Race Still Has A Place In Modern Medicine

02/09/2016 12:01 EST | Updated 02/09/2017 05:12 EST
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GP listening to young male patients heartbeat using stethoscope (Photo by Universal Images Group via Getty Images)

Biomedical knowledge should always be considered in its socio-historical context, as social factors cannot be divorced from science.

Through much of the 19th and early 20th centuries, medical experiments were performed on vulnerable populations including the infamous Tuskegee University-affiliated investigation concerning "Untreated Syphilis in the Negro Male" and those carried out by the Third Reich.

It is, in fact, a physician whom we can credit -- or blame -- for being the first to employ the term "race." During his travels, François Bernier introduced the term in his 1684 novel, New Division of Earth by the Different Species of Races which Inhabit it, in which he contends that that "[Humans] differ so clearly that people who have traveled widely can thus often distinguish unerringly one nation from another."

Bernier continues to describe having "observed that there are in all four or five types of race among men whose distinctive traits are so obvious they can justifiably serve as the basis of a new Division of the Earth."

In the late 19th century, the work of comparative anatomist Johann Friedrich Blumenbach gained posthumous appreciation. Blumenbach proposed that Europeans were the original "racial type" that all other races degenerated from.

This study of physiognomy was primarily concerned with assessing an individual's character from their outer appearance and often considered those of African extraction to be intellectually inferior based on pseudoscientific analyses of skull sizes and facial characteristics.

Race is a social construct because individuals of different continental origins are not categorically different. Overall, there are more differences within those of the same continental origin than between groups differing in continental origin.

As the Human Genome Project delineated, the DNA of humans is 99.9 per cent identical. "Ethnicity" refers to a multidimensional construct that reflects biological, historical, cultural and linguistic factors. How a person identifies with these has been used to supplant or complement the term "race" in many settings.

As members of ethnic minority groups have suffered historically because of what has erroneously and malevolently been ascribed as innate inferiority, should physicians avoid reifying race by espousing a "colourblind" practice?

It depends.

The emerging field of ethnic dermatology serves as an example of how an understanding of socio-historical forces shaping fundamental aspects of medical pedagogy is paramount.

For most of the history of dermatology, description of skin and hair disorders was based almost exclusively upon patients of European ancestry. This one-size-fits-all approach mirrors the way in which the 70kg white male was considered the standard for American medical research during the 1970s and 1980s.

We have learned that nuances in skin and hair properties among different ethnicities may prove clinically relevant. There is evidence that the severity of atopic dermatitis in patients of African ancestry is greatly underestimated compared to white children when erythema (redness of the skin from inflammation) is included compared to when this factor is excluded.

"Race, insofar as it was historically conceived to 'unerringly' delineate categorical differences between people of differing continental origins, should be discarded outright."

Because erythema is difficult to assess reliably in pigmented patients, Vachiramon et al. recommend that physicians rely especially upon on the report of the families of African American children when determining severity score -- upon which treatment is based.

Many lesions that appear red in lightly pigmented individuals will appear violet in heavily pigmented patients, and the latter may undergo unnecessary biopsies. In general, the fact that heavily pigmented skin, both within and outside of a medical context, is consistently described as a variant to the default lightly pigmented skin reflects signifies that progress remains before privilege is not tied to ethnicity.

But in this modern age, surely objective scales would prove useful to the unbiased practice of medicine?

As it turns out, these measures are not free from bias, either.

In an interview with the Atlantic, author Lundy Braun describes the origin of the spirometer. Samuel Cartwright was a 19th-century physician and plantation owner, and the first person to use the spirometer to compare pulmonary capacity between black slaves with whites.

Cartwright held that "the [lesser] development of lung tissue and accessory muscles of respiration among the negroes than for whites" proved a justification for slavery insofar that it increased the fitness of African Americans. As a result, the spirometer was created with a racial correction factor to decrease the value among African Americans. Braun explains that "the problem here is the survival of the framework of innate racial difference."

I completed a number of assessments of patients with work-related asthma in an occupational medicine clinic. After inputting values for age and sex, I realized that the machine retained "white" and "black" as racial identifiers on the drop down menu.

Race and ethnicity, as socially constructed labels of collective and individual identity, do not necessarily correlate with genes of medical consequence. Ethnicity as a proxy for genetics can be discouraged. Race, insofar as it was historically conceived to "unerringly" delineate categorical differences between people of differing continental origins, should be discarded outright.

However, ignoring ethnicity and phenotype altogether may prove disadvantageous.

Isosorbide dinitrate/hydralazine is a medication that has received FDA approval for treating heart failure in African Americans. If the "standard" population for clinical trials form the 1970s were employed, this benefit would remain unrealized. The same result would occur if a "colourblind" approach were employed in recruitment.

Emphasizing biological differences must not obscure minority status as a social determinant of health. Increased prevalence of hypertension in a person of African ancestry may be due to resistance to a certain first-line medications that work in non-African Americans but a number of socio-historical factors unique to black Americans should also be considered.

These include marginalized housing and, subsequently, fewer areas to walk safely. In addition, lower income, decreased level of health literacy, as well as stress related to lower socioeconomic status and living as a visible minority contribute.

Physicians should not strive to be colourblind. Patients should be treated as individuals. It would be remiss not to recognize ethnicity as a part of the profile of a patient. When done correctly, racial profiling in the medical sense can prove a worthwhile practice.

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