Practice Ancestry-Based Medicine, not Racial Essentialism

Sarah Inés Ramirez, MD, FAAFP
Posted on March 4, 2024

Dr. Ramirez is an assistant professor in the Department of Family and Community Medicine at Penn State Hershey Medical Center, Hershey, Pennsylvania, and the author of the AFP article “Prenatal Care: An Evidence-Based Approach.”

Racial essentialism uses race as a genetic proxy for disease. Since 2010, the United States has experienced a nearly 280% growth in those identifying as multiracial; hence, the continued practice of racial essentialism propagates health disparities. Take for example, the presence of genetic variants in people of African ancestry linking them to increased risk of preeclampsia. If such an association were ignored, individuals socially identified as White would not be considered to carry a similar risk. Similarly, racial-ethnic minorities socially identified as Black are more likely to experience health care discrimination and less likely to receive preventive health services than racial-ethnic minorities socially identified as White.

Race tells an incomplete story of disease inheritance. As a sociopolitical construct, race-based medicine propagates genetic discrimination. Physician-identified patient ethnicity is an unreliable proxy of genetic ancestry in carrier screening and is laced with bias. Patient self-reported ethnicity, on the other hand, is a more reliable proxy for genetic ancestry, with more than 90% of individuals having genetic ancestry consistent with self-reported ethnicity.

Furthermore, the use of race to drive clinical algorithms perpetuates disease stereotyping and implicit bias in the care of racial/ethnic minorities because these are often derived from largely dissimilar cohorts. Of the 35 million samples included in genome-wide association studies, less than 4% were from racial-ethnic minorities (i.e., Black, Hispanic, Native/Indigenous). Take, for example, the racist history of sickle cell screening.  At its inception, screening for sickle cell trait was exclusively offered to African Americans, resulting in this population being denied marriage licenses, employment, education, and health insurance. New recommendations by the National Society of Genetic Counselors for universal expanded carrier screening attempt to address inequitable carrier screening. The use of shared decision-making between physicians and their patients is paramount because expanded carrier screening may not be covered by all insurers.

Additionally, racial essentialism obscures the reality that the association of race with differential health outcomes is primarily mediated by factors rooted in social determinants of health. For example, worse outcomes for Black individuals in the United States as they relate to nutrition and obesity are not due to genetics, but rather historical racism. A dark chapter in the history of the United States is the practice of “redlining,” where the Federal Housing Administration stated that communities where Black individuals lived were economically too risky for banks to provide home loans. In turn, Black individuals were financially limited to residing in urban projects, thereby reshaping the sociopolitical stability of the community. Compounding this issue was the practice of “supermarket redlining,” where supermarkets were preferentially built in wealthier suburban neighborhoods rather than poorer urban neighborhoods. Taken together, the resulting food deserts would lead to increased rates of food insecurity, obesity, and obesity-related disease (e.g., cardiovascular).

An editorial published in AFP, "What Family Physicians Can Do to Reduce Maternal Mortality," advocates that family physicians’ role in reducing maternal mortality in the United States involves more than just reducing clinical risks; it also involves addressing social determinants, “engag[ing] deeply and meaningfully in equity work” and “recogniz[ing] one's own privilege and role in perpetuating or disrupting systems of oppression.” Knowing a patient’s ancestry continues to have value in medical decision-making, but there is no place for racial essentialism in family medicine.