“I can’t breathe.”

As the last words of far too many Black people who have been murdered at the hands of law enforcement, this slogan has become a cry for racial justice and police accountability. While chokeholds are one of the causes of respiratory deaths among Black people, it is not the most common. 

Black Americans have higher rates of COVID-19 cases, hospitalizations, and deaths. Beyond the current pandemic, they are more likely to die due to pneumonia and asthma. But why?

The disparities playing out during the times of COVID-19 can be explained by structural inequalities. While access to care, living in densely populated areas, and higher rates of comorbidities are all factors which influence infection rates and health outcomes, another explanation for the observed racial disparities lies in “race correction” used in American medicine. 

Although some point to inherent genetic differences between racial and ethnic groups, scientists have actually found that there is more genetic diversity within racial groups than there is between them. We must remember that race is in fact a social construct. Our skin colors and outward appearances do not make us inherently biologically or genetically different. But mainstream medicine continues to believe otherwise. 

For example, after studies found that Black people have lower lung volume than White people, race-based algorithms were incorporated into predicted lung function calculuations. One of the measures of lung function is forced vital capacity (FVC), or the maximum amount of air an individual can forcibly exhale after taking in a deep breath. Observations of racial differences in FVC from multiple studies led to the development of racial adjustments and equations which predict lung function. 

If Black people are assumed to have lower lung function, this can prevent them from getting help when they actually need it. Due to race correction, what is considered “normal” function for Black patients can be considered unhealthy for White patients, resulting in late diagnosis and inadequate treatment for Black people. It determines who is offered treatment, when treatment is offered, and how they are prioritized for receiving organ transplants. Even the United Network for Organ Sharing incorporates percent predicted FVC in its algorithm for determining priority for receiving a lung transplant. 

In effect, by upholding preconceived ideas regarding inherent racial differences, American medicine normalizes the social determinants of health which lead to poorer health outcomes. We cannot ignore that Black people breathe in dirtier air due to where they have been forced to live due to histories of segregation and redlining, are forced to do dirtier jobs, and receive inadequate medical care. Poor health outcomes in Black individuals are not due to biological inferiority, but rather the social determinants of health. 

And, we cannot ignore that these notions are rooted in racism and slavery. The race correction for lung capacity used today is based on assumptions that go back over 200 years. Thomas Jefferson proposed that “difference[s] in the structure of the pulmonary apparatus” meant that Black people were perfect fits for hard labor on plantations. 

These algorithms are harming our communities, and COVID-19 is just another example of how patients who actually need care for respiratory illness are not being taken as seriously. 

Recent studies are now pointing to errors in pulse oximeter readings among Black people. Pulse oximeters are devices used to measure blood oxygen levels. During the COVID-19 pandemic, many individuals have purchased pulse oximeters to use at home. They are used to determine when an individual needs to be admitted to a hospital, put on a ventilator, or transferred to the ICU. 

The problem with this, however, is that Black people are three times more likely to experience pulse oximeter errors, putting them at risk of the harmful effects of low blood oxygen. Pulse oximeters measure oxygen levels by passing light through skin. Nail polish or skin tone can slow the passage of light, resulting in inaccurate readings. When the first pulse oximeter was created in 1974, it was not tested among diverse groups of people, meaning that skin tone errors went undetected. Now, the Food and Drug Administration requires testing on a diverse group of subjects, but the skin tone diversity box is checked by having just two “darkly pigmented” individuals as test subjects. The pulse oximeters today continue to be inaccurate for Black and Brown people. A critically important piece of knowledge to have as we are in the midst of a pandemic of a respiratory virus.

It is important to note that there have been studies and publications in the 1980s and 1990s reporting that pulse oximeters may be inaccurate for darker-skinned individuals, but these findings are still not acknowledged and further investigated. 

As the Institute for Healing and Justice’s report on the abolition of biological race in medicine states, “the continued presence of the racist history of establishing race-based differences in lung function within the modern-day practice of pulmonology signals how the medical community has refused to address this hidden history of racism and subjugation of Black and brown bodies.”

Racism and social inequities continue to have an impact on the harmful racial health disparities we see today when it comes to lung function. Mainstream medicine needs to acknowledge and discuss this racist history and create meaningful change into how medicine is practiced. In the time of COVID-19, one’s life could depend upon it. 

Tubman Center Communications Intern Karina Patel is currently studying Public Health and Law, Societies, and Justice at the University of Washington. She is an aspiring public health professional passionate about social justice, anti-racism, and diversity, equity, and inclusion work. Reach her at karinap@uw.edu. Twitter: @karinappatel