Conversations About Race-Based Medicine: Sally Guttmacher, PhD
Race-based medicine, or the practice of treating people differently based on their racial and ethnic background, has long been a subject of interest to healthcare providers, public health practitioners, communicators and others. Now, with the introduction of Bi-Dil, the first medication approved for the treatment of a condition in a specific race (African Americans), the topic is once again gaining increased attention.
Given the intense interest in this subject, I have decided to conduct a series of periodic interviews with physicians, executives from medical societies, communications experts and others. Each interview subject provides his or her unique perspective on race-based medicine, which I then publish on this blog.
I invite all of you to comment on this issue. If you wish to be interviewed on this subject, please contact me. I can be reached at news at envisionsolutionsnow dot com.
Interview Subject: Sally Guttmacher, PhD
About Dr. Guttmacher: Sally Guttmacher is Professor and Director of the Masters Program in Public Health at New York University. Public health concerns, particularly as they pertain to world health, are at the center of Guttmacher’s research. She has published extensively on the topics of health policy, the prevention of chronic and infectious diseases and the intersection between policy and public health. She has also spent extensive time in South Africa focusing on the HIV epidemic there.
Interview
Q: There has been a lot of discussion recently about race-based
medicine. What are the benefits and/or drawbacks to using race as a means of treating and grouping patients?
A: All humans are identical for about 75% of genetic factors and about 95% of the variation is within racial groups rather than between them. This does not preclude any biological difference between races, but it tells us that the differences are not so great. Therefore, to focus on race as a basis for medical intervention seems inappropriate at best. Much more of the health and disease differences that we see between groups of people are related to socioeconomic status, age, life style, culture, and gender. It would seem to me to be much more productive to base medicine on these factors rather than race.
Q: In your mind, is there a link between race and disease or is
there something else going on?
A: As I just mentioned, there are many other things going on that by far outweigh the difference in health and disease related to race. Almost all disease is class related. Racism in the United States has played a major part in keeping non-whites, especially African Americans or Latinos from moving up the social class ladder. Non-whites are more likely to remain in the lower class and thus are more likely to die at an earlier age than whites from class related disease such as asthma, diabetes, heart disease, cancer, stroke etc..
Q: Pharmaceutical companies, advocacy organizations and others
spend a lot of time and effort attempting to communicate to different groups about diseases that impact them. From what you’ve seen, are these efforts effective?
A: This depends upon how you want to measure effective. I do not believe that secondary prevention is the way to go to decrease the health status difference between whites and blacks in the USA. I think that it is far better to prevent people from getting disease than getting people to use drugs to manage chronic disease once they are afflicted.
Increased education leading to life style changes is the way to prevent disease. Decreasing poverty is a far more efficient way to decrease the burden of disease because living in poverty is frequently associated with poor eating habits, increased use of illicit substances and decreased opportunity for healthy activities.
On the whole, pharmaceutical companies are in the business of selling drugs and making a profit for shareholders. Certainly, they have through advertising managed to reach every group that has access to mass media. Viagra is a good example of this. Sometimes this has been too effective in the sense that many sexually active young men have become careless in their sexual encounters because they now see HIV/AIDS as a chronic disease which can be effectively managed through the use of drugs. I do not think that the problem is that the pharmaceutical companies have been unable to reach people, the problem is that many people in the US lack health insurance and are unable to afford the drugs that they need to have to treat their disease.
Q: What would you do to improve them?
A: I don’t think that the problem is communication. You can not watch TV without seeing drug related advertisements. There are some things that pharmaceutical companies can do to help folks once they have developed treatable chronic diseases. They can work to keep costs down, possibly by spending less money on advertising. They can stop raising prices by bringing “new†drugs on the market that are simply reformulated versions of old drugs in new packaging. They can refrain from creating new markets that don’t necessarily lead to better health. Sleeping pills are a good recent example of this problem. They are currently being aggressively promoted so that their use has skyrocketed.
I believe that pharmaceutical companies have an ethical obligation to see that the drugs that are needed by folks in underdeveloped parts of the world such as sub-Saharan Africa have access to the drugs for major infectious diseases such as HIV/AIDS, TB and Malaria. This means allowing countries to produce these drugs themselves if the companies are not willing to produce them at low cost.
Q: Are there any ethnic/racial groups that are currently being neglected or overlooked in health promotion efforts?
A: I am not aware of any ethnic groups that are being overlooked. Those groups that are being overlooked by the pharmaceutical companies are the ones that do not have the money to pay for drugs.
Q: Have you been following the Jackson Heart Study? If so, what are your thoughts on this effort?
A: I am aware of the study and it certainly looks interesting and I would support such work. But as I have said above, there are many other factors such as class that are more clearly related to disease than race.
