Imogene Drakes, Dr. Rebecca Jones and the NAACP Health Justice Committee: Fixing racist algorithms in medicine

This commentary is by Imogene Drakes, PhD, Dr. Rebecca Jones and the members of the Windham County NAACP Health Justice Committee’s “Anti-Racism in Medicine” group.

Unbeknownst to many of us, racism in health care impacts Black, Indigenous and people of color, also known as BIPOC, from many directions. The deleterious effects exacerbate myriad health problems in BIPOC patients and especially in Black women.

BIPOC patients are more likely to receive lesser care from our medical system and have significantly poorer outcomes due to two-tiered systems that exist at many levels of our health care system.

To heal from the wounds of racism, many of which were initiated or perpetuated by a lack of scholarly thinking, and not necessarily by intent, and to prevent the creation of new ones, we need to be willing to look for and address wherever racism still impacts our health care system.

Algorithms are one insidious way racism remains embedded in medicine. Algorithms are shortcuts, formulas to help doctors make medical decisions. “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.

Race shows up in many specialties: Spirometers, which measure lung function, have a correction factor established in the 1700s by Thomas Jefferson that assumes Black patients have inherently weaker lung function than whites. Thoracic surgeons use algorithms that indicate Black patients are at higher risk for surgical complications. Kidney algorithms assume that Black people have higher creatinine , a proxy for kidney disease.

The rationales for these adjustments are opaque in ways that are not usual for health care. Whereas clinical decision-making typically is and should be firmly fixed in robust medical knowledge, these racialized metrics can lead to decision-making with little clear scientific reasoning and without any consideration of external, non-natural variables.

The explanation for elevated creatinine levels in Black people for instance was erroneously attributed to inherently higher muscle mass, which led to disregard of signals of disease. Racist algorithms, combined with a lack of curiosity about social determinants of health, are no doubt the reasons that Black people tend to have a higher rate of end-stage kidney disease and death due to kidney failure than non-Black people.

With regard to reduced lung capacity, pollution exposure connected with poverty and environmental injustice means racism rather than race is to blame for lung disease.

Differences in health at the group level should not be accepted as natural variation but an indicator that some external factor — often related to systemic racism — is causing the different measure. Regardless of reason, a sign of ill health should be a sign of ill health in any patient, period.

The American Heart Association’s intent to “increase the use of recommended medical therapy in high-risk patients and reduce resource utilization in those at low risk” coupled with their algorithm results in less care for Black patients. A 2019 study revealed that an artificial intelligence tool, using spending as a stand-in for clinical risk, directed care toward white patients and away from Black patients.

Since race is a social construct and not a natural category, and racism has direct health impacts upon BIPOC groups, health practitioners need to become more curious about health differences between people of color and white people.

According to the 2019 study we mentioned, “The racial differences found in large data sets most likely often reflect effects of racism — that is, the experience of being black in America rather than being black itself.”

Algorithm race adjustments overlook the causes of disparity and result in the directing of care away from patients who need it, thus perpetuating a system of injustice.

There are signs of change. The American Heart Association is funding research to examine race in its disease formulas.

“By inappropriately including race as a proxy for biological characteristics, algorithms may unintentionally perpetuate disparities in care,” said Dr. Nav Persaud, of their De-biasing Advisory Panel.

We have been working with Brattleboro Memorial Hospital and the area medical community to identify and resolve use of harmful race-based algorithms. The hospital continues to demonstrate commitment: In 2018, Brattleboro Memorial stopped using an algorithm that considers Black women more at risk for vaginal birth after C-section. They 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. Hospital cardiologists now mitigate their use of the Cerner-based risk calculator. The emergency room has for years used the Massimo brand pulse oximeter to measure blood oxygen, which typically gives better readings for all skin tones.

Brattleboro Memorial Hospital commits to do more of this work and we encourage others to share our goal:

“BIPOC who live and/or work in Windham County thrive by successfully accessing high quality and equitable systems of care. This will entail: advancing racist-free, culturally-humble medical services; reinforcing community networks and resilience and improving health outcomes for intersecting identities.”

Thank you.

Read the story on VTDigger here: Imogene Drakes, Dr. Rebecca Jones and the NAACP Health Justice Committee: Fixing racist algorithms in medicine .