Racism-Conscious Praxis: A Framework to Materialize Anti-Oppression in Medicine, Public Health, and Health Policy

This article refers to:

Materialized Oppression in Medical Tools and Technologies

Liao and Carbonell explore how oppressive medical technologies constitute materiality insofar as they reflect past oppression, embody oppression in the present day, and carry oppression into the future (Liao and Carbonell 2023). In the same vein, we advocate that solutions which materialize anti-oppression should redress past oppression, advance antiracist care in the present day, and carry equitable outcomes forward. Indeed, just as racism in medical tools might materialize oppression, anti-racist interventions regarding the same technologies can (and should) materialize anti-oppression.

In Pedagogy of the Oppressed, Freire defines praxis as “reflection and action directed at the structures to be transformed” (Freire 1972). Herein, to translate Liao and Carbonell’s aggregated systems approach into theory-driven action, we propose racism-conscious praxis by coalescing their framework with seminal works on race-conscious medicine (Cerdeña, Plaisime, and Tsai 2020) and Public Health Critical Race Praxis (PHCRP) (Ford and Airhihenbuwa 2010).

First, we highlight several interventions related to the estimated glomerular filtration rate (eGFR) algorithm in nephrology as examples of materialized anti-oppression at the clinician-patient, community, health system, and policy levels. Given that race-based clinical algorithms represent only one of many antiquated medical tools which require redress, we contextualize potential approaches within broader legal and ethical challenges. Finally, we explicitly distinguish racism-conscious praxis from race-explicit, race-based, and race-neutral (“colorblind”) interventions to elucidate pragmatic paths forward. Our operationalization of race-conscious medicine and PHCRP can be leveraged as racism-consciousness when designing, deploying, evaluating, and justifying equity-focused interventions.

ENDING RACE-BASED MEDICINE IN CHRONIC KIDNEY DISEASE

Chronic kidney disease (CKD) is defined by renal abnormalities or dysfunction present for >3 months. The diagnosis and severity of CKD are established through the estimation of kidney filtration by eGFR equations. These equations incorporate demographic characteristics (sex, race) and biological markers (creatine and/or cystatin C) to predict one’s kidney function. Until 2021, the two most widely used eGFR equations required a “Black” vs. “Non-Black” binary variable, meaning that one’s race alone could lead to clinically significant differences in eGFR. This “race correction” inaccurately essentialized race as conferring biological or genetic traits, obfuscated the true causal origins of racial disparities driven by multi-level racism, and crudely categorized heterogeneous racial groups within a binary, forcing patients and clinicians alike to adhere to a flawed assumption that the kidneys of Black individuals function differently than those of all other populations. (Cerdeña, Plaisime, and Tsai 2020; Yearby 2021; Heffron et al. 2022). Moreover, by systematically underpredicting the severity of CKD among Black patients, the race-based eGFR directly exacerbated inequities across the care continuum—from early diagnosis to appropriate disease staging to referrals for nephrology specialty care and kidney transplantation (Eneanya, Yang, and Reese 2019).

In 2021, after public outcry, the National Kidney Foundation and American Society of Nephrology released new recommendations supporting a new, more accurate eGFR equation refit without a “race” variable (Inker et al. 2021). The Organ Procurement and Transplantation Network (OPTN) and U.S. Pathology and Laboratory Society Leadership followed suit by recommending transplant hospitals and clinical laboratories only use race-free equations.

MATERIALIZING ANTI-OPPRESSION IN CLINICAL ALGORITHMS

The removal of race from eGFR marked an important first step, but cannot alone redress the harms caused by decades of race-based medicine (Heffron et al. 2022). Cystatin C availability and eGFR reporting in clinical laboratories remain tremendously heterogeneous nationwide, with some even relying on long-outdated equations generated in 1999 (Miller et al. 2022). Moreover, many clinicians may not yet recognize how intentional implementation of race-free eGFR could help redirect eligible patients to specialty kidney care and resources.

Fortunately, work has not stopped at modifying the eGFR algorithm alone. In October 2021, the New York City Board of Health passed a resolution declaring racism a public health crisis and calling for a strategic, citywide movement to redress structural and institutional racism. Soon after, the city’s health department convened the Coalition to End Racism in Clinical Algorithms (CERCA) in partnership with numerous stakeholders, including representatives from eleven of New York’s largest hospital systems (Khazanchi and Morse 2022). The primary objectives and commitments of CERCA member institutions were to end race adjustment in multiple clinical algorithms, evaluate the impact of using race-free algorithms on inequities in patient-centered outcomes, and meaningfully engage impacted patients to determine appropriate restitutory steps.

The praxis of CERCA was grounded in the Healing ARC paradigm and emphasizes reparative justice. The Healing ARC care delivery model pushes institutions to acknowledge how racism contributed to an inequitable outcome, redress the harm through restitution for marginalized populations, and facilitate closure through participatory reconciliation (Wispelwey et al. 2022). Within CERCA, this manifests through a strategic emphasis on patient and community engagement. Rather than solely relying on a one-size-fits-all implementation strategy to design and evaluate algorithm changes, the initiative motivates health systems to directly partner with their own patient populations to devise unique paths forward. As Liao and Carbonell might point out, this emphasis is appropriately responsive to the distinction between a biased technology and an oppressive one; a community-engaged approach better addresses the sociohistorical context within which racist algorithms still exist.

