OF RACE IN MEDICAL DIAGNOSIS
by Richard Garcia
The Chronicle of Higher Education, May 9, 2003. Volume
49, Issue 35, Page B15.
Reprinted with permission.
I am a 39-year-old Hispanic male born in Stockton,
Calif., to a mother who -- after many years of unwise eating --
has recently been diagnosed with diabetes and to a father I didn't
know who floated away at the end of a needle in his sister's garage.
I prefer being called Mexican to Hispanic, though I've never been
to Mexico. I eat a fat American's diet. Speak American English.
Although I don't smoke, I have been living in a big city with
polluted air. An American city where I recently was an assistant
professor of pediatrics, working in a profession that tries to
define my indefinable race without asking for my input.
I helped train medical students and residents who
are all taught, as I was when I was a medical student, to assess
each patient first in terms of age, race, and gender. Always in
that order. A 52-year-old white female, a 3-month-old Asian male,
a 39-year-old Hispanic male. The actual identity of patients remains
ignored: A 47-year-old African-American female -- who's never
been to Africa and prefers to call herself black if ever asked
by a white doctor, though none ever asks -- two-pack-a-day smoker,
still living with her mother in South Central Los Angeles, presents
The doctor asks the patient -- or the parent of
the patient, if you're a pediatrician -- for his or her age. The
gender is determined during the physical exam. But the doctor
usually just assumes the patient's race by looking at the person.
My professors told me, and current textbooks still say, that knowing
the patient's race helps the doctor make an accurate diagnosis.
So the doctor looks at the patient's skin, nose, hair, lips --
the silent mouth -- and defines ancestry in a single word: Asian,
Hispanic, white, African-American. I smiled when one doctor described
the Nigerian father of a patient as an African-American. The Nigerian
father didn't smile.
The textbooks say that a patient's race can, and
should, influence the doctor's thinking about possible diagnoses.
An Ashkenazic Jewish baby might have Tay-Sachs disease. A black
boy might have sickle cell anemia. A Southeast Asian girl might
have thalassemia. Of course, I know that Ashkenazic Jews get Tay-Sachs,
but the only baby I ever saw with Tay-Sachs was a Mexican child.
I didn't misdiagnose the disease because he was Mexican instead
Do all Hispanics have the same genetic risk for
asthma? Do Mexicans and Puerto Ricans eat the same diet? What
about a patient from Spain -- is he Hispanic in the same way that
My childhood friend Lela wasn't diagnosed with cystic
fibrosis until she was 8 years old. Over the years, her doctors
had described her as a "2-year-old black female with fever and
cough ... 4-year-old black girl with another pneumonia. Lela is
back." Had she been a white child, or had no visible "race" at
all, she would probably have gotten the correct diagnosis and
treatment much earlier. Only when she was 8 did a radiologist,
who had never seen her face to face, notice her chest X-ray and
ask, "Who's the kid with CF?"
An emergency-room physician referred a patient to
me with this history: "A 14 y.o. black male from South Central
LA with a positive tox screen presents with headache. He's probably
in a gang." I ordered a CT scan of the patient's head and discovered
a large cyst that had blocked the normal flow of cerebral spinal
fluid until the fluid had backed up and squashed his brain against
his skull. Yes, he had a headache, and he had smoked a joint before
going to the hospital.
Those are just two examples of incorrect diagnoses
caused by doctors who use racial assumptions to arrive at incorrect
medical conclusions. As a physician, such misdiagnoses disturb
me. I am also concerned as a father. I am Mexican from California,
and my wife is black from Los Angeles. Our daughter is blonde
with green eyes and pale skin. I have no known white ancestors,
and that kind of heritage -- even if it is just a legend -- would
not be left out of my family's stories. In my wife's case, her
mother is now tracing their family's roots back through American
history; as of 1843, she has not found a single white ancestor.
But my wife's relatives generally have fair skin, and I suspect
that my mother-in-law will eventually find a slave owner or overseer
or some other white man who is responsible for that, and for my
What concerns me is that many years from now, when
she is old enough to see a doctor with neither me nor my wife
present, the doctor will use what he assumes is her race to misdiagnose
her: "A 19-year-old white female presents with irritability."
Here is the crux of the problem: My daughter's race
can never be known. Her genetic risk for this or that disease
is necessarily imprecise because she is a person, not a race.
Americans used to define anyone who had "one drop
of Negro blood" as a Negro, but we now know that definition makes
no sense. We learn nothing if we group together as Asian-Americans
a man in Seattle who was born in the far eastern portion of the
former Soviet Union, a Korean woman living in Toronto, and a child
in California with maternal grandparents who immigrated from China
and a father whose ancestors came to New Jersey from Europe. There
are almost as many definitions of Hispanic as there are Hispanics.
Do I have the same genetic risk for sickle cell anemia as a Puerto
Rican, a Spaniard, or a Mayan? What about my daughter, and the
millions like her in this country, whose racial and ethnic ancestry
defies geography and time?
If by using a patient's ancestry in medical discourse
we can narrow the range of possible diagnoses, then at least we
must be careful to describe accurately the genetic, ethnic, cultural,
or geographical variables involved; guessing what category a person
fits in is not acceptable. And when "race" cannot possibly matter,
let us omit it. What difference does it make if it is an African-American
or an Asian who has an earache or ingrown toenail?
Medical-school professors must teach students that
a Hispanic is not real. That an Asian-American doesn't exist.
That whites exist only in America: They are Irish in Ireland,
Italian in Italy, Spaniards in Spain. That harm -- real, physical
harm -- can come from calling a child with cystic fibrosis an
Race does exist in America, alas. It's why my daughter's
history here starts in slavery. It's why my Mexican face identifies
me to strangers before they know I'm an educated member of the
middle class. It's why nobody dares to ask for details about anybody
Richard S. Garcia is a pediatrician at a medical
center in Stockton, California. He was an assistant professor
of pediatrics at the University of Nevada School of Medicine at
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