I think it this case it makes little difference what you call it. “People of African-American ethnicity”, if you prefer, appear to respond very well to a particular drug combination, and that’s pretty much all that has been said. Other folks may respond to it very well, too. In the final analysis, African-Americans may still be shown to respond better than folks of mostly or wholly European or Asian descent, for instance. I don’t think that much is even remotely known yet, but it would be interesting to find out, as it may help people better understand some of the etiological factors contributing to heart disease, both inherited and environmental.
Again, if there’s good evidence that black folks (I guess “black” is being recommended as the preferred term again) may have a higher risk of carrying a genetic variation (possibly related to the production of nitrous oxide, apparently, which is an endogenous vasodilator, among other things), using “black” as a proxy for assessing risk may prove beneficial in tailoring drug therapies. Or not. It’s a pretty new finding, and its implications aren’t altogether clear, so it’s not as if we really know a bona fide “black drug” has been formulated. Racial issues may wind up being moot when all the needed trials are done, if it turns out that this drug combo is highly efficacious for everybody. I’m not at work, so I can’t download the article yet; but I’ll give it a read, and try and see what the detailed rationale behind the study design was. There are some helpful editorials that should be interesting as well, and I believe directly address the controversy, vis. the pros and cons of using the race proxy. If tnd knows the other NEJM reference, one could check the current trial’s authors’ references to see if the other study mentioned above was considered informative, and whether or not the purported flaws were somehow glossed over.
If no group is really a race, then it’s probably not a good idea to define groups in terms of race. Of course, the OP specifically asked a question about race-based medicine, so if race doesn’t really exist, then race-based medicine doesn’t really exist either.
On the one hand, the distinction between population group and race is largely a matter of semantics. On the other hand, confused language leads to confused thinking. “Race” is a term with a preexisting meaning, the one I gave in my initial post.
“Ethnic group” is a useful and appropriate term for distinguishing between different population groups. The common use of “ethnic group” to distinguish different nationalities isn’t a problem, because different nationalities often have different genetic backgrounds. As Tomndeb demonstrated, the specifics of ethnic background can tell us something about genetic makeup. The designation “white” isn’t particularly useful, but “Cajun” and “Ashkenazim” can be very informative.
I’m not a doctor, but my wife is, so I have some insight into medical decision-making. One thing I observed while she was undergoing her training was that many, if not most, medical decisions contain a large non-scientific element. They are influenced by local custom, unquantified (and unquantifiable) experience, and rules of thumb. For example, every doctor “knows” that a patient who is fat, female, febrile and forty (sometimes they throw in fertile and flatulent) is more susceptible to gallstones than a patient who is not. Has there been a controlled, scientific study establishing statistical correlations between these factors and gallstone prevalence? Probably not, and there probably never will be, because most doctors already “know” there is a correlation.
Thus, doctors are going to continue to use perceived or self-identified ethnicity as an aid in diagnosis and treatment, just like they always have. If you take the position that these practices should not be done because they aren’t scientific, you would also have to stop most other kinds of primary-care medical decisions, because they are mostly unscientific, too. It’s unworkable, unless you give the NIH $50 billion to try to establish a strictly scientific basis for all of these rules of thumb.
The definition you gave for “race” in your initial post is incorrect. What is the source? In particular, you say it is “continent wide”. If we accept for the moment that there is such a thing as race (let’s say it’s a social construct or whatever), then the !Kung/San peoples would certainly be considered a race, yet no one would say they range “continent wide”. Races can easily be in geographic ranges of much less than a continent, and they can span multiple continents.
This brings up a question that I was thinking of asking, and will here as it sort of fits:
Are some things, though true, too damaging to society to talk about. Like there may be actual differences between ‘races’, and gender and other groups besides slight cosmetic and plumbing differences.
Is it just too dangerous to talk about the possibility? Should we not even thing this way?
I don’t think that such topics are too dangerous, although there are people who do feel that way. However, given the large number of cases in which decisions were based on pre-conceived notions or societal prejudices, I believe that any such discussion had better be anchored firmly in fact–and we had better be sure that we do everything possible to eliminate societal tainting of the perceived facts.
There was a study on enalapril in 1992 and a second study (the one that prompted the NEJM editorial) in 2001: NEJM Volume 344:1351-1357 May 3, 2001 Number 18, “Lesser Response to Angiotensin-Converting–Enzyme Inhibitor Therapy in Black as Compared with White Patients with Left Ventricular Dysfunction,” Derek V. Exner, M.D., M.P.H., Daniel L. Dries, M.D., M.P.H., Michael J. Domanski, M.D., and Jay N. Cohn, M.D. (The same NEJM issue also carried a separate article, with less news play, that indicated that Carvedilo was equally effective for both whites and blacks.)
I do not know that this study specifically prompted the study mentioned in the OP. (I do know that about the time that this study was released, the Surgeon General called for more studies for black-specific medicines.)
Interestingly, Dr. Dries (second name on the study, above), returned to the issue and conducted a study that indicated that enalapril was not less effective for blacks. He points out (in this article), that the principal determinant of “effectiveness” in the earlier study had been “hospitalization,” which, as he notes, could have multiple causes for which the earlier study did not account.
I’m using the definition of race initiated by Linneaus, and continued by Blumenbach, Coon, and others. I believe this definition corresponds to widely held beliefs about race in the general public:
Researchers in the decades following Blumenbach classified the Malay and American races as branches of the Mongolian, leaving only the Caucasian, Mongolian, and Ethiopian races. Further explication in the early and mid twentieth century, notably by American anthropologist Carleton S. Coon, arrived at three primary races (Negroid, Caucasoid, Sinoid) with a small number of less widespread races (especially “Australoid”).
