When Racial Bias Makes Healthcare Sick

August 3, 2020

At any given time, there are 200+ actual sledgehammers present in the Heartbeat office. To celebrate their first year on the team, each HB’er receives their very own sledge—a nod to our daily pursuit of tearing down tiresome healthcare marketing. To determine what is built in its place, we often turn to outside industries, cultural forces, and personal experiences. We eagerly share them with one another, and now we’re sharing them with you. Clear the way—here comes The Sledgehammer.

Imagine you are having your kidney function tested. (Yeah, yeah… just go with us on this!)

You’re a Black patient and after your doctor’s appointment you meet up with a white friend for lunch. You start discussing your kidney function test results—sharing exciting stats like creatinine levels.

Funny enough, your white friend mentions they had the exact same levels when they took the test a couple months back. Yet, your final overall score for the test is higher than your friend’s.

They also mention they were prescribed medication and you were told just to come back in a year for another test.

“Hmm, that’s weird. Why would that be?” you wonder. Maybe your friend has other complications or a family history of kidney failure. Maybe he advocated for more aggressive care. Or maybe, your suspicious side thinks, he got the medication and you didn’t because he is white and you are Black.

Sadly, your suspicion might be right.

You see, the assessment calculator commonly used by physicians to evaluate kidney function actually factors certain demographic info into its formula, including race. This results in slight but meaningful inflations of scores for Black patients.

Seems like it might be a good thing, since a higher score indicates more favorable kidney function. However, a lower score is what triggers additional care measures—medication, dialysis, or even higher priority for a kidney transplant. So, your white friend—with the same creatinine levels—gets a lower score, more attention, and earlier intervention.

In short, he gets more preventative treatment, even though Black patients:

• Are more likely to have the conditions that are precursors to chronic kidney disease, like diabetes and high blood pressure¹
• Are less likely to receive a kidney transplant^1,2
• Are three times more likely to suffer from kidney failure¹

Kidney disease is not the only health condition that is evaluated differently for Black patients. A surprising amount of healthcare decision-making is based on similarities within demographic groups. Just think about all the times you’ve heard about women being more likely to have a condition, or populations from a certain region of the world being genetically predisposed to having a disease.

And yes, clusters of biological similarities do exist in racially similar groups—these can develop over time due to environmental or societal reasonings (think “food deserts” that limit nutritious, affordable food options) or can be attributed to geographical origins (like the prevalence of the trait for sickle cell anemia in sub-Saharan African populations).

Yet, because it can be complex and time-consuming to uncover and then constantly assess these clustered differences, we have slipped into a sloppy shortcut of “race.” And that’s where these types of medical calculators truly undermine healthcare.

Because race, itself, isn’t biological; it’s social. There is no absolute difference between the makeup of all Black people and all white people (or any other racial or ethnic groups).

A patient may check “African American” on their medical forms, but that checkbox is actually asking them how they identify socially. It fails to deliver on the factors that could yield health differences and thus the actions that follow checking that box can incorrectly shape one’s medical past, present, and future.

In the case of kidney disease, there are surely other ways to further evaluate Black patients—additional testing, more frequent screening for those at risk, or leveraging big data and AI to more accurately identify meaningful influential factors. Like eschewing any shortcut, such options require more time and energy to get to the destination: a more conclusive answer. As a positive sign of progress, health systems in Seattle and Boston have recently dropped race from their own testing formulas.

Institutionalized racial biases aren’t limited to checkboxes and calculators in our healthcare systems, however. There are huge disparities in the quality of care across race and class. Clinical trials are overwhelmingly conducted with white patients. In many diseases (e.g. Alzheimer’s disease), we have not gathered the data to draw scientific conclusions about treating racial minorities or other marginalized populations. Exacerbating this reality is the horrific history of medical experimentation on vulnerable populations that seeds distrust of both clinical trials and the medical establishment.

The consequences are grave—people of color receive worse healthcare than white people and, as a result, see higher mortality rates in a multitude of categories.

As healthcare marketers, we may not have the power to directly alter diagnostic tools or trial design, but we can influence our audiences through our work. We can model greater inclusion in our workplaces and our creative communications and, by doing so, promote broader consideration in all facets of healthcare decision-making.

We have the power to imagine a better, more equitable world and the talent to make it manifest, one initiative at a time. Initiatives we can—and should—engage today:

• • Customer insights: Research usually involves a collection of consumer voices—a focus group, a social media analysis, a survey, a conversation recorded in a doctor’s office. But what kinds of biases were involved in the choice of whose voice is included? Only people who could afford the time away from work or childcare to attend a focus group? Only people with broadband or smartphones who can be frequently active on social media? Only people who are insured and can afford to see a specialist?

• • Representation: Who and how are patients showing up in our work? It’s not just about skin color (diversity), but about context, identity, and experience (inclusion). You may be thinking, “But my brand is for a condition that disproportionately affects white people.” We’d counter that with, “Did you know that your consumers of all races want to see diversity in their advertising and are more trusting of brands who commit to this?”

• KOL selection: It’s no secret that there are race and gender disparities among folks who work in science and medicine today. Many life science brands and companies partner with KOLs—the folks at the top of their field. How much of the power structure that perpetuates this imbalance is reflected (or reinforced) in which KOLs get “airtime” with pharma companies or Congresses? Diversify your list of advisors and speakers by sharing the research and voices of minority (and female) HCPs in the field.

To borrow the words of the recently and dearly departed Rep. John Lewis: “There comes a time when you have to say something. You have to make a little noise.”

Let’s make some noise.

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1 https://www.kidney.org/news/newsroom/ factsheets/African-Americans-and-CKD
2 https://www.ncbi.nlm.nih.gov/ pmc/articles-/PMC4929989/