Sophie Sandler
Professor Kenaley & Professor Jewett
Science and Technology in American Society
November 2018
Gender, Racial and Socioeconomic Inequalities of Transplantation
As Professor Jewett has stated, science is supposed to be objective, neutral, and unbiased, yet, medicine has proven time and time again to favor those with power and money. Last year I observed this first hand, when I interned for Dr. Timothy Pruett, the head of the surgical transplant department at the University of Minnesota, Twin Cities. Through observation and research I have learned that recipients of transplants (specifically cadaver donor kidney transplants) are more often than not white, wealthy, males. In fact, eligible African Americans recieve 35% less transplants when compared to caucasian recipients (JASN), males are 8% more likely to receive a kidney transplant within 5-year compared to women (JAMA), and poor people are 14.6% less likely to have ongoing care than their rich counterparts (AHRQ). For a system that claims to be so unbiased, medicine has proven to have gender, racial and socioeconomic inequalities.
Racial minorities receive 35% less transplant when compared to to white recipients because of issues with access to care, delayed referral for transplantation and subsequent delay in access to the national waiting list. The issue of access to care stems from the lack of healthcare options for minorities. In fact, in 2008, the percentage of people with a specific source of ongoing care was lower for African Americans than for Caucasian (84.7% compared with 86.3%) and significantly lower for Hispanics than for non-Hispanic Whites (77.1% compared with 88.6%) (AHRQ). Racially diverse patients have less access to adequate care, which delays them from getting a referral for transplant evaluation. This has proven to be because of a lack of educational efforts regarding transplantation for racially diverse patients. This leads to a lack of preemptive transplants for patients of minorities: in fact only 1% of preemptive transplants are racially diverse (Dialysisdata). This leads to delayed access to organ waitlists. In fact, registry data revealed that African Americans wait 76.5 more mean days longer per 5 years on the waiting list (Health Disparities in Kidney Transplantation for African Americans). This data leads us to conclude that minorities don’t have access to care to learn more about there option, aren’t referred for transplant evaluation in a timely manner, and are not put on the waitlist soon enough: which gives them a disadvantage in receiving a transplant compared to a caucasian.
While racial minorities are less likely to receive a cadaver donor kidney transplants compared to their white counterpart, the 5-year probability of receiving a kidney transplant is also 47% for men and at 39% for women (Sex Inequality in Kidney Transplantation Rates). One of the causes of this is the fact that women have less access to insurance because of decreased income. Kjellstrand C.M studied this and observed that in the United States, the reduction in Medicare eligibility after transplantation may have served as a greater deterrent to transplantation for women relative to men because of sex differences in income and insurance coverage. This indicates that men may have been more able to afford additional costs related to transplantation, because of either increased income or supplemental insurance plans obtained through their employer (Sex Inequality in Kidney Transplantation Rates). While this study proves that men have more access to insurance, which gives them more opportunities to receive a transplant, this is also true for racial minorities and low income patients. Some rationalize that men are favored on the waiting list because of their ‘tougher immune system’. This is simply false. In a study of midwestern US patients undergoing renal transplantation, Kjellstrand observed a ‘significantly elevated percentage of patients who underwent transplantation among men relative to women, which persisted on exclusion of patients who had cytotoxic antibodies against 90% or more of random donors, but disappeared when the cut point was lowered to 50% or more’ (Sex Inequality in Kidney Transplantation Rates). Hospitals have also been known to increased waiting times for women. For example, for coronary heart disease, male patients are reportedly treated more aggressively than female patients, independent of disease severity. Women experiencing chest pain also reportedly wait longer than men in emergency departments before they are examined (Sex Inequality in Kidney Transplantation Rates). This proves that women are less treated, and less likely to receive expert medical care before their male counterparts: this leads to decreased referral to transplant evaluations and delay in access to the national waitlist. Further research is clearly needed in this area. Unfortunately many physicians are reluctant to consider the possibility that sex bias exists. Yet, from this research it is apparent that because women have less access to insurance, have increased waiting times, and are perceived as passive, they are less likely to receive a transplant compared to their male counter parts.
It could be suggested that because women and minorities have statistically less income then there white, male counterparts, that all of the systematic inequality in organ transplantation is socioeconomic. This is not true because white, males that are of a lower socioeconomic state are also at a disadvantage. R. E. Patzer produced a study showed that poor white patients were less likely to be put on the national waitlist compared to a average wealthy patient (The Role of Race and Poverty on Steps to Kidney Transplantation in the Southeastern United States). While this study proves that poor, white patients are at a disadvantage for cadaver donor kidney transplants, African Americans were still 57% less likely to be waitlisted than whites in poor neighborhoods (Neighborhood Poverty and Racial Disparities in Kidney Transplant Waitlisting). Another reason for socioeconomic inequality in cadaver donor kidney transplants is the fact that people that have more money have the ability to go to more centers to be on more regional waitlists. While being on multiple regional waitlist for an organ has proven to increase the likelihood of getting cadaver donor organs sooner, the potential downside of multiple listing is its effect on patients not on multiple lists. Meaning that only high income patients will have access to this advantage. These rich patients that are on multiple wait lists for organs also have decreased likelihood of needing extensive procedures because of their decreased wait time. Multiple listed patients less often received therapy with intra-aortic balloon pumps, ventricular assist devices, or inotropic medications at initial registration and were less often hospitalized or treated in an intensive care unit- each of which also predicted longer wait among single listed patients (The Impact of Socioeconomic Status on Patients Supported with a Left Ventricular Assist Device). This demonstrates that not only are multiple listed patients requiring less expensive surgeries to keep them alive (because of decreased wait times) they also are healthier. This divide between rich and poor cadaver donor organs patients has become a major debate among physician: in fact, Dr. Raymond Givens, a fellow at Columbia University Medical Center in New York, states that "We [the medical community] firmly believe the multiple listing policy needs to be reconsidered." Rich people are at a systematic advantage compared to poor, because of multiple listers: who are 59% more likely to have private insurance (The Impact of Socioeconomic Status on Patients Supported with a Left Ventricular Assist Device) .
United Network for Organ Sharing (UNOS) is the current system incharge of waitlists and the distribution of organs. UNOS currently uses a national computer system and strict standards are in place to ensure ethical and fair distribution of organs (UNOS). Some may argue that despite all the statistics proving otherwise, the UNOS system transplantation is unbiased and fair: not based on money, gender or race. It can be argued that because of the simple ranking system that UNOS used, the system gives no person an advantage over another: but the data above proves that while it may be a simple waitlist system, its access into that system isn't fair. While the UNOS system in place definitely decreases biased, there should be a new system in place that eliminates all biased in receiving cadaver donor organs. The improved system should address the active organ assignment along with the entry into this system: creating a better, fairer system for everyone.