Quick recap:

• The first article focused on the history of race in American medicine.
• The second article focused on how predictive algorithms came to be in spirometry.
• The third article focused on the history of race in specifically spirometry.
• Today, in the final article of the series, we’ll focus on the impact of these factors.

Baltimore Asbestos Lawsuit

Dr. Lindy Braun started researching for her book Breathing Race into the Machine when she heard about a case in Baltimore in 1999.¹ A lawsuit was underway, and lawyers for an insulation manufacturer were refusing to allow Black Americans to even qualify for a class-action lawsuit unless they could prove their lung health was worse due to asbestos exposure beyond the scores of White Americans.¹

Because of the massive amount of asbestos lawsuits in Maryland, in 1992, Maryland Circuit Court Judge Joseph H.H. Kaplan came up with guidelines that stipulated lung lawsuits can use the racial correction factors as guidance for determining appropriate test values.¹

Experts came to speak on behalf of both sides. The American Medical Association, who recently came out acknowledging racism as a public health threat,² at the time supported race as a qualification in considering lung health. A pulmonologist at the University of Pennsylvania spoke in support of using a correction factor for racial differences while a pulmonary specialist in Virginia mentioned that are many other factors that account for lung capacity.³

Other medical and asbestos specialists as well as an anthropologist denounced the validity of using race as a correction factor in pulmonology.¹ After hearing the case, Jude Kaplan overruled his previous guidelines and adjudicated race as an inappropriate factor in asbestos lawsuits in Maryland.³

Lawsuits on asbestos ended up making their way to a congressional bill called the `Fairness in Asbestos Compensation Act of 1999' that died in a previous congress after not receiving a vote, where predicted values were again defined by factors including race and/or ethnicity.⁴

While this lawsuit happened nearly two decades ago, its implications in spirometry, and even value of life and compensation, ring true in 2020. This lawsuit was not factored into medical history as a clause on how we view race in spirometry.

As a result of those previous court rules, Black Americans could not sue asbestos manufacturers for their injuries. Misusing racial “corrections” in spirometry has cost these communities millions in recompense, further increasing racial health disparities. Instead, studies have continued to solidify racial and/or ethnic differences, that can end in the devaluing of life, and the downsizing of important and significantly evidence-based factors that affect lung function (i.e. asbestos exposure).

Impact of Spirometry

Spirometry is used in diagnosing respiratory conditions like asthma or COPD, but it may also be used in screening for occupational-related lung disorders.⁵ OSHA, or the Occupational Safety & Health Association, also harps on the importance of recording an individual’s race/ethnicity during an occupational spirometry screening, using an individual’s race from their personal record.⁶

OSHA recognizes that some of the predictive algorithms are not able to correctly account for individuals of mixed-racial background or of ethnicities that don’t currently have research populations. As a result, they ask individuals to approximate to the closest ethnic group that is accounted for.⁶ Ethnic identity can often be a deeply important aspect of one’s identity. Asking someone to conform to another ethnic group for the purpose of their health may serve as an additional microaggression against their identity.

Spirometry may result in asthma management techniques and prescription changes,⁸ lung cancer screenings,⁹ and as history has shown even accessibility to health-related lawsuits.

We truly believe in the importance of spirometry as a clinical tool that can be hugely beneficial to patients. We also must be mindful of the history, implications, and extent of a positive impact each factor plays in reporting spirometry.

Other Factors

Disaggregating Social Determinants of Health

We’re here to think about the other factors that impact one’s lung health, and what’s most useful from research, patient, and provider perspectives. While the Race & Spirometry blog series is on its final official blog post, we’ll be ramping up other stories about the factors that affect lung health.

Currently we’re investigating things like time, coaching and education, and air quality. Air quality, for example, can be a proxy for a social determinant of health like income, in which individuals from impoverished areas tend to face more pollutants.¹⁰ ¹¹ It is incredibly important in impactful healthcare that we seek to disaggregate social determinants of health to what they truly are. In this case, one’s distance from a pollution source.

