger, the chief medical officer and emergency medicine physician at Grace Cottage. "And it turns out that race is a bad idea."

"Between a Black person and a white person, there's so little difference genetically, other than skin and hair," he said. "I mean, there are facial features, there might be more common body types, but medically, [race distinctions are] based more on social factors than it is on biology."

Those differences do matter. For example, take those little non-invasive pulse-oximeter devises that nurses put on your finger to check your pulse and oxygen levels.

Can this device be racist? The answer is yes.

"The machine uses a color-response beam," said Dr. Rebecca Jones, a dermatologist in private practice in Brattleboro, who is white. The device emits light and analyzes the red of the red blood cell to measure how much hemoglobin it has.

"You see me, and my skin is darker, right?" said Imogene Drakes, the director of laboratory services at BMH. In Black people and other people of color, the color-response beam is "thinking that this means hemoglobin, when it actually means melanin."

'No biological significance'

Drakes, along with Jones and several others, are part of Anti-Racism in Medicine, a subcommittee of the Windham County NAACP Health Justice Committee.

The group is studying the way racism innocently inhabits medicine.

Mainly, it's through algorithms.

"Algorithms are shortcuts, formulas to help doctors make medical decisions," the subcommittee said in a recent letter to the public. "Yet 'race' has no biological significance - it has no biological basis below skin color and is not a proxy for genetic variability - but still it has been used to make important and sometimes life-and-death decisions for patients.

"Doing so has resulted in the directing of attention and resources away from Black and other minority groups and toward white patients," the group writes.

The committee began its work during the pandemic, when it saw data from Covid testing. Black people accounted for 25% of the people who tested positive and 39% of the COVID-19 related deaths, while only making up just 15% of the general population.

This data largely pointed to environmental, economic, and political factors - not race.

"And from that work, we realized that there were racial inequities here in Vermont," Drakes said. "And we need to start thinking about ways to make sure that the Covid data is not something that is emblematic of our system."

But in many ways, it is.

Correlation and causation

It has been generally and widely accepted that African American people have a genetic disposition to sickle cell anemia. That perception turns out to be wrong.

"It is a genetically passed-down condition that is completely unrelated to color of skin," Jones said. "And so anyone who happens to have that gene can have it.

"Now, the gene probably developed from evolution in areas where malaria was plentiful, because it's a response to malaria," she said - which could account for the disease's disparity in the Black population.

"But as we know, people had sex with each other from all kinds of backgrounds," Jones continued. "And so there are plenty of people who share genetics who look different from each other."

Or take the GFR (glomerular filtration rate) test, which is used for diagnosing kidney problems. Until doctors realized that the algorithms they depended on for diagnosis might be wrong, the medical establishment assumed that Black people have higher creatinine, a waste product that is normally filtered by one's kidneys. Its presence in the blood is considered a proxy for kidney disease.

"The glomerular filtration rate is used to indicate whether someone is likely to be having kidney damage or kidney disease," Drakes said. "And what was happening for more than two decades is that we had one GFR [interpretation] for people who are Black and one GFR for everybody else."

The cutoff GFR value for deciding whether someone was likely to have kidney disease was 60.

"Because of the GFR calculation for Black people, it meant they would [be considered healthy with] a number like 65 or 68," Drakes said.

Despite the fact that white people with those same values would be considered in need of treatment, she said, "it meant that the [Black] person was healthy and not in need of care."

"And for many decades, many people of color, especially Black people, were actually very sick," she continued. "And it was noted that many more of these people were in end-stage renal disease. It was delaying care for people who have kidney disease."

In 2020, an important paper in The New England Journal of Medicine acknowledged that the kidney disease factor gives the wrong result for people of color. A new calculation incorporating the use of another metric came into effect for all people, regardless of race.

Re-examining preconceived notions

The Anti-Racism in Medicine committee began studying what else would be needed to change inadvertantly racist hospital practices.

In one odd discovery, they realized that spirometers, which measure lung function, have a correction factor that was established in the 1700s by none other than Thomas Jefferson. He assumed Black patients had inherently weaker lung function than whites, and his assumptions were the foundation of medical practice for the next three centuries.

"Pollution exposure connected with poverty and environmental injustice means racism rather than race is to blame for lung disease," the committee wrote.

It is far more likely that the experience of being Black in America, rather than being Black itself, causes these unfair disparities in care.

"What's dangerous about an algorithm is that it's taking something subjective and making it sound objective because you're putting a number on it," Jones said.

"Think about all of the white supremacy cultural/patriarchal ideas we have," she continued. "Think about all the algorithms around women's care versus men's care. We know that women get much less care than men. Women are often overlooked when it comes to heart disease and so on. These preconceived notions are dangerous."

'It's caused unintended harm with when you start throwing race in it'

The committee has been working with BMH and Grace Cottage to change some of these harmful practices.

"BMH continues to demonstrate commitment: in 2018 BMH stopped using an algorithm that considers Black women more at risk for vaginal birth after C-section," the committee wrote.

The hospital "also eliminated the race-based correction for kidney function ahead of the National Kidney Foundation. The birthing center stopped using correction of anemia in Black prenatal mothers [and] the emergency room has for years used the Masimo brand pulse oximeter to measure blood oxygen, which typically gives better readings for all skin tones."

Grace Cottage is also changing over its pulse-ox devises. And, like BMH, it is working to root out and eliminate other medical fallacies.

"Medicine has discovered that some of these well-intentioned algorithms for individualized care are wrong," Terwilliger said.

"What those efforts were saying was, 'Oh, well, let's look at race and age and gender, and see if people differ on risk factors and such.' They thought they were doing everyone a favor by discriminating based on age, race, and gender. And it turned out it was a good idea for age and gender, but it's caused unintended harm when you start throwing race in it."

Race is more of a social construct than a biological one, Terwilliger said.

"So these algorithms did introduce social factors and political factors into medical care, which we found out is a bad idea," he said.

"I think it was well-intentioned, but also I think most medical providers have decided that we really don't want to do this anymore," Terwilliger said.

"I don't think there's been any resistance from anyone I've talked to. I don't think that the medical organizations like the AMA or American College of Physicians have put up any resistance.

"They just want to make sure we're doing it right," he said. "Don't do something stupid. Be careful. That's all."

This News item by Joyce Marcel was written for The Commons.

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