From race-based to race-conscious medicine: how anti-racist uprisings call us to act

The brutalisation of Jacob Blake and murders of George Floyd, Breonna Taylor, Ahmaud Arbery, Tony McDade, and countless others—coupled with horrifying statistics about the disproportionate burden of COVID-19 on Black and Brown communities—have forced the USA and the world to reckon with how structural racism conditions survival. Although clinicians often imagine themselves as beneficent caregivers, it is increasingly clear that medicine is not a stand-alone institution immune to racial inequities, but rather is an institution of structural racism. A pervasive example of this participation is race-based medicine, the system by which research characterising race as an essential, biological variable, translates into clinical practice, leading to inequitable care. In this Viewpoint, we discuss examples of race-based medicine, how it is learned, and how it perpetuates health-care disparities. We introduce race-conscious medicine as an alternative approach that emphasises racism, rather than race, as a key determinant of illness and health, encouraging providers to focus only on the most relevant data to mitigate health inequities. Research in clinical medicine and epidemiology requires explicit hypotheses; however, hypotheses involving race are frequently implicit and circular, relying on conventional wisdom that Black and Brown people are genetically distinct from White people. 1Kaufman JS Cooper RS In search of the hypothesis. Public Health Rep. 1995; 110: 662-666PubMed Google Scholar This common knowledge descends from European colonialisation, at which time race was developed as a tool to divide and control populations worldwide. Race is thus a social and power construct, with meanings that have shifted over time to suit political goals, including to assert biological inferiority of dark-skinned populations. 2Roberts D Fatal invention: how science, politics, and big business re-create race in the twenty-first century. The New Press, New York and London2011Google Scholar In fact, race is a poor proxy for human variation. Physical characteristics used to identify racial groups vary with geography and do not correspond to underlying biological traits. Genetic research shows that humans cannot be divided into biologically distinct subcategories. 3The American Society of Human GeneticsASHG denounces attempts to link genetics and racial supremacy. Am J Hum Genet. 2018; 103: 636Summary Full Text Full Text PDF Scopus (53) Google Scholar, 4Mersha TB Abebe T Self-reported race/ethnicity in the age of genomic research: its potential impact on understanding health disparities. Hum Genomics. 2015; 9: 1Crossref PubMed Scopus (255) Google Scholar Furthermore, ongoing overlap and mixture between populations erodes any meaningful genetic difference. 5American Association of Physical AnthropologistsAAPA statement on race 38: 150-158Crossref PubMed Scopus (335) Google Scholar Angiotensin-converting enzyme (ACE) inhibitors are considered less effective in Black patients than in White patients, and they might not be prescribed to Black patients with hypertension (table). 1Kaufman JS Cooper RS In search of the hypothesis. Public Health Rep. 1995; 110: 662-666PubMed Google Scholar, 6National Kidney FoundationFrequently asked questions about GFR estimates. https: //www. kidney. org/sites/default/files/docs/12–10–4004ₐbefaqsₐboutgfrrev1bₛingleb. pdfDate: 2014Date accessed: February 28, 2020Google Scholar, 7Hsu WC Araneta MRG Kanaya AM Chiang JL Fujimoto W BMI cut points to identify at-risk Asian Americans for Type 2 Diabetes screening. Diabetes Care. 2015; 38: 150-158Crossref PubMed Scopus (335) Google Scholar, 8Streja E Nicholas SB Norris KC Controversies in timing of dialysis initiation and the role of race and demographics. Semin Dial. 2013; 26: 658-666Crossref PubMed Scopus (14) Google Scholar, 9Chapman EN Kaatz A Carnes M Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013; 28: 1504-1510Crossref PubMed Scopus (760) Google Scholar, 10Grubbs V Precision in GFR reporting: let's stop playing the race card. CJASN, 2020https: //doi. org/10. 2215/CJN. 00690120Google Scholar, 11Lee H Woo BKP Perceptions of and attitudes toward diabetes among Chinese Americans. J Am Osteopath Assoc. 2018; 118: e33-e40Crossref Scopus (4) Google Scholar, 12Thomas DM Bredlau C Bosy-Westphal A et al. Relationships between body roundness with body fat and visceral adipose tissue emerging from a new geometrical model. Obesity. 