Can historical racism in medicine help explain current racial differences in medical care?

Past instances of racism in medical care and the resulting distrust among Black Americans have been cited as factors in COVID-19 vaccine hesitancy. Rana Hogarth is a medical historian and a history professor at the University of Illinois Urbana-Champaign who teaches the history of Western medicine and African American history, and the author of “Medicalizing Blackness,” about medical beliefs in racial differences, some of which persist to the present. Hogarth is the adviser for a series of podcasts being created by the Science History Institute in Philadelphia to explore issues of racism in science and medicine. She talked with News Bureau arts and humanities editor Jodi Heckel.

How does understanding past racism in medical science help us understand contemporary issues in health care?

Race continues to exist as a proximate marker of bodily difference thanks to medicine and its allied scientific fields. Underlying assumptions about innate racial difference, including assumptions that Black people’s bodies are somehow peculiar in relation to whites, is a feature, not an aberration, in the production of medical knowledge. This means that it was not just a few bad historical actors, such as slavery apologists, who were responsible for racism in medicine. If we look at the historical record, we see that there was no shortage of competing theories about why Black people’s bodies were different from whites.

What is also troubling is that the assumption that they were different remained unquestioned. To assume that Blackness needs some kind of explanation is the problem. To assume innate differences – for example, thinking that there are “Black diseases,” as was the case with sickle cell anemia – is to reify race and give credence to the notion that Black people are different from whites on account of their race. In other words, race has been made “legible” on the body through the efforts of physicians and scientists, and that continues to cause problems for us now, because assumptions of innate racial difference continue to surface, often subtly, in medical practice and scientific research today.

What is an example of a past racist practice that affects health care today?

Medical devices like the spirometer have race correction built into them. The spirometer is a device used to measure the volume of air that can be exhaled after a deep breath. Spirometers use a race-based correction, or a so-called ethnic adjustment, which assumes a smaller lung capacity for Black people in comparison to whites. It was devised in the 19th century and used to measure “vitality.” Comparisons of lung capacities between Blacks and whites from the 19th-century United States showed Black people to have lower lung capacities, which was what was expected, as the idea that Black people had less robust lungs than whites was not uncommon.  Spirometers are still used today, and race correction is built into them. It is not as if a clinician maliciously corrects for race; rather, they assess what race the patient is and simply input that into the device.

Another instance of a seemingly “objective” tool used in medicine to assess physiological function is eGFR, or estimated glomerular filtration rate, which historically has been used to assess kidney function. It relies on age, gender, race, and creatinine – the waste that kidneys filter out of blood – to see how well a person’s kidneys are working. The issue is that the race component works as a binary of Black or not Black. If a patient falls into the category Black, they get points added to their kidney function score. That rationale for that has to do with old data from a few studies that suggested “higher average serum creatinine concentrations among Black people than among white people. Explanations that have been given for this finding include the notion that Black people release more creatinine into their blood at baseline, in part because they are reportedly more muscular,” according to an article in the New England Journal of Medicine.

The problem, of course, is who constitutes a Black person. Black is a socially constructed term, not a biological one, so using it to assess health is not doing the precision work that the clinician might think. It also is giving credence to the idea that race determines how one’s organ functions. To suggest that by sheer virtue of being designated in the social category of Black, one’s kidney function is different from a white person’s is problematic.

Are there factors other than historical racism affecting racial differences in health care that you hope the podcasts will explore?

I do hope that this podcast will demonstrate the ways in which the processes of making new knowledge and measuring and assessing health are not as objective as people think. There is an assumption that science and medicine are neutral fields framed by the progress narrative. The reality that we learn from the history of medicine, science, and public health is that the processes of creating knowledge, testing out ideas and treatments, and making diagnoses are framed by social contexts, including politics. The very research questions people ask, how they frame what they want to study and who they want to treat, and how they message information to distinctive groups of people is hardly objective.

Editor's note: For more from Rana Hogarth on race and science, watch her 2021 Dean's Distinguished Lecture, "Slavery, Science, and the Eugenic Impulse: Re-examining Charles B. Davenports Race-Crossing Studies."