The COVID-19 pandemic is providing further evidence that medical tools, methods and interventions optimized for white or western populations do not work equally well in other ethnicities or health settings.
In light of the respiratory problems caused by COVID-19, the United Kingdom recently ordered a review of oximeters used to determine levels of blood oxygen in several conditions including pneumonias and COVID-19. The review followed the discovery that the global standard oximeters dangerously overestimated levels of blood oxygen in Black and Asian patients
We have known about the poorer performance of oximeters in dark skinned people since the 1980s and from several recent scientific papers and discussions in the media. This this is just the latest example to forcefully remind us of the reality that modern medicine is largely built on data, risk analysis and tools designed, tested and optimized for a narrow cohort of the White population. Oximeter studies in Africa and Asia have demonstrated the importance of evaluating the performance of medical devices in all end-user populations.
Current tools in use which poorly serve Black Africans range from child development assessment tools that ignore cultural and health setting differences, breast cancer treatment ineffective in Black women, even sizes of condoms critical in the fight against HIV, and tools inappropriate or not evaluated in African health systems.
I recently co-authored work highlighting shortcomings of the diagnosis of the autoimmune disease systemic sclerosis (SScl) a disease with higher incidence and prevalence in people of Black African descent. SScl diagnosis is based on international criteria set by the American Rheumatism Association (ARC) using patients predominantly in Europe and Northern America. Our study conducted in Zimbabwean Black, White and Asian patients, shows that the international diagnostic criteria overlook significant features that occur in Black African patients. Another important finding was the high frequency of SScl in Black children under the age of 16 years, suggesting that a high index of suspicion is required in investigating and managing Black patients with unexplained respiratory and cutaneous symptoms. This is becoming a pattern for autoimmune diseases. We have previously shown that the diagnostic criteria for lupus overlooked a variant of the disease prevalent in patients of Black African descent. These non-inclusive diagnostic criteria might be contributing to the differences in disease severity and prognosis between different racial or ethnic groups reported at the ARC’s annual meeting this year.
The treatment of the parasitic worm disease, Schistosomiasis (bilharzia), the second most important parasitic is a good example of how inappropriate policies and tools can compromise health in Africa. It has taken years to have guidelines revised that excluded children aged 5 years and under to address a health inequity in Africa.
The schistosomiasis example demonstrates the range of systemic root causes of health inequalities in Africa. First, the children were excluded from treatment because the original multicentre clinical trials were conducted in adults and children older than six. This was due to the lack of evidence of patterns of exposure of these children to infection and it was incorrectly assumed their risk of infection was low. So the safety and efficacy of the drug were unknown in the young children. Second, there was no scientific evidence of the disease burden in the children as no relevant studies had been conducted in Africa; therefore, these young children were not prioritised in public health programmes. Finally, there were no strategies for accessing and treating the young children within African health and healthcare systems which differ from those in Europe Asia or the USA. I have lead research that has methodically addressed each of these failings culminating in the WHO changing treatment guidelines to include these children in schistosomiasis treatment programmes. This work has also contributed to developing a paediatric formulation for treating schistosomiasis, which completed phase 3 clinical trials this month.
From these few examples, it is clear that in order to change medicine’s current biases, African scientists, health professionals, policy makers and stakeholders must do the following five things. First, current diagnostics, medical devices, treatments and vaccines must be evaluated in appropriate African populations and the data made publicly available. Second, going forward, future[MF1] clinical trials for drugs and vaccines for deployment in Africa should be conducted in the target end-user African populations. Third, these should be evaluated specifically within the African health systems they will be deployed. Fourth, African countries must strengthen their biomedical research ecosystem to support the first three activities. Finally, African countries should formulate and implement locally relevant health policies driven and informed by local data. Until this happens, Africans will continue to rely on medical devices, tools, interventions and polices that do not work optimally for them.
Francisca Mutapi, Fellow of the African Academy of Sciences, is a Professor of Global Health Infection and Immunity at the University of Edinburgh and deputy Director of the NIHR Global Health Unit TIBA (Tackling Infections to Benefit Africa).
