A medical student with white skin is about to describe a patient newly admitted to the hospital to her attending physician. She will start by giving the patient’s age and sex (“A 58-year-old man was admitted to the hospital last night after presenting to the emergency department with slurred speech and weakness in his left arm and leg”). Should she also mention in this opening statement that the patient is a “58-year-old Black man?”
To think she should would be to assume that race is a fundamentally biological trait that is embedded in a person’s genetic makeup (the genome) and inherited from the previous generation. Here we see a complicated apparent paradox.
One the one hand, scientists tell us, based on substantial research, that race is really a social construct and has very little if any biological meaning. On the other hand, there is serious interest lately in the notion that ethnic minorities should be included in higher proportions in research studies because we should not assume that Black, Latinx, and white people will all respond similarly to different medical interventions. That sounds as if there must be a biology somewhere involved in race. How we work out this apparent paradox is critical if we are to begin to undo centuries of healthcare discrimination and abuse of ethnic and racial minorities in the United States.
The Case for Race as a Social Construct
Why do anthropologists tell us that race is not a function of biology? This is because while conventionally assigned race may be associated with some diseases (e.g. white people are more likely to have cystic fibrosis and Black people more likely to have sickle cell anemia), in these cases race itself is still only an association (Black people can also have cystic fibrosis and white people also have sickle cell anemia). If you sequenced the genome of any individual and got their complete genetic code, nucleoside by nucleoside, you would not be able to determine from this information whether they are white, Black, Asian, Latinx, or Native American (although according to some you may be able to determine what geographic region of the world their ancestors came from). Two people with dark skin may identify themselves as Black and two people with light skin call themselves white, but the two Black people and two white people are likely to be more genetically different from each other than either white person is with either Black person. That is, there is often more genetic diversity between two people of the same race than there is between two people of different races.
If, then, race has little biological significance it would seem irrelevant for the medical student to mention it when presenting the new case to her professor. Race has been used as an excuse to discriminate against people and to create huge inequalities and inequities among racial groups, so perhaps pointing out that someone is Black in the course of giving a medical report would only serve to perpetuate bias. An oft-noted example is that for the same level of pain, Black patients are systematically prescribed less and lower doses of pain medication than white patients. What if the attending physician harbors latent racist views and is prone to take the complaints of Black people less seriously than those of white people? Isn’t it better to think about the patient’s problems blinded to his race in order to ensure an objective assessment and equitable treatment plan?
The answer to the above question is probably yes and until medical students and attendings go to see the patient at the bedside to gather more information and perform a physical examination, there is probably no reason to identify the patient as belonging to any one of the conventional racial groups.
In Some Cases There are Biological Considerations
Yet in other contexts within medicine, we are actually encouraged to consider the possibility that race does entail differences that are biologically meaningful. Recently during clinical trials of vaccines against the virus that causes COVID-19 the concern was raised that research participants should represent the same racial mix as they are in the general population. About one-third of Americans are identified as Black, Latinx or another group other than white and the question raised here is whether we would know if a vaccine worked in Black or Latinx people if they weren’t included in representative numbers in the research studies. But if race is not biological and if two white people are likely to be more genetically dissimilar than a Black and a white person, why should the racial make-up of a clinical trial make any difference?
One reason is because some studies have shown that different racial groups, on average, respond to certain medications differently or have different risks for acquiring some illnesses. For example, a category of medications called ACE inhibitors used to treat some cardiovascular problems seem to work less well in Black patients than in white patients. A difference in the genes for an enzyme that metabolizes drugs in the liver between Asians and whites makes the former group more sensitive to antipsychotic medication, therefore making it best for Asians to take lower doses. Black people have a higher rate of venous thromboembolism than people of other racial groups and also have a higher risk for developing systemic lupus erythematosus.
Of course, because of genetic differences within groups, not all Blacks, whites, or Asians will manifest these or any other differences in a given drug’s effectiveness or risk for a specific illness. Furthermore, whether or not a drug works in any individual also depends on many non-biological factors, like whether or not a person can afford to buy the drug in the first place. Nevertheless, race does seem to make a difference in some ways that are biologically meaningful in medical practice.
