Eliminating race-based medicine in pediatrics and beyond

Mistreatment, undertreatment, and cruel practices for nonwhite people have plagued the medical industry for centuries. From experimental vesico-vaginal fistula repair procedures on unaesthetized enslaved women to Thomas Jefferson’s unsubstantiated hypothesis of diminished lung capacity in Black people, the use of race as a reason or differentiator in medical diagnosis and care has a sordid history.

Still in 2022, glimpses of these race-based medical practices remain. In a recently published policy statement from the American Academy of Pediatrics, authors highlighted the historical significance of these practices and the science of why physicians must abandon race-based medicine as part of a “broader commitment to dismantle the structural and systemic inequalities that lead to racial health disparities,” according to the press release announcing the policy statement.^1,2

Race-based medicine is defined as the inappropriate use of race and ethnicity as risk adjusted variables in clinical decision making, according to Joseph Wright, MD, MPH, lead author of the new policy and chief health equity officer at the University of Maryland medical system.

“When we're talking about race-based medicine, we're talking about the inappropriate use of race and ethnicity as risk adjusting variables to make clinical decisions,” Wright said. “That conflates the premise that race is a social construct—a social construct that in many ways was used to divide and marginalize people. But the needs in medicine are to use very objective criteria to drive clinical decision making.”

When asked if the use of race-based medicine is strictly an American issue, he noted that while the policy is framed through an American history lens, the problem reaches far beyond one countries border.

“It is a societal issue; it is a very human issue, in that there has been marginalized populations across the world,” he said. “The premise is still the same that we should not be using socially derived criteria to apply clinical decision making, especially when the roots of many examples were originally designed to marginalize certain populations.”

In the policy statement, the authors highlighted historical examples of racism in medicine that continue to permeate medical education and clinical practice.

One such example used in the statement was a 2016 study by Hoffman et al of white medical students and residents which endorsed the false belief that the way in which Black people experience pain is associated with lower pain score assessments. This resulted in inaccurate treatment recommendations for Black patients when compared to their white counterparts in mock clinical scenarios.³

“Over decades—if not hundreds of years—pain is a particularly insidious misperception rooted in that Black people have thicker skin, so therefore don't experience pain in the same way as other people,” Wright explained. “[It] is documented in the medical literature from the 18th and 19th century.”

And these race-based practices could even further impact pediatric patients. “[Children] are in particularly vulnerable because not only are children also subject to the biases and discrimination but we're also learning the ways that toxic experiences are embedded in child development, and that marginalized and vulnerable populations begin to experience the toxic effects of adverse childhood experiences early on,” he said. “These impacts can be manifest across a lifetime and we're also understanding that they can even be manifested intergenerationally. Children have the longest runway and the greatest opportunity of exposure to these toxic effects of racism, which is a social determinant of health.”

The authors elaborated on the potential intergenerational manifestation of toxic stress. They explained that epigenetic events—defined as the structural adaptation of chromosomal regions to register, signal, or perpetuate altered activities—can lead to a combination of genes that produce differential developmental outcomes if changed. Basic science, according to the statement, has shown that the intergeneration elaboration of stress can result in disruptive biological, physiological, and neurodevelopmental mechanisms that can manifest in utero and persist in subsequent generations much farther from an initial exposure.⁴

Additionally, the transmission of toxic stress intergenerationally may contribute to chronic disease development, and physiological issues in some populations of color.

“This area of science wasn't around when I was in medical school, but it recognizes the impact of toxic stress on populations, and how that can embed over generations and result in negative outcomes,” Wright noted. “This is a science that needs to be taught. It needs to be shared. I happen to be an administrator and in a largely adult health system, where people don't appreciate the fact that hypertension and diabetes are potentially linked to impacts in childhood or even preconception. We have to deconstruct the systems that perpetuate this toxic stress.”

After critically examining these flawed practices, the AAP gave recommendations on how to stop perpetuating race-based medicine to eliminate long-standing inequalities in health care.

The recommendations included:

• All professional organizations and medical specialty societies identify and examine policies and practice guidelines for the use of race and ethnicity as independent variables or modifying factors.
• The AAP will advocate for all leadership across health care to advocate for the elimination of race-based medicine.
• The AAP with use its relationships with medical schools, academic health systems and accrediting bodies to ensure health equity curricular content. This will include a specific focus on the elimination of race-based medicine to.
• They will examine, deconstruct, retire, or revise all practice guidelines or policies that include race-based medicine.
• The AAP will use its Words Matter document to ensure all authors, editors, presenters, media, or other content contributors recognize race as a social construct and not use it in reference to a biologic proxy.⁵

“This is generational transformational work, no question,” Wright said. “But we have to start with some very basic first steps. A lot of the momentum here is being driven by students and learners and early career people who are challenging dogma, they are not accepting what has been taught. But not until we have the absolute co-signature of those in a leadership position can we make that kind of transformational change.”

References:

1. Wright JL, et al. Eliminating race-based medicine. American Academy of Pediatrics. Published May 2, 2022. Accessed May 2, 2022.
2. American academy of pediatrics calls for elimination of race-based medicine. American Academy of Pediatrics. News release. Published May 2, 2022. Accessed May 2, 2022. https://www.aap.org/en/news-room/news-releases/aap/2022/american-academy-of-pediatrics-calls-for-elimination-of-race-based-medicine/
3. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci USA. 2016;113(16):4296-4301.
4. Heard-Garris NJ, Cale M, Camaj L, Hamati MC, Dominguez TP. Transmitting Trauma: A systematic review of vicarious racism and child health. Social Science & Medicine. 2018;199:230-240.
5. Words matter: AAP guidance on inclusive, anti-biased language. Crisis and Recovery Enhancement. Assessed May 2, 2022. https://care-mhsa.org/resource/words-matter-aap-guidance-on-inclusive-anti-biased-language/