The concept of race has no biological basis. Racism, not race, has been and continues to be a key determinant of health outcomes, especially in the United States. Research that falsely biologizes race dates back to colonialization and slavery, and contemporarily translates to poor clinical guidelines. And yet, medicine continues to uphold the idea of biological race—and, thus, racism—in diagnosis and treatment schema.

What does this look like in context? Clinicians will use a patient’s skin color and ethnicity as heuristics to determine their diagnosis and treatment plan. In fact, race serves as a shortcut for clinical thinking from the onset of training, as evidenced in the United States Medical Licensing Examination.

A study question tweeted by the American College of Obstetricians and Gynecologist (@ACOGAction) reads,

 “A 33 year old married African American woman comes to your office and admits to thoughts of suicide for the last month. She was previously diagnosed with bipolar disorder, but has never attempted suicide before. Which of the following characteristics is associated with an elevated epidemiological risk for suicide? The listed options are A. Age < 35, B. Bipolar disorder, C. Lower socioeconomic status, D. Being married, and E. Black race.”[1]

Although the correct answer, according to the ACOG, is B. Bipolar disorder, question writers likely included “Black race” as an option, because they thought test-takers would rely on the pervasive, yet false, assumption that race is an epidemiological risk factor for various pathologies.

Another test prep resource offers the following on sickle cell anemia:

“Sickle cell disease (SCD) is a multisystem disorder and the most common genetic disease in the United States, affecting 1 in 500 African Americans.”[2]

Robbins and Cotran Pathologic Basis of Disease (9e), one of the foremost pathology textbooks for medical students nationwide, offers this epidemiologic look at sickle cell disease:

            “About 8% to 10% of African Americans, or roughly 2 million individuals, are heterozygous for HbS…. There are about 70,000 individuals with sickle cell disease in the United States. In certain populations in Africa the prevalence of heterozygosity is as high as 30%.”[3]

Both sources pathologize—and racialize—African Americans as the only potential population for sickle cell anemia. This risks missing diagnoses in other populations or oversimplifying clinical reasoning for African Americans.

Yet another test prep blog offers this summation:

Board questions reflect an extremely judgmental worldview with heavy-handed generalizations about race, sex, and a wide variety of stereotypes. African American females in their 30-40s have sarcoidosis.[4]

 Race is thus used as a tool to expedite not only test questions but also diagnostic processes. Frankly, this short-cut can be dangerous and inaccurate. For test questions, this enforces racial bias that may be present, or introduces new ones.[5] This translates directly to clinical care, where a patient’s race is seen as a risk factor for disease and requires that providers associate certain illnesses with certain races. As such, providers may never inquire into the root causes of illness for a person experiencing racism and inequality (such as structural and social determinants of health), or may miss more complicated and nuanced diagnoses. Furthermore, they may overlook diseases in patients of races and ethnicities that are not traditionally associated as “risk factors”. For example, sickle-cell is thought of exclusively as a Black(-only) disease and thalassemia as a Mediterranean(-only) disease. Cystic fibrosis is underdiagnosed in populations of African ancestry, because it is thought of as a white disease.[6]

In the following section, we provide examples of how healthcare and biomedical research conflate race with biology. We discuss the racist underpinnings of the diagnosis and treatment of heart, kidney and lung disease. We also explore faulty science that reifies biological race within precision medicine. If medicine is to help alleviate racial health disparities, we need to eliminate these embedded heuristics and false assumptions while addressing social and structural determinants of health.