Headlines have to grab attention, and the two headlines in the Sunday Times certainly did that. Usually considered a mildly conservative Sunday paper, with a circulation of 648,000 it is twice as popular as the next rival, the Sunday Telegraph. A Sunday paper is often the one that families are most likely to read and discuss together.
Sajid Javid orders racial bias review after Covid deaths
Medical devices ‘made for white people’ may have driven higher minority fatality rates
‘Racist’ oxygen device may explain why Covid hit minorities so hard
So, that is two “racist” implications to begin your family Sunday.
Notice that the paper did not say that there was to be an investigation into the possible causes of Covid fatalities, which would be the sensible way to approach the topic, since all possible causes could be mentioned and discussed.
For example, the death toll in the first wave of Covid hit over-weight people particularly hard. Racial differences in body mass index, and overall high national body mass index may have been an important cause, but there are many others.
My own view is that we do not yet know what caused the racial differences in fatalities. In the latter phase of the pandemic, differential uptake of vaccinations will have been a new factor.
Now, back to the main story. Racism has been given pride of place, to the detriment of other factors. Perhaps Sunday newspaper editors and writers find that irritating their readers actually boosts readership, but this is a distinctly odd way to approach an unresolved issue.
The Health Minister has said:
When I walk to my office, there’s a board showing everyone who’s held this role for over a century, and being the first name on that list from an ethnic minority is a responsibility I take very seriously.
I’m determined to take a fresh perspective to this position, and do whatever it takes so that in this country, your health and your experience of health and care isn’t dictated by where you live or where you come from.
Because although we’ve come together as a nation to fight this virus, the pandemic has shown that in many areas we’re far apart. At the height of the Covid peak last winter, black, Asian and other minority ethnic groups made up 28 per cent of critical-care admissions in England — about double their representation in the population as a whole. So one of my first visits in this role was to Blackpool, one of the parts of this country where life expectancy is in decline. I spoke about the Office for Health Improvement and Disparities, an organisation that was launched last month and has so much potential to tackle these injustices.
Notice the phrase “these injustices”. Different outcomes may be due to differences in life styles and differences in genetic susceptibilities. At the moment, we are not sure, but the condemnation has already been issued by the Health Minister. In his judgment, someone has perpetrated an injustice on ethnic minorities.
Odd that a national priority is being favoured on the basis of the genetic background of a Health Minister. Imagine if the next one says: “being White British, I think that poor whites should be a priority, because after all, they are the majority of the users of the health service, and also, they have short lifespans”.
Also, it is a bit odd to get into this issue without talking about lifespan data, this being the keystone of most health inequality debates.
Here is what the Office for National Statistics says about lifespan and racial background:
- In the period 2011 to 2014 in England and Wales, both males and females in the White and Mixed ethnic groups had lower life expectancy at birth than all other ethnic groups, while the Black African group had statistically significant higher life expectancy than most groups.
- Statistically significant higher age-standardised mortality rates from cancer were present among males and females of the White ethnic group compared with Black and Asian ethnic groups.
- Statistically significant higher age-standardised mortality rates from circulatory (heart and related) diseases were present among Indian, Bangladeshi and Mixed males and Pakistani, Indian and Mixed females compared with the White group.
- Cancers and circulatory diseases account for 61% of male and 53% of female deaths in the study and are therefore an important influence on the life expectancy differences seen between ethnic groups.
- These results reveal important patterns in life expectancy and mortality by ethnic group which are complex but nevertheless consistent with most previous studies; further research is required to investigate the reasons for the differences, with potential explanations including past migration patterns, socioeconomic composition of the groups, health-related behaviours, and clinical and biological factors.
So, whites and part-whites (and some other mixed groups) live shorter lives, Black Africans longer ones. (For the avoidance of doubt, I am not accusing Black Africans of racism towards white people, but in these extraordinary times I feel I need to make that clear).
Sajid Javid is of Pakistani origins, so his children would have lifespans which are higher than those of White British. Here is the relevant Table, ranked by male lifespan.
