Copyright 2002 The New York Times Company May 5, 2002, Sunday, Late Edition - Final SECTION: Section 6; Page 56; Column 1; Magazine member of our species to show where this kind of analysis But the enalapril researchers were doing something useful. Their study informed thousands of doctors that,when it came to their black patients, one drug was more HEADLINE: I Am a Racially Profiling Doctor likely to be effective than another. The study may havesaved some lives. What's more useful than that? BYLINE: By Sally Satel; Sally Satel, a fellow at theAmerican Enterprise Institute, is the author of "PC, M.D.: Almost every day at the Washington drug clinic where How Political Correctness Is Corrupting Medicine." I work as a psychiatrist, race plays a useful diagnostic role.
When I prescribe Prozac to a patient who is African-- American, I start at a lower dose, 5 or 10 milligrams in-stead of the usual 10--to--20 milligram dose. I do this in In practicing medicine, I am not colorblind. I always part because clinical experience and pharmacological re- take note of my patient's race. So do many of my col- search show that blacks metabolize antidepressants more leagues. We do it because certain diseases and treatment slowly than Caucasians and Asians. As a result, levels of responses cluster by ethnicity. Recognizing these patterns the medication can build up and make side effects more can help us diagnose disease more efficiently and pre- likely. To be sure, not every African--American is a slow scribe medications more effectively. When it comes to metabolizer of antidepressants; only 40 percent are. But practicing medicine, stereotyping often works.
the risk of provoking side effects like nausea, insomnia But to a growing number of critics, this statement is or fuzzy--headedness in a depressed person -- someone viewed as a shocking admission of prejudice. After all, already terribly demoralized who may have been reluc- shouldn't all patients be treated equally, regardless of the tant to take medication in the first place -- is to worsen color of their skin? The controversy came to a boil last the patient's distress and increase the chances that he will May in The New England Journal of Medicine. The jour- flush the pills down the toilet. So I start all black patients nal published a study revealing that enalapril, a standard with a lower dose, then take it from there.
treatment for chronic heart failure, was less helpful to In my drug--treatment clinic, where almost all of the blacks than to whites. Researchers found that significantly patients use heroin by injection, a substantial number of more black patients treated with enalapril ended up hos- them have hepatitis C, an infectious blood--borne virus pitalized. A companion study examined carvedilol, a beta that now accounts for 40 percent of all chronic liver dis- blocker; the results indicated that the drug was equally ease. The standard treatment for active hepatitis C is an antiviral--drug combination of alpha interferon and rib- These clinically important studies were accompanied, avirin. But for some as yet undiscovered reason, African-- however, by an essay titled "Racial Profiling in Medical Americans do not respond as well as whites to this reg- Research." Robert S. Schwartz, a deputy editor at the jour- imen. In white patients, the double therapy reduces the nal, wrote that prescribing medication by taking race into amount of virus in the blood by over 90 percent after six account was a form of "race--based medicine" that was months of treatment. In blacks, the reduction is only 50 both morally and scientifically wrong. "Race is not only percent. As a result, my black patients with hepatitis C imprecise but also of no proven value in treating an indi- must be given a considerably less reassuring prognosis vidual patient," Schwartz wrote. "Tax--supported trolling . . . to find racial distinctions in human biology must end." Without a doubt, there are many medical situations Responding to Schwartz's essay in The Chronicle of in which race is irrelevant. In an operation to repair a Higher Education, other doctors voiced their support. "It's broken leg, for example, a patient's race doesn't matter.
not valid science," charged Richard S. Cooper, a hyper- But there are countless situations in which the race factor tension expert at Loyola Medical School. "I challenge any should be considered. My colleague Ronald W. Dworkin, an anesthesiologist in a Baltimore--area hospital, takes All of these examples fly in the face of what we are race into account when performing one of his most im- increasingly told about race and biology: namely, that the portant activities: intubation, the placement of a breath- two have nothing to do with each other. When the pre- ing tube down a patient's windpipe. During intubation, he liminary sequence of the human genome was announced says, black patients tend to salivate heavily, which can in June 2000, many felt the verdict was conclusive. Race, cause airway complications. As a precautionary measure, it was said, was an arbitrary, nefarious biological fic- Dworkin gives many of his black patients a drying agent.
tion. Scholars heralded the finding of the Human Genome "Not every black person fits this observation," he con- Project that 99.9 percent of the human genetic comple- cedes, "but there is sufficient empirical evidence to make ment is the same in everyone, regardless of race, as proof every anesthesiologist keep this danger in the back of his that race is biologically meaningless. Some prominent or her mind." The day I spoke with him, Dworkin attended scientists said the same. J. Craig Venter, the geneticist a hysterectomy in a middle--aged Asian woman. "Asians whose company played a key role in mapping the human tend to have a greater sensitivity to narcotics," he says, genome, proclaimed, "There is no basis in the genetic "so we always start with lower doses. They run the risk of apnea" -- the cessation of breathing -- if we do not." What does it really mean, though, to say that 99.9 per- Could doctors make a diagnosis for and treat a patient cent of our content is the same? In practical terms it means properly if they did not know his race? "Most of the that the DNA of any two people will differ in one out of time," says Jerome P. Kassirer, a professor of medicine at every 1,000 nucleotides, the building blocks of individual Yale and Tufts. "But knowing that detail early on helps genes. With more than three billion nucleotides in the hu- me make educated guesses more efficiently." man genome, about three million nucleotides will differamong individuals. This is hardly a small change; after Kassirer, the former editor of The New England all, mutation of a single one can cause the gene within Journal of Medicine, is a renowned diagnostician. He is which it is embedded to produce an altered protein or en- legendary among trainees for what he can tell about a case zyme. It may seem counterintuitive, but the 0.1 percent of from just a few facts. He gave an example from a recent human genetic variation is a medically meaningful fact.
