Mixed Race Studies

If doctors and clinical educators rigorously analyze algorithms that include race correction, they can judge, with fresh eyes, whether the use of race or ethnicity is appropriate. In many cases, this appraisal will require further research into the complex interactions among ancestry, race, racism, socioeconomic status, and environment. Much of the burden of this work falls on the researchers who propose race adjustment and on the institutions (e.g., professional societies, clinical laboratories) that endorse and implement clinical algorithms. But clinicians can be thoughtful and deliberate users. They can discern whether the correction is likely to relieve or exacerbate inequities. If the latter, then clinicians should examine whether the correction is warranted. Some tools, including eGFR and the VBAC calculator, have already been challenged; clinicians have advocated successfully for their institutions to remove the adjustment for race.^43,44 Other algorithms may succumb to similar scrutiny.⁴⁵ A full reckoning will require medical specialties to critically appraise their tools and revise them when indicated.

Darshali A. Vyas, Leo G. Eisenstein, and David S. Jones, “Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms,” The New England Journal of Medicine, Volume 2020, Number 383, 882. https://dx.doi.org/10.1056/NEJMms2004740.

Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms

The New England Journal of Medicine
Volume 2020, Number 383
pages 874-882
2020-08-27 (published on 2020-06-17, at NEJM.org.)
DOI: 10.1056/NEJMms2004740

Darshali A. Vyas, M.D., Resident Physician
Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
Harvard University, Cambridge, Massachusetts

Leo G. Eisenstein, M.D., Resident Physician
New York University Langone Medical Center, New York, New York

David S. Jones, M.D., Ph.D., A. Bernard Ackerman Professor of the Culture of Medicine
Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts

Physicians still lack consensus on the meaning of race. When the Journal took up the topic in 2003 with a debate about the role of race in medicine, one side argued that racial and ethnic categories reflected underlying population genetics and could be clinically useful.¹ Others held that any small benefit was outweighed by potential harms that arose from the long, rotten history of racism in medicine.² Weighing the two sides, the accompanying Perspective article concluded that though the concept of race was “fraught with sensitivities and fueled by past abuses and the potential for future abuses,” race-based medicine still had potential: “it seems unwise to abandon the practice of recording race when we have barely begun to understand the architecture of the human genome.”³

The next year, a randomized trial showed that a combination of hydralazine and isosorbide dinitrate reduced mortality due to heart failure among patients who identified themselves as black. The Food and Drug Administration granted a race-specific indication for that product, BiDil, in 2005.⁴ Even though BiDil’s ultimate commercial failure cast doubt on race-based medicine, it did not lay the approach to rest. Prominent geneticists have repeatedly called on physicians to take race seriously,^5,6 while distinguished social scientists vehemently contest these calls.^7,8

Our understanding of race and human genetics has advanced considerably since 2003, yet these insights have not led to clear guidelines on the use of race in medicine. The result is ongoing conflict between the latest insights from population genetics and the clinical implementation of race. For example, despite mounting evidence that race is not a reliable proxy for genetic difference, the belief that it is has become embedded, sometimes insidiously, within medical practice. One subtle insertion of race into medicine involves diagnostic algorithms and practice guidelines that adjust or “correct” their outputs on the basis of a patient’s race or ethnicity. Physicians use these algorithms to individualize risk assessment and guide clinical decisions. By embedding race into the basic data and decisions of health care, these algorithms propagate race-based medicine. Many of these race-adjusted algorithms guide decisions in ways that may direct more attention or resources to white patients than to members of racial and ethnic minorities…

Read the entire in PDF or HTML format.

How Personalized Medicine Became Genetic, and Racial: Werner Kalow and the Formations of Pharmacogenetics

Journal of the History of Medicine and Allied Sciences
Volume 68, Number 1, January 2013
pages 1-48
DOI: 10.1093/jhmas/jrr046

David S. Jones, A. Bernard Ackerman Professor of the Culture of Medicine
Harvard University

Physicians have long puzzled over a well-known phenomenon: different patients respond differently to the same treatment. Although many explanations exist, pharmacogenetics has now captured the medical imagination. While this might seem part of the broader interest in all things genetic, the early history of pharmacogenetics reveals the specific factors that contributed to the emergence of genetics within pharmacology. This paper examines the work of one pioneering pharmacologist, Werner Kalow, to trace the evolving intellectual formations of pharmacogenetics and, in particular, the focus on race. Working in the 1950s and 1960s, Kalow made three arguments to demonstrate the relevance of genetics to pharmacology, based on laboratory techniques, analogies to differences between other animal species, and appeals to the logic of natural selection. After contributing to the emergence of the field, Kalow maintained his advocacy for pharmacogenetics for four decades, collecting more evidence for its relevance, navigating controversies about race and science, and balancing genetics against other possible explanations of patient variability. Kalow’s work demonstrates the deep roots of the genetic and racial preoccupations in pharmacology. Understanding this history can restore attention to other explanations of individuality in medical practice, something of increasing importance given the current interest in personalized medicine.

