Transforming the Way We Think About Race in Medicine

RWJF - Roberts

By Dorothy Roberts

Dorothy Roberts’ work in law and public policy focuses on urgent contemporary issues in health, social justice, and bioethics, especially as they impact the lives of black women and their families. She is the George A. Weiss University Professor of Law and Sociology and the Raymond Pace and Sadie Tanner Mossell Alexander Professor of Civil Rights at the University of Pennsylvania.

An 8-year-old black girl is repeatedly hospitalized for lung infections. None of her doctors can figure out what’s wrong. Finally, a doctor looks at her X-ray without knowing her race and correctly diagnoses her with cystic fibrosis. None of the other medical professionals had considered cystic fibrosis because of the myth that certain genetic traits exist only in certain races—the myth that black people don’t get cystic fibrosis. It’s a classic case of misdiagnosis based on racial assumptions.

The racial concept of disease—that people of different races suffer from different diseases and experience common diseases differently—goes back centuries to the promotion of slavery. White slaveholders argued that, because of their biological peculiarities, enslavement was the only condition in which black people could be healthy, productive, and disciplined.

Today, medicine perpetuates this long history of defining disease in racial terms. Medical students are taught to treat their patients according to race, and this contributes to the racial inequities that plague every aspect of medical care. For example, studies show that blacks and Latinos are less likely than white patients to receive pain medication for the same injuries. Some theories attribute this to stereotypes among healthcare providers that blacks and Latinos are more likely to exaggerate their pain, can stand more pain, or are predisposed to drug addiction.

This problem persists in medical devices and tests, such as the test that is used to evaluate a patient’s risk of kidney failure. Patients who self-report as black will get a different result than those who self-report as white. The calculation measuring kidney function is set to interpret the level of creatinine concentration in the patient’s blood differently if the patient is black. This is based on the absurd assumption that black people have more muscle mass than people of other races. Assumptions such as these are often extrapolated from old studies that get from one generation to the next.

Countless research projects also search for genetic causes to racial gaps in asthma, infant mortality, diabetes, cancer, and other medical conditions. But scientists routinely use sloppy, inconsistent, and ambiguous definitions of racial categories in biomedical and genetic research, and leap to genetic conclusions without ruling out more logical social explanations for health disparities.

Although studies typically attempt to control for participants’ socioeconomic status, researchers routinely fail to account for many other unmeasured factors—such as the experience of racial discrimination or differences in wealth, not just income, or rates of incarceration—that are also related to health outcomes and differ by race. Any one of these unmeasured factors might explain why health outcomes vary by race. We would expect social groups that have been systematically deprived for centuries to have worse health than social groups that have been systematically privileged—but the reasons are social, not genetic.

The hypothesis that health disparities are caused by genetic difference is founded on a misunderstanding of race as a naturally created biological division, rather than a politically invented social division. Race is a political construct that has staggering biological consequences because of the impact that social inequality has on people’s health. As a result of race-based medicine, health inequities persist — and divert attention and resources from work that could actually help address the social inequities that produce these gaps in health.

Understanding race as a political construct that affects health reframes the way scientists approach the relationship between race and biology. A growing number of researchers from a variety of disciplines, including medicine, biology, psychology, anthropology, and epidemiology, are investigating how racial inequities in wealth, housing, and education, along with experiences of stigma and discrimination, translate into bad health.

We need to work together to transform the way the medical profession thinks about race. We must change medical school curriculum to incorporate a stronger understanding of the social and structural determinants of health, so that future providers will be trained in treating the whole patient.

We need to stop treating patients by race. We need to start valuing people equally as human beings, while working to understand the impact that racism and social inequality have on their health. And we need to join the forefront of the movement to end the structural inequities that produce racial gaps in health.