morning report, the daily session in which young doc-tors describe to senior physicians the most vexing cases Not surprisingly, many human genetic variations tend admitted to the hospital the previous night. During one to cluster by racial groups -- that is, by people whose report, the resident began: "The patient is a 45--year-- ancestors came from a particular geographic region. Skin old Asian male who came to the emergency room com- color itself is not what is at issue -- it's the evolutionary plaining of 'feeling weak and wobbly in my legs' after history indicated by skin color. In Africa, for example, the drinking two bottles of beer." Kassirer stopped her right genetic variant for sickle cell anemia cropped up at some there. "Here's what I infer from that information," he said.
point in the gene pool and was passed on to descendants; "First, we know that sudden weakness can be caused by as a result, the disease is more common among blacks a low concentration of potassium in the blood, and we than whites. Similarly, Caucasians are far more likely to know that Asian males have an unusual propensity for carry the gene mutations that cause multiple sclerosis and a rare condition in which low potassium causes tempo- rary paralysis. We know that these paralytic attacks are Admittedly, race is a rough marker. A black American may have dark skin -- but her genes may well be a com- Of course, the patient could have been suffering from plex mix of ancestors from West Africa, Europe and Asia.
some other muscular or neurological disease, and Kassirer No serious scientist, in fact, believes that genetically pure instructed the trainees to consider those as well. But in populations exist. Yet an imprecise clue is better than no this case the patient's potassium was low, and the diag- nosis was correct -- and confirmed within 24 hours by Jay N. Cohn, a professor of medicine at the University simply observing the patient. Thanks to racial profiling, of Minnesota, explains that skin color and other physi- the Asian patient was spared an uncomfortable and costly cal features can be a diagnostic surrogate for the genetic work--up -- not to mention the worry that he might have differences that influence disease and response to treat- something like Lou Gehrig's disease.
ment. "Physical appearance, including skin color, is now "Rather than casting our net broadly, doctors quickly the only way to distinguish populations for study," he focus on a problem by recognizing patterns that have clin- says. "You'd have to use a blindfold to keep a physician ical significance," Kassirer says. "Typically, the clinician from paying attention to obvious differences that may and generates an initial hypothesis merely from a patient's should influence diagnosis and treatment!" Lonnie Fuller, age, sex, appearance, presenting complaints -- and race." a professor emeritus at Morehouse School of Medicine, says: "Drugs can stay in the body longer when their good conscience, be colorblind. Researchers predict that metabolism in the liver is slower. We know this can vary it will eventually be common practice for doctors to gen- by race, and doctors should keep it in mind." erate a "genomic profile" of every patient -- a preciseanalysis of a person's genetic makeup -- so that decisions Recognizing that our one--size--fits--all approach to about therapies can be based on subtle characteristics of medicine has serious flaws, some doctors are urging re- the patient's enzyme and receptor biology. At that point, search into the development of racially targeted drugs. In racial profiling by doctors won't be necessary. Until then, March 2001, the Food and Drug Administration allowed however, group identity at least offers a starting point.
the testing of a drug called BiDil in about 600 black sub-jects who will participate in the African--American Heart A high level of sensitivity about race is understand- Failure Trial, the largest clinical trial ever to focus exclu- able in view of eugenics programs in early 20th--century America and ethnic cleansing abroad. The memory ofthe Tuskegee syphilis study, in which hundreds of rural In previous studies including both white and black pa- blacks were never told they had the disease nor offered tients, BiDil provided a selective benefit for the black sub- penicillin for it, still haunts the U.S. Public Health Service, jects. White subjects did no better on average than those the agency that conducted the study. Other scholars have given a placebo. The leading explanation for this dispar- expressed the worry that genetic differences among races ity revolves around the molecule nitric oxide, a chemical could become the only explanation for the health dispari- messenger that helps regulate the constriction of blood ties among them -- allowing interest in examining social vessels, an important mechanical dynamic in the control of blood pressure. High blood pressure contributes to andworsens heart failure because it makes the heart pump Indeed, the public seems to have embraced the idea of harder to overcome peripheral resistance in the arteries.
colorblind medicine. "In the last decade, many Americans BiDil acts by dilating blood vessels and replenishing local have urged that the concept of race be abandoned, purged stores of nitric oxide. For unexplained reasons, blacks are from our public discourse, rooted out of medicine and more likely than whites to have nitric oxide insufficiency.
exiled from science," writes Troy Duster, a sociologist atN.Y.U.
To be sure, a small percentage of blacks with high blood pressure do not have low nitric oxide activity. And But in this case, the public is wrong. As rough a bi- the fact that BiDil's intended use relies on a crude predic- ological classification as race may be, doctors must not tor of drug response -- a poor man's clue" is how one sci- be blind to its clinical implications. So much of medicine entist described race -- is something its developers at the is a guessing game -- and race sometimes provides an University of Minnesota School of Medicine readily ac- invaluable clue. As citizens, we can celebrate our genetic knowledge. Nevertheless, in the sometimes cloudy world similarity as evidence of our spiritual kinship. As doc- of medicine, a poor man's clue is all you've got. Perhaps tors and patients, though, we must realize that it is not in that's why members of the Congressional Black Caucus patients' best interests to deny the reality of differences.
voiced support for the clinical trial. So did the Associationof Black Cardiologists, which is helping recruit patients for the trial. B. Waine Kong, the organization's head of-ficer, put it simply: "It is in the name of science that we Doctors look forward to the day when they can, in

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