Tackling inequity in health care
Emily E. Volk, MD
July 2022—The CAP has been looking to identify areas where pathologists can help overcome institutional bias in medicine. As you may have seen, the CAP recently issued a statement supporting a new position from the American Medical Association that calls for a change to the FDA’s policy about blood donations from men who have sex with men. The current rule, established in early 2020 in response to a drastic blood shortage associated with pandemic lockdowns, prohibits blood donations from gay or bisexual men who have engaged in sexual activity in the prior three months. Previously, only gay or bisexual men who abstained from sex for a full year were eligible to donate blood.
Many of you remember as I do the societal rejection of HIV-positive patients that occurred in the late ’80s. I was in medical school at this time, working at the county hospital in Kansas City, Mo. A lack of access to health care elsewhere was only one form of rejection to which our HIV-positive patients were subjected. Added to the list were access to good housing, access to nutritious food, and access to social support.
As a pathology resident interested in blood banking, I accepted the ban on blood donations from gay men as part of the fabric of the time. But even then we certainly acknowledged that there was some degree of hypocrisy to it, since no such permanent ban applied to heterosexual high-risk behavior.
All these decades later, we have testing technology that can ensure the safety and quality of a blood donation regardless of who provided it. There is no more implicit danger for a gay man to donate blood than for anyone else. These discriminatory restrictions on blood donations from gay or bisexual men are holdovers from the original AIDS epidemic, wholly unrelated to the science of blood banking.
Dr. Volk
Of course, this is not the only area of institutional bias where we can and should make a difference. I am pleased that guidelines have changed for how we calculate estimated glomerular filtration rate (eGFR). In the past, we adjusted the score for patients who identified as Black; the adjustment may have prevented some African-American patients from qualifying for kidney transplants. The concept behind the adjustment was based on unscientific and antiquated ideas of race. Again, with our commitment to seeking the truth in all test results, we pathologists can reduce inequities in patient care by leading with science. If your lab has not adopted the latest eGFR testing guidelines that eliminate race-based calculations, I urge you to do so as soon as possible.
Another area where we can make health care more equitable is in establishing reliable reference ranges for our transgender and elderly patients. For transgender patients, these ranges are still being worked through, and I believe the CAP will help guide laboratories in choosing the optimal numbers. For geriatric patients, we may need reference ranges to more accurately represent the physiological differences among people who are 80 years or older. In both cases, we must rely on data to improve our understanding of ideal reference ranges for these patient groups. If you manage a lab, I encourage you to consider the community you serve and make sure that the reference ranges you’re using truly reflect that patient population.
There are many disparities in health care that cannot be fixed with greater attention to a patient’s numbers and how those numbers are generated or interpreted. But whenever we see an opportunity to deliver more equitable care based on laboratory strategies or technologies, we should work together and make the most of it.
Dr. Volk welcomes communication from CAP members. Write to her at president@cap.org.