By now, we’ve all heard the statistics. In America, Black and brown communities have disproportionately felt the pain of COVID-19 infections and deaths. Anyone familiar with the past and present realities of racism can offer some clear reasons for the disparities: years of medical neglect that have limited many people’s access to health care, of employment discrimination that have forced them into high-risk “essential” positions, of redlining policies that have pushed them into dense neighborhoods with poor infrastructure. In short, years of structural abuse has engendered an unequal system whose cracks show even more when bearing the weight of a pandemic.
But when asked about the high U.S. COVID-19 mortality rate in May, U.S. Secretary for Health and Human Services Alex Azar preferred a more simplistic explanation: “Unfortunately, the American population is very diverse. And it is a population with significantly unhealthy comorbidities [like diabetes and hypertension] that do make many individuals in our communities—in particular, African American, minority communities—particularly at risk here.”
Many Black Americans do, in fact, face higher rates of chronic illness. Racism has created various conditions that facilitate poor health, including discriminatory structures in health care and the biological toll of unyielding stress due to confronting everyday racism. Without acknowledging these realities, however, Azar’s language dangerously implies that Blackness somehow intrinsically predisposes people to their health conditions, as if one’s race is itself a meaningful diagnostic risk factor.
Race is a social construct, not a biologically defined category. Scientists and sociologists, from Human Genome Project director Francis Collins to 20th century scholar W.E.B Du Bois, have emphasized this time and time again. The categories of race in America have changed throughout history based on what white leaders have deemed most useful. Humans share 99.9 percent of all our DNA with each other, and in many cases, individuals of the same race vary more in their genetic information than do individuals of different races.
Despite this, the idea that one’s skin color can predict deeper biological difference persists in our everyday conversations. As Azar’s comments disturbingly reveal, that idea has weaved its way into medicine, too. And for many patients—Black patients in particular—it further amplifies the life-threatening inequalities embedded in our health care system by every other form of abuse and discrimination.
It is not surprising that misconception about race is so widespread in medicine, given that medical science played a crucial role in constructing race in the first place. Imperialist studies of racial difference began with 17th– and 18th-century Europeans, who placed those of the white race at the top of racial hierarchies for their “gentleness” and large skulls primed for intelligent thinking, in contrast to the “caprice” and misshapen skulls of those with “black complexion.” These racial hierarchies promoted sweeping characterizations about Black people’s innately different physiology. Black people possessed an “insensibility” such that “what would be a cause of insupportable pain to a white man, a negro would almost disregard,” wrote Benjamin Mosely, an 18th-century physician. They were apparently immune to some diseases, like Yellow Fever, and uniquely afflicted by others, like drapetomania, “the disease causing negroes to run away [from enslavement]” despite their “submissive” nature. And Black women’s supposedly hypersexual physiology primed them to be “breeder[s].” Historian Rana Hogarth describes these conclusions as “medicalized Blackness,” a pseudoscientific backing of innate racial difference that has persisted for centuries.
We see echoes of medicalized Blackness in race-based health care practices that persist today. A 2016 study, for example, found that medical students and residents frequently gave less accurate pain treatment recommendations to their Black patients due to misconceptions about race-based biological difference. The problem transcends individual physician bias. A recent New England Journal of Medicine article discussed the pervasiveness of algorithmic “race corrections” that ingrain racial generalizations in the very standards used to determine diagnosis and treatment. In urology, the STONE score predicts that patients who complain of flank pain are less likely to have a kidney stone if they are Black, and neither the algorithm’s developers nor external studies have provided scientific reasons for why. An obstetrical algorithm forecasts that Black and Latinx patients are less likely to have successful vaginal births. The algorithm notably neglects other factors known to be predictive, such as insurance status, and may lead patients to resort to C-sections, which are more dangerous and have longer recovery times. And the algorithm for estimated glomerular filtration rate routinely assesses Black patients to have better kidney function, which may delay providers from recommending more specialized treatment or transplantation. The science behind this algorithm is heavily debated and has been justified in part by the claim that Black patients’ “more muscular” physique assists them.
Black patients are known to face higher rates of death due to childbirth and kidney disease. Though no study has directly linked algorithmic barriers to these outcomes, medical providers ought to note their association.
It’s true that ancestry can influence one’s likelihood of expressing certain forms of genes. This is due to environmental conditions, not intrinsic racial difference. For example, the gene variant that causes sickle cell anemia, which many misleadingly racialize as a “Black disease,” confers malaria protection. So, while the sickle cell trait is seen in people with ancestry in certain parts of Africa, it is also prevalent in those with ancestry in other regions of similar climate, including in Mediterranean countries and in India.
Beyond genetics, we can, and should, acknowledge widespread race-based health disparities, so long as we first and foremost recognize the racism that upholds them. But it is very, very different—and incorrect—to say that a mythical innate racial difference directly causes diverging health outcomes.
Modern medicine has greatly improved due to personalization, which takes into account each patient’s unique physiology and genetic profile during diagnosis and treatment (though it’s worth noting that low-income patients and patients of color might not benefit from these therapies, which are often expensive and based on research that disproportionately represents those of European ancestry). Individual differences do determine how we experience and respond to medical treatment. Race, however, is a crude and lazy approximation of that difference. Generalizing health conditions to an entire race allows medicine to ignore the destructive societal inequalities that harm certain groups more than others. Beyond that, it ignores the complex stories that make up each individual’s experience and ancestry, stories that race alone cannot capture. Such oversimplifications can directly threaten lives.
“Race medicine is bad medicine. It’s poor science and it’s a false interpretation of humanity,” said leading scholar and sociologist Dorothy Roberts in her 2015 TED talk, “The problem with race-based medicine.”
We’re all familiar with the most overtly dangerous implications of “scientific” racism—that certain races are more suitable to enslavement or more likely to commit crimes, that others deserve to weld an entire country’s social, political, and economic power. Most of us, hopefully, acknowledge that these ideas are grossly incorrect. But even modern statistics about racial differences in health often do not reveal the whole picture. When medicine relies on arbitrary standards based on race alone, when it blames “comorbidities” without acknowledging the roots of these inequalities, ultimately, it plays into the same false ideas that fuel the more obvious forms of racism. And when medical blindness leads to sub-par treatment for Black patients or other patients of color, its effects can be just as dangerous.
Secretary Azar should stop blaming Black and brown Americans for the burdens their communities bear during this pandemic. Instead, he might examine how his own words and misconceptions help create their pain.