Earlier this year, four medical students published a report — Toward the Abolition of Biological Race in Medicine: Transforming Clinical Education, Research, and Practice — that examined the problematic nature of race in medicine and why the healthcare community needs to move away from race-based medicine.
When healthcare providers (HCPs) use a person's race as an element to define their health, that is race-based medicine. This interconnection between race and medicine is not new — in fact, its roots go all the way back to the 17th century — but doctors and HCPs are viewing the practice with fresh scrutiny.
The authors are students in the joint medical program between the University of California's San Francisco School of Medicine and Berkeley School of Public Health. I recently spoke with two of them — Noor Chadha and Bernie Lim — about their report and what motivated them to research the issue.
“We were learning about the body and pathophysiology and disease, and at the same time we were engaging in conversations about the historical roots of racism, of scientific technologies and of a lot of health disparities beyond social determinants of health, and how these [disparities] relate to structural inequality," explained Bernie Lim.
Noor Chadha added that there was a dichotomy between their discussions of the history of and current manifestations of racism and their medical classes, where race was discussed as a biological rather than a social concept.
Roots in slavery
In her 2015 Ted Talk, The Problem with Race-Based Medicine, Dorothy Roberts, founding director of the Penn Program on Race, Science & Society in the Center for Africana Studies at the University of Pennsylvania Carey Law School, described how race is deeply embedded in the practice of American medicine. “It shapes physicians' diagnoses, measurements, treatments, prescriptions — even the very definition of diseases," Roberts said.
Many of the racialized ideas of healthcare started from people trying to find scientific justifications for enslaving Black and African people. Ironically, the same man who wrote that “all men are created equal" in 1776 also wrote that the lungs of Black slaves and their white masters were different. In 1832's “Notes on the State of Virginia," Thomas Jefferson wrote of “a difference of structure in the pulmonary apparatus" between slaves and colonists.
Following Jefferson's assertion, physician and slaveholder Samuel Cartwright used the newly invented spirometer to measure and compare the lung capacity between enslaved Africans and whites. He concluded Blacks had deficient lungs.
In 1869, Benjamin Apthorp Gould published a study validating Cartwight's findings. The study failed to account for differences in diet or living and working conditions among newly emancipated slaves, but still concluded that “full blacks" had lower pulmonary capacity than "whites."
Despite its questionable methods, Gould's study was still being cited decades later, and the idea that Blacks had inferior lung capacity to whites persisted into the early 20th century — by which time it was established as fact.
“Toward Abolition" reports that beliefs about racial differences in lung capacity still exist in some areas of modern medicine. This suggests that race could potentially be used to diminish the severity of lung-related diseases in people of color.
Dangerous assumptions
In a 2018 blog post about race-based medicine for Scientific American, Dr. Jennifer Tsai, an emergency medicine physician, wrote, “Rather than a risk factor that predicts disease or disability because of genetic susceptibility, race is better conceptualized as a risk marker—of vulnerability, bias or systemic disadvantage."
Tsai went on to write that, “Notions of racial difference are embedded across every organ system and specialty."
Indeed, the use of racial adjustment or correction factors and the assumption of race as a health risk are still commonplace.
Racial correction factors are when values used to test or diagnose individuals differ based on the race of the person. For example, the estimated glomerular filtration rate (eGFR) is a value that helps HCPs analyze the level of kidney function. Currently, there exists a correction factor of about 1.2 for Black people. In lay terms, that means that if a Black person has a GFR of 50 (which is stage three kidney disease) it is “corrected" to a GFR of 60 (which is milder stage two kidney disease).
Race as a risk factor stems from the idea that certain races have biological predispositions to certain diseases.
“Just saying that because you're Black you're prone to have hypertension, well it goes a bit deeper than that," explained Dr. Daihnia Dunkley, Ph.d., RN, an assistant professor at Farmingdale State College and member of HealthyWomen's Women's Health Advisory Council. “It's not your race. It's the racism and the systemic effects of that racism that have brought us to the comorbidities that we see in Black people that were 'predisposed' to it."
Race-based medicine also negates the realities of the international and diasporic elements of people. “Being Black encompasses not only people who live in the United States, but could refer to some from the entire content of Africa. So one correction factor can not possibly encompass all of those people," Chadha said.
For example, a 2015 study comparing the blood pressure of participants in Africa, the United States and the Caribbean found that participants of lower social status in multiracial societies (particularly the U.S. and South Africa) had higher rates of hypertension.
The way forward
Across the country, there is a movement to shift away from race-based medicine. Notably, a push to remove racial correctional factors from calculating eGFR for Black patients has gained ground recently, with numerous institutions, including Vanderbilt Medical Center and University of Washington Medicine, making the change.
That's a start, but we have a long way to go. HCPs need to be trained about the racist roots of some medical literature and many current practices. Only then can all patients be treated equally.
