Science
An essential medical device fails people of color. A clinic is suing to fix that
Roots Community Health Center was slammed in 2020, with lines for its COVID-19 testing stations stretching around the block and exam rooms full of people struggling to breathe.
Patient after patient at the East Oakland clinic extended their fingers so that healthcare workers could clip on a pulse oximeter, a device that measures the degree to which red blood cells are saturated with oxygen. For healthy people, a normal “pulse ox” reading is typically between 95% and 100%.
The Centers for Disease Control and Prevention had instructed providers to give oxygen therapy to any COVID patient with a pulse oximeter reading below 90%. Like their counterparts around the country, Roots doctors advised concerned patients to buy inexpensive pulse oximeters so they could monitor their levels at home.
As the pandemic ground on, it became clear that Black and brown patients were dying of COVID at disproportionately high rates, both across the U.S. and in Roots’ own Alameda County.
In the rare hour when she wasn’t in the clinic, Roots founder and Chief Executive Dr. Noha Aboelata paged through medical research in search of answers that might help her patients, the vast majority of whom were Black or brown.
One paper in the New England Journal of Medicine stopped her cold. University of Michigan researchers examined records of thousands of hospitalized COVID patients and looked for instances of “occult hypoxia” — a situation when a patient’s pulse oximeter reads in the healthy range, but their actual blood oxygen levels are dangerously low. The researchers found that this happened to Black patients nearly three times as often as it did to white patients.
Dr. Noha Aboelata said it was “devastating” to realize that researchers had known for years that patients with dark skin were more likely to get false readings from pulse oximeters.
(Carolyn Fong)
Aboelata recalled the “devastating feeling” of diving further into the literature and realizing that this disparity was not a new discovery.
Research dating back to 1990 found that inaccurate pulse oximeter readings were more common in Black patients than non-Black ones. In 2005, detailed lab experiments showed that pulse oximeters frequently overestimated blood oxygen levels in patients with more skin pigmentation.
“This device is really used almost like a vital sign, like you would use a blood pressure cuff,” Aboelata recalled. “How horrified you would feel if you suddenly found out that your blood pressure cuff didn’t work on a certain demographic of your patients?”
She alerted colleagues to the findings and investigated the effect the devices had on the fates of COVID patients of color. She asked the Food and Drug Administration to require pulse oximeter makers to test their devices on people of color and to warn consumers about the heightened risk of false readings. Attorneys for Roots sent letters to companies that made or sold pulse oximeters in California asking them to improve their products and disclose their limitations.
When little changed, Roots filed a lawsuit in November against CVS, Walgreens, GE Healthcare and nine other companies that make, sell or distribute pulse oximeters in California.
“The pigmentation-derived inaccuracies of pulse oximeter readings in people with darker skin consistently skew — or are biased — in one dangerous direction: showing that their blood is more oxygenated than it is in reality,” the lawsuit states. “Individuals with darker skin who use the devices are no less entitled to accurate readings than individuals with lighter skin.”
The suit asks that the companies either find a fix or place warning labels on the products to alert users that skin pigment may affect results.
Before pulse oximeters were widely adopted in the 1980s, the only way to gauge a patient’s blood oxygen saturation was to draw a sample of blood from their arterial vein, a painful procedure that had to be followed by immediate laboratory analysis. The portable, noninvasive oximeters were “a true innovation,” said Dr. Phil Bickler, a neuroanesthesiologist who directs the Hypoxia Research Laboratory at UC San Francisco.
“It’s arguably one of the most important clinical monitors ever devised,” Bickler said, second only to the thermometer.
Clinical research coordinator René Vargas Zamora opens a drawer of pulse oximeters at UC San Francisco’s Hypoxia Lab.
(Corinne Purtill/Los Angeles Times)
A pulse oximeter works by shining a light that passes through skin, blood and tissues in the finger and then measuring how much light comes out the other side.
Oxygen-rich blood absorbs more infrared light. So does melanin, the pigment that helps determine skin, hair and eye color. As a result, patients with darker skin tones are more likely to get pulse oximeter readings that show their blood oxygen saturation to be higher than it actually is.
