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What Kids and Kidneys Can Teach Pediatricians About Racism in America

January 5, 2021
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O.N. Ray Bignall II, MD, FAAP, director of Kidney Health Advocacy and Community Engagement, explores how "race modifiers," structural racism and health disparities are perpetuated in kidney care for kids, highlighting important areas primed for change.

Have we finally reached the point where the consciousness of our communities has been awakened to the reality of racial injustice in America? This is a question I have raised in the many presentations and interviews I have had the opportunity to do this year.

2020 has brought to light our vulnerability to a global pandemic — SARS-CoV-2. And the national epidemic of racism in America.

Racism works in tandem with systems of inequality that permeate nearly every aspect of American life.

In health-related research, we’re all too familiar with health disparities related to race. Structural inequalities and racism create health disparities — inequitable differences that are systemic and, most importantly, avoidable. Health disparities are differences that don’t have to exist.

A key component of the discussion on health disparities is that there exists no biological basis for race. Race is a social construct. Yet the mark of race, racism and systemic inequality are found throughout research and medicine.

One of the most common uses of race in medicine is the presence of the “race modifier” — for example, in adult estimating equations for glomerular filtration rate (GFR).

While race is not a factor in the estimate of GFR in children, many of pediatricians and pediatric nephrologists see adolescent and young adult patients for whom the use of an adult estimate equation would be considered a reasonable alternative.

For years, two of the most popular equations have used a “race modifier” to account for statistically significant differences in GFR when the study population was divided by race into “Black” and “non-Black” cohorts. But if race is a social construct, how can it be consistently and appropriately applied to eGFR? How was it measured? Is genetic variation taken into account? What about the races of other participants? This methodology raises more questions than answers.

And, in fact, many nephrologists are beginning to rethink this methodology.

Dr. Amaka Eneanya, a nephrologist and researcher at the University of Pennsylvania, and her colleagues note that using the race modifier in the estimate of GFR can result in a significantly higher GFR for African American patients that may have negative, unintended consequences, including exacerbated disparities in access to chronic kidney disease (CKD) referral, transplant wait list and dialysis initiation.

Put simply: race is real, but as a social construct, and its inconsistent and biased use in drawing biological conclusions is incredibly fraught, and as careful pediatricians who seek to “first do no harm,” it should give us pause.

This is just one example of many where health disparities are perpetuated by structural inequity and racism.

Quinn Capers, IV, MD, professor of Medicine and vice dean of Faculty at The Ohio State University College of Medicine, put it succinctly in a tweet this summer following the killing of George Floyd by a white police officer: “We rack our brains looking for genetic reasons African Americans have so much high blood pressure, stroke and heart attack. To live in an environment where [racism] is excused is a 24-7 stress on your vasculature. We must teach this in medical school and create physician-activists.”

Likewise, Dereck Paul, MS, a medical student at UC San Francisco, tweets that “When clinical medicine can’t do any more to help your patient, but society can, social advocacy becomes the standard of care.”

Our world has been dramatically changed because of the twin pandemics of COVID-19 and racism. And we will have an opportunity to vaccinate ourselves against SARS-CoV-2. The question remains, will we also take the steps necessary to inoculate ourselves against racial injustice in America?