Brian Anderson: Welcome back to the 10 Blocks podcast. This is Brian Anderson, the editor of City Journal. Joining me on today's show is Stanley Goldfarb. He's a physician and the chairman of Do No Harm, an organization dedicated to protecting healthcare from divisive and discriminatory ideologies. He's also a former associate dean of curriculum at the University of Pennsylvania's Perelman School of Medicine. He's written several pieces for City Journal on a disturbing theme, the racialization of medical research and care and the push for prioritizing black patients for essential treatments. His work on this topic and other important topics has appeared not only in City Journal, but also in the Wall Street Journal, the New York Post, the Washington Free Beacon and other distinguished publications. So today, we're going to discuss the rise of racial preferences in medicine. Stanley, thanks very much for joining us.
Stanley Goldfarb: Well, thank you very much for having me.
Brian Anderson: So on average, black Americans have shorter life expectancies, worse treatment results, and higher rates of maternal and infant mortality compared with white Americans. In recent years, leading medical journals have run studies attributing racial disparities in medical outcomes to what is purportedly a discriminatory medical system. I wonder what your sense is of those studies, and can we trust their veracity of methods and results?
Stanley Goldfarb: I think, Brian, that these are almost all studies that show correlations. So they show correlations between race and clinical outcomes. I don't think that they've successfully identified the real causes, and I think simply because they haven't really looked for the real cause. The real cause of disparities in almost every case is because of patients seeking care late in the course of their illnesses. So even speaking about the problem of black maternal mortality, which is substantially higher than whites, although in Hispanics, it turns out somewhat lower than whites as well. But even in those cases, the problem is that black women tend not to get prenatal care in the first trimester, and they show up with complications of pregnancy rather late, which is almost always the main cause of why they have difficulties in pregnancy.
Preterm delivery is the most important cause of infant mortality and therefore, the poor prenatal care that they get contributes to the high rate of infant mortality as well. But one can go down almost every diagnosis which is associated with disparities in outcomes between blacks and other racial groups, not only whites, but Asians and even Hispanic patients, that the difficulty is really that when they first encounter the healthcare system, they come late in the course of their illness and therefore, their outcomes are going to be systematically worse. There really is no evidence that the way they're actually treated when they show up in the healthcare system is the cause of these healthcare disparities.
Brian Anderson: Recently, there's been a push for matching patients and providers based on race. Proponents of what's called, I think the term is “racial concordance” in medicine, cite a study from the American Economic Review that contends matching black patients with black physicians is going to save lives. So is there any evidence for racial concordance?
Stanley Goldfarb: There's a fair amount of evidence that black patients will report some increased comfort with black physicians, and I think the particular study that you're citing is one which was a complicated study. It was done at Oakland, if we're talking about the same study. It really showed that in a very short-term analysis that was done in a somewhat controlled fashion, that it seemed that black patients, when given advice about preventative care by black doctors, seemed to accept the advice more readily than they did when they got the advice from white doctors. But none of this really speaks to long-term outcomes and none of it speaks to the issue of whether this is generally a good thing. Actually, the largest study that was conducted, which was about 15 years ago, looked at large databases and compiled the studies from multiple databases and tried to look at when the information was available and failed to show that over the long term, black patients who were getting care from black doctors had better health outcomes.
This could not be ascertained, and there have been other large studies that have really failed to show that there's any difference in the long term. So short term, there may be a little bit more comfort for black patients. But to me, this is the biggest difficulty with this racial concordance, because it's setting up a system of medical apartheid, really, because I think if black patients are going to come to a healthcare system and say, "I want to have a black doctor," it would seem to me that that's going to allow white patients to come to the same healthcare system and say that they want to have a white doctor. I can tell you that when I was practicing, which was up until a few years ago, if a white patient came into our hospital at Penn and demanded that they not have any Black doctors, they were told that they should probably seek another hospital for their care, that this was unacceptable. I don't think that we should make that acceptable now. So the difficulty is A, there really is no evidence over the long term that outcomes are different, and B, it's setting up a situation in which there's going to be real racial disharmony over being able to pick the race of your doctor.
Brian Anderson: You've just written a very interesting and disturbing piece for City Journal, which we published last week where you noted that two major organ transplant institutes, the Organ Procurement and Transplantation Network and the United Network for Organ Sharing, they're planning to change their criteria for determining who is going to receive a kidney transplant in order to favor black patients. Blacks make up a lower percentage of kidney transplant recipients than their proportion of the kidney dialysis patient population would suggest. Is, again, systemic racial bias to blame for this racial disparity among kidney transplant recipients? How are these new policies, if they are adopted, going to affect the, I don't know what the number is, 100,000 patients who are currently on the wait list for kidney transplants, because there's just not enough kidneys to go around?