Disaggregating factors linked to social determinants of health, help us all to reduce racial, economic and social biases that also creep into the medical office, where privacy and safety are already concerning for marginalized communities in particular.

It also pushes us to reevaluate “normal” and who gets to be qualified as the comparison group, when our country is becoming increasingly diverse across genders and racial groups.¹² Who gets to tell our stories as Americans? How do we want them told and upheld?

In blog posts to come, Ryan and Luke will lead us through topics of air quality, and reflections on news articles on how we can focus in on some of the factors that deeply affect lung health, and what we can do about it: both as companies in healthcare, and as individuals. We’ll work on educating our communities around asthma control, spirometry functioning, and the factors that affect asthma most.

Working at VitalFlo: A Digression

At VitalFlo we invite people on our team who are not only great at what they do, but their experiences and passions are diverse. We recruit individuals who think from many angles and help us build a product that is truly beneficial to all patients and to the community that we’re a part of in Raleigh.

We think critically with medical and university partners to ask hard and meaningful questions that contribute to research. We want to ensure that the providers have the most useful tools in pulmonology at their disposal, and that patients are well-informed about the benefits, impacts, and education around our product. If this sounds like a good fit to you, you should check out our “Working at VitalFlo” section and follow us on LinkedIn for job announcements.

References

1. Texeira, E. (2018, October 12). Racial basis for asbestos lawsuits?; Owens Corning seeks more stringent standards for blacks. Retrieved November 24, 2020, from https://www.baltimoresun.com/news/bs-xpm-1999-03-25-9903250041-story.html
2. O’Reily, K. B. (2020, November 16). AMA: Racism is a threat to public health. Retrieved November 18, 2020, from https://www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-health
3. Franklin, J. (1999, March 26). Owens Corning Can’t Bar Lawsuits. Retrieved November 24, 2020, from https://apnews.com/article/1663c6c757a578952015db70c5c420f4
4. Fairness in Asbestos Compensation Act of 1999: Hearing before the Committee on the Judiciary, House of Representatives, One Hundred Sixth Congress, First Session, on H.R. 1283, July 1, 1999.; 2000.
5. https://www.congress.gov/bill/106th-congress/senate-bill/758/text
6. Spirometry. (2017, August 17). Retrieved November 24, 2020, from https://www.mayoclinic.org/tests-procedures/spirometry/about/pac-20385201
7. Occupational Safety and Health Administration, 2013. Spirometry Testing in Occupational Health Programs. Best Practices for Healthcare Professionals. Osha 3637–03 2013. Washington, DC: OSHA. Retrieved November 24, 2020 from https://www.osha.gov/Publications/OSHA3637.pdf
8. Horak F, Doberer D, Eber E, et al. Diagnosis and management of asthma — Statement on the 2015 GINA Guidelines. Wien Klin Wochenschr. 2016;128(15–16):541–554. doi:10.1007/s00508–016–1019–4
9. Mohamed Hoesein FA, de Jong PA. Personalized lung cancer screening: the value of spirometry and emphysema as risk modifiers. Ann Transl Med. 2016;4(15):293. doi:10.21037/atm.2016.05.59
10. Katz, C. (2012, November 01). People in Poor Neighborhoods Breathe More Hazardous Particles. Retrieved November 24, 2020, from https://www.scientificamerican.com/article/people-poor-neighborhoods-breate-more-hazardous-particles/
11. Disparities in the Impact of Air Pollution. (2020, April 20). Retrieved November 24, 2020, from https://www.lung.org/clean-air/outdoors/who-is-at-risk/disparities
12. Vespa, J., Armstrong, D.M. and Medina, L. (2020 February). Demographic turning points for the United States: Population projections for 2020 to 2060. Washington, DC: US Department of Commerce, Economics and Statistics Administration, US Census Bureau.