The practice of medicine and medical science is characterized as being beneficent with the ultimate goal of promoting health and healing. However, medicine is not immune to the systemic inequalities that pervade our society.
The history of medicine and health care in the United States is embedded in racism and other forms of structural violence; dating back to crude medical experimentation done to Black slaves against their will to the manifestations of racial disparities in Covid-19 outcomes.
Racial health disparities are a major concern and race-based corrections are still widely used across the health care industry. However, there is no meaningful correlation between race and biological difference so the way we talk about racial health disparities—and possible solutions—is fundamentally flawed.
The myth of "race-based" health and its consequences
Current standards operate under outdated and racist assumptions that non-White people are biologically different from White people. Using race alone as a scapegoat for health disparities detracts from systemic and societal causes for differences in health outcomes.
Today, numerous equations used in medicine use race-based corrections and clinical reference values are adjusted for race, even though science has recognized that race is a social construct and a poor proxy for human genetic variation (Table 1).
The use of race in clinical decision-making is a controversial point in U.S. medical practice and education. There are consequences to utilizing race-based corrections and in doing so, pathologizing race.
Race-based corrections pervade numerous therapeutic areas of medicine, but race-based correction is not a scientific way to capture the lived experiences of structural racism and its manifestations. Race-based care might drive health inequities by propagating racialized assumptions about health status and reducing quality of care for patients of color.
Moving from "race-based" to "race-conscious" care
Race-conscious care considers racism as a social risk factor for illness rather than race as a biological risk factor for illness. Using racial identification in medicine is problematic because differences related to genetic ancestry are not captured by a person's self-reported racial identity, an issue that only becomes more complex as mixture between populations continues.
Institutional and organizational level changes and recommendations are enabling health systems to move from race-based to race-conscious medical practice. Some examples of organizational changes made include:
- NYC Health system's medical racism initiative, developed by the NYC Department of Health's Coalition to End Racism in Clinical Algorithms (CERCA), investigates and recommends race-based assessments for elimination.
- The National Kidney Foundation has issued guidance that a new race-free calculation should be used for eGFR and advises that the use of the unadjusted eGFR equation can impact patient care and help reduce inequalities in kidney disease management.
- Massachusetts General Brigham health system was an early adopter to eliminate the race-based correction from being used in its laboratories when reporting eGFR, clinical staff was also sent messaging to discourage use of the correction.
- Last month, the University of Maryland Medical Center implemented a revised VBAC calculator that eliminates race as a factor in birthing decisions.
While some argue that politics should be "kept out of the doctor's office," the misrepresentation of race in clinical medicine and medical education has political and social implications. Health care practitioners should commit to culturally competent care and leverage their expertise and cultural capital to advocate for race-conscious policies in their place of work.
Health systems and hospitals should issue guidance around race-based corrections across their institutions and work proactively to investigate race-based corrections and make recommendations for race-conscious medicine.
How precision medicine can create a more equitable future
Precision medicine paints a patient-centered future of personalized medical diagnostics and clinical decision-making that takes into account individual differences in genes, environments and lifestyles. Data is the foundation of precision medicine, but current data collection practices are heavily tied to race-identification, potentially furthering racial bias. Ensuring that precision medicine combats racial inequities requires:
- Wide-scale and representative genetic data collection: currently most of the genetic data we have has been skewed white, male, and affluent creating a misrepresentative standard to measure against. The NIH All of Us study is building a cohort of one million volunteers living in the U.S. across different races, age groups, geographic regions, and gender identities. Sufficient genetic data can be used to research genetic material and associated diseases across large populations, enabling scientists to determine meaningful genetic variation between ancestral groups rather than using race as a rough proxy.
- Scientific consensus about the difference between ancestral genetic variation (differences in DNA between individuals and populations) and social categories (typified by lived experiences e.g. race and gender): our understanding of race, racism, and its consequences has changed a lot in the last 20 years. All stakeholders in the health care ecosystem, especially health systems, laboratories, and clinicians, need to be able to critically consider if the use of race or ethnicity is appropriate and be willing to revise.
- Clinical trial models that ensure equitable access to participating in studies and research: decentralized clinical trials can drive inclusion by leveraging technology to identify a larger and more diverse set of eligible participants, connect participants with clinical trial sites and investigators, and allow remote monitoring and participation. The health care industry needs to proactively re-think the constraints around access and scale of data lending/sharing of study data to accelerate innovation to help find solutions for individual patients.
Early successes of precision medicine research have identified opportunities to improve imprecise prescribing practices of ACE inhibitors for Black patients. However, the translation of genomic data into clinical care is very complex and necessitates investment across the health care industry. With the nation's current focus on health equity, now is the time to act and enable race-conscious medicine.