Phila Msimang (Stellenbosch University), "Prescribing Race: No Blank Scripts for Using Race and Ethnicity in Health"

Argumenta, 2024

By Phila Msimang

When should we use race and ethnicity in healthcare settings, and what do ethnic and racial classifications mean in these contexts? These are the kinds of questions that have motivated my research over the last few years. In working on the whether these classifications are relevant to health, I explore in what ways they may be of use and in what ways their use may be misled, harmful, or inappropriate in ethically and scientifically relevant ways.

My new paper “Prescribing race: no blank scripts for using race and ethnicity in health” in the journal Argumenta continues on this line of enquiry. The paper is in some ways a development of the argument that I made in the book chapter “Social races in biomedical settings” in which I interrogated the use of race as a proxy for social and biological variables in health. In that paper, I argued that the use of race and ethnicity as proxies in health should be avoided whilst arguing for the relevance of race and ethnicity to specific healthcare contexts like disparity research. In my new paper, I take a closer look at how these classifications may play a role in those healthcare contexts.

I address two main questions in this paper. The first question is a conundrum about whether to use externally ascribed racial and ethnic classifications or to use how people themselves choose to identify on those dimensions. The second question, following from the first, assesses what it means for us to speak of a racially or ethnically specific health risks for individual members of a race or ethnic group.

The first question is a conundrum at the very centre of the use of race and ethnicity in health. It is standard practice today that we self-report how we should be identified by race and/or ethnicity at healthcare facilities where such information is collected. This information is collected from patients for two main reasons in countries like South Africa and the United States of America. On the one hand, it is to comply with policy and legal requirements that assist governments to keep track of demographic changes for equity purposes; on the other hand, it is because race and ethnicity have strong associations with differences in health outcomes between groups. These healthcare outcomes are mediated by the race or ethnicity that other people classify a patient as rather than what they alone may identify as. This raises the obvious question: then why do we use self-identified racial and ethnic classifications in health if the variable of significance in terms of these healthcare outcomes is how others would classify the patient? Would it then not be better to use the classifications that other parties ascribe to that patient rather than the self-identified classification(s) they would report? I make a case for why—counter-intuitively in terms of this conundrum—that it turns out that we should use self-identified racial and ethnic classifications in clinical contexts as the ethically and scientifically better performing ways of identification for healthcare purposes.

In addressing the second question, I look at some challenges with the use of racial and ethnic classifications in clinical reasoning. In general form, the problem I am looking at is about how individuals relate to the groups that they supposedly belong, and vice versa. Particularly, I am concerned about making sense of talk about risk to some disease-relevant exposure an individual has given their belonging to some racial or ethnic group said to have some special risk to that exposure. This is an important question in the study of racial and ethnic disparities in health. After I reinforce the well-made point in the literature for the need to disaggregate data along relevant dimensions, I make the argument that the relevance of group-level descriptors depends on the level of the intervention being made. Whereas in the clinic one may be dealing with and best reasoning at the level of the individual, when writing policy or allocating budgets one could be dealing with and best reasoning in terms of underserved regions or population groups. In the clinic you deal with the health of the person in front of you, whereas in policy you may be addressing public health across groups—some of which could be racially and ethnically defined such as in highly racially and/or ethnically segregated societies.

Overall, I propose in this paper a novel case for the importance of context and the need to consider the level of the intervention in whether or not a population descriptor like race or ethnicity is relevant to that particular healthcare setting. In between this all, I make a few interventions about how we are to understand the concepts of race and ethnicity both as social classifications and as identities. This is work I plan to continue. Please do enjoy the paper and feel free to share your feedback about it with me.