Conversations About Race-Based Medicine: Richard Allen Williams, MD
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 am conducting 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: Dr. Richard Allen Williams
About Dr. Williams: Dr. Williams is founder of the Association of Black Cardiologists and professor of medicine at the UCLA School of Medicine. In 1987, Dr. Williams established the Minority Health Institute, which is designed to improve health care for African Americans and other minorities. Black Enterprise magazine named Dr. Williams one of the 100 best doctors in America in 2001.
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: First, I’d like to say that I question the term “race-based medicine.â€
If race-based medicine exists, then we are basing treatment decisions on a person’s skin color, which I don’t think is appropriate.
That being said, I think that race should be factored into treatment decisions. For example, there are differences in how people of different backgrounds respond to medications.
About 25 years ago, I wrote a book, the “Text Book of Black Related Diseases,†which is currently out of print. The book provides information on how disease is expressed in people of varying ethnic backgrounds. I decided to write the book because I was struck by the variations in disease incidence among people of different backgrounds. For example, hypertension and sickle cell anemia tend to strike African Americans more often.
In addition, as I mentioned earlier, it is also a good idea to look at race because some drugs work differently in certain populations. Research indicates that there are genetic polymorphisms that affect how patients respond to different medications. For some patients, the medication may be beneficial and in others, the response is not as good.
Differences in responses to medications can lead to dangerous results. Let’s look at beta-blocker use in people of Chinese descent as one example. We know that because these individuals do not react very well to these medications, we should use them very carefully – if at all.
Finally, I hope that no one is tempted to pit so called “race-based†medicine against evidence-based medicine. We should be relying on data from randomized clinical trials and scientific research to guide treatment practices.
Q: In your mind, is there a link between race and disease or is there 
something else going on?
A: I believe that disease is caused by a number of factors, not just race. A person’s socioeconomic background is one important factor. In fact, economics, combined with genetics, may influence disease incidence.
I would caution against citing a person’s genetics as the sole reason they develop a certain disease. People need to consider all of the contributors to disease expression and progression.
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? What would you do to improve them?
A: I think that efforts to educate patients from different backgrounds are not as effective as they could be. But, I think it is a good thing that people are pointing out variations in disease incidence among those of different racial backgrounds.
However, I think that pharmaceutical companies should engage in an activity that is just as important as education: testing. While I would not advise studying every medication to determine if it is going to be more effective in a specific group, we need to know more about how medications work differently in people of various backgrounds.
This all has to do with making sure that drugs are both safe and effective. You want to be sure that a medication is not going harm a certain group. However, you also want to be certain that it is equally effective in as many groups as possible.
Q: Are there any ethnic/racial groups that are currently being neglected or overlooked in health promotion efforts?
A: I think that all minority groups underserved. More needs to be done to collect data on disease incidence in people from different backgrounds. As long as we have a system that does not have adequate data on how certain racial groups are affected by diseases and medications, we won’t have enough information to manage people properly.
Some may say: “we don’t need this information.†I say we do. As physicians, we have to live up to our basic core principle of “do no harm.†We have to be sure we are not causing more problems than we are solving. We have to avoid medications that cause adverse events like sudden cardiac death.
Q: Have you been following the Jackson Heart Study? If so, what are 
your thoughts on this effort?
A: I recently toured the site of the Jackson Heart Study [the study is being conducted in Jackson, Miss.] with Dr. Herman A. Taylor Jr., the director of the project.
I think the Jackson Heart Study is impressive and important because:
- It will give us the most detailed information on African American heart health we’ve ever had.
- It will parallel the Framingham Heart Study. Specifically, the Jackson Heart Study is being conducted in a very in-depth and scientific fashion. It will look at the heart health of patients enrolled in the study and follow them forward. Importantly, the study will determine African Americans’ responses to different medications.
Overall, I am very impressed by the study and have nothing but praise for Dr. Taylor and his staff.
Q: Is there anything going on overseas around race-based medicine 
that disturbs or inspires you?
A: I’m not really cognizant about what is happening in other countries. However, I do know that there seems to be a great deal of consternation about terminology. There are a lot of people who want to toss the word “race†out of the window. There is some merit to this because race is a term that does not have a great deal of meaning.
