Toward the Abolition of Biological Race in Medicine

Section 4: Looking Ahead

Epigenetics: One Intersection of Biology with Sociopolitical Determinants of Health

Despite the many ways in which new scientific developments like precision medicine threaten to entrench biological racism, new fields such as epigenetics, developmental origins, and life course research are contributing to our understanding of how racism, not race, has biological effects on the body. Epigenetics and other biopsychosocial fields are pulling together biology, psychology, and upstream determinants of health to answer how racism “gets under the skin,” showing how the social and structural determinants of health (mediated or created by racism) can literally embed themselves in our cells. 

Research in the developmental origins of disease has shown that the first one thousand days after conception (up to age two) is a critical period in which the developing fetus and child’s cells are most susceptible to outside influences. During this period, the fetus grows from one cell to trillions, so any early changes in these cells will be replicated and reproduced for the entirety of one’s life. Thus, exposures in the uterine environment and early childhood environment can either be protective or increase the risk of developing chronic diseases in adulthood. Literature shows, for example, that low childhood socioeconomic status both increases the physiological response to stressors and increases the reactivity to social support.152 That is, growing up poor can both increase the body’s stress response and increase the body’s ability to calm down or resists those responses in the presence of social support. Furthermore, certain exposures during this critical or sensitive period have been shown to increase the risk of type 2 diabetes, stroke, heart disease, some cancers, impaired cognitive function, and mental health issues. 

The exposures posited to increase chronic disease risk in adults include environmental exposures, such as toxins and pesticides, but also “normal” or endogenous exposures produced by the mother and transmitted to the fetus in utero.153 Although the majority of literature has focused on the effects of cortisol, the stress hormone that acts as a danger signal for the growing fetus, there is also a role of environmental racism (a form of structural racism) that increases exogenous exposures. These articles posit that the more stress a mother is under during pregnancy (including overt physical and mental, as well as more subtle or everyday stressors, such as racist microaggressions), the more cortisol reaches the cells of the fetus. This is also referred to as the mother’s “allostatic load,” or amount of biochemical response to stress.

Over time, a constantly high allostatic load can cause the stress response to stay on permanently. High allostatic load impacts neuroendocrine, cardiovascular, immune, and metabolic systems, in turn contributing to various forms of damage, including cardiovascular disease, neurological atrophy, psychiatric symptoms, mortality, mobility limitations, cognitive decline, and functional impairments.154 The fetus interprets high levels of cortisol in utero as a signal that the postnatal environment will be stressful, and reprograms the developing stress response systems to stay on high alert with a short fuse, as well as inhibit the growth of some organs. This predisposes the child to increased stress-related biological damage and increases the risk of adult chronic diseases. Most importantly, as shown in section 1, the mother’s stress can be due to racist social and structural determinants of health, such as white supremacy and inequities in neighborhoods, rather than some biological aspect of their race. 

A number of studies further document how racism is stressful. For example, one study at Duke University found that Black students had higher levels of salivary cortisol after learning about a violent racist crime on campus.155 Another study showed how the mere anticipation of prejudice is associated with poor physiological and cardiovascular responses.156 Amani Nuru-Jeter, a social epidemiologist at the University of California, Berkeley, further found that chronic stress from frequent racist encounters is associated with chronic low-grade inflammation.157 This literature illustrates the biological pathway through which racism leads to increased risk of adult chronic diseases. 

Epigenetics, a related but slightly different field, shows similar biological causal pathways for health disparities by embedding racism’s effects under the skin. One of the major threads of current epigenetics research focuses on the body’s varied responses to stress and how these epigenetic responses, rather than inherent genetic causes, lead to racial health disparities.158 Genetics refers to the static genes inherited from a person’s biological parents, but, as noted elsewhere, these genes do not create or explain race nor many other salient physical characteristics. Epigenetics, however, are changes in the way those inherited genes are turned on or off. In other words, these are the dynamic volume controls that tell genes to amplify certain proteins while muting others, despite the same initial signal from the static genes. Epigenetics provides one mechanism by which our health and our body is dynamically created in real time by the environment inside us and outside us. More specifically, “weathering” is a term used by epigeneticists to describe how constant stressors increase allostatic load and create biochemical and cellular level by-products that wear down the body’s normal ability to regulate itself over time. Weathering may help explain racial health disparities by proposing a mechanism for the physical wear and tear of chronic stress caused by all levels of racism.159 The effects of epigenetic weathering are further exacerbated by structural factors including inequitable access to quality health care. 

