Is There Any Place for Race in Medicine?

What prescription would you recommend?” my attending physician asked me.

We had just admitted a patient to the large teaching hospital where I was a medical student. He had been in hypertensive crisis with type-2 diabetes and would soon need a medication he could take at home. This was the first Black patient I had helped evaluate with this condition, and I knew we could not recommend the standard medications, the ones prescribed to all of the patients I had seen up to that point in my medical training.

His prescription would have to differ because a series of decades-old studies, “adjusted” for race (“Black” vs. “non-Black”), found that Black research participants had a suboptimal response to the standard, first-line treatment.

Physicians often still assess—and treat—Black patients differently.

I knew this common wisdom well from graduate school training in epidemiology, where decisions like these were about numbers and statistics. As expected, the team prescribed this Black patient a calcium channel blocker rather than a standard ACE (angiotensin converting enzyme) inhibitor or an ARB (angiotensin receptor blocker) that non-Black patients received.

It was only later that I learned that this recommendation was based on studies that had looked specifically at the responses of African-Americans. But we had been treating an immigrant from West Africa at a Canadian hospital. Which meant that we were making a prescription decision not based on data from people of his particular genetic background or lived experience but on his skin color alone. And that felt like a flimsy clinical benchmark. But it was 2011, and I was still a medical student, so I went along with the established, “best practice” recommendation.

Today, despite decades of work to deconstruct the ingrained racism in North American medicine, physicians often still assess—and treat—Black patients differently. As a rationale, scholars and clinicians point to statistics. It is known as the “correction for race.”

Over the years, researchers have tried to theorize about potential genetic underpinnings of this “correction” in an attempt to find biological plausibility. But this is treading on infamously dangerous territory previously trod on by myriad biological-anthropological scholars who attempted to perpetuate the myth of the superiority of whites.¹

These centuries-long misconceptions have been so deeply woven into the fabric of medical training and research that, even in an era defined by rigorous research, their presence still appears in the sorts of clinical decisions I was part of daily, with lasting health implications for many.

The work of undoing these tangled webs of reasoning may be difficult, but with careful and persistent work, the result could one day be truly equitable, better care.

The West African patient’s particular treatment “correction” was just one of many we learned in medical school. I also learned how to “correct” for an apparent difference in glomerular filtration rate (a reflection of kidney function, which would be used to dose medications) in Black patients. This was based on a theory that presumed higher muscle mass in Black patients would lead, ultimately, to a difference in a measure of this filtration rate. And I was taught to “correct” lung volume for breathing tests, based on the theory that Black patients had larger lung capacity on average compared to other races, which had implications for evaluating and treating everything from chronic obstructive pulmonary disease to asthma.

Beyond the bedside, some of these “corrections” are now embedded in the code of electronic medical record algorithms addressing a variety of conditions, including determining likelihood of death, with dire implications for care.

Over the past few years, however, the shaky foundations of these assertions have finally begun to show cracks—first with lung function, and then for kidney disease, more recently for how febrile Black children are assessed.

In their key 2020 commentary in the New England Journal of Medicine, Harvard Medical School professor of the culture of medicine David Jones and colleagues carefully analyzed several clinical practice guidelines that use the variable of race—typically “Black” and “non Black”—to decide on medical management.

Thinking back to the patient I helped assess years ago, who was sent home on a different standard of care, we now know (from a study published in 2022²) that these prescribing patterns actually may lead to worse blood pressure management, lower access to the right medications, and, ultimately worse outcomes. Similarly, a 2022 study in JAMA Pediatrics found that for guidelines in children’s medical care that incorporated race or ethnicity, nearly half had a potential negative effect for providing adequate care.³ The authors of that study concluded inequities could be exacerbated, more often than helped, by using race.

Yet these damaging “corrections” persist. For example, the adjustment for kidney filtration rate retains implications for kidney treatment, including suggesting lower priority for many Black patients for dialysis or transplant.

And in looking at impacts on children, one team of researchers argued against using “Black” in determining risk for urinary tract infections in pediatric patients with a fever, as it had been for years.⁴

“It didn’t seem possible that they could all share a common invulnerability to UTI,” Rachel Kowalsky, an assistant professor of emergency medicine and pediatrics at New York-Presbyterian Weill Cornell Medicine and a coauthor of the 2020 paper, says of Black children across the United States. “Race was being inappropriately used as a proxy for biology. And, because the guideline applied to the majority of infants 2-24 months old coming to the ER or clinic with fever, an enormous number of children could be negatively affected by its use.”