Skin pigment isn’t the only variable that can skew those results. Cold hands, trembling fingers, incorrect probe placement, even nail polish can throw a reading off by a few percentage points too. Knowing this, doctors traditionally used the pulse ox as one data point among many when determining a patient’s course of treatment.
Then COVID-19 hit. As emergency rooms filled and oxygen tanks grew scarce, the CDC anointed pulse oximeter readings as the official standard in its guidelines for COVID care: Below 90%, the patient should be started on oxygen therapy. Above that, it was the doctor’s call.
As the sheer volume of patients grew, so did the number of people with occult hypoxia. Their pulse ox readings were 92% or higher, yet they often had shortness of breath, erratic heartbeats, headaches, confusion and other symptoms of low oxygen saturation.
Many providers around the country also noted that patients with occult hypoxia were more likely to have darker-toned skin.
“Honestly, we had no idea what to make of it,” said Dr. Michael Sjoding, a pulmonologist at the University of Michigan.
He and his colleagues initially wondered whether something about the SARS-CoV-2 virus itself made it harder to detect hypoxia.
Then Sjoding came across an article by Amy Moran-Thomas, a medical anthropologist at MIT. After spending sleepless nights monitoring her husband’s pulse oximeter readings as he suffered through COVID, Moran-Thomas began digging into the history of the device.
She found the 1990 paper that noted hypoxic Black patients were more likely to get deceptively high readings. She found the 2005 study from Bickler’s lab noting the devices were more likely to overestimate oxygen saturation in patients with dark skin than in those with light skin, results the lab confirmed in a follow-up study two years later.
“I was shocked, because I’m a pulmonary critical care physician, I’m a lung doctor, and I didn’t know this whole literature,” Sjoding said.
He and his colleagues pulled data from their own hospital and found Black patients had nearly three times the rate of occult hypoxia as white patients. They published their results in December 2020.
After Aboelata read their paper, she scoured her memory for patients the devices might have betrayed.
She recalled a Black man she had tried to get approved for home oxygen therapy prior to the pandemic. Medicare only paid for the treatment if a patient’s oxygen saturation was below 90%, and “his pulse ox reading just looked too good compared to what I was seeing,” Aboelata said. She sent him to the hospital for an arterial blood gas draw. Sure enough, his oxygen was low enough to qualify.
Patients shared similar stories, “things like, ‘The ambulance didn’t take them to the hospital because they said that their reading was fine,’ or, ‘We were sent home from the emergency department because they said our reading was fine,’” Aboelata said.
In normal times, she said, providers are much more likely to err on the side of caution for a potentially hypoxic patient. But in the worst days of COVID, every bed, oxygen tank and minute was precious. Providers relied on what they believed was the pulse oximeter’s impartial measure to make extremely difficult decisions, unaware that the device did not evaluate all patients equally well.
Aboelata and colleagues from UCSF and Sutter Health’s Institute for Advancing Health Equity published their own study in the American Journal of Epidemiology showing that Black patients whose pulse oximeters overestimated blood oxygen levels waited an extra 4½ hours, on average, to start supplemental oxygen. They were also slightly less likely to be admitted to the hospital or receive oxygen therapy at all.
“There’s just no way to really know how far-reaching this impact is,” Aboelata said. “The likelihood [is] that people were left home to die, or sent home to die.”
In February 2021, the FDA issued a safety notice cautioning users that pulse oximeters can be thrown off by a number of variables, including skin pigment.
The following year, the FDA convened an advisory committee on the topic. The panel recommended the agency demand better consumer labels and more stringent testing from companies seeking approval for their devices.
Currently, the FDA recommends — but doesn’t require — that pulse oximeter makers ensure that in their clinical trials, either two participants or 15% of total participants are “darkly pigmented” people, a definition open to interpretation.
Clinical research coordinator René Vargas Zamora holds up an example of the Monk Skin Tone Scale at UC San Francisco’s Hypoxia Lab.
(Corinne Purtill/Los Angeles Times)
This month, the panel advised the FDA to require that new devices be tested on at least 24 people whose skin tones collectively span the Monk Skin Tone scale, a 10-color palette often used to train artificial intelligences to recognize people of different colors. The proposal would divide the scale into three parts, with each part represented by at least 25% of study participants.