Coming back to the United States, our history is based on racial differences and it is hard to get away from that. Race is a big part of our legacy. Unfortunately, we don’t have a colorblind society. Because we have racial groups, we also have to acknowledge racism and continue to contend with issues relating to race.
If we look at what is happening in medicine, I think that racism is the cause of many healthcare disparities. It’s the underlying principle, the driving force behind the differences we’ve observed in how people of color are [medically] managed in this country.
Without eliminating racism, we can’t eliminate race and we won’t have a colorblind society.
Q: Can you provide any general commentary on this issue?
A: A lot of what I have to say about this issue is covered in my response to the last question. However, I’d like to add that we live in a country that is governed by laws. This means that we’ll ultimately have to turn to the law to eliminate health disparities. Only a legislative solution will enable us to achieve our goal of evening out differences in how people from different backgrounds are managed.
This is a difficult track to take because a legislative solution will require that we engage the political process and that we all become committed to eliminating differences in health treatment. Achieving this goal via government will take a lot of work. The first step will be to convince the public to make healthcare available to all people – especially those most in need.
May 26th, 2006 at 9:15 am
[…] Q: Dr. Richard Allen Williams has suggested that legislative solutions are required to eliminate racial, ethnic and socioeconomic disparities in healthcare. Do you agree with this assertion? […]
July 29th, 2006 at 12:14 am
[…] Q: Dr. Richard Allen Williams, founder of the Association of Black Cardiologists has told me that he disagrees with the term “race-based medicine.†In your opinion, is NitroMed furthering the practice of “race-based†medicine? Does NitroMed view this term positively or negatively? […]
March 3rd, 2007 at 10:19 pm
Title: Treating the individual rather than the race
Topic: Genetics role in race
In the interview, Dr. Richard Allen Williams states, “I think race should be factored into treatment decisions. For example, there are differences in how people of different backgrounds respond to medication.” Dr. Williams continues on to say that he is against using genetics as the sole basis for disease and that socioeconomic status may affect the manifestation of a disease in a particular patient.
While I agree that people respond differently to treatment, I disagree with linking race to this response. Every patient has the potential to vary on response to treatment based on genetic make-up and how the patient’s body is set up to deal with the treatment provided. In a 2005 article in Advances in Nursing Science I found, “it has been confirmed that there is more genetic diversity with in the groups we call races than between them” (Tashiro 207). Thus, it is likely that a white person could share the same reaction to a drug as a black person, which might be a reaction that is entirely different from the reaction of the general populace. Studies may show that certain racial groups have similar responses to medications, but is race necessarily causative of this similar response or merely correlative? It is possible that the link between the response to a medication and the group is not race but socioeconomic status, or geographic location. I believe more studies should be done to make sure this idea that there are “differences in how people of different backgrounds respond to medication” is based on the “right” difference instead of some arbitrary thing the group of people had in common, such as race. “While the large disparities in health and disease between majority and minority populations in the United States have led to a search for contributing genetic factors, most research on health disparities strongly implicates social causes for them through such pathways as racial discrimination, residential segregation, poverty, and educational, behavioral, and cultural factors”(Tashiro 207).
Overall, I hope what is at the heart of every physician/patient interaction is the well being of the patient. I would like to think that every doctor treat his patient as an individual, separate from whatever groups or classifications the patient might be associated with. I also hope that doctors continue to use evidence based medicine and try to rely on studies that are not biased.
Sources: Tashiro CJ, Advances in nursing science. Jul-Sept-2005;28(3):203-11.
