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Sickle cell disease often receives the most attention when clinicians think about blood disorders affecting Black people, but it is not the only hematologic condition that warrants consideration.
Research shows that anemia is over three times more likely in Black patients than in their white peers. Black Americans can also present with conditions like G6PD deficiency, certain thalassemias, and multiple myeloma. Additionally, Duffy null-associated neutrophil count (DANC) can complicate how clinicians interpret common blood test findings. Some of these conditions are easy to identify, while others can be misdiagnosed when clinicians attribute abnormal results to race rather than to serious conditions that merit a second look.
For clinicians caring for Black patients, recognizing patterns in blood work and common genetic distinctions can help distinguish between expected physiologic variation and findings that require further evaluation.
Adeel Khan, MD, MPH, MS, is a hematologist, oncologist, and epidemiologist who serves as the Director of Myeloma Epidemiology Research and Clinical Director of the Monoclonal Gammopathy Precursor Clinic at UT Southwestern Medical Center. His work focuses on hematologic malignancies, mainly multiple myeloma, which disproportionately affects Black patients.
He explained that multiple myeloma and other monoclonal gammopathies can be identified using commonly available blood tests such as serum protein electrophoresis (SPEP), immunofixation (IFE), free light chains (FLC), and quantitative immunoglobulins, including IgA, IgG, and IgM. But physicians would need to refer patients for these tests, as they are not standard laboratory tests.
For Black patients presenting with unexplained back and bone pain, lethargy and fatigue, or kidney dysfunction, these tests should be considered to get at the root of the problem before prescribing medication, which might only alleviate symptoms.
Dr. Khan emphasized that anemia is more prevalent in Black patients than white patients. The disparity is particularly pronounced among Black women, who experience anemia at approximately three to four times the rate of white women. With this in mind, clinicians may use a complete blood count (CBC) to assess patient wellness and prescribe medications — such as NSAIDs — that can contribute to iron-deficiency anemia.
Sickle cell anemia is not the only blood disorder to test for or be concerned about when considering complex symptoms in Black patients.
Anemia is a particularly important example of why clinicians should resist treating an abnormal CBC as a diagnosis in itself.
A low hemoglobin or hematocrit may have many possible causes, including iron deficiency, blood loss, hemolysis, nutritional deficiencies, chronic disease, inherited hemoglobin disorders, or malignancy. For Black patients, however, the higher prevalence of several hematologic conditions could signal that a systematic evaluation is needed, rather than jumping to the most obvious explanation.
Dr. Khan recommends that, when anemia is identified, consider iron studies that include serum iron, total iron-binding capacity (TIBC), and ferritin. A hemolysis evaluation can include lactate dehydrogenase (LDH), reticulocyte count, and haptoglobin. “Additional testing such as blood smears and hemoglobin electrophoresis are also widely available to identify types of anemia,” he advised.
An inherited hemoglobin disorder or another hematologic abnormality may also be something a patient has lived with so long that they have grown accustomed to treating symptoms as facts of life.
Clinicians should also consider whether they are evaluating patient complaints of pain or discomfort in all due fairness, given the long-standing concerns about racial bias in pain management and treatment of chronic pain among Black people.
People with Duffy null-associated neutrophil count, sometimes referred to as “benign ethnic neutropenia,” have a naturally lower neutrophil count (the main infection-fighting white blood cell) without increased infectious risk compared to the broader population, Dr. Khan explained.
“People of West African, Arabian, Mediterranean, and particularly African American background are primarily affected,” Dr. Khan said. “With this, it is important to view white blood cell counts on CBCs, particularly the neutrophil count, with a personalized lens. Notably, there is a genetic test that is clinically available to confirm the presence of the Duffy null-associated neutrophil count.”
The old terminology has fallen out of favor because it implies that the finding is an ethnic characteristic rather than a genetically associated variation.
The distinction matters because an isolated low neutrophil count can raise concern about infection, immune disorders, medication effects, or malignancy. Still, this condition occurs in patients who naturally have lower neutrophil counts and do not experience an increased risk of infection compared with the broader population.
“Given the prevalence of anemia in Black patients, work-up towards a specific diagnosis such as iron deficiency anemia or hemolytic anemia is important,” Dr. Khan advised.
Clinicians have to be careful not to be trapped by race-based standards when addressing individual patients. A persistently low hemoglobin result should not simply be labeled normal without an explanation. Dr. Khan recommends that physicians escalate testing in a practical sequence: begin with the CBC, use iron and hemolysis testing when appropriate, and add a blood smear or hemoglobin electrophoresis when the clinical picture warrants it.
Dismissing patient pathologies without a standardized sequence could cause underdiagnosis of serious conditions or overreacting to CBC results. In both cases, misdiagnosis can lead to longer referral times for specialist evaluation and eroded patient trust. Hematologic disorders are complex to diagnose and hard to live through, so physicians and patients will need to work together to develop customized diagnostic plans. There are simply no shortcuts.
The goal is not to order more tests simply because a patient is Black or to dismiss odd test results as normal for one ethnic group over another. Instead, genetics, clinical history, and laboratory results can help physicians make sense of a full diagnostic picture.
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