http://www.culturekiosque.com/nouveau/comment/bidil_and_race_profiling_in_targeted_medicine175.html

1. Lewontin 1973 “The Apportionment of Human Diversity” in Evolutionary Biology 6:381-397

However, our country’s troubled history and the “persistence of race-related disadvantage” sheds light on the tight-rope that researchers walk, by attempting to use race as a distinction underlying physiological differences, in a culture so strongly influenced by political correctness. These supposed differences have had a “central role in the ‘scientific’ stories about race told by apartheid theorists, American white supremacists, anti-Semites, and assorted other theorists of bigotry”, so the argument against using race as a correlate for biological differences may have more to it that simply political correctness.

Still, the use of race in medicine can make a therapeutic difference as is evident by the BiDil trial’s strikingly positive results. The evidence suggesting biological differences between racial groups regarding genetics is strong. Dr. Burchard spoke of the risk factors for Alzheimer’s Disease and the “racial modifier” involved in the chances of developing the disease on top of having the ApoE4 gene, which is “common in people from all backgrounds”. Whether race is being referenced to as a “biological construct” or a “social characteristic”, the list of research-backed correlates goes on, citing differences in risk factors, therapeutic effectiveness and prognosis for various conditions. Being able to identify these differences that are impacted by race may mean better outcomes and the ability to tailor medicine as a very individualized and personal practice. Race based medicine may mean saving lives, and as Dr. Bloche wrote, “we shouldn’t sacrifice lives or health merely to avoid classifying patients by race”.

I enjoyed reading these discussions surrounding race based medicine; it is a topic of obvious debate during a time when medicine is moving towards becoming increasingly individualized while researchers attempt to avoid and discourage race-based stigmas that, given our history, are a social risk. Perhaps when using race as a “stand-in” or “proxy” for poorly-understood factors, it is important to concurrently emphasize the temporary nature of the description. Dr. Burchard mentions the need for more effort from government institutions, and Dr. Bloche agrees, including academic medical institutions, in the ethical obligation to “treat racial classification as an interim measure, pending the search for genetic and environmental determinants”.

References
M.G. Bloche, “Race, Money and Medicines”. Journal of Law, Medicine & Ethics, Fall (2006): 555-558.

Until that time however, I hope that the race-based medicine that we practice has a positive impact on the actual outcome of diseases. Thinking about this on a different level I found that as a patient I have gravitated to a certain level of race-based medicine. For example I would prefer to be treated by a dermatologist who has a lot of experience in treating darker skin. I trust that such a physician will be able to distinguish between normal hyper-pigmentation that is common in darker skin versus some pathology and that he would do this with ease. So you see if we are honest already, we tend to gravitate to health care that will treat our individual needs no matter how subtle these differences may be. Years ago quite a few parents were accused of child abuse because some doctors were unaware that Mongolian spots are common among dark-skinned babies, instead they thought the spots were bruises.

As a patient I know I will want the most optimal level of care and this means care that will treat my individual needs. The reality is, my race, ethnicity, culture, socioeconomics and spiritual beliefs all make me who I am and all contribute to my overall health. So if by practicing race-based medicine my doctor could say better treat my hypertension by including a diuretic then I say let us not be afraid but let us move forward.

He puts it well when says that, “race is an inexpensive and simple, but crude way to measure how [environmental and biologic] variables impact health in certain individuals.” It is just that: crude and inexpensive. For now, it is a valuable tool in the arsenal of any physician. He must know how his patient’s “racial” background will impact the likelihood and nature of many diseases. For these purposes, it is not really fruitful to discuss whether the impact of these diseases on a certain population is due to socioeconomic or biologic factors. We cannot control for these variables, or use one at the neglect of the other. Ultimately, “race” must be used in concert with all the other elements of a patient’s story to help deliver the most effective treatment possible.

Interview with Dr. Burchard
http://fardj.prblogs.org/2006/05/18/conversations-about-race-based-medicine-esteban-gonzalez-burchard-md/#comments

For decades, epidemiological studies have highlighted the differences in disease incidence and prevalence among the various races. “In the context of the US Census, race is usually considered a fixed characteristic of the individual, linked to his or her genetic makeup” (Burchard et al, 2005). I agree with Dr. Burchard when he states in his interview, “Regarding genetics, it is clear that there are significant biologic differences between racial groups.” Breast cancer, cystic fibrosis, diabetes, and numerous other diseases have been shown to affect the different races unequally. Furthermore, there are genetic tests for conditions such as cystic fibrosis that are tailored to a specific race or subpopulation with the purpose of incorporating the most likely set of disease-causing genes in the analysis.

Physicians are expected to provide the best possible treatment to their patients in hopes of achieving a desirable outcome, even if this means prescribing a treatment that utilizes a person’s race and background. As Burchard et al (2003) comments, “Knowledge of a person’s ancestry may facilitate testing, diagnosis, and treatment when genetic factors are involved.”

With that said . . . it is most important to focus on the individual patient and to devise a treatment that is tailored to fit his or her needs. Although race and genetics do have biological implications, we have only just begun to analyze the mechanisms of disease that may have a racial component. Therefore, it is critical not to stereotype individual patients by prescribing the same drug or treatment plan to all people of a given race. As similar as human beings are, there are still many differences between races and especially within one’s own race. Each new patient is an “experiment” when it comes to selecting and initiating a treatment.

