Conversations About Race-Based Medicine: Esteban González Burchard, 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 BiDil, 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. Please click here to read the other interviews in this series.
Interview Subject: Dr. Esteban González Burchard
About Dr. Burchard: Dr. Burchard is assistant professor of medicine at the University of San Francisco Medical Center. Dr. Burchard’s research interests center around identifying “ethnic-specific†genetic and biologic risk factors for asthma, asthma severity and drug responsiveness among U.S. ethnic and racial minority groups. In addition, he focuses on how race and racially specific genetic differences influence disease and response to pharmaceutical therapies.
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: Race is a proxy for a variety of variables that influence health including environment and biologic factors. We do not fully understand how these factors influence disease or how to measure them. Despite this, race is an inexpensive and simple, but crude way to measure how these variables impact health in certain individuals.
Having said this, it is clear that race is a highly controversial subject. When we talk about race in medicine it conjures up negative feelings about controversial events like the Tuskegee experiment and the forced sterilization of Mexican women of certain backgrounds.
Overall, we (as scientists) feel that there are tremendous benefits from studying “race-based medicine.†We shouldn’t be afraid of studying the medical implications of race or genetics. The information we gather from these types of studies may help further medicine in the long-run. We didn’t let fear prevent us from going to the moon, Mars or other planets although the same technology employed to achieve those milestones is used to make bombs. We should feel the same way about race-based medicine.
Q: In your mind, is there a link between race and disease or is there
something else going on?
A: There is a huge debate going on between those who believe that race is a biologic construct and people who think that race is a social characteristic. What I mean by this is that some think that racism and socioeconomic factors significantly impact whether people will develop certain conditions. Others believe that genetics and race have more of an influence.
I think that this debate is fueled by the media and miscommunication between biologists, clinicians and social epidemiologists. People from both sides are painted as being in one camp or the other.
My view is that the situation is more complex. Disease is caused by combination of biologic and sociological factors. So, we can learn from both sides of the debate. For example, it is clear that discrimination and socioeconomic conditions can be internalized and lead to an expression of disease. Racism and poverty are both social factors that are expressed as medical conditions.
Regarding genetics, it is clear that there are significant biologic differences between racial groups. For example, there is a very well known risk factor for Alzheimer’s Disease, the ApoE4 gene. Many people agree that if you carry this gene your chances of developing early-onset Alzheimer’s is significantly increased.
What is less discussed is that there is a racial modifier for Alzheimer’s disease. Japanese and Caucasian people with the ApoE4 gene develop this disease at much higher rates than African Americans. Specifically, if you have this gene and you are Japanese, your risk of developing Alzheimer’s is increased by a factor of 33. If you are Caucasian your risk increases by a factor of 15. However, if you are African American, your risk is only increased by a factor of six.
In sum, you have this major risk factor for Alzheimer’s, the ApoE4 gene, which is common in people from all backgrounds. However, Japanese and Caucasians with it are more likely to develop Alzheimer’s than African Americans. We don’t know why this is. (Editor’s Note: For more information on the link between Alzheimer’s risk and race, please see “The importance of race and ethnic background in biomedical research and clinical practice,†by Burchard and colleagues in The New England Journal of Medicine, March 20, 2003, p. 1170.)
My point is that we cannot close our eyes to the links between race and disease because of fear or political correctness. Otherwise we will never be able to identify clinically important risk factors and responses to medications caused or impacted by race.
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 many efforts to communicate to different races and ethnic groups about disease is pure marketing. I also think that activities are very uneven and depend on whether there is a market for a disease.
For example, there are a lot of people dying of malaria and AIDs in many parts of the world. However, there isn’t enough emphasis on educating these groups because there is no market in areas where people are affected by these conditions.
I think there needs to be more effort from government institutions like the National Institutes of Health (NIH). It’s even harder now that funding for public health initiatives has been reduced across the board.
Q: Are there any ethnic/racial groups that are currently being
neglected or overlooked in health promotion efforts?
A: There are tons of groups in the United States that are being neglected – in research and health promotion efforts. For example, from a research perspective, there is a lot we don’t know about how people from different racial and ethnic groups respond to pharmaceuticals.
