Inferiority and oppression

History provides many examples of the varied sources used to promote biological differences among races—based on anatomy, physiology and mental faculties—such as writings from antiquity, ‘natural scientists’ endless and largely fictional catalogues of racial traits’ and biblical scholarship all informing scientific and medical theories of Black health.10 Even historical ideals of beauty, as reflected in art and literature, were imbued with ‘medical’ significance; the social desirability and ‘purity’ of White skin on canvas and in print served as a proxy for the superior strength and vitality of the White race.25 Working in tandem, these scientific and cultural forces identified racial disparities in health within individuals rather than their social environments. Favouring ‘naturalistic’ explanations of non-white racial inferiority in matters of health, the consistent neglect of socioenvironmental influences was integral to promoting a ‘blame the victim approach… with no systematic, logical, or rigorous scientific methods to test [these] theories’ of innate inferiority.10

Dispelling the aura of objectivity surrounding scientific and medical thought is key to understanding the persistence of racial science. As Harriet Washington notes, ‘the science of race has always been an amalgam of logic and culture’, and race itself ‘is an important but nebulous and shifting facet of scientific medical thought’,10 such that the prevailing theories defining race in a given era—ranging from Greek thought on environment and temperament, to Linnaean concepts of taxonomy and differential evolution, to White supremacist ideologies of Black inferiority—give rise to medical practice and scholarship further reinforcing these beliefs. More to the point, medical research has been consistently deployed as a tool of oppression and a large body of scholarship in the history of medicine and social studies of science documents the many ways in which non-White bodies have been manipulated to legitimise, quantify and preserve the racial hierarchy.10 25–29

Most representative of this manipulation is the forcible and/or misleading recruitment of Black adults for scientific experimentation, often premised in a desire to prove the innateness of racial differences in health and disease rather than to objectively question these assumptions. Using crude intelligence tests and the faux-science of craniometry to demonstrate intellectual inferiority, coupled with assumptions about an innate ‘hardiness’ that enabled survival and work in harsh climates, early racial science rationalised slavery and manual labour as optimally suited for Black bodies.10 However, the notion that Blacks have any physiological ‘advantages’ was soon replaced by pity and inferiority, premised on medical experimentation identifying ‘black diseases’ and mental illness (having either entirely imaginary or entirely social aetiologies). Under this framework, slavery and the artificial concern for Black well-being provided a way for Whites to simultaneously ‘care for’ Blacks—in providing the barest of food, shelter and work—and also be ‘protected from’ Blacks—either through their enslavement or racial segregation.10

Though slavery provided a convenient rationale for legitimising Black inferiority, the focus of early 20th century racial science and medicine sought to frame Blacks as a uniquely diseased race, inferior to Whites and ‘too delicate to survive’.10 The medically manufactured idea of ‘bad blood’ was emblematic of this effort. Rather than a discrete disease or health condition, doctors framed the condition as an imprecise cluster of physical and mental ailments and symptoms somehow unique to Black adults, especially men. However, as extensively covered in the work of Allan Brandt and James Jones, the ‘bad blood’ of Black men was an easily diagnosable and curable form of syphilis, whose treatment was withheld in an effort to validate assumptions about that the same disease presenting differently among Blacks than Whites.26 27 Critically, the Tuskegee Syphilis Study, and the numerous other instances of callous and unethical experimentation with Black bodies,30 demonstrates how medical research helps to maintain a racial hierarchy; framing racial health disparities as originating within the body contributes to narratives of inferiority on the basis of innate differences. In turn, this medically validated physical and mental inferiority was used to justify the subjugation of dark-skinned individuals, across numerous historical and geographic contexts.28 Evident from this historical and anthropological work is the degree to which scientific medical research is quickly marshalled to change the meaning and origins of poor health among Blacks in support of changing social rationales and contexts for White supremacy.

