11/17/21, 2:25 PM Oximeters Used to Be Designed for Equity. What Happened?

| WIRED

AMY MORAN-THOMAS IDEAS 06.04.2021 09:00 AM

Oximeters Used to Be Designed for Equity. What

Happened?
The pandemic drew attention to the racial bias built into pulse oxes. But calls to create a fairer
device are missing one thing: It once existed. 

ILLUSTRATION: WIRED; GETTY IMAGES

T H E G R AY OX I M E T E R sitting on my kitchen table looks like a record player. A product of the 1970s, its alarm for low
blood oxygen levels is set by analog dial. I bought it on eBay late last year, after writing a story about the racial bias built
into oximetry for the Boston Review. A professor of medicine at Yale, Meir Kryger, reached out afterward with a
suggestion: I should also look into the models predating contemporary pulse oximeters, specifically one made by
Hewlett-Packard. It’s a technological dinosaur, but in certain ways, its inner workings are more advanced than many
devices that measure blood oxygen in hospitals today.

For decades, researchers have documented that many pulse oximeters commonly used in hospitals do not meet FDA
safety thresholds for people of color. Since these devices assess oxygen in the blood through optical color-sensing, they
can be riddled with errors for people with darker skin, due to racial biases in the calibration process. But when Covid-19
first hit, pulse oximeter readings were nonetheless hailed as a “biomarker” for early hospitalization and during triage.
Some patients of color who told ER doctors they couldn’t breathe well were actually sent home when the device
indicated they didn’t need oxygen.

https://www.wired.com/story/pulse-oximeters-equity/ 1/10
11/17/21, 2:25 PM Oximeters Used to Be Designed for Equity. What Happened? | WIRED

It wasn’t until a team of physicians at the University of Michigan reinvestigated the device last December that the broader
medical community began to pay more attention. “When a pulse oximeter says 91 percent [oxygen saturation], more than
50 percent of Black patients actually had a value less than 88 percent,” notes study coauthor Tom Valley. The issue has
since been taken up by senators and the FDA, drawing intense interest from doctors and engineers, as well as confused
patients. There are now widespread calls for redesigning the “pulse ox”—as well as rethinking the review systems that
failed to catch or prevent these errors for decades.

But these crucial debates about what may be possible for future models are often still missing an important fact:
Oximeters designed to work equitably regardless of skin color, gender, and disability status actually existed back in the
'70s. Yet somehow, the history of the device sitting in my kitchen has been mostly erased.

PHOTOGRAPH: AMY MORAN-THOMAS

B AC K I N T H E ’60s and ’70s, Hewlett-Packard was collaborating closely with NASA engineers to create devices for the

health of astronauts, where the precise measurement of oxygen played a vital role. When the company expanded into
hospital markets, it carefully designed an oximeter that could similarly be calibrated for individual patients. It was based
on a transmittance approach (shining light through tissues), incorporating fiber optics and eight wavelengths of light.
(Many current pulse oximeters use only two wavelengths.) Hewlett-Packard's engineers knew the device would need
different brightness settings to work consistently across a range of skin colors. The company offered a transparent and
thoughtful discussion—still accessible today in its archive of newsletters—of how it went about building a light-sensing
technology that would work equally well on all skin tones.

As steps toward mitigating racial bias, Hewlett-Packard’s engineers marshaled a range of more inclusive approaches to
oximetry. The instrument’s baseline calibrations were set by working with a “carefully selected” group, including 248
Black volunteers—which is, notably, 246 more nonwhite people than the FDA currently suggests for pre-market testing of
https://www.wired.com/story/pulse-oximeters-equity/ 2/10
11/17/21, 2:25 PM Oximeters Used to Be Designed for Equity. What Happened? | WIRED

the oximeters in hospitals today. Most importantly, the device could be adjusted for each individual. There was an option
to squeeze a small droplet of blood from the wearer’s ear to scan the blood using spectrophotometry. This measurement,
which helped discern exactly how much light was being absorbed by an individual’s skin and tissues, allowed the
physician to personalize light-level calibrations and optimize the device’s accuracy.

SUBSCRIBE

Subscribe to WIRED and stay smart with more of your favorite Ideas writers.

Get the Latest Covid-19 News

Sign up for our Coronavirus Update newsletter, providing the latest insights on the pandemic, vaccine rollouts, and more.
Your email

Enter your email

SUBMIT

https://www.wired.com/story/pulse-oximeters-equity/ 3/10
11/17/21, 2:25 PM Oximeters Used to Be Designed for Equity. What Happened? | WIRED

By signing up you agree to our User Agreement and Privacy Policy & Cookie Statement

The oximeter could also account for circulation idiosyncrasies. Unlike modern pulse oxes that are tested only on healthy
people, Hewlett-Packard’s device was designed to work for people who may be sick. The sensor was not made for the
fingertip, for instance, because then the device wouldn’t work as well for patients with common health conditions such
as shock, sepsis, and certain chronic illnesses. Instead, Hewlett-Packard placed its sensor on the top curve of the ear, one
of the last parts of the body to be impacted by circulation issues during illness. This choice helped prevent building
ableism into oxygen measures, while also avoiding gender disparities due to poor device fit. While ear oximeters still
exist in specialty niches, by far the most common models in ERs and homes today are nonadjustable and built to fit the
“average” geometry of a man’s finger, at times producing suboptimal readings for all others that may well compound
with other errors.