Q: Is there anything going on over seas around race-based medicine that disturbs or inspires you?
A: I am not really aware of any work in this area. I work in South Africa for part of each year and I do not know of anyone in South Africa who is focusing on race based medicine. As far as I know such a focus was abandoned when South Africa made the transition from Apartheid to Democracy.
Q: Can you provide any general commentary on this issue?
A: Definitions of race have changed over time and have often been developed uncritically (i.e. skin color). At the turn of the century national origin was thought of as race, i.e. Italians or Irish. The definition of African American has changed from African to Black to African American. Currently ‘ethnicity has been “racialized†to Latinos, Whites, blacks/African American. Certainly the biological meaning of race continues to be refuted by work in population genetics, anthropology and sociology. Do these current concepts of race add anything to our understanding of health and disease? Perhaps a more important question for us in the US is to develop an understanding of how racism contributes to ill health.
I will end my response to your questions with the following quote by Thomas LaVeist:
“Only when we move beyond race as a proxy and directly measure those concepts believed to be measured by race, will we make truly important advances in describing the true nature of racial variation in health. And, only then can we begin what is really the important work: eliminating disparities in health status.â€
February 22nd, 2006 at 11:34 am
[…] Envisioning 2.0 has an interesting interview about race-based medicine with Sally Guttmacher, professor and director of the Masters Program in Public Health at New York University. Is this a direction CME is going in? I’d say, given the fact that New Jersey recently mandated cultural competency CME, joining California in demanding physician education in this area. […]
August 30th, 2006 at 7:39 pm
even though i am a lpn, i do believe ethniticy plays a very major part in healthcare. i am italian in the south. they do not know of mediterrian diets such abundace of fresh fruit, vegetables and of course olive oil. i get treated as if i am very underweight which i am not, they do not understand my culture and i am refferring to the md’s i have. i have tarlov cyst that i know that can not be cured. they think i have the wrong mental state when i tell them i know i will be ok. because my ethnic background(catholic) teachings tell me to have hope and pray to the good virgin mary.so in other words you treat the pt to their level let alone socio-pathway of being poor you can accomplish alot. even poor pts will do what is asked. because having some religous or superstitious beliefs is what we nurses have to overcome to educate the pts. so should the md’s.
September 2nd, 2006 at 6:13 pm
Mary:
Thanks so much for visiting this blog and for provding your unique insights on this issue. I hope you have found the rest of the series useful.
Fard
February 27th, 2007 at 10:33 pm
Thank you Fard for doing these interviews and posting them. The topic is a very interesting, and we all in healthcare need to be continually thinking about the cultural aspect of medicine. Currently I am a medical student in New Mexico.
I really agree with Dr. Guttmacher (which btw means “Good maker” in German, a name that fits well reading her credentials.) Specifically Dr. Guttmacher stresses the point that there is no such thing as “race” in the biological sense in humans. Our similarities far outweigh any differences. As such we must ask what the cause for differences in health outcomes between groups of patients is. The answer is more cultural and specifically socio-economical. As long as African Americans are at the bottom of the ladder they will have worse health outcomes. It starts with diet. Then you add unsafe working environments, unstable homes, dangerous neighborhoods and much less preventative medicine. This is what “predisposes” to illness. Then once the disease has set in there is a reduced access (to everything from healthcare workers to medications) due to lack of insurance.
I just want to conclude with a quote. It speaks about our humanness which is not changed by color, ethnicity or social-economic status. It is from someone how has spoken much of the necessity to see medical care as an intrinsic right. Anything less causes us to judge people either on color or ability to pay. This is wrong and we must do everything to fight it.
“I recommend the same therapies for all humans with HIV. There is no reason to believe that physiologic responses to therapy will vary across lines of class, culture, race or nationality.â€
Paul Farmer (on braineyquotes.com)
March 2nd, 2007 at 1:44 pm
[…] Joshua Frederiksen On Sally Guttmacher’s Interview […]
March 3rd, 2007 at 4:09 pm
1. Title: People and medicine, more than just race.
2. Topic: Race-based Medicine
3. Interview response: Dr. Guttmacher interview
4. Name: Isabel Ross
5. Date posted: 3/3/07
Treating people based on their race is a misguided attempt to help improve healthcare for all. Although I can see where the thought might have originally come from, the end outcome fails to recognize the true source of healthcare disparities. I agree with Dr. Guttmacher when she states in her interview, “I think that it is far better to prevent people from getting disease than getting people to use drugs to manage chronic disease once they are afflicted.” The approach only serves to treat the symptoms, not the underlying problems that have landed a person in the state of health they are in. Each person must be assessed on their individual history… and yes this history does often include “race”, but it plays a small role amongst many different factors. If the trend continues to treat people based on this concept of “race”, we are headed down a road that leads to further discrimination, stereotyping, and disparities between social classes. Dr. Guttmacher goes on to state that, “All humans are identical for about 75% of genetic factors and about 95% of the variation is within racial groups rather than between them… Much more of the health and disease differences that we see between groups of people are related to socioeconomic status, age, life style, culture, and gender. It would seem to me to be much more productive to base medicine on these factors rather than race.”