Stanley Goldfarb: Right. It turns out to be a very, very complicated question, but I'll try to take them in turn. So for years, nephrologists, and I was a nephrologist when I was actively practicing, have sought to make sure that black patients had the opportunity to get kidney transplants because we know it's a much better therapy for replacing lost kidney function because of chronic kidney disease. Patients have a much better lifestyle and they have much greater longevity if they get a kidney transplant. There are two sources of kidney transplants. One is living related transplants, which is almost entirely a transplant donated by a family member, although there are some exceptions to that, but the vast majority are that way, or going on a waiting list and waiting for a cadaveric kidney to become available to you. Black patients tend not to be able to get their relatives to donate kidneys to them, nor do they really seek kidney transplants as frequently as white patients do.
They have been queried about this. There have been studies of interviewing Black patients that have end-stage kidney disease and some of them say they were interested in getting kidney transplants, but a lot say that they don't want to go through a surgical procedure that is required for a kidney transplant. They don't want to get an organ from someone else implanted into them, and they don't particularly want to go through the very extensive evaluation system that's required. To get a kidney transplant, you have to opt in. You have to initiate the process. The reason for that is because as you say, it's such a scarce commodity that it just needs to be given only to patients that are willing to adhere to a very complicated evaluation process in a very complex medical regimen because if you fail to take your medications for a couple of days, you could lose the kidney through organ rejection.
So there are lots of reasons why black patients don't get kidneys. The last thing I would say is it falls under the comment I made earlier about seeking care late in the course of their disease. The patients go on kidney transplant wait list several years before they actually are going to need a kidney transplant because it takes three or four years in many instances to get a kidney from the cadaveric kidney transplant wait list. And unless patients are seeking out medical care and being closely followed, they're not going to know that they have kidney failure because it really tends to be symptomless until fairly late in the course of their disease and therefore, they don't get on the waiting list on that basis. If they get on the waiting list once they're on dialysis, they generally are older, sicker, and in many cases, their physicians may feel like a kidney transplant is not the best treatment for them because of their coexistent other diseases.
So there's been a huge effort in the kidney world to inform Black patients about this option and try to get them to opt in and to pursue kidney transplantation. But again, it's been a much less common event compared to white patients proportionally. What UNOS and the OPTN are attempting to do here is to say that any black patients that are on the waiting list, they're trying to move them up so that their wait time for kidney transplantation is shorter. The way they're doing this is to go back in retroactively, and in one situation and look at the way their kidney function had been monitored for those patients that had been monitored and had decided to go on a kidney transplant wait list, it turns out that the formula that was used is one of the ways of assessing whether the patients are appropriate for the kidney transplant wait list, that formula required a correction factor which caused the physicians to correct the assessment of kidney function in black patients to a slightly higher level than the formula for white patients.
This was not done because of anybody trying to be racist, it was done because for very complex reasons, black patients required this correction. It was totally empirically determined, and it was determined over and over again in many studies. But the formula was felt to be racist because it had this correction factor that was used in it that would seem seemingly raise black patients' level of kidney function above the cutoff point needed to go on the transplant wait list. So it was determined that a new formula ought to be used. The trouble is, the new formula now artificially lowers kidney function in black patients and raises kidney function in white patients. So as I said, it's a very complex issue, the derivation of this formula and the elements that go into it. But suffice it to say that the old formula was fine, it just required two separate calculations, one for white and one for black patients.
The new formula they came up with doesn't require separate calculations, but it's no more accurate than the old formula because it now introduces an error into the white patient's calculation and into the black patient's calculation. The net effect is a new formula is going to be applied. Now this would be fine to do prospectively. It's if they want to change formulas, change formulas, but unfortunately they decided to go back in time, recalculate black patients' kidney function, artificially lower it to compare to where it really was. This would qualify patients to go on a kidney transplant list, and putting those patients on to the kidney transplant wait list at the time that they had the original calculation of their kidney function using this new formula that artificially lowers their level of kidney function.
So in many ways it's really an unfair change in the kidney transplant wait list using a new formula that was designed to allow more black patients to get on the wait list and now retroactively going back in time and displacing white patients that are on the kidney transplant wait list and making them wait longer for their kidneys in favor of black patients. Now, how many patients this is going to influence is unclear, but this is a requirement that's been demanded of all kidney transplant units in the country. So there will be a reshuffling of the kidney transplant wait list, and people who now think that they're going to get a kidney transplant in a relatively short amount of time are going to have to wait longer and how much longer remains to be seen.
