Race in Medicine
Race is a central topic of discussion in heated conversations today, including medicine. This is evident on an episode of FOX’s medical drama series “House M.D.” In this episode, a black patient who has heart disease refuses to accept the physician’s prescription for a drug approved specifically for “self-identified” African-Americans. When Dr. House sees that same patient for a follow-up, he recommends the same prescription. However, the patient refuses, “I am not buying no racist drug, OK?” Dr. House asks, “It’s racist because it helps black people more than white people? Well, on behalf of my peeps, let me say, thanks for dying on principle for us.” The patient replies, “Look. My heart’s red, your heart’s red. And it don’t make no sense to give us different drugs” (House Season 2). Who is right, Dr. House or the patient?
Doctors often take into account a person’s stated race when treating patients or prescribing medicine, as race or ethnicity helps doctors identify genetic differences that influence risk for some diseases. It is assumed that this self-identification would help doctors reduce those risks by making sure they receive quality care. More specifically, these genetic differences allow doctors to diagnose patients with diseases such as sickle-cell disease, Tay Sachs disease, or cystic fibrosis. “Sickle-cell disease is most commonly found in ethnic groups such as: people of African descent (including African-Americans), Hispanic Americans from Central and South America, and people of Middle Eastern, Asian, Indian, and Mediterranean descent” (American Society of Hematology 2018).
Yet, there seems to be disagreement among doctors and patients about the idea of ‘race’ and the role that it plays in medicine. Is it a social group or a biological designation? It is true that there are subtle differences in racially-associated genetic makeup that affect responses to drugs for specific diseases; is there any way to serve everyone medically while avoiding the reinforcement of stereotypes? Although there are some benefits to using race as one dimension in treating patients, if practitioners do not keep the pitfalls in mind, they will do their patients a disservice.
Wall between scientific use of race and race as a social construct
What exactly is the intersection between the science of race and the social meaning of race? In an article detailing this dilemma, Dorothy E. Roberts states,
On one hand, some African American scholars, scientists, and advocates have criticized race-based medicine as a scientifically flawed and commercially corrupted misuse of biomedical research on health inequities that threatens to reinforce dangerous biological understandings of race. On the other hand, others have supported racial therapeutics precisely to redress past discrimination and fulfill long-standing demands for science to attend to the health needs of African Americans (538).
Roberts is one of many scholars, scientists, and advocates who are at odds with race-based medicine and its commercially corrupt misuse of biomedical research. In Roberts’ TED Talk, she dicusses the problems that she finds with race-based medicine. She contends that the biggest problem that she points out about using race as a determinant is that gives doctors a reason not to look at patients’ symptoms, genetic illnesses, family history, or their individual illnesses – potentially crucial evidence. Roberts claims that race medicine is bad medicine. She further argues that it is inefficient science and a misjudgment of humanity. “The problem with race medicine extends far beyond misdiagnosing patients” (Roberts). Race medicine aims its attention at innate racial differences in illnesses and diverts attention from the social determinants that cause racial gaps in health.
Such social determinants include the lack of access to high-quality medical care, vulnerability to toxic environments, lack of food in poor neighborhoods, and the stress of racial inequality. In a qualitative study carried on by doctors Frank et al., there were physicians who had negative attitudes toward the use of race-based medicine. These physicians all agreed on the idea that there was a weak connection between race and genetics. “Everyone would agree there is a relationship, but it’s such a tangled mess…It is very hard to tailor a treatment based on such a broad classification” (387). Other researchers and medical analysts also emphasized the inadequate parallel between genetics and race or ethnicity.
Conversely, there are many physicians who hail race-specific medicine. Not only do they believe that it is a crucial diagnostic tool, but it is a “promising new model for drug development” (Harder 2005). Frank et al., conducted a study that draws on the positive attitudes of primary physicians towards race-based medicine. The positive viewpoints were based on the effectiveness of medications across different racial groups, often citing the example of ace inhibitors. The greater part of the focus group expressed that black patients with heart problems would not respond to ace inhibitors to the same degree that white patients would. An ace-inhibitor is a pharmaceutical drug used primarily for the treatment of hypertension and congestive heart failure, which in this case is the enalapril which is further discussed below.