So instead of treating people from the most superficial of all levels we should strive to achieve treatments and health plans that look at each persons individual history, background, lifestyle, genetic factors and risks, and what their goals are
Isabel Ross
First year medical student at the University of New Mexico School of Medicine
March 3rd, 2007 at 5:24 pm
Race based medicine
Is there a relationship
Interview with Sally Guttamacher
Bill Block
3-3-07
Race-based medicine is a touchy topic. The correlation between disease and its prevalence in particular races is one that must be tip toed around for lack of offending different groups. Although I feel that “race-medicine” can be an important asset helping to reveal the correct diagnoses. When researching the epidemiology of different diseases some have are more common in certain segments of the population whether it be socioeconomic status, race, or sexual preference to just name a few. Knowledge of the prevalence or lack of health problems statistically in different groups of people is a tool that clinicians use in order to make the appropriate diagnosis. For example you might consider sickle cell anemia more seriously in an African American who is complaining of fatigue, and pain throughout the body, in the chest, stomach arms and legs than in a white patient. Although as Dr. Guttmacher pointed out most diseases are class related and not race related. Thus it would be much more efficient to focus on diseases affecting those in different social classes than to focus on race alone. Although racism in America has forced African Americans and Latinos into lower socioeconomic status as Dr Guttmacher explained. As stated in the article those in lower socioeconomic classes have higher rates of asthma, diabetes, heart disease, cancer and stroke. Therefore the relationship between the prevalence of disease can be related to race. But this relationship shouldn’t be a means of discrimination but be used as one of many tools used by the clinician in order to come up with the correct diagnosis.
March 4th, 2007 at 11:44 am
1. Title: People and medicine, more than just race.
2. Topic: Race-based Medicine
3. Interview response: Dr. Guttmacher interview
Elena Bissell 3-4-07
Treating individuals as individuals is a very important factor in medicine. Each person has a unique biology, experience, background, etc. To treat each individual as if they were merely part of a larger group both marginalizes the individual and could be harmful to the patient. It is vital that the patient be regarded in a number of factors: the person’s ethnicity, socioeconomic status, culture, diet, geography as well as their wishes regarding their healthcare. Race, as currently understood in the US does not account for differences in geographic location, diet and lifestyle. As Dr. Guttmacher stated in the interview, “to focus on race as a basis for medical intervention seems inappropriate at best. Much more of the health and disease differences that we see between groups of people are related to socioeconomic status, age, life style, culture, and gender”. Educating and treating the individual based on these factors seems much more appropriate than treating based on race alone.
There are certain ethnic groups that are at a higher risk for developing certain diseases and conditions: Diabetes Mellitus is a condition that affects about 16 million people in the US, across all ethnicities. The risk, however, “is 2 to 5 times higher in the African American, Hispanic, and Native American communities” (Kumar, et al, 1190). Whether the greater risk is genetic, socioeconomic, or due to lifestyle is not described but one can imagine that all of these factors come into play. To simply assume that the risk is due to race would be a huge oversight. Preventing disease is a much more effective method than treating after development. Addressing and educating about the risk factors such as diet and lifestyle across all ethnic groups would be an effective method to prevent those diseases which are caused by such factors. As Dr. Guttmacher suggests, “increased education leading to life style changes is the way to prevent disease”. This method could lead to a drop in the prevalence of preventable diseases across all “racial” groups.
References
Interview with Dr. Guttmacher
Kumar, Abbas, and Fausto. Robbins and Cotran: Pathologic Basis of Disease 7th ed. Elsevier Saunders, 2006.
March 4th, 2007 at 4:12 pm
This series of interviews on race based medicine brings up some very interesting and opposing views. I have to agree for the most part with Dr. Guttmacher’s viewpoints about the role of race in medicine. Ideally it would not have to be a factor but unfortunately historical and present discrepancies make it an important factor in healthcare. It seems to me that race is a factor more because of what it might entail about various access to care differences between races than because of actual differences attributable to race itself. As Dr. Guttmacher pointed out, there is greater genetic variation within races that between races; the same could also be said for any other factors that may affect health outcomes such as socioeconomic status, lifestyles, cultural variables, etc. It seems that grouping a patient into a certain race could be used as a substitute to actual understanding of important cultural, genetic, economic, and other factors of necessary consideration. Ideally we could actually understand the patient’s individual situation instead of using race as an estimate of their situation. For example, with genetic risk for a disease, it would obviously be much better to estimate risk based off of various genetic markers than off of a patient’s race which is more of a gross estimate of genetics. Hopefully that will be the future direction of medicine, more individualized assessment and less and less grouping. But of course, race will always be an important issue because of the differences that currently exist; we should keep in mind that the actual individual differences in patients are much more important than their race.
