Issues in Interdisciplinarity 2020-21/Truth in Definitions of Race and Implications in Black Maternal Care

Introduction The case of black maternal care provides a microcosm in which the wider concept of race can be examined. The truth behind a biological basis of race has been challenged since the concept’s inception, and yet racial categorizations are still used to inform medical practice. To define is to reach a consensus that attributes a meaning to a word, so that each word reflects a truth that allows people to communicate. By exploring how misguided definitions of race adversely affect health outcomes for black patients in the US and the UK, this chapter highlights the problems caused by different conceptions of truth. Care provided to black women during pregnancy will serve to exemplify our arguments by applying them to reality. thumb|329x329px|Illustration from Types of Man by Josiah Clark Nott and George Robins Gliddon, 1854 Bio-Anthropology As a discipline concerned with the synergy between biology and culture, biological anthropology has often been looked upon to inform wider definitions of race.Wagner JK, Yu JH, Ifekwunigwe JO, Harrell TM, Bamshad MJ, Royal CD. Anthropologists' views on race, ancestry, and genetics. American Journal of Physical Anthropology. 2017 Feb;162(2):318-27. With the discipline’s origins rooted in Western Euro-American scholarship however, early conceptions of race within anthropology were marked by racial discrimination and prejudice.Fuentes A. Biological anthropology's critical engagement with genomics, evolution, race/racism, and ourselves: Opportunities and challenges to making a difference in the academy and the world. American Journal of Physical Anthropology. 2020;. Emphasis on morphology combined with the existing white-supremacist ideology arguably led to the black and white dualism which has since been regarded as a true natural distinction upon which biological research should be based.Billinger M. Another Look at Ethnicity as a Biological Concept. Critique of Anthropology. 2007;27(1):5-35. Since, biological anthropology has moved away from evolutionist definitions and has instead focused on ancestry, genetics or society to inform their notions of race. The variability in approaches to understanding ‘race’ however, has meant that definitions of race are unstable and localised – a major issue when used to inform medical interventions.Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences. 2016 Apr 19;113(16):4296-301 Researchers investigating genetic research have either stressed the need to reevaluate biological conceptions of race, which, as they note, are "so disputed and so mired in confusion",Yudell M, Roberts D, DeSalle R, Tishkoff S. Taking race out of human genetics. Science. 2016;351(6273):564-565 or falsified the entire notion.Kolbert E. There’s No Scientific Basis for Race—It's a Made-Up Label [Internet]. National Geographic. 2020 [cited 11 December 2020]. Available from: https://www.nationalgeographic.co.uk/people-and-culture/2018/04/theres-no-scientific-basis-race-its-made-label As such, contemporary anthropologists have come to understand race as a social construct used to arbitrarily categorise groups based on physical characteristics. Despite this, due to the higher prevalence of certain conditions in some groups, racial categories have been maintained in healthcare and are still used to inform maternal treatment. This can affect black patient outcomes two-fold: there is a risk of misguidedly extrapolating data on health from people with European ancestry to people with African ancestry (where relevant biological variation may eventually be found), and of black patients being treated differently based on unfounded conceptions of racial differences which are both reinforced by and products of, both personal and institutional biases. Biomedicine Within biological taxonomy, where race is considered no more than an informal rank, races are “thought to be discrete, exclusive, permanent, and relatively homogenous”.Cho M. Racial and Ethnic Categories in Biomedical Research: There is No Baby in the Bathwater. The Journal of Law, Medicine & Ethics. 2006;34(3):497-499.Gravlee C. How race becomes biology: Embodiment of social inequality. American Journal of Physical Anthropology. 