In recent times we have paused to rethink the relatively high mortality of blacks and ethnic minorities during this COVID-19 pandemic. Though mortalities have been significantly low on the African continent, these numbers must be of concern to all. Many reasons have been adduced for the low mortality on the African continent; ranging from trained immune systems of the majority of the citizens to a low median age. However, in recent times, as new variants of the SARS-CoV-2 virus have emerged, mortality has seen a surge.
For example, as at the time of writing, 47.3% of all mortalities attributable to COVID-19 in Ghana have occurred in the first nine (9) weeks of 2021. Anecdotal evidence seems to suggest that this surge in mortality has also coincided with a drop in the ages of those who have lost their lives, and also an increase in complications of renal and respiratory failure in people in whom there was no evidence of comorbidity. This trend is similar to the mortality trends in the United Kingdom, where Office of National Statistics (ONS) data suggests that, it was more likely to die from COVID-19 complications with no underlying conditions if you were of black or ethnic minority extraction.
We have, as a result, tried to understand whether there is anything inherent in the clinical management of COVID-19 that could be a contributor to the prognosis of a black patient infected with the virus. We started by looking at the route through which the virus infects the human body. This has long been established as mainly through the respiratory system via the nose and mouth. This makes the lungs one of the prime targets for damage by this virus. This damage tends to lead to possible fluid accumulation in the lungs, and a decrease in the ability for oxygen exchange to occur. This is the basis of the low oxygen saturation that has been flagged as a preliminary marker of further COVID-19 complications.
One of the techniques employed to determine the functional ability of the lung is spirometry. This technique is a simple test used to help diagnose and monitor certain lung conditions by measuring how much air you can breathe out in one forced breath. Interestingly, spirometers (the apparatus used in spirometry) use a race-based correction or a so-called ethnic adjustment to determine how effectively a person’s lungs are functioning. This is based on an assumption that blacks have a 10–15% smaller lung capacity and Asians 4–6% compared with their White counterparts.
Readers may assume that these adjustments are based on credible science and we would not fault anyone if they held that view. The reality is, this has no scientific basis, and at best could be considered as pseudo-science. Medical history points to the fact that this race adjustment originated from 1785 when the then United States President Thomas Jefferson described “a difference of structure in the pulmonary apparatus between slaves and White Americans”.
This view was reemphasised by American physician and slave owner Samuel Cartwright, when he quantified a 20% difference in lung capacity between Black and White people. In doing so, he establishing race as an important factor influencing respiratory function justifying why slave labour was medically beneficial. Recent research has indicated that these views are scientifically unfounded. However, all spirometers in current use have these race-adjustments inbuilt. Readers may wonder all this means. It suggests the average black person may require to show at least 20% more damage to their lungs or kidney before urgent intervention is initiated. Thus, it has been argued that this structural inequality could result in clinicians missing important early signals of respiratory relapse. This view is buttressed by the emerging evidence globally that restrictive ventilatory dysfunction is emerging as a major cause of re-hospitalisation of COVID-19 patients in the first 14-days post-discharge.
Another complication that seems to be common in people hospitalised with COVID-19 is renal failure. According to Christopher John Sperati, Associate Professor of Medicine at John Hopkins University, 30% of patients hospitalised with COVID-19 in China and New York developed moderate or severe kidney injury. Further emerging evidence seems to suggest that the percentage could be even higher. Clinically, to determine renal function, an equation termed the Estimated Glomerular Filtration Rate (eGFR) is used. This helps to measure the level of kidney function and to determine the stage of any kidney disease present.
This equation relies on the kidneys’ ability to eliminate a breakdown product from the human muscle called creatinine. However, when this equation was being initially written, a race-correction was made with an assumption that people of black extraction had higher muscle mass compared with whites. This was because in the 1970s when this equation was designed, there was a reliance on sampling from health institutions where disproportionately blacks engaged in blue-collar and menial jobs and thus had larger muscle build. This situation does not hold currently, especially in Africa, where disproportionally those being hospitalised and losing their lives are those engaged in white-collar jobs, devoid of muscle bulk. To use this equation in such patients therefore, will result in delaying renal interventions and possible poorer prognosis as the renal function has to be 20% worse off before interventions are commenced. Yet, this equation has been relied on in renal interventional decision making all through the pandemic.
We will want to emphasise that there are many other medical parameters such as pain threshold concerning COVID-19 that are determined with race in mind. However, science has established that race, if anything, is a social rather than a biological construct, and should not be implicated in such crucial medical decisions. Though some of these debates predate COVID-19, the current pandemic points medicine to a need for a relook at many of these diagnostic aids that may be putting people of black and African extraction at disproportional risk.
This is where African countries role in research and development, when it comes to medical science, shows up again. We cannot continue to sit on the fence when many of the diagnostic parameters being taught and practiced are riddled with these diagnostic biases, and expect others to address the discrepancies. Neither can we shout for these to be corrected without any scientific evidence to show that the initial assumptions were flawed. As the saying goes, history is written by those who choose to partake in the crafting of the future when they opt to document their contribution. These flaws have benefited from the gifts of history and will only be corrected if we decide to craft the future and document our findings. To do this will require a rethink of our approach. We will end by asking, are we ready?