The Edge Episode 21: Abolish Race (in Medicine)!

Show Notes

For centuries, doctors have medically treated people differently according to their race because they believed that race is biological. But in the last few years, medical professionals and activists have argued that this is both wrongheaded and can be dangerous to people’s health. In this episode, we talk to Stephen Richmond, a primary care physician and assistant professor at Stanford about the movement to abolish race from medicine and how race and biology do and do not intersect. 

Further reading: 

• Stephen Richmond’s 2022 paper “How Abolition of Race-Based Medicine Is Necessary to American Health Justice” in the AMA Journal of Ethics
• A 2020 report, “Toward the Abolition of Biological Race in Medicine,” published by the UC Berkeley Othering & Belonging Institute
• Congressional report from House Ways and Means Committee: “Fact versus Fiction: Clinical Decision Support Tools and the (Mis)Use of Race”

This episode was written and hosted by Laura Smith and Leah Worthington and produced by Coby McDonald. 

Special thanks to Pat Joseph and Stephen Richmond. Art by Michiko Toki and original music by Mogli Maureal.

Transcript: 

LEAH: So Laura, last month, I was trolling around Google searching for anything related to Berkeley and abolishing things…

LAURA: Right. Because as you may know from our last episode, which was about abolishing cars, our theme for the next several episodes is abolishing stuff.

LEAH: Yep. And I came across this very intriguing paper. It came out earlier this year, and it’s called “How Abolition of Race-Based Medicine Is Necessary to American Health Justice.” I was like, huh, what does that mean? So, I kept reading, and what I found kind of blew my mind.

LAURA: [reacts]

LEAH: Well, the paper, which was written by two clinicians/medical professors, is basically an argument for completely rethinking a central part of modern medicine—which is how we deal with race. For centuries, doctors have treated, as in medically treated, people of different races differently, all because of this very fundamental belief that race is biological. But in the last couple of years, there’s been a sort of revival of the conversation. The main argument is that biological race has no place in medicine and can actually be dangerous to people’s health by impacting the kind of care they get. So the idea is to completely change the way race is understood in a medical context. 

LAURA: Ok but isn’t race to some degree biological?

LEAH: Well, yes and no. Yes, the color of our skin is determined by our genes. But no, people categorized in the same racial group are not necessarily more genetically related than they are to people of other racial groups. We’ll get more into that later.

LAURA: Ok…but aren’t there some diseases, like diabetes, that do affect people in certain racial groups more than others? 

LEAH: Yeah, GREAT question. I wondered the same thing. And, in short, it’s complicated. When it comes to diseases like diabetes and even some kinds of cancer, there is overlap with certain racial groups. But the deeper causes of those correlations are complex and include  poverty, education, and other factors that ultimately have roots in systemic racism. In other words, race is relevant, but using it as a shortcut to make medical predictions or treatment plans misses the bigger picture.

LAURA: So yeah… complicated. 

LEAH: And that’s why I think you’ll find today’s guest really interesting! He’ll also talk about a fascinating, real-world example of the detrimental outcomes of race-based medicine on people’s health care.

[THEME MUSIC] 

LAURA: This is The Edge, a podcast produced by California magazine and the Cal Alumni Association.

LEAH: In this episode we are talking to a doctor about the movement to abolish biological race from medicine. 

LAURA: I’m your host, Laura Smith. 

LEAH: And I’m your other host, Leah Worthington.

[MUSIC OUT]

LEAH: Today we’re talking to Stephen Richmond, a primary care physician and clinical assistant professor at Stanford. He’s also a proud Cal alum who got his degree in molecular and cell biology. Quick aside—Stephen wanted to make clear that his remarks are his own and don’t represent his institution.

LEAH: Anyway, so for Stephen, practicing and teaching medicine isn’t just about healing individual health problems…

STEPHEN: 

I think of medicine as a way in which I make change, it’s a vehicle for social justice.

LEAH: And for the last few years, he’s been really actively involved in the effort to abolish biological race from medicine. So, the belief that race is a biological reality is deeply entrenched in how we study and practice medicine. But Stephen says that’s all wrong.

STEPHEN:

So a common misconception for a lot of people is that race is biological. 

Race at the end of the day is not a biological construct. It’s a social construct. 

LEAH: If that’s surprising to you…you’re not alone. I’ll admit, I was surprised to learn that there’s pretty much no empirical merit to the “race is biological” theory.