2013; 21: 2264-2271Crossref PubMed Scopus (257) Google Scholar, 13Centre for Metabolic Bone DiseasesFRAX fracture risk assessment tool. Welcome to FRAX. https: //www. sheffield. ac. uk/FRAX/index. aspxDate: 2020Date accessed: March 24, 2020Google Scholar, 14Silverman SL Calderon AD The utility and limitations of FRAX: a US perspective. Curr Osteoporos Rep. 2010; 8: 192-197Crossref PubMed Scopus (89) Google Scholar, 15Fausto-Sterling A The bare bones of race. Soc Stud Sci. 2008; 38: 657-694Google Scholar, 16Scanlon PD Shriver MD ‘Race correction’ in pulmonary-function testing. New Engl J Med. 2010; 363: 385-386Crossref PubMed Scopus (26) Google Scholar, 17Braun L Wolfgang M Dickersin K Defining race/ethnicity and explaining difference in research studies on lung function. Eur Respir J. 2013; 41: 1362-1370Crossref PubMed Scopus (88) Google Scholar, 18Braun L Race, ethnicity and lung function: a brief history. Can J Respir Ther. 2015; 51: 99-101PubMed Google Scholar, 19James PA Oparil S Carter BL et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311: 507-520Crossref PubMed Scopus (6174) Google Scholar, 20Donato A Brown K In Black Africans with hypertension, amlodipine-based therapy vs perindopril–hydrochlorothiazide improved BP control. Ann Intern Med. 2019; 171: JC5Google Scholar, 21Roberts KB Revised AAP guideline on UTI in febrile infants and young children. Am Fam Physician. 2012; 86: 940-946PubMed Google Scholar, 22Shaw KN Gorelick M McGowan KL Yakscoe NM Schwartz JS Prevalence of urinary tract infection in febrile young children in the Emergency Department. Pediatrics. 1998; 102: e16Crossref PubMed Scopus (242) Google Scholar, 23Sabin JA Rivara FP Greenwald AG Physician implicit attitudes and stereotypes about race and quality of medical care. Med Care. 2008; 46: 678-685Crossref PubMed Scopus (225) Google Scholar, 24Bennett G Coady S Levy D O'Donnell C Shero S Sorlie P 2013 Report on the assessment of cardiovascular risk: full work group report supplement. National Heart, Lung, and Blood Institute, 2014Google Scholar, 25Golomb BA Evans MA Statin adverse effects. Am J Cardiovasc Drugs. 2008; 8: 373-418Crossref PubMed Scopus (551) Google Scholar, 26Williams DR Priest N Anderson NB Understanding associations among race, socioeconomic status, and health: patterns and prospects. Health Psychol. 2016; 35: 407-411Crossref PubMed Scopus (618) Google Scholar, 27Wong RS Bussel JB Saleh MN et al. Efficacy of eltrombopag in adult east Asian and non-east Asian patients with chronic immune thrombocytopenia (cITP): results from the Extend study. Blood. 2016; 1284930Google Scholar, 28Rajman I Hirano M Honma W Zhao S New paradigm for expediting drug development in Asia. Drug Disc Today. 2020; 25: 491-496Google Scholar We argue that such approaches are harmful and unnecessary, contributing to health-care disparities among the exact populations they are intended to help. TableExamples of race-based medicine, the potential harm to patients, and race-conscious alternativesHow race is usedRationale for race-based managementPotential harmRace-conscious approacheGFR6National Kidney FoundationFrequently asked questions about GFR estimates. https: //www. kidney. org/sites/default/files/docs/12–10–4004ₐbefaqsₐboutgfrrev1bₛingleb. pdfDate: 2014Date accessed: February 28, 2020Google ScholareGFR for Black patients is multiplied by 1·16–1·21 the eGFR for White patients, depending on the equation usedBlack patients are presumed to have higher muscle mass and creatinine generation rate than patients of other racesBlack patients might experience delayed dialysis and transplant referral8Streja E Nicholas SB Norris KC Controversies in timing of dialysis initiation and the role of race and demographics. Semin Dial. 2013; 26: 658-666Crossref PubMed Scopus (14) Google Scholar, 9Chapman EN Kaatz A Carnes M Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013; 28: 1504-1510Crossref PubMed Scopus (760) Google ScholarUse eGFR equations that do not adjust for race (eg, CKD-EPI Cystatin C). 10Grubbs V Precision in GFR reporting: let's stop playing the race card. CJASN, 2020https: //doi. org/10. 2215/CJN. 00690120Google ScholarBMI risk for diabetes7Hsu WC Araneta MRG Kanaya AM Chiang JL Fujimoto W BMI cut points to identify at-risk Asian Americans for Type 2 Diabetes screening. Diabetes Care. 2015; 38: 150-158Crossref PubMed Scopus (335) Google ScholarAsian patients considered at risk for diabetes at BMI ≥23 vs 25 for patients of other racesAsian patients are presumed to develop more visceral than peripheral adiposity than patients of other races at similar BMI levels, increasing risk for insulin resistance7Hsu WC Araneta MRG Kanaya AM Chiang JL Fujimoto W BMI cut points to identify at-risk Asian Americans for Type 2 Diabetes screening. Diabetes Care. 2015; 38: 150-158Crossref PubMed Scopus (335) Google ScholarAsian patients screened for diabetes despite absence of other risk factors might experience increased stigma and distrust of medical providers11Lee H Woo BKP Perceptions of and attitudes toward diabetes among Chinese Americans. J Am Osteopath Assoc. 