The call came on June 8 as Dia’Londa Bagley, 42, was at a Chuck E. Cheese birthday celebration for her nephew: A kidney had arrived. Could she be at Johns Hopkins the following morning?

The Johns Hopkins patient safety attendant was more than ready. After struggling with lupus, followed by kidney failure, she had been undergoing peritoneal dialysis overnight at home for six years so that she could continue to work. Bagley left the party and awaited further instructions that came several hours later:

Miss Bagley, they're signing for your kidney right now. Can you get to the hospital?

“I said, ‘Give me a minute to pack my bag,’’’ she recalls. “I got there about midnight, went up to the ninth floor, and they told me that they were going to do the surgery at 8 o’clock the next morning. I was like, ‘Wow! Yeah!’”

On June 9, 2024, Bagley got a new kidney — and with it, a new life.

Now back at work full time, Bagley is assisting the hospital nursing staff, going out at night to meet friends and even making travel plans. “I’m looking forward to being normal, to just be free of all the stuff I’ve had to drag around,” she says. “Every day I feel better.”

Just a few years ago, Bagley would not have been eligible for the kidney, due to a race-based equation, long in place at Johns Hopkins and at hospitals around the country, that often judged Black patients to have less advanced kidney disease than non-Black patients. But in 2022, following the recommendation of the National Kidney Foundation-American Society of Nephrology Task Force that reassessed this practice, the Johns Hopkins Health System removed race modifiers used to estimate kidney function. The move was part of a national movement aimed at eliminating race as a factor in medical testing and health evaluations.

Because there are no biological differences in the kidney that are attributable to race, it should not be considered in the testing equation, says nephrologist Deidra Crews, deputy director of the Johns Hopkins Center for Health Equity and president of the American Society of Nephrology.

“There is no biological basis to race,” says Crews. “Race is a social construct. There's no blood test that you could do and then come away and say, she’s a Black person. Society determines that. A lot of people have been concerned that we were using this social construct of race in a way that had biologic consequences.”

For someone on dialysis, getting a transplant “triples your life expectancy,” notes Bagley’s physician, Johns Hopkins nephrologist Derek Fine. “She’s had a lifesaving therapy because someone had been thoughtful enough to say, ‘You know, this [diagnostic equation] isn't done right.’”

Indeed, in specialties across Johns Hopkins Medicine — including pulmonology, cardiology, obstetrics and pediatrics — clinical leaders and educators are actively working to correct long-entrenched misconceptions about race and health: misconceptions that in some cases date back to the era of slavery.

Injustices, Not Immutable Facts

There has been a long-standing practice in medicine to calibrate lab results with equations that consider such factors as age and gender. More recently, however, there has been a growing discussion within the medical community about some tests that also use race-based measurements.

Then in 2020, as the COVID-19 pandemic was revealing myriad health disparities, George Floyd’s murder and the Black Lives Matter movement amplified conversations about structural racism and racial inequities in medicine.

That same year, the New England Journal of Medicine published “Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms.”

Medical internist Jeremy Greene, professor of medicine and the history of medicine at Johns Hopkins, says the landmark article showed “how there is almost no domain of clinical medicine in which you cannot find a race-based algorithm for either diagnosis, treatment or prevention.”

The article’s authors wrote that the racial differences in large data sets “most likely often reflect effects of racism — that is, the experience of being black itself — such as toxic stress and its physiological consequences” and cautioned that “when clinicians insert race into their tools, they risk interpreting racial disparities as immutable facts rather than as injustices that require intervention.”

Instead, the authors wrote, clinicians should consider social determinants of health, such as socioeconomic status, housing, education and access to health care.

At Johns Hopkins, the subsequent commitment to identify and undo the false use of race as a biological category, Greene says, has increased collaborations between faculty members in the history of medicine, social sciences, clinical medical science and medical education.

One example: In 2020, Nancy Hueppchen, associate dean for undergraduate medical education, and assistant dean Janet Record began a longitudinal working group with faculty members and students to examine and improve teaching on social determinants of health, including race, in the medical school curriculum. They started by updating learning goals in the “Structural Competency and Health Inequities” strand of the curriculum, which is integrated across the four-year medical degree.