Even calculations where race would potentially tilt treatment in favor of earlier interventions for Black individuals are problematic, some scholars argue. In a 2022 article, Joseph Wright, a professor of pediatrics and health policy and management, and Chief Health Equity Officer of the University of Maryland Medical System, and his colleagues describe the example of the risk for clogged arteries, or atherosclerosis, and resulting cardiovascular disease.⁵ “One might argue that the ASCVD Risk Estimator may be protective in terms of potentially skewing early cardiovascular care toward Black patients,” they write. “However, the inherent danger is directing differential treatment to Black versus white patients on the basis of a flawed phenotypic signal in the face of what might otherwise be identical underlying risk profiles. Incorporating race as proxy for the biological effects of differential lived experience is misplaced.”

The cognitive dissonance, for me, is not dissimilar to the Brown vs Board of Education decision: Separate care is prima facie unequal care.

So if the intention behind these “corrections” was to lead to more equitable care, how did it end up doing the opposite?

The efforts to incorporate race in medical research and clinical decision-making had noble goals, including sniffing out health disparities and ensuring research studies were adequately representative of the broader population to make their results generalizable. To that end, since the 1970s, medical researchers in the U.S. have collected data on race and ethnicity and used it as a variable (as well as sex, education, socioeconomic status) to analyze results. The aim has been to determine how a specific treatment impacted a subgroup.

There is an important distinction though: When research studies lead to clinical practice guidelines, no guideline suggests using one approach or therapy over another based on sex, education, or socioeconomic status for something like blood pressure management. No “correction” exists for these variables. Race stands alone: a social construct that’s misused as a biological one.

This approach to dragging race into health has a deeply shameful history in Western-based medicine. In an early example, Thomas Jefferson wrote about “dysfunctional” Black lungs, justifying slavery as a way to improve blood supply to further develop these lungs. Jefferson was suggesting that slavery was beneficial to Black physiology, without noting that any lung differences likely had a social cause that was due to slavery and over-exertion.

Separate care is prima facie unequal care.

Ensuing centuries of dubious claims for scientific racism failed to turn up solid rationale for the biological differences of races. Finally, in a seminal 2003 New England Journal of Medicine article, a team of prominent geneticists asserted: “Meaningful biologic differences simply do not exist between different races in a correlation or association.”⁶

Indeed, any differences may be explained by sociocultural differences and lived experience. Neuroimaging studies have found, for example, only cultural links (not racial ones) to brain appearance. As Nigerian-British writer Chimamanda Ngozi Adichie has expressed, the dangers of applying a single story to a group, to assume each individual has a similar experience, are many. When these ideas are applied to health, it’s catastrophic.

The arrival of genetics-based studies in the first decade of the new millennium was supposed to save us from all of this. They were to usher in a new, agnostic era of precision medicine. But race has proven a stubborn habit to kick, even in the time of rapid genome sequencing and big data.

“I always find it ironic that when it comes to biomedical research, there’s a lot of emphasis on precision medicine,” says Genevieve Wojcik, an assistant professor in the department of genetic epidemiology at Johns Hopkins Bloomberg School of Public Health who studies diverse populations and genetic associations. But, she says, there remains “an acceptance of some kinds of imprecision, such as race, which is a very imprecise variable.”

The variable of race becomes especially tricky when larger studies are translated into clinical decision-making, she tells me. “Race in most contexts is used as a proxy, and disentangling it from what we really want to measure is a challenge that would require research to distill these variables down into their sort of root causes … For example, is it race we want to measure or the effects of racism?” Wojcik asks.

Ongoing debate around affirmative action in college admissions echoes some of these same chords. Is it simply a matter of race, or is it a matter of social factors or experiences of adversity? Of course, race and social adversity don’t have a 1:1 association, in the same way that a given gene is not 1:1 associated with race. Might social adversity, not race, be a better marker of pluralism—and more equitable medical treatment? So perhaps ridding ourselves of the last remnants of race-based medicine, much like pushing for race-neutral college admissions policies, makes sense.

My research and reporting thus far had led me toward that conclusion. But then things got more complicated.

I met Gregory Hall at a medical conference in February. Hall is a primary care physician based in Cleveland, the medical director of University Hospital’s Cutler Center for Men, and an associate professor in Internal Medicine at Northeast Ohio Medical University College of Medicine. He is also the author of Patient Centered Clinical Care for African Americans: A Concise Evidence-Based Guide to Important Differences and Better Outcomes, and his patient population is predominantly African-American, an ethnic group he also identifies with.

Hall disagrees with the principle of dismissing race altogether in clinical decision making. He gives the example of a study that looked at rates of prostate cancer. The study found prostate cancer risk was 10 times higher in African-American men compared to West African men, and so the cause was likely not along race lines but due to inequity and other social factors. He also cites the higher prevalence of HER2-negative breast cancers in African-American women and the higher likelihood of aggressive prostate cancer that metastasizes to bone in African-American men. These race-based differences are essential to acknowledge, he says.

