Reimagining Race in Research
The Case for Talking About Structural Racism, Not Just “Race”
Being a medical student at a time when race is in the national spotlight, I often question my role in perpetuating racial inequity. As a future physician researcher, I am particularly concerned with how we frame race in clinical research. Race as a category is found everywhere in medicine: a box to check on a form, an input on a diagnostic testing algorithm, or a variable in a regression model. This emphasis on race — a social construct without biological meaning — takes attention away from the social determinants of health, which have adversely affected Black Americans throughout decades of structural racism and anti-black oppression.
There are myriad ways in which structural racism exists in our society: from newly imposed employment requirements for Medicaid, a program that disproportionately serves people of color, to the unavailability of healthy food in poor, predominantly black neighborhoods to false beliefs about biologic differences between black and white people. These, in turn, manifest as disparities in health: black women are three times more likely to die from pregnancy complications than white women; the incidence of heart failure in young, black men is 20 times the incidence in whites; and fewer painkillers are prescribed to black patients than their white counterparts. These disparities are the result of complex interactions between many insidious forms of structural racism.
Yet in our clinical research, we assume our job is complete once we have included ‘race’ in our models. What if we examined structural racism, not just race? What if we included variables like, ‘experiencing homelessness’ or ‘lives in a food desert’ or ‘not insured’ in our models? Using these variables instead of simply using race would prevent our society from explaining away health disparities as differences in biology and encourage us to focus on eliminating structural racism. Sure, there are statistical considerations to bear in mind such as over-explaining the data or including highly correlated covariates, but this should not stop us from trying as these concerns can be appropriately managed.
Many clinicians have questioned the utility of race in research. As one puts it, “When a person’s race is ascertained and used in measurement, is it merely an indicator for race, or does it mask or mark racism?” Other scientists go even further and say that the use of race as a variable in research should be abolished altogether. Thus, this is not an entirely new concept for the scientific community. Medicine, in particular, would benefit from this shift away from race as it would lead to better patient care and improved population health.
For example, if I were a physician who focused on the adverse effects of homelessness on the management of diabetes — as opposed to race and diabetes — I would try to help my diabetic, homeless patients in more than one way. I would recognize that my patient’s diabetes is exacerbated by the stress of being homeless and that the rising costs of insulin may threaten proper, long-term treatment. Thus, my role as a physician would be not only to treat my patient’s diabetes, but also to alleviate their homelessness. On a larger scale, I would advocate, as many before me have done, for policies that benefit all patients experiencing homelessness, thus improving the lives of not just one patient, but the population as a whole.
For decades, the medical establishment has acknowledged and exposed racial disparities in health by including race as a variable in clinical research models. This blind focus on race does a disservice to our patients because it legitimizes the notion that race predestines one to a lifetime of substandard health. Our patients lose when we focus on race alone rather than structural racism.
By acknowledging that racism — not race — causes substandard health outcomes, we can recognize that we have the ability to change the structures that perpetuate racism. In this age of flagrant and unchecked racism, we have a unique obligation as health professionals to dismantle structural racism in an effort to serve all our patients well.
Kshipra Hemal was a 2016–2017 Global Health Corps fellow and is currently pursuing a medical degree. The opinions expressed in this post are solely representative of the author and do not necessarily reflect those of Wake Forest University or the NC Albert Schweitzer Fellowship.
Global Health Corps (GHC) is a leadership development organization building the next generation of health equity leaders around the world. All GHC fellows, partners, and supporters are united in a common belief: health is a human right. There is a role for everyone in the movement for health equity. To learn more, visit our website and connect with us on Twitter/Instagram/Facebook.