In fact, the completion of the Human Genome Project in the early 2000s showed that, at the DNA level, humans are basically identical and that there is no genetic basis for what we call race. Did you know you actually can’t determine someone’s race from their genes at all? In fact, studies have shown that there’s more variation within racial groups than between racial groups. DNA tests like 23andMe can give you information about where someone’s genes are from, geographically, but being from Africa, for instance, doesn’t necessarily make you Black. In other words, the racial groups that we put people in have much more to do with how we, as a society, perceive them, than some deeper, biological reality. 

LAURA: I guess it makes sense that a white South African, for instance, wouldn’t necessarily be more closely related to someone who is white Australian, just because they have similar skin color, compared with, say, a multiracial South African. 

LEAH: Right exactly. But that’s the root of the problem. Scientists long believed that people with more similar skin tone were more genetically—and therefore medically—similar. Which means there are all these ways in which the health care system has tailored diagnosis and treatment on arbitrary, and often incorrect, groupings.

STEPHEN: 

It doesn’t make a lot of sense to define or make scientific or medical decisions on something that is fluid and changeable. 

So race-based medicine is this really erroneous system of creating clinical decisions and science around a social construct.

STEPHEN: 

Anybody can identify as Black. And in fact, race is quite, quite fluid. There are individuals who identify as Black for a certain portion of their life. And then later on, they get more in touch with, say, their indigenous roots, or their white roots, or the Hispanic roots, and they change their identification. But does that mean that all of a sudden their calculation or the medical calculation of their kidney function should also change? 

How Black do you have to be to qualify for the equation? 

When we talk about science, what we’re talking about is precision based on observable, unchangeable sort of indelible characteristics of nature, you know, that are quantifiable. You can’t quantify how Black somebody is, right? It’s something that is, is very personal, very intimately related to a person’s self concept.

LEAH: Second of all, Stephen said that using race as a determining factor in what sort of medical treatment to give a patient sort of misses the forest for the trees. 

STEPHEN: 

When you when you look at the statistics, the epidemiological statistics of disease and use stratified by race, African Americans are oftentimes at the highest risk for so many different things, right, they’re out there that, you know, they have the highest risk of heart disease and kidney failure and diabetes and premature birth. And it’s like, wow, you know, is it just that the Black race, you know, something about being Black really confers all of these bad things to happen to you? Or is there something else a little bit more nefarious going on, insidious going on in the background?

The bigger story here is it’s racism, not race, that’s the problem. 

LAURA: So he wants to abolish race from medicine…but what does that mean exactly? 

LEAH: Right, so there’s an important distinction here: between race as biological and race as social. According to Stephen, using biological race in medical practice is outdated, fundamentally flawed, and dangerous to people’s health. And THAT’S what he wants to abolish. Or, rethink, rather.

STEPHEN: 

Removing race out of medicine is not the way forward or the intention of what we’re trying to achieve. That is a slippery slope to what we call colorblind racism, wherein people are not acknowledging that race exist at all, as a social construct or otherwise. 

STEPHEN: 

We don’t want to make that mistake where we don’t consider race in medicine at all. it’s an effort for us to get closer to something that looks like equity, which means how do we abolish racism in medicine, but understand that race is with us? It’s not—there’s nothing that we can do about it now. Right? It’s here.

LAURA: Ok let me see if I’m getting this: So basically the idea is that race is a social construct, but because of racism in society and in medicine, it has real health impacts? So it’s both not real and very real at the same time? 

LEAH: Yeah that’s a big part of it. This movement is really an attempt to reframe our understanding of race

STEPHEN: 

The alternative approach, I would say, to race-based medicine is something that’s called race consciousness.

It’s an idea that you have a better understanding of people’s lived experience as a function of the race in which they identify. 

Race consciousness is an effort to transform our thinking around race and wake us up to the sensitivity that racism exists in all the lives of our patients and shows up in different ways in their health, whether that be hypertension, or diabetes.

Because now you have contextualized their existence, you’ve seen them more than more than a cofactor in an equation, you see them as human beings who have had a different lifestyle and a different way of walking through the world as compared to you. 

LAURA: In other words, Stephen and his colleagues are advocating for looking at people more holistically and as a product of their living conditions, rather than just making  arbitrary blanket assumptions based on the color of their skin. 

LEAH: Exactly. I should say, Stephen and his fellow activists because people have been pushing for this for years.

LAURA: That makes sense. But this seems like a hard thing to change. What specific ideas do they have for how it could be done? 

