Write an essay of around 1,100 words in response. That should fill around five pages of double spaced text in 12 point Times New Roman.Showing detailed knowledge of assigned readings and lecture material is mandatory – you should engage with and cite at least five readings from three different weeks of class. Finding additional relevant sources to support your thesis is optional but encouraged.1) Did the changes in scientific ideas about racial differences that took place between the American Revolution and the 1930s play a crucial role in shaping the lives and health of the inhabitants of the United States?(Hint: to answer this question properly you need to talk about three things: (first) how scientific ideas about racial differences changed over the period, (second) how lives and health changed along racial lines during the period, and (third) whether the changes in scientific thinking were crucial in driving the changes in lives and health. Also remember that you have to take a clear yes or no position on the third item as your thesis statement).General Hints1. Remember your audience. Your paper is not a private communication between you and your professor or TA. You should have in mind an audience of intelligent, well educated people who are not necessarily experts in the topic of this paper. Remember also that there are some things that we do in informal writing (contractions, abbreviations, slang) that are not appropriate in formal writing.2.. Have a thesis and state it. Your thesis is a clear, original answer to the question posed. State it at the start of the paper. The rest of the paper is all about elaborating on and supporting your thesis. By the end of the paper it should have been clearly demonstrated.3. Structure the paper into several sections. Each section supports one aspect of your overall thesis, and provides detailed evidence for it.4. Give supporting evidence. Strengthen your argument by referring directly to the text of the readings and other sources. Don’t just repeat what happened in the readings, interpret it. Analyze the evidence to show how it supports your thesis. Quoting phrases or single sentences is fine, but don’t include large chunks. Give page numbers for specific points.5. Remember that there are two parts to citing sources — an indication at a specific point in your text where you use the material from the source, and a full reference. That is true whether you use in-text citations, like (Haigh, 2018) and put the references in a list at the end, or if you use the other approach and insert a footnote with the reference in. Having a bibliography without footnotes or in-text citations does not do the job of citing your sources and will hurt your grade substantially.How to Cite SourcesThe style I use in most of my work is favored by historians. All references go in footnotes and the footnote number appears in the text at the point where the source is being cited. Inside the footnote, the reference is formatted as follows: From a book: Sidney Pollard, The Genesis of Modern Management (Cambridge, MA: Cambridge University Press, 1963). From a journal: Clarence H. Danhof, “The Farm Enterprise: The Northern United States, 1820-1860,” Research in Economic History, 4 (1979), 127-191. From a collection: Albert Fishlow, “Antebellum Interregional Trade Reconsidered,” in R.L. Anderson, ed., New Views on American Economic Development (Cambridge: Schenkman Publishing Company, 1965) pp. 187-200. From the Web: Jon Surmacz, “A Second Look at CRM,” Dawin Magazine, 11 June 2003 [cited 08 August 2003]. Available from http://www.darwinmag.com/learn/numbers/number_detail.cfm?ID=all&METRIC=558. (Note: if you find material from a print newspaper, journal or magazine in an electronic database then cite the original print version — not the electronic repository in which it is archived).Everything you could ever want to know about the technicalities of academic writing is contained in the Chicago Manual of Style. However, the book itself may be a little too complete for your current needs.You will find a more user friendly version of the same material in Kate Turabian. A Manual for Writers of Term Papers, Theses and Dissertations. 8th edition. (Chicago: University of Chicago Press, 2013). This is the standard work recommended for student writing. There’s a quick summary of the citation style here: http://www.press.uchicago.edu/books/turabian/turabian_citationguide.html 8/23/2017
Racial Categories in Medical Practice: How Useful Are They?
Racial Categories in Medical Practice: How Useful Are They?
Lundy Braun, Anne Fausto-Sterling
, Duana Fullwiley, Evelynn M Hammonds, Alondra Nelson, William Quivers,
Susan M Reverby, Alexandra E Shields
Published: September 25, 2007
https://doi.org/10.1371/journal.pmed.0040271
Citation: Braun L, Fausto-Sterling A, Fullwiley D, Hammonds EM, Nelson A, Quivers W, et al. (2007) Racial Categories in
Medical Practice: How Useful Are They? PLoS Med 4(9): e271. https://doi.org/10.1371/journal.pmed.0040271
Published: September 25, 2007
Copyright: © 2007 Braun et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author
and source are credited.