To better understand the relationship between skin pigment and pulse ox accuracy, the FDA funded a study at Bickler’s UCSF lab. Results are expected this summer.
“Some companies have posted data showing good performance with darkly pigmented skin for their devices. But I know that those have been tested under ideal conditions,” said Bickler, whose lab investigates the effects of low oxygen on the human body and the devices that measure it. “When pulse oximeters are used in the real world, conditions are not ideal. People are dehydrated, they’re in shock, they’re moving. There’s all kinds of interference that can happen and that get in the way of good performance.”
For Bickler, it’s gratifying to see the government finally address a problem that has been known for decades but that device manufacturers seemed reluctant to address.
“There’s a lot of inertia and denial in the industry,” he said. “It was an inconvenient problem that could be ignored, up until COVID.”
Dr. Phil Bickler is a neuroanesthesiologist who directs the Hypoxia Research Laboratory at UC San Francisco.
(Corinne Purtill/Los Angeles Times)
The Times reached out to all the defendants being sued by Roots. Those that responded declined to comment on pending litigation.
Only one company has taken actions to address Roots’ concerns. Illinois-based NuvoMed pulled its pulse oximeters from the market in California and agreed to place warning labels on their remaining inventory after receiving Roots’ October letter, said Jonathan Weissglass, the clinic’s attorney.
“Ideally, we’d like the pulse oximeters to be fixed so that the problem doesn’t occur,” Weissglass said. “In the meantime, we feel there needs to be an adequate warning about the inaccuracies for people with darker skin. … We’ve all seen warning labels that say, ‘Pregnant women should consult with a doctor before using’ or something like that. It’s the same basic idea.”
On a recent afternoon at the clinic, medical assistant Evelyn Rivas clipped a pulse oximeter onto Ja-May Scott’s index finger as she checked his vital signs.
The devices are still an important part of Roots’ toolkit. But “we just view it with more suspicion, frankly, in a lot of our patients,” Aboelata said. “We would really like to be equipped with devices that we know can be accurate for all skin tones. And we feel like in 2024, this shouldn’t be too much to ask.”

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Video: SpaceX Rocket Launch Creates a Glowing Spiral in Night Sky

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SpaceX Rocket Launch Creates a Glowing Spiral in Night Sky
Frozen fuel from the SpaceX Falcon 9 rocket created a luminous swirl that lasted for several minutes and could be seen from Britain and much of Europe.
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A Fungi Pioneer’s Lifelong Work on Exhibit

On an early summer day in 1876 near Druid Hill Park in Baltimore, a middle-aged woman carrying three large, putrid mushrooms repulsed fellow travelers riding a horse-drawn trolley car.
Even wrapped in paper, the stench of the aptly named stinkhorn mushrooms was overpowering, but the woman stifled a laugh upon overhearing two other passengers gripe about the swarm of flies around them. The smell didn’t bother her. All she cared about was getting the specimens home to study them, she would later write.
This was Mary Elizabeth Banning, a self-taught mycologist who, over the course of nearly four decades, conducted seminal research on the fungi of her state, Maryland.
Miss Banning characterized thousands of specimens that she found in Baltimore and the surrounding countryside, identifying 23 species new to science at the time.
A gifted artist, she collected these observations into a manuscript called “The Fungi of Maryland.” It consisted of 175 stunning watercolor plates, each an accurate yet intimate portrait of a given species, along with detailed scientific descriptions and anecdotes about collecting the mushrooms.
The manuscript was Miss Banning’s life’s work, and she yearned to see it published. But it ended up in a drawer at the New York State Museum in Albany, forgotten for almost a century.
A selection of her watercolors makes up the backbone of an exhibition at the museum that opened this month and runs until Jan. 4 of next year. The exhibition, called “Outcasts,” recognizes Miss Banning’s long-overlooked scientific legacy as well as the museum’s mycology collection, which is one of the most historically significant in the country, according to Patricia Ononiwu Kaishian, the museum’s mycology curator, who conceived the exhibition.
