The History of Race-Based Medicine in the Pages of Pediatrics: A Review of the Last 75 Years

One stark example is found in a Pediatrics article, published within its first 4 years, on birth and mortality rates among enslaved infants in the pre-Civil War South.³  The authors argued that “There was nothing the planter was more interested in than the increase of his slaves through the birth and rearing of children, and within the bounds of medical knowledge of the period, he took the time and effort to promote conditions that were conducive to the rearing of large families…Crude as this care was in comparison to our knowledge today it was still far superior to anything the Negro had known in Africa.”³ 

The authors provided no data to support the assertion that enslaved Africans received better care than Indigenous Africans, and no acknowledgment was made of the knowledge enslaved Africans carried with them and shared with Europeans, like the introduction of inoculation in 1721.⁴  The data presented primarily compared enslaved infant mortality rates to the infant mortality rates among Black infants at the turn of the 20th century and around the time of the article’s publication in 1952. The purpose of the article was not to decry the inequitable conditions of slavery or Jim Crow policies that resulted in these disparate outcomes but instead to bolster the ultimate point the authors wished to convey, that “the neonatal care of slave infants was very good for these ante-bellum plantations.” By publishing this article, the editors of Pediatrics signaled, tacitly or explicitly, that they agreed with the assertion that Black infants were better subjected to chattel slavery on plantations than free in Africa.

The idea that Black children would be better enslaved helped advance the notion that race was a biological construct. A belief that an individual’s Black skin, instead of the social and environmental conditions in which one exists, explains health disparities is littered throughout medicine. From the creation of race correction in the spirometer in the 1800s⁵  to the current use of race to ascertain one’s risk as a kidney donor,⁶  the flawed science behind race as a biological construct is an enduring belief within medicine. This belief has led to conclusions that observed racial health disparities were primarily due to flaws within individuals and communities, not the systems or conditions in which they were living. A 1981 Institute of Medicine report titled “Health Care in a Context of Civil Rights” did not cite Jim Crow laws as a significant reason that racial health disparities existed. They did, however, attribute them to “medical care decisions of minority group members.”⁷ 

Whether arguing in 1958 for the “Precocity of African children,”⁸  examining in 1989 the “Genetic and environmental determinants of growth in Mexican-Americans,”⁹  or incorporating “race” as a risk factor in clinical algorithms for the management of hyperbilirubinemia¹⁰  in 2004 or febrile urinary tract infection¹¹  in 2011, Pediatrics did not acknowledge the effect of racism, rather than race, for decades.

This historical blind spot to the role Pediatrics has played in perpetuating race as a biological factor, and the harm that stems from that, illustrates why the publication of the 2022 Eliminating Race-Based Medicine (ERBM) policy statement¹²  was a landmark step toward realizing the journal’s mission: to encompass the needs of the whole child in his or her physiologic, mental, emotional, and social structure, for all children.¹³ 

Building on another watershed publication, 2019’s The Impact of Racism on Child and Adolescent Health,¹⁴  the 2022 ERBM statement traces the roots of the concept of race as a biological construct, highlights how this false equivalency and flawed science has infiltrated clinical practice, and provides recommendations for the future.

Included in these recommendations is the important nuance that although race should rarely, if ever, be used as a proxy for biological difference or risk when making clinical decisions at the bedside, it remains an important proxy at the population level to measure and act on the effect of structural and institutional racism. Recent work has highlighted how this can be approached through public health research¹⁵  and improved standards when publishing on racial health inequities.¹⁶  The ERBM statement’s recommendations for pediatricians, researchers, institutions, and the American Academy of Pediatrics (AAP) itself illustrate an ongoing shift from only measuring and reporting racial health disparities to moving to action that substantively addresses them. It calls out that the use of race pervades pediatrics from recognizing symptoms to diagnosing and treating the underlying disease, making it imperative to root out all forms of racism in all aspects of clinical practice.

It was not long ago that journal articles including terms such as structural racism or race-based medicine were not found in the journal Pediatrics. To not use language that calls attention to racism’s effect on health is a notably significant omission in a journal that reaches >67 000 AAP members in print and millions more digitally, has one of the highest impact factors of all pediatrics journals and is one of the top 100 most-cited journals in all of science and medicine worldwide. Yet, Pediatrics is not alone, because the last few years have brought to light the role of leading journals in what has been called “academic redlining,” or the bolstering of, “ideas favorable to their status, and by challenging, distorting, or suppressing knowledge that questions the legitimacy of their power.”¹⁷ 

Many have cited the civil unrest nationally and globally after the murder of George Floyd in 2020 as a “racial reckoning” that led to the current shift in how medicine talks about race and racism. However, “reckoning,” by definition, requires accountability. Although people and organizations involved in many areas of American society and the medical profession rushed to acknowledge some or all of the roles they have played in perpetuating racism, people and organizations in few areas have examined and discussed their own ongoing contribution to structural racism. Fewer still have attempted to imagine what something different than the status quo can look like and how their profession will help lead our society to that vision. The AAP took concrete steps in 2021 toward accountability by retiring 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.¹⁸  With the blueprint provided by the ERBM statement, Pediatrics and the AAP provide hope that medicine can and will bring an end to race-based medicine and a beginning to a more scientifically rigorous and ultimately equitable view of the effect of racism on health. By acknowledging the roots of race-based medicine, the flawed science race-based medicine promotes, committing to end the practice of using race as a proxy for biology or genetics in all their educational events and literature, requiring race be explicitly characterized as a social construct when describing risk factors for disease, the AAP calls out pediatrics’ history, reckons with its current state, and calls all in to a future in which Pediatrics, both the journal and profession, truly meet all the needs for all children to live full and healthy lives.

Thanks to Dr Nia Heard-Garris for her review of the manuscript.

AAP

American Academy of Pediatrics

ERBM

Eliminating Race-Based Medicine