The Philadelphia Inquirer has been covering health inequities and potential remedial solutions for years. One recent story described how a new policy requires that patients’ kidney function be estimated without taking their race into account, highlighting the case of a Black woman whose kidney transplant was delayed five years because the medical center relied on an outdated race-based formula to determine her kidney function, making the woman seem healthier than she really was.
In fact, hospitals nationwide have notified more than 3,700 Black people with kidney disease awaiting transplants of the error caused by an unnecessary modifier in calculating their estimated glomerular filtration rate (eGFR). By the end of this year, hospitals must go through their lists and recalculate the kidney function of all Black patients using a race-neutral formula. Transplant programs must review their lists of waitlisted candidates and credit those who may have been impacted by the use of the race-based calculation.
Another article in the Inquirer covered the failure of the Mütter Museum to repatriate the remains of Native Americans to their tribal descendants, as required by the Native American Graves Protection and Repatriation Act of 1990. The world-famous Mütter museum in Philadelphia, Pennsylvania, houses many rare and one-of-a-kind medical artifacts and anomalies ostensibly used for educational purposes. But the museum has recently been caught in the crosshairs of the Act and uncertainty surrounding best practices for the ethical and respectful display of human remains. The remains of 49 (86 percent) of 57 Native Americans housed by the Mütter museum have not yet been made available for return to tribes, according to ProPublica’s repatriation database.
The idea of remediating wrongs and injustices to racial and ethnic minorities, including indigenous peoples, dates back to the bible. Deuteronomy 15:12-15 states: “And when you release [Hebrew slaves], do not send them away empty-handed. Supply them liberally from your flock, your threshing floor, and your winepress.”
In John Locke’s Second Treatise of Government (1689), he wrote, “… he who hath received any damage has, besides the right of punishment common to him with other men, a particular right to seek reparation …”
Ta-Nehisi Coates made a compelling case for reparation in his 2014 award-winning essay in The Atlantic. Coates wrote: “Two hundred fifty years of slavery. Ninety years of Jim Crow. Sixty years of separate but equal. Thirty-five years of racist housing policy. America will never be whole until we reckon with our compounding moral debts.”
Jesse McCarthy, another powerful Black writer and critic on race and culture, recently published the book Who Will Pay Reparations on My Soul, borrowing the title from Gil Scott-Heron’s classic rap/song of the same title, which appeared on his 1970 debut album “A New Black Poet – Small Talk at 125th and Lenox.” McCarthy. a Harvard professor, addresses the question of reparations by arguing that true progress will not come until Americans remake their institutions in the service of true equality.
Scott-Heron’s version of reparations, however, clearly focuses on Native Americans, more than 50,000 of whom were dislocated from southeastern U.S. states to present-day Oklahoma, many dying along the Trail of Tears and while crossing the Mississippi River between 1830 and 1850 in forced compliance with the Indian Removal Act.
What about the red man
Who met you at the coast?
You never dig sharing;
Always had to have the most.
And what about Mississippi,
The boundary of old?
Tell me,
Who’ll pay reparations on my soul?
Scott-Heron’s song remains as relevant, angry, and unanswered as ever — as we head into an election campaign where race, gender, and voting inequities — among many other inequalities – take center stage. And, oh yes, let’s not forget health disparities.
Medical reparations are long overdue for Blacks, Latinxs, Native Americans, Native Hawaiians, Native Alaskans, the LGBTQIA+ community, and many other marginalized groups who have been targets of bias and discrimination by the medical profession. In my specialty of psychiatry alone, racial and ethnic bias in diagnosis is a huge problem affecting clinical decision-making and treatment planning.
Making reparations goes far beyond calling out one specialty, however. The impact of racism and bias found within health care as a whole, in terms of differential morbidity and mortality, is more than enough to justify reparations for injuries and psychological harm inflicted upon patients. Historical examples include not only biased diagnoses and algorithms flawed by “adjustments” for race but also the widespread misuse of biological concepts of race in research and education.
From cardiology to nephrology to obstetrics to urology, race has been used in algorithms to determine organ function, although there are often no racial or ethnic differences that inherently exist. Race correction actually reinforces long-established patient hierarchies in medicine. As the Inquirer article points out, correcting for race in the assessment of kidney function masks the complexity of the lived experience of societal neglect that damages health. The reality is that medicine and its technological foundations have been deeply intertwined with the histories and legacies of slavery, segregation, class oppression, and indigenous genocide.
Although reparations typically refer to financial compensation, reparative processes can also be embedded in policies directly or indirectly related to payments — for example, expanding Medicaid coverage, increasing reimbursement for diseases more prevalent in minority populations, funding community-driven interventions to address social determinants of health, and mandating community leaders on hospital governance boards and medical school admission committees. Equally important is the project of making medicine a more antiracist field.
In summary: “So long as policies seek to rectify past injustices of specific populations as well as remedy current inequitable outcomes, regardless of whether there is a financial component, they are reparative.”
Toni Martin, MD, an African American primary care physician with a multiethnic practice, was largely responsible for highlighting the fatal flaw behind the “adjustment factor” previously used to inflate kidney function (eGFR) in African Americans. She wrote “that even her patients became suspicious of the methodology, “born of years of experience with separate and unequal.”
For example, Martin said, “Many of my patients and I are old enough to remember the days when our dense bones were proposed as the reason so few of us learned to swim. And yes, our bones, on average, are denser. But we couldn’t swim, not because of our dense bones, but because the pools were segregated.”
Martin further noted, “Some characteristics may be slightly different from race to race, on average, but generally, the average differences between two racial groups are smaller than the differences within a group.” She implored the National Kidney Foundation to interpret all laboratory tests in a clinical context irrespective of race and reminded her colleagues “that the clinical context is always more important than a single number.”
“That’s our job as physicians,” Martin concluded. In other words, to continue to push to remove racial bias from medical practice while paying reparations to our patients’ souls.
Arthur Lazarus is a psychiatrist.
