Race and Medicine

I'm taking a bit of a different turn this week, spurred on by an article I read recently, and some discussions we've had among our classmates. There are two prongs to this discussion: first, the concept of race or ethnicity in health, and second, the role of the medical provider in ethnic communities.

One of my classmates was African. As in, she immigrated from Central Africa (I, sadly, forget the exact country) to the US, and much of her family still lives there. During the first two years of medical school, when we were learning about various diseases that can afflict people, she became irritated with the idea that race and certain diseases had a correlation. She felt that we should be race blind, because it's impossible to tell someone's background by just looking at them.

In some ways, I see her point. Race is a human construct. It is more useful to define people by culture than by race, as there is more genetic variation within a given 'race' than between them. And with how open we've come to interracial couples, it really is hard to determine someone's race by simply looking at them.

But, at the same time, there is a correlation in several diseases, and race or ethnicity can help us narrow the list of diseases a patient is likely to have. For instance, individuals descended from Africans are more likely to have sickle-cell disease. Why? Because malaria is very prevalent in Africa, and there is an evolutionary advantage to having sickle cell trait, as it protects you from dying from malaria. But, when two people with sickle cell trait have a child together, there is a 1 in 4 chance of their child having sickle cell anemia, a disease that can cause loss of limbs and intense pain. If you are descended from an Ashkenazi Jew (Jews who lived in northern and central Europe), you are far more likely to have a number of diseases, including Tay-Sachs (a disease that causes multiple problems with the brain) and breast cancer, just to name a few. This is because the Jewish population of Europe had a great deal of intermarriage, partly due to religion and partly due to various anti-semitic pressures in the area. Even Caucasians are not immune to this racial bias, as Cystic Fibrosis is 4-5 times more common in Caucasians than in African Americans, and is even more rare in Asians.

All these are genetic diseases. What about those that aren't genetic? According to the CDC, non-Hispanic black patients are 50% more likely to die of cardiovascular disease than their non-Hispanic white counterparts. Adult diabetes is much more common in Hispanic and Native American populations than it is among white and Asian populations. A good portion of this is due to socioeconomic pressures; you're more likely to develop diabetes if you live in a low-income neighborhood than if you live in an affluent neighborhood, likely due to the access to fresh and healthy foods. Some of it is due to healthcare access: either these individuals cannot afford proper healthcare, they don't have access to the proper healthcare, or they choose not to seek healthcare due to cultural norms.

In this sense, I think ethnicity is a very important part of medicine.

Recently, I have heard discussions over medical school admissions and what role race should play in these decisions.

See, in many cases, patients reportedly like doctors of the same race as them. Thus, black patients prefer black doctors, Hispanic patients prefer Hispanic doctors, etc. There are many reasons for this; there is a certain distrust of the US medical system, and specifically white physicians, among black patients, thanks to experiments such as the Tuskegee Syphilis Experiment, there are subtle differences in culture, such as how patients perceive and express pain, etc. Even my own classmates have noticed that when they speak to Hispanic patients in Spanish, even if the entire interview is not conducted in Spanish, the patient tends to open up more and express their concerns more. Whether this actually helps in all cases is debatable.

So, the goal among many medical schools is to train a more diverse student body, to train more black and Hispanic physicians, rather than white and Asian or Indian physicians, in order to better meet the needs of these underserved populations. The degree to which race plays a role in medical school admissions is uncertain, based on what I've heard from friends on admissions committees. But there is no doubt that it does play some role. Some argue that this tactic is necessary in order to develop more mentors in underrepresented minorities, so that more of these individuals will enter medicine in the future. Others argue that it's a poor way judge a person's experiences, in that an African American from a well-off family will have a much different experience than a white person from a poor family, but the African American will naturally be judged to have better experiences thanks to the color of his skin. In essence, it's attempting to combat racism with racism, and is not the best way to go about things.

I'm not sure what the answer is from that front, but I do have no doubt that some people are inherently more comfortable with people from similar cultural backgrounds. Whether we should select medical school candidates based on that trait--I don't know, but I don't have a better solution for the fact that African Americans, Hispanics, and Native Americans are less likely to make it to the level of med school than a white or Asian person.

Racism, even 'benign' racism such as that we use in medicine, is still prevalent in our society today. It's not going to be an easy fix to change that, but I think we're trying. Hopefully within the next generation, this won't need to be a topic of discussion any longer.