Race and Medicine

Does race matter in medicine? Only a few people would answer an absolute no. Most would accept that even if only a marker for social class, race does have an effect, and many would go much farther in assigning poor health in minorities to societal factors directly related to race

A more intriguing questions is if genetic differences between races should play a role in medicine. As a recent BMJ editorial (Rahemtulla and Bhopal) notes

In 2001 NitroMed began the African-American heart failure trial (A-HeFT), the first heart failure trial conducted exclusively in African-American patients, claiming that “observed racial disparities in mortality and therapeutic response rates in Black heart failure patients may be due in part to ethnic differences in the underlying pathophysiology of heart failure.” The study found that BiDil (a fixed dose of isosorbide dinitrate and hydralazine, . . . ) combined with standard therapy for heart failure reduced mortality by 43% among black patients.

I believe that the therapy had failed to show efficacy in a trial of the general population (all races). Presumably, this effect in a single racial group is due to genetic differences between races, although it is possible that environmental factors (smoking, diet, exposure to pollution) could explain some of the difference.

Given the trial results, is “race-based” medicine justifiable? Not everyone thinks so.

Many researchers and policy makers argue against the use of racial or ethnic categories in medicine, saying that classifying people according to race and ethnicity reinforces existing social divisions in society or leads to discriminatory practices.

I would find it hard to withhold beneficial medicine (in this case BiDil) from patients it would help on the basis of political correctness. “Sorry Mr. Jones, this medicine would reduce you risk of death by nearly half, but I won’t prescribe it for you because I don’t agree with using racial categories in medicine.”

But race must just be a proxy for underlying biological differences. Whether the variations are genetic or environmental, race is just a marker for differences in the disease itself (heart failure in this case). What we really need is a better understanding of these variations.

In 20 years, we should be prescribing BiDil for patient A not because he is black, but because he has genetic polymorphisms B and C, low levels of D and E in his blood and environmental risk factors F and G.

I hope this kind of tailored medicine is what we are moving to, and race based therapies will be but a rest stop on that path.