By Layal Liverpool and Jennifer Tsai
Roberto Cigna
SHOULD your race or ethnicity influence the prescription you get from your doctor? Both are still used in medicine to interpret test results and guide treatment decisions, but the evidence is questionable and the approach can cause serious harm.
Medical guidelines in the US, UK and elsewhere often recommend the use of algorithms that contain adjustments for a person’s race or ethnicity, from tools used to assess bone fracture risk to devices containing embedded racial or ethnic adjustments for measuring lung function. The latter can be partly traced back to the suggestion by US slaveholder Samuel Cartwright in the 1800s that Black people had naturally low lung capacity and so were healthier when enslaved.
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These algorithms are finally coming under significant scrutiny. Recently, the US National Kidney Foundation and the American Society of Nephrology formally established a consensus against the use of race adjustment in kidney function equations. A similar race-based kidney test adjustment was also removed from UK medical guidance set by the National Institute for Health and Care Excellence (NICE). These decisions came in response to growing concerns that the race adjustment was contributing to underdiagnosis and undertreatment of kidney disease among Black people.
Yet race-based decisions are still permeating other parts of medicine with little evidence to support them. NICE, for example, has declined to review its guidance on high blood pressure treatment that recommends different drugs for Black people compared with everyone else. The guidance currently says that doctors should prescribe drugs called ACE-inhibitors to people under the age of 55 with high blood pressure – unless they are of “black African or African-Caribbean family origin”, in which case they should receive different drugs.
Dipesh Gopal, a general practitioner who is also at Queen Mary University of London, and his colleagues have written to NICE twice over the past year requesting an urgent review of this guidance, but it declined in both cases, responding that evidence suggests there are “clinically meaningful differences in the effectiveness of treatments for individuals in these family origin subgroups”.
But Gopal and others dispute this evidence, particularly given that race and ethnicity are poorly defined social constructs with no biological basis. Indeed, according to the data, people’s treatment responses quite literally aren’t black and white.
In response to Gopal and his colleagues, and to the content of this article, NICE said that “there is not a clear-cut biological and genetic homogeneity amongst all Black and White people” and that “the guideline does not account for people with mixed heritage”. But it said performing the relevant tests on everyone wasn’t possible due to “the expense, and the additional time”.
Using race or ethnicity as an indicator of biology in this way is lazy and imprecise. NICE and other health organisations globally should start systematic reviews of race-based recommendations across their guidelines immediately. A doctor’s glancing assumption about a person’s race or ethnicity doesn’t offer meaningful biological information that can guide medical decisions. They aren’t biological variables and can’t be used as a proxy for genetic make-up.
This doesn’t mean medicine should become colour blind. Racism clearly drives health inequities in many countries and this must be addressed. But perpetuating harmful and unscientific ideas about biological differences between races in medical guidance isn’t the solution.
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