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 the relationship between race and illness 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 from 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.
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 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 seems 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.
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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. Black people have higher rates of hypertension than whites. Does knowing that this patient is Black make any difference? Probably not much in making the diagnosis or 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.
Interestingly, Black people living in the United States have higher rates of hypertension than black people living in Africa, so ancestry does not seem the key factor here. Rather, socioeconomic factors are most likely key to understanding 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 are 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.
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 are every healthcare professional’s duty to help remedy.