Abstract
Definitions
History
Conclusions
Discussions
References
“I believe when you open up someone, you see the heart, the lungs, everything. I think it's all the same. […] I don't think like this calculating and everything, I don't think it should be like that because I don't see a difference [by race].”
- Quote from a participant when asked about their thoughts of using RBCs in medical testing [1]
Abstract
Spirometry is a test used in Pulmonology (the study of lungs) to determine how much air a person can inhale, and how much they can exhale (Cleveland Clinic, 2024). This test traces its roots back to the mid-19th century when the English Surgeon John Hutchinson conducted the first large-scale research study regarding its efficacy (Braun, 2021, p. 1671). After this study was published, an American plantation physician by the name of Samuel Cartwright conducted a study comparing the lung function of White participants and enslaved Black people, concluding that the 20% difference in lung functioning he found was a result of biological differences due to race. This historical idea survives to this day in modern medicine through the use of race based corrections for spirometry tests depending on if a patient identifies as either Black or Non-Black. Many other studies on the lung function of Black people have been performed since then, and reached similar conclusions. A study from 1922 firmly cemented the idea of race causing a difference in lung function, as one of its comparisons for spirometry scores was between Irish or Italian children and Colored (Black) children (Braun, 2021, p. 1672). The authors of the study ended up removing the data obtained from Black children when creating average scores for pulmonary function, further pushing the narrative that White people had normal functioning lungs compared to Black people. In the modern day, when a patient identifies as Black, the physician will reduce the original score by 10-15% to reach the final result (Vyas, Eisenstein, & Jones, 2020, p. 5). Spirometry is the cornerstone of pulmonary medicine, so its racialization means that every subsequent test of the lungs will be indirectly racialized as well.
The test requires a “normal” value to compare the test value against. This is determined through four variables: height, age, sex, and race.
The above definition will be the understanding of race used in the following research. It upholds that race is not a biological concept, but a social one.
History of Spirometry Research
[1860] Samuel Cartwright performs a spirometry test between free White and enslaved Black Americans to determine a correlation between race and lung function
Cartwright determines that Black people’s lungs are 20% less effective than White’s. He does not account for environment in his calculations.
[1925] The first book of standardized spirometry values and mathematical algorithms is published by J. A. Myers.
It establishes definitively that race is a biological factor of lung function and must be considered when calculating people’s spirometry scores
[1966] Anthropologist Albert Damon performs an anthropological study on the difference of lung function in Black and White Army drivers
He concludes that the difference in lung function identified is due to genetic differences between the races and does not account for environmental factors
[1974] British statistician Charles Rossiter and US pulmonologist Hans Weill publish a book about the differences in lung function across races
They also exclude environmental factors and justify themselves by writing, “it is possible that social or economic factors may have contributed to the differences observed, but the consistency with which the finding of a large ethnic difference in lung function occurs suggests that these factors may be unimportant.”
[2012] A large-scale research study performed by the Global Lung Function Initiative (GLI) tested the lung functioning of over 74,000 people internationally.
The participants were split among their racial groups. Over 57,000 of the people tested were Caucasian (White) and only 3,545 were Black. It once again did not account for environmental factors in calculations.
There is no single answer to the question of “why do we still use RBCs in spirometry tests” because the topic is so complex. Instead, I have identified a few different reasons that may contribute to its continued use.
Race is still seen as a biological determinant of health in the field of pulmonology (the study of lungs)
Centuries of confirmation bias in spirometry research have led to inherently biased testing standards
It takes a lot of time and money to change an entire diagnostic standard, especially since spirometry is the cornerstone of pulmonology
The importance of getting correct values for people’s health cannot be understated. Spirometry is used for more than just determining if someone has a lung problem: it’s required for getting jobs, for insurance coverage, and it can prevent unnecessary deaths[5]. As an example, Black people used to be turned away from jobs in factories because of racist and biased values.
We need to remember that correlation does note equate to causation. Samuel Cartwright was correct when he identified a 20% difference in lung function, but his assumption was not. He didn’t think about how working in the fields all day, having poor nutrition, and constant abuse may reduce a person’s lung functioning. Using race as an explanation for biological concepts is a gross generalization for wider reaching social and economic issues that people face every day.
[1] Schmidt, I. M. et al. (2023). Patients’ Perspectives on Race and the Use of Race-Based Algorithms in Clinical Decision-Making: a Qualitative Study. JGIM: Journal of General Internal Medicine, 38(9), 2045–2051. https://doi.org/10.1007/s11606-023-08035-4
[2] Braun, L. (2021). Race correction and spirometry: Why history matters. Chest, 159(4), 1670-1675). https://doi.org/10.1016/j.chest.2020.10.046
[3] Brown Med-Peds. (n.d.). Racism in Medicine: Spirometry. Brown Med-Peds. https://brownmedpedsresidency.org/racism-in-medicine-spirometry/
[4] Cleveland Clinic. (2024, January 08). Spirometry. Retrieved March 11. 2026, from https://my.clevelandclinic.org/health/diagnostics/17833-spirometry
[5] Marciniuk, D. D., et al. (2023). Effect of race and ethnicity on pulmonary function testing interpretation. Chest, 164(2), 461-475. https://doi.org/10.1016/j.chest.2023.03.026
[6] Quanjer, P. H., et al (2012). Multi-ethnic reference values for spirometry for the 3–95-yr age range. European Respiratory Journal, 40(6), 1324-1343. https://doi.org/10.1183/09031936.00080312