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Sharmin, Lindsey, and Alex discuss a clinical unknown with Dr. Natasha Chida from Johns Hopkins

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Dr. Natasha Chida

Dr. Chida is an Assistant Professor in the Division of Infectious Diseases at Johns Hopkins University School of Medicine. She serves as the Associate Program Director for the infectious diseases fellowship training program. She is also the Co-director of the Osler and Bayview Internal Medicine Residency Programs Medical Education Pathway, and firm faculty in the Osler Program, where she serves as a resident coach. Her research interests include career development for early-career professionals, women in medicine, and HIV education for fellows.

This is the first episode of a three-part series on understanding and dismantling race-based medicine by unearthing its origin and exposing the paucity of rigorous evidence in support of it. In this episode, we invite Critical Race Theory scholar Edwin Lindo, JD to discuss the invention of race, how its definition has changed over time, and how the fields of science and medicine contributed to its legitimacy as a tool for political and social oppression. 

Episode Learning Objectives

After listening to this episode learners will be able to…

1. Define race and what is meant by “race is a social construct”
2. Describe the influential role of science and medicine in creating race 
3. Understand why race is a poor proxy for genetics or ancestry

Credits

• Written and produced by: Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Naomi Fields, Chioma Onuoha, Jazzmin Williams, Dereck Paul, MS, and Utibe R. Essien, MD, MPH 
• Show Notes: Jazzmin Williams
• Hosts: Dereck Paul, MS, Rohan Khazanchi, LaShyra Nolen
• Infographic: Creative Edge Design
• Guests: Prof. Edwin Lindo, Assistant Dean for Social & Health Justice, University of Washington School of Medicine (@EdwinLindo) 

  Time Stamps

  00:00 ​Music/intro
  00:11 ​Our mission and vision
  00:38 ​Introduction to the Antiracism in Medicine team
  02:08​ ​Introduction of this episode and the Dismantling Race-Based Medicine series 02:49 ​Introduction of Prof. Edwin Lindo
  03:28 ​What is race? How is race a social construct? Why was it constructed in the first place?
  16:10​ Why color-blindness is not a solution to dismantling race-based medicine
  20:00 ​How has medicine played a key role in defining race throughout history? 37:50​ Race vs. ancestry vs genetics–implications for research and clinical practice 52:02 ​What can we start doing tomorrow?
  57:35 ​Conclusion and outro

  Episode Takeaways:

1. History matters​. Medicine has never been an apolitical field, and understanding the specific ways the medical field contributed to socio-political definitions of race through practices rooted in medical racism can help us avoid repeating the same harms of the past (e.g. racial essentialism). This education needs to span the whole MedEd continuum.

2. Definitions matter​. In research, clinical practice, and MedEd, we need to be explicit in our understanding and discussion of race vs. ethnicity vs. ancestry, and how each of these categorizations does or does not impact biological or genetic traits.

3. Bias is everywhere​. Objectivity is a top priority in medicine and research; however, history shows us how initial assumptions have tainted both study design and interpretation of results.

Conversation Starters and Reflection Questions for Trainees​ & ​Faculty

What teachings lie at the root of your belief that race has a biological basis?
– Dismantling race-based medicine starts at home by asking yourself, colleagues, and

classmates this question. Much of the data promoting biological difference amongst races comes from poorly-designed studies where race as a variable is ill-defined or confounding variables are inadequately controlled. This reflexive acceptance that race is rooted in biology comes from stereotypes created by Carl Linnaeus and other racial taxonomists.

How is racism causing the outcomes that I am seeing in my patient?
– Recognizing that racism, not race, is the root cause of racial health disparities is the first step to improving health outcomes for Black, Indigenouls People of Color (BIPOC) patients. Acknowledging this truth highlights the necessity of mitigating the harms of racism as part of any comprehensive treatment plan. This is done on an individual level, by offering existing support and resources, as well as on a systemic level through advocacy.

Pearls

Defining Race

Race is a socio-politically constructed taxonomy that was invented based on factors such as perceived skin color and culture, not science or biology. The concept of race emerged for the purpose of allocating and/or extracting resources. In the United States, the concept of race was key to extracting resources from Black and Indigenous peoples during the formation and expansion of the country.

The Role of Science and Medicine in Defining Race and Racism

Scientists and physicians legitimized race as a category by positing “objective” proof that white persons were biologically superior to other races. In 1735, Carl Linnaeus, often known as the the “father of taxonomy,” classified four “varieties” of human species and ascribed stereotypical characteristics to each race: “Native Americans as reddish, stubborn, and easily angered; Africans as Black, relaxed, and negligent; Asians as sallow, avaricious, and easily distracted; while Europeans were depicted as white, gentle, and inventive.”

