Equal Risk

Second Opinion

Does race have a role in calculations of health risks?

Feet on unbalanced scale
Illustration: Eglė Plytnikaitė; Portraits: Nigel Buchanan
Dr. Monika Safford

Dr. Monika Safford, M.D. ’86

Chief, Division of General Internal Medicine     
Co-director, Cornell Center for Health Equity     
John J. Kuiper Professor of Medicine     
Professor of Medicine  

There is no biological basis for race. Black bodies and white bodies function the same way, yet the beliefs that there are differences are pervasive because of historical roots from the Jim Crow era and before. Unfortunately, we often unwittingly carry these practices forward without really questioning them.

A great example is the way we have measured lung function for over 100 years. The spirometer, which measures lung function, was invented by a British physician in the mid–1800s. A plantation physician built one and collected measurements. He immediately saw that the lung function of the enslaved people was worse than that of the white plantation owners and their families. He didn’t consider that putting slave shacks next to the railroad tracks with coal-fired engines could impact lung function.

This led to tables of race-specific normal lung functions from the 1850s until January 2023, when the American Thoracic Society finally retired them. Similarly, the American Heart Association removed race from its risk predictions last November, and the National Kidney Foundation removed race from its kidney function estimator.

When you include race-specific norms or “adjust” for race, you systematically bias the detection of disease. Hypertension is one of the sharpest examples. For decades, we’ve been looking for the “Black gene” for hypertension, and it just doesn’t exist. You see huge disparities, but they are socially, not biologically, determined. The reality is being a Black person in our society contributes to much-earlier onset, worse hypertension and all the downstream consequences.

The way we provide health care contributes to these problems. Medicaid, which is used in greater numbers by Black and brown people, is another example of structural racism leading to poor health outcomes for people of color. The amount of money that Medicaid reimburses both physicians and hospitals is much less than the actual cost of providing care and services. We’ve disincentivized the average physician to accept patients from historically underserved communities.

There’s a teachable moment right now and recognition that we have to do better. While ancestry is a real issue — there are heritable disorders like Tay-Sachs disease in Ashkenazi Jews — having dark skin does not put you at risk of anything except social aggressions. Many medical societies are concluding that we should not have race in risk-prediction equations, but it doesn’t happen overnight. After a 2017 study of racial bias in pain assessment and treatment recommendations, the Association of American Medical Colleges added teaching standards that address racial disparities in treatment to medical school licensing criteria. More work to root out additional, deeply seated racist practices in health care is long overdue.

Dr. Kevin Kensler

Dr. Kevin Kensler

Assistant Professor of Population Health Sciences

Race is a social construct that we’ve created that gets socially assigned to us generally based on our outward physical appearance. It’s not an immutable biologic trait.

Medicine uses predictive models to help identify patients at risk of developing certain conditions and to predict outcomes of treatment interventions. When you include race in a model, it often comes back as significant. I would argue that’s not a causal effect of race in and of itself, but a downstream result of racism experienced by patients. The U.S. health-care system disproportionately minoritizes racial and ethnic groups, who experience reduced access to care and often receive lower levels of care. That can be reflected in the data.

It can be very difficult to find a data set that includes all the necessary social, environmental and genetic factors that you would want to tease apart and accurately predict disease risk. As a cancer epidemiologist interested in health disparities, I’m particularly focused on prostate cancer, where we see very large disparities by race and ethnicity. Incidence is much higher among Black men, and much lower among Asian men, with white and Hispanic men in between. Studies have shown that disparities in prostate cancer survival are entirely preventable. Black men and white men who present with the same type of tumor at the same age, with all else being equal, should have the same outcomes. But due to U.S. health-care system inequities arising from structural racism, Black men do worse.

We’re an increasingly multiracial society. People don’t fit into neat boxes, and these risk calculators require neat boxes. It’s a much more complicated web using genetics, social, environmental and lifestyle factors to try to understand which of these factors is leading to the observed differences that we see by race and ethnicity.

This is a solvable problem with, yes, enormous challenges in pulling together different data types, but it’s getting easier. There have been some instances where taking race and ethnicity out of a model does not diminish the model’s performance, while in other instances, it has. In those latter circumstances, we really need to prioritize research to figure out what underlying causal effect is being captured by that variable within the model, since it is almost certainly not an effect of race. Policymakers and those developing clinical guidelines also need to think about equity considerations in how these models are used.

Dr. Andrew Alexis

Dr. Andrew Alexis

Vice-Chair for Diversity and Inclusion, Englander Department of Dermatology
Professor of Clinical Dermatology
President, Skin of Color Society

Self-identified categories are not biological, and they are highly subjective. But in dermatology, knowing race, geographic ancestry or cultural identity does help us better understand the individual patient. In dermatology, it’s important to consider the patient’s self-identified racial and ethnic background. With skin, hair and nail disorders, we see population variations in epidemiology, clinical presentation, quality of life impact and nuances in recommended approaches to treatment.

For dermatologists, having insight into the patient’s constitutive skin pigmentation, ancestry and tendency toward hyper- and hypopigmentation, for example — assessed, in part, through self-identified race or ethnicity — is important. Individuals with increased skin pigmentation have higher risks of hyper- or hypopigmentation from laser and other energy-based device procedures.

Women who self-identify as Black and have Afro-textured hair disproportionately experience central centrifugal cicatricial alopecia (CCCA), a scarring form of hair loss rarely seen in any other group and coupled with haircare practices common in that community. It’s a very specific disorder affecting one racial, ethnic and gender group.

Not recognizing variations across diverse patient populations has led to gaps in medical education and research. When treating a dermatologic condition [that] disproportionately affects patients with skin of color, research on causes and therapeutic approaches is far more limited. Clinical textbook examples of common skin disorders are mostly individuals of European ancestry with lighter skin complexions. We need more funding for studies that specifically address dermatologic conditions in specific populations to ensure research is representative of our U.S. population. There is a low percentage of dermatologists who self-identify as an underrepresented group. Clinician diversity benefits cross-cultural awareness and provides patients with options of clinicians who have some insights into their cultural background.

The Skin of Color Society is providing guidance to researchers and clinicians on appropriate population descriptors used in research and clinical contexts and is actively expanding education on dermatologic disorders and populations with skin of color. The American Academy of Dermatology also is expanding education and diversity within dermatology. At Weill Cornell Medicine, I work closely with Dr. Eva Kerby and the Center for Diverse Skin Complexions on patient care, clinical research and education related to diverse skin types. Our residents have a robust set of didactic and practical educational modules on best practices for treating these various conditions across diverse patient populations.

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