New England Journal of Medicine Itai Bavli, Ph.D., and David S. Jones, M.D., Ph.D.
In May 23, 1968, Howard Goldman, director of the New York Bureau of X-Ray Technology, acknowledged that x-ray technicians routinely exposed Black patients to doses of radiation that were higher than those White patients received.1 This practice, which adhered to guidelines from x-ray machine manufacturers, may have been widespread in the 1960s. Senate hearings held that month, as political unrest rocked the country, prompted public outcry and led to calls from state and federal officials to end the practice. Yet in the 21st century, despite growing interest in the problems of race and racism in medicine, race adjustment of x-rays has received little attention.2-6 It's important to understand the origins of this practice, its rationales, its possible harms, and related controversies. The history shows how assumptions about biologic differences between Black and White people affected the theory and practice of medicine in the United States in ways that may have harmed patients. These insights can inform ongoing debates about the uses of race in medicine.7-10
......................................... despite recent attempts to mitigate the harmful effects of racial biases in medicine, race-based beliefs and practices, especially the use of racial categories, remain widespread.8 The history of race adjustment for x-ray dosing reveals how mistaken assumptions can be admitted into medical practices — and how those practices can be ended.
Racialization of the X-Ray
The discovery of x-rays in 1895 revolutionized medicine. It allowed doctors to diagnose and treat many medical problems more easily.22 The ability to image teeth also transformed dental care. However, as x-ray technology developed in the early 20th century, false beliefs about biologic differences between Black and White people affected how doctors used this technology.
Ideas about racial differences in bone and skin thickness appeared in the 19th century and remained widespread throughout the 20th.
....................................... The belief that Black people have denser bones, more muscle, or thicker skin led radiologists and technicians to use higher radiation exposure during x-ray procedures.
............................................ In the 1950s and 1960s, x-ray technologists were told to use higher radiation doses to penetrate Black bodies. Roentgen Signs in Clinical Diagnosis, published in 1956, described the radiographic examination of a Black person's skull as a "technical problem" that required a modified technique...................................
Debate and Denial in the Senate
The practice of giving larger x-ray doses to Black patients was brought to national attention in May 1968, when the U.S. Senate held hearings about the Radiation Control for Health and Safety Act of 1968.27
.............................. At the hearings on May 15, Ralph Nader mentioned that technicians exposed Black patients to higher x-ray doses: "A practice widespread around the country is that by technologists and their supervisors giving Negroes one-fourth to one-half larger X-ray dosages than white patients because of a generalized intuition or folklore."27
.......................................... Race classifications have traditionally been based on skin pigmentation and other superficial physical traits. One might have expected x-ray technologies, which see through the skin to deeper structures beneath, to be spared racialization. They were not. During the 20th century, radiologists and device manufacturers embedded racial assumptions in the basic practices of radiology. Nader, a consumer advocate working on radiation safety, exposed the practices of race adjustment to public scrutiny, triggering investigation and rapid action by federal and state officials and by physicians and device manufacturers. However, radiologists and technicians retained the ability to determine x-ray exposures. We do not know how long the practice of race adjustment actually endured............................. more https://www.nejm.org/doi/full/10.1056/NEJMms2206281
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