The Issue Between Race and Medicine
A study in the November 2004 issue of the New England Journal of Medicine (NEJM) reported on a drug that was effective in treating heart failure in African-Americans. Only people who self-identified as black were included in the study.
In an October 2004 commentary in Nature Genetics , the authors listed 29 medications identified to be either safer or more effective in certain populations than others, based on genetic differences. The authors are quick to point out that the claim that drug response is affected by race and ethnicity is controversial.
The controversy is brewing between those who believe that focusing on race can help scientists isolate physiological factors affecting treatment, and those who believe that the focus on race is misplaced. Other factors, such as environment and social factors, which are correlated with but not determined by race, exert a greater influence on certain health outcomes than race itself. Focusing on race, opponents contend, will draw attention to the ways that racial groups are genetically different from one another. This could be dangerous if it leads to stigmatizing or generalization to other traits, such as intelligence. As M. Gregg Bloche, MD, JD, author of an editorial accompanying the NEJM study said in a previous interview, “Anything that invites the perception of African-Americans as biologically different is a huge worry.”
Scientists do agree that all people, regardless of race and ethnicity, possess individual factors that affect their bodies’ responses to disease and treatment. So should medical practice approach each person as an individual, not a member of any particular group, and strive to be colorblind? Or are race and ethnicity legitimate means to get to the unique biology inside?
Race as a Social Marker
Opponents of race-based medicine define race as a social construction. They feel that race is often self- or family- assigned, and strongly related to shared physical features, language, lifestyle, traditions, and other cultural attributes. Social race is weakly associated with genetics. Social race is a marker for the myriad of other factors affecting health outcomes: factors such as socioeconomic status, education level, environmental conditions, and access to healthcare. Putting race under the microscope not only distracts researchers from these other factors, but can perpetuate stereotypes that race is intrinsically linked with these lifestyle factors.
There is also concern that healthcare professionals may develop unconscious racial biases. They may inadvertently commit “bedside bias”—making assumptions about a patient’s condition based on race. The result may be less-than-optimal care in screening, diagnosis, and treatment.
To account for all these factors, an extensive medical history is essential for all patients. By asking detailed questions, a healthcare provider can gain a wealth of useful information about an individual person’s lifestyle, health status, and family history.
Race as a Biological Marker
Proponents of race-based medicine, such as Sally Satel, MD, agree that race serves as a marker, but argue it is rooted in biology, rather than society. Dr. Satel emphasizes the important distinction between social race and biological race. Biological race refers to ancestry. It is concerned with the “fact that people who share a common lineage are more likely to have more gene variants in common with each other than with people whose ancestors are from a different group.” Many of these commonalities have yet to be discovered. In the meantime, race—specifically ancestry—serves as a marker for not-yet-determined genetic variations among people.
For example, noting that a pregnant woman is white is often of little use. However, inquiring about ancestry and learning she is of Ashkenazi Jewish descent is medically useful information; this group of women has a much higher incidence of ]]>Tay Sachs]]> disease than white people of other ancestry. This condition can be tested for during pregnancy. Likewise, blacks of African descent are more likely to carry the genetic trait for ]]>sickle cell anemia]]> than blacks from other continents. Most states screen all newborns for sickle cell anemia, as early diagnosis and treatment is essential.
Supporters of race-based medicine see the research presented in the NEJM study as a step toward greater personalization in medical care. As Dr. Satel explains, “Someday geneticists hope to be able to conduct genomic profiles of each individual, making group identity irrelevant. But until then, race-based therapeutics has its virtues.”
Dr. Bloche agrees there are virtues, but is still cautious. As he explains in his NEJM editorial, “We need not shy away from the potential benefits of race-conscious therapeutics, but we should manage its downside risks. Greater awareness among physicians and the public that race is at best a placeholder for other predispositions, and not a biologic verity, would be a first step.”
While the best use of racial and ethnic information is still up for debate, it is clear that matters of health and disease are not black and white. A colorblind approach to medicine overlooks key factors in an individual’s health profile. Race and ethnicity certainly have their place along with gender, age, family history, and the many other characteristics that affect health status, as long as each factor is treated appropriately.
National Human Genome Research Institute
National Institute of Health
Bamshad M, Wooding S, Salisbury BA, Stephens JC. Deconstructing the relationship between genetics and race [abstract]. Nature Reviews Genetics. 2004;5:598-609.
Bloche MG. Race-based therapeutics [editorial]. NEJM. 2004;351:2035-2037.
Lillquist E, Sullivan CA. The law and genetics of racial profiling in medicine. Harvard Civil Rights-Civil Liberties Law Review. 2004;39:391-483.
Satel S. Race and medicine can mix without prejudice: How the story of BiDil illuminates the future of medicine. Medical Progress Today. 2004. Medical Progress Today webiste. Available at: http://www.medicalprogresstoday.com/spotlight/spotlight_indarchive.php?id=449 . Accessed December 20, 2004.
Sickle cell anemia. National Heart, Lung, and Blood Institute website. Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/Sca/SCA_WhatIs.html . Accessed January 10, 2005.
Tate SK, Goldstein DB. Will tomorrow’s medicines work for everyone? Nature Genetics. 2004;36:S34-S42.
Tay-Sachs disease. March of Dimes website. Available at: http://search.marchofdimes.com/cgi-bin/MsmGo.exe?grab_id=353&page_id=15663360&query=tay+sachs&hiword=sachs+tay+ . Accessed January 10, 2005.
Taylor AL, Ziesche S, Yancy C, et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. NEJM. 2004;351:2049-2057.
Last reviewed April 2007 by ]]>Marcin Chwistek, MD]]>
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