Not So Black and White: Examining Race and Ethnicity in Clinical Articles

Christina T. Loguidice is the editorial director of Annals of Long-Term Care and Clinical Geriatrics . She is also a medical and technical writer and a published author. 

Although racial issues have never dissipated, they’ve been garnering a lot more attention recently. First, there was a lot of press by the mainstream media about celebrity chef Paula Deen using the n-word. Shortly thereafter, the Zimmerman trial verdict ignited more racial tension and debate over what it means to be “white.” But no matter what you think of Paula Deen or the outcome of the Zimmerman trial, these cases and the reactions they generated show that race continues to be a hot-button issue in America.

Because race is such a sensitive topic, authors sometimes don’t know how to address it in their writing. How do you describe a patient’s race without offending anyone? Of course, we all know that using racial slurs like the n-word is completely unacceptable, and certainly no one would even think to use such unsavory terms, but do you use “African-American” or “black,” “Caucasian” or “white,” and should you use “Asian,” “Hispanic,” or something else? Do you even have to report a patient’s race or ethnicity? Because racial awareness is particularly heightened at the moment, I thought it might be a good time to examine the use of racial and ethnic designators in the clinical literature.

Race Versus Ethnicity

In the US medical literature, noting race and/or ethnicity is often important because this country is home to people with all kinds of genetic backgrounds, which can have clinical relevance. Although race and ethnicity are sometimes used synonymously, they are different. Race refers to “each of the major divisions of humankind, having distinct physical characteristics”; for example, white people, black people. Ethnicity drills down deeper and refers to “characteristics of a human group [that have] racial, religious, linguistic, and certain other traits in common”; for example, Italians, South Africans, Brazilians.

Do you need to report a patient’s race or ethnicity?

Case reports often begin with something like “An 87-year-old white woman reported to the emergency department with…”. The objective is to set the stage so that readers can visualize who is being treated. Race is generally one helpful descriptor in a string of other descriptors, but is it really necessary to include? We know that race can affect a patient’s risk factors for certain diseases and their outcomes. For example, persons of Chinese ancestry are often lactose intolerant; sickle cell disease is predominantly seen in individuals of West African descent; and an Ashkenazi Jewish background can predispose to genetic mutations that increase the risk of breast cancer. Therefore, if a patient’s race or ethnicity may in any way affect his or her medical condition, it’s useful to include this information. But if this information has as much bearing as what the patient ate for breakfast on Independence Day in 1998, then this information can be safely omitted. Of course, if a patient has a condition that is highly unusual for his or her genetic history, then noting the patient’s race can be helpful as well. 

When race/ethnicity is reported, whether in a case report or a research report, it’s often useful to establish why race/ethnicity is a relevant factor. Readers may not always automatically make this connection for themselves.

How do you choose which racial/ethnic terms to use?

Once you establish that race/ethnicity reporting is relevant, you need to determine how to do so accurately and sensitively. Let’s do a quick rundown:

• African-American vs black: This is generally where sensitivities run the highest. As a result, most authors prefer to use “African-American” because “black” can sound harsh to some ears. But “African-American” isn’t always accurate, as it doesn’t account for people of African descent who live elsewhere in the word. Therefore, the term should only be used to describe persons of African ancestry who are US citizens. In other cases, the American Medical Association (AMA) indicates that using “black” is best. In such cases, specifying ethnicity may also be useful; for example, Brazilian of African descent.
• Caucasian vs white: This is an area where there is perhaps the most confusion. Although “Caucasian” sounds more pleasant than “white,” it’s only technically accurate if you’re referring to a person who has descended from the Caucasus region of Eurasia, which is the swath of land between the Black Sea and the Caspian Sea. As a result, “white” should be used when referring to race, and ethnicity can be used if there is a need to provide additional background information. For example, if a patient has cystic fibrosis (which is more common among Northern Europeans), it might be useful to clarify a patient’s genetic heritage.
• Hispanic/Latino: The AMA recommends avoiding the terms “Hispanic” or “Latino” because they mean different things to different people. For example, “Latino” is thought to exclude persons of Mexican ancestry. Therefore, it’s best to use ethnicity as a designator when referring to Spanish-speaking persons from the Americas or to their descendants. You can do this by using terms like “Puerto Rican,” “Peruvian,” or “Argentinian,” and tacking on “American” if the individual is a US citizen (eg, Cuban American).
• Asian: People with many different genetic heritages live in Asia. Therefore, the term “Asian” or “Oriental” (the latter of which is derogatory) should be avoided in favor of using the person’s ethnicity, which is much more specific and meaningful in establishing any relevant clinical relationships between his or her medical condition and genetic history. Consider using terms like “Japanese,” “Pakistani,” “South Asian Indian,” and adding the term “American” if the person resides in the United States (eg, Chinese American).  
• Native American vs American Indian: When referring to the descendants of persons indigenous to North America, the term “American Indian” is favored because it doesn’t include Alaskan natives, Hawaiians, and several other genetic heritages. However, whenever possible, it’s ideal to specify the nation (eg, Navajo, Inuit), as this may provide the most meaningful descriptor.