March 4th, 2007 at 5:06 pm
1. Title: People and medicine, more than just race.
2. Topic: Race-based Medicine
3. Interview response: Dr. Guttmacher interview
4. Name: Richard Vestal
5. Date posted: 3/4/07
The correlation between race/ethnicity and certain diseases or disorders is well documented. Whether it be an increased incidence of Sickle Cell Anemia in African populations, or an increased risk of just about everything else in Ashkenazi Jews, the presence of a particular race or ethnicity is clearly established as a risk factor in many situations. The majority of these race-based risks are likely related to geographical isolation, environmental factors, cultural practices or some other external element, however, to suggest there is no genetic relationship, or that whatever genetic relationship exists is small and clinically insignificant, is simply incorrect, in my opinion.
The argument that differences in socioeconomic status are a better indication of health risk is an obvious one. However, I believe that Dr. Guttmacher’s suggestion that socioeconomic concerns be the primary focus of medical/pharmaceutical attention is, quite frankly, unrealistic. To simply suggest that all we have to do to improve the health quality of the world population is to end poverty is a drastically oversimplified belief. The work and focus of countless people and organizations has been to do just that, and their work, while honorable and necessary, has met with limited success.
By focusing some, by no means all, of their attention to the genetic relationships between certain races/ethnicities and particular treatments of certain diseases, the medical/pharmaceutical community is pursuing a course that is more realistic than trying to end poverty, and it is also a more appropriate course, given the scientific educational background of the doctors and scientists involved.
While the faults and ethical ambiguities of pharmaceutical companies are many, their efforts, along with those of the medical community, to widen their research into the genetic/ethnic basis of disease in an attempt to progress the ongoing battle against it should be applauded, and to associate such a powerful word as racism with such efforts is irresponsible, in my opinion.
March 4th, 2007 at 6:07 pm
1.Title: People and medicine, more than just a race
2.Topic: Race- based medicine
3.Interview response: Dr. Guttmacher interview
4.Name: Ian Medoro
5.Date posted: 3/ 4/ 07
There is a fine line between attempting to treat people on the epidemiological basis of race and confusing this observed event with the socioeconomic factors that create disease states in certain populations. So the question is, do particular races have a biological and genetic predisposition to certain diseases or is it the social inequality that drives these genetic predispositions to a greater incidence of chronic disease?
For example, per the National Center for Health Statistics, the life expectancy in 2002 for whites was 78.0 years and for African Americans the life expectancy was 72.7 years. Also in 2002, the percentage of whites with hypertension was 77.3% and for African Americans 85.6%. Does this mean that drug research should be aimed specifically toward blacks who have a genetic predisposition for hypertension? Or should the healthcare system work more towards alleviating the socioeconomic factors that help contribute to hypertension? I think healthcare professionals should focus on the socioeconomic factors that contribute to this disease state. The environmental conditions, psychological stress, low social class, and social isolation issues should be addressed for proper preventative care in the context of those who have poor access to medicine. In the end, the entire US healthcare system needs to overhaul its frame of reactive medicine to preventative care with a particular focus on addressing the specific needs of each individual community with its own unique complications and needs.
What I see occurring is a shift in the focus of attempting to solve the root of the problem by placing a band-aid over the wound. As healthcare professionals, we must remember the importance of race and epidemiology, but in the context of how they are living and their access to healthcare.
But, to also play devil’s advocate, if it can be proven that despite socioeconomic factors, a particular race is predisposed to a particular disease, then as medical professionals we should be committed to providing the best treatment available. If a certain medication may prove to be more efficacious in recovery, or prevent chronic disease from occurring within a specific population, then we can reduce the necessity for other less useful medications and provide a better quality of experience for the patient.
References: National Center for Health Statistics website
March 4th, 2007 at 6:47 pm
1.Title:People and medicine: more than just race.
