Race is not a biological category that produces health disparities due to genetic differences; rather, it is a social category that can have devastating biological consequences. Social inequality impacts people’s physical and mental health. In other words, race should not be viewed as a risk factor that predicts disease, disease severity, and disability but as a risk marker of bias, discrimination, and vulnerability.
Race as a Mediator of Structural Inequalities
In 2019, the American Academy of Pediatrics (AAP) cautioned against false notions of racial biology in its policy statement “The Impact of Racism on Child and Adolescent Health,” naming racism as a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families.1
The policy denounces race-based medicine as “flawed science…used to solidify the permanence of race, reinforce the notions of racial superiority, and justify differential treatment on the basis of phenotypic differences as people from different parts of the world came in contact with each other.” The policy reminds us that just because there is no such thing as biological race, it does not mean there is no racism, cautioning that “failure to address racism will continue to undermine health equity.”
In viewpoint published in the October 2020 issue of The Lancet,2 Cerdena et al describe race-based medicine as a “system by which research characterising race as an essential, biological variable, translates into clinical practice, leading to inequitable care” and names racism, rather than race, as a key determinant of health. They propose introducing “race-conscious” medicine as an alternative.
Ending Race-Based Medicine’s Destructive Legacy
Last summer, the AAP Annual Leadership Forum passed a resolution, “Prohibit the Use of Race-Based Medicine,”3 which states that “the Academy shall end the practice of using race as a proxy for biology or genetics in all their educational events and literature, and…require [that] race be explicitly characterized as a social construct when describing risk factors for disease with all presentations at AAP-sponsored conferences.”
The AAP Equity Agenda,4 which sets forth explicit and intentional actions to support and implement the Academy’s commitment to equity, diversity, and inclusion, also lists eliminating race-based medicine and other forms of bias in all CME/MOC activities as a key objective.
In addition, the AAP “Words Matter” guidance5 on the use of antibiased, inclusive language specifically states that “race should be acknowledged as a social construct and should not be used as a biological or genetic descriptor…[nor] used as a biological proxy for disparities.”
Retirement of the Academy’s Urinary Tract Infection Clinical Practice Guideline
Following these principles and direction, the AAP Board of Directors in May 2021 voted unanimously to immediately retire the guidance “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months” because of improper use of race as a factor in disease risk.
First published in 2011 and reaffirmed in 2016, the Academy’s urinary tract infection clinical practice guideline6 came into question when Kowalsky et al7 expressed concerns in a commentary published in the January 2020 issue of JAMA Pediatrics, stating that this guideline “systematically indicates differential care for black or non-white children based on a theoretical lower risk of UTI.”
Given the clear evidence and overwhelming consensus that action was needed, the AAP Board of Directors took this firm stance against the use of race-based medicine in our current and future policies and is continuing its efforts to address previous harms and promote equity and transparency throughout all AAP core activities and functions, including education, programs, policy, and research.
All AAP Policies to Acknowledge Race as Social Construct and Consider Health Inequities
Despite the evidence, unfortunately, the use of race as a proxy for biology persists. The fact remains, however, that even when practiced in good faith, race-based medicine is bad medicine that leads to inequitable medical care and hurts the health and well-being of people of color.
AAP members have been asked to systematically apply an equity lens to all core activities and functions. To realize these ideals and make this goal a reality, all AAP authors are now required to consider health inequities and the conditions needed to achieve equitable health outcomes when developing policy.
All AAP authors are now asked to do the following:
ensure race is acknowledged as a social construct rather than a genetic or biological descriptor;
consider whether use of racial and/or ethnic categories in models, analyses, and selection of comparison groups is explicitly justified when reviewing literature; and
write all policies in accordance with the Academy’s “Words Matter” guidance, which encourages use of inclusive, antibiased language to mitigate and combat bias, remove stigma, and avoid stereotypes.
As AAP Immediate Past President Sally Goza, MD, FAAP, acknowledged, “Like other institutions in our society, medicine has much work to do to right the wrongs of the past and ensure that current systems are equitable. Only through honest introspection can we truly begin to disentangle the thread of racism sewn through the fabric of society and move forward toward a brighter future for all children and families.”8
American Academy of Pediatrics Executive Committee
Lee Savio Beers, MD, FAAP, President
Moira Szilagyi, MD, PhD, FAAP, President-Elect
Sara H. Goza, MD, FAAP, Immediate Past President
Warren M. Seigel, MD, MBA, FAAP, Secretary/Treasurer
Mark Del Monte, JD, CEO/Executive Vice President
American Academy of Pediatrics Board of Directors
Wendy S. Davis, MD, FAAP – District I (Burlington, VT)
Warren M. Seigel, MD, MBA, FAAP – District II (Brooklyn, NY)
Margaret “Meg” Fisher, MD, FAAP – District III (Long Branch, NJ)
Michelle D. Fiscus, MD, FAAP – District IV (Franklin, TN)
Lia Gaggino, MD, FAAP – District V (Kalamazoo, MI)
Dennis M. Cooley, MD, FAAP – District VI (Topeka, KS)
Gary W. Floyd, MD, FAAP – District VII (Keller, TX)
Martha C. Middlemist, MD, FAAP – District VIII (Centennial, CO)
Yasuko Fukuda, MD, FAAP – District I: (San Francisco, CA)
Madeline Joseph, MD, FAAP – District X (Jacksonville, FL)
Constance S. Houck, MD, MPH, FAAP – At Large (Boston, MA)
Charles G. Macias, MD, MPH, FAAP – At Large (Cleveland, OH)
Joseph L. Wright, MD, MPH, FAAP – At Large (Upper Marlboro, MD)
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.