• Hannah Comiskey

The End of Race-Norming in NFL Brain Injury Assessments

In June 2021, the National Football League announced an end to its use of a race-based formula to assess the eligibility of former players for injury compensation. This follows nearly a decade of racially biased evaluations to determine a retired player’s eligibility since the scheme's introduction in 2013.

Under this practice, the NFL determined the basis for brain injury compensation by comparing a player’s cognitive test score with the norm for their demographic group – namely age, gender and, more controversially, race. Coined as "race-norming", this practice worked under the false assumption that Black players exhibited lower pre-injury baseline levels for cognitive function. Therefore, Black players were required to demonstrate lower cognitive function than their white counterparts in order to receive compensation for football-related brain injuries such as dementia or memory loss.

Used to limit 70 per cent of brain-injury compensation claims made by retired NFL players, three-quarters of whom are Black, this system has been widely criticised as discriminatory and systemically racist. It makes it significantly more difficult for Black players to prove they had suffered neurological damage from sports-related concussions, whilst simultaneously casting racist and unsubstantiated assumptions over the comparative cognitive functioning of healthy white and Black NFL players.


Race-Norming in the NFL


In the case of Najeh Davenport, a retired Black NFL player who filed for brain injury compensation in 2020, the NFL appealed on the basis that his doctor had not used "full demographic norms" in cognitive scoring. In other words, they had not assumed lower baseline cognitive function because of Davenport’s race. Following the NFL’s requested use of race-normed data to curve Davenport’s initial test results, his initial dementia diagnosis was reversed and he was denied compensation.


Similar racial biases in neurocognitive evaluations were used to deny compensation for Kevin Henry in 2020. This prompted a civil-rights lawsuit in 2021 from both Henry and Davenport against the use of race-normed evaluations in the NFL compensation scheme.

However, until recent backlash culminated in NFL's announcement of an end to their use of race-norming last month, such a stance was fiercely defended by the NFL for years. It was justified as being based on "widely accepted and long-established cognitive tests and scoring methodologies" such as IQ. This highlights a concerning use of "intelligence" rating systems to justify what has since been exposed as blatant structural racism.


Race-Norming's Racist Roots

Such pseudoscientific claims of fundamental differences between the intelligence of white and Black people are deep-rooted in a long and ugly history, attempting to preserve white rule and legal segregation of races. From the pro-slavery scientists of the 1800s to the eugenicists and segregationists of the 1900s, claims of innate racial differences of intelligence or biology have been used to justify the marginalisation of Black communities for centuries.


Disturbingly, the modern-day use of IQ in compensation determination has a concerning resemblance to these eugenic ideologies of the 1900s which relied on a similar use of IQ test scores to exclude, marginalise and justify the unequal treatment of those in African-American communities. Used in 1927 to legitimise and target the compulsory sterilisation of nearly 65,000 “feeble-minded” US citizens – a disproportionate amount of whom were Black – the same pseudoscientific racism lurks behind the scientific jargon and empirical language of IQ tests and has been used to justify the reduced compensation for Black NFL athletes suffering from football brain traumas.


Racism in Healthcare and Medicine

Yet, despite the fact the NFL has now pledged an end to this race-norming practice from June, the disturbing resilience of racism in modern-day science, sport and healthcare remains widespread. The uncovering of race-norming by the NFL merely brings to the surface the deeper issue of "racial correction factors" in healthcare.

From the diagnosis of dementia to kidney transplant eligibility and cardiology treatment recommendations, the use of race to inform everyday clinical decisions is omnipresent across multiple fields in medicine. Many medical providers still hold onto the idea of race as a biological variable rather than a social construct and adjust their patient risk calculations accordingly. Unbeknown to many patients, their race is used as data input in treatment guidance and risk analysis algorithms in the same way as blood pressure, age, sodium level or heart rate. This is despite the fact that, in many cases, there is no direct proven link between race and a medical outcome.

Growing reliance on the use of equations and algorithms as a treatment guiding tool makes this issue of race-norming in medicine increasingly relevant and potentially dangerous. The inclusion of race as an input variable has real-life consequences on perceived disease progression and treatment outcomes.

In cardiology’s "heart failure risk" tool, a Black patient has three points automatically subtracted from their risk score because the tool’s research basis suggests Black heart failure patients have a lower risk of dying in hospital. This results in a lower likelihood of scoring high enough to be eligible for certain treatments. In the diagnosis of kidney disease and subsequent priority for transplants, Black patients are assumed to have higher baseline functioning – with a racial correction factor of 1.2 commonly applied to inflate Black patients' eGFR kidney measurements to take this into account.


Limitations of Race-Norming


However, without adequate scientific backing suggesting that race is a key mechanism driving a higher baseline functioning, this sweeping assumption and race-norming can have devastating consequences. This is because it leads to potential misdiagnoses, delays in referral and exclusion from transplant waiting lists and, ultimately, life-saving treatment. Similarly, an algorithm risk score may even discourage or encourage heart surgery depending solely on the colour of a patient’s skin which is derived from findings of higher risk of death amongst Black patients compared to white. A pregnant black woman may also be encouraged to get a C section as a risk calculator makes natural delivery look disproportionately dangerous for Black patients. With this race-norming data output comes a real-life outcome of longer recovery and potential surgery risk for these women.

Critics of race-norming in medicine argue that the use of race-correction factors is unreliable as these are based on unsubstantiated assumptions that Black bodies are fundamentally different from others. Projects such as "The Human Genome" have taken further steps to debunk this assumption, revealing that any two human beings are 99.9 per cent identical at the DNA level with the remaining factor not varying according to race. Similarly, it has been found that no DNA test has the capacity to determine an individual’s race.

Such findings reinforce the idea of Black and white races as mere socio-political concepts which, in the majority of medical cases, do not explain differences in biological baseline functions. While biological factors such as heart rate or age have scientific backing used to justify their influence in guiding medical treatment recommendations, there remains a concerning lack of clear medical justification for using race to influence medical decisions in a similar way.


With this in mind, the ethics and legality of such widely used race correction factors stand on shaky ground going forward. Where robust medical justification is lacking, instead, unsettling pseudoscience remains. It is used to legitimise and fuel systematic racism and discrimination practices such as those used until recently by organisations such as the NFL.


Future

As medical schools become increasingly diverse, there is increasing scrutinisation and a growing number of medical professionals speaking out against the prevalent influence of skin colour in diagnosing diseases. While experts such as Dr Fair and Dr Jones argue that medicine should not be “colour-blind” the role of race in healthcare should only have influence if there is clear justification. One such example is evidence which points to greater risk of prostate or breast cancer in African Americans which could prompt recommendations for earlier cancer screening amongst these groups. Crucially, race considerations in these medical decisions would not set Black patients at a disadvantage or at risk of delayed treatment.

Going forwards, however, momentum is growing for a shift away from race being used as a blanket proxy for socioeconomic status, healthcare access, income or education factors. These are actually more likely to be driving disparities in health outcomes between races than race itself. Instead, there is a need for an approach that considers the influence of these specific factors on an individual’s risk calculation. This would set the stage for an approach which is not only more fair but also more accurate.

While the announcement that the NFL will stop using race-norming to determine compensation eligibility is positive, it is undeniably concerning that an end to this practice occurred less than a month ago. While it remains in the headlines, there is a valuable opportunity to create change regarding the wider issue of race-norming which it has brought into focus.