Rethinking Race-Based Medicine 

The health care industry is experiencing a paradigm shift in the way it incorporates race into medical practice. Once viewed as an appropriate compass for guiding assessments of what risks a patient might face and what medications they should take, race is increasingly understood to be a poor proxy for a host of complex interactions between social, environmental, physiological, and political factors. Its use as a single variable may therefore, in many cases, be unfounded, ineffective, and even harmful to racial minorities, particularly Black patients. As a result, many institutions have begun to rethink race-based medicine.

Race-based medical practices are widespread across specialties, from pain management care to nephrology, maternal medicine, and cardiology. A 2020 Lancet Viewpoint article, published amidst national outrage at race-based public health disparities, highlights studies finding Black patients are consistently less likely to receive opioid prescriptions for severe pain. In one study, medical students engaging in mock clinical work rated Black patients as feeling less pain and offered less accurate treatment recommendations, based on erroneous assumptions that Black patients have longer nerve endings and thicker skin than White patients.¹ 

The fact that racialized thinking impacts clinical decision-making is not surprising, given that even national guidelines include race as a relevant clinical variable. As the Lancet Viewpoint authors discuss, a widely used metric for evaluating renal function (estimated glomerular filtration rate, or eGFR) historically has used race in its calculations because studies have shown that people who self-identify as Black tend to have higher levels of serum creatinine (a waste product produced by muscles, which influences eGFR calculations). Indeed, studies have shown that failing to account for self-identified race or genetically-determined racial ancestry when using serum creatinine levels to estimate GFR does result in clinical misclassifications — however, GFR could be adequately estimated, without using race or ancestry as a variable, through calculations that rely on another protein filtered by the kidneys, cystatin C. This could help ensure that Black patients receive more precise and expedient care.² 

In September of 2021, the National Kidney Foundation and the American Society of Nephrology outlined new recommendations for diagnosing kidney disease that do not depend on race (the eGFR 2021 CKD EPI creatinine equation). They also recommended increased use of cystatin C and serum creatinine to confirm kidney function assessments.³ Pivots such as this one highlight that race can be replaced by more physiologically based considerations in diagnostic and prognostic activities.  

Preeclampsia (gestational hypertension) is another example of a disease increasingly being understood from a molecular viewpoint that transcends socially constructed notions of race. Preeclampsia is more prevalent in Black pregnant people compared to non-Black pregnant people. However, researchers found that pre-eclampsia may be successfully predicted with a screening model that analyzes the expression patterns of a specific type of RNA, called cell-free RNA, circulating in maternal blood. This screening model, which performed seven times better than conventional risk-assessment models, did not rely on race. Cell-free RNA profiles, rather than race, are more indicative of the underlying mechanisms of a complex disease and can help physicians better understand its etiology.⁴ 

Many race-based medical protocols persist, which is why physician groups like the American Academy of Pediatrics have announced initiatives to re-examine all guidance — from clinical guidelines and educational materials to textbooks and newsletter articles — to eliminate recommendations that may be falsely rooted in reductive, race-based assumptions.⁵ 

Reassessing race-based medicine can be challenging in cases where best practices remain unknown. For example, long-standing guidelines for treating hypertension dictate that Black patients be treated initially with a thiazide diuretic or a calcium channel blocker, instead of an angiotensin converting enzyme (ACE) inhibitor and/or angiotensin receptor blocker (ARB), which are often prescribed to non-Black patients. Some studies have indicated that thiazide diuretic/calcium channel blocker is more effective for Black patients, but others have provided evidence that calcium-channel blockers may be combined with a thiazide diuretic or ACE inhibitor to lower blood pressure in Black patients.^6,7 Furthermore, an analysis of over 10,000 patient records found that 46.4 percent of Black patients still had uncontrolled hypertension, compared to 39 percent of non-Black patients, in a pool in which most physicians followed the long-standing race-based recommendations for hypertension treatment. Median blood pressure was similar for Black and non-Black people regardless of which medications they were prescribed. But notably, Black patients with three or more primary care visits during the study period had a significantly reduced likelihood of uncontrolled hypertension compared to those with two visits or fewer — testifying to the importance of health care access overall in improving outcomes.  

These findings point toward the confluence of social and physiological conditions that underly the onset of disease, which may often correlate with race, but remain independent of it. Combating the idea of “racial essentialism” — which encourages the false belief that biological factors define all members of a racial category — is therefore a core resolution of the American Medical Association’s health equity campaigns, which have expanded significantly since its November 2020 Special Meeting.^9,10 By reconfiguring an understanding of race as it relates to a disease — as a social marker beyond a biological one — the medical field can play an important role in advancing racial justice in the United States. 

References 

1. Cerdeña JP, Plaisime MV, Tsai J. From race-based to race-conscious medicine: how anti-racist uprisings call us to act. Lancet. 2020;396(10257):1125-1128. doi:10.1016/S0140-6736(20)32076-6 

2. Hsu CY, Yang W, Parikh RV, et al. Race, genetic ancestry, and estimating kidney function in CKD. N Engl J Med. 2021;385(19):1750-1760. doi:10.1056/NEJMoa2103753 

3. Delgado C, Baweja M, Crews DC, et al. A unifying approach for GFR estimation: Recommendations of the NKF-ASN Task Force on reassessing the inclusion of race in diagnosing kidney disease. Am J Kidney Dis. 2022;79(2):268-288.e1. doi:10.1053/j.ajkd.2021.08.003 

4. McElrath TF, Cantonwine DE, Gray KJ, et al. Late first trimester circulating microparticle proteins predict the risk of preeclampsia < 35 weeks and suggest phenotypic differences among affected cases. Sci Rep. 2020;10(1):17353. doi:10.1038/s41598-020-74078-w 

5. American Academy of Pediatrics. American academy of pediatrics calls for elimination of race-based medicine. AAP. Published May 2, 2022. https://www.aap.org/en/news-room/news-releases/aap/2022/american-academy-of-pediatrics-calls-for-elimination-of-race-based-medicine/ 

6. Brewster LM, Seedat YK. Why do hypertensive patients of African ancestry respond better to calcium blockers and diuretics than to ACE inhibitors and β-adrenergic blockers? A systematic review. BMC Med. 2013;11(1):141. doi:10.1186/1741-7015-11-141 

7. Leake I. Lowering blood pressure in black African patients. Nat Rev Cardiol. 2019;16(6):323. doi:10.1038/s41569-019-0193-2 

8. Holt HK, Gildengorin G, Karliner L, Fontil V, Pramanik R, Potter MB. Differences in hypertension medication prescribing for Black Americans and their association with hypertension outcomes. J Am Board Fam Med. 2022;35(1):26-34. doi:10.3122/jabfm.2022.01.210276 

9. Ansell D, Dissanayake V. AMA’s new language guide is a step toward health equity. STAT. Published January 11, 2022. https://www.statnews.com/2022/01/11/ama-new-language-guide-step-toward-health-equity/ 

10. Keeys M, Baca J, Maybank A. Race, racism, and the policy of 21st century medicine. Yale J Biol Med. 2021;94(1):153-157.