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The Inequities of Kidney Disease

Racial disparities in kidney disease contribute to suffering and premature death for Black people.

By Lindsay Smith Rogers | September 3, 2020


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Tanjala Purnell, PhD, MPH, and Deidra Crews, MD, of the Johns Hopkins Center for Health Equity see harsh health disparities among Black people through the lens of their work around kidney disease.

Black Americans experience kidney failure at three times the rate of whites.

Along with other racial and ethnic minority groups, they also suffer from some of the highest rates of diabetes and hypertension, two leading causes of kidney failure. These health outcomes are not the result of any predisposition to poor health, Purnell says. A confluence of factors—especially racial discrimination in opportunities for housing, education, food, health care, and employment—contribute to this discrepancy. Like other minorities, Black Americans tend to have lower incomes and live in areas with less access to healthy foods—both key to following a healthy diet for kidney and other chronic disease prevention. 

Another byproduct of racial discrimination is that many Black people lack access to diagnosis and treatment for chronic health issues. Timing is critical for managing kidney disease and Black Americans often aren’t diagnosed until the later stages of the condition, or even upon kidney failure, which makes the disease harder to treat and worsens the prognosis. 

In most cases, a kidney transplant is preferable to long-term dialysis in terms of quality of life and life expectancy. However, there’s a lengthy evaluation process often followed by a long wait on a deceased donor list. Finding a living donor can shorten the wait for a kidney but, for Black Americans and other people of color, this isn’t always easy given the high numbers of chronic health problems, a lack of education around living kidney donation, and fear and distrust of medical institutions in minority communities.

Further contributing to and exacerbating kidney disease and other chronic illnesses, Purnell and Crews say, is “weathering.” Weathering is eroded health caused by repeated harmful experiences like racism. The associated chronic stress, which starts in utero, has a cumulative effect on physical and mental health throughout a lifetime. 

Dual Epidemics: COVID-19 and Racism

For Black Americans, both the COVID-19 pandemic and incidents of violence against Black people are major contributors to weathering. 

“In 2020, the COVID-19 pandemic on top of very high profile cases of violence against Black individuals are yet another adverse experience for Black Americans to ‘weather,’” says Purnell. “Organ donation and transplants are layered on top of watching, in real time, as Black individuals are being gunned down or feeling as if Black lives are being marginalized.”

COVID-19 has also introduced exceptional challenges to care for kidney patients. Procedures like the surgery needed to place an access tube so patients can receive dialysis were postponed as “nonessential surgeries” earlier in the pandemic which prolonged the wait for treatment. Those on dialysis are likely being treated several times a week in a center where there are further risks of exposure. The resumption of postponed transplant surgeries has now created an additional level of risk for both donors and recipients, especially for Black people.

“Asking family members or loved ones to donate an organ when they’re not sick—basically asking them to come and put themselves potentially in harm’s way—these are all things that have very real consequences,” Purnell says. 

Purnell also points out a pernicious aspect of weathering: none of these factors can be looked at in isolation. The challenges compound each other and contribute to generations of harm. 

Trauma is also cumulative, Crews says, and it’s something that can be experienced vicariously. 

David Williams’s work highlighted the issue of ‘vicarious trauma’—so not only the experiences that Black individuals and other marginalized populations may have themselves directly, but there’s also an effect when you witness these things. Those have also been shown to have negative impacts [on health] and they’re also things that have to be weathered,” says Crews.

Dismantling Racism to Improve Health Outcomes

Investing in the health and well-being of Black people means addressing the root causes of weathering and, by default, of systemic racism. This has to happen both on a societal level and on an individual level. 

“Each of us has a role to play in this,” says Crews. “At a societal level, every one of us has a role to play in dismantling the structures that have led to what we see today in these inequities.”

From her standpoint as a clinician, Crews says that this role starts with one-on-one patient care. “When you’re seeing a patient, one of the things we can do is to just acknowledge that the person sitting in front of you may have experienced these things or may be weathering these things. It’s so key, especially in this time, to acknowledge the grief that people are experiencing.”

Public health professionals have a duty to try to study these issues, Purnell says, not just to provide evidence documenting these problems, but to develop solutions.

“We all, collectively, have an obligation to talk about the nuanced complexities of how we are measuring race, what it means, and to think about the role of structural racism and the differences in social, political, and economic barriers and how these lead us to many of the observed differences by race in a lot of our outcomes across the board.” 

But addressing health disparities upstream doesn’t just fall on clinicians and researchers. Both Purnell and Crews say that all of us as individuals have an obligation to advocate for change.

“Each and every one of us can use our platform—and all of us have a platform, some of us greater than others,” Crews says. “At the local level, we can advocate for challenges around basic needs that people of color and low incomes are struggling with that have been magnified by COVID-19. [We can advocate for] access to high quality housing that is health-promoting as opposed to health-detracting. We’re also seeing spikes in the number of food insecurities during this time due to economic reasons and because food outlets have had to close. [We can] individually support people who may be struggling, and also advocate for expansion of policies like the Supplemental Nutrition Assistance Program (SNAP) or food stamp program.”

Racism and discrimination are key contributors to kidney disease and other chronic illnesses that lead to suffering and premature death. Ultimately, the health and well-being of Black people and people of color has to start further upstream before anything can be improved downstream.


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