This is a very interesting, and somewhat unexpected, set of results. As usual, there are potential complicating factors, including the younger ages and better health of some recent immigrant groups. Infant mortality, cardiovascular disease (CVD) and diabetes are higher among Black and South Asian ethnic groups. An analysis of data from the Clinical Practice Research Datalink (Lawson et al 2020) showed that people in the South Asian ethnic group (including Bangladeshi, Indian and Pakistani ethnic groups) had higher ischaemic heart disease, hypertension and diabetes prevalence than those in the White ethnic group. Conversely, those in the Black ethnic group had lower ischemic heart disease than those in the White ethnic group.
In fact, different racial groups have different patterns of health problems. If lifespans are seen through the lens of racism, then whites and part-whites have a grievance against all more recent arrivals.
It would have been useful to include these findings in the article, but we are reading a newspaper, after all.
The Health Minister continues:
For example, research has shown that oximeters, which monitor oxygen levels and are used to see whether treatment is needed for Covid-19, are less accurate on people with darker skin. One of the founding principles of our NHS is equality, and the possibility that a bias — even an inadvertent one — could lead to a poorer health outcome is totally unacceptable.
Sajid Javid is working with his American counterpart, Xavier Becerra, on introducing new international standards to ensure that medical devices have been tested on all races before they are allowed to be sold.
I think that Javid and Becerra are making an ethical mistake. If someone anywhere has produced a device which might save a life, they should use it to save a life immediately. The intended prohibition of the sales of devices will be to the detriment of patients, and will punish innovators and the countries which produce those innovators. A better approach would be to get the devices to market immediately, with supportive documentation showing the patient samples on which they had already been tested. Other countries can then conduct their own standardisations. That would be fair, otherwise the innovators will be burdened, without any responsibilities being placed on those who do not invent things.
In my view, if a Japanese person invents an oximeter, Japanese people should be allowed to use it and sell it, and we will work out our own table of figures from a standardisation study later. My compliments to Takuo Aoyagi, who invented the device for us in 1974. It was “the greatest advance in patient monitoring since echocardiography”
If pulse oximenters give erroneous readings for black patients, then this should not take long to investigate.
In fact, the work has already been done:
Volume 26, Issue 2, February 2008, Pages 131-136
Diagnostic room-air pulse oximetry: effects of smoking, race, and sex
Of 871 eligible subjects, 50 (5.7%) had an Spo 2 value less than 97%, and 13 (1.5%) had an Spo 2 value less than 96%. Lower readings were associated with the following characteristics (odds ratio with 95% confidence interval): male sex, 3.8 (2.5-5.6); age ≥60 years, 2.4 (1.3-4.5); white race, 5.3 (3.6-7.8); obesity, 3.2 (2.1-4.8); history of asthma, 3.2 (1.6-6.2). Smoking was not associated with lower Spo 2 values.
Room-air Spo 2 values less than 97% are rare in asymptomatic, awake adults. White race and male sex are associated with lower Spo 2 readings.
Comment: good sample size, so we have base-rates, a crucial guide to understanding any readings from the device. Whites are more likely to get low readings. Fatter people get lower readings, even when not ill. (If one ethnic group is fatter than another, that will affect results).
The next publication is more directly involved in the measurement of oximeters in clinical settings with very ill patients. It is this paper which may have generated the projected investigation.
Racial Bias in Pulse Oximetry Measurement Among Patients About to Undergo Extracorporeal Membrane Oxygenation in 2019-2020: A Retrospective Cohort Study
Pulse oximeters may produce less accurate results in non-White patients.
Do pulse oximeters detect arterial hypoxemia less effectively in Black, Hispanic, and/or Asian patients than in White patients in respiratory failure and about to undergo extracorporeal membrane oxygenation (ECMO)?
Study Design and Methods
Data on adult patients with respiratory failure readings 6 h before ECMO from 324 centers, January 2019 to July 2020, were provided by the Extracorporeal Life Support Organization registry. Our primary analysis was of rates of occult hypoxemia—low arterial oxygen saturation (Sao 2 ≤ 88%) on arterial blood gas measurement despite a pulse oximetry reading in the range of 92% to 96%.