2009;139(1):47-57. While that may have been popular opinion when races were first classified, we have come to understand through anthropology that genes unique to racial ancestry are very rare.Hinds DA, Stuve LL, Nilsen GB, Halperin E, Eskin E, Ballinger DG, Frazer KA, Cox DR. Whole-genome patterns of common DNA variation in three human populations. Science. 2005 Feb 18;307(5712):1072-9. Articles using the term 'race' rarely offer a definition, and it is often used as a term for environmental, behavioural and genetic factors. This ambiguity favours the prevailing belief that “race” means “gene pools”, thus neglecting the sociological and anthropological factors that lie at the very foundation of race. Therefore the greatest issue with research lies not in the definition of race, but the lack thereof.thumb|Malaria prevalence around the world.One widely publicised study connected higher rates of preterm birth in black patients to genetics, but gave no genetic evidence to support this.Kistka Z, Palomar L, Lee K, Boslaugh S, Wangler M, Cole F et al. Racial disparity in the frequency of recurrence of preterm birth. American Journal of Obstetrics and Gynecology. 2007;196(2):131.e1-131.e6. Articles like these, in which racial inequalities are attributed to gene pools, through eliminating social factors alone, falsely pose as empirical truths and misinform practitioners. Using race as a blanket term for both environmental and genetic factors is also problematic. For example, where Sickle Cell Disease – which causes many complications in pregnancyManagement of Sickle Cell Disease in Pregnancy [Internet]. Rcog.org.uk. 2020 [cited 12 December 2020]. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_61.pdf – can be reliably traced back to malaria-prevalent countries, increased rates of high-blood pressureHigh blood pressure (hypertension) and pregnancy [Internet]. nhs.uk. 2020 [cited 12 December 2020]. Available from: https://www.nhs.uk/conditions/pregnancy-and-baby/hypertension-blood-pressure-pregnant/ and pre-eclampsiaFingar K, Mabry-Hernandez I, Ngo-Metzger Q, Wolff T, Steiner C, Elixhauser A. Delivery Hospitalizations Involving Preeclampsia and Eclampsia, 2005–2014 [Internet]. Ncbi.nlm.nih.gov. 2020 [cited 12 December 2020]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK442039/ are largely attributed to environmental factors. Both of these complications are classified by race in research, but relate to distinct ancestral (genetic) and environmental (sociological) aspects. Clarifying these differences is necessary if we are to minimise the ambiguity surrounding ‘race’, and its impact on health outcomes. Sociology Healthcare access has long been thought to be influenced solely by the socio-economical and/or geographical circumstances of the individual,Racial and Ethnic Disparities in Obstetrics and Gynecology [Internet]. Acog.org. 2020 [cited 4 December 2020]. Available from: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/12/racial-and-ethnic-disparities-in-obstetrics-and-gynecology especially in the US, where free healthcare is not assured by the state. However, regardless of personal background, black mothers still suffer under racial disparities in maternal care outcomes, including a 30% higher pregnancy related mortality rate.Roeder A. AMERICA IS FAILING ITS BLACK MOTHERS. HARVARD PUBLIC HEALTH [Internet]. 2019 [cited 12 December 2020];. Available from: https://www.hsph.harvard.edu/magazine/magazine_article/america-is-failing-its-black-mothers/ Whilst positivist truth can be obtained empirically,Feigl H. Positivism | Definition, Characteristics, History, & Facts [Internet]. Encyclopedia Britannica. 2018 [cited 12 December 2020]. Available from: https://www.britannica.com/topic/positivism sociology emphasises constructive truth.Leeds-Hurwitz W. Social Construction of Reality. Encyclopedia of Communication Theory [Internet]. 2009 [cited 12 December 2020];1:892-894. Available from: http://doi:10.4135/9781412959384.n344 These contrasting belief systems shed light on how healthcare is impacted by racial biases.Topping A. 'Something has to be done': tackling the UK's Black maternal health problem. The Guardian [Internet]. 