Funding: This work was funded by the Robert Wood Johnson Foundation (DF), the Office of the Provost, Harvard University
(EMH), the Social Science Research Fund Grant, Yale University (AN), the Mellon Faculty Renewal Fund, Wellesley College
(SMR), and the National Human Genome Research Institute P20 Grant HG003400 (AES). None of the funders were involved
in our decision to write and publish this paper.
Competing interests: The authors have declared that no competing interests exist.
The Trouble with Race
Is it good medical practice for physicians to “eyeball” a patient’s race when assessing their medical status or even to ask them to
identify their race? This question was captured in a 2005 episode of “House M.D.,” Fox television’s medical drama. In the episode,
a black patient with heart disease refuses a hospital physician’s prescription for what is clearly supposed to be BiDil, the drug
approved by the United States Food and Drug Administration only for “self-identified” African-Americans [1]. Dr. House, on seeing
the patient for follow-up, insists on the same prescription. The patient again refuses, telling House, “I’m not buying into no racist
drug, OK?” House, a white physician asks, “It’s racist because it helps black people more than white people? Well, on behalf of my
peeps, let me say, thanks for dying on principle for us.” The patient replies, “Look. My heart’s red, your heart’s red. And it don’t
make no sense to give us different drugs.”
Who is right here, House or his patient? And what does this episode tell us about the way race plays itself out in the physician–
patient clinical encounter? What of clinical importance can be learned by making a quick racial assessment [2]? That an ACE
(angiotensin-converting enzyme) inhibitor may not be effective? That screening for sickle cell anemia is a waste of time? Sorting
patients by race may seem useful during a time-constrained interview, but we argue that acting on rapid racial assessment can lead
to missed diagnoses and inappropriate treatments.
Both historical evidence and contemporary genetic research suggest that “racial profiling” in medicine can lead to serious medical
errors. Assessing risk through race is more problematic than its typical depiction in the media and in scholarly literature [3]. Some
argue that race can stand in for human genetic variance until individualized genetic medicine is fully developed. But such a position
produces a critical paradox: the rates of morbidity and death from particular diseases are not uniformly distributed among socially
defined racial and ethnic groups throughout the world [4–6]. In order to monitor the success of attempts to address these health
inequalities, we need to keep health records based on racial and ethnic categories. This is a descriptive use of ethnoracial
categories. Descriptive statistics derived from population surveys using racial definitions based on self-identity, however, are not
biological or attributive categories appropriate for individual treatment [7]. How should physicians treat individuals who present with
a perceived race but who may not bear the average characteristics of a studied population, even while collecting data based on
perceived race or ethnicity and qualifying individuals for clinical research trials [8,9]? This problem is illustrated in Box 1, which
describes an “on the ground” dilemma of administering a drug to individuals who do not fit “standard” racial categories.
From Census Categories to Research Plans
Racial categories, with shifting meanings and culturally determined parameters, have always shaped medical practice and thinking,
leading to vigorous debates about their use in epidemiology, public health, and medical research journals [10–17]. Throughout the
20th century, race had no standard definition in medical, epidemiological, or health services research [18–21]. In epidemiology, race
vaguely referred to “persons who are relatively homogenous with respect to biologic inheritance” [18]. One survey of medical and
epidemiological dictionaries found that well into the 1980s definitions assumed that race reflects ”underlying genetic homogeneity”
rather than (or even in addition to) shared social experience [22]. Few of the studies making claims for race controlled for
socioeconomic status or lifestyle variables.
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The embedding of legal and social practices into the “common sense” meaning of race in medical research has been developing for
centuries [23]. In the last several decades, poorly defined racial categories became reified in biomedical research practices, in part
because of the widespread use of US census categories [24]. Since 2001, NIH-funded researchers have been required to
categorize study participants into the five racial or ethnic categories defined by US Office of Management and Budget Directive No.
15 (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, or White, and
Hispanic/Latino or not Hispanic/Latino) [25]. Thus, state-sanctioned but ill-defined categories of race have entered medical research
and practice with the admirable intent of ensuring full racial and gender inclusion in clinical trials, but with unanticipated
consequences for health outcomes [26].