LEAH: Well, on a micro-level, there are little things that Stephen says healthcare workers could do that would make a big change. For example, he said that clinicians will often use a “one-liner” to describe each patient, like “a 39-year-old Black male with a history of chronic lung disease and high blood pressure is presenting with shortness of breath,” blah blah blah. But is including that race identifier helpful, or does it just trigger people’s biases? According to Stephen, it’s not uncommon for doctors to hear “Black” and make assumptions about patients’ lifestyle, drug usage, etc. And then treat them differently as a result.

LAURA: So Stephen would advocate for just not including that racial identifier at all?

LEAH: Exactly. So, that’s just one example of a seemingly small change that, broadly speaking, is part of a larger effort to take racism and implicit bias out of medicine. Which, obviously, is a huge task and requires work on many different levels from medical training to national healthcare policies.

STEPHEN:

So, when you take your scientific method, and you encode in it, this idea that race is part of the natural world, and then you begin to generate evidence on the basis of that fact, it’s hard to refute that evidence because the bias was a part of the initial design mechanism, right? The initial construction of the method or the research to begin with. So it’s a little bit of a—sorry to use crude language—but it’s a little bit of a trash in, trash out sort of situation.

LEAH: 

You talk about these things that are—race being encoded into the medical system. In what way? 

STEPHEN:

Race-based medicine often shows up in clinical algorithms, calculators, decision rules.

LAURA: Leah, How common is that?

LEAH: Surprisingly common. Like, right now I’m scrolling through a list of 13 examples of medical practices that use a “race correction.”

LAURA: That… sounds problematic.

LEAH: Oh, yeah, it is. There are really qualitative ways in which medicine has tried to adjust for racial differences by actually factoring it into the calculation. Like in predicting mortality in patients with acute heart failure or in estimating survival rates among patients with certain types of cancer. The most notorious example, and the one Stephen talks about in his paper, is the eGFR equation. The race-based eGFR equation, to be specific, which Stephen calls the “quintessential example” of race being mis-used in medical practice—and the devastating impacts it’s had on people’s lives.

LAURA: Hold on. What’s eGFR?

LEAH: To understand this, you need a little bit of basic physiology. Ready? Ok so, the kidney is an organ whose main function is to filter toxins out of the blood stream. Obviously a very important job. And one of the ways doctors measure how well the kidney is working is with something called the estimated glomerular filtration rate, or eGFR.

STEPHEN:

This number is not a natural number. It’s not a biomarker, for example, it’s not something that we can just pull out of thin air and just test directly. It’s an estimate, it’s a calculation that’s done.

LEAH: In other words, it’s not something you can directly measure. It’s a made-up calculation that combines data from a blood test with other factors, including a person’s age, sex, and body type to estimate kidney function.

STEPHEN: 

And it basically gives us a sense of how good a job your kidneys are doing at filtering the blood. And by virtue of that filtering waste products out of the body. 

LEAH: For years, researchers have been trying to fine-tune that calculation to more precisely measure kidney function. And one of the ways they thought to do that was by factoring people’s race into the equation. In other words…

STEPHEN:

You know, if African Americans or Asians are different, then maybe we can adjust these equations based on the color of their skin, and it will give a more precise measurement of how the kidneys are functioning in this particular population. 

LAURA: Is there any validity to that thinking?

LEAH: Actually, yes. Well, sort of.

STEPHEN: 

There has been study after study that has shown that there are slight differences when you stratify, or you create subsets. And look at, for example, the eGFR of African Americans specifically, it’s slightly different than white counterparts about 20% different in certain subpopulations. 

And so, this for a long time has created a situation or a state in which the kidney function for African Americans has been calculated differently. In fact, there is a race correction factor wherein for African Americans, essentially the number that you get out as compared to the white counterparts is multiplied by 20% factor. And so what ends up happening as a result of that is after the the results that are produced by this race adjusted equation, make African American identified individuals kidney function appear better than it actually is. Because it up-adjusts that biomarker, so it falsely improves their kidney functioning and may, to a family medicine doctor, like myself, look like, oh, this person’s kidney function is doing fine. When it’s actually 20% worse than what we’re seeing the number is.

STEPHEN:

Yes. And that’s how it’s been for 30 years.

LAURA: Wow. But why is the number incorrect? Like, how did that even happen?

