COMMENTARY

How Medicine Perpetuates the Fallacy of Race

Seema Yasmin, MD

Disclosures

March 11, 2020

When I was in medical school in England during the early 2000s, I was taught that black women have wider sacrums than white women, allowing them to enjoy an easier childbirth; that black men have more muscle than white men; and that Asians have a wider range of joint movement.

A professor pointed to me, the only brown student in the room, to demonstrate this last point. "Bend over and touch your toes," he said. So I did. I pressed my palms into the musty carpet of the Cambridge college, betrayed by tendons that confirmed a professor's race-based beliefs about my body.

"My hands reach the ground because of a decade-long yoga practice," I wanted to say, not because my parents and their parents were born in Asia, a continent spanning almost 50 countries.

But I didn't say anything. And when I qualified as a doctor, I continued the medical tradition of using race as a proxy for disease risk, a marker of bone density, and a determinant of organ function. I followed algorithms suggesting that my black patients needed different blood pressure medications from my white patients. I accepted that the lab multiplied the results of kidney filtration tests by 1.212 for my black patients. It must be due to the higher muscle mass, I assumed.

This wasn't so much race-based medicine as it was racist medicine. My eyes were being trusted to decide who was "black enough" to swallow a particular pill. I was treating my patients on the basis of beliefs about what our culture thinks of as race, and I was ignoring the greater genetic diversity that exists within racial groups than between racial groups. In the case of those kidney filtration tests, race-based adjustments might not be the best medicine and can potentially limit transplant access in black patients.

...medical education does not tell the truth about race, that it is a social construct...Medicine, obsessed with its evidence and gold standards, has accepted a made-up thing as a natural phenomenon.

Medicine upholds race as a biological characteristic, a proxy for genetic ancestry and disease risk. And yes, racial categories tend to share ancestry, have similar customs and lifestyles, and intermarry. But clearly a race such as African Americans represents a large, heterogeneous group: There is no reason to believe that any single genetic trait is uniformly and exclusively distributed in the entire population. Race is not a proxy for genetics, and any effort to ascribe such is shallow and lacking in understanding.

The social construction of race dates back to at least the 18th century when German scientist Johann Friedrich Blumenbach published a book called On the Natural Variety of Mankind. Blumenbach is credited with inventing one of the first race-based classifications, and in his book he listed five categories, including Ethiopian (the black race) and Caucasian (the white race). Blumenbach's system was useful to white Americans during the American Revolution. They used this "science" to maintain that whites possessed innate qualities that made them superior and that allowed them to justifiably enslave black people.

The social construction of race is also demonstrated by the convenient manipulation of racial categories over time to suit those in power. From 1790 (when the first decennial census took place in the United States) to 1950, it was census takers who determined the race of the people they counted. It wasn't until 1960 that Americans could choose their own race and 2000 when they could include themselves in more than one racial category. The 2020 census will be the first census absent the racial category "Negro."

In a study of 350 mandatory preclinical lecture slides presented at an Ivy League medical school, race was mentioned in 102 slides. In 96% of those slides, race was presented as a biological phenomenon. Medicine, obsessed with its evidence and gold standards, has accepted a made-up thing as a natural phenomenon. Not lazily or accidentally, but purposefully, because as physicians we hold power over the bodies of the voiceless and vulnerable, and it makes sense that those who yield power, any power, are trained to perpetuate the beliefs that uphold the dominant culture.

The controversy over race and medicine was stoked in 2005 with the approval of a heart failure drug specifically for black patients. BiDil, the manufacturer NitroMed claimed, would improve survival and functional status for "self-identified" black patients. The drug's race-specific labeling was supported by the majority of the FDA's Cardiovascular and Renal Drugs Advisory Committee.

Among supporters of BiDil's approval was the Association of Black Cardiologists, which said race could offer a useful measure of drug efficacy, particularly in a marginalized group underserved by medical systems. The organization claimed that there were real differences in the manifestations of heart failure among African Americans compared with white people.

I wanted out of the wards with their revolving doors, where patients were patched up and discharged into the same environments that made them sick.

Indeed, heart disease manifests earlier and with more severe symptoms in black people compared with white people, and carries a higher risk for hospitalization and death. But as Drs Kirsten Bibbins-Domingo and Alicia Fernandez from the University of California, San Francisco, pointed out, there are flaws in BiDil's race-based indication. The makers of the drug initially sought approval in the general population but were denied by the FDA due to statistical concerns; on the basis of results of the African-American Heart Failure Trial (A-HeFT), the FDA chose to approve BiDil in black patients only. The decision implied, without any supporting evidence, that the drug isn't effective in non-black patients, rendering its use in other demographic groups as "off-label." The irony is that the generic combination of two compounds in BiDil — hydralazine hydrochloride and isosorbide dinitrate — is approved as an alternative to standard therapy for all patients.

