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Race correction in health care: a primer
What is race correction in health care?
Health care providers often use tests to assess a patient's health. In many cases, health care providers calculate test results differently for Black people than they do for everyone else. Health care providers may also use different criteria when deciding whether or not Black people are good candidates for specific surgeries. In addition, they may use different criteria when deciding whether or not the symptoms Black people are reporting require treatment. These are examples of "race correction" in health care, a harmful practice which is also referred to as "race adjustment," "race modification" or "race norming." Race correction can occur at many different points in a Black person’s health care journey, and across different specialties, physicians and health care providers. As a result, it can be difficult to figure out when and where race correction has been applied, and what this may mean for someone’s access to treatment and supports.
What are the consequences of race corrections in health care?
Race corrections are based on the old, discredited and racist idea that Black people are inherently biologically different from white people. For example, health care providers frequently calculate kidney function tests differently for Black people than they do for everyone else. This “race correction” makes Black people seem healthier than they are. That means that a Black person can have serious kidney problems, but, after the race correction is applied, their test will come back as "normal." An examination of US health data from 2015 to 2018 found that, without race correction, 300,000 additional Black people would have qualified for a referral to a kidney doctor, and 31,000 additional Black people would have become eligible for kidney transplant waitlists (Tsai, et al, 2021).
Lung function tests are another example (Braun, 2005). Once again, the race correction applied to these tests makes Black people seem healthier. As a result, Black people are less likely to be diagnosed with lung disease, and less likely to receive appropriate treatment. An examination of lung function tests performed at the University of Pennsylvania Health System between 2010 and 2020 found that, without race correction, diagnoses of lung disease in Black people would have increased by 20 per cent (Moffett, Eneanya, Halpern & Weissman, 2021).
Overall, race correction means that Black people are systematically diagnosed late, or never diagnosed at all, for serious conditions from heart, kidney and lung diseases to cognitive impairment. It also means that Black people are systematically excluded from timely access to life-saving treatments like organ transplants and other surgeries.
How do health care providers decide who is "clinically Black?"
That's a good question, because there's no such thing. “Race” is not biological (Graves, 2015; Opara, Riddle-Jones & Allen, 2022). It is a social construct that is applied differently in different times and in different places (Roberts, 2011; Deyrup & Graves, 2022). In fact, scientists have shown us that people have more in common genetically across "racial" groups than within them (Graves, 2015). In addition, as is obvious, people classified as "Black" in the health care system come from a wide variety of ancestral and geographic backgrounds (Deyrup & Graves, 2022; Opara, Riddle-Jones & Allen, 2022).
Anti-Black racism has serious implications for health, and these negative consequences can be seen in health outcomes (Graves, 2015; Opara, Riddle-Jones & Allen, 2022). This does not mean, however, that Black people's body systems work differently than white people's body systems. They do not. This is why the "logic" of race correction is completely unscientific. Because it assumes that any differences in health outcomes between Black people and white people are based on fundamental differences in biology, and therefore should result in adjustments to health care treatment (Vyas, Eisenstein, & Jones, 2020).
If you are confused, we understand, because it makes no sense. The ideas that underpin race correction were never based on real science. For example, the race correction that is applied to lung function tests is based on the myth that Black people have naturally lower lung function than white people, an idea first expressed by slave owners and their apologists in the United States (Braun, 2014; Grubbs, 2020; Roberts, 2021). When researchers trace the assumptions that led to race corrections back to their origins, they routinely find no science, bad science, or nothing at all:
Some algorithm developers offer no explanation of why racial or ethnic differences might exist. Others offer rationales, but when these are traced to their origins, they lead to outdated, suspect racial science or to biased data (Vyas, Eisenstein & Jones, 2020).
More generally, the whole idea of biological “races” was invented to justify colonization and slavery:
The idea that human beings are naturally divided into biologically distinct races was developed in 18thcentury scientific justifications for European conquest, dispossession, and enslavement of other peoples. In the 19th century, US doctors promoted the racial concept of disease to legitimise slavery as based on innate distinctions rather than on white supremacy (Roberts, 2021).
These racist myths became embedded in medicine and health care, and are the basis of the race corrections that are still used today.
What are some examples of race correction?
Take a look at this Table for some of the different contexts in which race correction is applied (Vyas, Eisenstein & Jones, 2020). Remember while you look at it, however, that race correction is only applied systematically to Black people. There may be some contexts in which this is applied to other people, such as people referred to as "Hispanics" by the health care system in the US. Generally, however, race correction is only applied to Black people across body systems and on a regular basis. It's also important to remember that this is not an exhaustive list—there are many examples of race correction that are not included.
What is happening around race correction in the US and Canada?
Physicians in the US and their respective associations are finally making changes after decades of grassroots advocacy from Black patients, medical students, physicians, scientists and communities. For example, the National Kidney Foundation and the American Society of Nephrology have issued new guidelines that eliminate race correction from kidney function tests in the US. Unfortunately, the same is not true in Canada, where there has been no systematic action to address race correction.
Why is it important to end race correction in health care now?
