Race and Ethnicity in Pulmonary Function Test Interpretation: An Official American Thoracic Society Statement.

Current American Thoracic Society (ATS) standards promote the use of race and ethnicity-specific reference equations for pulmonary function test (PFT) interpretation. There is rising concern that the use of race and ethnicity in PFT interpretation contributes to a false view of fixed differences between races and may mask the effects of differential exposures. This use of race and ethnicity may contribute to health disparities by norming differences in pulmonary function. In the United States and globally, race serves as a social construct that is based on appearance and reflects social values, structures, and practices. Classification of people into racial and ethnic groups differs geographically and temporally. These considerations challenge the notion that racial and ethnic categories have biological meaning and question the use of race in PFT interpretation. The ATS convened a diverse group of clinicians and investigators for a workshop in 2021 to evaluate the use of race and ethnicity in PFT interpretation. Review of evidence published since then that challenges current practice and continued discussion concluded with a recommendation to replace race and ethnicity-specific equations with race-neutral average reference equations, which must be accompanied with a broader re-evaluation of how PFTs are used to make clinical, employment, and insurance decisions. There was also a call to engage key stakeholders not represented in this workshop and a statement of caution regarding the uncertain effects and potential harms of this change. Other recommendations include continued research and education to understand the impact of the change, to improve the evidence for the use of PFTs in general, and to identify modifiable risk factors for reduced pulmonary function.

Race/Ethnicity in Medical Education: An Analysis of a Question Bank for Step 1 of the United States Medical Licensing Examination.

Phenomenon: There is growing concern over racial/ethnic bias in clinical care, yet how best to reduce bias remains challenging, in part because the sources of bias in medical education are poorly understood. One possible source is the routinized use of race/ethnicity in lectures, assessment, and preparatory materials, including question banks for licensing examinations. Because students worldwide use question banks to prepare for the United States Medical Licensing Examination, we examined how race/ethnicity was used in one of the most commonly recommended question banks. APPROACH: We analyzed the use of race/ethnicity in all 2,211 questions in a question bank for Step 1 of the United States Medical Licensing Examination for the following: the frequency of mentions of racial/ethnic groups, whether the use of race/ethnicity was merely descriptive or was central to any part of the question, and whether the question associated race/ethnicity with genetic difference. FINDINGS: In sum, 455 of the 2,011 (20.6%) of the questions in the question bank referred to race/ethnicity in the question stem, answer, or educational objective. The frequency of mentions of racial/ethnicity was disproportionate to the U.S. POPULATION: 85.8% referred to White/Caucasians, 9.70% to Black/African Americans, 3.16% to Asian, 0.633% to Hispanics, and 0.633% to Native Americans. No cases referred to Native Hawaiians/Pacific Islanders. The proportion of mentions of race/ethnicity classified as either a routine descriptor or central to the case varied by racial/ethnic category. The association between genetics and disease in cases also varied by racial/ethnic category. Insights. The routinized use of race/ethnicity with no specific goal in preparation materials, such as question banks, risks contributing to racial bias. The implications of routinized use extend to assessment in medical education. Race/ethnicity should be used only when referring to social experiences of groups relevant to their health, not as a proxy for genetics, social class, or culture.

Theorizing Race and Racism: Preliminary Reflections on the Medical Curriculum.

The current political economic crisis in the United States places in sharp relief the tensions and contradictions of racial capitalism as it manifests materially in health care and in knowledge-producing practices. Despite nearly two decades of investment in research on racial inequality in disease, inequality persists. While the reasons for persistence of inequality are manifold, little attention has been directed to the role of medical education. Importantly, medical education has failed to foster critical theorizing on race and racism to illuminate the often-invisible ways in which race and racism shape biomedical knowledge and clinical practice. Medical students across the nation are advocating for more critical anti-racist education that centers the perspectives and knowledge of marginalized communities. This Article examines the contemporary resurgence in explicit forms of white supremacy in light of growing student activism and research that privileges notions of innate differences between races. It calls for a theoretical framework that draws on Critical Race Theory and the Black Radical Tradition to interrogate epistemological practices and advocacy initiatives in medical education.

Race, ethnicity and lung function: A brief history.

Spirometry is the most common lung function test and represents the cornerstone diagnostic and management tool for individuals with chronic respiratory diseases. Variability and changing temporal trends in lung function measurements, however, have contributed to the problem of standardizing spirometry, especially with regard to 'race correction'. This article examines the history of the practice, the dilemmas encountered by researchers and the implications of adhering to long-held beliefs without considering more complex explanatory frameworks.

Perspectives on Using Race in Pulmonary Function Testing: A National Survey Fellows and Program Directors.

