Date Published: September 25, 2007
Publisher: Public Library of Science
Author(s): Lundy Braun, Anne Fausto-Sterling, Duana Fullwiley, Evelynn M Hammonds, Alondra Nelson, William Quivers, Susan M Reverby, Alexandra E Shields
Abstract: Is it good medical practice for physicians to “eyeball” a patient’s race when assessing their medical status or even to ask them to identify their race?
Partial Text: Is it good medical practice for physicians to “eyeball” a patient’s race when assessing their medical status or even to ask them to identify their race? This question was captured in a 2005 episode of “House M.D.,” Fox television’s medical drama. In the episode, a black patient with heart disease refuses a hospital physician’s prescription for what is clearly supposed to be BiDil, the drug approved by the United States Food and Drug Administration only for “self-identified” African-Americans . Dr. House, on seeing the patient for follow-up, insists on the same prescription. The patient again refuses, telling House, “I’m not buying into no racist drug, OK?” House, a white physician asks, “It’s racist because it helps black people more than white people? Well, on behalf of my peeps, let me say, thanks for dying on principle for us.” The patient replies, “Look. My heart’s red, your heart’s red. And it don’t make no sense to give us different drugs.”
Racial categories, with shifting meanings and culturally determined parameters, have always shaped medical practice and thinking, leading to vigorous debates about their use in epidemiology, public health, and medical research journals [10–17]. Throughout the 20th century, race had no standard definition in medical, epidemiological, or health services research [18–21]. In epidemiology, race vaguely referred to “persons who are relatively homogenous with respect to biologic inheritance” . One survey of medical and epidemiological dictionaries found that well into the 1980s definitions assumed that race reflects ”underlying genetic homogeneity” rather than (or even in addition to) shared social experience . Few of the studies making claims for race controlled for socioeconomic status or lifestyle variables.
Historically created racial categories often carry hidden meanings. Until 2003 medical reports were cataloged in PubMed/MEDLINE and in the old Surgeon General’s Index Catalogue using 19th century racial categories such as Caucasoid, Monogolid, Negroid and Australoid . Originally suggesting a scale of inferiority and superiority, today such groupings continue to connote notions of human hierarchy [27,54,55]. More importantly, PubMed’s newer categories, such as continental population group and ancestry group, merely overlay the older ones. Assuming that “African” origin can capture the complexity of migrations, artificial boundaries, and gene drift is scientifically unsupportable. So too is continued use of the concept of Caucasian (meaning from the central Asian countries surrounding the Caucus Mountains) to emphasize the similarities between disparate European groups rather than their population substructures or variations.
But the debate remains. Even given the history of the (mis)use of racial categories, are they nevertheless useful in the physician’s office? Does a quick administrative assessment of race help to diagnose a presenting ailment, or accurately assess future risk of illness? Environmental exposures, family histories, the stress of dealing with racism, access to and quality of care may be left unexamined if a physician simply diagnoses “race” . In the United States a rule that assumes “one drop” of African blood defines an individual as African American  seems to prevail . Presented with a black patient, in the face of medical uncertainty, rather than applying individual analysis the doctor can fall back upon general statements that derive from population studies, such as “You should get tested for glaucoma because you are African American and African Americans have a higher rate of glaucoma.”
Clinicians will make better educated patient evaluations if they familiarize themselves with the history of the particular communities they serve. For the clinical encounter, the cultural competency paradigm is sometimes offered as a tool for improving quality of care. Cultural competency advocates have spurred curricular reform so that clinicians in training learn to be attentive to cross-cultural issues. A cultural competency paradigm has recently been suggested as a powerful tool in the arsenal to combat the prevalence of racial and ethnic health disparities . However, when not thoughtfully executed, the cultural competency paradigm can abet the simplistic thinking on race it seeks to address. On the one hand, this perspective brings greater attention to the attitudes and behaviors that patients may bring to the clinical encounter. On the other hand such cultural stereotyping could produce poor health outcomes if the clinician is more attentive to what he or she thinks they know about this “type” of patient than to the individual before them .
Medical researchers want tools that will allow physicians to understand how the individual biosocial system represented by a patient standing before them has either produced symptoms, or has a certain future likelihood of doing so. Whether or not the recent announcement of a $10 million cash award for the first team to sequence 100 genomes in 10 days will get us closer to individual genomic medicine remains to be seen . But in the meantime, race remains a social characteristic of populations and it is inappropriate to use it as a central diagnostic tool for an individual patient.
Improved medical training about race can sharpen diagnostic skills. Cultural competency instruction should be modified to include information on the history of racial categories, current controversies about their biological significance, and the limits of their utility. A teaching unit on race would also contrast the differences between race as a population concept with its meaning when applied to the lives of individuals. In this context it would be appropriate to teach about geographical variations in specific allele frequencies for genes linked to particular disease processes, as well as the cultural practices, historical trends, and environmental conditions that favor their prevalence or not.
In the long run, the problem of whether or how to use race as a diagnostic aid and research category requires an international consensus meeting with representatives from all the biomedical fields. Such a meeting should be organized by the US National Institutes of Health, the World Health Organization, and other international health institutes. In the short run, the National Institutes of Health needs to re-examine its race-based research rules, weighing the balance between attempting to include minority populations in our health care system, on the one hand, without forcing us into a misconstrual of race as biology on the other. Medical courses also need to improve the teaching of the complexities of using race in the clinic. The overall goal of such an effort would be to make clear that “For meaningful statements to be made about health disparities, careful consideration must be given to the way in which race and ethnicity are conceptualized, the choice of definition categories, and the way in which individuals are assigned to categories” . Anthropologist Michael Montoya’s distinction between using ethnoracial categories in a descriptive mode, to document progress in the health status of populations, but not using basically social categories to produce biological attribution of causes will be an essential part of this effort . In the end we have to be able to answer the patient’s question—if all hearts are red then why do we need different drugs for different individuals based on race? To provide the best health care we must be able to say why and when race matters and why and when it doesn’t.