“Collaboration in the structural competency working group has led to productive conversations with course faculty about how we could advance thinking about intersections of structural inequities and pathobiology,” the deans point out — beginning with the first course in medical school, Disparities and Inequities in Health and Health Care, and continuing with required sessions, such as Race and Sickle Cell Disease and Do Organs Have Race?

Since 2021, school of medicine course and clerkship directors have been given a checklist to guide how to assess bias in medical educational materials. Students can also use a real-time website to report any concerns for bias or stereotypes they might notice or experience in the curriculum.

Amid such curricular changes came a conference in May 2022 that Greene describes as “a breakthrough moment of potential and possibility.”

The two-day national conference at Johns Hopkins, Reckoning with Race and Racism in Academic Medicine, was sponsored by the Department of the History of Medicine along with the Center for Africana Studies; the Program for Racism, Immigration and Citizenship; and the Center for Medical Humanities & Social Medicine.

It attracted more than 1,000 attendees, including historians, sociologists, medical educators, medical trainees and activists from around the United States. Their goal: to bring the social sciences and clinical sciences of health and medicine into conversation to transform how race and racism are addressed in medical education and clinical practice. In medical education, this means something very specific: identifying the diagnostic, therapeutic and preventive algorithms that falsely treat race as a biological category and working to undo the harm these practices cause.

“It was the largest event of any kind that the department has ever held,” Greene says. “Many students who have led groups to undo race-based algorithms at their own schools talked about those efforts. Many of the faculty who have been involved in undoing race-based diagnosis in renal and pulmonary diagnosis talked about the potential for transformation.”

He continues, “The conference became a way of understanding how medicine has been a uniquely important site for reproducing notions of race and racism. It showed how a thoughtful partnership between the people who focus on the social dimensions of health and health care, and the people who focus on the biological aspects of research and clinical development can help us find new ways to repair the harms that the medicalization of race have done in the past, many of which continue in the present.”

Bigger Muscles and Weaker Lungs

Today, Black Americans are more than three times likelier than white Americans to have kidney failure, according to the National Kidney Foundation. Despite these higher rates, however, they are less likely to be listed to receive kidney transplants, in part because of the use of kidney function equations that incorporated race.

Until recently, the equation used to determine how much waste kidneys filter added a measure for race to “correct” for different levels of creatinine, a waste product released from muscles, observed in studies of Black versus non-Black people. The “correction” was based on the incorrect assumption that Black people have higher muscle mass. It meant that they were often judged to have a less advanced stage of kidney disease than non-Black patients.

In similar fashion, another false concept took hold in the medical community regarding interpreting the health of lungs. In the 1850s, when it was determined that enslaved people scored lower on a spirometer breathing test than their white owners, that score was attributed to their race. In reality, their poorer lung function was due to the harmful environmental conditions they were forced to endure.

“The ease with which physicians have generally accepted that Black people have fundamentally different lungs from white people, or different bone density, or different thresholds for pain, these all have a long history that traces back to the racial sciences of 19th-century medicine,” Greene says. He notes that physicians’ published accounts of the biological inferiority of Black bodies were used to justify slavery in antebellum years and then justify Jim Crow apartheid after emancipation.

Because of this history, many clinicians continued to believe that lung disease in Black people was less severe than the breathing tests indicated, leading to misdiagnosing pulmonary disease. 

At Johns Hopkins, pulmonologists eliminated race-based standards in lung function tests in March 2023, notes Meredith McCormack, associate director of the Division of Pulmonary and Critical Care Medicine and co-author on the American Thoracic Society statement calling for the removal of race in pulmonary function testing.

“We went to the new standards that no longer include race,” McCormack says. “Even though generations of physicians were trained to believe there are biologic differences between races, there’s a growing appreciation and understanding that any differences likely represent environment, environmental stress and the impact of structural racism.”

According to a NEJM study published in 2024, removing a patient’s race from tests for lung disease could mean that millions of Black people in the U.S. would receive a diagnosis of abnormal lung function and that hundreds of thousands would qualify for disability payments.

Another damaging misconception is the “salt-slavery hypothesis,” which has been used to explain high rates of hypertension in African Americans. This false notion claimed that there was a salt deficiency in the West African populations that supplied the slave trade. It suggested that those enslaved people who were better at storing sodium in their bodies had a survival advantage during the Middle Passage and slavery, and passed that ability on to their descendants, leaving them at a higher risk for hypertension due to the modern diet’s high salt content.

