The indispensability of race in medicine

**Background:** A growing movement in the US calls for eliminating race from medicine, driven by concerns that race correction in algorithms (e.g., eGFR, spirometry) perpetuates flawed biological assumptions and harms patients. The authors agree that race correction and biological race concepts should be removed, but caution against blanket eliminativism. They argue that race, as a social construct, remains indispensable for explaining and addressing the health effects of racism.

**Methods:** This is a narrative review and philosophical analysis. The authors examine the movement against race-based medicine, critique its ambiguity regarding whether to eliminate all race references or only biological ones, and apply Bruce Link and Jo Phelan's fundamental cause theory to racism. They argue that racism satisfies all four features of a fundamental cause: (1) it influences multiple disease outcomes; (2) it affects outcomes through multiple risk factors; (3) it involves access to flexible resources; and (4) the association is reproduced over time via replacement of intervening mechanisms. The paper uses the example of preterm birth, which is 58.2% more likely in Non-Hispanic Black Women than Non-Hispanic White Women in the contemporary US, to illustrate why race cannot be eliminated from clinical medicine.

**Key Results:** The authors present several arguments against eliminativism: (1) Race is a non-referring concept (like 'witchcraft') that nonetheless has causal explanatory power because it appears in beliefs and drives actions producing biological effects. (2) Racism is a fundamental cause of health inequalities, meaning it cannot be reduced to more proximate risk factors like SES—controlling for SES does not eliminate racial health disparities. (3) Eliminating race from epidemiology would make it impossible to denounce health inequities caused by multilevel racism, as data would only show associations with proximate factors (e.g., air pollution) without revealing how racism increases exposure. (4) In clinical medicine, race grants access to the cumulative biological effects of racism that no set of biomarkers can currently capture. The authors note that preterm birth is a complex phenotype where racial differences are very likely to have racism among their fundamental causes, making it unacceptable for obstetricians to ignore race when estimating prematurity risk.

**Clinical Implications:** The authors advocate for a 'race-conscious' rather than 'race-free' medicine. They argue that race should be eliminated from medical genetics, where it is used as a proxy for genetic ancestry, but retained in epidemiology and clinical medicine to study and address racism's biological effects. They acknowledge social costs of continued race use (e.g., reinforcing biological race beliefs, patient resignation) but argue the total cost of elimination would be higher, as it would blind medicine to health inequalities produced by systemic racism. The paper concludes that critically employing race today is essential for achieving the goal of eventually being able to eliminate it in the future.