Conflating Race and Genetics among Newborns with Neonatal Abstinence Syndrome

Race is not genetic. Race is a social and political construct. Yet, the conflation of race and genetics is one way that racism persists in medicine and research. We found two recent examples of this conflation in the pediatric literature.^1,2 Both of these observational studies examined racial differences in the development and treatment of neonatal abstinence syndrome (NAS), sometimes more specifically called neonatal opioid withdrawal syndrome (NOWS), among Black and White study participants. These studies interpret racial differences in treatment as reflecting genetic differences between Black and White study participants. This interpretation is fallacious. The problems with this interpretation are that (1) race is not genetic and (2) racism provides a reasonable interpretation for study findings but is not considered. Our purpose in writing this is to highlight something that is common in research and the medical literature. It is only in becoming aware of this that we can change.

One of these studies, published in 2019, reported that Black newborns required less pharmacologic treatment than White newborns for NAS after observing that they received less treatment.¹ A response letter by Grossman et al. pointed out the received verses required issue, as well as the lack of attention to clinician bias.³ The authors acknowledged the critique of their article and addressed the roles of health care disparities, unconscious bias, and prescriber bias. They continued, however, to defend their interpretation that the findings reflected a genetic difference between races.⁴ The other study, published in 2020, reported a similar finding but stated inversely: that more White (70%) than Black (40%) newborns required pharmacological treatment for NOWS when, again, what they observed is that they received less treatment.² In offering this interpretation of study findings, this paper also perpetuates racism by offering genetics as an explanation for racial treatment differences among newborns with NOWS.² What both of these studies were demonstrating, however, was that there was a racial disparity in the treatment received by newborns with NAS. In associating the findings with a false genetic difference between Black and White newborns, the articles are effectively perpetuating racism. While this conflation of race and genetics can be seen in other scientific literature, we present specific cases of this conflation in the NAS literature to point out the history behind this conflation, why it is a fallacy, what it means for the individuals the research pertains to, and what we need to do about it.

The history behind the conflation of race and genetics.

In the early history of colonialism in the United States, there were both Black and White unfree laborers who inhabited the same social strata.⁵ These Black and White laborers socialized together, made families together, and rose up together, most notably in Bacon’s Rebellion in 1675–1676. The legal categories of White, Negro, and Indian, with corresponding social benefits given to the White group, were established following this uprising as a way to divide Black and White people in order to squelch further uprisings.⁵

As slavery and specifically the enslavement of Black people was codified, there was a need to develop theories that made Black people more “other” and less human. This was so that the atrocities that White landowners committed on Black people would not trouble their consciousness as deeply.⁵ As a result, race was made a biological concept as a moral apology for the inhumanity of chattel slavery.⁵ Science was a handmaiden to this endeavor. Attempts to make a biological case for race can be seen in the historical use of phrenology (then, cutting edge science) and in the “scientific” theory that Black people feel less pain than White people. This latter belief is still held today and influences clinical practice.^6,7

Why it is a fallacy.

It is well known that there is more genetic variation on the continent of Africa than between Black and White people in the United States.⁵ In addition, racial groups are heterogenous.^5,8 Accordingly, the attempt to use genetics to make a biological case for race is a fallacious one. The two articles on NAS that we cite are examples of this phenomenon,^1,2 but certainly not the only examples that exist. As scientists, we must take great care to understand the implications of our interpretations and receive feedback with humility. Disparities between Black and White people come from social inequalities, not biological ones.⁸

What this conflation means for human beings.

When biology and race are conflated in the context of NAS, misdiagnoses and under-diagnoses result. Such conflation also serves as a continued reinforcement of racist beliefs and systems. For instance, clinicians might undertreat the symptoms of NAS among Black newborns if they believe that these newborns require less treatment to be well managed.¹ Especially concerning is the call for genetic studies to support supposed racial differences.^1,2 Such conclusions may lead to policies and practices that may further reinforce scientific mistreatment for people who clinicians identify as Black. These calls use science to support and build up racism. We were pleased to find that at least one study published since 2019 with a much larger sample of mother-infant dyads refuted findings of a racial difference in treatment requirements among newborns with NAS.⁹ This refutation of a racial difference in treatment requirements does not mean there is not a racial disparity in how the newborns are treated. We contend that the pertinent question is whether there is a difference in treatments received based on race.

What we need to do about it.

Dismantling a way of thinking that is centuries old is going to take sustained, strenuous efforts on the part of scientists and clinicians together. We need to admit that race is a social construct and conduct research accordingly. Continuing education is urgently needed for scientists and clinicians (e.g., journal articles,¹⁰ webinars) about the differences between genetics and race. Along the same lines, we need to reconstruct how we educate the next generation of scientists and clinicians. Additionally, we need thorough peer review and specialized education for peer reviewers about the differences between genetics and race. We echo Yudell et al.’s call that the U.S. National Academies of Sciences, Engineering, and Medicine should “convene a panel of experts from biological sciences, social sciences, and humanities to recommend ways for research into human biological diversity to move past the use of race as a tool for classification in both laboratory and clinical research.”⁸ The conflation of genetics and race leads to poor science and clinical care that extends well beyond NAS. For example, racialized assumptions about who develops cystic fibrosis may lead to the underdiagnosis of this disease among Black people.¹¹

While we focused on two articles published in the NAS literature, this phenomenon can be seen throughout pediatric research. Widespread acceptance about the lack of a relationship between race and genetics is still needed. We have nothing to lose but false ideologies, and everything to gain from better science to better clinical care.