In August 2019, the landmark AAP policy statement The Impact of Racism on Child and Adolescent Health called out the fallacy of racial biology. The statement emphasized that race is a social, not a biologic, construct, and using race assignment as an independent proxy for factors such as genetic ancestry is scientifically flawed. There are many examples in health care in which race has been inserted as a risk-modifying variable in guidelines or algorithms designed to direct clinical care.
A new policy statement Eliminating Race-Based Medicine published today in Pediatrics specifically addresses race-based medicine, which is characterized as the misuse of race as a corrective or risk-adjusting variable in clinical algorithms or practice guidelines. The historic roots of race-based medicine and current reconsiderations and corrective actions also are discussed.
The AAP has been on an equity journey for the past several years. Well before the social unrest following the murder of George Floyd and the transparent exposure of the systemic and structural inequities that have impacted historically marginalized populations disproportionately during the COVID-19 pandemic, the Academy has prioritized activities focused on equipping pediatricians with knowledge, skills and resources to create equitable systems of care delivery and optimize health opportunities for all children.
Among those activities was creation in early 2021 of Words Matter: AAP Guidance on Inclusive, Anti-biased Language as an amendment to the AAP Board policy manual. Words Matter ensures that all authors, editors, presenters, media spokespeople and other content contributors recognize race as a social construct only and desist from any use, or its reference, as a biological proxy.
Last year, the AAP retired Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months in which race was inserted in the decision-making algorithm as default biologic proxy in lieu of incompletely explained epidemiologic observation. Coincident with retirement of the guideline, the AAP Board of Directors and Executive Committee re-emphasized in a perspective in Pediatrics the organization’s commitment to operationalizing the elimination of race-based medicine.
The new policy lays the groundwork for dismantling deeply and historically rooted contributors to the practice of race-based medicine. It also initiates a path forward to replace inappropriate biologic proxies with measures that more authentically represent the socially determined factors that define the differential lived experiences of the patients, families and communities for which we are all accountable.
Of particular note in the Eliminating Race-Based Medicine policy statement are the sections devoted to elucidating the historic, non-evidence-informed roots that underlie much of the flawed science responsible for the persistence of some beliefs that continue to fuel disparities today.
One such example is the 300-year history of racialization in the assessment of lung function in which unsubstantiated assertions of deficient lung capacity in Black individuals by slave-holding medical professionals in the late 18th and early 19th centuries have led to the race-norming that is programmed into spirometers today.
It is critically important to understand the genesis of race-based medicine in order to unwind its roots. Acknowledgement of the transgressions that have characterized the institutionalization of racism in medicine, and society more broadly, requires an honest appraisal and warrants an exercise of truth, reconciliation and transformation. Calling the question on where we have fallen short, addressing current challenges with integrity and looking forward through an unwavering equity lens is how we’ll ultimately realize our goal.
Dr. Wright, a lead author of the policy statement, is a member of the AAP Board of Directors and chair of the Board Committee on Equity.