I don’t have Coon’s work at hand, but I recall that he classified the San peoples as part of the Negroid group.
A race, by this definition can span over more than one continent, but that just makes the definition broader, and more inclusive of heterogenous groups.
The smaller the benefit of an intervention, the larger the study it takes to demonstrate that benefit. My understanding is that this combination (ISDN + hydralazine) is probably beneficial across the board (we use it fairly routinely in people who can’t tolerate an ACE inhibitor for whatever reason), but the benefit is small enough that it would take big, expensive study to prove it. Since these are both generic, ridiculously cheap drugs, no big expensive studies are going to get done on them anytime soon. (There does appear to be some money in the combo pill, but I’m not sure what’s up with that.)
However, if you take a subset of people in which the benefit appears to be larger, it would take a much smaller study to prove that, and this is what happened here. So while there may be across-the-board benefit, it remains undemonstrated, but we have solid evidence of benefit in this particular group.
I’m all about evidence-based medicine, so I’ll use it, and I hope the combo pill gets approved. My biggest concern is that standard therapy for CHF already consists of at least four and as many as six drugs (beta-blocker, ACE-I, aldactone, aspirin, diuretic, digoxin), so at some point the regimen just becomes unwieldy and compliance goes down the tubes.
I don’t know if this was directed at me, but I will respond in case it was. First, I’m black and not all that liberal, and I don’t see where anything in my post would give you that impression.
The debate I hoped would arise would be one of how a policy of “race” based medicine would be effective or beneficial to society as a whole. I didn’t really want to have a debate on whether “race” exists, or how it should be defined. I am more interested in the implications such policies might have in the future. While it would certainly have many positive results, I can think of a few negatives that similar policies/attitudes have had that give me pause.
I have noticed that my insurance carrier doesn’t cover many dematological medications primarily used by African-Americans and other similarly complected peoples, while other medications used mostly by white people are covered. I realize how lucky I am to have decent insurance, and that I have not had to find out if these discriminatory policies extend to treatments that are of greater urgentcy, but I would imagine that they do in many cases. I don’t necessarily attribute this to racism, but I do think it clearly shows that insurance companies don’t treat all people equally, and would have no problem giving short shrift to a few minorities to satisfy their bottom line. I think many companies wouldn’t cover a medication that would only be approved for a small percentage of their customers.
As many of you have mentioned, certain diseases tend to affect particular racial/ethic groups. As a result, many have not been a high priority. If HIV/AIDS initially struck a more diverse group of people, it wouldn’t have been considered a “gay disease” for so long.
Even if discrimination enters in to the equation, I would have a hard time begrudging anyone a medication that could be used to save their life. But I think that a lot of damge is done by discriminatory policies. If medicine were only about doing good and trying to keep people healthy, I would believe these policies were fine. But healthcare doesn’t exist in a bubble, and the biases of drug companies and the people involved in every step from production to prescription have to be considered.
Excellent point. I would hope that the discovery of medications that have greater efficacy in specific ethnic groups would be utilized in the diagnosis and treatment of diseases by doctors, rather than in the creation and marketing of medicines by drug companies. There is a huge difference between the two. One allows your doctor to tailor a treatment for you, while the latter allows a drug company to avoid providing services for a segment of the population it deems unprofitable or undesirable. I’m not naive to the fact that this aready happens today, but should this behavior be encouraged. Of course that brings up a question of whether a drug company has a responsibility to the public- but that is another debate all together.
Cites are required for factual claims, not for personal opinions. Quite a few posts on this thread indicate discomfort with the notion of race-specific medical treatments; whether they are from whites or liberals is my own assumption. (I’m white and somewhat liberal, and when my doctor told me about the race-specificness of prostate cancer, I was taken aback.)
This is Great Debates not IMHO, MPIMS or The Pit. This is a premise of your debate and so requires a cite. If you don’t want a proper debate post the question somewhere else.
Unless you have evidence that there is a white liberal antipathy to this technology the subject is a non-starter.
Your personal experience and interpretations of what’s in the minds of other posters are not evidence. I for one see no discomfort in posters here, just nuances I’m not sure you pick up. Your personal shock at hearing that some illnesses and medicines are race-specific says more about you and your general knowledge than what white liberals think about the technology in question.
Last I heard, which was probably about a year ago, the American College of Medical Genetics recommended that doctors offer CF testing to Caucasian women who were pregnant or planning to become pregnant, but not to women of other races, because it’s so much more common in Caucasians. And also because the recommended testing panel tends to pick up more mutations that are usually found in Caucasians than in other races. If a woman from another race requested CF testing, they recommended she be given it, but she should not be offered it if she didn’t request it.
To clarify my own position–which has clearly irked some participants in this thread–I’m okay with race-specific approaches to treating race-specific illnesses, or illnesses that overwhemingly tend to favor one ethnicity over all others. If it breaks down to “Don’t offer this patient/insurance subscriber a treatment option he is statistically unlikely to afford,” I’m against that. I’m certainly against “Antibiotics for the white patents, leeches for the black ones,” to whatever degree this actually occurs. Hope this clears things up.
In my case, because I am almost entirely descended from Quebecois (from the Bas Saint-Laurant area), my wife was told by her OB-GYN in no uncertain terms that she be should be tested (even though she has no French in her whatsoever), and she strongly recommended that I pay for tests myself to see if I’m a carrier. The guy who built my home is from the same region, and two of his grandkids have CF. His son married another French Canadian (decendant of immigrants from downstream of St. Anne de Beaupre, near the Saguenay region, where it’s most common I hear).