Bibbins-Domingo and Fernandez argue that approving a medication for a specific demographic group should "require a compelling scientific argument with clear evidence of the biological mechanism underlying the differential response." Though pharmacogenomic advances may someday provide this evidence, such data are not available in most cases. They add that race-based labeling could strengthen claims of racial differences and even racial inferiority, hindering efforts at eliminating health and healthcare disparities.

I started medical school in England a few months after BiDil was approved in the United States, oblivious to the backlash over its approval. After I qualified as a doctor, I decided I wanted out of the wards with their revolving doors, where patients were patched up and discharged into the same environments that made them sick. I wanted to study the determinants of health, dig into the whys and hows and wheres of disease. So I moved to the US to train as an epidemiologist in the Epidemic Intelligence Service.

Epidemiologists are well versed in talking around race and not about race. Why weren't we — those charged with looking for patterns, trends, and health injustices across populations — challenging the continued use of race in science? Epidemiologists are trained to disentangle the myriad root causes of illness. It is our job to demonstrate that — along with genes, which play a part in a person's health — access to libraries and fresh groceries are also powerful predictors of health.

Few researchers who use the construct of race in their studies bother to explain what race means or why they use it. When they do, those explanations can be inconsistent, conflating race with ethnicity, confusing race with socioeconomic factors. Authors of a 2007 study looked at 330 randomly selected genetic studies that used one or more words from a list of races and ethnicities. The idea was to assess how frequently research that includes racial distinctions actually defines what those distinctions mean. Not one of the studies discussed the concepts of race or ethnicity or defined them. Fewer than 10% of the studies included explanations as to why racial or ethnic labels were assigned to people.

Of course, there is genetic variation between populations which influences health and disease risk, but arbitrarily assigning a patient a certain risk — or prescribing them a particular medication —on the basis of their skin color, as opposed to a specific genetic profile, is futile and regressive.

But race continues to be misconstrued as a surrogate marker for genetic ancestry, and upholding race as a biological phenomenon in medicine will enable this misconception to be taught to future generations of healthcare providers.

While ancestral alleles can affect the rate of disease in a population and determine how well some treatments might work, these alleles do not necessarily align with our racial categories. In the case of BiDil, the drug does appear effective in black patients, but perhaps in other patients too. Because there are no genetic traits "uniformly and exclusively distributed in African Americans," as the Association of Black Cardiologists said following BiDil's approval, the lived experiences of black people in America, and the physical and mental impacts of discrimination, are the more important factors in their health. 

In the 1970s, an epidemiologist at UNC Chapel Hill studied the health differences between black and white people in North Carolina and gave a name to the health effects of racism. Professor Sherman James called the physical and mental strain of surviving racism "John Henryism," after both the steel-driving John Henry of folklore who works himself to death, and John Henry Martin, a retired black sharecropper who James interviewed in the 1970s. At their first meeting in the summer of 1978, John Henry Martin told James that his high blood pressure, arthritis, and abdominal surgery (for an ulcer so large that half his stomach had to be removed) were consequences of having "pushed too hard in the fields" to earn his independence and become a black landowner.

While race is a social construct, the socioeconomic discrepancies that racism has helped fuel are real. They have real effects on lungs and wombs and hearts. Policies that house black and brown children in homes where lead paint peels off their bedrooms walls, raise them in food deserts, and exclude them from better-performing schools at higher rates than their white peers are some other ways racism manifests in our bodies and minds.

If we, in the business of fixing bones and soothing phobias, dared to unravel the lie that race is a biological phenomenon, perhaps this system would fall apart, or at least be bettered.

But we don't. Some doctors and medical students who are not black believe that black people have thicker skin, thicker blood, thicker nerves. That black couples are more fertile than white couples, that black people have a keener sense of smell than white people. Some of us non-black doctors hold magical beliefs about our black patients, and based on these magical beliefs are less likely to believe a black patient's pain, less likely to ease that pain with the appropriate analgesics. That my professor said black women's bodies are designed to give birth more easily is especially egregious when black women in the UK and the US are at least three times more likely to die during or soon after childbirth compared with white women.

Drugs like BiDil and lab tests that "correct" for black patients purport to individualize medicine while grouping together billions of genetically diverse people and asking doctors and patients to decide who is "black enough" for a particular test or treatment. The promise of truly personalized healthcare, including genomic medicine with diagnostics and therapies targeted to a person's genetic makeup, remains to be fully realized but hopefully will help address the problem as advances in the field continue.

When deconstructing race in medicine, it is not okay to say that you are "color blind," as a leader in medical education recently announced to me, with glee. We must be acutely aware that racism is baked into our medical institutions, and that we teach racist medicine every time we choose to exclude a history of the concept of race in our medical curricula. By not challenging the construct of race and its continued misuse in medicine, we perpetuate a system of oppression.

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