Darlene Francis and related researchers have shown that epigenetic mechanisms could be a key mediating process by which the social and structural determinants of health become incorporated into biochemical changes.160 This has implications for both risk and resilience to disease processes. Human development research demonstrates that many of these processes occur during the postnatal “critical period.” Epigenetic changes can be harmful, protective, or both. Other research shows implications for epigenetic changes as a link between early life (e.g., maternal stress during pregnancy) and adult health disparities along racialized lines for conditions such as hypertension, diabetes, stroke, and coronary heart disease.160 Kuzawa and Sweet note that epigenetics help explain how the effects of social-environmental exposures combine with plasticity of phenotypes (i.e., physical traits determined by genetics) in response to those environmental exposures. Most importantly, Kuzawa and Sweet make the explicit link between racism and epigenetics. Social and structural effects of racism lead to environments that affect many aspects of bodies of color. 

Dr. Francis interprets this as a call to action: “If we hypothesize that racial discrimination is capable of directly altering the epigenomic profiles of genes that are important to the stress response, we can then predict that targeting and ameliorating discrimination and racism should have an equally direct, potent, and protective effect on the stress-axis epigenome.”162 Her paper “Conceptualizing Child Health Disparities: A Role for Developmental Neurogenomics” demonstrates that the social, structural, and psychological worlds in which a child is living can influence the sensitivity of a child’s stress axis during the critical period. Developmental neurogenomics, which is a hybrid of sorts between developmental origins and epigenetics research, posits a biological plasticity in early developmental life that moves away from characterizing health disparities as purely biological, purely environmental, or psychological. Instead, the effects of racism are experienced somatically as a product of immediate environment, genes, and sociopolitical context.

Epigenetics and related research provide the language and a framework for the intersection of critical race theory and biology, which should be used across clinics and research labs. It begins to elucidate how the sociopolitical effects of racism are quite literally changing the building blocks of biochemical life. This allows critical race theorists and clinicians alike to show how socially constructed race categories and racist society cause intergenerational harm on the cellular level. In other words, “critical philosophy of race should also be critical physiology of race” and vice versa.163 These fields of research show most clearly that as clinicians and researchers, we cannot engage in health without understanding both biology and critical race theory.

It is crucial to recognize that research in epigenetics and developmental origins complements but does not replace the understanding of social and structural determinants of health. Exposures at every level, from cortisol in utero up through mass incarceration, environmental racism, and white supremacy, contribute to biological risk. Thus, it is necessary and critical to clearly articulate that epigenetics does not constitute scientific evidence that Black and brown bodies are permanently damaged or broken. We as clinicians and researchers need to be loudly unequivocal that epigenetics is one line of promising research into how the many levels of racism cause biological harm, and that race is not a risk factor for disease. 

This understanding of epigenetics calls on clinicians and medical educators to learn critical race theory, to become active in investigating social and structural determinants of health, and to equip themselves with the language and tools to identify racism, not race, as a cause of racial health disparities.

As medical students, we have seen that such physicians and health-care professionals are thus compelled to not only treat the medical concerns but also the structural ills in society. Our training in both medicine and critical race theory has taught us that race has no business in clinical guidelines and that the use of race in clinical guidelines is just one symptom of much larger systems of oppression. Further, the conflation of race with biology has real, negative consequences when it is incorporated into clinical practice. We are not the first to say this. Yet we seek to be physician-activists who change it. Therefore, we call on our colleagues and our educators to discontinue the use of race in guidelines as one step toward equity. We call on students, physicians, and educators to use the power of medicine to help create an equitable world in which racism no longer causes biopsychosocial harms for this generation and the ones to come.

