“Race is a social construct.”
This is a statement that we hear frequently but don’t fully believe or understand. In the United States, we may superficially state that race is a social construct, but in reality, we understand it as genetic underpinnings. In medicine especially, race and genetics are often understood as interchangeable.
“Hypertension and diabetes are especially prevalent among African Americans.” “Risk factors for sarcoidosis: young, female, African-American.” “Kawasaki’s: most prevalent in young, Asian children.” When we talk about predispositions to disease, we assume that they are due to genetics because we are given no further explanation. When making differential diagnoses, we adjust the list simply based on the race of the patient, without considering the why we do so. We learn that black and Asian people have lower pulmonary function capacities, just because. What we are not taught: in reality, the spirometer was used by plantation physicians to prove black slaves had poorer lung capacities than white people to justify that forced labor was what kept black bodies alive; these race-corrected spirometric measures are still used today.
The social stratification of race in medicine has taken on the mask of genetics and has consequently become even more dangerous. It makes assumptions about medical differences that are based on a social construct rather than a biological one. The difference between understanding race as social rather than biological construct is understanding the distinction between the external nature of race and the internal nature of biology. While our biology is dependent on our ancestry and our genes, thus yielding certain predispositions or immunities to diseases, our race is variable depending on our social environment. Someone who is considered black in the United States may be considered white in Brazil; the fluidity of race is therefore dependent on social context. Thus, race as a biologic or genetic construct suggests that race determines our biology as a “natural progression of events,” while race as a social construct means that it is externally imposed on us by societal norms.
In medicine, though, these two constructs are often blurred. For example, the greatest factor contributing to the difference in lifespans between white and black Americans is largely known to be cardiovascular disease. The way that this is often presented in medical education is as fact without any explanation for the “why” or “how.” When we do differential diagnosis activities, we are expected to change or rearrange possible diagnoses depending on the race of the patient — if the patient is black, hypertension and diabetes shoot to the top of the list, regardless of the patients’ height, weight, home environment or diet.
These quick assumptions result from the buzzword-nature of medical school learning, but are also the product of the medical system’s lack of conversation defining what “race” actually means. To dismiss race as genetics is easy because it is a straightforward answer to questions that have a million possible responses — but ultimately, it is a false answer. To equate race with genetics is wrong and lazy because it indicates an ignorance or unwillingness to explore the truths behind what actually causes health and equality disparities between racial groups. Studies have shown over and over again that race is the not the same thing as ancestry: a recent study looked at genetic data to determine if racial classification explained genetic differences in cardiovascular diseases. It amounted to nothing statistically significant.
Most research studies looking at race as a subject stratification method fail in their classifications because people and ethnicities cannot be pigeonholed. Does a Nigerian immigrant count as “African American?” What does “Asian” really mean, considering it covers 48 countries and contains 60 percent of the world’s population? And does Caucasian really mean white, when the term is derived from the Southern Caucasus region that includes Armenia, Azerbaijan and Georgia, and was coined by a racist German philosopher who believed that human beings were classified as two races (Caucasians and Mongolians), with Caucasians being the more physically attractive race?
Stating that race is not genetics does not discredit the effect of genetics on health. There certainly is a high risk of certain diseases, such as Tay-Sachs or cystic fibrosis, in people of Ashkenazi Jewish ancestry compared to others. However, ancestry is not the same as race, and when it comes to diseases like hypertension and diabetes, which are often behaviorally and environmentally-related, the assumptions based on race become underlying presumptions on an individual’s behavior based on their race, which manifests as implicit racism. Hypertension and diabetes are often associated with unhealthy lifestyles, poor nutrition and lack of exercise. These two illnesses are also prevalent among the black American population. It we ascribe to the assumption that these diseases are prevalent in these patient populations simply because of race, we falsely conclude that these unhealthy behaviors are choices that these individuals have made, leading to their disease. Instead, we ignore additional factors beyond individual control — food deserts that bar access to cheap and fresh foods, unsafe neighborhoods that prevent exercise, the history of racial redlining that led to segregated housing districts — that could invariably force unhealthy lifestyles.
Understanding race as a social construct therefore does not mean denying its existence. Race is a very real thing — it affects our lives on a daily basis, affects the opportunities in our future, and certainly affects our health and medical care. To deny that race is a factor in our lives — in other words, to believe in a race-blind or color-blind society — is actually a privilege because it denies that there are institutional benefits to being one race or another.
In medicine, we do an excellent job of noting people’s races while doing an equally poor job understanding and defining what exactly race is. We take note of patients’ races and then don’t discuss the factor any further. We include race in the chief complaint, constantly reinforcing the buzzword association between disease and race of the patient, and in midst of all other symptoms and factors to take into consideration, our brains turn to the easiest explanation — the one that media and history have fed us our entire lives — race is genetics.
Thus, I’m not saying to take race out of the medical history completely. Doing so would deny the impacts of race: since racism is externally projected onto an individual, to omit race would be to ignore the harmful effects that racism has had on said individual. Race certainly affects quality of life and studies have long shown that the difference in hypertension between black and white Americans varies based on skin color and the degrees of racism that African Americans experience. What needs to happen in medicine — and certainly outside of it as well — is an explicit explanation of what race actually is and to rewrite what we are taught from a young age. Race as a genetic construct is not real. However, race as a social construct and the impacts of living in a racist society — however explicit or implicit you may deem it to be — are very real.
So we do need to talk about race because we still don’t really know what race is and what it isn’t. Only by accepting race as a social factor and not a genetic one can we begin to understand the other factors that grant privileges to certain groups over others based on race. We need to understand exactly what we mean when we ask patients to check the “what are you” identity box, because only then can we observe the multitude of factors that affect not only our patients but ourselves on a daily basis. Only then can we begin to tackle the how’s and why’s of disparities in health, equality and opportunity.