You may not know it, but your doctor might be making health care decisions based, at least in part, on your race.
It’s a practice, now under some scrutiny, called race-based medicine: Health care providers use race to make medical decisions, such as which treatments will be offered to patients or which diagnoses they receive.
Race shows up in an equation that determines how well a person’s kidneys are working in a test to evaluate lung function; in a calculator to decide whether a woman should be offered a vaginal birth after a cesarean section; and in the guidelines that estimate a person’s risk of breaking a bone, among many other places in medicine.
This practice has wide-ranging and devastating effects on health equity and the health of individuals. In the race-based equation for kidney function, for example, Black people’s kidney function is overestimated by about 16% when compared to someone of a different race.
This results in delays in Black people being placed on kidney transplant lists, and in substantially increased wait times for donor organs once listed — which in turn leads to more years on dialysis and fewer kidney transplants for Black patients, compared to their white counterparts.
Race-based medicine also assumes a lower level of lung function is normal for Black people, resulting in delayed diagnosis of lung diseases and more severe symptoms before receiving treatment. Black, Asian and Hispanic patients are also less likely to be treated for low bone mass, which puts people at risk for fractures.
Centuries of discrimination
Race-based medicine can be traced back to chattel slavery and the desire of enslavers to justify their treatment of Black people and maintain their privilege. At that time, slaveholders and medical professionals argued that the Black “race” was biologically inferior to others and pointed to “evidence” such as smaller skull sizes and lower lung capacity — which, when present, were likely due to the abysmal nutritional and other environmental factors on plantations.
The spirometer, which was a precursor to the lung function test in use today, was racialized and popularized on a plantation by enslaver Samuel Cartwright, and its racist calculations have traveled with it.
The idea that race is biological flourished during the eugenics movement, which gained popularity in the 1920s, and at some point, became an accepted part of medical practice, with the inclusion of race no longer seen as needing justification.
Despite well-supported facts that race is a social, not biological, construct, and racism, not race, causes health care disparities, the misuse of race in medicine persists.
In 2020, the New England Journal of Medicine published a list of race-based calculators and guidelines, all used in medical practice today.
In response, the American Society of Nephrology and the National Kidney Foundation have recommended the immediate implementation of a race-neutral equation to estimate kidney function. The United Network for Organ Sharing is giving credit for time on the transplant waiting list to Black patients who were harmed.
The American Thoracic Society has also advocated for a race-neutral calculation of lung function, and the original creator of the Vaginal Birth After Cesarean calculator made a race-neutral version without compromising accuracy.
A path forward
While taking steps in the right direction, this problem is far from fixed.
Many health care institutions have not made these recommended changes, and not all race-based clinical decision tools have a clear replacement or path to removal.
Further obscuring the path to more equitable health care are continued proposals looking to embed race in medicine in new ways, such as with body mass index, touting different race-based cutoffs as personalized medicine.
Certainly, medicine should be anti-racist and equitable. Yet despite initiatives and increased focus on diversity and inclusion, many elements of the health care industry remain a source of structural and overt racism.
To be sure, many health care providers, medical organizations and researchers have proposed arguments to justify the continued use of race in medicine, such as it being the “best for now” proxy to capture the health inequities experienced by people of color.
But changing the system is not advocacy for the practice of race-blind medicine. Rather, it is advocacy for the thoughtful and evidence-based inclusion of race that recognizes it as the social construct that it is.
As Dorothy Roberts, sociologist and a professor at the University of Pennsylvania’s Africana Studies, stated about her 2016 article in the journal, Science, “Race is not a biological category that naturally produces these health disparities because of genetic difference. Race is a social category that has staggering biological consequences because of the impact of social inequality on people’s health.”
Amanda Bradke, M.D., is a physician at Rush University Medical Center in the division of Hospital Medicine. She founded and co-chairs the Chicago Coalition for Antiracism and Equity in Health, a committee dedicated to dismantling race-based clinical decision tools.
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