Inclusion and (financial) opportunity

Only recently in the scope of the medical and racial history of the USA has the explicitly racist framework for biomedicine been replaced by a new framework of ‘inclusion’ and equality. Driven by recognition of past racial injustice in science, the advancement of civil rights and the persistence of racial disparities in health, this crucial shift in intentionality among researchers represents an example of social and cultural forces seeking to positively shape scientific knowledge.11 Combatting past discrimination, many leading government and regulatory agencies overseeing biomedical research (eg, National Institutes of Health (NIH), Federal Drug Administration (FDA)) have instituted diversity recommendations and/or mandates for funded projects. As discussed by Steven Epstein and others, the NIH Revitalization Act represents the pinnacle of this movement with its explicit requirement for the inclusion and representation of multiple racial and ethnic groups in research, whereon the onus on researchers is to justify why their studies would not require a racially diverse sample, at the risk of losing funding or receiving a poor evaluation.11 30–32

The drive for inclusion has gained momentum given the attention and excitement surrounding individualised medicine and treatment as the future of healthcare and delivery and a pathway to address racial disparities in health. Often called personalised or genomic medicine, it constitutes a ‘rapidly advancing field… informed by each person’s unique clinical, genetic, genomic, and environmental information’,33 made possible the by the falling cost and increasing availability of genetic testing.34 Many scholars have argued on behalf of ‘accelerating’ the translation of human genome research into tangible, medical treatment that can benefit patients in numerous ways.35–39 The most promising manifestation of personal medicine is the emergence of pharmacogenics, studying heterogeneity in individuals’ responses to medicine in an effort to design ‘magic bullet’ drugs uniquely tailored patients’ needs.40 Assuming that better knowledge of the human genome will lead to better and more precise medicine that targets the biogenetic roots of disease,41 biomedical research has sought to target individuals—or groups of individuals, on the basis of some shared genetic, racial ancestry—with customised drugs and treatment protocols. Towards this end, having more racially diverse and inclusive research samples engenders a greater diversity of biomedical solutions.

The intention behind inclusion mandates, and the personalised medical research they are intended to support, is noble; given the well-documented racial variation in the efficacy of medical treatment, greater diversity can begin addressing racial disparities during the research and development process. Yet many scholars argue that the growth of biogenetic research coupled with social, economic, regulatory and legislative pressures has given rise to a form of colour-blind racial science; the phenotypic differentiation of race (ie, skin colour) has been replaced by genotypic variation in biomedical research.29 Inclusionary policies presume a priori that racial differences exist and thus encourages the search for these disparities with no clear theory or expectation of the importance of race or underlying causal mechanisms.11 Consequently, any observed racial differences are interpreted as genetic rather than socioenvironmental, further essentialising race as a biological, rather than socially constructed, category.42–44

The role of market-driven forces perpetuating ‘colour-blind’ biomedical research cannot be overlooked either. Pharmaceutical and clinical research are profit-driven, multibillion dollar industries, whose substantial investments in creating medical treatments come with an expectation of even greater returns. As seen with pharmacogenomics and the surge of ‘racially tailored’ drugs, this return-on-investment model favours the identification of group differences in medical efficacy, as the ‘niche marketisation’ of products aimed at specific racial groups effectively multiplies the number and diversity of drugs that can be sold.11 45 Though the burgeoning field of ‘personalised’ medicine implies a focus on individuals, terms like ‘uniquely tailored’ and ‘whole-genome approach’ overstate the current ability of biomedicine to craft solutions catered to the needs of a single person.46 Instead, the resulting compromise is a new middle-ground—or ‘middle-level’11—where groups of similar individuals are the target of biomedical research, rather than the individuals themselves.

For instance, as Jonathan Khan demonstrates in his analysis of BiDil’s marketing and development as a drug for congestive heart failure in African-Americans, genomic and biomedical data can be manipulated to produce racial differences in the effectiveness of medical treatment, thus improving marketability and profitability.12 Specifically, a confluence of media, legal and political forces, and the growth of social and scientific faith in genomic research, allowed racial disparities in heart failure mortality to become reified as evidence of genetic differences in racial responses to medical treatment, paving the way for BiDil as a ‘black drug’. Nearly 30 different medications have been designed to target racial variation in efficacy, though systematic reviews did not find evidence to substantiate a majority of the biogenetic causal mechanisms underlying these claims.ⁱ ,47 Lee refers to this misappropriation of race in pharmacogenomics as a product of the ‘infrastructure of racialisation’, where pre-existing conceptions of racial variation in the human genome, epidemiologic and clinical data of racial health disparities and market forces encouraging group-specific specialisation, collectively promote race-based medicine as successful in targeting true biogenetic, racial differences within the population.22