We need a lot more information on Native Americans, Asians, Hispanics and other groups. There is tremendous value in looking at these populations to determine how medications work and diseases are expressed in different racial, social and cultural environments.
Overall, I think we have a long way to go.
Q: Have you been following the Jackson Heart Study? If so, what are
your thoughts on this effort?
A: I don’t have a lot of knowledge about the Jackson Heart Study. However, from what I’ve heard of it, I think that it’s a great effort. 90 percent of research dollars are directed at Caucasians and we need to target more resources toward African Americans and other ethnic and racial groups.
I also think that we need to examine how we respond to news about studies that are conducted in non-white populations. We conduct one large-scale study in African Americans and it is characterized as race-based medicine. These perceptions have to do with how we view this type of work and who decides the overall direction of scientific research. That direction is driven by the scientists who are initiating and reviewing grants that are funded by the NIH. These individuals tend to be white males so it is not surprising to me that the majority of funded studies are conducted in Caucasians.
I’m convinced that if we had grant review committees headed by African Americans we would see real differences in the types of studies that are funded.
Q: Is there anything going on overseas around race-based medicine that disturbs or inspires you?
A: I am not aware of any large scale studies that are going on overseas focusing on race-based medicine.
However, I do know that Mexico is trying to get a better understanding of how race and racial admixture influence disease expression. My group has proposed a study on this topic to the Mexican government and they have expressed some interest in pursuing it. This is because Latinos are a mixed population of Europeans, Native peoples and Africans. This study will help us gather important information about how disease is expressed in populations with diverse ancestries.
My group has published a number of papers showing that disease risk varies depending on a person’s racial background. For example, the more Native American you are, the milder your asthma. However, the more European you are, the more severe. The Mexican study is the only example I know of where a political body or a country has decided to examine this issue on such a large scale.
There are projects headed by independent investigators in different countries looking at racial differences between Maori people in New Zealand and whites. However, these projects are driven by individual scientists.
Q: Can you provide any general commentary on this issue?
A: Unfortunately, race based medicine is one area of science that is mired in politics and political correctness. White supremacists like this topic because it validates their assumptions. People who are politically correct don’t like it because it shows that there are variations between different groups of people.
I think in the long run we will see there is value to this type of research. We will understand how different diseases are expressed in a variety of environments (genetic, cultural, dietary, socioeconomic). Once we get beyond our terrible past and the history of race in America, we will begin to understand that there are great benefits to looking at how race impacts medicine.
We also need to make sure that public, taxpayer-funded research is conducted in all populations so that everyone can benefit from it. I don’t think that everyone (or every group) has gotten their fair share.
November 6th, 2006 at 3:49 am
There’s some interesting points in your articles
it’s great to read them.
Blog has been booked marked, and really
looking forward to coming back
March 1st, 2007 at 9:03 pm
From a medical student’s point of view, these interviews are very interesting. The interviews focus on a topic that will be brought further into the light as treatments start being tailored toward a person’s individual genetic make up.
Although, race and ethnic background have been used in the United States as a cause for discrimination and prejudice, the medical community does derive beneficial use of these categories. Racial and ethnic categories have their purpose in epidemiologic/clinical research and in evaluating a patient’s risk for various diseases. As cited by Dr. Burchard in this interview, there is a clear link between race and your risk of developing Alzheimer’s disease. It is true that socioeconomic factors play a major role in determining health outcomes and the prevalence of disease within a population but I think it is hard to ignore the genetic connection different races and ethnic groups share.
Dr. Burchard says it best, “My point is that we cannot close our eyes to the links between race and disease because of fear or political correctness. Otherwise we will never be able to identify clinically important risk factors and responses to medications caused or impacted by race.†Additionally, at the end of the interview I think Dr. Burchard is correct in stating, “Once we get beyond our terrible past and the history of race in America, we will begin to understand that there are great benefits to looking at how race impacts medicine.â€
This is an exciting time in medicine and I can only look forward to what the future will bring. Additionally, thank you Fard for taking the time to perform these interviews.