Researchers rely on respondents’ self-identification to collect data on race and ethnicity. Every research grant must report its study
population in these terms, leading to their universal use in recruitment of research subjects. It thus becomes almost “natural” to use
these same variables in the subsequent analysis and theoretical framing of the research, even though there is nothing particularly
“natural” about the census categories. While the Office of Management and Budget’s categories dominate researchers’ analyses of
human differences in disease, granting agencies’ regulations do little to clarify the extent to which racial and ethnic categories are
intended to capture biological, cultural, or social dimensions of human diversity. The US Institute of Medicine, for example, holds
that race should not be considered a biological reality, but rather “a construct of human variability based on perceived differences in
biology, physical appearance, and behavior” [27]. And self-identities are given reality by the very categories we use to describe
them [28,29].
Over the past several years, editors at leading medical and scientific journals have promoted a much needed dialogue among
researchers and practitioners on the meaning of racial categories [30–40]. The current situation, however, remains confusing. As
genetic findings assume an increasingly prominent place in biomedical research, some have concluded that self-identified
race/ethnicity, routinely collected in biomedical research studies, is a reasonable proxy for genetic homogeneity and may lead to
important insights into health disparities [36,41–43]. Others, citing the genetic heterogeneity within self-identified groups [44–46],
argue that race should not be used in genetic research [47–50]. A related perspective comes from those who argue that selfidentified racial/ethnic categories may be practical for recruitment into studies, but should not be used in genetic analyses, given
that more biologically precise measures of human genetic heterogeneity are available [17,51]. A recent study of geographic
patterns of genetic variation, for example, found that “commonly used ethnic labels are both insufficient and inaccurate
representations of the inferred genetic clusters, and that drug-metabolizing profiles…;differ significantly among the clusters” [52].
Box 1. Grace’s Dilemma
“What should I do with my Cape Verdean patient?” insists Grace, a third-year medical student. “The clinical protocol for
hypertension requires me to identify his race but I don’t know how. Is he black or white? This man immigrated to the US at a
young age. Is he now African American or should I consider his health needs from the perspective of his immigrant status?”
The data on response to therapy seem to suggest that hypertension in blacks is somehow special, implying a separate
genetic factor for blacks. But the enormous national differences in hypertension rates do not support this argument. African
Americans suffer at rates 3.5 times those of Nigerians living in Africa, although African Americans experience only 0.75 the
rates of Germans in Germany [79]. Which category matters more for Grace’s patient, country of origin or social status in the
adopted nation?
Physicians everywhere face similar dilemmas. In clinical research projects or in the clinic, the assignment of race assumes an
equivalence between census categories and genetics embodied by patients. The large Cape Verdean population in New
England resists any simple categorization. The inhabitants are the descendents of Portuguese colonists, former slaves,
explorers, and sailors of various nationalities. We suggest that, as with Cape Verdeans, census race cannot be assumed to
reflect a particular genetic make-up.
Racial Categories Are Historical, Not Natural
Historically created racial categories often carry hidden meanings. Until 2003 medical reports were cataloged in PubMed/MEDLINE
and in the old Surgeon General’s Index Catalogue using 19th century racial categories such as Caucasoid, Monogolid, Negroid and
Australoid [53]. Originally suggesting a scale of inferiority and superiority, today such groupings continue to connote notions of
human hierarchy [27,54,55]. More importantly, PubMed’s newer categories, such as continental population group and ancestry
group, merely overlay the older ones. Assuming that “African” origin can capture the complexity of migrations, artificial boundaries,
and gene drift is scientifically unsupportable. So too is continued use of the concept of Caucasian (meaning from the central Asian
countries surrounding the Caucus Mountains) to emphasize the similarities between disparate European groups rather than their
population substructures or variations.
Racial definitions are historically and nationally specific. In her comparison of the history of racial categories in the US and Brazilian
census from the late 18th century to the present, political scientist Melissa Nobles demonstrated that categories emerge and are
deployed in different ways over time [56]. For example, during the mid-19th to the early 20th centuries, at the height of US anxiety
about “miscegenation,” categories such as “mulatto” were vehicles for expressing and containing cultural anxiety about racial purity.
Bolstered by scientific ideas about race, data collected on the numbers of “mulattoes” were shaped by the desire to prove that
“hybrids” would die out.
