Speaker: Justice in kidney health care requires intentional action
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KANSAS CITY, Missouri — To achieve true justice in kidney health care, clinicians must identify disparities in practice and develop a sustainable plan to address them, according to a presenter at the Annual Dialysis Conference.
In her keynote talk, Unini Odama, MD, MPH, recalled the fourth principle of the Hippocratic oath.
“We often forget about justice,” Odama, vice president of medical affairs at DaVita Kidney Care, said. “Health and health care must be part of the discussion of justice, because it's only the healthy that have the full opportunity for well-being and flourishing.”
The crux of justice and health equity consist of political, social and environmental determinants of health, Odama said. While justice in health care has improved, it was not long ago that the Life and Death Committee, also known as the God Panel, existed in Seattle to judge dialysis candidates on their sex, race and economic status. Until the approval by Congress in 1972 to fund treatment of kidney disease, patients who were men, white, economically stable and Protestant were prioritized to receive dialysis because of limited resources, Odama said.
This is no longer the case, but she pointed to a study conducted in 2021 showing that those who are most at risk for chronic kidney disease remain women and people who are not white.
Disparities in access
Disparities remain in providing patients with access to treatment of CKD, Odama said, including efforts to slow end-stage kidney disease progression, access to transplantation, offering alternative dialysis modalities and more.
“A common theme is that some members of our community, many of whose voices are often not heard — Blacks, Hispanics, American Indians and the poor — are consistently scoring lower [in access to care] than whites,” Odama said. “If nothing changes, nothing changes.”
Recently, the kidney community has addressed removal of the race coefficient in measuring eGFR. Although the American Society of Nephrology, the National Kidney Foundation and the Organ Procurement and Transplantation Network have adopted a race free eGFR equation, there are still many who have not, Odama said, citing a recent study in JAMA that showed 54% of labs are unsure of adopting the new measure.
Suppressed voices
Odama encouraged the attendees to examine their own implicit bias and said that it is necessary that everyone in the community works to prevent harm, or change will be elusive. Additionally, change must be intentionally designed to become as deep rooted as the inequities that existed before it, she said.
First, look for exploitation, marginalization, powerlessness, cultural imperialism and violence — the five faces of oppression and injustice, Odama said. When patients with these faces come to a dialysis center with kidney disease, listen to their struggles and needs, she said. Often times, the voices of these patients are not heard or elevated, she said.
Another helpful tool to identify suppressed voices is PROGRESS (Place Race Occupation Gender Religion Education Socioeconomic status Stigmatized mental health).
Once the voices of the oppressed are heard, action must be taken, Odama said, that addresses environmental racism (redlining and plantationocene) to help solve marginalization (housing, food and water), which will eventually improve violence (toxic hazards, air and digital redlining), and ultimately resulting in justice.
While health equity improves patient outcomes, provider experiences, patient experiences and reduces costs of care, “... we should not do health equity solely for the sake of lowering the cost of care,” Odama said, “because no human must be used as a means to an end.
“Will you intentionally adopt a kidney health justice framework and have measurable and transparent actions to achieve equitable health?” Odama said. “I hope the plan will include a comprehensive view of justice and be anchored firmly in ethical principles of justice, such as dignity, care, solidarity, virtue, capabilities and collaboration for the flourishing of all patients and all of humanity.”
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Odama U. Health disparities in chronic kidney disease. Presented at: Annual Dialysis Conference. March 3-6, 2023; Kansas City, Missouri.
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