March 3rd, 2007 at 12:13 am
As a first year medical student, I will admit that I have a lot to learn about race and ethnicity in medicine. The more I learn about how diseases may have different etiologies or possibly different treatment options based on different racial groups, the more important I realize this topic is. As a future physician, I can’t help but feel that the more we know about how a disease process might tend to work in an individual, the better care we can give, and this is the whole point of medicine in the first place. This is why I fully agree with Dr. Buchard’s statement that there is a tremendous benefit to studying race-based-medicine.
I have much respect for Dr. Burchard’s work on asthma. I have enjoyed reading the following paper: “Lower Bronchodilator Responsiveness in Puerto Rican than in Mexican Subjects with Asthma.” In this paper, he concludes that “Puerto Ricans with asthma had more severe disease than did Mexicans on the basis of lung function measurements, responsiveness to ?2-adrenergic agonists, and health care use”. He also concludes that “Puerto Ricans with asthma respond less to albuterol than do Mexicans with asthma.” These findings have direct implications to the care of patients with asthma. If another pharmaceutical is found to work better in Puerto Ricans than albuteral, for example, but not better in Mexicans, obviously the care should be changed to be optimal for both groups. To ignore differences in people that might lead to them having better health, and thus better lives, seems completely absurd. I am very interested to see the results of future race-based research studies. I have very much enjoyed reading Dr. Burchard’s interview.
Esteban Gonza´lez Burchard, Avila PC, Nazario S, Casal J, Torres A,Rodriguez-Santana JR, Toscano M, Sylvia JS, Alioto M, Salazar M, Gomez I, Fagan JK, Salas J, Lilly C, Matallana H, Ziv E, Castro R, Selman M, Chapela R, Sheppard D, Weiss ST, Ford JG, Boushey HA, Rodriguez-Cintron W, Drazen JM, and Silverman EK. Lower Bronchodilator Responsiveness in Puerto Rican than in Mexican Subjects with Asthma. Am J Respir Crit Care Med 2004;169:386–392.
March 3rd, 2007 at 6:57 pm
I found myself very much in agreement with the remarks of Dr. Burchard. In my view, they constitute a reasonable and informed approach to the issues raised by “race-based medicine.” He acknowledges that the interactions of health and medicine are complex and incompletely understood. He points out the determinants of health have both biological and sociological components, an assertion that seems both intuitively obvious and empirically supported. Dr. Burchard also acknowledges that race-based medicine is an inherently controversial and politically charged subject, since its discussion takes place in a society that is still struggling with a troubled legacy of racial discrimination. But he is firm and clear in explaining that there is more to be gained by considering the biological and sociological elements of race in medicine than by simply ignoring them or pretending they don’t exist.
Epidemiologically, there would be no point in ignoring racial backgrounds, as this gives potential insights into both the biological and social elements of disease. Genetically, it is clear that some populations have greater predispositions to certain diseases. In the case of diseases like cystic fibrosis and sickle cell anemia, the genetic variations are fairly well understood. As Dr. Burchard points out with his example of Alzheimer’s disease, in other cases the genetic contributions to disease are important but the details and nuances remain murky. As the BiDil controversy has exposed, there seem to be different responses to medications among ethnic groups. The emerging field of pharmacogenomics clearly suggests that drug responses and side effects are closely related to genetic makeup. Race may primarily be a matter of social and cultural construction and experience, but there are still biological factors that lay beyond these notions.
Still, at the end of the day, physicians treat individual patients, not racial groups. The study of race-based medicine, just like the study of geographical, environmental, sex-based, and age-based factors in medicine, only gives the clinician some broad information to consider in making a diagnosis and prescribing treatment. To this extent, it is useful but also limited. If a certain ethnic group is more likely to contract a disease or respond to a treatment, then as a doctor, I would certainly want to have access to that knowledge. But I would only see it as helpful, not determinant. We learned in our study of genetics that individual genetic variation within an ethnic group can exceed genetic variation between ethnic groups, a finding that offers immediate and direct repudiation of racist thinking, beyond what we already know from personal and social experience, i.e. that racism depends on ignorance and learned stereotypes rather than biological differences. As medical science continues to unravel the secrets of genetics and brings concepts like genetic microarrays into clinical practice, perhaps we will be able to leap over race as a concept in diagnosis, prognosis, and treatment, and move directly to where we would like to be, i.e. seeing and treating the patient as an individual rather than just as a stereotyped member of a group. In the meantime, we remain stuck with the useful but limited idea of breaking people into racial categories and so can end this comment with the words Dr. Burchard perceptively and concisely used in beginning his interview remarks: “Race is a proxy for a variety of variables that influence health including environment and biologic factors. We do not fully understand how these factors influence disease or how to measure them. Despite this, race is an inexpensive and simple, but crude way to measure how these variables impact health in certain individuals.”
