WHEP Scholar Clarissa O'Conor
Drexel University College of Medicine, Class of 2021
There is a long history of science and medicine being used to justify slavery and racism. Examples include the pathologization of escape attempts by enslaved people as a psychiatric diagnosis of "drapetomania," and the eugenics movement and its obsession with skull measurements to prove the racial superiority of white people. These beliefs persist today in the form of race used as a genetic and biological category. Race, however, is a social and political category designed for power and subjugation. Racial definitions have changed dramatically over the decades to suit this goal. The "one-drop rule," where even the most remote African ancestry classified someone as "non-white" was the prevailing system. It was only in 2000 that someone could identify as multi-racial on the census. Africa is the most genetically diverse continent on Earth, but enslaved people were taken from one small part of Africa: West Africa. Indeed, most African Americans have West African ancestry, but many also have a great deal of European ancestry due to the brutal history of sexual violence against enslaved women. An estimated 94% of genetic diversity lies within racial categories.
It is clear that race is not a genetic and biological category, but race is not irrelevant to health. It is important to be clear that racism affects health tremendously. There are huge racial disparities in health, and there is more and more research on the detrimental physiological effects of the chronic stress of experiencing racism. A common pitfall in scientific research is the misuse of race as an independent variable. In 1993, in response to low numbers of women and minorities participating in research studies, the NIH mandated that NIH-funded studies include women and minorities. The unintended consequence was that researchers started using race as an independent variable. Very few research studies define race, yet many make claims about racial differences.
Notable examples of the perils of race-based medicine include BiDil, a heart failure drug marketed to African American patients. While this would seem to bolster the claim that race is genetic, the history of the drug tells otherwise. Dr. Jay Cohn developed the BiDil drug combination in the 1970s and found that it was more effective than placebo. However, another drug entered the market that was more effective. Dr. Cohn still wanted to market his combination, but no pharmaceutical company would test it. He finally found a company to partner with, but the FDA denied his request for approval. Then Dr. Cohn went back to his data and retrospectively controlled for race, with just 49 African American male participants, and found a difference. He then designed a trial with just African American participants and marketed the drug. There is no evidence it doesn't work for all races of people.
Another example comes from pulmonology, where a race correction is often used for spirometry. This belief in lung function differences between Black and white people comes from the time of slavery, where Thomas Jefferson and other slaveholders wrote about their belief in inferior lung capacity among African Americans. One of the most common and pervasive uses of a race-based algorithm in medicine is the race correction for renal function. There are great racial disparities in renal failure, which is not surprising when African American patients are being referred later for renal transplant when the race correction is used. A common explanation for the race correction is that African Americans have greater muscle mass than other races, a claim not based in any scientific fact and one with roots in the justification of slavery.
Finally, the claim that race is a genetic and biological category does harm. In one study of 419 medical students, participants endorsed almost 12% of false beliefs about racial differences, like Black people's nerve endings are less sensitive than white people's and Black people's blood coagulates more slowly than white people's. These findings have clinical significance, evidenced by the fact that Black children with appendicitis receive less pain medication than white children.
The stakes are high. Millions of dollars of research funding are poured into finding genetic explanations for racial health disparities, explanations that do not exist. This distracts from the real work of addressing systemic racism to solve racial health disparities. Over the past year, this issue has gained more attention, and some institutions, like Massachusetts General Hospital, Beth Israel Deaconess Medical Center, and the University of Washington are no longer using the race correction for eGFR. This is a step in the right direction, but more work needs to be done.