BACKGROUND: Pulmonary function tests (PFTs) have historically used race-specific prediction equations. The recent American Thoracic Society guidelines recommend the use of a race-neutral approach in prediction equations. There are limited studies centering the opinions of practicing pulmonologists on the use of race in spirometry. Provider opinion will impact adoption of the new guideline. The aim of this study was to ascertain the beliefs of academic pulmonary and critical care providers regarding the use of race as a variable in spirometry prediction equations. METHODS: We report data from 151 open-ended responses from a voluntary, nationwide survey (distributed by the Association of Pulmonary Critical Care Medicine Program Directors) of academic pulmonary and critical care providers regarding the use of race in PFT prediction equations. Responses were coded using inductive and deductive methods, and a thematic content analysis was conducted. RESULTS: There was a balanced distribution of opinions among respondents supporting, opposing, or being unsure about the incorporation of race in spirometry prediction equations. Responses demonstrated a wide array of understanding related to the concept and definition of race and its relationship to physiology. CONCLUSIONS: There was no consensus among providers regarding the use of race in spirometry prediction equations. Concepts of race having biologic implications persist among pulmonary providers and will likely affect the uptake of the Global Lung Function Initiative per the American Thoracic Society guidelines.

Defining race/ethnicity and explaining difference in research studies on lung function.

The 2005 guidelines of the American Thoracic Society/European Respiratory Society recommend the use of race- and/or ethnic-specific reference standards for spirometry. Yet definitions of the key variables of race and ethnicity vary worldwide. The purpose of this study was to determine whether researchers defined race and/or ethnicity in studies of lung function and how they explained any observed differences. Using the methodology of the systematic review, we searched PubMed in July 2008 and screened 10 471 titles and abstracts to identify potentially eligible articles that compared "white" to "other racial and ethnic groups". Of the 226 eligible articles published between 1922 and 2008, race and/or ethnicity was defined in 17.3%, with the proportion increasing to 70% in the 2000s for those using parallel controls. Most articles (83.6%) reported that "other racial and ethnic groups" have a lower lung capacity compared to "white"; 94% of articles failed to examine socioeconomic status. In the 189 studies that reported lower lung function in "other racial and ethnic groups", 21.8% and 29.4% of explanations cited inherent factors and anthropometric differences, respectively, whereas 23.1% of explanations cited environmental and social factors. Even though researchers sought to determine differences in lung function by race/ethnicity, they typically failed to define their terms and frequently assumed inherent (or genetic) differences.

Race Correction and Spirometry: Why History Matters.

In recent months, medical institutions across the United States redoubled their efforts to examine the history of race and racism in medicine, in classrooms, in research, and in clinical practice. In this essay, I explore the history of racialization of the spirometer, a widely used instrument in pulmonary medicine to diagnose respiratory diseases and to assess eligibility for compensation. Beginning with Thomas Jefferson, who first noted racial difference in what he referred to as "pulmonary dysfunction," to the current moment in clinical medicine, I interrogate the history of the idea of "correcting" for race and how researchers explained difference. To explore how race correction became normative, initially just for people labeled "black," I examine visible and invisible racialized processes in scientific practice. Over more than two centuries, as ideas of innate difference hardened, few questioned the conceptual underpinnings of race correction in medicine. At a moment when "race norming" is under investigation throughout medicine, it is essential to rethink race correction of spirometric measurements, whether enacted through the use of a correction factor or through the use of population-specific standards. Historical analysis is central to these efforts.

Racialized algorithms for kidney function: Erasing social experience.

The rise of evidence-based medicine, medical informatics, and genomics --- together with growing enthusiasm for machine learning and other types of algorithms to standardize medical decision-making --- has lent increasing credibility to biomedical knowledge as a guide to the practice of medicine. At the same time, concern over the lack of attention to the underlying assumptions and unintended health consequences of such practices, particularly the widespread use of race-based algorithms, from the simple to the complex, has caught the attention of both physicians and social scientists. Epistemological debates over the meaning of "the social" and "the scientific" are consequential in discussions of race and racism in medicine. In this paper, we examine the socio-scientific processes by which one algorithm that "corrects" for kidney function in African Americans became central to knowledge production about chronic kidney disease (CKD). Correction factors are now used extensively and routinely in clinical laboratories and medical practices throughout the US. Drawing on close textual analysis of the biomedical literature, we use the theoretical frameworks of science and technology studies to critically analyze the initial development of the race-based algorithm, its uptake, and its normalization. We argue that race correction of kidney function is a racialized biomedical practice that contributes to the consolidation of a long-established hierarchy of difference in medicine. Consequentially, correcting for race in the assessment of kidney function masks the complexity of the lived experience of societal neglect that damages health.

Race, populations, and genomics: Africa as laboratory.