March 4th, 2007 at 3:22 pm
Few would argue with Dr. Burchard’s points that race is a universal, relatively easily identified and defined (compared with say someone’s entire genetic and/or socio-behavioral profile) variable that has a very strong impact on how a given individual or group of individuals will respond to a medication or experience a disease. Dr. Burchard says “Race is a proxy for a variety of variables that influence health including environment and biologic factors. We do not fully understand how these factors influence disease or how to measure them. Despite this, race is an inexpensive and simple, but crude way to measure how these variables impact health in certain individuals.” Put simply, a person’s race can be thought of as largely indicative of both their genetic make-up and pattern of behavior, and thus can be used as an easy and cost-effective way of getting at the incredibly complex network of variables created by those two factors. I do not dispute this point and feel that given that our current knowledge of genetic factors, while expanding, is relatively limited, and applying that knowledge in a clinical setting on a regular basis is not practical or cost effective, and further that obtaining a complete socio-behavioral profile of an individual patient is met with the same practical limitations, using race as a discrete variable in relation to response to treatment and disease process is the best option we have when researching these subjects.
However, it should not be forgotten that race, in and of itself, is meaningless. It is an indicator of a complex of other variables and likely has a very large amount of variability and validity within itself, and therefore cannot be considered to impact treatment decisions in the same way that, say, an individual’s ApoE4 gene status can. In a talk given by Dr. Melissa Gonzales at the University of New Mexico School of Medicine on racial and ethnic disparities in health care the issue of “stereotyping” is brought up. She sites specific evidence of disparities that exist between different racial and ethnic groups in access to end stage renal disease treatment and describes how the act of “stereotyping” can, consciously or unconsciously, influence the decisions a physician makes, perhaps causing them to be less likely to support pursuing a transplant operation in patients of certain backgrounds. Essentially, it appears that a person’s race can influence their likelihood of receiving a transplant despite the fact that race does not influence how likely a person is to respond to a transplant. Given this fact, the dangers of practicing “race-based medicine” are a bit more clear. The danger is not found in using race as a marker of other variables, but rather in using race as a sole marker, a “short-cut,” and making treatment decisions that are not evidence-based or in the best interest of the patient.
Research should absolutely examine how different racial and/or ethnic groups experience various diseases and respond to treatments. However, the aim of that research should not be to categorize a certain ethnic or racial group as responding in a certain way, but rather to tease out the specific genetic and socio-behavioral characteristics that contribute to why a certain group of people responds the way that they do.
March 4th, 2007 at 5:19 pm
Response to Dr. Esteban Gonzalez Burchard
The issue of race-based medicine is quite interesting to me as a future physician. I agree with Dr. Gonzalez Burchard when he states that race based medicine is an important area of research for the future. If people of different races can be treated more effectively with certain drugs as first-line therapy and this influences health outcomes, it is important to do the research to maximize the health of each individual. I also think it is interesting that Dr. Gonzalez Burchard is of the opinion that this issue is not only biological, but also socioeconomic in nature. These two factors do need to be sorted out: research that focuses not only on race, but also on differences between socio-economic groups within a race of individuals. I do see one potential problem that needs to be addressed. It is important to ensure that people will not be discriminated against for insurance based on the outcomes of the studies. For example, when applying for some life insurance, the rate is based on age and health. It may be determined by the race-based studies that some races have less of an ability to respond to certain medications, and therefore have poorer health outcomes. For example, according to the national center for health statistics in 2002 white individuals over the age of 75 have hypertension at a rate of 77.3% and African Americans have HTN at a rate of 85.6%. If research were to show that Africans Americans also respond to current HTN medications at a much lower rate, the potential arises for an increased amount of discrimination to prevent financial burden on an insurance company based on a racial basis. If such differences are found, no matter what the race, it is important to prevent insurance companies from increasing rates for people who happen to be a part of that specific race.