Surprisingly, the physicians who supported race in medicine and race-based therapies came to the conclusion that drugs for specific races may motivate patients to cooperate with therapies and encourage changes in health behaviors by creating the idea that the medication is customized for that individual. This wall between the scientific use of use and race as a social construct underscores distinct understandings of race-based medicine and points to a caution regarding its use by doctors and physicians. Should race be used in medicine? If so, to what extent should race be considered when treating a patient or prescribing medicine?
History of BiDil
In the episode of House referred to above, the drug in question is clearly suggested to be BiDil. Doctors consider many factors when diagnosing a patient or prescribing medicine; some use race as a useful determinant. BiDil, a medicine that contains two drugs (isosorbide and hydralazine) and is used to treat heart failure in patients regardless of race, was first introduced in the 1980s. In 1999, a drug company called Nitro Med bought the BiDil patent in hopes of developing it into a secondary drug treatment specifically for African-American patients. Studies show that compared to white people, blacks are thirty percent more likely to die of heart disease and forty percent more likely to die due to a stroke. The U.S Food and Drug Administration approved the drug in June of 2005 as a medicine prescribed for self-identified black patients. This action provoked controversy in the medical world, raising the question: “Is race-based medicine good for us?” The availability of race-based medicine forces us to consider, whether in the context of medicine and public health, race is a biological proxy for a certain set of characteristics often in DNA or merely a social construct.
FDA’s approval of the drug was dependent on the results of a clinical trial; two placebo-controlled trials (V-HeFT I and A-HeFT) and one active-controlled trial (V-HeFT II), to which participants were randomly assigned. The results from the trials did not show any notable differences between the treatment group and the placebo. However, doctors noted a trend towards improvement. Retrospective study showed that the pattern was correlated with the self-identification of racial groups: the patients who identified themselves as black or African-American showed advancements in survival, while those who self-identified as white or Caucasian-American patients showed little to no difference from the placebo group.
Race as strictly a social construct
In her Ted Talk, Roberts’ further argued that race-specific medicine helps to promote biological rationalization for racial disparities, and thus hides the sociopolitical causes. Therefore, it requires a particular and market-based solution rather than social change. This means that social change is not enough to solve these biological rationalizations for racial disparities, there is a specific solution that would change the fact that race is not a biological shortcut. As an example, she elaborates on the case of Cystic Fibrosis. Doctors will typically not diagnose a black patient with symptoms of cystic fibrosis because it is viewed as a white disease. This was evident in the case of a young African-American girl who had continuing respiratory problems. The little girl returned to the emergency numerous times from the ages of two to eight. Finally, a radiologist who had not met the child looked at an x-ray of her chest, and asked “Who is the kid with cystic fibrosis?” Roberts further states that if the girl had been white, the doctors would have diagnosed her right away. Race, Roberts states, “is a social category that has staggering biological consequences because of the impact of social inequality on people’s health”(“Dorothy Roberts: What’s Race Got to Do with Medicine?” 2017).
How does Roberts’ analysis apply to BiDil? “At its very origins, BiDil had its commercialization strategy contaminated by a long history of perceived and genuine racial exploitation of black patients and racially biased inequities” (Brody and Hunt). Jonathan Khan argues that “there is no genetic basis for race: There are no unique genes that classify (those who many see as) white people as white and (those who many see as) black people as black, and so on” (Nobis W4). Moreover, he believes that race-specific medicine in general is improbable, given the lack of biological means that are needed for this drug to perform at its potential. This means that Khan concludes that race-specific medicine is existent because there were results that showed it was successful in specific races, but there are no biological intentions for this drug to be exceptional. While Khan disagrees with race-based medicine, he offers various proposals regarding how race should be considered in health and medicine. Khan calls for greater “rigor, precision, and care” when using racial profiling in research and law, especially when deciding between the ideas of race as a biological designation or a social construct. Other authors, like Morris, Sankar, Brody and Hunt, and Yu et al., further argue that race only came into the picture because it was used as a means to revive the commercial existence of BiDil. But, BiDil evidently worked for African-American patients.
