More Than Just a Social Construct
The fiction that race has no biological basis is more likely to exacerbate health disparities than narrow them.
“In support of efforts to confront our country’s history of racism and injustice,” stated an American Medical Association press release in 2020, “the nation’s leading physicians voted to adopt two new policies today recognizing race as a social construct—rather than a biological construct—at the American Medical Association’s (AMA) Special Meeting of its House of Delegates (HOD).” This kind of statement from the leaders of American medicine has become increasingly common in recent years.
The National Institutes of Health holds that, “Race is a social construct used to group people. Race was constructed as a hierarchal human-grouping system, generating racial classifications to identify, distinguish and marginalize some groups across nations, regions and the world.” The America College of Physicians has stated that race is “social rather than biological.” The American Academy of Pediatrics says its members believe that, “Race is a historically derived social construct that has no place as a biologic proxy.” The American College of Obstetricians and Gynecologists has stated, “Race is a social category, not a biological or genetic condition that elevates risk for certain diagnoses and health disparities.”
This refusal to acknowledge that race is an important variable in patient care runs contrary to what I was taught during my medical training several decades ago. Back then, when presenting the results of a patient’s medical history and physical examination to an attending physician, the medical student, intern, or resident was expected to start the description of the case by stating the patient’s age, race, and sex. Why? Because these were believed to be important factors when determining potential susceptibility to disease and appropriate treatment.
But there is a growing belief in medical academia that identifying the race of the patient or prescribing race-specific treatments may lead to “systemic racism” on the part of healthcare professionals or the perpetuation of existing health disparities. In the past, race was used in presentations precisely because it was helpful to the patient. Now, any mention of race in a case presentation is strongly discouraged in medical education. In an article in the New England Journal of Medicine published in December 2021, the authors write:
Given persistent racism in medicine and the growing recognition that racial and ethnic categories are socially constructed and not biologically coherent, the practice of mentioning race or ethnicity immediately in case presentations—alongside age and sex—is worth revisiting.
“We believe.” they conclude, “that in medical schools and residency programs where this practice remains prevalent, clinician educators should acknowledge its potentially problematic impact on clinical reasoning and use it as a springboard for discussions of stereotyping and racism in medical practice.”
Such delicacy about the use of race as a descriptor extends to all races, but it is especially pronounced regarding black patients because they are said to have suffered the most from systemic racism in the past. I do not wish to argue that there are no social dimensions to race or that racism does not exist. Rather, I want to draw attention to the biologically valid reasons for including race in patient discussions, evaluations, and treatment decisions. This is not simply an abstract point about political correctness—the exclusion of race as a variable when determining patient susceptibility and treatments may leave medical practitioners unable to provide black patients with optimal care.
In 2018, a review article in the journal of the American Heart Association reported that hypertension is more prevalent in blacks than in other groups, which means that US blacks have much higher rates of several types of strokes: “black patients were more likely to be aware they were hypertensive, more likely to be treated for hypertension, more likely to be treated more intensively, but less likely to have their BP [blood pressure] controlled.” The blood pressure of black hypertensives is difficult to control because they “tend to retain salt and water” more than other groups. “Black patients of African origin have more severe and resistant hypertension, often because of genetically determined predisposition to salt and water retention, with suppressed plasma renin activity.” This has consequences for treatment—diuretics (“water pills”) are recommended for first-line treatment of hypertension in blacks but not for other groups.
A complication of longstanding hypertension is congestive heart failure, but it has been found that self-identified black patients have a 43 percent reduction in mortality when treated with a combination of isosorbide dinitrate and hydralazine compared to standard treatment. Following clinical studies, the Food and Drug Administration has approved a fixed-dose combination (marketed as BiDilTM in the US) of these two medications. These medications in combination do not show the same benefit in white patients. An article in a European medical journal has noted that these medications in combination have been “underused for patients of African ancestry.” Another article likewise stated that this combination of medications “remains markedly underutilized in this population.” One of the listed possible reasons for this underutilization was “social caution over race-specific therapy.”
Black patients also have different outcomes to other groups for several different forms of cancer. Although differences in outcomes are often attributed solely to “social determinants of health,” there is ample evidence that biological factors are also important. For instance, black women are much more likely than women in other groups to develop “triple negative” breast cancer (TNBC). The authors of a 2018 study reported that, “TNBC disproportionately affects black women and is an aggressive subtype of breast cancer with limited treatment options compared with receptor-positive breast cancer.” Another report stated, “Our comprehensive ancestry quantification process revealed that ancestry-associated gene expression profiles in TNBC include population-level distinctions in immunologic landscapes.” In other words, genetic factors affect the likelihood that a black woman will have TNBC.
Regarding prostate cancer, it has been reported that, “African-American men (AAM) have the highest reported incidence rates in the United States and their mortality from the disease is markedly higher than that of European-American men (EAM).” Another report found that, “The underlying reasons for this disparity are not well understood, although existing evidence implicates important genetic components.”
Black Americans also have more difficulty than other groups in being immunologically matched for organ transplants. Difficulty in obtaining good tissue matches between a patient and a donor result from differences in human leukocyte antigens (HLA), which are genetically determined. Black patients wait longer for a compatible donor organ and are more likely to experience immunological rejection of that organ after transplantation. This has been shown to be true for bone marrow, kidney, and liver transplants. As stated in a recent review, “Transplant survivorship disparities are influenced by HLA as a genetic construct of race.”
