The Racial Making of Health Disparities

Framing an Approach to Identifying Clinical, Diagnostic, and Legacy

Sources of Disparate Racial Outcomes and Persistent Health Inequity

Among Aged North Carolinians

An Abstract Prepared For Consideration By

The North Carolina Coalition on Aging Health Equity Committee

Black, Indigenous, and People of Color Work Group*

THE ORIGINS OF HEALTH DISPARITY AMONG OLDER BLACK NORTH CAROLINIANS ARE FOUND IN HISTORY, PUBLIC POLICY, AND CUSTOM

That racially based health disparities are endemic to the American healthcare system is no

longer seriously questioned. The American Medical Association, official voice of medical

practitioners in the United States, has declared racism to be a public health threat. North

Carolina, like other former Confederate states, has a deep-rooted heritage of slavery, racial

oppression, and state-sanctioned Jim Crow segregation woven into its social fabric. Historically North Carolina hospitals and medical providers routinely applied racist policies to Blacks. This history has deeply affected older Black North Carolinians born into a society where they were legally excluded from or received intentionally inferior treatment. By at least one recent measure North Carolina still ranks low in achieving racial and ethnic healthcare equity.

State sanctioned racial segregation impacted the health status of an entire generation of

African American boomers (Black North Carolinians over the age of 60), who spent their youth, adolescence, and young adulthood constrained by discriminatory laws enacted by the North Carolina Legislature and the state administrative apparatus. They also endured racist customs legally enforced to maintain African American subordination and exclusion from ordinary social interactions. Historic discrimination related to health factors may be one reason older African Americans are forced into retirement earlier than other groups, putting them at greater risk of an impoverished old age, forcing reliance on a range of social services and supports.

TWO EXAMPLES OF DISPARITY-PRODUCING CLINICAL PRACTICE

The physical and psychological toll of historic racism is imprinted on the health status of older Black North Carolinians, but the damage is layered. In addition to historic harm, this elderly cohort is subject to ongoing inequities generated by the contemporary healthcare system. This abstract will look at two specific examples of current clinical practice known to contribute to disparate outcomes between Blacks and Whites in the healthcare system. It will also consider a legacy inequity—one rooted in the long history of racial discrimination through separation— that will likely contribute to exacerbating disparities going forward, particularly among older Black North Carolinians, because of structural changes now taking place in the delivery of healthcare services. The two areas of clinical focus are:

1. Flawed artificial Intelligence products, diagnostic tools, and metrics that are known to

generate racially disparate outcomes and yet continue to be used in clinical settings.

2. Empirically observable outcomes that are clear statistical anomalies with no

scientific basis or rational explanation other than racial bias in treatment and provider

behavior.

The third area of consideration addresses geographic/demographic realities affecting the

delivery of healthcare services to racially segregated populations confined to under-invested

and under-resourced areas that—because of historic discrimination—lack the physical

infrastructure as well as institutional and business capacity needed to provide quality,

accessible, culturally compatible, community-based care.

3. This is an area where heightened future racial disparities can be predicted by the

decentralization of healthcare services delivery exemplified by home-and-community-

based trends such as home-based dialysis and Hospital at Home. Measures to limit

geographically determined inequities need to be taken now.

Evidence shows that these disparity-generating conditions are common throughout the entire healthcare system. Discovering the extent of their prevalence in North Carolina and what to do about them is the mission of the NCCOA Health Equity Committee. This abstract simply offers up some specific examples and guidance as to where inquiries might begin, interventions to be contemplated, and possible cures or best practices.

‘RACE NORMING’ AND ARTIFICIAL INTELLIGENCE

Flawed AI and Biased Diagnostic Metrics

Kidney analysis offers a clear case of AI-based diagnostic tools contributing to clinical decisions that drive racially disparate treatments and outcomes. Renal disease is the kind of ‘comorbidity’ older patients often contend with, so racial disparities in its diagnosis and treatment is highly relevant to both the NCCOA and this work group’s mission. This problem flows from two sources: bad ‘science’ and flawed technology based on that ‘science’. Algorithms used to measure kidney function assign a numerical value to test results that physicians use to make decisions about what treatments to pursue. Researchers using discredited, poorly designed studies that became standardized in the field, assigned an arbitrary ‘value’ to non-Whites that has been proven to make it more difficult for people of color to qualify for higher quality kidney treatments such as dialysis and especially, kidney transplants.

This disparity is so obvious and egregious that professional kidney associations have criticized testing based on these ‘race norming’ adjustments and called for discontinuing the practice. However, these algorithms and many others like them continue to be used. In fact, they permeate medical practice. Such a test was applied to this writer just a couple of months ago. When I posted a message in my electronic medical record about the flawed instrument’s use, my healthcare provider (a large, state-supported, university affiliated medical institution) replied that my result was indeed calculated using the biased test, which they hoped to discontinue soon because it was “no longer accurate and reliable.” Of course, the test was never accurate or reliable which is why it has been discredited. The continued use of this tool and many others is doing real harm every day to people of color—and particularly older African Americans—who suffer disproportionately from kidney disease.

NFL Chronic Traumatic Encephalopathy (CTE) Scandal

Non-empirical, non-algorithm-based diagnostic ‘methodologies’ can have the same

discriminatory result. The controversy over NFL concussions is one well-known example. An

arbitrary model of ‘cognitive capacity’ conjured by NFL hired ‘experts’ assigned higher baseline mental and intellectual values to White players than Black players that made it more difficult for Black players to qualify for brain-injury benefits than Whites with similar levels of disability. There was no scientific basis for the assumptions underlying these assigned racial values. A lawsuit by Black players and resulting public uproar forced the NFL to abandon this outright discriminatory practice that coincidentally saved team owners millions of dollars that would have been paid to Black players had their game-related cognitive decline been accurately measured.