Despite these achievements, when the personal computing market exploded in the 1980s, Hewlett-Packard shifted its
focus and stepped back from medical equipment shortly before it released a long-planned miniature version of its
oximeter. But Kryger still describes its larger device as “the best oximeter ever made.” His lab’s publications from that
time show that the HP oximeters were in a number of ways more accurate than the pulse oximeters that soon came to
replace them. They were referred to in clinical studies as the noninvasive "gold standard" by which early pulse oxes were
tested, because Hewlett-Packard oximeter readings more closely matched the invasive arterial blood gas tests.

As the pandemic has painfully reminded us, the consequences of such inaccuracies can be devastating. Because today’s
hospital oximeters are not made with the capacity for personalization, they can inadvertently feed flawed data not only
to doctors but also to other machines. Oximeter numbers provide key inputs to a range of computing systems, including
the algorithms guiding ICU triage and certain insurance reimbursements. They are also on closed-loop algorithms with
many ventilators—and when fed error-ridden inputs, such devices may not be able to optimize as effectively. 

Having these conversations now is crucial: As part of AI’s growing role in health care, a wide range of noninvasive
sensors are being developed with the pulse oximeter as their model. Some, like certain optical sensors for sepsis or blood
glucose, may already be at your local hospital or present in your home. Without care, a coming generation of optical
color sensors could easily reproduce the unequal errors for which pulse oximetry is now known across many other areas
of medicine.

W E T E N D TO assume that technology will unfold with a kind of linear progress, and that useful features or key questions
will be built into future models. The history of devices often gets written later as if this had always been the case—that
alternative approaches didn't succeed because they were inferior. But like any history, it is useful to ask who wrote it and
what’s left out.

You could tell the story of these lost oximeter features as a case of happenstance: When Hewlett-Packard shifted its focus
away from medical devices in the '80s, most of the smaller firms that came to fill the hospital device niche didn't have
the kind of broadly applied, multidisciplinary experience that years of working with NASA had brought. So when
American companies began commercializing the Japanese bioengineer Takuo Aoyagi’s “pulse” addition to oximetry
models, they adopted his insights without giving equity considerations a public-facing accounting the way their
predecessors had for US markets. Many hospitals that purchased these devices for the first time didn't even realize the
newer oximeters were missing features that had previously existed in other models, because the "pulse ox" was their first
exposure to noninvasive oxygen measurement at all.

This technological loss could also be told as a story about shifting historical and societal norms over time. Hewlett-
Packard's 1970s model included a transparent discussion of equitable design—but this also took place against the
backdrop of the hard-fought gains of the Civil Rights movement, when issues of racial equity were being more publicly
discussed across sectors. Meanwhile, the later pulse ox models (the first in the US was patented by Biox in 1980) became
one more face of the corporate enclosures of the era. When they first came to market, Kryger recalls, he tried to ask the

https://www.wired.com/story/pulse-oximeters-equity/ 4/10
11/17/21, 2:25 PM Oximeters Used to Be Designed for Equity. What Happened? | WIRED

engineers about calibration data, as was once considered standard safety practice. But they would no longer share it.
“They were black boxes hidden with proprietary algorithms,” Kryger says. “The engineers at the time would not give any
technical information such as accuracy in people with dark skin pigment.”

People often refer to today as the age of precision medicine. But the Hewlett-Packard oximeter stands as evidence of a
more uneasy and uneven story.

When black-boxing began further encroaching into medical technology in the ’80s and ’90s, there was a flurry of studies
by doctors concerned about pulse ox accuracy. Eventually, though, doctors got used to not knowing and stopped asking
certain questions about the bias built into devices. Blind spots grew. “Today coded inequity is perpetuated precisely
because those who design and adopt such tools are not thinking carefully about systemic racism,” Princeton professor
Ruha Benjamin observes in Science, in examining the range of ways racial biases are built into hospital algorithms.
People often refer to today as the age of precision medicine. But the customizable Hewlett-Packard counter-model
stands as evidence of a more uneasy and uneven story about what happens when data and design decisions are put in a
black box, severed from public accountability despite insidious errors.

