Racial Profiling in Medicine: a brief history and a look at where we are now

CMAJ Photograph OgunyemiBoluwaji Ogunyemi is a Dermatology Resident Physician in Vancouver, BC, and a freelance writer for the Huffington Post, Ubyssey Newspaper, and the Online Journal for Community and Person-centered Dermatology

 

Few topics evoke as much controversy and emotion as that of race.

Though much has been said about differences in the physiology of minority groups seen as “other”, there exists no clear consensus of the meaning and utility of these findings.

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 - with being the first to use the term “race.” In his 1684 novel, “New Division of Earth by the Different Species of Races which Inhabit it,” written during his travels, François Bernier 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.” [1]

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 intellectuality 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% identical. The term “ethnicity” refers to a multidimensional construct that reflects biological, historical, cultural, and linguistic factors and how a person identifies with these and had 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 inferiorities, should physicians avoid reifying race by espousing a “colorblind” practice? It depends.

The emerging field of ethnic dermatology, also known as ‘skin of color 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. [2] When considering patients of more varied ethnicity for assessment, we learn about nuances and variations that can 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 in the rating of severity compared to when this factor excluded. Because erythema is difficult to assess reliably in pigmented patients by dermatologists and others, Vachiramon and colleagues recommended that physicians rely on the report of the families of African American children when determining erythema and factoring it into severity score, upon which treatment is based. [3]

Many lesions that appear red in white patients 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 the medical arena, is consistently described as a variant to the default white skin reflects the fact that progress remains before privilege is not tied to ethnicity. In ethnic dermatology, approaches to treatment are based on phenotype rather than employing race as a proxy for how an individual’s specific set of genes will respond to a given treatment.

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 Magazine, 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 “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 last year. After inputting values for age and sex, I realized that the machine retained “white” and “black” as racial identifiers on the drop down menu. Biomedical knowledge should always be considered in its socio-historical context as social factors cannot be divorced from science.

A recently-developed scale, by French scientist Genevieve Lorssouarn and colleagues, attempts to replace terms such as “straight”, “wavy”, “kinky,” and “afro-textured” with standardized descriptions and objective measurement of human hair. Based on 2449 subjects from 22 countries, a hair type score ranging from 1 - 8 is comprised of measurements including hair curve diameter and number of twists per unit length. [5] When this scale is used, patients can be treated based on the phenotype of their hair rather than the ethnicity that the patient or physician may identify the patient as.

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

Ignoring ethnicity and phenotype altogether may prove disadvantageous for some groups. A combination medication called Isosorbide dinitrate / hydralazine has received FDA approval for the treatment of heart failure in African Americans but no other ethnic group. If the “standard” population for clinical trials form the 1970s were employed, the benefit for those of African extraction would remain unrealized. The same result would occur if a “colorblind” approach were employed in recruitment. Modest differences in the response to cardiovascular medications among African Americans compared to Americans of European ancestry has been documented for some time, purportedly due to differences in the relative importance of biochemical pathways in the manifestation of high blood pressure. [2]

Each patient should be assessed individually. Recognizing that a person who may be identified as having African heritage based on physical characteristics should prompt a physician to consider a medication proven to work this group but not necessitate this course of action. Doctors should not be colorblind but should not stereotype either. Importantly, 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 and less access to grocery stores. In addition, lower income, decreased level of health literacy, as well as stress related to lower socioeconomic status or living as a visible minority contribute. Indeed, ethnicity may inform a physician about many aspects relevant to overall health.

Putting social context aside, epidemiological differences in prevalence of disease clearly exist. Many diseases are much more common in individuals of different continental backgrounds such as lactose intolerance, sickle-cell anemia and cystic fibrosis.

Physicians should not strive to be colorblind. Patients should be treated as individuals. It would be remiss of us 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.

References

[1] Jablonski, N. (2012) Living Color: The Biological and Social Meaning of Skin Color. Berekely: University of California Press. 2012; p.125-6.

[2] Epstein, S. Inclusion: The Politics of Difference in Medical Research. Chicago: University of Chicago Press, 2007; p.125-6

[3] Atopic Dermatitis in African American Children: Addressing Unmet Needs of a Common Disease. Vachiramon V, Tey H, Thompson A, Yosipovitch, G. 2012; Vol 29, No. 4 395-402.

One thought on “Racial Profiling in Medicine: a brief history and a look at where we are now

  1. Chinenye Ezike

    Enlightening article! Western medicine has seemingly drifted from Blumenbach’s perception of the European race being superior to one that is more receptive of biological differnces associated with each race. e.g. the knowledge longitudinal melanonychia is a benign condition in people of color vs in caucasians is a prodrome for subungual melanoma. Nevertheless acknowledging racial predilection of medical conditions and stereotypes can be a challenging concept to delineate.

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