Race-based medicine is a system that treats race as a biological variable in clinical decision-making. In practice, this has meant plugging a patient’s race into diagnostic formulas, adjusting test results based on racial categories, or using race to determine treatment eligibility. The core problem: race is a social construct, not a biological one, and using it as a stand-in for genetics or biology has led to misdiagnoses, delayed treatments, and widened health disparities for millions of patients.
How Race Became a Medical Variable
Racial categories in the United States have roots that go back centuries. The first U.S. Census in 1790 classified the population as free white males, free white females, other persons, and slaves. By 1890, census categories had expanded to include white, black, mulatto, quadroon, octoroon, Chinese, Japanese, and Indian. These were political and social categories, not scientific ones.
The framework for sorting people into racial groups in medicine traces partly to Johann Friedrich Blumenbach, a German anthropologist who in 1795 defined five categories of humankind: Caucasian, Mongolian, Ethiopian, American, and Malayan. He coined the term “Caucasian” to describe white Europeans. These categories filtered into medical research over the following centuries. PubMed, the largest database of biomedical literature, cataloged racial categories as “Caucasoid, Mongoloid, Negroid, and Australoid” until 2003.
By the late 20th century, race-based adjustments were widely embedded in clinical algorithms, influencing decisions ranging from kidney transplant eligibility to birth plans and cardiovascular treatments. The assumption behind many of these adjustments was that observed differences in health outcomes between racial groups reflected innate biological differences, rather than the effects of poverty, environmental exposures, unequal access to care, and the cumulative toll of racism itself.
Where Race-Based Formulas Were Used
Three areas of medicine illustrate how race was built into everyday clinical tools.
Kidney Function Testing
The estimated glomerular filtration rate (eGFR) is how doctors assess kidney health. For years, the standard formula included a race-based adjustment that increased the calculated kidney function for Black patients by roughly 16%. The rationale was a debunked assumption that Black individuals naturally have higher levels of a waste product called creatinine because of greater muscle mass, regardless of physical activity. In practice, this meant Black patients could have significantly impaired kidneys and still appear “healthy” on paper. The inflated numbers delayed diagnoses of kidney disease and pushed patients further back in line for transplants.
Lung Function Testing
Spirometry, the most common type of pulmonary function test, was long interpreted using race-specific reference equations. These equations assumed that Black and Southeast Asian patients naturally had lower lung capacity than white patients. A clinician using these race-adjusted references might look at a Black patient’s reduced lung function and see it as “normal for their race” rather than a sign of respiratory disease. This directly affected whether additional testing was ordered, whether a diagnosis was made, and whether the patient was referred for treatments like lung transplantation.
Cesarean Birth Calculators
A widely used tool for predicting whether a patient could safely attempt vaginal birth after a previous cesarean section included race and ethnicity as variables. The 2007 version of this calculator systematically underestimated success rates for Black and Hispanic patients, making it less likely their doctors would offer them the option to try labor. International versions of the calculator that excluded race and ethnicity actually performed better, revealing that race added no meaningful predictive value.
BiDil and the First Race-Labeled Drug
In 2005, the FDA approved a heart failure medication as the first drug with a race-specific indication. It was labeled for “self-identified black patients” as an add-on to standard heart failure therapy, intended to improve survival and reduce hospitalizations. The approval was based on a clinical trial that enrolled only Black participants, which meant there was no comparison group to determine whether the drug worked differently across racial lines. Critics argued that the racial label was a commercial strategy after a previous trial in a general population failed to show a clear benefit, and that the drug likely worked through biological mechanisms unrelated to race. The case became a flashpoint in debates about whether race-based prescribing advances equity or reinforces the false idea that races are biologically distinct categories.
Real Consequences for Patients
These weren’t abstract academic debates. Race-based algorithms changed who got care, how quickly, and what kind.
The kidney function formula’s race adjustment delayed transplant eligibility for Black patients. Because the formula made their kidneys look healthier than they were, patients crossed the threshold for “severe kidney disease” later in the progression of their illness, losing time on transplant waiting lists. In lung transplantation, a retrospective study of all U.S. patients listed between 2009 and 2015 found that switching to race-neutral equations would reduce wait times for Asian and Black candidates by an average of 4.3 days while increasing wait times for Hispanic and white candidates by just 1.1 days.
In obstetrics, the updated 2021 birth calculator that removed race as a variable more accurately predicted vaginal birth success across racial groups. The older version had been steering Black and Hispanic patients away from attempting labor after a cesarean, contributing to higher rates of repeat surgical deliveries and the complications that come with them.
Not every correction is straightforward, though. In cardiology, a newer race-neutral heart risk calculator cut high-risk estimates for Black adults roughly in half compared to the previous race-adjusted version (from 10.9% to 5.1%). While the old formula may have inflated risk in ways that weren’t scientifically justified, the practical result of removing race was that fewer Black patients qualified for preventive medications like cholesterol-lowering drugs. This highlights a core tension: removing race from a formula doesn’t automatically produce more equitable outcomes if the underlying disparities in health aren’t addressed through other means.
What Has Changed
Major medical institutions have moved decisively away from treating race as biology. In 2020, the American Medical Association adopted a formal policy stating that “race is a social construct and is distinct from ethnicity, genetic ancestry, or biology.” The AMA called for ending the practice of using race as a proxy for biology or genetics across medical education, research, and clinical practice. It recommended that clinicians focus instead on genetics, the experience of racism, and social determinants of health when describing risk factors for disease.
In nephrology, the National Kidney Foundation and the American Society of Nephrology formed a joint task force in July 2020 to reassess race in kidney disease diagnosis. By September 2021, the task force released its final recommendations: immediately replace existing eGFR formulas with a new equation developed without race as a variable. The updated formula relies solely on age, sex, and creatinine levels. It was tested in diverse populations and performs with similar accuracy to the old equations without disproportionately affecting any one group.
The American Thoracic Society, endorsed by the European Respiratory Society, issued an official statement that race and ethnicity should no longer factor into interpreting spirometry results. The new recommendation calls for using an average reference equation, sometimes called the race-composite Global Lung Function Initiative equation, instead of race-specific ones. The society’s position is direct: there is a burden of proof for any continued use of race in pulmonary function testing, and that burden has not been met.
Race-Conscious vs. Race-Based Medicine
The shift isn’t about ignoring race entirely. The emerging framework is called “race-conscious” medicine, which recognizes that a patient’s racial identity shapes their health through social pathways like neighborhood conditions, exposure to discrimination, income inequality, and access to quality food and healthcare. It treats race as a marker of lived experience, not a biological input.
This distinction matters because racial health disparities are real and measurable. Black Americans have higher rates of hypertension, kidney disease, and maternal mortality. But race-conscious medicine attributes these patterns to systemic factors rather than innate biological differences. A doctor practicing race-conscious medicine would recognize that a Black patient faces elevated cardiovascular risk not because of their DNA, but because of the cumulative health effects of structural racism, chronic stress, and disparities in care.
Genetic ancestry is a separate concept from race. Two people who both identify as Black may have vastly different genetic backgrounds, and two people from different racial categories may share more genetic similarity than two people within the same category. Precision medicine increasingly uses specific genetic markers, not broad racial labels, to guide treatment decisions. This approach captures the actual biological variation that matters for drug metabolism, disease risk, and treatment response, without relying on a social category as a shortcut.