Interview with Dr. Richard Allen Williams March 22, 2006 http://fardj.prblogs.org
March 4th, 2007 at 8:24 pm
1. Title: Genetics will resolve race based medicine
2. Topic: Race-based Medicine
3. Interview response Dr. Richard Allen Williams
Leo Arko 3-4-07
Race is a superficial classification that is easy to make because outward appearance is easy to asses, but it does not correctly identify potential health problems or treatment outcomes. There have been many genomic studies that show what we think of as race really doesn’t account for most of our genetic diversity. “Consider an apportionment of Old World populations into three continents (Africa, Asia and Europe), a grouping that corresponds to a common view of three of the ‘major races’. Approximately 85?90% of genetic variation is found within these continental groups, and only an additional 10?15% of variation is found between them” (Jorde & wooding) A more in-depth analysis of a person should be taken into account, because superficial racial evaluation may lead to unwanted health outcomes. An evaluation of racially based studies should take place as well as what classifies racially based disease.
One problem with racially based medicine is the lack verification. The studies conducted that lead to the first racially based medication was poorly done, and completed in a poor manner just to allow a drug to stay on the market longer. When BiDil, the first race approved drug, was originally studied there was found to be no efficacy (Cohn). Then the study designers decided to break the statistics into racial categories. There was found to be some small efficacy in African Americans. A new study was then designed but this time only African Americans were involved and efficacy was found to be greater than placebo). ( NitroMed) This was a poorly conducted study, because it did not compare the African American against other races, like a study testing race approval should. This study does not hold up to the standards of evidence based medicine.
There are several studies that show the there is more to disease than racial classification. One study looked at hypertension in people of African descent to people of European descent North America, Europe, and Latin America. “This study found that Surveys from Cuba, Trinidad and Brazil have also shown a smaller black-white gradient in BP than found in North America.”(cooper et. al) This study greatly points out that there are many factors influencing disease than just racial classification. Because of multifactor causes, an in-depth look into each patient should take place rather than racial classification.
With the advances in speed and knowledge of the human genome racially based medicine will soon become obsolete. The growth in knowledge about the true cause of a genetic illness will become more apparent and racial classifications will no longer be needed.
“When large numbers of loci are evaluated, it is often possible to infer individual ancestry, at least approximately. If done accurately and with appropriate reservations, ancestral inference may be useful in genealogical studies, in the forensic arena and in the design of case-control studies. This should not be confused, however, with the use of ethnicity or race (genetically measured or self-identified) to make decisions about drug treatment or other medical therapies. Responses to these therapies will often involve nongenetic factors and multiple alleles, and different populations will often share these alleles. When it finally becomes feasible and available, individual genetic assessment of relevant genes will probably prove more useful than race in medical decision making.” (Jorde & wooding)
Cohn J N. The Vasodilator-Heart Failure Trials (V-HeFT):mechanistic data from the VA Cooperative Studies. Circulation1993: 87 (suppl 6 ): V 1–2.
Cooper RS, Wolf-Maier K, et. all. An international comparative study of blood pressure in populations of European vs. African descent. BMC Med. 2005 Jan 5;3:2.
NitroMed. Press Release: NitroMed receives FDA letter on BiDil NDA, a treatment for heart failure in black patients. March 8, 2001.
Jorde L B & Wooding S P. Genetic variation, classification and ‘race’.
Nature Genetics 36, S28 - S33 (2004)
March 5th, 2007 at 12:29 am
1.Title: The Delicate Topic of Race Based Medicine- Two Issues in One
2. Topic: Race-based Medicine
3. Interview response Dr. Richard Allen Williams
The topic of race-based medicine is one that is very important and needs to be discussed- just in the right context. When discussing race-based medicine there are actually two different subjects at hand. One of these is the topic of a genetic association and treatments. I agree with Dr. Richard Allen Williams in the interview with Fard Johnmar as he states, “it is also a good idea to look at race because some drugs work differently in certain populations. Research indicates that there are genetic polymorphisms that affect how patients respond to different medications. For some patients, the medication may be beneficial and in others, the response is not as good.” This statement is the bottom-line in race based medicine and brings us back to what will determine if race-based medicine is beneficial or detrimental to our progress in equality-, which is evidence-based medicine. Evidence-based medicine has shown time and time again that there is a link between people of a certain race and responses to medications, predispositions to illness and genetic disorders. The other topic that the term “race-based medicine” brings up is the issue of different races and their actual treatment by physicians. In the study by the Department of emergency medicine, Emory University School of Medicine, “Racial and ethnic disparities in the emergency department: a public health perspective,” multiple resources showed that racial and ethnic health care disparity exists within the ED. This supports an additional study conducted in 1999 by IOM, which is a private, independent institute of the National Academy of Sciences, which studied if racial and ethnic disparities in the quality of care existed and showed significant evidence supporting this. This type of disparity among treatment is a risk that we run increasing if we begin treating people according to the color of their skin. Race based health care is a very delicate balance that requires we acknowledge and encourage research regarding race and our differences genetically, while at the same time trying to reduce the factor that race has on the actual care of patients. These are very important issues that must be addressed and researched further. If used properly race based medicine has a great possibility of closing the gap in treatments allowing us to better tailor health care to different races and their associated health problems, it is just important that we do not let it dictated our quality of care.