2.Topic:Race based medicine
3.Interview response:Dr. Guttmacher interview
4.Name: Mona Flores
5.Date posted: 3/4/07
As humans, our genetic makeup is unique to each one of us; each one of us has a unique genetic fingerprint which is what defines us as individuals. Although as stated by Dr. Guttmacher in her interview, that “all humans are identical for about 75% of genetic factors,” variation still does exist, not only between individuals, but between ethnic groups. It is this genetic variation between ethnic groups which allows one to respond differently to medications, illness, disease and treatment. For instance in the Jack Heart Study, documented by the National Heart,Lung and Blood Institute, it was stated that CVD has a higher incidence in the African American population, with this information one can argue that race does impact the risk of acquiring certain medical conditions, for it can be mere mutations that are more common in certain ethnic groups which predisposes one to various illness such as Sickle Cell Anemia for the African American community, Tay-sachs in the Jewish population and DM in the Hispanic population. Although I agree with Dr. Guttmacher’s notion that SES, age, lifestyle, culture and gender do play a significant role in medicine and illness, however I feel that these factors are not to be isolated from ethnic/racial status, for it is one’s culture or racial identity which predisposes one towards certain illness and response to certain treatments. In conclusion I feel that ethnicity does play a major role in healthcare and we as current and future healthcare providers should be cognizant of this reality and responsive to the challenges that it presents in the field of medicine, for being attuned to such variation, will allow for individualized/ tailored therapy and better patient care.
References: Interview with Dr. Guttmacher
Department of Health and Human Service, NIH- National heart, lung and blood institute website.
March 4th, 2007 at 7:03 pm
1. Response to Dr. Sally Guttmacher’s Conversation About Race Based Medicine
2. Topic: Are ethnic groups overlooked based on income?
3. Interview response to Dr. Sally Guttmacher
4. Name: Tuhama Rihani
5. Date: March 4, 2007
As a first year medical student, we have been taught that there are certain diseases which are more prevalent in the Hispanic, African American, Native American, and White populations, but I have yet to learn what diseases are more prevalent in other populations, such as the Arabic population. Being an Arab American, I believe Arabs have increased risks for diabetes and heart disease, to name a few diseases, but little or no research is being done to prove this. Although Dr. Guttmacher states, “I am not aware of any ethnic groups that are being overlooked. Those groups that are being overlooked by the pharmaceutical companies are the ones that do not have the money to pay for drugs,” I disagree with this statement. There are many ethnic groups being overlooked not because they cannot afford medication, but because they would not necessarily be a profit for the pharmaceutical companies. In the article, “Arabs in Foreign Land,” Moises Naim states, “Whereas 24 percent of Americans hold college degrees, 41 percent of Arab Americans are college graduates. The median income for an Arab family living in the United States is $52,300—4.6 percent higher than other American families—and more than half of all Arab Americans own their home.” Therefore, it is evident that the Arabic population is being overlooked for reasons other than not being able to afford medication. With that said, it is important that races other than the ones mentioned above be researched and studied so we can fully understand how disease correlates with race, ethnicity, and/or culture. And we are only doing a disservice to our patients, if we categorize many ethnic groups into one category. For example, the Hispanic population includes many North American, South American and European countries, but the culture and socio-economic factors can greatly differ between the countries. The same is true of the “White” population, where it can include groups of people from very different parts of the world. Therefore, if we want to study different racial groups it is important to keep these factors in mind, and realize that just because it is “proven” that one race has an increased risk for a certain disease, there are a lot of issues we have overlooked.
References:
Conversations About Race-Based Medicine: Sally Guttmacher, PhD. http://fardj.prblogs.org/2006/02/15/conversations-about-race-based-medicine-sally-guttmacher-phd/
Moises, Naim. “Arabs in Foreign Land.” Foreign Policy. May/June 2005: http://www.foreignpolicy.com/story/cms.php?story_id=2781&print=1
March 4th, 2007 at 8:37 pm
Race, Poverty, and Healthcare
A Response to: Conversations About Race-Based Medicine: Sally Guttmacher, PhD
Nathaniel Bonfanti, MSI
3/4/2007
“Progress is the attraction that moves humanity.” A contemplation of the civil rights activist Marcus Garvey.
Using race as the fulcrum for an examination of the fair distribution of medical care deliberately ignores the chief disparity. S. Guttmacher is adamant in her argument that economics trumps race. It really isn’t an argument, in terms of sheer numbers. The economic problem that prevents care access nationally and globally is enormous. No one disputes that poor people in general have the steeper climb on this issue. But race is still a divisive force in healthcare. History disputes the fixture of equal access. Contemporary evidence and attitudes separate the integral puzzle pieces of trust from the finished picture of care. The impact of one’s race on access to care, as well as every other facet of life, is still a problem.
