Chapter 1: The Role of Race in Medical Diagnosis

In the realm of medicine, particularly as depicted in shows like Grey’s Anatomy, patient histories often begin with a succinct summary. For instance, “Mr. B is a 56-year-old male with a history of heart disease presenting with chest pain.” This one-liner encapsulates the essential demographic and medical history needed for the attending physician to understand the case at hand.

During my third year in medical school, I encountered a physician who insisted on including the patient's race in this summary. This led me to believe that race was a significant factor in her medical assessments. While this practice is not universally accepted, it is not entirely uncommon either.

The physician, a woman of color, helped alleviate my initial discomfort regarding her request. Nonetheless, I found it surprising. It's well-known that the prevalence of certain diseases does vary by race, making race a potential “risk factor” from a public health standpoint. This rationale parallels the inclusion of a patient’s age in medical evaluations; for instance, chest pain in a 56-year-old man is fundamentally different from that in a 12-year-old girl. However, framing individual patients solely through the lens of public health data can lead to a cognitive error known as "anchoring."

Anchoring occurs when a physician overly relies on an initial piece of information, such as race, when making decisions. Interestingly, in medical examinations, this bias is often encouraged. The lengthy, timed nature of board exams compels us to identify anchors to quickly arrive at a diagnosis. In the context of multiple-choice questions, race frequently emerges as a critical piece of information. For example, when presented with the scenario of “Ms. B, a 33-year-old African American female with a cough,” my mind instinctively considers rare diseases like sarcoidosis, solely based on her racial background.

However, I've heard numerous cautionary tales from seasoned physicians about the pitfalls of assuming a patient's condition based on race. One such story involved a White woman whose lung disease went undiagnosed for years because doctors neglected to consider sarcoidosis—typically associated with Black patients. Conversely, a Black child was incorrectly diagnosed with sickle cell disease based solely on racial assumptions.

This raises the question: where should we draw the line? Indeed, sarcoidosis and sickle cell disease are more prevalent among African Americans. Other diseases, like cystic fibrosis, predominantly affect Caucasians, while certain common illnesses disproportionately impact specific racial groups. For instance, the CDC reports that African Americans aged 18-49 are twice as likely to succumb to heart disease compared to their White counterparts. This data supports the notion of race as a risk factor, but does it imply that race itself causes disease?

Epidemiological teachings, such as the Bradford Hill criteria, present nine guidelines to consider when establishing causality, most of which rely on population data. However, two criteria—coherence and biological plausibility—demand scientific evidence. For race to be deemed a “cause” of disease, biological science must demonstrate a plausible connection. A coherent relationship between biological findings and population trends would reinforce this link.

The pressing question then becomes: is there a scientific basis for race to be a causative factor in disease? With the advent of genomic mapping and advances in precision medicine, this inquiry is particularly relevant today. Yet, the allure of such scientific exploration cannot overshadow the historical context of scientific racism.

In March 1851, Samuel A. Cartwright, a physician, introduced a so-called disease called drapetomania to the Medical Association of Louisiana, claiming it affected enslaved individuals who attempted to escape. He cited supposed anatomical differences in Black individuals as justification, using “science” to frame a natural desire for freedom as a pathological condition that reinforced racial inferiority. This kind of scientific racism paved the way for eugenics, a corrupted offshoot of Darwinian theory, aimed at perpetuating “desirable” traits. Alarmingly, in 1927, the U.S. Supreme Court sanctioned the sterilization of individuals deemed “unfit,” a decision that has never been formally rescinded. Science, often regarded as objective and factual, has repeatedly been wielded as a tool to justify and promote racism, sexism, and various forms of discrimination.

This context makes the quest for scientific validation that labels 'Blackness' as a cause of heart disease deeply unsettling, particularly since research has established that race is fundamentally a social construct. Nevertheless, advancements in genetic research can tempt scientists to explore these connections. For instance, a 2013 study identified a gene variant associated with elevated cholesterol levels, found more frequently in populations of African descent. While this research may hold promise, it risks overshadowing the critical social determinants of health.

The urgency of this discussion has intensified amidst the global pandemic, where the intersection of race and science has become glaringly apparent. In the U.S., COVID-19 has disproportionately affected the Black community. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, noted, “Health disparities have always existed for the African American community, but this crisis highlights how unacceptable that is.” He emphasized that the issue lies not in susceptibility to the virus but in the prevalence of pre-existing health conditions within the Black community, resulting in increased ICU admissions and mortality rates.

U.S. Surgeon General Jerome Adams provided a clear insight: “We do not think people of color are biologically or genetically predisposed to get COVID-19, but they are socially predisposed to coronavirus exposure.” He is articulating a truth that many may hesitate to confront. For instance, many essential service jobs are filled by African Americans, complicating social distancing efforts. Additionally, a greater reliance on public transportation and lower homeownership rates in this community hinder isolation measures. Furthermore, systemic health disparities—such as higher rates of asthma—exacerbate the risks associated with COVID-19 infection. Lastly, the historical mistrust of the medical community, rooted in unethical practices like the Tuskegee Study, leads to reluctance in seeking treatment among many Black individuals.

The necessity for our Surgeon General to address scientific racism is alarming, albeit not surprising. The pandemic has compelled society to confront public health issues, yet some individuals are leaning towards discrimination rather than understanding. For instance, the rise of anti-Asian sentiment has prompted official comments from the CDC, while calls for older individuals to sacrifice themselves for economic stability echo eugenic ideologies, deeming frailty as 'undesirable.'

If African Americans are deemed “socially predisposed” to COVID-19, it’s clear that race does hold significance. We cannot claim to be color-blind in our approach to health disparities.

So, should medical trainees incorporate race in their presentations? The answer remains ambiguous. While it may not be essential from a biological or epidemiological standpoint, acknowledging race might provide insight into a patient’s social circumstances. Regardless, it is vital to continue highlighting health disparities, fostering discussions, and investigating underlying causes. This is how solutions can emerge. However, we must not allow “objective” science—like that wielded by Samuel Cartwright—to eclipse the crucial role of social determinants in health. As we delve into the intricate relationship between science and race, particularly in the context of COVID-19, we must remain vigilant against the resurgence of scientific racism.

This video discusses the historical context of scientific racism in America, exploring how medical practices have been influenced by race.

Chapter 2: Understanding the Complexities of Race and Health

This video examines the intersections of science and racism, focusing on how societal structures influence health outcomes across different races.

Section 1.1: The Influence of Race on Medical Practice

The inclusion of race in medical assessments can lead to both insights and pitfalls. While it may offer valuable context, it also risks reinforcing stereotypes.

Subsection 1.1.1: Historical Examples of Scientific Racism