Despite this critical portrayal of inclusionary politics in biomedical research, the push for diversity should not be misconstrued as a wayward pursuit of political correctness by biomedical researchers or an overcorrection for the past mistakes of racial science. Rather ‘inclusion’ is the product of an uncritical perspective on race and the significant role of science as a social institution creating knowledge further essentialising race; as more diseases and conditions are linked to race, and as more race-specific medicines cater to these diseases and conditions, race assumes greater medical significance and is further crystallised as a biological construct. Some have argued that beyond ‘racialising’ disease, biomedical research has been used to ‘create’ racialised diseases themselves, such as the promotion of ‘metabolic syndrome’ as a cluster of health conditions especially prevalent among Black adults.29 Clearly then, biomedical researchers’ own understandings of race have far-ranging social implications as well. While the above-described inter-relationship between sociopolitical factors and scientific practice helps establish a broader framework for the essentialisation of race throughout history, in the following section I narrow my focus to consider how race is understood and used within the biomedical community.

The present state of race

The majority of current academic and clinical work in biomedicine implicitly essentialises race by treating it as a proxy for a myriad of potential genetic and/or biological traits underlying health and disease.ⁱⁱ ,32 42 44 61 This default assumption is sufficiently prevalent that a lack of significant racial differences is often reframed as an issue of statistical power; researchers argue that differences are small rather than non-existent.31 42 Many in the health, medical and social science communities have challenged this commonplace understanding of race as undertheorised and misleading in its continued reification of race as a biological entity.42 62–64 In a review and critique of race variables in genetic studies, Shields et al note a lack of ‘constructive interdisciplinary dialogue’ in the design and implementation of race measures, and numerous logical fallacies committed by geneticists who ignore a ‘long social history of destructive uses of racial categories in science and medicine’, by arguing that there is no ‘value system’ inherent to findings associated with race.65 While conceding that geneticists have largely abandoned the search for racial typologies in the human genome, Foster and Sharp note a continued reliance on associating ‘biological findings with the social identities of research participants’, thus using genetic features to ‘reconstruct’ population histories and ‘redefine’ commonalities as genetically immutable.66

Ultimately, critics of this uncritical use of race and/or ethnicity in biomedicine push for a ‘new vocabulary’ facilitating the unbiased inclusion and testing of bioancestral variation.67 68 Though the hope is these ‘improved’ measures and definitions of race would help to avoid the danger of biogenetic data being used to reaffirm ‘old prejudices’ of perceived differences and similarities among individuals,69 70 there is concern that current approaches for redefining race as a continuous rather than discrete measure (eg, ‘clinal classes’71) are prone to the same biases of insinuating a biological basis for race.72 73

The ‘stickiness’ of essentialism

Importantly, these dynamic yet consistently essentialist views of race—and the biomedical researchers who rely on them—do not exist in a sociohistorical vacuum. Scientific knowledge is imbued with significant cultural authority and power in society, informing social understandings, beliefs and norms regarding race. Research with simple vignettes about race as either a biological or social construct consistently demonstrates that lay individuals internalise and rely on scientific and biomedical knowledge in informing personal views on the origin of race and its implications for health.74–76 Analyses of news reports in recent years, with a focus on the presentation and language used to describe scientific research on race and health, uncover an upward trend in the discussion of race-specific diseases and framing of race as a risk factor for disease, supporting Troy Duster’s prescient warning that the modern biogenetics movement may provide a ‘backdoor to eugenics’ in its reification of race as biological and consequential to health.74

The process of normalising race as an essentialist construct is not exclusive to the formation of lay knowledge about race, genetics and health; researchers are not immune to similar messages and cues about race in their environment and training. Despite increased recognition of race as socially constructed, and social scientists’ assumptions about the positive uptake of this belief in the natural sciences, research suggests that this constructionist viewpoint is not highly prevalent.77 Indeed, there is ample sociological and anthropological evidence to suggest that narratives and framing surrounding race as a biological concept are created and reinforced at multiple points in the acquisition and formalisation of biomedical knowledge.