2018; 118: e33-e40Crossref Scopus (4) Google ScholarScreen patients with lower BMIs on the basis of indications of increased body fat (eg, body roundness, 12Thomas DM Bredlau C Bosy-Westphal A et al. Relationships between body roundness with body fat and visceral adipose tissue emerging from a new geometrical model. Obesity. 2013; 21: 2264-2271Crossref PubMed Scopus (257) Google Scholar body fat percentage), not based on raceFRAX13Centre for Metabolic Bone DiseasesFRAX fracture risk assessment tool. Welcome to FRAX. https: //www. sheffield. ac. uk/FRAX/index. aspxDate: 2020Date accessed: March 24, 2020Google ScholarProbability of fracture is adjusted according to geography or minority status, or bothDifferent geographical and ethnic minority populations are presumed to have varied relative risks for fracture on the basis of epidemiological dataSome populations, including Black women, might be less likely to be screened for osteoporosis than other populations14Silverman SL Calderon AD The utility and limitations of FRAX: a US perspective. Curr Osteoporos Rep. 2010; 8: 192-197Crossref PubMed Scopus (89) Google ScholarScreen patients for osteoporosis on the basis of clinical risk criteria, rather than race; counteract existing biases that place Black patients at risk because of racial essentialist beliefs about variation in bone density15Fausto-Sterling A The bare bones of race. Soc Stud Sci. 2008; 38: 657-694Google ScholarPFT16Scanlon PD Shriver MD ‘Race correction’ in pulmonary-function testing. New Engl J Med. 2010; 363: 385-386Crossref PubMed Scopus (26) Google ScholarReference values for pulmonary function are adjusted for race and ethnicityRacial and ethnic minority groups are presumed to have varied lung function on the basis of epidemiological dataBlack patients might experience increased difficulty obtaining disability support for pulmonary disease17Braun L Wolfgang M Dickersin K Defining race/ethnicity and explaining difference in research studies on lung function. Eur Respir J. 2013; 41: 1362-1370Crossref PubMed Scopus (88) Google ScholarUse unadjusted measures of lung function for all patients; counteract existing biases that harm Black patients because of racial essentialist beliefs about variation in lung capacity18Braun L Race, ethnicity and lung function: a brief history. Can J Respir Ther. 2015; 51: 99-101PubMed Google ScholarJNC 8 Hypertension Guidelines19James PA Oparil S Carter BL et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311: 507-520Crossref PubMed Scopus (6174) Google ScholarTreatment algorithm provides alternate pathways for Black and non-Black patientsACE-inhibitor use associated with higher risk of stroke and poorer control of blood pressure in Black patients than in patients of other racesBlack patients might be less likely to achieve hypertension control and require multiple antihypertensive agents20Donato A Brown K In Black Africans with hypertension, amlodipine-based therapy vs perindopril–hydrochlorothiazide improved BP control. Ann Intern Med. 2019; 171: JC5Google ScholarConsider all antihypertensive options for blood pressure control in Black patients; adjust as needed to achieve goals and manage adverse effectsPaediatric UTI diagnosis21Roberts KB Revised AAP guideline on UTI in febrile infants and young children. Am Fam Physician. 2012; 86: 940-946PubMed Google ScholarWhite race in girls and non-Black race in boys are considered independent risk factors for UTIStudy of febrile children in the emergency department found highest prevalence of UTI among White girls and non-Black boys22Shaw KN Gorelick M McGowan KL Yakscoe NM Schwartz JS Prevalence of urinary tract infection in febrile young children in the Emergency Department. Pediatrics. 1998; 102: e16Crossref PubMed Scopus (242) Google ScholarExperimental data suggests that these guidelines could affect management of UTI by race23Sabin JA Rivara FP Greenwald AG Physician implicit attitudes and stereotypes about race and quality of medical care. Med Care. 2008; 46: 678-685Crossref PubMed Scopus (225) Google ScholarTreat UTI in children on the basis of clinical presentation, regardless of raceASCVD risk estimationRace-specific equations included to estimate ASCVD riskASCVD events higher for Black patients than patients of other races with otherwise equivalent risk burden24Bennett G Coady S Levy D O'Donnell C Shero S Sorlie P 2013 Report on the assessment of cardiovascular risk: full work group report supplement. National Heart, Lung, and Blood Institute, 2014Google ScholarBlack patients might experience more adverse effects from recommended statin therapy, including persistent muscle damage25Golomb BA Evans MA Statin adverse effects. Am J Cardiovasc Drugs. 