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Chapter Summary

This chapter defines the taxonomy and historical context of race, ethnicity, diversity, and bias and sets the root causes of disparities impacting cardiovascular disease. The epidemiology and consistently higher burden of cardiovascular disease are described according to race, ethnicity, indigenous, and immigrant status. By understanding that race is a social and not a biologic construct, the chapter suggests a more plausible reframing around genetics and ancestry. Racial and ethnic minorities experience a disproportionate burden of cardiovascular disease (see Fuster and Hurst's Central Illustration), which is strongly associated with the social condition and further amplified by subconscious bias with resultant health disparities. It has become increasingly clear that social determinants of health drive outcomes. Emerging science links life and living circumstances to an increased burden of cardiovascular risk, plausibly mediated via inflammatory pathways and subsequently yielding an increased burden of cardiovascular disease. As such, addressing the still evident race/ethnicity-based health disparities in cardiovascular disease will require a longitudinal committed and multifaceted approach that raises awareness, reduces the influence of bias, introduces more diversity in the healthcare workforce, involves more genetic discovery, targets more equity in the built environment, and roots out racism in medicine.

eFig 81-01 Chapter 81: Race, Ethnicity, Disparities, Diversity, and Heart Disease


Race can be described as a grouping of humans based on shared physical, cultural, and social qualities in categories viewed as distinct by others.1 Most scientists, however, assert that race is not biological and rather they define race as a social construct, meaning that race congregates humans according to shared life and living experiences. Moreover, race is a political construct where, especially in the United States, the designation of race evolved from a history that emanates from slavery and that still fuels racism. Racial categorization allows for broad generalizations and stereotyping, which can be counterproductive in cardiovascular medicine.

The correct ascertainment of race per se is by self assignment. The greater question is why is the ascertainment of racial status important in contemporary medicine? The social context, inferred by race, is of great importance in the attainment of health and access to health care, but for conditions, including cardiovascular conditions, presumed to be inherited or to have a genetic basis, ancestry is the more appropriate biologically based clinical inquiry. Race is not a proxy for genetics, but ancestry does serve as a surrogate for familial or shared inherited genetics that not only define groups of people but inform the likelihood for certain conditions and/or the response to certain therapeutics. Even ancestry is complicated because the ancestry of Black people in the Americas can be traced to the period from 1619 to 1850 when millions of indigenous West and Central Africans from seven African coastal regions were kidnapped and transported to the Americas.1,2...

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