LEAH: Long story short, there were some studies in the 70s, 80s, and 90s that incorrectly concluded that the average muscle mass of Black people was higher than that of white people. Because muscle mass was found to be correlated with kidney function, researchers proposed a multiplication factor that artificially increased Black people’s kidney function to compensate for their muscular differences. 

LAURA: Which aren’t real. 

LEAH: Right. And that was all codified in a 1999 landmark study that introduced the revised eGFR calculation with a coefficient, or race adjustment, for Black patients.

LAURA: So, they created a completely different calculation, exclusively for Black people?

LEAH: Yep. A calculation that, as Stephen mentioned, falsely boosts Black people’s apparent kidney health—by roughly 16%. And the impacts of that mis-calculation have been pretty profound.

STEPHEN: 

In a country, in an environmental and societal setting, where we know, African Americans have a higher rate of chronic kidney disease, and a higher rate of kidney failure, and higher rates of hypertension that impact the kidney and higher rates of diabetes that impact a kidney, in this setting where kidney disease is actually more prominent, more prevalent in African Americans, we have been adjusting their kidney function, their kidney function, so it looks better than it actually does. 

STEPHEN: 

And so African African American identified patients, because of this faulty, flawed system of adjusting the eGFR may not get referred to life saving treatment or life saving transplants as frequently as their white counterparts because of how this race-based mechanism mechanism is cooked into the system. 

LEAH: And this isn’t just anecdotal. Stephen told me about a recent paper that showed there are real-world, measurable consequences from this race-based kidney treatment.

STEPHEN: 

There is a significant difference in both referrals and and to transplant ultimately to transplant. 

LEAH : 

So there are thousands, if not more, African American folks who should have received care or even a transplant and didn’t because of some kind of misleading numbers?

STEPHEN:

Yeah, yeah. 

LEAH: And, in fact, some recent studies have tried to quantify what would happen if we removed the race coefficient from kidney treatment. Preliminary data showed that it would result, among Black adults, in more diagnoses of chronic, more diagnoses of advanced stage kidney disease and more referrals to nephrologists.

When you can demonstrate that people’s lives are changed as a result of the way in which we treat them, then it calls into question how we treat them and if it’s the right way forward. 

It is an example of structural racism, the way in which inequity is essentially baked into medical practice. And one of the reasons why there has been this massive movement to abolish race based medicine in this country over the last couple of years.

LEAH: And this is hardly the only example of race being used as a determining factor in medical procedures.

STEPHEN: 

There’s so many different examples of clinical algorithms and calculators that use some sort of race-adjusted form of equations to help determine people’s hypertension, or their pulmonary function, or vaginal birth after C-section, or even kidney stones.

This is just one example that is convenient to discuss, and the low hanging fruit, which has been kind of the template for this movement, or this revolution away from race based medicine, and towards its eradication.

LAURA: But there are measurable differences, right? Stephen said so himself—that kidney function is something like 20% lower among some Black populations? I guess the key word being some. 

LEAH: Yes, that’s a really important question. If there are health differences between people of different races, why would we abolish race from medicine? So, one point Stephen made is that, the difference detected in that one study is only looking at one, isolated population, so deciding medical risk factors based on race alone doesn’t capture the full complexity of a person’s medical reality.

STEPHEN: 

Do we have enough faith in that 20% that it’s going to work anywhere in the world under any conditions at all times forever? Probably not. Because people in different places who identify as Black are under various different societal and environmental conditions that influence the way that their kidneys function.

LEAH: And that raises his second point—that people’s health is largely a product of their environment and access to resources. In other words, the way society has grouped people according to this constructed idea of race has had real economic and health outcomes. And fixating on race as the determining factor in someone’s health can do more harm than good, by overdiagnosing people of certain races, undertreating others, and generally distributing healthcare inequitably. And, most importantly, it misses the larger point: there’s a big, centuries-old issue of racism in medicine. And that’s really what he’s trying to abolish.

STEPHEN: 

We know, for example, as I had mentioned to you before, the two primary conditions that impact kidney disease in this country are hypertension, which is high blood pressure, and diabetes. A lot of this results from nutritional intake.

Think about people in food deserts, right, where there’s not access to good quality foods that are sodium-free.

So we need to think about how we change the conditions of our society, we need to figure out how we eliminate structural racism in our environment. So that people have better access to good quality foods, they have better access to open space where they can, you know, work out, they have better access to medications and things like that, so that we’re not having to even apply faulty equations to begin with. 

