Episode 176: Antiracism in Medicine Seri...

“There’s nothing new under the sun, but there are new suns” – Octavia E. Butler

Summary: We invite social justice champion and acclaimed scholar of race, gender, and the law, Dorothy E. Roberts, JD, to discuss the history of race-based medicine and the movement for health equity and justice.

Episode Learning Objectives

After listening to this episode learners will be able to…

1. Understand race as a social construct and political invention
2. Explore the history of race as a proxy for genetics and ancestry
3. Explore the history of race-based pharmaceuticals
4. Explore the history of race-based clinical algorithms

Credits

• Written and produced by: Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Chioma Onuoha, Jenny Tsai, MD, Jazzmin Williams, Dereck Paul, MS, and Utibe R. Essien, MD, MPH 
• Infographic: Creative Edge Design
• Hosts: Dereck Paul, MS, Utibe R. Essien, MD, MPH, Michelle Ogunwole, MD
• Guest: Dorothy E. Roberts, JD (@DorothyERoberts)

Timestamps:

00:00 Introduction

03:40 Defining Race

13:40 Responses to Common Race Based Medicine Arguments

20:40 Race as a Proxy for Racism

31:00 BiDiL and Race Based Medicine Definition

42:00 Dr. Duana Fullwiley and the “African Gene”

49:30 Debunking Folklore Health Narratives

53:30 Slavery Hypertension Hypothesis

57:00 Importance of Intentional and Plausible Research Methods

1:00:00 Race in Medical Algorithms 

1:12:00 Moving Away from Relying on Simplistic Biological Concepts of Race

1:15:48 Advice for Listeners

1:21:00 Closing Remarks 

Takeaways:

1. Definition of Race: Race is not a biological category, instead it is a permeable, flexible, and unstable social construction and political invention that facilitates political and economic inequality. However it is important to remember that this political invention DOES affect biology because of the way that it creates social inequity.
2. Historical Context: Historically, laws such as interracial marriage bans have protected established structures of white supremacy and reinforced the social construct of race.
3. Race is a Poor Proxy for Genetics: Diseases with genetic or population associations are often evolutionary adaptations to specific geo-environments. Race, a social construction, groups people from large swaths of of global territory based on superficial phenotype is often a poor proxy for these genetic associations with disease. 
4. Race is a proxy for Racism: race was invented as a way to classify people into subordinate groups and support the political sanctioning of inequity.  The very function of race is thus to support and uphold racism. When we evaluate race in medicine we have to recall  this origin story and not rely on race as a placeholder for anything else except racism.
5. The Root of Inequities: Health inequities are overwhelmingly caused by differences in social status, living conditions, and experiences of discrimination. When we cling to race as the cause of  health inequities, we obscure and divert attention away from these social factors that need to be addressed.
6. Intersectionality: Race and racism intersect with socioeconomic status, education, geography, sexual orientation, religion, immigration status, gender and other identities with differential impact. 
7. Our responsibility in medicine: “What we have to do is include medicine in the political movement to bring down the structures of racism and white supremacy and the way in which medicine incorporates those and promotes those. And [this] HAS to be in conjunction with broader social movements…that are dedicated to radically transforming our world into one in which human beings are equally valued…”-Dorothy E. Roberts JD
8. For the patient I see tomorrow:  Beyond recognizing that race is not a proxy for biology, we can all ask ourselves “What way is structural racism affecting my patient and what can I do about it?” The answer to this question may not be easily answered and may not always be found in the clinical setting.

Pearls:

“Genetics is not the end all be all of understanding disease” – Dorothy E. Roberts JD

An Emphasis on Genetics is Not the Solution to Race-Based Medicine

Being antiracist in medicine does not mean being more precise in our understanding of genetics. Rather we need a deeper and broader understanding of the influence of the structural and political determinants of health inequities. Part of the problem with focusing on race in medicine is that it limits our perspectives and encourages research practices that lack the rigor required to identify root causes of racial health inequities. We should be focusing on root causes rather than proxies. It does not mean that we should stop exploring genetic causes of disease, but rather that we should not pretend that understanding genetics is the solution to addressing disparities. Dr. Roberts put it expertly: “to be anti-racist, it doesn’t mean, well, then let’s just be more precise in our genetics. It means being anti all the things that race and racism do.”

Medicine Must Move Beyond Othering Black People

All too often in medicine, Black people are singled out from all other human beings as having different bodies from the norm, aka whiteness. Examples of this include: BiDiL, the blood pressure drug marketed solely to black people; arguments for race-based medicine that cite sickle cell, a disease that is most common in Black people because of geographic varietion rather than innate difference; and the slavery hypertension hypothesis which posits that hypertension disparities observed in Black people are a result of the stress of slavery and the middle passage rather than the longitudinal impacts of structural racism. Rather than searching for obscure explanations for inequalities, we must instead recognize the ways that racism impedes health at both individual and structural levels. 