March 4th, 2007 at 9:02 pm
As a first generation American born to two immigrant parents I feel race has always been an issue in my life. Although neutrality has always been my goal when discussing racially based issues I agree with Dr. Burchard when he says “…race is a highly controversial subject.” Whether the issue at hand is affirmative action, controversial research studies, or race based medicine, the underlying subject of race makes people uncomfortable.
Now, as a first year medical student with limited clinical experience, it is apparent that race, cultural beliefs, past experiences, and many other factors play an immense role in how an individual person decides to manage their health. Disease and its treatment has only been considered regarding biological systems. There are many more variables involved that can affect a person’s outcome. Learning these differences amongst patients can lead to successful and more economic treatments. If research can figure out the amazingly complex variable of race and its associations with medicinal treatments perhaps more patients can be treated successfully.
Unfortunately, the “…miscommunication between biologists, clinicians, and social epidemiologists” that Dr. Burchard commented on in his blog will be a constant source of barriers for this effort of race based medicine. This conflict will only lead to the delay in dispensing essential treatment information to the people who need it the most – patients.
Ultimately, I think the outcomes of this type of research can lead to much needed changes in how we manage the direct treatment of individual patients. I can only hope the information will be available and of good use for me and my future medical colleagues.
March 4th, 2007 at 11:10 pm
Of the posted interviews, I found Dr. Burchard’s to be the most realistic. In his interview he commented on how members of the medical community do not study race to avoid the implications of doing so. Studying the effects of genetics and race on medicine do not make someone more ‘prejudice’ towards racial groups. In my opinion, it is studying a target group of individuals with the goal to understand or better learn how to treat a disease. Race is just as significant a factor in the predisposition of a disease as is socio-economics. Race is the one thing that patients can not change about themselves, it is always a constant.
While there is variation within different races, I don’t think there is enough to not take race into account. An article titled “Race in Medicine” published in Science in 2003 discussed the different metabolism of medications between racial groups. The following quote from “Race in Medicine” is just one example. “Genaissance Pharmaceuticals in New Haven, Connecticut, has found a mutation of a major metabolism-controlling enzyme that occurs in 30% to 40% of Asians and less than 5% of members of other groups. Such findings help explain what many doctors have long observed — that many people of East Asian ancestry need smaller than average doses of a variety of heart, pain, and psychotropic drugs.” If research like this wasn’t being conducted physicians wouldn’t have any evidence to why East Asian individuals need a smaller dose of medication. By conducting research that focuses on race the knowledge within the medical community will grow. The information obtained will be used to help patients and provide better medical care.
Research scientists should not be worried that colleagues will think they ‘prejudice’ for conducing research with a race component. I agree with Dr. Burchard when he said “We shouldn’t be afraid of studying the medical implications of race or genetics.”
Krysta Johnson
Race and Medicine , By: Holden, Constance, Science, 0036-8075, October 24, 2003, Vol. 302, Issue 5645
Burchard, Esteban, Conversations About Race-Based Medicine: Esteban González Burchard, MD
March 4th, 2007 at 11:49 pm
The issues touched upon in the interview with Dr. Burchard are quite intriguing. It would be hard for me to disagree with anything he commented on regarding race-based medicine. As a first year medical student with a moderate amount of basic science knowledge I would have to say that there is strong link between race and disease. This may come about in various fashions such as genetic predisposition, lifestyle, diet, and socioeconomic background. Whatever the case may be, tailoring therapy, pharmaceutical or otherwise, seems like a no-brainer. It’s kind of like a clothing company only selling one kind of shirt to everybody regardless of their size or style preference. It’s just not going to work. The therapies need to be diversified to better fit the individual needs of each patient.