Our Conclusions

  1. Medicine has willfully ignored its racist history despite ongoing calls from scholars and activists to rectify its violent and oppressive past. This has resulted in medicine continuing to inflict and perpetuate racism that harms communities of color.
  2. Using race as a heuristic for diagnosis of disease and interpretation of symptoms masks racism. 
  3. Because of the biological use of race in clinical guidelines and education, patients of color are being systematically misdiagnosed and undertreated and are at risk for bad health outcomes.
  4. Race-based medicine teaches people of color that their bodies and communities are abnormal, deficient, and broken, increasing stress and the burden of racist stigma. 
  5. As medicine fails to confront and rectify its origins of violence against vulnerable communities, it will continue to perpetuate an agenda that is an unwelcoming, hostile space for people of color. 

If we don’t dismantle race-based medicine, it will be perpetuated. 

Vision Forward

As physicians-in-training, we envision a world where the social construct of race is not conflated with biology and where the health consequences of racism are acknowledged, addressed, and cared for in all their forms.

To make this a reality, medicine must adopt antiracist institutional practices regarding research, practice, and education.

  1. Medicine must unveil and teach how racism has shaped scientific advancements, tools, and diagnoses.
  2. In order to account for the health consequences of racism, clinicians should prioritize social history intake and be aware of how social and structural stressors perpetuate racial health inequities. 
  3. We must adopt the same standards and guidelines for diagnosis and treatment of all patients regardless of race. 
  4. Race cannot and should not be used as a biological determinant in clinical guidelines nor the research informing them. Rather, clinical guidelines on racial health outcomes must take into account the consequences of racism in racial health disparities. Racial differences are not the cause of disparities; they are the result of multilevel racism. 
  5. Health-care providers play a key role in combating racism. In order to support their patients in feeling happy, healthy, and strong, clinicians must seek to affirm the strengths their patients bring, not assume they are a collection of risk factors. Clinicians need a paradigm shift to approaching patients of color as whole, rather than broken. 
  6. Medicine must break down its own intellectual silos and hierarchy to build interdisciplinary alliances with thought leaders who have built foundations on the intersections of racism and health. Rather than using race as a differential diagnosis shortcut, elimination of race-based medicine presents an opportunity to call for interdisciplinary dialogue and action in solidarity with those from affected communities, critical race theorists, community-based organizations, and racial justice initiatives.

Next Steps 

In order to move this vision forward, everyone from trainees to clinicians to critical race theorists to community members must not only read and dialogue, but also act. While barely scratching the surface, the following list offers a few suggestions to various types of readers to create and practice antiracist medicine. 

Trainees

  • Seek out literature and research on critical race theory and antiracist research. See appendix for suggestions.
  • Teach yourself to question when you hear race used in clinical medicine. 
  • Ask questions of those around who are using race-based medicine. Question its usage, and teach others if you can. 
  • Don’t use race in the problem statement of your notes or clinical presentation.
  • Seek out antiracist trainings in your area or online, especially if you are white or hold other privilege. This is for your patients, fellow trainees, and other providers. 
  • Organize for change. Push your educators to teach antiracist medicine and push for your clinicians to practice antiracist medicine. One idea: 
    • Don’t use the race-corrected GFR or spirometry values. Start a campaign to have your academic hospitals remove the race correction. 

Clinicians and Providers

  • Seek out literature and research on critical race theory and antiracist research. See appendix for suggestions.
  • Seek out antiracist trainings in your area or online, especially if you are white or hold other privilege. This is for your patients, fellow providers, and staff. 
  • Teach yourself to question when you hear race used in clinical medicine. 
  • Use your power to ask questions of those around who are using race-based medicine. Question its usage, and teach others. 
  • Don’t use race in your notes or clinical presentation, especially not in the problem statement. 
  • Organize for change. Push yourself and your peers to teach and practice antiracist medicine. One idea: 
    • Don’t use the race-corrected GFR or spirometry values. Start a campaign to have your institution remove the race correction. 
  • Learn and use structural competency to begin to name and address the societal and structural factors that hinder patients’ ability to live to their highest level of well-being. 
  • Get active outside the clinic to address these structural issues. 
  • Help make medicine a less hostile space for both patients and providers. 

Educators

  • Seek out literature and research on critical race theory and antiracist research. See appendix for suggestions.
  • Create a learning environment that is both safe for students and critical of race-based medicine. You must be trained in how to talk comfortably and critically about race in your classrooms and teaching settings. Seek out antiracist trainings to increase your skills and tools. 
  • Teach trainees in both critical race theory and the nuances of biology. Teach trainees to hold complexity and be powerful advocates for their patients. 

