November 2004

Race, Medicine, and Public Policy

BiDil Heart Drug: The Nexus of Race and Medicine

Keith C. Ferdinand, M.D.
Xavier University

Cardiovascular disease is the leading cause of death for African-American males and females, and heart disease is the leading cause of hospitalization.  For African Americans, "heart attacks" are less frequently the problem, whereas hypertension is the most common cause of congestive heart failure at three to seven times more common than in non-African Americans.  The likelihood of end-stage renal disease as a result of hypertension in African Americans is twenty times more common.  In fact, most heart-related risk factors, including the mortality rate, are higher for the black population.  Culture plays a major part in health disparities between races and populations, and it is possible that African Americans distrust the health care system more and therefore may receive less or worse treatment.  Nonetheless, there are genetic polymorphisms that may contribute to the pathogenesis of cardiovascular disease (CVD) in African Americans by influencing a poor lifestyle.  Further, CVD treatments such as beta blockers and ACE inhibitors do not work as well in African Americans.  At this time, race and ethnicity are the terms, however insufficient, we must use as a substitute for complex genetic information and socioeconomic factors contributing to the inconsistencies between races when it comes to certain medical conditions.  There have not been adequate studies to be entirely confident about race and medicinal issues, but further medical study would continue to define genetic, socioeconomic, cultural and environmental issues.

In the meantime, BiDil must be explored due to pressing statistics showing the increased mortality of African Americans with heart disease, the weakened response to medications such as beta blockers and ACE inhibitors, and the lower availability of nitric oxide (NO).   Nitrates and hydralazine increase the availability of NO, and therefore the hydralazine isosorbide dinitrate in BiDil proves effective for African Americans with heart disease in slowing the progression of congestive heart failure.  The clinical trial A-HeFT involving BiDil shows recovery rates to improve in African Americans taking the drug more so than those taking a placebo.  Such a health benefit is adequate proof at this time to proceed with BiDil, although race in itself cannot be the sole reliable predictor for genetic polymorphisms.  The most critical factor is how we treat patients.  We ought not to be deterred by the increasing complexity of science, but rather continue to pursue the best possible humanistic, direct patient care.

Race and Clinical Practice

Sally Satel, M.D.
AEI

In May 2001, the New England Journal of Medicine published a groundbreaking article detailing the differing effects of beta blockers and ACE inhibitors on patients of different races.  This week's article further indicates the relevance of race to medicine.  Because diseases and responses vary in prominence between races, it is evident that disease is not colorblind and, therefore, doctors should not be either.  Doctors must consider many factors, including age, sex, and occupation, and there is no reason to exclude race, and specifically ancestry, from medical consideration.

African-American patients diagnosed with hepatitis C, for example, are not as responsive to standard therapy as whites. Because, on average, African Americans metabolize antidepressants more slowly, patients in my inner city clinic should be started on low doses.  Skin color then becomes a proxy for medically important biological traits related to ancestry. In the future, we hope to use personal pharmacogenomic profiles that transcend patient self-report, but until then, ancestry gives us useful clinical information.

Jon Entine
AEI and Miami University

Jews have long been scrutinized for genetic disorders.  As with any population, some traits may be linked to social and cultural factors, but genetic components are undeniable.  In the year 900, diseases began to emerge among the Jewish population, and over the course of the centuries to follow, the insularity of the Ashkenazi Jewish population allowed for genetic homogeneity to carry through the generations.  Over this time, genetic mutations occurred, stemming from genes that may have initially provided a benefit--much like the Mediterranean trait defending against the contraction of malaria--but can translate over time into genetic disorders.  The Ashkenazi Jews are still predisposed to many Mendelian disorders, a genetic mutation they share with Sephardic Jews.  Only in the twentieth century has the insularity of the Ashkenazi Jews begun to dissipate through intermarriage. 