Dr. Burchard commented on many races being underrepresented in healthcare promotion, education, and research not only in the United States, but throughout the world. I couldn’t agree more. Many lives can be positively affected if the focus of healthcare was broadened to be all-inclusive. Not only would those who have been neglected benefit from such a change, but medicine and science as a whole would gain much needed insight. As Dr. Burchard pointed out most of the direction as to where money goes for research and education comes from white males. Hence, most of the research and education is focused on whites, and that’s the way it has been for a very long time. The most logical way to change this is to incorporate diversity into the upper echelons of government agencies and large companies. As we all know change is slow. Until we can get the needed diversity in such positions, those who are currently making the decisions need to hear from us who are informed on such subjects as race-based medicine.
March 5th, 2007 at 12:31 am
I definitely agree with Dr. Burchard’s comments. In today’s world of political correctness, it is difficult to forget the controversy surrounding socioeconomic and racial issues. While some might argue that race is merely a social construct, and others argue that race is purely genetic, Dr. Burchard’s view that disease is based on genetics and sociological factors seems to be the key point. Regardless of whether or not race is genetic, what is important is that disease itself is caused by many different factors, and addressing each of those factors independently allows scientists to best study disease.
Instead of viewing BiDil (and other medications targeting disease within particular races) as a racist medicine segregating society, why not view it as scientists’ attempt to understand a group of people that have been underrepresented in academic studies? As Dr. Burchard said, 90% of research dollars are used on Caucasians. Based on the composition of this country it only makes sense that more research money go towards other groups of people.
Clearly, race (and its link to disease) is a very sensitive subject. However, the underlying point is that until doctors are 100% sure of all the causes of disease, every little bit of research helps. Until, we are able to effectively target every major disease, research into potentially causative factors (including genetics, socioeconomics, etc) is necessary.
March 5th, 2007 at 1:29 am
People who disagree with research based on race and ethnicity and medicine practiced based on that evidence are probably reaching that decision because they lack some very important knowledge. An important point they might be overlooking is that scientists or physicians who do not actually believe that races differ by inherent qualities that make one better than the other. When studying health disparities the goal of a researcher is to try and figure out why racial or ethnic differences exist. Many differences can be explained by cultural differences affecting access, diet and exercise. Others can be explained by genetics or socioeconomic and environmental factors. Now when the conversation comes to genetics people are again confused because they think that this implies a genetic difference between races. The Human Genome Project has clearly shut the door on that possibility. The reason this type of research is important is because historically different racial groups have been separated geographically and have mated mainly within those groups. This has led to aggregation of some specific genes in those populations. Some genes may be detrimental to health, like the ApoE4 gene referenced above. Others may provide protection, ApoE2, for example. Also, probably because of interaction of other genetic factors, those genes pose different levels of risk or benefit to different racial populations. The main point I am trying to get across is that there are some common misconceptions, even in the medical and biomedical research fields, that are inhibiting research into the exact cause behind racial disparities. If we can pinpoint the causes we will have taken the first step towards resolving them. Another way to think of it is to try to find what factors may be providing a benefit to the group with lower incidence. We can then better target preventative education. Additionally there is the role of pharmacogenetics and cultural attitudes toward medicine. With the progression of genotyping and genome sequencing technology we will one day not need to assume genetics based on race. Unfortunately the hospitals are probably the last place that technology will show up. Many areas of medicine depend on the physician to make decisions based on limited time and information. We practice evidence based medicine whenever the evidence is available, yet we remember that most statistics are not all or none. Balancing this is the art of medicine which is passed on from previous generations of physicians.
March 5th, 2007 at 11:58 am
[…] Nick Anast On Esteban Gonz¡lez Burchard’s Interview […]
March 5th, 2007 at 7:39 pm
Even in the small amount of medicine that I have acquired thus far, I have seen a substantial amount of evidence to support Dr. Burchard’s linkage between race and disease. For example, the epidemiological studies make it impossible to ignore the increased risk of Alzheimer’s for Japanese and Caucasians versus African American. As a medical student, I found that I never examined the underlining connotation behind associating race and disease. That is, I did not contemplate how feelings of racism and discrimination could be provoked once the medical world started delving into these issues. However, the lack of evidence to conclude why there is a racial discrepancy highlights the vast deficit of scientific knowledge that must be looked into further.
