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Advocating for a shift from race-based to race-conscious medicine

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“I am Italian-Chilean-American (Mapuche), Marie is Haitian-American, and Jenny is Taiwanese-American. We have all experienced racially-tailored care at some point in our lives. Our lived experience enhances the authority of our work,” says Yale School of Medicine MD-Ph.D. student Jessica Cerdeña, MPhil.

Cerdeña is referencing her co-authors, Howard University Ph.D. student Marie Plaisime, MPH, and Yale Emergency Medicine physician Jennifer Tsai, MD, MEd—and their article, From race-based to race-conscious medicine: how anti-racist uprisings call us to act, recently published in The Lancet.

Cerdeña, Plaisime, and Tsai had submitted their article to The Lancet, after the medical journal, in June, announced a commitment to action following George Floyd’s murder and the Black Lives Matters protests. “Our task is to educate ourselves and others about racism. We must support Black and minority ethnic health workers,” The Lancet stated. It pledged “to use science as an instrument for social change,” in part through “the research we publish, the authors we commission, and the individuals we choose to profile and recognize.”

Cerdeña, Plaisime, and Tsai, according to Cerdeña, saw this commitment to action as an opportunity “to speak to longstanding issues of race-based medicine.” In their article, the authors state that medicine “is an institution of structural racism” and that a pervasive example of this is race-based medicine, “the system by which research characterizing race as an essential, biological variable translates into clinical practice, leading to inequitable care.”

The authors seek to shift from race-based to race-conscious medicine, “to promote conscious, antiracist practices over unchecked assumptions that uphold racial hierarchies.” Additionally, as Cerdeña describes, “we had seen other work discussing issues of racism in medicine and race-based medicine, but we had not seen any actionable tools that proposed a way forward. We hope that our work provides a model for how to dismantle race-based medicine and instead address the health consequences of structural racism.”

The authors note that during European colonialization, “race was developed as a tool to divide and control populations worldwide. Race is thus a social and power construct, with meanings that have shifted over time to suit political goals, including to assert biological inferiority of dark-skinned populations.”

They describe how despite “the absence of meaningful correspondence between race and genetics, race is repeatedly used as a shortcut in clinical medicine”—and how medical education often trains students to continue this harmful practice. For example, “race is often learned as an independent risk factor for disease, rather than as a mediator of structural inequalities resulting from racist policies.” When health disparities are presented without context, students learn to associate race with disease conditions, for example, cystic fibrosis and hypertension, and develop dangerous stereotypes. Clinical rotations often reinforce these lessons, when students are taught that race is relevant to treatment decisions, and because of power dynamics, cannot “question the racialized assumptions of their supervisors.”

The authors argue that health inequities would be reduced if there was a shift to race-conscious medicine, which emphasizes “racism, rather than race, as

Pediatric Fractures Shift During Pandemic

Editor’s note: Find the latest COVID-19 news and guidance in Medscape’s Coronavirus Resource Center.

Pediatric fractures dropped by 2.5-fold during the early months of the COVID-19 pandemic, but more breaks happened at home and on bicycles, and younger kids were more affected, new research indicates.

The study of 1745 patients also found that those with distal radius torus fractures were more likely to receive a Velcro splint during the pandemic. Experts said this key trend points toward widespread shifts to streamline treatment, which should persist after the pandemic.

“We expected to see a drop in fracture volume, but what was a bit unexpected was the proportional rise in at-home injuries, which we weren’t immediately aware of,” said senior author Apurva Shah, MD, MBA, of Children’s Hospital of Philadelphia (CHOP) and the University of Pennsylvania Perelman School of Medicine in Philadelphia.

“As time went on, it became more apparent that trampoline and bicycle injuries were on the rise, but at the beginning of the pandemic, we didn’t intuitively expect that,” he added.

“Whenever there’s a major shift in how the world is working, we want to understand how that impacts child safety,” Shah told Medscape Medical News. “The message to get out to parents is that it’s obviously difficult to supervise kids while working from home” during the pandemic, “and that supervision obviously is not always working as well as intended.”

