I know you’ll all be mightily impressed to learn that I read The Lancet [although I hardly understand any of it]. I even have a subscription – actually several subscriptions: to The Lancet, The Lancet Diabetes and Endocrinology and The Lancet Oncology [I have “email subscriptions” to these journals, which are free and contain lots of links to paywalled content I can’t afford to read and probably wouldn’t understand anyway]. Despite being imprisoned by the Evil Elsevier Empire, there is actually plenty of open access Lancet content available to anyone with a web browser [and delusions of scientific literacy in multiple areas of cutting-edge medical research]. Some of that content is accessible in every sense of the word, and so outstanding that you might consider becoming a regular reader of The Lancet yourself. Exhibit A comes from the current issue: a “Viewpoint” titled From race-based to race-conscious medicine: how anti-racist uprisings call us to act.*
The opening paragraphs make fast work of dispensing with the fiction that “race” has any meaningful basis in biology or genetics. Race is a social construct rooted in European colonization and deployed “to divide and control populations worldwide.” If that were not so, its meaning would not conveniently drift and change over time to the benefit of various political goals and power structures.
Medicine is pervaded by structural racism as much as any other Western institution, with all of the inequities for BIPOC we see everywhere else. Why wouldn’t it be? Along with all the other axes of privilege and oppression, race-based disparities in medicine will persist at least until they are laid bare, critically examined, widely acknowledged and utterly replaced with the widespread adoption of entirely different paradigms.
This is what the authors attempt to do, by making a case for distinguishing “race-based” from “race-conscious” medicine. On its face, this may seem like a distinction without a difference, not to mention contradictory to the authors’ explicit premise that race is a false, misleading and harmful construction leading directly to poorer health outcomes for BIPOC. Happily, this turns out not to be the case: while race should be viewed as functionally irrelevant in the context of medicine, racism should not. In fact, they argue quite persuasively that systemic and structural racism accounts for much of the disparity in illness and wellness among different populations. Rather than taking the shortcut and relying on scientifically unsupported assumptions about inherent racial characteristics, a wiser course is one that emphasizes instead the well-documented harms of racism. Put much more eloquently:
[P]ropagation of race-based medicine promotes racial stereotyping, diminishes the need for research identifying more precise biomarkers underpinning disparities, and condones false notions about the biological inferiority of Black and Brown people. Hence, even if significant findings or clinical anecdotes support the use of racially tailored practices, they should be rigorously critiqued and mediating variables, such as structural conditions, should be analysed accordingly.
So far, so theoretical. But the real world implications really drive the point home:
[M]edical students who endorsed the false beliefs that Black patients had longer nerve endings and thicker skin than White patients also rated Black patients as feeling less pain and offered less accurate treatment recommendations in mock medical cases. This racialised belief in diminished pain sensitivity of Black patients translates to consistently inadequate pain management and their reduced likelihood of receiving opioid prescriptions for severe pain. Furthermore, race-adjusted instruments might also affect disease management. The assessment of renal function in Black patients is based on a higher estimated glomerular filtration rate (eGFR), which might mask kidney failure, delaying dialysis and listing for transplant. Race corrections for pulmonary lung function tests also reduce the likelihood that Black patients can obtain disability support for their lung disease. These examples show the necessity of transitioning from a race-based system of clinical care to race-conscious practice.
More detailed examples of race-based medicine are listed in this table, along with the flawed rationales behind them, their potential (or actual) harm to patients and alternative race-conscious approaches. Right there in black and white, race-conscious medicine appears as compelling as it is promising. What’s more, despite appearing in the rarefied pages of one of the world’s most venerated medical journals, pretty much anyone can understand it. [Except for Sam Harris obviously.]
That said, as with other manifestations of racism I suspect the greatest resistance to this change will come not from medical practitioners who consciously and willfully hold racist views (even if they are wise enough not to publicly espouse them). It will come instead from those who fervently believe that because they do not consciously hold racist views, they are immune to perpetuating racial biases. It is most unfortunate that embedded in the very nature of privilege itself is a reflexive blindness to the enduring structural legacies that accrue to one’s own benefit. This is precisely how and why unjust systems stubbornly self-perpetuate. It is also why anti-racist work is such a monumental undertaking.
I cannot help but think of the late, great Dr. King’s words in his Letter from a Birmingham Jail:
I have almost reached the regrettable conclusion that the Negro’s great stumbling block in his stride toward freedom is not the White Citizen’s Counciler or the Ku Klux Klanner, but the white moderate, who is more devoted to “order” than to justice; who prefers a negative peace which is the absence of tension to a positive peace which is the presence of justice.
–Martin Luther King, Jr.
*From race-based to race-conscious medicine: how anti-racist uprisings call us to act. Jessica P Cerdeña, MPhil, Marie V Plaisime, MPH, Jennifer Tsai, MD. The Lancet, Viewpoint | Volume 396, ISSUE 10257, P1125-1128, October 10, 2020. Open Access | DOI: https://doi.org/10.1016/S0140-6736(20)32076-6.