Grey’s Anatomy got (at least) one thing right about medicine: all patient presentations begin with a one-liner. Something like, “Mr. B is a 56-year-old man with a history of heart disease who presents with chest pain.” The presenter (often me, the trainee) distills the patient’s demographics and medical history into a concise statement that tells the attending everything she needs to know — no more, no less.
During my third year of medical school, I worked with a physician who required the race of the patient to be included in the one-liner. To me, this meant that race was vital information to her medical decision-making. In my brief experience on the wards, this is not common but is also not unheard of.
The physician was a woman of color, easing my initial resistance to her request. But still, I was surprised. Of course, disease prevalence does vary by race. So, from a public health perspective, race can be considered a “risk factor.” Such logic is why we include age of the patient (e.g. chest pain in a 56-year-old man is categorically not the same as chest pain in a 12-year-old girl.) But using public health information to frame individual patients also carries the risk of “anchoring.”
In medical practice, anchoring is a cognitive error where the physician depends too heavily on an initial piece of information (like race) when making a decision. But in medical test-taking, anchoring is actually rewarded. Our board exams are 9 hours long and timed so that we cannot spend more than 90 seconds per question. We are encouraged to find anchors to make a diagnosis quickly, then move on. In the land of multiple choice, the patient’s race is often vital. For example, when I read, “Ms. B is a 33-year-old African American female who presents with a cough,” I immediately consider a rare disease like sarcoidosis only because the patient is Black.
But I have heard many cautionary tales from wizened doctors about how “patients don’t read the textbook.” For example, I heard about a White woman who had a lung disease that went undiagnosed for years because no one thought of sarcoidosis — an epidemiologically “Black” disease. Conversely, I heard about a Black child whose diagnosis was incorrectly presumed to be sickle cell disease, a presumption made on the basis of race.
So where do we draw the line? After all, sarcoidosis and sickle cell disease are more likely in African Americans. Other diseases, like cystic fibrosis, are more common in Caucasians. And some common diseases disproportionately affect certain races. For example, the CDC tells us that African Americans ages 18–49 are 2 times more likely to die from heart disease than Whites. This type of data is what makes race a risk factor. The ensuing question is, does race cause disease?
A teaching in epidemiology, known as the Bradford Hill criteria, offers nine guidelines that should be considered when inferring causality. Most of the guidelines rely on population data. But two — coherence and biologic plausibility — require scientific evidence instead. If race is to be considered a “cause” of disease, then biologic science must show that race can plausibly cause disease. And coherence between biology and population trends will strengthen the causal relationship.
The question becomes: is there a scientific reason that race might cause disease? With mapping of the entire human genome and the new goals of precision medicine, this question is certainly ‘in vogue.’ But its newness cannot erase the history of scientific racism.
In March 1851, a physician named Samuel A. Cartwright introduced a new disease to the Medical Association of Louisiana: drapetomania (drapetes, a runaway, and mania, madness). He explained that this malady was affecting slaves in the South, causing them to flee their owners. He called upon the evidence of Negroes’ smaller brains and blood vessels to make his case. Basically, he used “science” to diminish a human desire for freedom into a disease that only reinforced Black social inferiority. Such scientific racism birthed eugenics, the hateful half-cousin of Darwin’s natural selection (actually created by Darwin’s half-cousin, Francis Galton) that ‘arranges’ reproduction to propagate ‘desirable’ characteristics. In 1927, the Supreme Court actually permitted sterilization of the “unfit” (a decision which has not ever been expressly overturned). Science, revered for being objective and factual, has been used over and over again to not only justify but also encourage racism as well as sexism and homophobia and other modes of hate.
All of this to say, searching for scientific evidence that makes ‘Black’ the cause of heart disease makes me uneasy. Especially because science has shown race to be a social construct. But new technology and understanding of the human genome makes such scientific inquiry enticing. For example, one study in 2013 reported the discovery of a gene variant linked to high cholesterol levels that is more common in “African-derived populations.” And perhaps they are onto something; the promise of precision medicine pushes genetic studies forward. But, such research can potentially be done at the expense of overlooking social determinants of health.
And now, amidst a global pandemic, the intersection of race and science is more relevant than ever. Specifically, in the United States, COVID-19 is tearing through the Black community. Dr. Fauci, the director of the National Institue of Allergy and Infectious Disease, commented on this phenomenon: “I see a similarity here because health disparities have always existed for the African American community, but here again, with the crisis…it’s shining a bright light on how unacceptable that is.” He explained that the issue is not infectivity. Instead, the prevalence of underlying health conditions in the Black community is leading to more ICU admissions and higher death rates.
Furthermore, U.S. Surgeon General Jerome Adams offered as clear an explanation as any: “We do not think people of color are biologically or genetically disposed to get COVID-19, but they are socially predisposed to coronavirus exposure.” He is telling us something that we already know but maybe are afraid to admit. For one, many of our “essential” service-oriented jobs are filled by African Americans, making social isolation hard. Secondly, more African Americans use public transportation regularly and less African Americans own their own home, making social isolation harder. Plus, African Americans are sicker at baseline — for example, with higher rates of asthma — in part because of environmental exposures, making them more likely to be sicker if infected. And finally, Black people are not only less likely to trust doctors (known informally as the Tuskegee effect, named after the horribly unethical experiment spanning 1932–1972), but are also more likely to face hidden biases to care, making treatment more difficult to obtain.
The fact that our Surgeon General had to directly address scientific racism is concerning, though perhaps unsurprising. The pandemic has forced us all to learn about public health. And some folks are doing less learning and more discriminating. For example, anti-Asian xenophobia is common enough that the CDC had to officially comment on it. And rumblings that older people should sacrifice themselves for the economy is eugenics all over again: frailty is ‘undesirable’ so perhaps we ought to give natural selection a boost.
But, if African Americans are “socially predisposed” to COVD-19, then race does matter, right? We cannot claim to be color-blind.
So, should trainees include race in oral presentations? I’m really not sure. It might be relevant to medical decision-making, if not biologically or even epidemiologically than perhaps in what it might indicate about a patient’s social circumstances. Either way, it is important to continue exposing health disparities, discussing them, and investigating why. After all, this is how solutions are found. At the same time, we must not allow “cold, hard science” — the same science that Samuel Cartwright used — erase social determinants of health. Ultimately, as we learn about the intersection of science and race, in COVID-19 and in general, let us be vigilant about avoiding scientific racism.