Empirical work in recent years—most notably studies conducted among biomedical researchers and students15 78 and through analysis of their materials79 80—reveals a latent ‘stickiness’ or tendency towards essentialism in the institutions and knowledge resources that researchers use to gain expertise. Throughout interviews conducted with students, faculty and researchers at leading universities, Ann Morning notes the many obstacles impeding the penetrance of non-biological understandings or race in biological research. Given the hierarchical power dynamics in academia—such as between instructors and students or principal investigators and research assistants—traditional and essentialist definitions of race held by more senior scholars remain dominant and thus become adopted by more junior researchers.15 Even if biologists are exposed to anthropological, socially based definitions of race, the inability to see these definitions applied in a biomedical research or classroom environment contributes to a reversion to existing, biologically based thinking.15 For instance, journals and other outlets for scientific knowledge continue to prioritise genetic interpretations of race in publications and avoid challenging researchers to be more critical in their use of race.81 82 Studies have also shown how the mandated inclusion or careful attention paid to race in scientists’ proposals is often absent in subsequent publications and reports.31 Most troublingly, while content analysis of textbooks and other ‘repositories of knowledge’ used by biologists, clinicians and biomedical researchers notes change in the definition of race over time,79 80 ‘the fundamental message about the nature of race has changed little’ and, if anything, ‘the overall impact of genetics has been to bolster, rather than challenge’ an essentialist view.79

An important takeaway from this work is that reminding the biomedical community to entertain the idea of race as a ‘social construct’ proves insufficient. A lack of knowledge or awareness about non-essentialist views of race is not at issue; scientists acknowledge the existence of socially constructed definitions of race and some actively engage in ‘antiessentialism’, though without entirely conceding that race has no biological basis.77 The more salient obstacle to adopting constructionist views of race is a set of beliefs suggesting that: social explanations for race are incompatible with the methods and knowledge in biomedical research; explaining racial variation through social mechanisms is beyond the purview of biomedicine and genetics and that the social and biological sciences simply rely on different definitions of race that are most conducive to their research.32 83

Chronicling the difficulties in teaching race to medical students, Warwick Anderson captures all three processes at work in students’ resistance to a constructivist interpretation of race on the basis of concerns over ‘credibility’ and beliefs about who among social and biological scientists is best-equipped to define race.78 In interactions with students and instructors representing both the anthropological and biogenetic perspectives on race and health, most apparent are firm disciplinary guidelines favouring specific definitions of race enforced by explicit curricula and implicit norms. Medical students and geneticists—lacking formal instruction or significant exposure to social sciences—feel they are not in a position to evaluate the validity of race as a social construct, let alone apply it in their work. They are equally prone to question social scientists’ authority in arguing against the biological basis of race, given their lack of biogenetic training. In turn, social scientists’ arguments about the problematic nature of essentialist views on race fail to resonate, as they are incompatible with medical students’ and geneticists’ views that this essentialism instead helps dispel racism by valuing individualism and that understanding racial genetic variation is the key to addressing health disparities.78

Loops becoming loupes

Among the many theories and frameworks describing how scientific knowledge becomes social, Ian Hacking’s concept of ‘looping effects’ in the natural and clinical sciences proves to be a powerful tool for understanding the critical role of biomedical researchers in subverting essentialist views of race. Hacking’s analysis of sociohistorical trends in the changing classifications of individuals (or a ‘kind of person that is a moving target’23), often on the basis of their physical and mental health (eg, multiple personality disorder, autism, obesity), reveals a sustained and recurring pattern where: (1) a new scientific classification is established; (2) people meet the criteria for said classification; (3) institutions formalise the classification; (4) knowledge is established in the form of ‘presumptions that are taught, disseminated, refined and applied within the context of institutions’ and (5) finally, experts create and legitimise this knowledge through their work.23 Rather than purely a sequential process, the ‘looping’ aspect of this framework describes the reciprocal process by which experts’ work is channelled back towards solidifying and reifying these classifications.

While Hacking is cautious about applying this framework to race (or gender or other socially and historically embedded categories), he acknowledges its utility in ongoing debates surrounding the ‘scientific’ basis for race in contemporary research.87 For the purposes of this argument, the applicability of the looping framework to the use of race in biomedical research—rather, the theory underlying its use—is worth illustrating. As seen with the concentric circles in figure 1, biomedical research interfaces with the looping process at every stage: (1) classifying the origins of race as a risk factor for health and disease; (2) identifying the race(s), and thus individuals, having the greatest risk on the basis of these origins; (3) institutionalising concepts of race, health and underlying mechanisms; (4) producing biomedical knowledge or basic ‘facts’ about race and health and, finally, (5) providing the experts and arbiters of knowledge that create and interpret the role of race in their research settings. Critically, the looping framework situates biomedical researchers at the fulcrum of this process, as both shaping and shaped by prevailing social and scientific ideas concerning the aetiology of race.