It is unreasonable for minority groups to completely trust the overwhelmingly white medical establishment. From acts of racially-motivated violence here at home (James Byrd Jr.) to thinly disguised racial wars being fought overseas (Israel-Palestine), from the Tuskegee airmen to the barely considered epidemic of HIV/AIDS among young black people here in the U.S. (did anyone else feel their skin crawl and their heart sink when Cheney and Edwards punted on 1st down to moderator Gwen Ifill’s presentation of the situation in 2004’s campaign?). Work remains to be done. This is not a time for complacency. I’m not disputing Guttmacher’s premise: détente in terms of access will improve the health of the poor. But there is still growth wanting across the board, from all sides of the race issue. Until that growth has had time to take, in the national and global consciousness, there will not be a full and equal distribution.
March 5th, 2007 at 2:40 pm
1. Comments on Race-based medicine
2. Race-based medicine
3. Response to Dr. Sally Guttmacher
3/5/07
It seems that much of the debate that the issue of race-based medicine brings up has to do with health care disparities and whether race-based medicine will address these issues. Race-based medicine may be the start of research that includes minority populations that have largely been over looked and we may find differences that may be clinically relevant. However it does not address the basics of the problems of health care disparities. While we know that some populations may be more at risk for certain diseases, we also know that much of the differences result from differences such as socioeconomic status and access to health care, and much less to do with genetic variation. Also, Dr. Guttmacher makes the observation that the research into genetic differences will likely result in therapies that are beneficial for a relatively small number of people but make large profits for drug companies. Addressing the larger issues such as poverty and access to health care would be beneficial for a much larger number of people and should therefore be addressed even though it is not likely to make anyone much money. In the interview with Dr. Smedley he states, “There are also drawbacks to focusing on this topic. For example, I’ve been very concerned about how the media has framed this issue. Much of the reporting that I see continues to reify the concept of biological race.” This quote highlights some of the dangers in focusing on the differences between races. Race-based medicine findings may overshadow the similarities and allow the harder social issues to be ignored. We cannot use race-based medicine findings into genetic differences to ignore harder social issues such as poverty, pollution, access to health care and racism that may have a larger impact on public health.
March 5th, 2007 at 5:26 pm
1. Ability of Environment/Lifestyle to Greatly Influence Course of Disease
2. Race-based medicine
3. Dr. Guttmacher interview
4. Kanchan Kohli
5. March 5,2007
I think the whole concept of Race-based Medicine stimulates such different views across the board because the concept of race can mean many different things to many different people. As Dr. Guttmacher points out, “definitions of race have changed over time and have often been developed uncritically”. Thus, Race-Based medicine would have to evolve with the ever-changing modifications to the definition of race; and this could present problems, depending on what would define someone’s race. I agree with Dr. Guttmacher’s statement that “disease differences between groups of people are related to socioeconomic status, age, lifestyle, culture and gender” because I think these aforementioned traits take into consideration the vast individual differences that exist between people of the same racial/ethnic group. This statement also insinuates that environment plays a very big role in the outcome of disease. For instance, it is plausible to imagine that if two brothers, who live completely different lifestyles (Brother A smokes, eats purely fatty foods, does not exercise and brother B, who lives the complete opposite lifestyle of his brother), were followed throughout their lives, Brother A would have a higher probability of developing cardiovascular disease. This means that one’s environment and lifestyle has the capacity to greatly influence race/biological similarities (which are accounted for by the fact that the two men are brothers). Thus, instead of treating people based on their racial similarities, it may be more practical to treat patients based on factors that are known to cause greater health disparities between people such as socioeconomic factors and environment; hence, treating a person and not their race. Additionally, it can also be argued that it is not a person’s biological race that is causing the illness, but rather, their race is indirectly altering their lifestyle, which is causing an illness; a person could be facing racial obstacles and not able to earn a steady income, thus hindering his/her access to healthcare, resulting in disease. Lastly, the above comments are in no way meant to exclude the fact that some races are predisposed to certain types of illnesses (Tay-sachs) and in that sense, race-based medicine would be effective. But in general, there are so many similarities between different races that race-based medicine may not be the most effective way to treat illness.
references: “Conversations About Race-Based Medicine: Sally Guttmacher”
Jackson Heart Study Website
March 5th, 2007 at 5:46 pm
A large part of medical education is teaching students how to recognize patterns. Patterns are what allow us to condense and organize the overwhelming mountain of facts into usable constructs. While Dr. Guttmacher makes an excellent point regarding the fact that most “variation is within racial groups rather than between them,” unfortunately, a great number of epidemiologic studies focus on comparing the difference between races. After a semester of medical education I know that cystic fibrosis occurs more commonly in Caucasians, sickle cell anemia is more common in African Americans, and diabetes has a higher incidence in Native American populations. As a result, most of my dealings with race have been writing a patient’s race down under a list of risk factors. Knowing the race of a patient can indeed be helpful in ruling in and out diagnoses, however, I would agree with Dr. Guttmacher that knowing the socioeconomic status of a patient is probably more telling.
