By Aziza Ahmed
When Black Lives Matters (BLM) activists say “I can’t breathe,” they are acknowledging that breathing is not simply biological — it is enabled or disabled by law and politics. They are right.
In fact, the legal and political environment shapes and legitimates the very tools we use to monitor our capacity to breathe.
The racial justice uprisings and the COVID-19 pandemic have inspired advocates, scholars, and researchers to examine the assumptions about race that have embedded themselves into these tools — the medical technologies we use to measure if, and how, a person is breathing and absorbing oxygen.
Early in the pandemic, attention turned to the pulse oximeter, which measures oxygen saturation.
A troubling finding began to receive more attention: the pulse oximeter measures oxygen saturation differently for people with darker skin colors. The implications for COVID (and beyond) were deeply concerning.
As a commentary in the New England Journal of Medicine highlighted, Black people had three times the frequency of occult hypoxemia that was not detected due to pulse oximetry. The authors of the study featured in the commentary suggested that this could place Black patients at an increased risk for hypoxemia (a below-normal level of oxygen in the blood).
Beyond the COVID-19 pandemic, this design flaw with pulse oximeters means that individuals monitoring their own health at home, or patients being monitored in hospitals, could be at risk of low oxygen.
Following the NEJM article, and pressure from Senate democrats, the U.S. Food and Drug Administration (FDA) issued a safety communication warning users of pulse oximeters of their potential inaccuracies. Researchers and advocates called for fixing the racial bias embedded in the technology itself. Actual change will only come, however, with sustained pressure and attention to the failures of the pulse oximeter.
This is not the first time that the technologies to help measure people breathe manifested health inequalities.
In her powerful book, Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics, Lundy Braun, a historian of science, shows that even how we measure a breath — through a machine called a spirometer — has a racial bias.
She underscores the race “correction” built into the machine — one that suggests that Black people have lower lung capacity — as a manifestation of racial science. Thomas Jefferson, she writes, helped set this idea into motion when he wrote of “a difference of structure in the pulmonary apparatus” that may disable both inspiration and expiration in Black people. The lower lung functioning of Black people would become part of the logic justifying the racial superiority of Whites.
Perhaps most shockingly, the race correction still exists in the spirometer today. This tool is used to determine whether a person is deserving of health care after being exposed to toxins at work, and whether a person has asthma or not. The purportedly neutral scientific test will ensure that Black people will often fall objectively short of deserving necessary health care.
The COVID pandemic and the racial justice uprisings reveal to us that breathing is not simply biological. Our ability to breathe is shaped by the laws and politics that govern the use of technologies, and that validate racialized assumptions about people.
Law and public health scholars have developed many frames to begin to address the legal and social context that limits peoples’ ability to breathe and thrive, which results in health inequalities. Of these, the health justice framework aims to eliminate health disparities caused by discrimination and poverty. In its call to understand law and social context, a health justice framework makes room for identifying and considering the layered way race operates in the context of law, science, and medicine, with a view to eliminating health disparities these interactions produce. As the story of the pulse oximeter and lung spirometer teaches us, to remedy health inequalities requires an understanding of how ideas about race are embedded into the very instruments we use to measure and understand health outcomes. A health justice framework pushes us to take apart our assumptions, even those rooted in science and medicine.
Aziza Ahmed is a professor of law at University of California, Irvine School of Law.