Brian Anderson: Now, race-based school admissions and hiring preferences, they've been around for a while now, but the racialization, which you're describing here in a way of medical treatment and research protocols, that's a newer development, but the consequences of racially discriminatory medical practices are going to be potentially dire and they can be deadly for unfavored groups and degrade the overall quality of they're medical care. Then more fundamentally or philosophically, they represent a kind of profound undermining of the principle of equal treatment under the law. So I wonder, how can we call attention to this development, the racialization of medicine, and what can we do to push back, to safeguard fairness and excellence in medicine?
Stanley Goldfarb: Yes, it's a very good question, and the answers are not forthcoming. I would analogize a little bit what's been going on in the racial arena to this whole question of gender-affirming care. I know it's a very large topic and difficult to get into. But the point is that in each situation here, medical societies, professional medical groups have decided to adopt these ideological stances really in favor of the case of gender care, a controversial treatment and in favor of the racialization of medicine, changing medical practices in order to accommodate the disparities that have been found in health outcomes. Ibram Kendi has made the famous statement now that past discrimination requires present discrimination, and the remedy for present discrimination is going to be future discrimination.
So the view is that these discriminatory elements need to be injected into the healthcare system. I think that the important thing about this kidney area is that this is, I think, the first real example of widespread changes in the practice of medicine to accommodate an outcome that is felt to be required because of past disparities in outcomes. It's probably not going to change anything because I don't know that it's going to encourage any black patients to go on the kidney transplant list, which is the real difficulty here—getting them to be candidates for kidney transplant, getting them to want that and to pursue it. So I think it's a very difficult issue. Again, I would analogize the gender-affirming care as we're starting to see legislative agendas be played out in various states.
I think Tennessee right now has several bills on the desk of the governor, same in Florida, Kansas, Missouri, where gender-affirming care is going to be felt to be not acceptable and not allowed in these states. I think we may start to see the government have to get involved in all this to make sure that healthcare is provided equally to all. Again, the pushback is, "Well, it's discriminatory now and we've got to change that," but they're looking at an outcome and they've come up with a hypothesis to explain disparate outcomes without proof that the hypothesis is correct. In fact, I think there won't be proof because I don't think it is correct. I think that's not the problem. So they're creating remedies in an attempt to solve a difficulty, but the remedies do not represent attacking the cause of the illness in the first place. I think just legislative kinds of solutions may be required here.
Brian Anderson: Yeah, it's quite striking. Stanley, as a last point, could you just tell us a little bit about Do No Harm?
Stanley Goldfarb: Yes. Well, Do No Harm is celebrating its one-year anniversary right now. We're an organization of health professionals and concerned patients and others who are interested in avoiding the healthcare system undergoing these kinds of discriminatory influences that we've just spoken about. We have over 5,000 members now, and we've had over 1,000 donors to us, and we're a 501(c)(3) organization. I don't get paid at all for it, so all of our funds are going towards addressing these problems. We have three sorts of kinds of actions that we've taken. One is trying to inform the public through some of the op-eds that you spoke about in publications. Secondly, we've engaged in the legislative arena, we have lobbyists and we've tried to persuade legislators to support bills that have pushed back against the insertion of critical race theory into medicine and medical education.
We've had some legal efforts. We have several lawsuits in place, now four of them fighting back against practices that are discriminatory in medicine. The most notable one, I'll just mention one, is suing the federal government, which back in 2021, inserted into the Medicare system a plan to pay physicians who introduced some sort of anti-racism protocol into their clinical practices. They would get extra payments from Medicare to see such patients. Again, this is really discriminatory and treating one group of patients differently just simply based on skin color. That lawsuit was enjoined by eight states attorney generals, so it's working its way through the federal courts now, and I think it's likely that it'll be successful. So we're pushing as hard as we can back against this to aim for a colorblind healthcare system, a healthcare system in which everyone is treated optimally rather than treated differently because of their skin color.
Brian Anderson: Well, thank you very much. Don't forget to check out Stanley Goldfarb's work on the City Journal website, that's at www.city-journal.org, will link to his author page in the description. You can find Stanley on Twitter @one1iron. You can also find City Journal on Twitter @CityJournal and on Instagram @cityjournal_mi. As usual, if you like what you've heard on today's podcast, please give us a nice rating on iTunes. Stanley, thanks very much for coming on.
Stanley Goldfarb: Thank you so much.