A series of discussions between doctors presented another reason why race-based medicine is flawed. Other researchers and medical-policy analysts find a disconnect between racial identities and medicine.In fact, they point out there is a poor connection between race and disease (Johnmar 2014). It is based more on the entire genetic makeup of an individual rather than on skin color. A doctor cannot come to a complete diagnosis of a patient based on that patient’s descent nor on the color of their skin. Furthermore, at some points in United States history, Hispanic and Latino populations were considered white. At other times, Irish families were not considered white. Anthropologists further explained that because race has no static or scientific nature, it remains a social construct (Tsai 2018). Moreover, there are biracial, or even multiracial, patients who may choose to identify themselves as one ethnicity, the other, or both. Doctors then come to an understanding that a person’s skin color is not the only means of diagnosis. When it comes to assessing a patient, “it is more important to know a patient’s family history than to assess his or her race” (Braun et al 2007). It is more than just the race that makes up an individual.
Race should be a biological designation
A patient’s race and ethnicity have always been important regard for doctors when treating patients or prescribing specific medicines. Biologically rationalized ideas of racial inequalities have risen to prominence in the wake of the human genome project and the efforts to understand race-based genetic vulnerability to diseases such as hypertension. Genetic attributes do influence some differences in responses to therapies and disease proneness. Some researchers say that race, in fact, contributes meaningful stories of genetic ancestry while contributing to the development of personalized medicine and ethno-pharmacogenomics. Not only does race provide doctors with a history of genetic ancestry, but such classification can help with the development of tailored treatments for individuals. As stated by biologist David B. Goldstein of University College London, 29 other medications have distinctly different effects in different racial populations. These medicines were found to be either safer or more successful depending on genetic differences. This claim might at first seem questionable because of the fact that, according to the Human Genome Project, humans share 99.9 percent of their DNA. And yet, according to research,
The unshared amount residing in the .1 percent comprises over three million nucleotides–the building blocks of genes. A mutation of even a single nucleotide can cause the gene within which it is embedded to produce an altered protein or enzyme that determines disease or, theoretically, response to treatment (Satel 2004).
Satel explains that this small percentage of genetic differences creates a medically meaningful fact.
Furthermore, these variations cluster by racial grouping – especially in people whose ancestors reside from a specific geographical region. In her New York Times Magazinearticle, “I am a Racial Profiling Doctor,” Satel further states that her colleagues also profile their patients by race because recognizing specific patterns can help them to diagnose patients more successfully and prescribe medications that would work. “When it comes to practicing medicine, stereotyping often works” (Satel 2002). Sometimes, stereotyping is not always a bad thing, as Satel states. Furthermore, it is a useful diagnostic tool for her when it comes to prescribing. For example,
When I prescribe Prozac to a patient who is African-American, I start at a lower dose, 5 or 10 milligrams instead of the usual 10-to-20 milligram dose. I do this in part because clinical experience and pharmacological research show that blacks metabolize antidepressants more slowly than Caucasians and Asians. As a result, levels of the medication can build up and make side effects more likely (Satel 2002).
Lawrence Lesko of FDA’s Center for Drug Evaluation Research argues that race-based medicine is an advancement towards the goal of better ‘individual treatment’ for patients. He and his colleagues also stated that it is a step towards recognizing a person’s genetic makeup which is useful to tailor individual treatments (Harder 2005). What other reasonings do doctors have that they do not support the use of race-based medicine?