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Figure 1

The looping and ‘louping’ of race in biomedical research.

Following the ‘top-down’ version of this framework, as indicated by the left-hand arrow, societal-level norms and assumptions about the relationship between race and health as defined by ‘intrinsic’ (ie, genetic and biological) mechanisms are observed at multiple levels. Consistent with the prior discussion of sociohistorical processes helping to preserve an essentialist view of race, the presupposition of race as a biogenetic concept propagates the identification of ‘Black diseases’ and other genetically linked health conditions among Black individuals, which then reinforces the definition and use of race as a surrogate for genetic heterogeneity (such as within the NIH). This widespread use of race as a genetic proxy sustains the belief (and knowledge) that observed racial variation in health or response to medicine is attributable to biological differences. Thus, if and when biomedical researchers uncover racial variation in medical efficacy, their default interpretation of the results both confirms and reaffirms an essentialist view on race. In this manner, the looping framework provides a clear narrative of how biological and sociocultural notions (and definitions) of race inform one another and, critically, contribute to an overall reification of race as a category. Through this looping process—backwards and forwards, and over time—races indeed become ‘natural kinds’ or biosocial identities on the basis of shared and innate predispositions to disease or poor health.

However, I contend that this looping schema can instead be deployed to situate biomedical researchers as ‘agents of change’, positioned to promote a more socially conscientious view of race in health and medicine. As demonstrated by the right-hand arrow in figure 1, the looping creation of scientific knowledge has the capacity to become a ‘magnifying loupe’ through which the individual-level decisions of biomedical researchers expand outward in the knowledge creation process to challenge social-level essentialist thinking on race. The same discovery of ‘unexplained’ racial variation in the efficacy of a biomedical intervention can be framed as a function of social mechanisms, to the extent that the standard categories of race used by biomedical researchers reflect different social realities among study participants. Moving upward through the framework, such an explanation calls for a socially constructed basis for the definition and use of race in research, and instead identifies risk as originating in the disproportionate levels of discrimination, poverty and stress experienced by Blacks. Recognition of these social determinants of health, and their influence on biomedical research, can reorient scientists’ views on race and medicine as driven by ‘extrinsic’ mechanisms, which are primarily social, cultural and environmental. Reversing this ‘louping’ framework, the adoption of macrolevel constructionist views on race can inform the microlevel decisions of future biomedical researchers in their interpretation of race-based findings.

Importantly, this framework emphasises that epistemological change does not occur all at once; a single researcher’s or lab’s decision to focus on social factors contributing to racial variation in drug efficacy is unlikely to have a meaningful impact at a given point in time. Nor would the decision of a single journal or funding agency to have researchers more adequately control for socioenvironmental factors reverse decades of education, training and scholarship reinforcing an essentialist view. Instead, the twin processes of looping and ‘louping’ allow for gradual and sustained challenges to essentialism—such as biomedical researchers increasingly citing evidence from the social sciences and medical humanities in their work—to continually re-enter the knowledge production chain and become magnified and amplified over time, with the goal of gaining sufficient momentum to legitimise of a constructivist position on race in science. The importance of momentum is entirely consistent with grand theories of epistemological change often used to describe scientific research; new and improved evidence increasingly challenges existing theories until enough evidence accrues to substantiate a paradigmatic, discipline-wide shift in theory.88 89 Likewise, given the embeddedness of essentialism in contemporary biomedical science, we should expect that a broader recognition of socially driven racial differences in medicine will be slow and cumulative rather than acute and revolutionary.

