Ending Race-Based Assessments in Occupational Pulmonary Impairment: A Path to Fairness and Accuracy

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How do historical biases in reference data for pulmonary function tests contribute to the perpetuation of racial inequities in occupational lung disease diagnosis?

The Historical Context of Racial Adjustments in Pulmonary Function Testing

For decades, pulmonary function tests (PFTs) – crucial for diagnosing and assessing occupational lung diseases like coal worker’s pneumoconiosis, silicosis, and asbestosis – have incorporated race-based correction factors.These adjustments, intended to account for perceived differences in normal lung function based on race, have historically disadvantaged Black, Indigenous, and People of Color (BIPOC). The underlying premise, rooted in flawed science and systemic racism, assumed inherent physiological differences that justified lower predicted values for BIPOC individuals. This practice has led to underdiagnosis of pulmonary impairment and inadequate compensation for workers suffering from work-related lung disease.

Why Race-Based Corrections are scientifically Unsound

The scientific basis for race correction in PFTs is increasingly discredited. Genetic variation within racial groups is far greater than between them. Lung function is more strongly correlated with factors like height, age, sex, and smoking history than with self-identified race.

Here’s a breakdown of the issues:

Genetic Diversity: Human genetic variation is continuous, not neatly categorized by racial groupings.

Environmental Factors: Socioeconomic disparities, access to healthcare, and exposure to environmental pollutants significantly impact lung health and function, frequently enough disproportionately affecting BIPOC communities. These factors, not race itself, contribute to observed differences.

Historical Bias: The original reference data used to establish these corrections were frequently enough based on limited and biased samples, perpetuating existing inequalities.

Impact on Diagnosis: Applying race-based corrections can falsely classify individuals as having normal lung function when they are, in fact, experiencing significant respiratory impairment.

The Impact on Occupational Health and Workers’ compensation

The consequences of race-based PFT adjustments are particularly severe in occupational health. Workers in industries like mining, construction, and manufacturing are at increased risk of developing occupational lung diseases. When race-based corrections are applied, BIPOC workers are less likely to:

Receive an accurate diagnosis of pneumoconiosis or other dust diseases.

Qualify for workers’ compensation benefits.

Access necessary medical care and rehabilitation services.

Experience equitable outcomes in disability claims.

This systemic bias perpetuates health inequities and reinforces historical injustices. The World Health Organization (WHO) emphasizes the importance of occupational health and worker well-being, a goal undermined by discriminatory practices in assessment.

The Movement to Eliminate Race-Based Corrections

A growing movement, led by medical professionals, advocacy groups, and legal experts, is advocating for the elimination of race-based corrections in PFTs. Key milestones include:

2020: The American Thoracic Society (ATS) and the American Civil Liberties Union (ACLU) filed a petition with the Social Security Governance (SSA) to end the use of race-based corrections in disability determinations.

2021: The SSA proposed a rule to remove race as a factor in disability evaluations, including PFTs.

2024: Implementation of the new rule, marking a significant step towards fairness and accuracy.

State-Level Changes: Several states are reviewing and revising their workers’ compensation laws to eliminate race-based adjustments in PFTs.

Implementing Race-Neutral Pulmonary Function Testing

Transitioning to race-neutral PFTs requires a multi-faceted approach:

1. Utilize Race-Neutral Predictive Equations: Employ equations developed using diverse and representative populations, focusing on individual characteristics like height, age, sex, and ethnicity (when relevant for genetic predispositions not tied to broad racial categories).
2. Standardize Testing Procedures: Ensure consistent and high-quality PFT administration across all healthcare settings.
3. Comprehensive Medical History: Obtain a detailed medical history, including occupational exposures, smoking history, and any pre-existing respiratory conditions.
4. Consider Environmental Factors: Account for environmental exposures and socioeconomic factors that may influence lung function.
5. Ongoing Education: Provide ongoing education and training for healthcare professionals on the rationale for eliminating race-based corrections and the proper use of race-neutral PFTs.

Benefits of Eliminating Race-Based Assessments

Removing race as a factor in PFTs offers numerous benefits:

Improved Diagnostic Accuracy: More accurate diagnoses of occupational asthma, chronic obstructive pulmonary disease (COPD), and other respiratory illnesses.

Equitable Access to Benefits: Fairer access to workers’ compensation, disability benefits, and healthcare services.

Reduced Health Disparities: A step towards addressing systemic health inequities affecting BIPOC communities.

Enhanced Occupational Safety: Improved identification and prevention of workplace hazards leading to lung disease.

Ethical Practice: alignment with ethical principles of medical practice and social justice.

Practical Tips for Healthcare Professionals

Stay Updated: Keep abreast of the latest guidelines and recommendations from professional organizations like the ATS and the