Marketing of race-based medicine
Most doctors are concerned with the idea that race-based medicine, BiDil more specifically, exploits race to promote its products. As mentioned above, BiDil was initially created to treat heart failure, regardless of a person’s race or ethnicity. Later, NitroMed, presented FDA with new clinical results in order to revive BiDil after the medicine seemed dead in the water. Based on the successful results from the clinical trial on African-American subjects, FDA approved of the medicine. By the end, NitroMed held a secondary public offering that raised nearly $80 million to fund the BiDil launch. NitroMed now has an exclusive patent until 2020 (Sankar and Khan 2005). How exactly does this drug exploit race? It reifies and biologizes racial groups which has changed the meaning of race and the connection between race and biology. Additionally, it generates this idea that the solution to health disparities is through commercial drug development.
Is there any way to serve everyone in the medical field while avoiding the reinforcement of racial ideas? What if race-specific medicine was available but not marketed? The marketing of BiDil creates trouble in a doctor’s workplace because although they might think it is the preferable option, patients may think otherwise. This may result in commotion between the doctor and patient, or other doctors and it is likely that the doctor would receive an adverse reaction. It could be possible that there would be no social backlash if a race-specific drug was doctor-patient confidentiality, while being on the same page. Furthermore, a marketing ban could avoid encouraging racist groups from recruiting more and becoming more confident in their actions. Most people of color, and advocates of them, feel attacked because of the marketing of race-specific medicine. Kahn claims that the marketing of this drug is not supported by biological reasoning. Race was used to gain commercial advantage to revive BiDil. It could possibly avoid violence amongst the idea of a race-specific drug, which in turn, would help patients who are in need of it. If race-based medicine is an advancement in medicine, this could be a way to provide those with the specific drugs while avoiding the dangers of racism.
Perceptions and biases are so powerful because it often affects life or death differences. Everyone in this world has a difference of opinion. These differences of opinions may be because of one’s cultural, religious, or social traditions. Another important factor that shapes a person’s outlook on the world is education. People may receive an education that is not entirely the same. The information that they receive help form opinions. These opinions lead a person to formulate their views on the world, how it should operate, and how it influences their behavior. A person’s worldview dominates how they live. When it comes to race-based medicine, there are doctors and other professionals who believe that race should be a factor in medicine and those who believe that it is not necessary at all. These opinions may have been shaped by life experiences or they may simply be educated opinions. Aside from professional opinions, a patient’s outlook could directly affect the quality of his or her medical care. If that person believes that race-based medicine should come to end, but a race-based drug is the only means of health improvement, their beliefs may jeopardize their health care.
Conclusion
On the whole, while there are benefits to taking into account a person’s race in medicine, a doctor must keep in mind the potential repercussions. Although race may be a helpful determinant in diagnosing a patient, the diagnosis should not solely be based on the color of one’s skin. Though doctors provided that race could be helpful a helpful tool which looks at diseases that correlate with a specific race, all patients, regardless of their skin color, should be able to receive the same benefits and high-quality health care. Race can help doctors by providing a clue as to a patient’s possible genome, but it should not be the only means of diagnosis when treating a patient. Also, it is important to note that there are other diagnostic tools that avoid the danger of racism. Instead of depending on a person’s skin tone to determine ethnicity, physicians could have a patient’s genome sequenced directly and look as well at other factors such as their surroundings, lifestyle, or family history to help make sure that a person receives the right medicine at the right dose. These factors focus more on the individuals as a whole rather than just the color of their skin. Patients should always receive superb healthcare.
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Acknowledgements
I would like to give my sincere thanks to my peers Pam and Rene, my teacher’s assistant, Dan and lastly, Professor Monroe for their guidance throughout writing my paper. Without their active advice, I would not have been able to complete this long research paper about Race in Medicine. I would also like to thank the Dartmouth librarians who helped find sources for such a packed topic. The many suggestions that I have received have been a big help to this paper and made it easier to write.
Thank you,
Alejandra Ada