Miss Banning called fungi “vegetable outcasts.” Back then (and all the way until 1969) fungi were classified as a peculiar type of plant. Most botanists from the mid-19th century viewed their study as a research backwater.
Miss Banning herself was an outcast. “She wanted very much to be part of the scientific community,” said John Haines, who was the museum’s mycology curator until he retired in 2005 and who has extensively researched her history. But as a woman living in the 19th century, that path was largely closed to her.
Similar to contemporaries such as Beatrix Potter, who also sought to make her mark on the emerging field of mycology, “the sentiment was, ‘Well, you go home and make your pictures,’” Dr. Haines said.
One scientist did give her the time of day: Charles Horton Peck, who worked at the museum as New York’s first state botanist from 1868 to 1913. Mr. Peck, a pre-eminent figure in American mycology, dedicated most of his career to fungi, collecting more than 33,000 specimens in surveys across New York and describing more than 2,700 new species in his annual reports.
“A lot of the fungi that people recognize from New York or from the Northeast are ones that Peck described,” Dr. Kaishian said.
Miss Banning first wrote Mr. Peck in 1878, asking for feedback on her manuscript. Unlike other scientists she had tried to contact, he wrote back, and they corresponded for nearly 20 years. Her letters, some of which are exhibited, offer a window into their relationship.
“You are my only friend in the debatable land of fungi,” she wrote to him in 1879. She chronicled her collecting forays and scientific observations, and relayed her dreams for the manuscript. “I have a powerful will,” she wrote in 1889. “I have made up my mind to brave defeat sooner than not make an effort to have the plants of Maryland published.”
Miss Banning’s letters were often whimsical and passionate. None of Mr. Peck’s letters to her remain, but his tone in other letters suggested he was much more restrained. Nevertheless, he treated Miss Banning like a respected colleague — offering her scientific mentorship, publishing descriptions of species with her support and even naming species after her. Their scientific bond was undeniable.
“This is a love story, but not between the two people — they were both in love with fungi,” Mr. Haines said. A play he wrote about their relationship drawing from Miss Banning’s letters will be performed at the museum on April 4 at a gallery opening event for the exhibition.
Love triangles, though, are especially prone to turning sour. With no publishing prospects of her own in sight, Miss Banning sent her manuscript to Mr. Peck in 1890, hoping that he could publish it. “He would have had the resources to make it a permanent part of the mycological record,” Dr. Kaishian said. But he never did.
Although she expressed how difficult it was to part from the work and begged him to reassure her that he appreciated its contribution to the field, she did not receive such recognition. “It seems to me by her letters that she died without really understanding the legacy, the value of her work,” Dr. Kaishian said.
In one of her last letters to Mr. Peck in 1897, six years before she died, destitute and alone in a rooming house in Virginia, Miss Banning lamented the book’s loss. “I hardly know how I ever came to part with my illustrated book,” she wrote. “To tell you the truth, I long to see it and call it my own once more, but this could never be.”
“That just still brings tears to my eyes,” Dr. Haines said.
It was Dr. Haines who originally brought Miss Banning’s manuscript to light.
An eccentric curator showed it to him when he visited the museum for a job interview in 1969. He recalls being dazzled by the colors, which were superbly preserved by the fact that the pages had not been open to sunlight for decades.
He exhibited some of the paintings in 1981, and they were shown a few more times, including in Talbot County, Md., where Miss Banning was born. With the help of this spotlight, Miss Banning was inducted into the Maryland Women’s Hall of Fame in 1994. But since the mid-1990s, in part because the pigments degrade quickly in the light, the pictures had been packed away.
Beyond Miss Banning’s work, “Outcasts” gives visitors a glimpse into the broader historical context of mycology. “Fungi are enormously critical organisms that, going back hundreds of millions of years, have shaped the very texture of the earth,” Dr. Kaishian said. “But their stories are still mysterious and often neglected.”
In addition to Miss Banning’s watercolors and letters, the exhibition includes a host of other artifacts and experiences. Visitors can explore one of Peck’s microscopes and mushroom specimens collected by Miss Banning as well as ones collected recently by Dr. Kaishian, or marvel at a set of strikingly realistic wax sculptures of New York fungi made for the museum in 1917 by an artist, Henri Marchand, and his son Paul.