Researchers 

  • Learn critical race theory and structural competency (see appendix for suggestions), and then use it to hold yourself to the highest precision in both research design and publishing. You cannot control what people will do afterward, but you can contribute to making a body of research that is rooted in antiracism and clearly spells out the implications of your findings. 
  • Seek out antiracist trainings in your area or online, especially if you are white or hold other privilege.
  • Design and carry out research that corrects the current bad science. If the intended heuristic for using race in GFR is muscle mass, help find a marker of muscle mass or a faster way to measure it in clinic. 
  • Design and carry out research that measures and addresses root causes of poor health and health disparities, such as racism and structural causes. 

Community-based Organizations

  • Continue to form partnerships with physicians and clinics to address social and structural issues that impact well-being. 

Community Members

  • Question your provider’s use of race in your care. Some ideas (if you feel comfortable):
    • Ask about the race correction factor if your clinician uses a measure like GFR or spirometry.
    • Ask to see your patient record, and if race was used, ask your provider why it was relevant.
  • Organize groups of patients to become patient-advocates, and get involved in the clinic’s patient advocacy board or other governing bodies.
  • 152. Neha John-Henderson et al., “Socioeconomic Status and Social Support: Social Support Reduces Inflammatory Reactivity for Individuals Whose Early-Life Socioeconomic Status Was Low,” Psychological Science 26, no. 10 (October 1, 2015): 1620–29. https://doi.org/10.1177/095679761559596.
  • 153. Lawrence Wallack and Kent Thornburg, “Developmental Origins, Epigenetics, and Equity,” Maternal and Child Health Journal 20, no. 5 (May 1, 2016): 935–40. https://doi.org/10.1007/s10995-016-1970-8; Christopher Kuzawa and Elizabeth Sweet, “Epigenetics and the Embodiment of Race: Developmental Origins of US Racial Disparities in Cardiovascular Health,” American Journal of Human Biology 21, no. 1 (2009): 2–15. https://doi.org/10.1002/ajhb.20822.
  • 154. Robert-Paul Juster et al., “Allostatic Load and Comorbidities: A Mitochondrial, Epigenetic, and Evolutionary Perspective,” Development and Psychopathology 28, no. 4pt1 (2016): 1117–46. https://doi.org/10.1017/S0954579416000730.
  • 155. Laura Richman and Charles Jonassaint, “The Effects of Race-Related Stress on Cortisol Reactivity in the Laboratory: Implications of the Duke Lacrosse Scandal,” Annals of Behavioral Medicine 35, no. 1 (February 1, 2008): 105–10. https://doi.org/10.1007/s12160-007-9013-8.
  • 156. Pamela Sawyer et al., “Discrimination and the Stress Response: Psychological and Physiological Consequences of Anticipating Prejudice in Interethnic Interactions,” American Journal of Public Health 102, no. 5 (March 15, 2012): 1020–26. https://doi.org/10.2105/AJPH.2011.300620.
  • 157. Amani Nuru-Jeter et al., “Abstract 9550: Anticipatory Racism Threat and Superwoman Schema: Elucidating the Relationship Between Racial Discrimination and Chronic Inflammation,” Circulation 128, no. 22 (November 26, 2013): A9550–A9550. https://doi.org/10.1161/circ.128.suppl_22.A9550.
  • 158. Shannon Sullivan, “Inheriting Racist Disparities in Health: Epigenetics and the Transgenerational Effects of White Racism,” Critical Philosophy of Race 1, no. 2 (September 5, 2013): 190–218.
  • 159. Kuzawa and Sweet, “Epigenetics and the Embodiment of Race”; Sullivan, “Inheriting Racist Disparities in Health”; Wallack and Thornburg, “Developmental Origins, Epigenetics, and Equity”; Darlene Francis, “Conceptualizing Child Health Disparities: A Role for Developmental Neurogenomics,” Pediatrics 124, no. 3 (November 2009): 196–202. https://doi.org/10.1542/peds.2009-1100G.
  • 160. a. b. Francis, “Conceptualizing Child Health Disparities.”
  • 162. Francis, “Conceptualizing Child Health Disparities.”
  • 163. Sullivan, “Inheriting Racist Disparities in Health.”