Nephrology community must address ‘unconscious bias’ to promote anti-racist kidney care
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A speaker at ASN Kidney Week argued that it is necessary to address systemic racism, implicit bias and structural oppression if health equity is to be achieved in the United States.
“Every last one of us harbors bias,” Keisha Gibson, MD, MPH, FASN, of the North Carolina Kidney Center, said in her virtual presentation. “It is often unconscious and doesn’t necessarily align with intent.”
To illustrate this point, Gibson told the audience about an experience she had with her aunt who was diagnosed with kidney disease. As a nephrologist, Gibson accompanied her aunt to a doctor’s appointment and suggested her aunt be placed on home dialysis, an option not initially provided to her. Gibson later thought about why no physician had discussed transplantation during the 10 years in which her aunt had the disease and also wondered if she had not been at this appointment whether the nephrologist would have been amenable to the idea of home dialysis.
“It was not lost on me that her nephrologist was an older white male and my aunt was an African-American woman with a high school education, modest income [and] living in a rural town,” she said, noting that while she did not believe the nephrologist wanted her aunt to have a poor quality of life, she “absolutely” thought he made “automatic assumptions that [her aunt] would not be capable of managing home dialysis” based on the aforementioned factors.
Shifting from the personal, Gibson stressed that race is a social construct, a fact she said was made clear by Dr. Francis Collins – who she called “arguably the mastermind behind the Human Genome Project” – when he discovered humans are 99.9% identical in genetic makeup; the remaining 0.1% cannot be explained by the arbitrary designation of race, she argued.
“Yet, despite this, we continue to conduct, to publish, and to fund studies that apply significant weight on what is likely a minimal biological influence and consistently fail to address the impact of what this social construct enables,” Gibson said. “And that is racism and bias.”
According to Gibson, the first step to implementing policies that promote anti-racist kidney care is to think about how the science is being conducted that informs clinical practice.
“This tendency to use race as a biologic term is not only pervasive in health disparity studies but has also permeated several clinical algorithms,” she elaborated. “Several of the current hot button debates – including race in GFR estimations and kidney transplant allocation – are unfortunately modeling for the medical community at large our need to interrogate the origins of the science regarding this practice.”
Gibson added that the COVID-19 pandemic has highlighted the need to address inequalities in public policy, noting that Black, Latinx, immigrant and indigenous communities face higher rates of infection and mortality likely due to a higher prevalence of living in multigenerational homes, a higher likelihood of having “public-facing jobs” without adequate personal protective equipment and a lack of benefits, such as sick leave.
She contended that while these factors are not unique to nephrology patients, they have a strong impact as individuals with CKD are more likely to be of “minority communities.”
“As health care professionals, we have a responsibility to advocate for policies that will directly address social and structural factors that affect health, like transportation, housing, food insecurity and the digital divide,” Gibson concluded. “If we are bold and deliberate in our actions to push these policies, we may find ourselves closer to solving race-based health disparities rather than simply describing them.”
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Gibson K. Implementing antiracist kidney care. Presented at: ASN Kidney Week. Oct. 22-25, 2020 (virtual meeting).
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