In 1839, Dr. Samuel Morton asserted that White people were the most intelligent of all races and Black people were the least so based on head circumference and cranial capacity. In an 1850 report commissioned by the Louisiana legislature, Dr. Samuel Cartwright argued that Black people were lazier, less intelligent, and more susceptible to infectious diseases than White people because they had less lung capacity. Cartwright’s study influenced the equations that medical professionals still use to calculate the impact of various diseases on lung function. This baseless race correction impacts treatment decisions, which contributes to racial health inequities. In the early 1900s, eugenicists and social anthropologists claimed that Black people were predisposed to violent crime, which justified institutionalization and sterilization of Black people. Despite their claims being based on unproven assumptions, their research was praised for scientific rigor and used to justify subjugation based on race.

“The scientific method is only as strong as the variables you input into it and if you are not critical of the questions you are asking, who you are researching, how you are doing that research then the biases, the history, the legacy, they seep in.” – Edwin Lindo, JD

Why is color-blindness not a solution to dismantling race-based medicine?

Ignoring race and racism does not negate the profound impact that race and racism have on our BIPOC patients’ health. Colorblindness inflicts harm through erasure. Instead, researchers and clinicians must be aware of the impact of racism in order to explore ways of mitigating its damage. For more on this concept, stay tuned for the next episode!

Is race a good proxy for ancestry? For genetics?

Since race is a socio-political construct, its definition has changed over time and space. For example, racial categories in the US Census have changed numerous times, with new categories being created and others disappearing or returning depending on the political atmosphere at the time. In another example, a person who is considered Latinx in the US could be considered Mulatto in Brazil or Coloured in South Africa. Given that there is no standard definition of race, its imprecision does not meet the standards of clinical medicine. As Prof. Lindo states, “our eyes see race” when we study disease disparities, but the true risk factor may actually be racism, geographic ancestry, or a specific genetic variant. However, assuming a genetic difference based on a perceived association with race is poor science.

Links

References discussed throughout episode

1. “The Praxis” Podcast: ​https://clime.washington.edu/praxis

2. Boyd RW, Lindo EG, Weeks LD, McLemore MR. On Racism: A New Standard For

   Publishing On Racial Health Inequities. ​Health Aff Blog​. Published online July 2, 2020.

   https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/

3. Marya R, Lindo E. Healing the Nation’s “Broken and Scattered” Hoop. ​Common Dreams. Published online June 19, 2020.https://www.commondreams.org/views/2020/06/19/healing-nations-broken-and-scattered -hoop

4. Tsai J, Cerdeña JP, Khazanchi R, Lindo E, et al. There is no “African American physiology”: The fallacy of racial essentialism. ​J Intern Med.​ 2020;288(3):368-370. doi:10.1111/joim.13153

5. Chadha N, Lim B, Kane M, Rowland B. “Toward the Abolition of Biological Race in Medicine.” ​Institute for Healing & Justice in Medicine​; 2020. https://www.instituteforhealingandjustice.org/download-the-report-here

6. Wilkerson, I. (2020). Caste: The Origins of Our Discontents. Random House.

Additional references and papers as mentioned in episode

1. Roberts, D. (2012). Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-first Century (50852nd ed.). The New Press.

2. Braun, L. (2014). Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics (1st ed.). Univ Of Minnesota Press.

3. Harris, C. (1993). Whiteness as Property. Harvard Law Review, 106(8), 1707-1791. doi:10.2307/1341787

4. Williams DR. Miles to go before we sleep: racial inequities in health. J Health Soc Behav. 2012 Sep;53(3):279-95. doi: 10.1177/0022146512455804.

Disclosures

Mr. Khazanchi is a member of the American Medical Association’s Council on Medical Education, but the views presented herein represent his own and not necessarily those of the AMA or the Council. The hosts and guests report no other relevant financial disclosures.

Citation

Lindo E, Nolen L, Paul D, Ogunwole M, Fields N, Onuoha C, Williams J, Essien UR, Khazanchi R. “Episode 140: Dismantling Race-Based Medicine, Part 1: Historical & Ethical Perspectives.” ​The Clinical Problem Solvers Podcast.​ ​https://clinicalproblemsolving.com/episodes​ November 17, 2020.