In classes such as PIM and Foundations of Clinical Practice, we as medical students are taught to properly ask the most sensitive questions, such as their marital issues, illegal drug usage, and sexual practices and orientation. Using this personal information, we are able to treat the patient more effectively by tailoring it to include their risk factors. I would argue that using a physical characteristic, such as one’s skin color and adding it to the treatment plan is much less an invasion of privacy. However, many in the medical community, would probably agree with Dr. Burchard that adding race as a risk factor is an essential step for better care. Dr. Burchard sums up this point: “we cannot close our eyes to the links between race and disease because of fear or political correctness. Otherwise we will never be able to identify clinically important risk factors and responses to medications caused or impacted by race.”
However, I think the main discrepancy lies in lack of community’s understanding. Dr. Burchard states that there is a “debate is fueled by the media and miscommunication between biologists, clinicians and social epidemiologists. People from both sides are painted as being in one camp or the other.” What Dr. Burchard failed to mention is the action that the media, biologists, clinicians and social epidemiologists must do in order to alleviate this misunderstanding of care. Until these scientific groups can come together and present a united front to the media and thus to the public, there will continue to be mistrust in the usage of race-based medicine. Part of our responsibility of medical students, thus, should be to take on social issues and inform our patients why race-based medicine is so important and effective.
March 5th, 2007 at 7:54 pm
“Isn’t it all just genetics?”
“Race-based” medicine
Interview with Dr. Burchard
Cuoghi Edens
March 5th
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
March 5th, 2007 at 8:07 pm
As a future physician, I have grown weary of the generalized notion that states, “Disease is caused by [a] combination of biologic and sociological factors.” In the afore-mentioned example of Alzheimer’s disease, the raw data clearly backs up the risk factor statistics by race presented by Esteban Burchard. From there, various forces have somehow trained a good number of us to manipulate those statistics, for better or worse, and cater to different ethnic and racial groups based on them. But at a fundamental level, physicians are ideally trained to sit with a patient, listen to his/her story, form hypotheses, and then work to declare a diagnosis. At no point in my training so far have I been told to consider race while distinguishing hypotheses, and risk factor statistics like the ones presented for Alzheimer’s provide no substance for me to change that school of thought if I were to treat a patient with the disease.
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
March 5th, 2007 at 9:24 pm
With a quick Google search one can find many different definitions of race and whether it “exists” or not. However, it is something that we hear about on almost a daily basis and is a concept that most people seem to grasp. But in this country and around the world the word/subject of race has developed such a negative connotation that upon hearing the word one cringes and immediately has thoughts about hate and discrimination. I believe that this is one of a main factors leading to “controversies” over race-based medicine.
Just about everyone recognizes that members of particular races have distinctive physical features, so it would make sense to me that certain racial groups could and should have distinctive internal features that would cause them to be more or less susceptible to different diseases and cause them to react differently to various medications. Therefore it should only make sense that current medical research should be aimed at being able to medically treat each group, if not each individual, by the most accurate means possible.
It seems as though we have moved in the direction of more individually based medicine to some extent. For example, women’s health is becoming more and more of a focus. There are entire hospitals dedicated entirely to women. However, it seems, that the main obstacle race-based medicine faces is the connotations that have been created over time around the word “race.” It seems that some groups believe that this is just another way to discriminate against people and some see “eugenics” all over again. I believe that once people “get over it” and realize that this for their benefit then this movement can really take off and I believe personalized-medicine will vastly improve.
March 5th, 2007 at 10:12 pm
Title: The Impact of Genetics and Race on Patient Healthcare
Topic: Race-Based Medicine
Interview Response: Dr. Esteban Burchard Interview
Name: Dustin Richter
Date Posted: March 5, 2007
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.