Another example of the creation and stabilization of racial categories occurred in the mid-20th century under the apartheid
government in South Africa. Obsessed with racial purity, the nationalist government passed the first Population Registration Act in
1950, which defined three groups—coloured, white, and native. According to the Act, a “‘coloured person’ means a person who is
not a white person, or a native…‘native’ means a person who in fact is or is generally accepted as a member of any aboriginal race
or tribe of Africa…‘white person’ means a person who in appearance obviously is, or who is generally accepted as a white person,
but does not include a person who, although in appearance obviously a white person, is generally accepted as a coloured person”
[57].
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Over the next 30 years, however, numerous amendments attempted to harden those boundaries. By 1967, the definition of a white
person was extended to include “his habits, education and speech and deportment and demeanor in general” [58]. Coloured
became a residual category, comprised of any person who could not be neatly assigned to one of the two main racial groups. In this
definition, as with racial categories in both the United States and Brazil, cultural, class, and biological aspects of human variability
are confounded. Since the 1994 dismantling of the apartheid state, racial or “population” categorization remains a subject of
discomfort and public debate [59–61]. Categories such as white/European, African, coloured, and Asian, nonetheless, are still
widely used in health care settings and in studies of genetic predisposition to disease in South Africa. Differing local conventions in
racial categorization present difficulties in transnational collaborative research and peer review in international publications. South
African researchers, for example, may feel pressured to employ categories that make no sense in their context (A. Mall, personal
communication).
In the early 20th century in the United States, shades of blackness were assumed to affect medical outcomes. This view generated
supposed facts (the “fact” that blacks have lesser lung function, for example). Once a “fact” was linked to race rather than unhealthy
living and working conditions, it resisted further challenge and became part of clinical judgments. For example, until the widespread
use of penicillin, induced malarial fevers were used to treat neurosyphilis and differing malarial strains were deployed based on
racial lines [62,63]. As one key 1932 textbook explained, black resistance to tertian malaria could be overcome “the lighter or closer
to the Caucasian the particular Negro is” [64,65]. None of the texts explained how to measure color or why it was assumed that
blacks, unlike whites, would be exposed to differing malarial strains, as if the mosquitoes respected residential segregation and
could not cross a road or tracks. Even though retrospective data made it clear that syphilis was more likely to attack the
cardiovascular rather than the neurological system in both blacks and whites, it was assumed that since African Americans did
more labor than “brainwork,” they were more at risk for cardiovascular complications. Black cardiovascular deaths, in turn, were
often labeled syphilitic in origin without the benefit of autopsy, or misread when postmortems were done (S. M. Reverby, work in
progress).
Box 2. The Future of Research on Race and Health Disparities
Race-related differences in health outcomes can be analyzed at the societal, individual, cellular, and subcellular levels.
Studies focusing exclusively on one level often lose track of inter-level connections. Two research groups exemplify efforts to
integrate research on health disparities at the level of cellular effects (e.g., on tumor production and growth), of societal level
events (e.g., social support or toxin exposure), and individual life history events (e.g., reproductive history, stress, diet).
Epidemiologist Nancy Krieger [80–82] applies the concept of embodiment to an understanding of how the social effects of
racism and social inequality become symptoms [83] and illnesses that manifest as racially related health disparities (on
embodiment, see also Fausto-Sterling, 2005 [84]). Krieger understands embodiment to be a multilevel phenomenon that
serves as “an antonym to disembodied genes, minds and behaviors” [82]. Similarly, Masi and Olopade [85] propose a
multilevel perspective on racial and ethnic disparities in breast cancer. Their model illustrates how the dynamics of societal
and individual events over the life cycle can have specific cellular outcomes resulting in neoplasms with particular cellular
characteristics. To the extent that societal and individual events vary systematically with social race, biological outcomes may
result from social inequalities. The key to future understandings of health disparities lies in using frameworks such as those
proposed by Krieger and Masi and Olopade to design and interpret research at every level, from the social to the cellular.
“Knowing” Race: From Research Plans to Individual Treatment
But the debate remains. Even given the history of the (mis)use of racial categories, are they nevertheless useful in the physician’s
office? Does a quick administrative assessment of race help to diagnose a presenting ailment, or accurately assess future risk of
illness? Environmental exposures, family histories, the stress of dealing with racism, access to and quality of care may be left
unexamined if a physician simply diagnoses “race” [66]. In the United States a rule that assumes “one drop” of African blood
defines an individual as African American [28] seems to prevail [67]. Presented with a black patient, in the face of medical
uncertainty, rather than applying individual analysis the doctor can fall back upon general statements that derive from population
studies, such as “You should get tested for glaucoma because you are African American and African Americans have a higher rate
of glaucoma.”
