Moving beyond ‘race-based’ medicine to ‘race-conscious’ medicine

“Race, as we currently carry such a notion in our heads, is largely a myth, a fiction, or a stage of false consciousness… Race is a superstition, our modern-day witchcraft.” —Mahmoud El Kati.

“Race creates new forms of power: the power to categorize and judge, elevate and downgrade, include and exclude” —Ibram X. Kendi.

Our world is afflicted with a life-threatening disease that impacts and permeates virtually every aspect of our lives. It is dangerous and continually denies millions their rightful place in society. It is indiscriminate, leaving its mark on men, women, and children. 

This disease is racism. Sadly, a definitive cure for this disease continues to elude us. 

Given how widespread racism is in society, it should not be surprising that it affects the science and practice of medicine. Indeed, as far back as the 15th Century, race was used to justify atrocities against Black bodies. 

These justifications took the form of scientific racism, or rather, the pseudoscience of White biological superiority. Over the centuries, scientific racism has been effectively used to legitimize and spread anti-Black racism and White Supremacy.

Race-based medicine

The use of race in medicine remains one of the most deep-rooted and polarizing topics in U.S. medical education. Race-based medicine is the system that characterizes race as an essential biological trait that is then translated into clinical practice. Ultimately this results in inequitable care. 

Generations of physicians have been taught about race-based biological “differences” even though race is a social construct and a poor proxy for human differences. Research into the human genome has proven that human beings cannot be divided into distinct biological subcategories. We are indeed one human race. 

According to the American Academy of Pediatrics, race is not a risk factor that predicts disease, severity and disability. Race is instead, a risk marker of bias, discrimination and vulnerability. 

It is, therefore, essential to approach the practice of medicine with a conscious appreciation of the impact of race on patient illness and outcomes. Unfortunately, medical education and training have lagged in their appreciation of the relationships between race, racism and health.

The tendency to do this reflects deep-rooted societal beliefs and institutional norms. Medical schools have persisted in presenting racial and ethnic differences in disease without putting these differences in context. 

For instance, medicine has not traditionally viewed the higher rates of certain conditions in Black patients through the lens of residential segregation. This segregation has historical roots in “redlining” and unequal access to adequate housing and health care. Moreover, a tendency to link minoritized populations with an increased disease burden persists. 

Race-adjusted measures

The racialization of medicine has led to the development of guidelines that endorse racial categories in diagnosing diseases and conflate race and ancestry in treating illness. This includes the development of kidney and lung function measures adjusted for race. Other race-adjusted measures include a risk score for vaginal delivery after Cesarean section and a breast cancer risk calculator. 

These race-based measures have significant implications for BIPOC populations. For example, a recent study showed that 3.3 million more Black Americans would be diagnosed with Stage 3 chronic kidney disease without the race-adjusted measurements of kidney function. 

At this level, complications of kidney disease such as high blood pressure, anemia, and bone disease begin to develop. Having these diagnosed earlier would mean earlier treatment. 

The study found that 300,000 more Black patients would qualify for referral to a kidney specialist, and 31,000 more would become eligible for a transplant evaluation and inclusion on the transplant waitlist. The latter is significant since the time spent on the waitlist is one key factor in determining who receives a kidney transplant.

It is beyond the scope of this article to discuss the development of the drug BiDil specifically created and marketed to Black people. However, a social construct like race should not have served as a proxy for the unknown biological reasons for this drug’s efficacy.

Race-conscious medicine

The growing recognition of the negative impact of these race-based guidelines has led to changes. Recently, the American Society of Nephrology and the American Kidney Foundation released a new, race-free measure of kidney function. It encouraged the increased use of a blood test for cystatin C to evaluate kidney function. 

In 2021, the AAP withdrew the clinical practice guideline for diagnosing and treating urinary tract infections in infants and toddlers. The guideline’s use of race meant Black and other children of color were improperly deemed at lower risk for these infections. 

As the practice and science of medicine evolves, it will be essential to incorporate the context behind the racial disparities seen in illness. Medicine must not become “color-blind” but “race-conscious.” 

Those involved in the care of their fellow human beings should be mindful of the environment in which their patients exist. In addition, they should be aware of the impact of structural racism on the incidence of disease and the experience of medical care for minoritized populations.

Dr. Kiragu is an associate professor of pediatrics at the University of Minnesota and the co-medical director of the Pediatric Brain Injury Program at Hennepin Healthcare in Minneapolis. He is an associate of the Children’s Respiratory and Critical Care Specialist’s group and provides pediatric critical care at Children’s of Minnesota and Gillette Children’s.  Dr. Kiragu is a passionate advocate for children and is immediate-past president of the MN Chapter of the American Academy of Pediatrics and a past president of the Minnesota Association of African American Physicians.

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