Medicine must stop using race and ethnicity to interpret test results

Roberto Cigna

SHOULD your race or ethnicity affect 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 could cause serious harm.

Medical guidelines in the US, UK and elsewhere often recommend the use of algorithms that incorporate adjustments for a person’s race or ethnicity, from instruments used to assess fracture risk to devices with built-in racial or ethnic adjustments for measuring the lung function. The latter can be traced in part to the suggestion made by American slave owner Samuel Cartwright in the 1800s that black people naturally had low lung capacity and were thus healthier when enslaved.

These algorithms are finally being thoroughly researched. Recently, the US National Kidney Foundation and the American Society of Nephrology formally reached a consensus against the use of race matching in renal function comparisons. A similar race-based adaptation of the kidney test was also removed from UK medical guidelines drawn up by the National Institute for Health and Care Excellence (NICE). These decisions came in response to growing concerns that race adaptation was contributing to underdiagnosis and undertreatment of kidney disease in black people.

Yet race-based decisions still permeate other areas of medicine with little evidence to support them. For example, NICE has declined to review high blood pressure treatment guidelines, which recommend different medications for black people compared to everyone else. The guidelines currently say doctors should prescribe drugs called ACE inhibitors for people under 55 with high blood pressure — unless they are of “Black African or African-Caribbean family descent”, in which case they would need different drugs. to get.

Dipesh Gopal, a GP who also works at Queen Mary University of London, and his colleagues wrote to NICE twice in the past year asking for an urgent review of this guideline, but it was rejected in both cases, with in response that evidence suggests that there are “clinically meaningful differences in the effectiveness of treatments for individuals in these subgroups of family origin”.

But Gopal and others dispute this evidence, especially given that race and ethnicity are ill-defined social constructs with no biological basis. According to the data, people’s treatment responses are literally not black and white.

In response to Gopal and his colleagues, and to the content of this article, NICE said that “there is no apparent biological and genetic homogeneity among all black and white people” and that “the guideline does not take into account people of mixed heritage”. But it said it was not possible to run the relevant tests on everyone because of “the cost and the extra time”.

Using race or ethnicity as an indicator of biology in this way is lazy and imprecise. NICE and other health organizations worldwide should immediately begin systematic reviews of race-based recommendations in their guidelines. A physician’s cursory assumption about a person’s race or ethnicity does not provide meaningful biological information to guide medical decisions. They are not biological variables and cannot be used as a proxy for genetic makeup.

This does not mean that drugs should become color blind. Racism clearly leads to health inequalities in many countries and this needs to be addressed. But perpetuating harmful and unscientific ideas about race biological differences in medical care is not the solution.

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