Invited Commentary: "Race," Racism, and the Practice of Epidemiology

Imagine that you are an epidemiologist investigating the health status of the city Metropolis. You document that the east side of the city has twice the prevalence of disease X as the west side of the city. You become interested in the determinants of disease X. How will you proceed? 1. Vigorously explore the basis of the east-west difference in the prevalence of disease X, using all currently available data and collecting new data as necessary. 2. Focus on understanding other determinants of disease X in Metropolis, adjusting for the side of the city from which subjects come or restricting analyses to just one side of the city. Most readers would agree that option 1 is the preferable response to the findings in Metropolis. That is because option 1 treats the large east-west difference as an important clue to understanding the etiology of disease X, and it attempts to vigorously explore the basis of that difference. Option 2, on the other hand, merely treats the east-west difference as a confounder in understanding other determinants of disease X. Under option 2, the basis of the large east-west difference goes unexamined and therefore is likely to remain unknown. So consider now how we as epidemiologists typically deal with differences in health status observed by “race.” Race-associated differences in health outcomes are routinely documented in this country (1‐4), yet for the most part their basis remains poorly explained. Instead of vigorously investigating the basis of these differences, we tend to simply adjust for race in our analyses or restrict our studies to a single “racial” group (5). In this issue of the Journal, Kaufman and Cooper (6) provide guidelines for the appropriate use of race and ethnicity in etiologic research. However, their discussion is limited in two important ways. First, even as Kaufman and Cooper admit that race is a social construct and not a biologic reality (7, 8), they still conceptualize race as an individual characteristic and a matter of self-identity akin to ethnicity. Second, even as they thoughtfully assess the potential validity of five different uses of race by epidemiologists, they do not discuss how two of these uses that they judge to have high validity may actually diminish our ability to understand root causes of racial disparities. In this invited commentary, I discuss the meanings of race and make the case that race is a contextual variable, not a characteristic of the person. I also examine the practice of epidemiology with regard to the use of race and place the five uses of race discussed by Kaufman and Cooper in the larger context of the questions that we decide or neglect to ask. Finally, I urge epidemiologists to take an interest in elucidating the underlying causes of race-associated differences in health outcomes and conclude with eight recommendations for practice that will move us toward that goal.