Show Transcript

1. Music

2. Introduction

3. Introduction to the Antiracism in Medicine team

4. Introduction of this episode and the Dismantling Race-Based Medicine series

5. Introduction of Prof. Edwin Lindo

6. What is race? How is race a social construct? Why was it constructed in the first place?

7. Why color-blindness is not a solution to dismantling race-based medicine

8. How has medicine played a key role in defining race throughout history?

9. Race vs. ancestry vs genetics–implications for research and clinical practice

10. What can we start doing tomorrow?

11. Conclusion and outro

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Reza, Rabih, Sharmin, and Arsalan share their approach to CNS and lung lesions.

Lung Nodule Schema

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Reza and Rabih discuss an unknown case presented by Drs. Ramesh and Moriates at Dell Medical School

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Dr. Jan Ramesh

Jan Ramesh is the Hospital Medicine Fellow in Quality and Safety at Dell Medical School at The University of Texas at Austin.  Outside of the hospital, she enjoys writing poetry, drawing, and spending time with her husband and her two cats. 

Dr. Chris Moriates

Chris Moriates is a practicing hospitalist, Assistant Dean for Healthcare Value, and Associate Chair for Quality and Safety at Dell Medical School at The University of Texas at Austin, where he also directs the Distinction Track in Care Transformation for internal medicine residents and the Hospital Medicine fellowship. When not in the hospital, he most enjoys running around the lakes in Austin accompanied by his 9-year-old son on his bike, or hanging out with his 5-year-old daughter. 

Reza and Rabih tackle a case of pruritus.

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Reza and Rabih tackle a case of renal injury.

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Dr. Steph Le shares a story of gender discrimination and Emma and Annette discuss gender biases and stereotypes with UCSF’s Department of Surgery Chair, Dr. Julie Ann Sosa 

Dr. Julie Ann Sosa

Julie Ann Sosa, MD MA FACS is the Leon Goldman MD Distinguished Professor of Surgery and Chair of the Department of Surgery at the University of California San Francisco (UCSF), where she is also a Professor in the Department of Medicine and affiliated faculty for the Philip R. Lee Institute for Health Policy Studies. Dr Sosa came to UCSF in 2018 from Duke. Her clinical interest is in endocrine surgery, with a focus in thyroid cancer. She is an NIH-funded investigator and author of more than 325 peer-reviewed publications and 78 book chapters and reviews, all largely focused on outcomes research, health care delivery, hyperparathyroidism, and thyroid cancer, with a focus on clinical trials. She has authored or edited 7 books. Dr Sosa is Treasurer of the American Thyroid Association (ATA) and serves on the Board of Directors/Executive Council of the ATA and International Thyroid Oncology Group, as well as practice guidelines committees for the ATA, NCCN, and the American Association of Endocrine Surgeons; for the ATA, she is chairing the committee responsible for writing the next iteration of differentiated thyroid cancer guidelines. She is the Editor-in-Chief of the World Journal of Surgery and is an editor of Greenfield’s Surgery: Scientific Principles and Practice. She has mentored more than 90 students, residents, and fellows, for which she was recognized with induction as a full member to the American College of Surgeons Academy of Master Educators in 2020, and with the Lewis E. Braverman Distinguished Lectureship Award from the ATA in 2017. Dr Sosa was born in Montreal and raised in upstate New York. She received her AB at Princeton, MA at Oxford, and MD at Johns Hopkins, where she completed the Halsted residency and a fellowship.

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Description: Gizem Reyhanoglu presents a Human Dx unknown to Arsalan, Dr. Tranchito, & Dr. Kramer

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Gizem Reyhanoglu

Gizem Reyhanoglu is a 4th-year medical student at LECOM-Bradenton, applying to Internal Medicine this application cycle. She completed her undergraduate degree in biology at the University of Florida and completed a Master’s degree in Medical Sciences at the University of South Florida. In her spare time, Gizem enjoys watching The Office, training for half-marathon races, baking for her family/friends, and playing with her puppy, Leo. 

Lily Tranchito

Lily Tranchito is a PGY-3 at Case Western Reserve University/University Hospitals Internal Medicine program. She was born and raised in Cleveland, Ohio, earned her undergraduate degree from The Ohio State University, and graduated from Ohio University Heritage College of Osteopathic Medicine. She has a passion for medical education, cooking, gardening, daily walks around her neighborhood, and spending time with her family and friends. 

Patrick Kramer

Patrick Kramer is a PGY-3 in Internal Medicine at the Case Western Reserve University / University Hospitals Internal Medicine Residency Program in Cleveland, Ohio. Although he is originally just a kid from Akron, he took his talents to the University of Notre Dame and Loyola University Chicago – Stritch School of Medicine for his education. Career interests include pulmonary and critical care medicine as well as diagnostic reasoning and medical education. Outside of the hospital, Patrick has recently taken up disc golf in addition to his passions for coffee brewing, photography, and watching classic movies.