According to the American Red Cross, most cases of sickle cell anemia in the US occur in black patients, although there are occasional cases in patients of Mediterranean or Middle Eastern ethnicity. The Red Cross report goes on to say that:
Blood donors who are Black play a critical role in helping people with sickle cell disease, the most common genetic blood disease in the U.S. Patients with the disease may rely on regular blood transfusions throughout their lives to help prevent sickle cell complications, such as organ and tissue damage, severe pain, and strokes. It is essential that the blood they receive be the most compatible match possible, which generally comes from someone of the same race or similar ethnicity. Today, there aren’t enough blood donors to help meet this urgent need. African American individuals make up 13% of the U.S. population, but less than 3% of blood donors.
Furthermore, “many African American individuals and people of African descent have rare blood types, such as types U negative and Duffy negative.”
It has been shown that race can be determined by evaluation of a skeleton by a biological anthropologist at a rate of 57–95 percent—much higher than that predicted by chance. This technique has been successful in determining racial or ethnic identity from skeletal remains of not only “Whites, Blacks, and Native Americans but also male Hispanics, Chinese, and Vietnamese.”
The Human Genome Project has greatly advanced our knowledge of human genetics. Using the knowledge we have gained about variations in human DNA called single nucleotide polymorphisms (SNPs), it has become possible to detect genetic differences between groups of people based on geographical ancestry. A 2005 study examining the genetics of hypertension evaluated 326 gene variants in 3,636 individuals from several different racial and ethnic groups. Genetic laboratory tests correctly predicted the individuals’ self-reported race/ethnicity in 99.86 percent of cases. “Thus,” the researchers concluded, “ancient geographic ancestry, which is highly correlated with self-identified race/ethnicity—as opposed to current residence—is the major determinant of genetic structure in the U.S. population.” This kind of genetic analysis has greatly improved since 2005. Following a discussion of recent advances in genetic research in his book In the Know, psychologist and intelligence researcher Russell T. Warne writes, “This means that genetic ancestry tests from companies like ancestry.com and 23&Me function today only because race exists and can be identified at a genetic level.”
In a recent news story, Meghan, Duchess of Sussex, said that she is “43% Nigerian” based on a genealogy test performed a few years ago. She is reported to be the daughter of a white father and an African-American mother. Since most African-Americans have approximately 10–25 percent European DNA, the child of an African-American mother and a white father would be expected to have approximately 37.5–45 percent DNA from West Africa. The majority of her genetic heritage is therefore likely to be European. Meghan says that she plans to “dig deeper” into her racial heritage, and Ancestry.com reports being able to pinpoint specific areas within Nigeria in which Meghan’s ancestors may have lived.
The newest evidence that race is not simply a social construct has come from an unexpected source. Several teams attempted to create artificial intelligence (AI) systems to automate the interpretation of medical radiographs (x-ray images). To their surprise, they found that AI can detect the race of the patient by evaluating a radiograph at a much higher frequency than chance. Even though the AI system had never been programmed to detect race, it developed that ability by reading very subtle clues to racial differences undetectable by the human eye. The AI researchers found that “AI can accurately predict self-reported race, even from corrupted, cropped, and noised medical images, often when clinical experts cannot.” The researchers were apologetic and embarrassed by this finding, which they said, “creates an enormous risk for all model deployments in medical imaging.” Describing their methodology in their paper, the authors wrote:
In this modelling study, we defined race as a social, political, and legal construct that relates to the interaction between external perceptions (ie, “how do others see me?”) and self-identification, and specifically make use of self-reported race of patients in all of our experiments.
Despite not defining race in biological terms, they “found that deep learning models can accurately predict the self-reported race of patients from medical images alone. This finding is striking as this task is generally not understood to be possible for human experts.” In another recent study, AI was reported to be able to “predict the age, self-reported gender, self-reported ethnicity, and insurance status of a patient from a chest radiograph.” The researchers were again unable to explain how the AI system managed this.
In a 2021 article, five “researchers whose work is largely focused on genetics and who self-identify as Black men” discussed the divergence of opinion on the use of race in medical practice. “Either the use of race in clinical practice and biomedical research has substantial benefits,” they wrote, “or race has no biologic basis and thus no place in medicine.” They continued, “There is a remarkably strong correlation between a person’s continent of ancestral origin and self-identified race. Thus, we believe that race has both a genetic and a social component.” The authors add that, “Greater inclusion in genetic studies of participants of African ancestry could greatly advance scientific discovery,” and conclude: “We do not believe that ignoring race will reduce health disparities; such an approach is a form of naive ‘color blindness’ that is more likely to perpetuate and potentially exacerbate disparities.”
Those who argue that “Race-Based Treatment Decisions Perpetuate Structural Racism” typically provide no evidence in support of that claim. Such arguments appear to be based on ideology alone and simply ignore a growing body of empirical evidence to the contrary. In the examples of “race-based treatment” I have discussed, the practice resulted in improved clinical outcomes for black patients, which ought to be the goal of efficient and humane medical practice. If we wish to reduce health disparities, we will have to begin by acknowledging the biological reality of race.