In reality, there was no historic salt deficiency in the slaves’ homeland, and hypertension rates are not high among present-day West Africans — another indicator that the environment in the U.S., rather than biology, causes the condition.

“It’s time for us to move forward with removing some of our race-based algorithms," says Nadia Hansel, director of the Johns Hopkins Department of Medicine. Since existing algorithms often reflect underlying environmental and socioeconomic disparities, she says, “we have to make sure that we understand the impact of those disparities on our diagnostics and treatments. I think some of our historical approaches have put our Black community at a disadvantage at receiving therapies in a timely manner, and I hope that we are finally paying attention.”

It’s Complicated

But change nationally is coming slowly, in part because of insufficient information about the downstream impact of eliminating racial equations.

In a recent study in the Annals of Internal Medicine, researchers in the University of Pennsylvania’s Perelman School of Medicine found that removing race from evaluating kidney function seemed to reduce Black patients’ access to chemotherapy as well as their eligibility for clinical trials. It also affected their medication dosing.

McCormack has also completed research that attests to the trade-offs that can arise. Her 2024 editorial in the New England Journal of Medicine, “Beyond Diagnostics — Removing Race from Lung-Function Test Interpretation,” showed that removing the equation meant that more Black patients were eligible for lung transplantation and disability payments. However, they were less eligible for firefighting jobs, since candidates are typically required to pass a standardized pulmonary function test aimed at ensuring their safety when wearing face masks.

“As you dismantle a race-based equation, there could be unintended consequences,” says bioethicist Jeremy Sugarman, professor of bioethics and medicine at the Johns Hopkins Berman Institute of Bioethics.

Sugarman says that identifying potential negative outcomes of making these changes is also a matter of social justice that patients should be aware of. “We don’t want to hurt people outside of the clinic. As well as our health, we all have other aspects of our lives that are important to allow to flourish.”

He co-wrote “Ethical Considerations Regarding the Use of Race in Pulmonary Function Testing,” an editorial that appeared in Chest, with McCormack, Johns Hopkins pulmonology and critical care fellow J. Henry Brems and Johns Hopkins cultural anthropologist Kadija Ferryman.

The editorial lists some of the challenges and solutions for removing race-based equations from pulmonary function tests. They include minimizing physical, economic and social harms by thoroughly evaluating different proposed race-free equations.

Additionally, McCormack has co-authored materials that patients can review with their providers to better understand their pulmonary function tests and address any concerns, either before or after their tests.

Johns Hopkins cardiologist Chiadi Ndumele took testing outcomes into account when he began working to improve calculations for heart disease. Ndumele and nephrologist Janani Rangaswami of George Washington University ultimately received the 2024 award of meritorious service from the American Heart Association (AHA) for helping to establish and define cardiovascular-kidney-metabolic (CKM) syndrome.

“CKM is a new way of thinking about the overlapping effects of obesity, type 2 diabetes, chronic kidney disease and cardiovascular disease,” Ndumele explains.

The AHA removed race from its risk prediction models in 2023. Its new calculator, PREVENT, contains CKM components that help predict a person's likelihood of having a heart attack, stroke or heart failure. According to the AHA, this work is expected to transform patient-centric health care approaches around the world.

“It’s hard for a patient to navigate their illness when their cardiologist might be suggesting slightly different things than their nephrologist or endocrinologist or primary care physician. For optimal CKM care, we need to be thinking about treatment strategies from the standpoint of the patient,” Ndumele said in the AHA newsletter.

Since 1998, clinicians had estimated cardiovascular risk with equations based on data from the Framingham Heart Study, which began tracking patients who were nearly all white in a town outside Boston in 1948. In 2013, aiming to be more equitable, the data included more Black Americans but few from other racial groups.

PREVENT uses health information from more than 6 million adults from a variety of racial and ethnic backgrounds. In addition to CKM measures, it also includes a “social deprivation index,” linked to ZIP code, which considers such factors as wealth and levels of education.

“A priori, we didn’t put race in the model,” Ndumele says. “However, we do know that there are very significant racial disparities that we’re very interested in addressing as part of our prevention work. The model is capturing the fact that we still see these racial disparities, and we’re starting to focus more on the underlying social determinants of health.”