Murals made by museum artists illustrate the biology of fungi, the role they play in the ecosystem and their evolutionary history. A rare fossil of Prototaxites, a 30-foot-tall fungus that lived during the Devonian period about 400 million years ago, points to just how significantly the Earth has changed over time.
Overall, Dr. Kaishian said she hoped that the exhibition demonstrated why natural history collections like this one deserve public support and preservation.
The 150-year-old specimens hidden in cabinets that visitors rarely see help scientists map the limits of different organisms, both geographically and genetically — and that makes it possible to document changes to biological diversity in the face of climate change, for example.
“Natural history collections are active repositories for contemporary research,” Dr. Kaishian said. “There needs to be a lot more science communication about what goes on here and why it matters.”
Science
Supreme Court Will Not Hear Appeal in ‘Juliana’ Climate Case

The Supreme Court on Monday declined to hear an appeal in a landmark climate case brought by 21 young people against the federal government, ending its 10-year journey through the courts.
But the case provided a blueprint for numerous other climate-related lawsuits that have had greater success.
Juliana v. United States argued that the government had violated the constitutional rights of the plaintiffs with policies that encouraged the use of fossil fuels. But it was dismissed by the United States Court of Appeals for the Ninth Circuit, where the judges ruled that courts were not the right venue to address climate change.
“Rather, the plaintiffs’ impressive case for redress must be presented to the political branches of government,” Judge Andrew D. Hurwitz wrote in the 2020 opinion.
Our Children’s Trust, the Eugene, Ore., nonprofit law firm that represents the plaintiffs, made its final legal gambit in the case last year, when it asked the Supreme Court to vacate the appeals-court ruling and allow Juliana to proceed to trial in a lower court. That petition was denied on Monday.
Some observers had also considered it risky to ask the Supreme Court to consider the appeal, out of concern that a conservative court might use the case to jettison longstanding environmental protections.
The plaintiff the case is named for, Kelsey Cascadia Rose Juliana, now 29 and a teacher in Oregon, is the daughter of environmentalists and a longtime climate activist herself. The story of how she came to participate in the lawsuit was chronicled in the documentary “Youth v. Gov.”
The legal framework of Juliana has since been replicated in numerous lawsuits and legal actions across the country. And last year, Our Children’s Trust, which has filed many of the cases, scored two notable wins.
The group reached a settlement in Navahine v. Hawaii Department of Transportation in which the state agreed to cut emissions of carbon dioxide, the main greenhouse gas warming the planet, from its transportation system within 20 years. And it won Held v. Montana, in which a judge ruled that the state must consider climate change when approving fossil fuel projects. An appeals court upheld that decision in December.
The plaintiff that case is named for, Rikki Held, 23, grew up on a cattle ranch in Montana where she saw the effects of climate change firsthand, which led to her decision to participate in the lawsuit. She is now a science educator in Kenya through the Peace Corps.
On Monday, she said that the Juliana case had paved the way for her. “Juliana, through the unwavering dedication of its plaintiffs and legal team, has left an indelible mark on the landscape of climate litigation,” she said.
Julia Olson, the founder of Our Children’s Trust, had called on the Biden administration to discuss a settlement in the Juliana case, pointing to expressions of support from lawmakers and academics. She said on Monday that Juliana had “ignited a legal movement.”
But lawyers for the Justice Department had maintained that the court was not the right setting to address climate change, because a judge could not order or enforce any “workable remedy” to the problem.
And some experts had raised concerns about the organization’s strategy at the Supreme Court, noting the risk that the court’s conservative supermajority might take the Juliana case as a way to reconsider legal precedents that undergird environmental protections.
“Be careful what you ask for from this court,” said Patrick Parenteau, an expert on environmental law at Vermont Law and Graduate School, in an interview last year. “If you want an answer to this question, you probably will not like the answer you’re going to get.”
But he added that he still applauded the efforts of the young people and their lawyers.
Ms. Olson said environmentalists should not shy away from the courts. “If we don’t show up and we don’t bring claims forward, and we don’t shine light on injustice, then other forces will always prevail,” she said.
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