References:

1. Burchard EG, Borrell LN, Choudhry S, et al. Latino Populations: A Unique Opportunity for the Study of Race, Genetics, and Social Environment in Epidemiological Research. Am J Public Health. 2005; 95(12):2161-2168.

2. Conversations About Race-Based Medicine: Esteban Gonzalez Burchard, MD

3. Burchard EG, Ziv E, Coyle N, et al. The Importance of Race and Ethnic Background in Biomedical Research and Clinical Practice. NEJM. 2003; 348(12): 1170-1175.

Despite my qualms, I still believe epidemiological studies are critical in medicine. Such studies invoke curiosity about the root cause of problems, and that is where true enlightenment resides. For example, a 2002 article in Oncogene presented data that suggests:

The prevalence of smoking among African American high school seniors, declined substantially from 1976-1992. This phenomenon is not explained by factors such as differential dropout rate, differential misclassification bias, differential use of other drugs, age of smoking initiation, or confounding from background or other lifestyle factors (1).

This statement goes one step further and addresses factors that can be theoretically modified over time, while the Alzheimer’s disease risk factor numbers come from sheer data collecting and calculations with no link to social, political, or economic policy. So then, why are we basing marketing and treatment strategies simply on those risk factor numbers? Better yet, for those who have no control over devising such strategies, why are we tolerating them?

1. Giovino, GA. “Epidemiology of tobacco use in the United States.” Oncogene 2002;21:7326-40

What is really meant by this term “race-based” medicine? In “How Lay People Respond to Messages About Genetics, Health and Race,” Condit and Bates define race-based medicine as “screening, diagnosis, or prescription based on the assignment of a person into a social group associated with appearance, language, culture, which is presumed to serve as a marker of the geographic origins of their ancestors.” Essentially, this definition points to a common gene pool amongst a group of people. But when you think about it, medicine has been treating people with genetic disparities differently long before the entrance of BiDil on the market. You don’t see anyone up in arms when a woman receives a different medication than a man for the same medical problem. Persons who have genetic mutations for an uncountable number of diseases or those who’s gene pool are tainted with cancer, for example, obviously receive different medical treatment due to their genetic composition. So what is the big difference? The R word. The above groups, although differing genetically just people of certain ethnic backgrounds do, are not seen culturally as races. When people, medically-orientated or lay, hear the term “race” they go into panic mode. Race has become such a sensitive topic that everyone would rather sweep it under the rug than bring it out to the forefront where it needs to be. We have these huge, festering problems facing different racial groups in medicine, but no one wants to address them. “We shouldn’t be afraid of studying the medical implications of race or genetics,” states Dr. Esteban González Burchard. But the public and scientific world are very afraid. Why? In studying different races, are some worried that they are going to find out that people are not the same? People are different-no question- anthropology, a field which specifically studies the differences in specific races and cultures, has proved this over and over. I think the problem is that these differences are seen as negative traits, when really what is negative about the differences is how people react to them or treat people differently because of them.
There are reasons why some diseases peak in certain genetic populations- Why are Native Americans more likely to get diabetes but a Caucasian more likely to get Parkinson’s? We don’t know why, and we never will if research doesn’t follow clinical trends and findings. “Personalized” medicine and research, be it based on any characteristic determined by someone’s genetic make up, can only progress medical knowledge and care further. By studying specific gene pools affected by certain diseases, overall knowledge of the disease can improve which can only help any race (or gender or high risk population) afflicted with the disease, whether it be through treatment, diagnosis, screening, or prognosis. By studying these diseases we can also find non-medical ways in which people are different, maybe shining light on ways we can promote equality across the board in all groups concerning medical and non-medical arenas. People need to accept that there are differences amongst persons and amongst races. Don’t try to tip-toe around race claiming everyone is the same–in some ways people are the same, not all—more importantly, people should be treated the same, no matter how they differ from one another.
So, should we be practicing and encouraging race-based medicine? As I see it, good physicians are already doing this, and have been for years. Taking each person, their genetic make up and environmental influences on an individual basis and assessing them for risk factors based on their genetic material and other factors including their basis of race and gender should be a part of everyday medicine where no matter what race, gender, or sexuality a patient claims themselves as. Patients receive equal treatment tailored to them, not some computer automated result. But what is lacking in this current treatment? Scientific research to back up what has clinically been proven. Clinical medicine has already accepted that there are many differences among people, now research and pharmaceuticals need to identify these differences and cater to them so everyone can benefit from increased knowledge and therapy. It must also be taken into account that besides genetic information, education, income, gender, location, and mental status all cause health disparities, but are also causes of diseases themselves, be if for genetic reasons or environmental. If people are worried about “race-based” medicine creating health disparities, they need to also assess other areas of a patient community that have wide spread effect on disease epidemiology.

References:
Condit, C and B Bates. “How Lay People Respond to Messages About Genetics, Health and Race.” Clinical Genetics. 2005: 68, p97-105.

Interview with Dr. Burchard. http://fardj.prblogs.org/2006/05/18/conversations-about-race-based-medicine-esteban-gonzalez-burchard-md/#more-113