Kidney Disease Researcher Reveals How Race is Literally Factored into Medical Treatment

ST. JOSEPH, Mich.—It turned out to be perfect timing. On the very day kidney disease researcher Dr. Nwamaka Eneanya was telling a Zoom audience how Black people are harmed by several “race modifiers” used daily in algorithms to calculate risk of and treatment for a variety of diseases, a national task force said the kidney race modifier should be immediately replaced by two race-neutral equations.

She happily put a big red X over the words “Kidney function (Black race)” on a slide about race modifiers.
“It’s a win,” the assistant professor of medicine and epidemiology at the University of Pennsylvania said of the recommendation from the task force organized by the American Society of Nephrology and National Kidney Foundation. “We have a few more to go,” Dr. Eneanya said during a Community Grand Rounds: Healing the Trauma of Racism presentation sponsored by Spectrum Health Lakeland. Calling race modifiers both immoral and senseless, she said about Black people: “We are not different biologically.”

“We are not different biologically.” – Dr. Eneanya

The Nigerian-American nephrologist, or kidney disease specialist, leads health equity and anti-racism efforts in her medical school’s nephrology division and concentrates on intervening as early as possible in the kidney disease process. She has counseled and treated thousands of Black kidney patients. For a variety of reasons, they tend to be less informed than white patients about options in the continuum of kidney care, from onset to dialysis and transplantation to palliative care and end-of-life treatment.

In 2019 Dr. Eneanya and Penn colleagues published an article in the Journal of the American Medical Association that challenged the use of a Black race modifier to diagnose and manage kidney disease. The JAMA article prompted a national discussion. Blackness as a race is a political and social construct, not a biological fact, said the pwehavehysician-researcher, who noted that in 2003 the Human Genome Project found there is more genetic diversity within, rather than between, what are considered racial groupings.

In an interview at Lakeland on Sept. 23, the day of her presentation, Dr. Eneanya told Community Grand Rounds founder and leader Lynn Todman, PhD, Spectrum Health’s vice president of health equity: “I really feel like it’s my divine calling to do this work.” Kidney disease has significantly affected Dr. Eneanya’s family, and she carries a gene associated with a high risk for developing the disease and progressing into failure and dialysis.

“I really feel like it’s my divine calling to do this work.” – Dr Eneanya

The obstacles to good health confronting Black people and other people of color in the U.S. are deep-seated in time and society’s structure. Structural racism is the operative phrase.

To illustrate one product of structural racism—neighborhood segregation—she showed slide overlays of how Boston has distinct neighborhoods divided along racial and ethnic lines, with congruent and predictable separation by such factors as income, education and joblessness. Between the wealthiest area and a majority-Black area separated by 3.8 miles, the difference in life expectancy is 33 years. (In the Spectrum Health Lakeland service area, the greatest such gap along racial and economic lines is 19 years.)

Dr. Eneanya explained that the social determinants of health, or SDoH, are the elements that add up to healthy, or not-so-healthy living. Things like stable housing, nutritious food, good schools and parks can make the difference between a long life or one cut short. She indicated that health often comes down to where you live, work and play rather than individual choices.

Much of Dr. Eneanya’s interview and presentation concerned how to make health care outcomes more equitable between Blacks and whites. Eliminating antiquated assumptions—such as that Black people have thicker skin and feel pain less than whites—will help. Her own specialty has wrongly assumed over the years that Black people have naturally better kidney function, thus seeing them as healthier—even while kidney disease, and in particular kidney failure, disproportionately affect Blacks.

The profession must stop “othering” Black people as if they are physically distinct, Dr. Eneanya said. Doctors need to be aware of the biases they might be unconsciously imparting when they write words in charts about Black patients that could unconsciously be racially coded. Phrases like “poor insight” and “non-adherent,” for example, cropped up in the chart of a young Black woman whom Dr. Eneanya later treated for kidney disease. The woman was homeless, and so the notation of “missed dialysis” was true but unfair, because a stable home address is needed for dialysis.

And she said everyone, herself included, needs to be aware of their own implicit biases—because we all have them. People can confront these under-the-radar biases through such tools as Harvard University’s Project Implicit, found at Implicit.harvard.edu.
She encourages health systems to expand the use of multidisciplinary teams when it comes to patient care, so it is not just physicians alone who are deemed responsible for helping someone live healthier. A social worker can, for example, help connect a patient to food pantries with nutritious food.

Dr. Eneanya was asked in the interview, “What gives you hope?” Among encouraging trends, she said health equity work up to this point has largely been about “describing and documenting.” But she is now sensing a movement among younger people and even her contemporary colleagues to take action, which is “the next step.”

She is inspired by this growing energy to act. “This is awesome, that everybody wants to work on this … Health equity should be pervasive in everything that we do, until we no longer need to talk about it.”