March 5th, 2007 at 11:36 pm
The idea of race-based medicine is an interesting topic. I can see why there is much controversy. In a sense, I think the idea of race based medicine is beneficial but not complete. I believe it provides another means to ultimately provide better care for certain groups of people with certain conditions. Dr. Burchard gave reference to many conditions on which race had an affect on severity and risk for particular diseases (i.e. Alzheimers, asthma). Based on this fact, we know that race can influence health and be an easy recognizable risk factor for particular diseases. As a future physician I find this very promising. I think it is essential to look at ALL populations in the context of disease to help gain a complete understanding of risks and severity of diseases in a particular population. Dr. Burchard gave reference to the fact that 90% of research dollars are directed at Caucasians. The idea of research based on other racial groups is a step in the right direction. However, I do feel that race is only one ingredient to the recipe and that genetics, culture, diet, exercise, habits, and socioeconomic status also play an equally important role in the disease prevalence and progression. Correlations between smoking and lung cancer, diet and heart attacks, socioeconomic status and healthcare access has been shown repeatedly in research and prove that many factors play a role in disease. So although I believe that race-based medicine will prove very valuable one must not forget all the other factors that play their hands in disease.
Interview with Dr. Burchard
http://fardj.prblogs.org/2006/05/18/conversations-about-race-based-medicine-esteban-gonzalez-burchard-md/#comments
March 6th, 2007 at 1:04 am
I agree with some of Dr. Burchard’s thoughts as he articulates the inherent problems in using race as a tool in medicine. Truly, “race” as we know it is a social construct and the grouping of people based on loose ideas of skin color, ethnicity, or nationality is a remnant of this country trying to make sense of its identity during the influx of immigrants around the turn of the 20th century. But despite the imperfections of this categorization, it still bears some merit.
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.
March 6th, 2007 at 3:07 am
This particular debate about race-based medicine is missing a larger, more significant point in regards to healthcare in the 21st century: namely, pharmacogenetics. This is the practice of prescribing drug therapies based on a patient’s genetic profile, where in regards to specific maladies that have multiple treatment options, this can provide optimized strategies for prescribing one treatment over another, based on the patient’s susceptibility to different therapies (drugs or other treatments). At this stage of development, race serves as a first step towards classifying patient susceptibility to treatment (and disease), primarily because providing full genetic screening for every potential patient is cost prohibitive. As genetic screening technology advances and becomes faster and cheaper, race-based medicine will evolve into the more specific strategy of pharmacogenetics, and will no longer need to retain the historically-sensitive use of race as a means of patient and patient care classification.
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.
March 6th, 2007 at 10:23 am
The issue of race-based medicine brings valuable discussions forward surrounding the ideas of personalized medicine and the “social risks of racial classification”. Dr. Burchard suggests using race as a “proxy for a variety of variables that influence health”. This concept is also supported by Dr. Gregg Bloche, who writes in the Journal of Law, Medicine & Ethics that “race can be a useful stand-in for unstudied genetic and environmental factors that yield differences in disease expression and therapeutic response”.
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.
March 6th, 2007 at 12:13 pm
The biggest problem with the practice of so-called ‘race-based medicine’ is that it attempts to ascribe a fixed set of susceptibilities to incredibly diverse populations. Most scientists agree that ‘race’ is a social construct rather than a biological one. For example, the geneticist Richard Lewontin observed that 85% of human variation occurs within populations, not between them(1). Therefore if a clinician, upon merely looking at a patient, decides that this patient has a predisposition to a certain set of illnesses, the likelihood of a misdiagnosis suddenly becomes much greater. The fact that members of certain ethnic groups have readily identifiable characteristics (i.e. skin color) does not mean that they all share the same genes. Regarding the interview, I think that attempting to ascribe broad characteristics, be they medical, social, or otherwise to a large category of individuals is a slippery slope. While there may be a certain subset of individuals that share a susceptibility to a particular illness within any given group, there is much more at play than just the color of their skin. To equate that skin color to something other than just the amount of melanin in their skin is erroneous at best and racist at worst.
1. Lewontin 1973 “The Apportionment of Human Diversity” in Evolutionary Biology 6:381-397
April 21st, 2008 at 2:56 am
Dr David Jones at MIT (of the Center for the Study of Diversity in Science, Technology, and Medicine) is running a conference on Race-based medicine and its implications… He wrote an op-ed at Culturekiosque.com on the subject that just ran today.
http://www.culturekiosque.com/nouveau/comment/bidil_and_race_profiling_in_targeted_medicine175.html