Should 21st century health care still consider race-based clinical decision-making?

Tito Izard, MD

📌“Health disparities are not just about color. They are about where people live, the generations they come from, the resources they can access, and the lineage they inherit.”

Interestingly, the health care community is divided regarding whether race is an important variable to consider in assessing a patient’s health status or treatment plan. The more we investigate, the more we recognize the complexity: what once seemed a simple (and simplistic) pre-Civil Rights era question now challenges our presuppositions.

💡 Case in Point: Kidney Function Testing

Until 2021, kidney function labs used different “normal” ranges for Black patients, based on the assumption of higher muscle mass. In 2021, the National Kidney Foundation eliminated this race-based adjustment showing how flawed assumptions about race can mask the real causes of disparities. This example illustrates how medical use of race, rather than clarifying the causes of renal failure, can obscure the true social, environmental, and lineage-based factors driving unequal health outcomes.

The Challenge of Defining “Race”

Part of the difficulty lies in defining the topic itself. We can usually identify the extreme acts of “racism,” but the concept of race is harder to pin down. In 2020, the U.S. Census defined Black or African American as “all individuals who identify with one or more nationalities or ethnic groups originating in any of the black racial groups of Africa.” But this definition creates problems. It does not account for the diversity within the diaspora of Black people nor the expanding mixture of racial identities in America. How, then, can we meaningfully examine the statistical impact of health disparities apart from poverty alone? Health is influenced by the quality of our lived experiences. What happens to the critical examination for Americans whose lineage ties directly to slavery if we lack a national initiative to distinguish this unique citizenship experience? Even though it is well established that “race” is a social construct, its imprecise label has historically served as the only unifying identity for 38 million Americans bound together by shared struggle, exclusion, and lived experience. Classifying ADOS (American Descendants of Slavery) as “Black” or “African American” interchangeably leads to the same confusion as if we classified all Asians by ethnicity, regardless of their distinctive ethnocultural experiences as Indian, Japanese, or Hmong. (Hmong and southeast Asians are associated with greater health disparities) Such oversimplifications erase nuance and blur the lived reality of communities whose experiences with systemic barriers differ dramatically.

Reframing the Lens: From Color to R.A.C.E.

When we talk about health disparities in America, the conversation too often begins and ends with race as color. But “race” in that sense is a blunt instrument — a social construct that obscures the real forces shaping health outcomes. If we want to meaningfully address disparities, we need to shift the focus from color to R.A.C.E.: Residence, Age, Class, and Ethnocultural lineage.

Residence

Where a person lives, their neighborhood, zip code, and the ecosystem around them is one of the strongest predictors of health. Environmental exposures, food access, educational opportunities, transportation systems, housing stability, and local economies all shape health long before a medical diagnosis is ever made. For most non-vulnerable or non-disenfranchised ethnic minority groups, two families of the same ethnic background living in different neighborhoods can experience entirely different health realities because of the differences in their residences. But for historically disenfranchised groups, where you live might improve your health but it doesn’t statistically eliminate most of your health disparity outcomes.

Age

Generational context matters. The prevalence of poor health outcomes frequently increases with advanced age. Just as importantly, different age groups carry different lived experiences, and those experiences influence how people see the world and interpret health, risk, and opportunity. For example, an older adult who grew up before the Civil Rights Movement will interpret systemic barriers differently than a younger adult who came of age in the digital era. Age is not only a biological factor, it is also a cultural one, shaping perspective and expectations across the life course.

Class

Socio-economic status or wealth accessibility is a powerful determinant of health. Income, inherited wealth transfers, occupation, and access to resources determine whether a person can consistently meet their basic needs such as food, housing, healthcare, education, and environmental security. Class influences exposure to chronic stressors, vulnerability to illness, and access to protective factors that prevent disease. Health disparities often map onto class lines, reinforcing inequities across generations.

Ethnocultural Lineage

This final dimension is often overlooked when race is reduced to color. Ethnocultural lineage recognizes that within broad racial groups, people carry distinct historical legacies and cultural experiences. So how do we define ethnocultural lineage? It describes a group’s shared common lived experience. It is often expressed as the beliefs, behaviors, norms, and characteristics received from ancestors and passed down through generations.

📌"Ethnocultural lineage is your family’s resiliency story."

This story can manifest in many ways: through genetic expression, emotional trauma, societal position, economic exclusion, or spiritual connectivity. Lineage is shaped by our ecosystems- how we interact, behave, interpret, and respond within changing environments. Ethnocultural lineage is also experiential. It is influenced by one’s beliefs, perceptions, social roles, and lived opportunities. It distinguishes between mirrored lived experiences (projected onto one’s progeny through enduring systems like slavery or segregation) versus mimicked lived experiences (adopted temporarily by similar-appearing immigrants and their heirs as they adjust to a new society). The bottom line is this: ethnocultural lineage is not just ancestry. It is the resilience embedded in how families survive and adapt across generations. For example, Black Americans descended from slavery (ADOS — American Descendants of Slavery) have a different ethnocultural lineage than Black immigrants who arrived more recently from the continent of Africa or the Caribbean. Both may identify as “Black” in the U.S., but their lived experiences, historical burdens, and pathways of assimilation differ significantly. By acknowledging ethnocultural lineage, we avoid flattening unique histories into a single racial label.

Moving Beyond Color

By reframing disparities through R.A.C.E., we move from a superficial view of inequality toward a deeper, more nuanced understanding of how health inequities emerge and persist. Health outcomes are not simply about color; they are about the interaction of environment, generational experiences, socio-economic position, and ethnocultural history. This shift matters for academic, healthcare, and public health professionals. Policies, research, and interventions built on blunt racial categories miss the subtleties of why disparities persist in some groups but not others. They also risk perpetuating stereotypes instead of dismantling them.

✅“When we look at health through the lens of R.A.C.E., we move from stereotypes to solutions.”

When we see health disparities as the product of lineage, environment, and lived experience, not merely surface-level classifications, we open the door to more precise interventions, greater equity, and stronger, healthier communities.

✅ In short: It’s about R.A.C.E., not color.

* This manuscript was edited with the assistance of ChatGPT, an AI language model developed by OpenAI. The author takes full responsibility for the content.