NMA 2024: M. Roy Wilson, MD, touches upon reconceptualizing the use of race in medicine

M. Roy Wilson, MD, touches upon reconceptualizing the use of race in medicine as part of his Robert Copeland Distinguished Lecture at the National Medical Association's annual conference in New York City, NY.

Video Transcript:

Editor's note: The below transcript has been lightly edited for clarity.

M. Roy Wilson, MD:

I think that most people, at least most scientists, acknowledge that racism is a social construct and not a biological one. However, I think it's very easy for people to forget that and start using race as a biological construct, so one of the things that has to be done is to continue to not use race as a biological construct because that leads into things like race-based medicine and other things that has deleterious effects on minoritized people. I think that's one of the major misconceptions. The second is there's a lot of conflation of terms. Race is difficult to define. Harvard historian Evelyn (Brooks) Higginbotham once said something to the effect that everybody thinks that they know what race is, but then it's hard for us to define it when we’re asked to define it. She said that well before the human genome was mapped. Even with the mapping of the human genome, the definition of race is still pretty elusive. It's very difficult. Race is oftentimes conflated with ethnicity, and it also oftentimes conflated with a genetic ancestry. One of the things that has to be done is to precisely define these terms, and not junk them all together.

One of the ways that racism is used is in clinical algorithms. A very well-known one is the estimated glomerular filtration rate. Another one is spirometry. There's a lot of them, but take the estimated glomerular filtration rate first. With the race correction, actually (in) gay African Americans (the results) appeared to be better estimated glomerular filtration than was actual, and so a lot of African Americans did not get referred for kidney transplants because their estimated kidney function was better than it really was based on this race correction. Spirometry is something that's often done, and because of some very racist foundations many centuries ago about the pulmonary capacity of blacks versus whites, there was a race correction that is still operational to modern day. Although, I think that most hospitals recognize that these kinds of algorithms, having race as a correction, is problematic. In this case, if you race correct, then your spirometry results are going to seem to be worse because the thinking was that the pulmonary function of blacks, particularly slaves at that time, was limited compared to white. The algorithm factors that in. For example, I’m a cyclist and I have very high pulmonary function, very high spirometry results. Typically, it measures somewhere in the top 1% in my age group. The last time I got a physical examination, it wasn't that good. I mean, it was still good, but it wasn't in the top 1 or 2%. It was a little bit above average, and so I started looking at what happened. Did I have long COVID? Did something happen to my pulmonary function? And then I realized that what happened is that I went to a different provider, and they coded me as white versus black. Just that difference, not having that racial correction because they coded me as being white rather than black, changed my spirometry results from a level that would be considered superior or even elite to one that is good, but not nearly in that top 1, 2% category. The only difference was just the changing of my assigned race by the doctor.

Yeah, that's really a good question. There does seem to be a bit of a difference in approach with physicians and social scientists, and what I mean by that is that social scientists will argue very strongly that race is a social variable, and that biology is not only unimportant but it's meaningless. I think that most physicians we've been trained to look at probabilities, and there's no question that there are some diseases in which African Americans are more prone to. We use that to narrow our differential diagnosis. Commonly in medicine, we do use the fact that there was a higher prevalence or incidence or burden of disease in one group versus another, whereas some other groups think that that's wrong to do and that we should be looking for social determinants that cause those differences. I think that looking for social determinants is very important, and so regardless of whether or not you think that there are some diseases that are in higher prevalence and incidence in a person of a particular race, you should still look for some more meaningful factors than then race to explain that difference. I don't think that it's biologically meaningless. There are some biological consequences, even though it's not a biological construct.

Racism is a core variable to explain genetic variation. There's more variability among many people of the same race than among people of different races. I like to give the example of (James D.) Watson, who was the first person who had his human genome mapped, and then (John Craig) Venter, who was competing with Watson to get the genome mapped. The fifth person to get the genome map was Kim (Seong-jin), and when you looked at the all the alleles of these three gentlemen, Watson had more in common with Kim and Venter had more in common with Kim than Watson had with Venter. The two white people had less in common than either one of them with an Asian in terms of the number of alleles that were common between the two, so that gives you an example of how racism is really a very poor indicator of genetic variability. I think that what we have to do is look deeper and find out what are the causes of why we see these health disparities. Oftentimes, it may be socio-economic status or some other factor, social determinant, that is the causative factor as opposed to race, which could just be a confounding factor.

I think the first thing is to really interrogate whether or not it's even appropriate to use race as a variable. There are cases in which it is appropriate, but to really question it and to question it at different points of the study so that it's not just once and then you're done with it. There are different stages of research that race as a variable can mean different things at various stages. If it is appropriate, and there are cases in which it is, for example, to look at health disparities and things like that, then to really looking at what some of the underlying factors might be. There's a PhD thesis that I was able to read recently of a PhD candidate, who recently wrote an article in American Journal of Ophthalmology related to race. He found in his research that socio-economic status was a mediator for race, and by controlling socioeconomic status that one could diminish the role that race had based on different racial categories. That's just an example of how there could be these mediators and confounders, if you look deep enough, that you'll be able to uncover it. Many times, people consider race as a risk factor for various diseases like glaucoma. I mean, I made my career on that, but the fact that it's a risk factor doesn't mean that there was a causative relationship there. It may be something that we measured that we know about like central corneal thickness, or it may be something that we don't know about at all, there's something unmeasured. A deeper look at social variables, looking at potential biomarkers, there are a host of ways to look at this in a way that is more comprehensive than just using race as a variable just because it's convenient to do.

I've just mentioned that there is a National Academy of Science, Engineering, and Medicine. All three of the National Academies have recently had a consensus committee on the use of race and research, and I was fortunate to chair that committee. Our work was completed just a couple of weeks ago and it's under review right now, and there will be a report that comes out probably in October.