Well-intentioned medicine

In recognising the importance and confounding influence of social determinants in their work, biomedical researchers must remain vigilant to avoid the creation and perpetuation of knowledge that undermines a socially based approach to addressing racial health disparities. The associations among race, disease and medical efficacy are important to identify and have clear social and scientific utility; but clarity and transparency with respect to the specification of mechanisms at work is critical as well. In many cases, race takes on the value and meaning of leftover variation ‘unaccounted for’ or ‘unexplained’ by the existing set of variables in analyses; that is, the hypothesised biogenetic mechanisms sought by science.32 Yet biomedical research is governed by a paradigm of knowledge that seeks to eliminate uncertainty and provide concrete answers or scientific ‘truths’.85 Thus race becomes a way to avoid conceding a lack of a definitive understanding of the role of genetics and biology in explaining racial variation in health and medical research.

Kahn,12 Epstein11 and Braun44 all raise the issue of how this ‘in the meantime’ use of race contributes to the ongoing reification and essentialisation of race. In suggesting that future scientific advances will validate the biogenetic origins of race, the ‘temporary’ geneticisation or biologisation of race nonetheless provides an objective, scientific basis that informs and biases current and future research.11 44 Thus, beyond redefining race as a socially constructed variable, biomedicine must also put this knowledge into practice by acknowledging that observed racial variation is equally liable to capture the social consequences of individuals’ race and how they influence medical efficacy. Even when biomedical researchers avoid making explicit proclamations about the biogenetic origins of race or racial variation in outcomes,42 61 a failure to offer an alternative explanation for observed differences allows for the idea that race might be grounded in some objective, biological reality to fill this vacuum of meaning.

However, researchers’ intentions to explain away racial differences represents more than compliance with the biomedical paradigm’s aversion to uncertainty. In contrast to the past history of racial medical science, I believe it is necessary to emphasise that the contemporary racialised framing of biomedical research is fundamentally motivated by the researchers’ desires to eliminate racial health disparities. In this era of ‘well-intentioned medicine’, the most sophisticated, promising and cutting-edge biomedical research is deployed in an effort to establish racial health equality, rather than to legitimise racial inferiority. At the structural level, these positive intentions are reflected in the aforementioned creation and enforcement of the NIH’s inclusion mandate and similar policies established by other federal agencies.10 11 While the push for inclusion has had the unintended consequence of creating and justifying racial disparities in medicine on the basis of biological difference,11 the underlying premise continues to be one of social and racial justice in medicine and treatment. Similarly, the continued definition and treatment of race as a biogenetic concept is motivated by a belief in the importance of recognising and treating individual differences in health, countering the extant and historical White-centric bias of medicine and genetics.78

The individual-level intentions of biomedical researchers seeking racial equality in medicine are equally important to examine, especially given their pivotal role in the validation and reformation of scientific and social thought on the nature of race. As evidenced in Dana Fullwiley’s ethnographic work, there are numerous subjective influences on researchers’ interpretations of the value attached to race in their analytic models and how they establish the clinical meaningfulness of their results. In fact, many researchers—often having a non-White background—openly acknowledge that their scientific agenda for studying racial disparities in biomedical research serves as a means to advance a personal agenda of reducing racial health disparities at the societal level. Based on interviews and observations collected among researchers in medical genetics laboratories, Fullwiley chronicles the deep, ethical sense of ‘duty’ experienced by non-White scientists studying the poorer health and severity and impact of diseases on ‘their communities’.13 By counteracting the white supremacist and racist framing in past studies of race, medicine and health, researchers view their work as a form of affirmative action; their goal is to ‘rely on good science and hard data to include minorities in medicine, not to advance an unjust agenda’ and identify the appropriate biomedical solutions.13 Likewise, this justice-oriented agenda becomes a way to assert that sociocultural factors—such as diet or unhealthy behaviours, ostensibly specific to a given race/ethnic group—are not to blame either, as a genetic basis for poor health or response to medicine is free of moral judgement.

Even when biomedical researchers acknowledge that a biological understanding or race may be inaccurate, the desire to stimulate positive change is sufficient to rationalise the use of race in biomedical research as vital to the broader goal of addressing racial disparities. One researcher invokes what is best described as an intuitive sense of race as biological (based on his research and interaction with patients) in explaining the ‘responsibility’ of researchers—‘as physician-scientists [and] as members of the population’—to continue the study of minority populations and the genetic origins of disparities.13 Yet, absent a full understanding of biological mechanisms, these physician-scientists maintain that wholly ignoring race would be ‘premature’ and ‘negligent’,13 as the knowledge gained from biomedical research is useful for understanding differences in population health. However, the usefulness of race does not justify its meaningfulness and the implications this meaning has for scientific and social knowledge.