The rate of pre-ECMO occult hypoxemia, that is, arterial oxygen saturation (Sao 2) ≤ 88%, was 10.2% (95% CI, 6.2%-15.3%) for 186 White patients with peripheral oxygen saturation (Spo 2) of 92% to 96%; 21.5% (95% CI, 11.3%-35.3%) for 51 Black patients (P = .031 vs White); 8.6% (95% CI, 3.2%-17.7%) for 70 Hispanic patients (P = .693 vs White); and 9.2% (95% CI, 3.5%-19.0%) for 65 Asian patients (P = .820 vs White). Black patients with respiratory failure had a statistically significantly higher risk of occult hypoxemia with an OR of 2.57 (95% CI, 1.12-5.92) compared with White patients (P = .026). The risk of occult hypoxemia for Hispanic and Asian patients was equivalent to that of White patients. In a secondary analysis of patients with Sao 2 ≤ 88% despite Spo 2 > 96%, Black patients had more than three times the risk compared with White patients (OR, 3.52; 95% CI, 1.12-11.10; P = .032).
Compared with White patients, the prevalence of occult hypoxemia was higher in Black patients than in White patients about to undergo ECMO for respiratory failure, but it was comparable in Hispanic and Asian patients compared with White patients.
A very large-scale study came to similar but more cautious conclusions.
Analysis of Discrepancies Between Pulse Oximetry and Arterial Oxygen Saturation Measurements by Race and Ethnicity and Association With Organ Dysfunction and Mortality
An-Kwok Ian Wong, MD, PhD; Marie Charpignon, MS; Han Kim, MSE; Christopher Josef, MD; Anne A. H. de Hond, MSc; Jhalique Jane Fojas, MSE, MSc, MRes, PhD, PhD;Azade Tabaie, MSc; Xiaoli Liu, BS; Eduardo Mireles-Cabodevila, MD; Leandro Carvalho, MD; Rishikesan Kamaleswaran, PhD; R. W. M. A. Madushani, PhD;Lasith Adhikari, PhD; Andre L. Holder, MD, MSc; Ewout W. Steyerberg, PhD; Timothy G. Buchman, PhD, MD; Mary E. Lough, PhD, RN; Leo Anthony Celi, MD, MS, MPH
Discrepancies in oxygen saturation measured by pulse oximetry (SpO2), whencompared with arterial oxygen saturation (SaO2) measured by arterial blood gas (ABG), maydifferentially affect patients according to race and ethnicity. However, theassociation of thesedisparities with health outcomes is unknown.
JAMA Network Open.2021;4(11):e2131674. doi:10.1001/jamanetworkopen.2021.31674
Hidden Hypoxemia by Race and Ethnicity
Hidden hypoxemia occurred across all racial and ethnic subgroups, assessed using the first ABG measurement with an SpO2level greater than 88%. Patients self-identified as Black had higher SaO2variability for any given SpO2value, as evidenced by a larger IQR (eg, median [IQR] SaO2at SpO2of88%, Black patients: 90.10% [10.13]; White patients, 90.00% [9.10]). There was a varying incidence of hidden hypoxemia among racial and ethnic group in descending order: Black, 1785 [6.8%]; Hspanic, 160 [6.0%]; Asian, 92 [4.8%]; White, 2822 [4.9%] (P< .001)
In summary, it is possible, but not certain, that oximeters under-record low oxygen levels in black people. However, normal healthy white people probably have lower oxygen levels than black people, (and fatter people lower oxygen levels than slimmer people). Also, white people in the UK have shorter life-spans than immigrant groups, and the reason for that is not clear. It is worth investigating if any medical device has an unacceptable error term, but on balance oximeters save lives.
In a break from reading medical papers, I chatted to a hospital doctor about this controversy. In a kindly manner he explained that the problems caused by oximeter readings “from dark skins had always been known about (for obvious reasons) but is adjusted for”. It is a sign of the times that so much attention can be paid to something which is a minor part of our current health problems.
It is unlikely that racism, even very broadly defined, is the reason for errors of oxygen level estimation in patients. Wild accusations aside, on the bright side, there is general agreement that, where health is involved, it is perfectly acceptable to talk about race.