Much of the recent debate over race, genetics, and health has focused on the extent to which typological notions of race have biological meaning. Less attention, however, has been paid to the assumptions about the nature of "populations" that both inform contemporary biological and medical research and that underlie the concept of race. Focusing specifically on Africa in the 1930s and 1940s, this paper explores the history of how fluid societies were transformed into bounded units amenable to scientific analysis. In the so-called "Golden Age of Ethnography," university-trained social anthropologists, primarily from Britain and South Africa, took to the field to systematically study, organize, and order the world's diverse peoples. Intent on creating a scientific methodology of neutral observation, they replaced amateur travelers, traders, colonial administrators, and missionaries as authoritative knowledge producers about the customs, beliefs, and languages of indigenous peoples. At the same time, linguists were engaged in unifying African languages and mapping language onto primordial "tribal" territories. We argue that the notion of populations or "tribes" as discrete units suitable for scientific sampling and classification emerged in the 1930s and 1940s with the ethnographic turn in social anthropology and the professionalization and institutionalization of linguistics in Western and South African universities. Once named and entered into international atlases and databases by anthropologists in the U.S., the existence of populations as bounded entities became self-evident, thus setting the stage for their use in large-scale population genetic studies and the contemporary reinvigoration of broad claims of difference based on population identification.

Avoiding Racial Essentialism in Medical Science Curricula.

A wave of medical student activism is shining a spotlight on medical educators' sometimes maladroit handling of racial categories in teaching about health disparities. Coinciding with recent critiques, primarily by social scientists, regarding the imprecise and inappropriate use of race as a biological or epidemiological risk factor in genetics research, medical student activism has triggered new collaborations among students, faculty, and administrators to rethink how race is addressed in the medical curriculum. Intensifying critiques of racial essentialism are a crucial concern for educators since bioscientific knowledge grounds the authority of health professionals. Central ethical issues-racial bias and social justice-cannot be properly addressed without confronting the epistemological problem of racial essentialism in bioscience teaching. Thus, educators now face an ethical imperative to improve academic capacities for robust interdisciplinary teaching about the conceptual apparatus of race and the recalibration of its use in teaching both genetics and the more pervasive and urgent social causes of health inequalities.

Asbestos-related disease in South Africa: the social production of an invisible epidemic.

South Africa was the third largest exporter of asbestos in the world for more than a century. As a consequence of particularly exploitative social conditions, former workers and residents of mining regions suffered--and continue to suffer--from a serious yet still largely undocumented burden of asbestos-related disease. This epidemic has been invisible both internationally and inside South Africa. We examined the work environment, labor policies, and occupational-health framework of the asbestos industry in South Africa during the 20th century. In a changing local context where the majority of workers were increasingly disenfranchised, unorganized, excluded from skilled work, and predominantly rural, mining operations of the asbestos industry not only exposed workers to high levels of asbestos but also contaminated the environment extensively.

Reifying human difference: the debate on genetics, race, and health.

The causes of racial and ethnic inequalities in health and the most appropriate categories to use to address health inequality have been the subject of heated debate in recent years. At the same time, genetic explanations for racial disparities have figured prominently in the scientific and popular press since the announcement of the sequencing of the human genome. To understand how such explanations assumed prominence, this essay analyzes the circulation of ideas about race and genetics and the rhetorical strategies used by authors of key texts to shape the debate. The authority of genetic accounts for racial and ethnic difference in disease, the author argues, is rooted in a broad cultural faith in the promise of genetics to solve problems of human disease and the inner truth of human beings that is intertwined with historical meanings attached to race. Such accounts are problematic for a variety of reasons. Importantly, they produce, reify, and naturalize notions of racial difference, provide a scientific rationale for racially targeted medical care, and distract attention from research that probes the complex ways in which political, economic, social, and biological factors, especially those of inequality and racism, cause health disparities.

Collaborative research, participatory solutions: research on asbestos in Kuruman, South Africa.

The 1998 South African National Asbestos Summit proposed a post-apartheid asbestos policy for the country. In the areas of environmental rehabilitation, health care, and compensation, it envisioned connecting asbestos mitigation to participatory development. In 2001, the Asbestos Collaborative, an international and interdisciplinary team, conducted follow-up research on the recommendations of the 1998 Summit, researching environmental, health, and compensation issues through consultation of documents and interviews with officials in urban areas and with people in Kuruman, a former crocidolite-mining site with high rates of asbestos-related disease. In Kuruman, local opinion supported the recommendations of the Asbestos Summit, insisting that policies to mitigate the problem of asbestos must also address poverty. In the wake of the 2001 research, a new organization, the Asbestos Interest Group (AIG), has been founded to facilitate grassroots participation in asbestos issues. One success of the AIG has been the settlement of a lawsuit by former workers against the former mining company in Kuruman.

Scientific controversy and asbestos: making disease invisible.

Despite irrefutable evidence that asbestos causes asbestosis, lung cancer, and mesothelioma, asbestos mining, milling, and manufacturing continue. The authors discuss three scientific debates over the roles of fiber types, viruses, and genetics in the development of mesothelioma. While these controversies might appear internal to science and unconnected to policies of the global asbestos industry, they argue that scientific debates, whether or not fostered by industry, play a central role in shaping conceptualization of the problem of asbestos-related disease. In South Africa, India, and elsewhere, these controversies help to make the disease experience of asbestos-exposed workers and people in asbestos-contaminated communities invisible, allowing the asbestos industry to escape accountability for its practices.