The Importance of Social Determinants
Returning to our medical student’s patient, he turned out to have suffered a non-fatal stroke on the right side of his brain. He also had a history of poorly controlled high blood pressure (hypertension), a known risk factor for stroke and heart disease. Now Black people have higher rates of hypertension than whites. Does knowing that this patient is Black make any difference? Probably not much in making a diagnosis and deciding on treatment. The signs and symptoms of stroke are identical across all racial groups and the treatments the same. Perhaps this patient will not be prescribed an ACE inhibitor to treat his hypertension, but there are many other choices that work equally well in Blacks and whites. The patient’s race may, however, have a profound influence on how he is treated. This would not be because of biology in this case but rather because of prejudice and non-biological factors.
Some have stated that ethnicity may be more useful than race in making medical decisions. Our stroke patient appears to be Black to our medical student and attending physician, but his background is complicated. His father emigrated to the United States from Brazil, identifies as Black, and speaks Portuguese. His mother was born in the United States of parents of Italian ancestry. Our patient speaks a little Portuguese, likes to eat Italian food and practices the Catholic religion. His African ancestry is therefore more remote than his Brazilian and Italian backgrounds. Ethnicity takes into account all of these factors of origin, religion, language, and behavior in addition to skin color. In this context it is very likely that our patient would even have a good response to an ACE inhibitor. Illnesses that are often thought of as occurring in only one racial group, can actually occur in many. Sickle cell disease, for example, while most common among people of African ancestry, also occurs in people of European, Middle Eastern, and Asian ancestry.
Why do Black people have higher rates of hypertension than white people? Interestingly, black people living in the United States have higher rates than black people living in Africa, so ancestry does not seem the key factor here. Rather, socioeconomic factors are most likely key to understand the differences in rates of hypertension. Living in a low-income neighborhood is associated with hypertension. There is less access to medical care and less money to afford healthy food and medications. The chronic stress of living in an economically deprived neighborhood and of facing racism and racial discrimination is also linked to hypertension. A study showed that when residents of racially segregated neighborhoods move to less segregated communities they experience a decrease in blood pressure. Thus, one’s race profoundly determines the socioeconomic factors that affect one’s health and the healthcare received.
In coming up with a comprehensive treatment plan for our stroke patient, knowing his skin color is less important than understanding the socioeconomic factors that may influence his rehabilitation, recovery, and avoidance of future strokes. Does he have social support? Is he someone who is usually adherent to prescribed medications? Can he follow a healthy diet and get exercise? Can he afford quality medical care? Is quality medical care even available where he lives?
These factors, often called the social determinants of health, turn out to be far more important than race in determining medical outcomes. In fact, about 80% of health outcomes is said to be a function of social determinants of health. They are, unfortunately, too often not felt to be part of a physician’s purview, although that is changing rapidly.
The history of racial discrimination, racism, and inequities has had a profound effect on healthcare in the United States. People of color receive less quality care and have higher rates of morbidity and mortality for many conditions than white people. Because of persistent structural racism, it is definitely important to ensure that racial and ethnic minorities are included in numbers that at least mirror their population representations for things like clinical trials. It is absolutely possible that some Black people, for instance, might react differently to a COVID-19 vaccine than some white people and therefore having them in these studies is critical. Similarly, we should not ignore race as we strive to overcome inequities and inequalities in the provision of healthcare, improvement of health outcomes, and the distribution of healthcare professionals.
Still, for any individual patient it would seem that neither race nor ethnicity is going to make a major difference in making a diagnosis or selecting interventions. Rather, we need to boost our attention to the underlying factors that create differences in health outcomes among races—the social determinants of health. Our stroke patient turns out to have a loving, supportive family and adequate resources to obtain medical care. He is generally adherent to medical recommendations and prefers to see Black physicians. Factors like these are highly important in determining how well this patient will do. Another patient without social support or adequate resources will not do as well unless these factors are attended to.
When thinking about race, then, it is true that healthcare providers need to bear in mind that there are some instances in which biology may properly influence decision-making. But it is more important for them to understand how decision-making is all too often influenced by irrational attitudes about race of which they may be unaware. These attitudes have led to massive health disparities that it is every healthcare professional’s duty to help remedy.