Race has proven a stubborn habit to kick, even in the time of rapid genome sequencing and big data. 

Some health organizations in Hall’s state of Ohio have stopped collecting race data in efforts to be race-neutral. Beginning in 2020, several U.S. hospitals also began to halt the use of race as a variable in their clinical decision making. The University of Washington stopped using the race-based kidney filtration variable in their clinical decision making, and a multidisciplinary, multi-institution, group created an alternative “race-free” equation to assess kidney failure. In 2021, physicians from the University of Pennsylvania recommended that the American Thoracic Society revise their guidelines for assessing lung function in 2021.

Last year, in the Lancet Digital Health journal, Jones’ colleagues at Harvard published a paper recommending a revision to the atherosclerotic cardiovascular disease calculator to exclude race.⁷ A few months later, a group at the University of Pittsburgh looked at Kowalsky’s claim and, in their study in JAMA Pediatrics, using the data from 16 previous studies (covering almost 180,000 children) found that replacing race with previous history of UTI and fever duration was found to be similarly accurate at predicting risk of UTI in statistical models. The American Academy of Pediatrics has since offered a new, race-agnostic management guideline.

But some of these actions, though they seem in their own way corrective, concern Hall.

“My worry is if we take race totally out of things, communities that have serious health problems that need targeted attention will not be readily identified,” Hall tells me. “Biologically we are 99.9 percent the same, and based on that alone, race really is a social construct. But that social construct has created the health landscape that we currently live in,” he says. “If we completely remove race as a consideration in our clinical thinking and how it impacts patients’ predispositions, treatment, health, and access to services, we will be ignoring some very critical aspects of their overall health.”

Hall’s perspective led me to understand that a deeper issue was indeed at play. It wasn’t simply about whether to remove race from a series of clinical decision-making algorithms. It was about how to use race in a way that would best inform overall care.

Unbiased healthcare provision is not attained simply by deleting “corrections” from medical texts, but will require taking the harder path of shifting systemic barriers that consistently lead to worse health outcomes in Black patients.

So rather than turning a blind eye to race in medicine, “we need to collect much more comprehensive data about patients’ social and economic exposures, and do so longitudinally,” Jones says. “This will require a ton of work—but so did the human genome project. If doctors agree that something is important, then the needed research will get done.”

Indeed, to move from race-based to race-conscious medicine requires bravely challenging the very structures that were responsible for creating the healing profession in the first place.⁸

In March, the National Academy of Sciences released a new report, which makes clear the ongoing concerns around presuming race and ethnicity has biological underpinnings, but acknowledged that the data were helpful demographically—something Hall agrees with.

“To be ‘race-conscious’ of something is to consider race as part of the decision-making process,” Hall says. “No medical decision should be purely race-based.”

If the patient I had seen in medical school were back in the hospital today—or in the very near future—hopefully his care team would look beyond outdated, black-and-white statistics to turn a careful eye to things like systemic barriers to optimum blood pressure management. They would be aware of his race but would not automatically prescribe a medication simply because of it.

Amitha Kalaichandran is a public health-trained physician, medical journalist, and health tech consultant based in New York.

Lead image: Nicoleta Ionescu / Shutterstock

References

1. Deyrup, A. & Graves Jr., J.L. Racial biology and medical misconceptions. The New England Journal of Medicine 386, 501-503 (2022).

2. Holt, H.K., et al. Differences in hypertension medication prescribing for Black Americans and their association with hypertension outcomes. The Journal of the American Board of Family Medicine 35, 26-34 (2022).

3. Gilliam, C.A., et al. Use of race in pediatric clinical practice guidelines: A systematic review. JAMA Pediatrics 176, 804-810 (2022).

4. Kowalsky, R.H., Rondini, A.C., & Platt, S.L. The case for removing race from the American Academy of Pediatrics clinical practice guideline for urinary tract infection in infants and young children with fever. JAMA Pediatrics 174, 229-230 (2020).

5. Wright, J.L., et al. Eliminating race-based medicine. Pediatrics 150, e2022057998 (2022).

6. Cooper, R.S., Kaufman, J.S., & Ward, R. Race and genomics. The New England Journal of Medicine 348, 1166-1170 (2003).

7. Vyas, D.A., James, A., Kormos, W., & Essien, U.R. Revising the atherosclerotic cardiovascular disease calculator without race. The Lancet Digital Health 4, e4-e5 (2022).

8. Cerdeña, J.P., Plaisime, M.V., & Tsai, J. From race-based to race-conscious medicine: How anti-racist uprisings call us to act. Lancet 396, 1125-1128 (2020).

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