2020 [cited 4 December 2020];. Available from: https://www.theguardian.com/lifeandstyle/2020/oct/02/something-has-to-be-done-tackling-the-uks-black-maternal-health-problem Stereotyping and racial biases influence practitioners' and advisors' recommendations, widening the gap of racial disparities. Women who experienced racial discrimination during previous treatments were almost three times more likely to avoid postpartum treatments – regardless of their socioeconomic backgroundAttanasio L, Kozhimannil K. Health Care Engagement and Follow-up After Perceived Discrimination in Maternity Care. Medical Care. 2017;55(9):830-833., potentially resulting in further complications. Practitioners' racial biases are perhaps grounded in education, as research has found medical students commonly believe black people are less susceptible to pain. The ‘strong black woman’ narrative observed in Euro-American societies delegitimises patient's claims, which can lead to worse actual and perceived health outcomes.Emma Kasprzak. Why are black mothers at more risk of dying? [Internet]. 2019. Available from: https://www.bbc.co.uk/news/uk-england-47115305 Raising racial awareness in medical education should help to eliminate biases before they become embedded into medical practice.Omeish Y, Kiernan S. Targeting bias to improve maternal care and outcomes for Black women in the USA. EClinicalMedicine. 2020;27:100568. There is a pressing need for new policies to improve regulations in women’s health services, thus a collaborative approach to public policy will be critical. Statistics and its Implications in Policy making Public policy making is significantly influenced by statistics, which supposedly represent reality.Rao CR. Statistics, Statisticians and Public Policy Making. Sankhyā: The Indian Journal of Statistics, Series B (1960–2002), 45(2), 151–159. Available from: http://www.jstor.org/stable/25052287 However, policies addressing disparities in women’s maternal care involve defining race, which is problematic due to limitations in producing unbiased statistical data.Black Women’s Maternal Health: [Internet]. Nationalpartnership.org. 2020 [cited 5 December 2020]. Available from: https://www.nationalpartnership.org/our-work/health/reports/black-womens-maternal-health.html Thus, statistics shape both policies which directly affect black maternal care, and the definition of race in medicine itself. In statistics, the race of an individual is classified either by self-identification or by others’ perception. Individual classification is more frequently used for its consistency, nevertheless, it is common for a person’s race to be defined by an outsider – whose judgement may be based upon phenotypic characteristics. These judgements are disputable as they imply that physical features correspond with genetic or biological variation, a relationship which, as mentioned previously, has never been scientifically demonstrated.Egede L. Race, ethnicity, culture, and disparities in health care. Journal of General Internal Medicine. 2006;21(6):667-669.Williams DR, Rucker TD. Understanding and addressing racial disparities in health care. Health care financing review, 21(4), 75–90. Further, in a world of growing racial diversity, maintaining race-based statistics is increasingly challenging and decreasingly appropriate. A potential solution is to substitute the notion of race and instead establish categories through cultural partitioning. Culture-related habits and environment have been shown to have a greater impact on health than genetics and race, therefore a collaborative approach between statisticians and cultural anthropologists would be uniquely beneficial in achieving a more accurate classification system.Ifekwunigwe J, Wagner J, Yu J, Harrell T, Bamshad M, Royal C. A Qualitative Analysis of How Anthropologists Interpret the Race Construct. American Anthropologist. 2017;119(3):422-434. Conclusion Ultimately, healthcare institutions may believe they are following positivist truths about race founded in biology in their practice, when in fact their medical interventions are informed by notions of race which are constructed by the society in which they live. The failure to consider the social and environmental factors involved in health outcomes for black patients further reinforces the assumption of a biological basis for race. It becomes obvious therefore, that only an interdisciplinary approach combining anthropology, biology and sociology among others, can reveal the truth about race and its implications in healthcare. A proposal to shift from a race-based to a race-conscious approach in medicine has been suggested to overcome structural racism which results in major health inequalities.Cerdeña J, Plaisime M, Tsai J. From race-based to race-conscious medicine: how anti-racist uprisings call us to act. The Lancet. 2020;396(10257):1125-1128. References