References:
Keppel K., Pearcy J., Wagener D.: Trends in racial and ethnic-specific rates for the health indicators: United States, 1990–98. National Center for Health StatisticsHyattsville2002.
Heron SL; Stettner E; Haley LL Jr,: Racial and ethnic disparities in the emergency department: a public health perspective. Heron SL - Emerg Med Clin North Am - 01-NOV-2006; 24(4): 905-23
Interview with Dr. Richard Allen Williams March 22, 2006 http://fardj.prblogs.org
March 5th, 2007 at 5:21 pm
Name: Andrea King
Date Posted: 3/5/07
Interview: Dr. Richard Allen Williams
Topic: What is Race-Based Medicine?
It’s All in a Name
Really…what is Race-Based Medicine? We like to give catchy names to topics to stir debate and discussion but this type of naming has no place in the medical field. In attempting to maximize efficacy and minimize side effects, pharmaceutical development has become increasingly specialized. When analyzing treatments on a molecular level there will be a difference in the way each person responds. We all have a unique genetic make-up. This different genetic response will often follow racial lines because of ancestral environments. However, different responses to disease and treatment also follow gender and age lines. For example; breast cancer or depression incidence in females vs. males, CLL in seniors vs. youth. Treatments that take into consideration these unique factors don’t stir such debate. (Gardasil is perhaps an exception; however, the debate has more to do with sexual activity in youth as opposed to vaccine use specifically in women.) Dr. Williams mentions in his interview that “there are genetic polymorphisms that affect how patients respond to different medications”. Generally, I think that the medical community is in agreement on this reality.
That being said, there is such a thing as racism in medicine. This encompasses a wide variety of topics. Healthcare disparities most certainly exist because of socioeconomic differences, physician bias, access to care, or patient skepticism. These disparities often follow racial lines as well. For example, patient skepticism following racial lines is usually the result of a population’s previous poor treatment. A few reasons certain racial groups are skeptical of medical research are the fear of a Tuskegee repeat in the African-American population or the Navajo population’s refusal of genetic testing due to cultural beliefs and mistrust.
Physicians will always take into account race, gender, age, and other factors in treating a patient as it can help indicate a diagnosis and a treatment. Sadly, underserved communities may not always see fair and just treatment as a result of this common analysis. However, the subject of racism should play no factor in the analysis of the efficacy of a drug. Racism and pharmaceutical development for an individualized population are different topics. When these two topics seem to collide in the case of Bi-Dil, it hits a nerve in many people but the developers need to step back and analyze the problem of insurances not covering Bi-Dil from an evidence-based medical standpoint to counteract the opposition with facts and improvements to the drug (ex. extended release and trials comparing Bi-Dil with generic combos). Mixing the two topics can only lead to angry debate over the deep rooted, complex issue of racism in medicine and potentially stall the important process of much needed advancements in specialized treatments for genetically different populations.
March 5th, 2007 at 11:46 pm
Race based medicine is a socially charged concept that seems to me to be a distracter from the sound scientific investigations that are occurring here. Much of what science has learned about the pathology of disease has relied on isolating the genetic characteristics of disease based on the study of as genetically homogeneous a population as possible. As in other scientific pursuits, “Gene Hunters” look to minimize as many variables as possible and if using the artificial human constructed concept of race is a valid method to eliminate extraneous variables in getting at the true biological mechanism of disease, then I am all for it.