Socioeconomic status often dictates a patient’s access to health care, health food, and even a healthy lifestyle (i.e. access to a safe place to exercise and the time to do it). Dr. Guttmacher alludes to this when she is asked about her opinion on the Jackson Heart Study: “I am aware of the study and it certainly looks interesting . . . But as I have said above, there are many other factors such as class that are more clearly related to disease than race”. In fact, although the main objective of the Jackson Heart Study “is to investigate the causes of CVD in African-Americans to learn how to best prevent this group of diseases in the future”(NHLBI), considering that the study is examining a population from the state that has the lowest median household income in the nation (U.S. Census Bureau), class might actually have a higher correlation with the incidence of CVD than race. I agree with Dr. Guttmacher that our knowledge would probably be improved by focusing less on race and more on the social aspects of race and how they may be linked to socioeconomic status and, in turn, health.
March 5th, 2007 at 10:21 pm
As a country, we need to address problems with racism; especially ones that appear to be so deep-rooted people are unaware of them. Dealing with this unfortunate issue will help in many other aspects, not just our healthcare. As a medical student, I can see firsthand that both race and social status have very important implications for access to healthcare, ability to get medications, ease of compliance and other important healthcare barriers. As Dr. Guttmacher mentions, increased education will help overcome barriers for access to healthcare. I agree with Paula Braveman who addressed this issue stating, “the question is not which is more important, race or class, but how do we address both, including their complex interactions, with research and effective action.” She also stated that “racism…systematically sorts people into different socioeconomic positions, giving them different opportunities, race and racism cannot be reduced to class and class prejudice.” This shows how interconnected and integral race and socioeconomic status are to understanding health disparities and it is virtually impossible to talk about one without the other. This is partly because racism is a social construct and Dr. Guttmacher alluded to this in her interview stating how it has changed over time. I believe the best thing we can do to get people to take control of their healthcare is giving them access to resources and educating them about their health.
I also believe that unfortunately, the racism which has been ingrained in our society can create barriers to healthcare. One way to help with many of the health problems just in the United States would be to have healthcare providers strive for cultural competence (Johnson et.al, 2004). This is important because it would enable physicians to connect with their patients and allow the patients to open up about their problems. I have seen that this openness can help with compliance and satisfaction in healthcare settings. “Racial and ethnic minorities are more likely to perceive bias and a lack of cultural competence in the health system overall than are whites” (Johnson et al, 2004). If physicians are not connecting with their patients, worse health outcomes are to be expected. It is necessary for physicians to be aware of this barrier and to address it in every patient encounter because there may be a problem beneath the surface of the interaction that the physician would never recognize. Learning these skills will help all healthcare providers relate to their patients and be more effective in the management of their health.
References:
Sally Guttmacher. Conversations about Race-Based Medicine: Sally Guttmacher, PhD. Envisioning 2.0. http://fardj.prblogs.org/tag/conversations-about-race-based-medicine/. 2006.
Paula Braveman. The question is not: “Is race or class more important?”Journal of Epidemiology and Community Health 2005;59:1029
Rachel L. Johnson BA, Somnath Saha MD, MPH, Jose J. Arbelaez MD, MHS, Mary Catherine Beach MD, MPH, Lisa A. Cooper MD, MPH (2004). Racial and Ethnic Differences in Patient Perceptions of Bias and Cultural Competence in Health Care
Journal of General Internal Medicine 19 (2), 101–110.
March 6th, 2007 at 1:34 am
Thanks to Dr. Guttmacher and Envisioning 2.0 for such an interesting topic.
As an undergraduate in Anthropology and through various other life events, I have come to the realization that anyone justifying a conclusion on the basis of race simply has not looked deeply enough into the matter. In this case, the designation of medication as race specific begs the question: Where is the science?
In the original study of this medication, Dr Jay Cohn demonstrated that the combination of Isosobride Dinitrate and Hydralazine had statistically significant benefits in African-Americans with heart failure compared to all other ethnicities in the trial. The question then becomes: Why is this medication more useful in one population but not the other?
Is there variation in the receptors for DiBil and, if so, do they have a genetic basis? What is that genetic basis… On so on and so forth. And low and behold, we have made our way back to the scientific method. All of a sudden, there is rhyme and reason to our thought process in using medication other than assumptions based on the color of our patient’s skin.
Why is it necessary to stop with the race based classification of this medication? The past few decades have seen tremendous advances in our understanding of genetics and the role they play in health and wellness. Why not use these tools to understand the markers specific to DiBil to pinpoint those patients that may benefit most from its use regardless of their race? As he states in his commentary on DiBil, Gregory Petsko points out that “race is not the issue; the issue is who has the relevant trait.”