However you frame it, relearning these histories is a chance to envision different futures. Beyond this pandemic and
others that may follow, oximeters are used everyday in crucial and delicate moments, such as childbirth, that are already
notorious for amplifying racial inequities. That the pulse ox’s longstanding design problems have become harder to
ignore during Covid is a reminder of the ongoing stakes of remaking it—and the root causes that have made its biases
possible. Today a rising generation of physicians such as health policy specialist Onyeka Otugo and the transnational
critical care trainees who recently wrote in The Lancet join with the multidisciplinary engineers and social scholars of
health like Kadija Ferryman and Mikaela Pitcan, who are asking hard questions about hospital technologies anew, with
fresh insights for design policy.

And a few, like Kryger, still remember what got written out of later histories of oximetry: It is possible to engineer color-
sensing devices with a foundational commitment to equitable design. It is possible to ask companies to openly share full
calibration and accuracy data as a matter of medical safety and fairness. It is possible to design hospital devices that
work optimally for all patients. Hewlett-Packard’s oximeter accomplished all of these things nearly half a century ago.
The particular one sitting on my kitchen table doesn’t have all the proper retro cables, so it’s not really functioning. But
it’s become an important reminder for me: Equitable device design has been achieved before. It needs to happen again.

More Great WIRED Stories

📩 The latest on tech, science, and more: Get our newsletters!
The 60-year-old scientific screwup that helped Covid kill
We hiked along with cicada biologists so you don’t have to
The Ford F-150 Lightning is the electric vehicle of dystopia
SNL helped create the age of memes. Now it can't keep up
STEM’s racial reckoning just entered its most crucial phase
👁️Explore AI like never before with our new database
🎮 WIRED Games: Get the latest tips, reviews, and more
📱 Torn between the latest phones? Never fear—check out our iPhone buying guide and favorite
Android phones

Amy Moran-Thomas is a cultural anthropologist and associate professor of anthropology at MIT. 

https://www.wired.com/story/pulse-oximeters-equity/ 5/10
11/17/21, 2:25 PM Oximeters Used to Be Designed for Equity. What Happened? | WIRED
IDEAS CONTRIBUTOR

TOPICS COVID-19 MEDICINE RACISM BIAS HOSPITALS

MORE FROM WIRED

The Metaverse Is Simply Big Tech, but Bigger

It’s a rebrand of Silicon Valley's increasing power and reach. And it’s made for companies, not people.

CECILIA D'ANASTASIO

https://www.wired.com/story/pulse-oximeters-equity/ 6/10
11/17/21, 2:25 PM Oximeters Used to Be Designed for Equity. What Happened? | WIRED

India's New Rules for Map Data Betray Its Small Farmers 
The country says that more open access to terrestrial data will help rural farmers. More likely, will make it easier for corporations to
control their land.

PAYAL DHAR

‘The Great Resignation’ Misses the Point

The phrase has come to describe record levels of job turnover. But it overlooks the bigger story: a radical rethinking of our relationship to
work.

KATHRYN HYMES

Stripe Discriminates Against Witches 

Payment processing companies decide who is empowered to buy and sell online—and their policies show a gross misunderstanding of

https://www.wired.com/story/pulse-oximeters-equity/ 7/10
11/17/21, 2:25 PM Oximeters Used to Be Designed for Equity. What Happened? | WIRED
metaphysical practitioners.

MEG JONES WALL

The Future Is Bleak. Pondering Pangaea Gives Me Hope

In 200 million years, our far-flung continents may join up again. It reminds us of humans' tiny place in this intergalactic drama.

VIRGINIA HEFFERNAN

The Man, the Myth, and the Metaverse

Mark Zuckerberg wants you to believe his metaverse is the final frontier. The misconception comes with over a century of warnings.

LISA MESSERI

https://www.wired.com/story/pulse-oximeters-equity/ 8/10
11/17/21, 2:25 PM Oximeters Used to Be Designed for Equity. What Happened? | WIRED

‘My Body Is Used to Design Military Tech’

The prosthetics industry and military have a long history that doesn’t serve most people with limb difference. It’s time for a justice-
oriented approach.

BRITT H. YOUNG

How Apps Commandeered the Age-Old Idea of Takeout

Third-party delivery services have convinced us they are an essential part of our busy lives. But humans have managed to order food to-
go for centuries.

COREY MINTZ

https://www.wired.com/story/pulse-oximeters-equity/ 9/10
11/17/21, 2:25 PM Oximeters Used to Be Designed for Equity. What Happened? | WIRED

SPONSORED STORIES POWERED BY

TIPARENTS HOUSEDIVER ARTICLESKILL

[Pics] This Is What The Perfect Female Body [Pic] Remember Him Wait Till You See Him Now [Pics] Photos Show The Difference Between
Looked Like 100 Years Ago (and every decade Meghan & Kate's Parenting
since)

XFREEHUB GLORIOUSA ARTICLESVALLY

[Pics] Royal Family Confirms Unfortunate News [Pics] Here’s What 30 Historical Figures Actually [Photos] Confirmed: This is The Deadliest Snake
Looked Like on Earth

One year for $29.99 $10 SUBSCRIBE

Get WIRED

https://www.wired.com/story/pulse-oximeters-equity/ 10/10