Recently, the medical field identified mutations among Ashkenazi Jews of the breast cancer gene BRCA-1, a mutation which increases the likelihood of inherited breast and ovarian cancers.  Detection of this mutation can be a critical step in preventative health care for Ashkenazi women.  At this point in time, race/skin color is a crude indicator of genetic differences, yet it is the best available proxy for such detection if it can lead to the best possible health care.

Vincent Sarich
University of California--Berkeley

It is necessary to see through common misperceptions of race in order to fully recognize the ramifications of ignoring race in medicine.  Race is a legitimate classification of people based on genealogical lineage.  However, the notion that "race is skin deep" is false; populations from Africa, Indonesia and south India all have similar coloring and yet no genetic connection.  One cannot ask "how many races" exist because there is no answer to the question in that races are not entirely discrete.  Although races are not universally discrete, there remain biological differences that distinguish races from each other.

Examine disparities in certain traits between races.  People with ancestry linked to east Africa have genetic traits which can help them excel in mid-to-long distance running.  It is well known that eastern Asians and American Indians have a lower tolerance to alcohol.  The Eskimo population is especially susceptible to tuberculosis.  In a filmed study with babies of European, African, and Asian ancestry, European and African babies were found to be particularly averse to the stimulus of a blanket placed over their heads.  Asian babies scarcely reacted.  Through studies of this sort, researchers have linked even slight behavioral traits to genetics.  Therefore, it is our challenge to acknowledge the implications of genetic variability and to resist ignoring them as impediments of "equality."

William B. Lawson, M.D.
Howard University

Reports from the 1980s show black and minority health susceptible to increased mortality, lack of access to health care, and an unhealthier lifestyle.  African Americans have a higher risk for conditions like diabetes, glaucoma, cardiovascular disease, and benign leukopenia.
 
With mental disorders there may not be an increased prevalence among African Americans and minorities, but the black/minority lifestyle may lead to reduced access to treatment.  A major problem in health care lies in this illness burden and the lifestyle of minority populations.  The human genome project then helps us look at the genetics of the situation and assists in identifying the function of certain genes, giving insight to issues related to race.  Clinical findings show discrepancies such as fewer side effects to lithium in African Americans, the result of which typically means that African Americans receive higher doses of psychotropic medication, although they are less likely to receive newer medications. 

There is not enough data available to prove the success of race-based drugs.  Many times, patient ethnicity is not identified.  Less than one percent of academic physicians are African American, and research is often indirect.  More data is needed in order for race to be more adequately applied to medicine.

Pamela Sankar
University of Pennsylvania

In the broader context, NitroMed's drug BiDil may help African Americans as the studies indicate, but its credibility suffers from a flawed research design and conflict of interest.  While it is entirely possible that a drug like BiDil could help African Americans, inadequate proof exists to demonstrate its legitimacy at this time.  The political correctness of the drug is not what ought to compel the medical field, but rather how to proceed with developing such a drug.  Because the relevance of race to medicine is still highly contested--particularly as to whether race indicates a social or a genetic construct--there must first be compelling proof as to the effectiveness of the drug exclusively in African Americans and not simply in anyone with heart disease.

Many schools of thought agree that race cannot serve as an appropriate proxy to genetics.  The National Library of Medicine recently expunged its categorization of races, which consisted of four groups: Australoid (Oceanic), Caucasoid (European), Mongoloid (Asian), and Negroid (African).  The records now indicate that race is no longer a compelling predictor or biological traits.  Further, studies show that 80 to 90 percent of people react identically to medications and, furthermore, statistics exaggerate the ratio of African Americans to other races in frequency of heart disease.  As such, there is not enough proof at this point to move forward with a drug like BiDil.  Also, many of the scientists involved in the BiDil study have ties to its pharmaceutical company, NitroMed, and the stock rose significantly when the study was published.  While there is nothing "amiss" about the NitroMed study, the conflicts of interest within the study show its lack of convincing objectivity.

It is true that BiDil helps people with heart disease, but the study proves neither its particular use to African Americans, nor why there is a compelling need for a race-based drug.  The discussion of race and medicine needs to begin with the language defining the issue.

AEI program assistant Elizabeth White prepared this summary.