Race-based algorithms can produce inequity and there is a moral dilemma we must attend to

There is a persistent question about whether race-based clinical algorithms disadvantage patients and how we should think through use of them in clinical medicine. Professor Roberts offers some guidance: whenever you are stuck, go back to the origin story- what is race? Then you can ask yourself, how is race being used and does that use further inequity? 

Professor Roberts also offers a few scenarios.

1. Race-based algorithms: Race is being used as a biological construct AND it can produce harm. For example, GFR- race correction for Black patients. The use of race is  based on a false/biological concept of race AND many studies show that this can harm patients ( i.e. clinical resources are withheld based on results of algorithm). This is the rationale for NOT using these kinds of race-based algorithms.
2. Race “neutral” algorithms, which are used for allocation of resources for most fit patients. Race is not included in the algorithm, however because of the experiences of structural racism, certain groups will have worse scores. These worse scores may lead to the withholding of resources and ultimately further inequity. For example, the proposal of race neutral ventilator algorithms that were set up to allocate ventilators to the most fit patients during the COVID-19 pandemic. This race neutral algorithm could disadvantage Black patients, who because of structural racism may have lower fitness scores. This could worsen existing disparities in COVID-19 outcomes among Black patients. 

Moral dilemma: Including race as a biological construct in clinical algorithms can lead to inequity. However whenever structural racism isn’t included in clinical algorithms, we also risk denying a group who has experienced structural racism access to much needed resources. We have not thought about this enough in medicine and we don’t have a gold standard of how to include race as a proxy for structural racism in our clinical algorithms. As we move forward we must continue to think critically about the ethical and just way to include race or rather structural racism in clinical algorithms and ensure that our algorithms do not further inequity.

References:

1. Lindo E, Nolen L, Paul D, Ogunwole M, Fields N, Onuoha C, Williams J, Essien UR, Khazanchi R. “Episode 140: Dismantling Race-Based Medicine, Part 1: Historical & Ethical Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. November 17, 2020.
2. Eneanya A, Tsai J, Williams J, Essien UR, Paul D, Fields NF, Nolen L, Ogunwole M, Onuoha C, Khazanchi R. “Episode 4: Dismantling Race-Based Medicine, Part 2: Clinical Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. December 17, 2020.
3. Roberts D. Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-first Century. The New Press: 2012.
4. Roberts D. “The problem with race-based medicine.” TEDMED 2015. Link to talk.
5. Roberts DE. What’s Wrong with Race-Based Medicine?: Genes, Drugs, and Health Disparities. Minnesota Journal of Law, Science & Technology. 2011;12(1):1-21.
6. Yudell M, Roberts D, DeSalle R, Tishkoff S. NIH must confront the use of race in science. Science. 2020;369(6509):1313-1314. doi:10.1126/science.abd4842
7. Roberts DE. Is race-based medicine good for us?: African American approaches to race, biomedicine, and equality. J Law Med Ethics. 2008;36(3):537-545. doi:10.1111/j.1748-720X.2008.302.x
8. Taylor AL, Ziesche S, Yancy C, Carson P, D’Agostino R Jr, Ferdinand K, Taylor M, Adams K, Sabolinski M, Worcel M, Cohn JN; African-American Heart Failure Trial Investigators. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med. 2004 Nov 11;351(20):2049-57. doi: 10.1056/NEJMoa042934. 
9. The Slavery Hypertension Hypothesis: Dissemination and Appeal of a Modern Race Theory. (2003). Epidemiology, 14(1), 111-118. Retrieved May 9, 2021, from http://www.jstor.org/stable/3703292
10. Roberts, Dorothy E. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York: Pantheon Books, 1997.
11. Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. 2020 Dec 17;383(25):2477-2478. doi: 10.1056/NEJMc2029240.
12. Hansen H, Netherland J. Is the Prescription Opioid Epidemic a White Problem?. Am J Public Health. 2016;106(12):2127-2129. doi:10.2105/AJPH.2016.303483
13. Bibbins-Domingo K, Fernandez A. BiDil for heart failure in black patients: implications of the U.S. Food and Drug Administration approval. Ann Intern Med. 2007 Jan 2;146(1):52-6. doi: 10.7326/0003-4819-146-1-200701020-00009. Erratum in: Ann Intern Med. 2007 Apr 17;146(8):616. PMID: 17200222.
14. Roberts DE. Abolish race correction. Lancet. 2021 Jan 2;397(10268):17-18. doi: 10.1016/S0140-6736(20)32716-1. PMID: 33388099.

Transcript

Download transcript here

Disclosures

The hosts and guests report no relevant financial disclosures.

Citation

Roberts, DE, Onuoha C, Khazanchi R, Nolen L, Fields N, Tsai J, Essien UR, Paul D, Ogunwole M,. “Episode 8: Dismantling Race Based Medicine Part 3: Towards Justice and Race-Conscious Medicine.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. May 10, 2021.