Read the entire article here.

Book review: What’s the use of race? Modern governance and the biology of difference

BioNews
Number 634 (2011-11-21)

Dr. Rachael Panizzo

Decoding the human genome has revealed details of our evolution and patterns of migration across the world. The study of genetic diversity between ethnic groups can help explain the ways in which race influences our biology and susceptibility to disease. It promises to deliver a new era of personalised medicine, where an individual’s unique DNA profile is used to make predictions about their future health; where specialised drugs are tailored to individual patients, based in part on their genetic ancestry.

But what do we mean by ‘race’, exactly? Is race a relevant biological or medical category, and how is it defined in practice?

These issues are considered in the collection of essays What’s the use of race? Modern governance and the biology of difference, edited by Dr Ian Whitmarsh of the University of California San Francisco, and Dr David Jones at the Massachusetts Institute of Technology. The contributors explore the use of race in biomedical research and some of the emerging practical applications in medicine and forensic science. Their diverse and sometimes conflicting perspectives result in an engaging book that highlights the complexity of the issue.
 
Genetics has become the foundation of a new ‘biocitizenship’, where it is our civic duty to know and share our own genetic information and engage with our health at a molecular level. Common genetic make-up replaces common social experience, and group identities are carved along lines of shared genetic traits, ‘reinterpreting existing political identities and creating new ones’, says Professor Dorothy Roberts, from Northwestern University. Social and political categories of difference—such as gender or race…

…In the medical setting, subtle statistical differences are often interpreted as blanket differences between races, and individual patients are assumed to reflect the average characteristics of their race. But Jay Kaufman, associate professor of epidemiology at McGill University, and Professor Richard Cooper, of Loyola University, Chicago, demonstrate that in practice, a patient’s ethnic identity adds little to the diagnosis or prognosis of disease and is rarely medically relevant.

The essays of Professor Jonathan Kahn (Hamline University), and Pamela Sankar, associate professor of bioethics at the University of Pennsylvania emphasise how embedded racial categories are in forensic science, giving examples of DNA fingerprinting and phenotyping. Originally, racial information was used in DNA fingerprinting technology to improve accuracy, but as it has improved substantially, Professor Kahn argues it is now superfluous, irrelevant, and risks perpetuating racial stereotypes – ‘conflating race, genes and violent crime’…

…Should race be used at all in medical research? Many authors argue that its inclusion reifies the concept of race as a fundamental human characteristic. But Dr Kaufmann, Professor Cooper, and Harvard School of Public Health Professor Nancy Krieger suggest race does have a place in biomedical research, as a social category—including information about race or ethnicity is a way of documenting health inequalities, which would otherwise be invisible and ignored….

Read the entire review here.

What’s the Use of Race? Modern Governance and the Biology of Difference

The MIT Press
May 2010
7 x 9, 296 pp., 7 illus.
ISBN-10: 0-262-51424-9
ISBN-13: 978-0-262-51424-8

Edited by

Ian Whitmarsh, Assistant Professor
Department of Anthropology, History, and Social Medicine
University of California, San Francisco

David S. Jones, Associate Professor of History and Culture of Science and Technology
Massachusetts Institute of Technology

The post–civil rights era perspective of many scientists and scholars was that race was nothing more than a social construction. Recently, however, the relevance of race as a social, legal, and medical category has been reinvigorated by science, especially by discoveries in genetics. Although in 2000 the Human Genome Project reported that humans shared 99.9 percent of their genetic code, scientists soon began to argue that the degree of variation was actually greater than this, and that this variation maps naturally onto conventional categories of race. In the context of this rejuvenated biology of race, the contributors to What’s the Use of Race? investigate whether race can be a category of analysis without reinforcing it as a basis for discrimination. Can policies that aim to alleviate inequality inadvertently increase it by reifying race differences?

The essays focus on contemporary questions at the cutting edge of genetics and governance, examining them from the perspectives of law, science, and medicine. The book follows the use of race in three domains of governance: ruling, knowing, and caring. Contributors first examine the use of race and genetics in the courtroom, law enforcement, and scientific oversight; then explore the ways that race becomes, implicitly or explicitly, part of the genomic science that attempts to address human diversity; and finally investigate how race is used to understand and act on inequities in health and disease. Answering these questions is essential for setting policies for biology and citizenship in the twenty-first century.

Contributors: Richard Ashcroft, Richard S. Cooper, Kjell A. Doksum, George T. H. Ellison, Steven Epstein, Joan H. Fujimura, Amy Hinterberger, Angela C. Jenks, David S. Jones, Jonathan Kahn, Jay S. Kaufman, Nancy Krieger, Paul Martin, Pilar N. Ossorio, Simon Outram, Ramya Rajagopalan, Dorothy Roberts, Pamela Sankar, Andrew Smart, Richard Tutton, Ian Whitmarsh