Pulse Oximeters

A third example in this category can be found in the use of a medical device: pulse oximeters. These meters are fitted to a finger and measure the level of oxygen in a patient’s blood. The history of oximeter development is instructive regarding the fact that “Racial bias in pulse oximeters, or in any medical device, is never inevitable.” Equity requires intentionality. During the coronavirus pandemic when disproportionate numbers of non-White patients were suffering from acute respiratory distress, accurate measures of blood oxygen could make the difference between life and death because the numbers generated determined which patients got critical oxygen therapy and which didn’t. It was widely known years before the pandemic that inaccurately calibrated oximeters produced incorrect readings on dark skin—readings that disadvantaged the dark-skinned patient from a treatment standpoint. But they continued to be used throughout the pandemic and they continue in use today.

IMPUTED RACISM BASED ON DISPARATE OUTCOMES

Unlike AI, empirical metrics, and even devices that can claim to be derived from science-based research, the sources of some healthcare outcomes track to subjective factors and must be inferred from observable, objective evidence. This is the case for example with wildly disparate rates of limb amputation between Black and White patients. Black diabetics have limbs amputated at three times the rate of White diabetics, although there appears to be no scientific evidence that disease progression differs based on the race of the patient. The most obvious explanation for this disparity is that providers, who are overwhelmingly White simply devote less patience and care to the treatment of their Black diabetic patients, choosing amputation as an expedient, less troublesome, and perhaps more profitable way to resolve cases. It is notable that this practice appears to be concentrated in the former Confederate, slave-holding states of the South.

LEGACY CONDITIONS IN SEGREGATED COMMUNITIES

More than half a century after the repeal of legal segregation, geographic racial separation is

still the dominant characteristic of residential life in the United States. This is true for both

urban and suburban locations. There is not an abundance of research on bias in the

administrative aspect of healthcare decision making in North Carolina, but what evidence there is does not inspire confidence. In addition, “Nationwide, over 80% of low-income Black people and three-quarters of low-income Latino or Hispanic people live in communities that meet the federal statutory definition for ‘low-income’ communities.” Physical segregation due to a combination of race and income is a powerful factor limiting access to quality healthcare, especially by older African Americans whose lives have been more strongly impacted by the legacy of Jim Crow segregation. Even access to coverage under Medicare does not protect older Black patients from significant disparities in treatment and health outcomes. Both historically rooted and on-going residential segregation restrict opportunities for institution building and capacity development, as well as undermine the creation of a native healthcare-based business infrastructure to serve those communities.

4. Of the nation’s more than 900,000 health care and social assistance companies,

which include home health and other health services, roughly 35,000 — or fewer

than 4% — are Black-owned, according to data from the U.S. Census Bureau.

As a consequence highly segregated, resource poor African American communities—where

most of the Black population lives—are greatly underserved by healthcare providers, business enterprises, and service organizations. Rapid aging of the population is driving rapid decentralization of healthcare delivery. Increasingly the system is being restructured around a home-and-community-based model of care delivery. In a pluralistic society such as the United States currently is, this model of care delivery cannot achieve equity in the absence of institutional capacity that is native and culturally appropriate to the diverse communities being served. In other words, there can be no healthcare equity without ownership. The coronavirus pandemic offered a likely preview of what current trends portend. Without a shift in the physical location, ownership, and control of healthcare assets, disinvested African American communities, lacking the infrastructure to support home-and-community-based healthcare delivery, stand to suffer even greater health inequities in coming years.

SUMMARY

There are obvious, well-documented clinical tools, protocols, and practices that as a matter of course, generate racial disparities in medical treatment and outcomes in the normal operation of the healthcare system. These problems are not anomalies; they are extensive and pervasive, endemic to the system. This abstract has presented just a few examples: the discredited practice of ‘race norming’, the inequitable impact of some medical devices, and ‘subjective racism’ as indicated by wildly disparate amputation data for Black and White diabetics, especially in the South.

Separately—without irony—it is obvious that the state’s ineradicable history of residential

segregation creates a problematic landscape for the decentralization of healthcare services now underway, both through the application of technology and restructuring toward an

entrepreneurial home-and-community-based care model. The coronavirus pandemic has

generated abundant evidence of this challenge which is a tribute to the tenacity of racially

driven economic discrimination and disinvestment.

It is hoped that these examples and supporting source material provide a useful starting point for the BIPOC work group, the NCCOA Health Equity Committee, and the NCCOA board to deliberate policy recommendations that address the problems. From the constituent lens of the NCCOA and this committee’s specific charge however, it is evident that the generation of Black North Carolinians now aged 60 and above, have suffered specific healthcare harms due to the state’s support of Jim Crow segregation and adoption of explicitly racist public health policies during the most vulnerable formative years of their lives. The committee should consider the cohort of native Black North Carolinians over 60 as a special class in the design of future statewide healthcare policy. Such a designation would place the discussion of health disparities in its proper historical, social, and cultural context by making the important distinction between the legal, state-sponsored healthcare inequality of the recent past and ongoing structural inequalities of the present time.

*Some of the sources in this paper are paywalled and require a subscription to access.

As a Black person who is of African American descent, I use the two terms interchangeably.

© Harold M. Barnette, 2022. All rights reserved.