March 6th, 2007 at 2:23 am
As Dr. Guttmacher points out, “all humans are identical for about 75% of genetic factors and 95% of the variation is within racial groups rather than between them.” Therefore one would think that with such little difference between races the actuality of ‘Race Based Medicine’ will only be a matter of theoretical debate amongst bioethicists with little correlation to the real world and at the bedside of patients. To date there has not been a massive onslaught of drugs targeted to individual segments of the population with BiDil being a commonly sited drug targeted for use in African American cardiac patients. However, after reading the interview, I recognize her belief that a lot of disease could be prevented amongst groups of people if socioeconomic and environmental conditions improved, but I disagree with her pessimism towards this type of medical intervention when she states, “to focus on race as a basis for medical intervention seems inappropriate at best.” This type of research is a very rough first pass at eventually narrowing down how best to treat the individual patient in an attempt at ‘personalized medicine’ aka pharmacogenomics where drug choice and dosage is tailored to the patient’s genotype. Adverse drug reactions are the 4th leading cause of death in the US, points out there are indeed major differences in how individual patients metabolize and react to drugs making the need for pharmacogenetic research all the more important. This would lower costs of medication for patients, improve outcomes, and perhaps speed up drug development. The human genome project was completed just a few years ago, and it will take decades to decipher its entire meaning. Therefore research to date unfortunately has only focused on race as the major differing qualifier amongst large groups of people when it comes to drug development perhaps because it is an easy way to quickly separate out population groups despite the evidence that genetic differences between races are far lower than within races. There have also been cancer studies that show that immigrants to the US tend to adapt to the disease state of their new environment. For example if stomach cancer is the predominate type of cancer in the immigrant’s native country, and they move to the US there is a tendency for these populations to show a predominance towards cancers more prevalent to the US instead of their original country. This suggests that environment has more to do with disease than race alone. Therefore as the human genome is decoded it may be that grouping of populations will be done along the lines of the patient’s environment and specific genotype instead of along the unscientific and socially defined lines of race. Therefore it is possible that pharmacogenetics will shift towards population group treatment where a poor black male and poor white male from the Midwest will have tailored treatments based on a similar environment and risks. To be overly pessimistic towards ‘Race Based Medicine’ in its current form might stifle progress towards pharmacogenomics.
March 6th, 2007 at 3:26 pm
I agree with Dr. Guttmacher’s discussion on race-based medicine. It should not be the goal of pharmaceutical companies to target racial groups for the development of new drugs. Their goal should be to focus on decreasing the cost of current medications for chronic illnesses to make them more affordable to the general public. If pharmaceutical companies spent less money on advertisements to the public they could also lower the costs of infectious disease medications that are desperately needed in third-world countries. A problem in the U.S. with designing medications based on race is the factor that the population grows increasingly diverse with each generation. With the increasing diversity in the U.S., targeting a specific race will become more difficult in the future and less profitable. Advances in genetic testing will likely shift the focus of drug development to “tailor” made drugs for inherited chronic diseases not directed by race. The medical profession should focus their efforts on breaking down social barriers to accessing healthcare and treat all patients for their illness regardless of race. There are enough divisions in society, healthcare should not contribute or encourage to the segregation of patients. Healthcare should be focused on preventive care and education to decrease the incidence of chronic illnesses such as high cholesterol, and obesity for example. Health and disease differences between groups of people are often associated with their income and access to healthcare. Educating the public about healthcare and how to access the resources in their communities is more beneficial in eliminating chronic illnesses before they are diagnosed. This will decrease the incidence of disease and the need to over-prescribe medications to the public.
March 6th, 2007 at 5:06 pm
This discussion seems to be a decent examination of the problems that many people face in terms of race based medicine in this country. It is refreshing to see that more people are starting to look at race as a socioeconomic and cultural construct. We can only hope that these concepts continue to integrate into our healthcare system.
While this argument points towards class as one of the distinguishing factors in the concept of race, it seems to overlook one of the fundamental issues related to how race/class relates to health care disparity. Healthcare, at least in the US, is no longer a human right but a traded commodity. In those terms, specific socioeconomic groups are severely marginalized based on their class. The poor, and more often than not, the minorities are the ones that are far overrepresented in the forty seven million Americans that go without health insurance.
There is no doubt that our healthcare system needs drastic improvements in its perception of race both in the clinic and in the laboratory. These criticisms are practically moot if many of the minorities that require social justice have been ousted from the healthcare system entirely. While race may not be quantifiable, socioeconomic class certainly is. If we are really interested in providing equitable socially conscious healthcare, a universal healthcare plan needs to be the first step. While it is good to concern ourselves with the concepts of race it is imperative that we do not overlook some more general factors that need to be the foundation for improving our system.