A surrogate for future research

As Hacking contends, the usefulness of clinical knowledge rests on the ability for this knowledge to be put into practice; for example, racially tailored medications, such as BiDil, are only useful insofar as they help treat a specific disease within a specific race.87 Although the effectiveness of BiDil, and similar drugs, among Black adults continues to be misconstrued as evidence in favour a biogenetic essentialist view on race, the usefulness of pharmacogenomics reveals nothing about the meaning of race in biomedical research and the causal pathways through which it contributes to racial variation in outcomes. Meaningfulness is similarly imposed on race through the aforementioned process of treating it as a surrogate or proxy variable for yet-to-be determined biological mechanisms. As another example of researchers’ fundamentally ‘good’ and optimistic intentions for their research—anticipating future innovations that help explain and reduce racial differences—recent studies of the ‘framing’ of race in research describe this anticipatory quality to its use as a surrogate.32 63 Researchers’ arguments for the utility of race often hinge on the premise of ‘imminent medical progress’; they concede that race categories a crude marker of biological difference while also being ‘useful in the meantime, until the actual genetic variation itself is identified’… at which point ‘[d]iagnosis and treatment will then the appropriately tailored to the fit genetic variations on an individual basis’.32 Thus, at the very least race allows researchers to demarcate ‘potentially meaningful’ findings.32

This forward-looking approach to using and defining race provides a convenient way to simultaneously establish its usefulness and meaningfulness. Usefulness is readily demonstrated through the documentation of racial differences in biomedical research and the subsequent use of racially specific treatments as a solution. Meaningfulness, however, takes on a prospective quality, as race in the present takes on the hypothetical biogenetic origins that scientists expect to uncover in a not-too-distant future. Both qualities of race are valuable to ‘well-intentioned’ researchers, as they seek to locate solutions to racial disparities in health and medicine within the bounds of biomedicine. Thus, while problematic, an essentialist view of race simplifies the problem of addressing poor health among racial minorities by offering a clear point of individualised biomedicalised intervention, in contrast to the more complex task of changing the socioenvironmental determinants of racial health inequality.

Most importantly, the specific meaning to race and racial disparities established by biomedical research has further-reaching consequences than the particular medical/health phenomenon, condition or disease of interest in a given study. Scholars are increasingly vocal in their concern that searching for the biogenetic origins of medical conditions undermines the well-established understanding of health as a social phenomenon.46 90–92 Accepting race as a surrogate for fundamental biogenetic differences across groups diminishes the importance of social determinants of health extensively documented in the social sciences. This may give rise to arguments suggesting that the fundamental causes of health (eg, racism and socioeconomic status93 94) only appear to be ‘fundamental’ because we lack knowledge of more upstream, biogenetic causes of health disparities. Consequently, rather than focusing efforts on structural reforms that address these social processes—for example, systemic racism in the form of workplace discrimination, mass incarceration, residential segregation, barriers to education, healthcare inequality95–98—the emphasis shifts to biomedical solutions and innovations. While social determinants are not entirely ignored or rendered trivial, the unspoken implication is that that addressing health disparities at the biogenetic level provides a more comprehensive solution. However, Epstein,11 Lee22 and Braun21 are quick to note that we have as much to learn about social determinants of health as emergent biogenetic causes; moreover, overemphasising the latter explanations may come at the expense of better addressing the former.

While biomedicine is cognizant of issues surrounding the meaning race as a variable,62–70 much of the work rests on the assertion that meaning will emerge given sufficient time for research to uncover the biogenetic mechanisms underlying race.11 12 44 The argument for race as a surrogate is we don’t know what we don’t know when it comes biogenetics, race and medicine; thus there is no harm in having race temporarily bear the burden of this ‘unknown’ unknown. However, if biomedical research is entirely predicated on the assumption that racial disparities in health and medicine will be resolved through future knowledge of biogenetic pathways, then that is the direction where researchers will steer their work in the hopes of finding confirmatory results. Therein lies the danger of the essentialist view of race in biomedical research; rather than deductive, the research process becomes deterministic in promoting a social and scientific narrative that reifies racial disparities as a consequence of genetic deficiencies.