In the United States (US), there are marked racial and ethnic disparities with respect to a range of socioeconomic and environmental factors like poverty, educational attainment, access to healthcare, and proximity to pollutants [8]. Looking for a “purely genetical” explanation for differences in exposure to such factors and ensuing social or health outcomes does not do justice to the undeniable impact of racism and ethnocentrism. Instead, a focus on genes compounds, reinforces, and harmfully justifies racist and ethnocentric tropes.
To be clear, there is no evidence that genes drive racial and ethnic health disparities. Rather, racial disparities in health are better explained structural racism than by genetic differences. In the US, for every preventable disease, African Americans (AA) have the highest mortality rate and shortest expected years of life compared to non-Hispanic Whites [9,10,11]. This is true not because of DNA but because of differences in their lived experience, differences in the context in which individuals are “born, grow, work, live, and age” [12]. For instance, McKinnon et al. showed that Black women living in Canada have lower preterm birth (PTB) rates than Black/AA women living in the USA (8.9% vs 12.7%, respectively) [13]. Better birth outcomes among foreign-born Black women in the US compared to US-born Black/AA women [14], and COVID-19 case fatality rates that are lower among Africans in Africa than AA [15] further highlights that genetics cannot be used to explain health disparities; rather, it highlights again the importance of context. Indeed, this relationship between neighborhood context and health has been widely established [16]. As an example, in a study by Tessum and colleagues published in PNAS, AA individuals were exposed to 56% more pollution than they collectively contribute, and Hispanic individuals to 60% more pollution. Meanwhile, white individuals were exposed to 17% less pollution than what they contribute [17].
It is this context, and inequities therein, that drive between-group differences—disparities—in a range of health outcomes. We know that historically disadvantaged populations—including AA and Hispanic patients—have a higher burden of the comorbidities traditionally used by hospitals to stratify patients by risk. This is largely because of structural and socioeconomic factors. Studies and statistics suggest that, compared to their white counterparts, AA patients are 40% more likely to have high blood pressure, twice as likely to have heart failure, four times as likely to die from asthma-related complications, three times more likely to have chronic kidney disease, twice as likely to be diagnosed with colon and prostate cancer, and represent 44% of the HIV positive population. Across the US, we are seeing alarming statistics about the disproportionate toll of COVID-19 on AA and Latino people [11]. There has been a 21.6% increase in daily COVID-19 deaths in the counties with a higher population of AA residents vs. a 5% increase in counties with a higher population of White residents. To do the greatest good ethically and fairly, these persistent inequities must raise alarms.
These alarms, and the continued reality of racial and ethnic disparities, are real and require attention; they follow closely behind differences in the sociopolitical context that different racial and ethnic groups confront. There is plenty of evidence linking marginalization, segregation, and discrimination to a laundry list of adverse social, economic, environmental, and, yes, health outcomes. Race and ethnicity have been used to justify horrific discrimination across generations. This justification has been both explicit and implicit; it is at the root of the horrors we are now seeing in our streets. Indeed, George Floyd, Breonna Taylor, Ahmaud Arbery, Daniel Prude, Jacob Blake, and many more have borne the brunt of a classification schema built to perpetuate hierarchical tiers of status and power. These different tiers drive differences in the cleanliness of the air we breathe, the homes in which we live, and the resources we enjoy. Differences in health outcomes follow.
While there has been substantial effort in reconceptualizing the notion of racial disparities beyond genes/biology, the utility of the terms race and ethnicity remains problematic among scholars, the lay public, and other stakeholders. Genetic data can provide data on the nature of human biological diversity. How we incorporate this information into structural racism and race information will be critical in ensuring that modern understandings of human variation are viewed with anti-racist, anti-ethnocentric lenses. Yet, race and ethnicity must always be de-biologize and never be used interchangeably with genetics. Instead, they should be recognized as the sociopolitical [18] constructs that they are. In this way, we can use such categorizations, driven by self-report or self-identification, to monitor and, ultimately, narrow, longstanding equity gaps. By framing concepts of race and ethnicity in the context of racism and ethnocentrism, we can enumerate and then respond to the ramifications of generations of systemic, structural inequities from unjust policies and discrimination. We cannot eliminate disparities with medical treatments alone; instead, these social constructs must be confronted with social responses, with the pursuit of health (and social) justice.