Joshua T. Bram, a medical student, presented the study at the virtual American Academy of Pediatrics (AAP) 2020 National Conference.

Bram, Shah, and colleagues compared patients with acute fractures who presented at CHOP between March and April 2020 with those who presented during the same months in 2018 and 2019.

Overall, the number of patients with pediatric fractures who presented to CHOP fell to an average of just under 10 per day, compared with more than 22 per day in prior years (P < .001). In addition, the age of the patients fell from an average of 9.4 years to 7.5 years (P < .001), with fewer adolescents affected in 2020.

“I think when you cancel a 14-year-old’s baseball season” because of the pandemic, “unfortunately, that lost outdoor time might be substituted with time on a screen,” he explained. “But canceling a 6-year-old’s soccer season might mean substituting that with more time outside on bikes or on a trampoline.”

As noted, because of the pandemic, a higher proportion of pediatric fractures occurred at home (57.8% vs 32.5%; P < .001) or on bicycles (18.3% vs 8.2%; P < .001), but there were fewer organized sports–related (7.2% vs 26.0%; P < .001) or playground-related injuries (5.2% vs 9.0%; P < .001).

In the study period this year, the researchers saw no increase in the amount of time between injury and presentation. However, data suggest that in more recent months, “kids are presenting with fractures late, with sometimes great consequences,” Shah said.

“What has changed is that a lot of adults have lost their jobs, and as a consequence,

How The New Rapid Tests Could Drive A Coronavirus Testing Paradigm Shift : Shots

A new wave of rapid coronavirus tests have entered the market and have the potential to greatly expand screening for the virus.

Spencer Platt/Getty Images

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Spencer Platt/Getty Images

A new wave of rapid coronavirus tests have entered the market and have the potential to greatly expand screening for the virus.

Spencer Platt/Getty Images

A new generation of faster, cheaper coronavirus tests is starting to hit the market. And some experts say these technologies could finally give the U.S. the ability to adopt a new, more effective testing strategy.

“On the horizon — the not too distant horizon — there are a whole series of testing modalities coming on line,” says Dr. Ashish Jha, dean of the Brown School of Public Health. “And that gives us hope we can really expand our testing capacity in the nation.”

Until now, testing has been primarily used to diagnose people who may have COVID-19 and any of their close contacts who may also be infected. But a stubborn shortage of the molecular tests most commonly used — and slow turnaround time for results — has hobbled the nation’s ability to stop outbreaks and contain the pandemic.

That could change, argue Jha and other public health researchers, as new rapid tests — primarily antigen tests — become more widely available, enabling communities to start widespread screening of the highest-risk people.

“It is a paradigm shift,” Jha says. “What I think new testing capacity allows us to do is actually play offense — go and hunt for the disease before it spreads to identify asymptomatic people before they spread it to others. It really becomes about preventing outbreaks — not just capturing them after they’ve occurred.”

Jha and a team at the Harvard Global Health Institute have periodically evaluated how much testing the country and individual states need to effectively fight the spread of the virus.

In a new analysis the group completed for NPR, researchers developed daily testing targets, showing what would be needed to routinely screen large numbers of asymptomatic people. The researchers factored in the growing availability of the rapid coronavirus tests.

The U.S. would need 4.4 million tests every day, the analysis concludes, to reach what Jha calls “a basic level of proactive testing.” The idea is to do regular testing of some of the highest risk groups — stopping outbreaks before they can spill over to the rest of the community.

This scenario calls for screening all nursing home residents and staff twice a week and weekly testing of every prison inmate and guard, firefighter, police officer and emergency medical technician, as well as teachers and staff in K-12 schools, and all university students.

Using the older molecular test technology, the U.S. has never managed to perform more than about 1 million tests per day. But the companies that make the new antigen tests are ramping up production and additional tests are in the pipeline. As a result, Jha and others estimate that there could be enough