LEAH: And this gets to a really fundamental idea of Stephen’s work, which is that race-based medicine is bad for everyone. For instance, Stephen talked about a cholesterol lowering drug that, according to some studies, is metabolized differently among people of “Asian descent.” But as he pointed out, when we talk about people of Asian descent, who is that? Is it people from East Asia, Central Asia, Southeast Asia, all of the above? Unsurprisingly, grouping an entire CONTINENT into one population and giving them a different dose of a medication, means that some people aren’t getting the care they need. Point being, the negative impacts of race-based medicine are disproportionate for people of color, specifically Black people. But ultimately we ALL want a medical system that sees and treats us as more than just a function of the color of our skin.

LAURA: So, are they making progress on that front?

LEAH: Actually, yes. So, according to Stephen, this is an effort that has been ongoing for years. But recent events became a critical sort of inflection point.

STEPHEN: 

I think it was always a matter of like, you know, when is the timing right, you know, when will we move to a certain point in which, you know, we can start to leverage the moment, leverage people’s appetite for change, leverage a new awakening in our society. I think in the past couple years, probably around the time of the murder of George Floyd, that’s when that moment kind of arose for us. 

LEAH: There are a handful of recent papers that have challenged how the medical and scientific communities historically conceived of race. And then, Stephen did what anyone trying to make big, institutional change does: he started a petition calling for the removal of the race adjustment in eGFR calculations. 

STEPHEN: 

So after getting a couple 1000 signatures on this, we sent it to the National Kidney Foundation. And it was sort of this thing that they couldn’t ignore. And so the National Kidney Foundation as a result, essentially, put together a task force to go back and reevaluate this historic evidence. 

STEPHEN:

And in, I want to say September of 2021, released their report, which contains their final recommendations of removing race from the clinical assessment of kidney function. 

So now this is a nationally codified recommendation to not have race as a component of this, this calculation.

LEAH:

Wow. And how immediate or big is the impact of that change in recommendation?

STEPHEN:

Oh, I would say it’s, I would say it’s massive.

Somewhere around 400,000 African Americans in the country, because of this, now will have better access to nephrologists where they would not have before. And something like 2,300, a couple thousand, more African Americans, people who identify as Black or African American, now will be listed on transplant lists, and they will be getting this now where they would not have before.

LEAH: The National Kidney Foundation actually announced a new race-free calculation, which they’re working to implement in labs around the country. And this is just the beginning. According to Stephen, he and his colleagues are pushing to remove other race-based practices in medical and clinical institutions nationwide. Think LabCorp and Quest Diagnostics and Kaiser and other big players in the field. And that’s not all…

STEPHEN: 

Race based medicine is in consideration at the congressional level right now, like people are talking about it in the Capitol. So it’s happening there.

It’s such a huge thing, when you think about, like, this eGFR was just like, it was the foot in the door, right? Think about the ways in which it’s going to continue to propagate, and the movement is going to continue to grow, and so many more patients will have access, and so many more patients may have, you know, life-saving services or treatment, because of it.

LEAH: In 2021, a congressional committee released a report called “Fact versus Fiction: Clinical Decision Support Tools and the (Mis)Use of Race.” The committee chairman, Massachusetts Congressman Richard Neal, said: “One thing is for certain: the status quo is unacceptable. Racial correction in clinical algorithms contributes to worse outcomes for patients of color receiving treatment for a broad range of conditions, from cancer, to osteoporosis, to end-stage renal disease, to childbirth.”

STEPHEN:

It’s amazing, right? Because it started at such a small level in different spaces, you know, different corners of people just doing activism, you know, within their, within their little corners of the universe, and just like, okay, like, we can make this happen. 

And so, okay, like, we got that change, but we’re still thirsty. And so what about pulmonary function tests. What about this? What about that? 

You know, and so we’re like, ‘Okay, this started the snowball, but how big can we get this thing to grow?’ You know, we want an avalanche.

LEAH: Before we go, I just want to say that this is a really complex subject that we couldn’t possibly crack in a single episode. So please check out our show notes, where we’ll share links to additional reading and resources to learn more.

[MUSIC IN]

LAURA: This is The Edge, brought to you by California magazine and the Cal Alumni Association. I’m Laura Smith.

LEAH: And I’m Leah Worthington.

LAURA: This episode was produced by Coby McDonald, with support from Pat Joseph and Margie Cullen. Special thanks to Stephen Richmond. Original music by Mogli Maureal.

[MUSIC OUT]

Header image credit: Image licensed under Creative Commons 2.0