2008; 8: 373-418Crossref PubMed Scopus (551) Google ScholarRecommend preventive therapy on the basis of clinical metrics and comorbidities; consider pathways by which structural racism might increase cardiovascular risk among Black patients and promote resources to reduce racial stress and trauma26Williams DR Priest N Anderson NB Understanding associations among race, socioeconomic status, and health: patterns and prospects. Health Psychol. 2016; 35: 407-411Crossref PubMed Scopus (618) Google ScholarEltrombopag dosingEast Asian patients receive half the starting dose compared with non-east Asian patientsLimited pharmacokinetic studies suggest reduced metabolism of eltrombopag in patients of East Asian descent27Wong RS Bussel JB Saleh MN et al. Efficacy of eltrombopag in adult east Asian and non-east Asian patients with chronic immune thrombocytopenia (cITP): results from the Extend study. Blood. 2016; 1284930Google ScholarSome East Asian patients might receive inappropriate dosing28Rajman I Hirano M Honma W Zhao S New paradigm for expediting drug development in Asia. Drug Disc Today. 2020; 25: 491-496Google ScholarInitiate same starting dose for all patients, regardless of race, and adjust as needed on the basis of platelet responseExamples of race-based medicine were chosen to represent multiple racial groups (eg, White, Black, Asian) and domains in which race is essentialised as biological (eg, pharmacokinetics, bone density, lung capacity). ACE=angiotensin-converting enzyme. ASCVD=atherosclerotic cardiovascular disease. BMI=body-mass index. CKD-EPI=Chronic Kidney Disease Epidemiologic Collaboration equation. eGFR=estimated glomerular filtration rate. FRAX=fracture risk assessment score. JNC 8=Eighth Joint National Committee. PFT=pulmonary function test. UTI=urinary tract infection. Open table in a new tab Examples of race-based medicine were chosen to represent multiple racial groups (eg, White, Black, Asian) and domains in which race is essentialised as biological (eg, pharmacokinetics, bone density, lung capacity). ACE=angiotensin-converting enzyme. ASCVD=atherosclerotic cardiovascular disease. BMI=body-mass index. CKD-EPI=Chronic Kidney Disease Epidemiologic Collaboration equation. eGFR=estimated glomerular filtration rate. FRAX=fracture risk assessment score. JNC 8=Eighth Joint National Committee. PFT=pulmonary function test. UTI=urinary tract infection. Emerging scholarship underscores the harms of these race-adjusted practices, 29Vyas DA Eisenstein LG Jones DS Hidden in plain sight—reconsidering the use of race correction in clinical algorithms. New Engl J Med. 2020; (published online June 17. ) https: //doi. org/10. 1056/NEJMms2004740Google Scholar, 30Eneanya ND Yang W Reese PP Reconsidering the consequences of using race to estimate kidney function. JAMA. 2019; 322: 113-114Crossref PubMed Scopus (227) Google Scholar even as some continue to defend them, touting their ability to capture yet-understood differences in clinical measures between racial groups. 31Levey AS Titan SM Powe J Kidney race, and GFR 2020; (published online Scholar, Black kidney function use or of 2020; (published online Scopus Google Scholar of race-based medicine racial the for research more and about the biological inferiority of Black and Brown even or clinical support the use of they be and such as structural be medical their with racial biases that are Race is often as an independent risk for rather than as a of structural from Health disparities are leading to develop harmful stereotypes on the basis of the that some populations are more than to race with such as hypertension, and which their implicit of race as a biological J L N C George P Race and race in medical Med. 2016; Scopus Google Scholar, L racial in medical J Scopus Google Scholar might genetic which could be meaningful to a of (eg, with race (eg, M D S race of human 2016; PubMed Scopus Google Scholar, D and the of race as a biological BA race in a genomic Press, New New and Scholar On the that race is relevant to and have power to the of their SL Cooper race A of attitudes about the role of race in Health PubMed Scopus Google Scholar, H C The in medical of medical of PubMed Scopus Google Scholar, RS The of race in medical Scholar, J K S et racial in 2018; 9: Scopus Google Scholar In this race-based medicine is care might medical and increase health inequities. 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CJASN, 2020https: //doi. org/10. 2215/CJN. 00690120Google Scholar Race for pulmonary lung function reduce the that Black patients disability support for their lung L Race, ethnicity and lung function: a brief history. 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