Increasingly, health care systems are applying Artificial Intelligence (AI) to many different aspects of a person’s health care journey. AI is essentially a computer program that uses data to make decisions about a person’s course of treatment both inside and outside the hospital. This data includes things like current clinical guidelines and calculations. Unless race correction is removed from all health care processes, AI will take these processes, and make them automatic. At that point, it will be extremely difficult to detect and weed out anti-Black racism as it becomes embedded in layers of (often privately-owned) algorithms (Benjamin, 2019).
A second, urgent reason to end race correction now is the COVID-19 pandemic. “Long COVID” attacks many of the same body systems targeted by race correction. This means Black people will have a more difficult time getting appropriate diagnoses and treatment for long COVID. Race correction may also make it more difficult for Black people to access the benefits they are entitled to in the face of long COVID such as worker's compensation, or, in Canada, publicly funded pulmonary respiratory therapy.
What can patients do?
When Black people question what a health care provider is telling them about their own health, they can face severe consequences. Even with supportive health care providers, it can be difficult to figure out when and where race correction has been applied during your health care journey, and what this might mean for your treatment. Please contact us at [email protected] with your questions about race correction, and we will do our best to help. You will get a response from us within a week.
What can health care providers and organizations do?
Race correction has been with us for more than 150 years. Removing it is complex, and could have negative implications for patients in the short term if not done carefully. We will make sure you have the right tools to ensure that your patients, your department and your institution can end race correction responsibly and as soon as possible. Contact us at [email protected].
This primer was prepared in March 2022 and revised in March 2023 by Knowledge Translation specialist Amy Katz in conversation with content expert LLana James. It has been reviewed for accuracy by: Ijeoma Nnodim Opara, MD, Gbolahan Olarewaju, MSc, and Jo-Ann Osei-Twum, MSc, MPH. A huge thank you to Lundy Braun, PhD, Todd Coleman, PhD, Melanie Hoenig, MD, Patricia O’Campo, PhD, Vanessa Grubbs, MD, Andrea Deyrup, MD, Joseph Graves, PhD, Christopher McCudden, PhD, Rulan Parekh, MD, Vanessa Ferguson, Rania Belhadjhamida and Winnie Fu for their help in moving this project forward and for their contributions of time or resources. Knowledge Translation support was provided by the MAP Centre for Urban Health Solutions.
You can find more information on our website at: www.EndRaceCorrection.com
How to cite this document: Canada-US Coalition to End Race Correction in Health Care. (2023). Race correction in health care: a primer. www.EndRaceCorrection.com.
References
Benjamin, R. (2019). Race after Technology. Cambridge: Polity Press.
Braun, L. Spirometry, Measurement, and Race in the Nineteenth Century. Journal of the History of Medicine and Allied Sciences, 2005;60(2), 135-169. https://doi.org/10.1093/jhmas/jri021.
Braun, L. (2014). Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics. Minneapolis: University of Minnesota Press.
Deyrup, A., & Graves, J. L., Jr (2022). Racial Biology and Medical Misconceptions. New England Journal of Medicine, 386(6), 501–503. https://doi.org/10.1056/NEJMp2116224.
Graves, J.L. Great Is Their Sin: Biological Determinism in the Age of Genomics. The ANNALS of the American Academy of Political and Social Science, 2015;661(1):24-50. doi:10.1177/0002716215586558.
Grubbs, V. (2020). Precision in GFR Reporting: Let's Stop Playing the Race Card. Clinical Journal of the American Society of Nephrology, 15(8), 1201–1202. https://doi.org/10.2215/CJN.00690120.
Moffett, A.T., Eneanya, N.D., Halpern, S.D. Halpern & Weissman, G.E. (2021, Abstract). The Impact of Race Correction on the Interpretation of Pulmonary Function Testing Among Black Patients. American Journal of Respiratory and Critical Care Medicine, 203:A1030. https://doi.org/10.1164/ajrccm-conference.2021.203.1_MeetingAbstracts.A1030.
Opara, I.N., Riddle-Jones, L. & Allen, N. Modern Day Drapetomania: Calling Out Scientific Racism. Journal of General Internal Medicine, 37, 225–226 (2022). https://doi.org/10.1007/s11606-021-07163-z
Roberts, D.E. (2011). Fatal invention: how science, politics, and big business re-create race in the twenty-first century. New York: New Press.
Roberts, D.E. (2021). Abolish race correction. Lancet, 397(10268), 17–18. https://doi.org/10.1016/S0140-6736(20)32716-1.
Tsai, J. W., Cerdeña, J. P., Goedel, W. C., Asch, W. S., Grubbs, V., Mendu, M. L., & Kaufman, J. S. (2021). Evaluating the Impact and Rationale of Race-Specific Estimations of Kidney Function: Estimations from U.S. NHANES, 2015-2018. EClinicalMedicine, 42, 101197. https://doi.org/10.1016/j.eclinm.2021.101197.
Vyas, D. A., Eisenstein, L. G., & Jones, D. S. (2020). Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms. New England Journal of Medicine. 383(9), 874–882. https://doi.org/10.1056/NEJMms2004740.