CERCA’s hyperlocal and community-participatory strategy is not the only example of a restorative justice approach seeking to rectify the harms of racist medical tools. In December 2022, for instance, OPTN called upon all U.S. transplant centers to identify Black kidney transplantation candidates whose waitlist initiation may have been delayed due to inappropriate staging, determine the time at which they would have been listed with the new race-free equations, and retroactively modify their accrued waiting time (Organ Procurement and Transplantation Network 2022 Mohottige, Purnell, and Boulware 2023). Furthermore, the U.S. Department of Health and Human Services, U.S. House Ways and Means Committee, and Agency for Healthcare Research and Quality have each launched national efforts to address the impact of clinical algorithms on health disparities. This included adding a proposed clause (§ 92.210) to Section 1557 of the Patient Protection and Affordable Care Act, which would “explicitly prohibit discrimination in the use of clinical algorithms to support decision-making in covered health programs and activities” (Khazanchi, Tsai, et al. 2022). The root causes of racism in medical tools and technologies are fundamentally structural, and the downstream disparate impacts should arguably be prohibited by civil rights law (Primus 2003; Bridges 2021; Khazanchi, Tsai, et al. 2022; Han, Tsai, and Khazanchi 2023). As such, we agree that prioritizing structural and regulatory interventions—in tandem with patient- and community-centered efforts—will enhance the likelihood of achieving materially meaningful outcomes (Liao and Carbonell 2023).

LEGAL CONSIDERATIONS AND PRAGMATIC PATHS FORWARD

Despite the aforementioned successes, the practicalities of racism-conscious praxis continue to be shaped by nuanced legal and ethical debates. For example, due to the disproportionate impact of COVID-19 on minoritized populations, several private health systems, state health departments, and even the U.S. Food and Drug Administration recommended considering race to address the impacts of racism when allocating scarce resources (Khazanchi, Marcelin, et al. 2022). This guidance was met with politicized attacks and litigation, motivating some hospital systems and states to reverse course. Moreover, the U.S. Supreme Court is currently considering cases on affirmative action that will likely shift judicial interpretations of “narrow tailoring” and “compelling government interest” standards that previously upheld race-explicit interventions in higher education (Primus 2003). Indeed, the Roberts Court’s ongoing reinterpretation of the Equal Protection Clause and post-Civil Rights Era laws risks eradicating constitutionally justified interventions to redress structural racism (Bridges 2021). The legal tenuousness of race-explicit approaches will be felt within and beyond the medical field. Nevertheless, the federal government and healthcare institutions have legal obligations to ensure minoritized populations receive equal access to health care and treatment (Yearby, Clark, and Figueroa 2022).

If the primary objective of an intervention is to materialize anti-oppression, we advocate that multiple avenues for action remain. Settled and pending litigation regarding race-explicit clinical algorithms, diagnostic tools, and resource allocation schemes must explicitly note the historical and modern-day inequities facing minoritized populations and the need for racism-conscious redress (Ashworth, Soled, and Morse 2021; Yearby, Clark, and Figueroa 2022; Han, Tsai, and Khazanchi 2023). Though threats of litigation may hinder the practicality of race-explicit interventions, de facto approaches to prioritize allocating resources to marginalized groups, such as small areal unit deprivation indices which reasonably proxy downstream impacts of structural racism, remain both legally feasible (Persad 2021) and publicly well-supported (Schmidt et al. 2022). We name these ethical and legal tensions because they are integral to why racism-conscious praxis must be conceptualized more broadly than race-explicit design alone. If an intervention demonstrates a materially anti-oppressive outcome by still explicitly targeting mechanisms of oppression like structural racism, a de facto redress approach is both ethically and legally well-justified.

CONCLUSION

Racism-conscious praxis seeks to rectify historical and modern-day inequities by restoring care that has been historically withheld, with or without the requirement of a race-explicit mechanism. In contrast, race-based interventions reify racial essentialism, which manifests in the form of unequal treatment and can cause unjust prioritization of historically advantaged groups (Cerdeña, Plaisime, and Tsai 2020; Yearby 2021). Moreover, the “colorblind” lens of race-neutral interventions has never resulted in equal access to health care for marginalized populations (Khazanchi, Marcelin, et al. 2022; Yearby, Clark, and Figueroa 2022). Colorblindness is, at its core, “fair in form, but discriminatory in operation” (Griggs v. Duke Power Company 1971) and elides the structural nature of disparate impact (Primus 2003; Bridges 2021; Delaney, Essien, and Navathe 2021). With these important distinctions in mind, our definition of racism-conscious praxis pragmatically coalesces opportunities to redress structural oppression throughout the design, implementation, and evaluation of care delivery, health systems, and policy interventions.

Medical ethicists must continue to join interdisciplinary scholars, clinicians, and legal advocates in translating justice-oriented theories, like those discussed herein (Ford and Airhihenbuwa 2010; Cerdeña, Plaisime, and Tsai 2020; Liao and Carbonell 2023), into praxis. In highlighting exemplary interventions to materialize anti-oppression in medicine, we concretize how racism-conscious praxis can promote material restitution within clinical decision-making, scarce resource allocation, policy intervention, and beyond.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.