In an earlier interview on this topic Dr. Sally Guttmacher pointed out 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.” What a great starting point for the genetic exploration of the mechanisms of a disorder. If science can empirically notice a difference between two large sets of individuals, in disease course or response to a specific therapy, and these populations are only ~5% genetically disparate as a group, then I see real potential to make great insights into the pure biological factors of the disorders.
Dr. Michel L. Sabolinski stated in another interview on this site: “Skin pigmentation is at best a poor surrogate marker for looking at responses to medication.” We must accept that it is, to some extent, genetically determined and thus somewhat of a predictor of genotype. Though many of us desire to live in a “colorblind” society, the objective information that this trait gives us may be of some medical benefit as in the case of Bi-Dil.
I guess that I am being naive in thinking that physicians will not consider skin color in deciding whether or not to treat a patient a certain way unless there is clear evidence that a specific treatment will work better in a specific population with a specific genotype that can be outwardly indicated by such a stigmatized factor. I understand that the point of these interviews is to try to address some of the unfortunate racism that still lingers in our great country, but I feel that as scientists we must vigorously work to suppress any biases that we have acquired during our lives, especially ones so misguided as judging others based on outward physical appearances. Instead we should do as Dr. Williams has advised and become politically active to “convince the public to make healthcare available to all people, especially those most in need.” In my opinion, eliminating competition for this valuable resource would go a long way toward preventing groups from blaming the “other” for their inability to get treatment. The elimination of bias, real or perceived, in the allocation of resources in our society will go the furthest in eliminating racism and thus achieving the “colorblind” medical system that would be most beneficial to all members of society.
March 6th, 2007 at 12:48 pm
I agree with Dr. Williams that it would be naïve for people to think that all people respond to all treatments in the same manner. Differences in genetics, environment, culture and socioeconomic status cause certain groups of people to become afflicted with different ailments. The fact that certain races are afflicted with certain diseases more than others helps physicians narrow down their differential diagnoses. There have been many cases in which certain races seem to be intolerant of specific treatment options. Other racial populations seem to respond more favorably to certain treatment options. For example, the antihypertensive drug BiDil appears to be more effective in African Americans due to a “distinctive pathophysiology found primarily in African American patients” that causes nitric oxide insufficiency (1). In medicine, the patient’s best interest should come before all else. If a patient can benefit from a drug therapy that was produced with that individual’s race in mind, it should be used above therapies that have been shown to have questionable effects within that racial population. The main problem I see that may arise in the setting of developing therapies based on race, is that pharmaceutical companies may be less willing to spend time and money developing therapeutics for populations that tend to not have insurance. It seems likely that pharmaceutical companies will only develop race-based therapeutic for the more stereotypically affluent populations in society that have insurance and can afford the drugs. Also, pharmaceutical companies would be less likely to develop drugs for racial groups are a small portion of the population. Currently there is little if any regulation placed upon pharmaceutical companies that would prevent them from ignoring development of phamacogenomic products for races that are underrepresented or of low socioeconomic status (2)(3). I think it is very important for the medical field to explore the benefits of race-based medicine, but I also feel that the process needs to be done in a manner in which some form of equality can be guaranteed.
(1)Kahn J. How a drug becomes “ethnic”: law, commerce, and the production of racial categories in medicine. Yale J Health Policy Law Ethics. 2004;4: 1-46.
(2)Emilien G, Ponchon M, Caldas C, Isacson O, Maloteaux JM. Impact of genomics on drug discovery and clinical medicine. QJM. 2000;93(7):391-423.
(3)Rai AK. Pharmacogenomic interventions, orphan drugs, and distributive justice: the role of cost-benefit analysis. Soc Philos Policy. 2002;19(2):246-270.
June 6th, 2007 at 6:03 pm
Dr Richard Allen William I have several questions regarding CHF in African American women.
Thank You
August 9th, 2007 at 10:18 pm
Dr. Williams knew my dad (Smitty) Wilson Smith, from Wilimington Delaware. I would like to get in touch with him or he with me. Thank you,
Thomas J. Smith