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Challenges Revealed by Pandemic May Drive Innovation in Medicine, Kidney Care

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As former assistant secretary for preparedness and response at the US Department of Health and Human Services, Nicole Lurie, MD, MSPH, has learned that the key to a successful crisis response is having a plan and strong day-to-day systems in place before disaster strikes.

“If your day-to-day system is strong, you are going to do better than if it is not—coronavirus 2019 (COVID-19) is no exception,” Lurie said during the Kidney Week 2020 Reimagined session “Policy in a Post-COVID World.” Lurie gave the Christopher Blagg, MD, endowed lecture in Kidney Diseases and Public Policy during the session. She co-chairs the ASN’s Emergency Partnership Initiative.

Although the lack of a national plan has hindered the COVID-19 response, Lurie said disaster planning for dialysis patients by dialysis organizations and the American Society of Nephrology (ASN) has helped the nephrology community rapidly respond to the high rates of acute kidney injury in COVID-19 patients. Some governors and local leaders have provided “exemplary leadership,” and frontline caregivers and institutions like academic medical centers also have heroically stepped up to lead, she said.

“Crises can bring out the best in people,” she said. “One of the things I’ve seen with the kidney response and with ASN and frankly in many of our communities is just how much it has brought out the best in people.”

Lurie and her fellow panelists say now is the time to start addressing policy challenges like systemic racism, a weakened public health system, and immigration policies that harm international medical graduates who have played an essential role in delivering care during the pandemic.

“Never let a good crisis go to waste,” Lurie said. “This is really the time for us to be thinking about the way we want the world to look and the way we want kidney care to look going forward.”

Stepping into the void

Panelist Paul Klotman, MD, president and chief executive officer at Baylor College of Medicine in Houston, Texas, and other leaders of academic medical centers have found themselves and their institutions having to step in to fill gaps in COVID-19 information, testing, and policy. “We have had a failure of public health leadership in the country with this pandemic; it’s exposed a lot of problems, and as a result many of the academic medical centers have had to step up in ways we never intended,” he said.

At Duke University, panelist Mary Klotman, MD, dean of the School of Medicine and vice chancellor for health affairs and chief academic officer for Duke Health, and her colleagues have also stepped in to provide expertise and resources at the local, state, and national levels. Duke’s physician’s assistant program developed a contact tracing curriculum that allowed students to help support local contact tracing efforts while earning credit. Faculty members have contributed their expertise in science and policy to task forces developing plans to distribute vaccines. They’ve also created The ABC Science Collaborative (1) to guide schools on reopening, and the Latinx Advocacy Team and Interdisciplinary Network for COVID-19 to share information, educational materials, and resources in Latino communities.

“This type of work is not our normal daily operational work, but it has been so critical to advising our communities on how to move forward and how to do things safely,” Klotman said.

Experts from academic medical centers have also stepped up to advise the public, business leaders, and policymakers.

“In the media, many of our faculty have become trusted sources of truth,” Mary Klotman said. For example, Mark McClellan, MD, PhD, director of the Duke-Margolis Center for Health Policy, regularly shares his policy expertise on news programs, and Baylor’s Peter Hotez, MD, PhD, a leading infectious disease expert, makes frequent appearances to talk about COVID-19 and the national response to it.

Baylor stepped in to make COVID-19 tests, and the chief executive officer of the Texas Medical Center led an effort to pool COVID-19 data from area hospital systems and share it with the public and area leaders to guide local decision-making, Paul Klotman said.

“The biggest failure of the public health systems for this particular pandemic is we did not have access to actionable data,” Paul Klotman said. “We started sharing data in real time, and because we were developing all the tests we actually could follow the pandemic and the local effects of the pandemic.”

Stepping into these roles has led to some good things as well. Mary Klotman noted that institutions learned they could be much more efficient in getting research and partnerships under way, and they have built trust in their surrounding communities. For example, they opened clinical trial centers in communities hard hit by COVID-19, making it easier for people to participate in studies, and the university plans to keep them open going forward.

“Hopefully, we will use this opportunity to learn and be prepared for the next crisis, which undoubtedly is going to happen,” she said.

Envisioning an equitable future

The disproportionate effects of the COVID-19 pandemic on Black and brown communities, and civil unrest over police brutality against Black people have also brought renewed attention to the need to address all forms of racism in the United States, in healthcare and kidney care, panelists said.

“The COVID-19 pandemic has pulled the curtain back on the far-reaching effects of structural racism in this country,” said Keisha Gibson, MD, MPH, associate professor and chief of pediatric nephrology at the University of North Carolina, Chapel Hill.

The role clinicians’ biases play in contributing to race-based disparities in patient outcomes needs to be addressed, Gibson said. “Every last one of us harbors bias,” she said. “It is often unconscious and doesn’t necessarily align with intent. We owe it to our patients to not only acknowledge that, but to take steps to measure [our biases] and work hard to prevent their impact on our decision-making and conversations with our patients.”

To provide truly antiracist kidney care, Gibson said, research focused on race-based health disparities needs to be held to higher standards. She said that studies focusing on race as a biologic factor should be discouraged and that more research should be done on the role racism plays. For example, the LUMINA study, looking at the role of ancestry in lupus outcomes, found that Latinx patients in the United States fare more poorly than individuals with similar ancestry living in Latin America (2). Similarly, other studies have shown that adjustment for poverty and socioeconomic factors eliminates differences in lupus outcomes in white and Black patients receiving comparable treatment.

“We know that race is a social construct,” she said. “Despite this, we continue to conduct, publish, and fund studies that apply significant weight on what is likely a minimal biologic influence of race and that consistently fail to address the impact of what this social construct does enable, and that is racism and bias.”

Gibson said it is important to interrogate the origins of the science behind the inclusion of race in estimated GFR equations and other clinical algorithms. She noted that although the intent of such algorithms was to streamline care, that intent may have overshadowed biased assertions, tainting some of the research it was based on.

“All kidney health algorithms and policies that include race need to be reevaluated to interrogate the validity and the potential consequences of perpetuating disparities—largely unintended—and changed accordingly,” she said.

She noted that policies that hinder the use of unconscious bias training among federal contractors and at federal agencies may disrupt efforts to address implicit bias in care and research.

Greater efforts are needed to boost diversity in the kidney care workforce, both Gibson and Lurie argued. Immigration and travel policies that harm international students and medical graduates must also be addressed, they said.

“As bad as things are now, imagine how much more devastating our fight against COVID-19 would be if we did not have the critical mass of international medical graduates,” Gibson said. “Policies that threaten the ability of these colleagues to train and practice in the United States run the risk of absolutely crippling our critical nephrology workforce.”

Regarding the policy challenges that have come into stark relief during the pandemic, Gibson stated: “If we are bold and deliberate in our actions to push these policies, we may find ourselves much closer to solving race-based health disparities, rather than just describing them,” she said.

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