A dark-skinned, curly-headed person who identifies as African American may, indeed, have much in his or her history and
upbringing to justify that identification. But he or she may also have a white grandparent and several Cherokee ancestors. Thus,
returning to the example of glaucoma, it is more important to know a patient’s family history than to assess his or her race. And
collecting family history ought to mean not only compiling a list of which diseases family members have, but making some attempt
to assess common (familial) habits such as diet and life experiences (e.g., first- versus second-generation immigrants, living
conditions, or same versus widely varied work experience and geographical locations). Similarly, when the history of passing for
white is ignored, those who identify themselves as “white” are assumed to have no ancestral “black blood.” Finally, immigration
patterns constantly change. A “black” person walking into a Boston, Massachusetts clinic could easily be the child of a recent
immigrant from Ethiopia or Brazil who has a genetic makeup as well as cultural and environmental exposures that differ significantly
from the descendents of 19th century US slaves from the western coast of Africa [68,69].
Once race is presumed, the ways in which multiple genetic inheritances interact with the environment within that individual seem to
disappear (see Box 2). Clinical clues can become invisible. Even with the relatively few diseases “known” to have a 1:1 relationship
between a single mutant allele and a disease phenotype, reliance on a general idea of race can lead to misdiagnosis. In a different
American television series, ER, a “white” patient with sickle cell anemia was misdiagnosed because the condition is known as a
“black” illness. Sickle cell anemia (homozygous HbSS) results from a genetic alteration affecting the hemoglobin protein. Its high
prevalence in some populations bespeaks their historical burden of falciparum malaria. The simple gene change responsible for
sickle hemoglobin spans the continent of Africa and beyond. Its prevalence in the sub-Saharan region ranges between 10% to 40%
[70]. Within even smaller geographical areas this diversity is also apparent. In the tiny West African country of The Gambia, the
Mandinka people have an extremely low incidence at 4%, the Wolof are nearly on par with black Americans at 14%, and the more
socially endogenous Fula hover just below 30% [71]. Nonetheless, in a clinical encounter in North America, where census category
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definitions of race prevail, these groups and their descendents would, most likely, occupy the category “Black or African American.”
Moreover, some of the highest rates in the world are found in India, with rates of 33% and 35% in the Pardhan and Oktar people,
respectively [72]. Sickle cell disease is thus not “race-bound.”
So what is the practicing physician to do? In the case of sickle cell disease, it would be best to work from symptoms rather than
racial assumptions, and to enquire about geographic ancestry since sickle cell is more prevalent in populations from the
Mediterranean region, sub-Saharan Africa, and the Indian subcontinent [70].
Is Cultural Competency the Answer?
Clinicians will make better educated patient evaluations if they familiarize themselves with the history of the particular communities
they serve. For the clinical encounter, the cultural competency paradigm is sometimes offered as a tool for improving quality of
care. Cultural competency advocates have spurred curricular reform so that clinicians in training learn to be attentive to crosscultural issues. A cultural competency paradigm has recently been suggested as a powerful tool in the arsenal to combat the
prevalence of racial and ethnic health disparities [73]. However, when not thoughtfully executed, the cultural competency paradigm
can abet the simplistic thinking on race it seeks to address. On the one hand, this perspective brings greater attention to the
attitudes and behaviors that patients may bring to the clinical encounter. On the other hand such cultural stereotyping could
produce poor health outcomes if the clinician is more attentive to what he or she thinks they know about this “type” of patient than
to the individual before them [74].
Race in the Era of Individually Tailored Treatment
Medical researchers want tools that will allow physicians to understand how the individual biosocial system represented by a
patient standing before them has either produced symptoms, or has a certain future likelihood of doing so. Whether or not the
recent announcement of a $10 million cash award for the first team to sequence 100 genomes in 10 days will get us closer to
individual genomic medicine remains to be seen [75]. But in the meantime, race remains a social characteristic of populations and it
is inappropriate to use it as a central diagnostic tool for an individual patient.
The case of BiDil, the drug the fictional Dr. House prescribed to his skeptical African American patient, stands as a cautionary tale
[76]. Depending on how the age-specific morbidity data on heart disease are read, the case for the urgency of additional treatments
for African Americans can be made. Those advocating for BiDil argued that the dangers of the disease are so grave that there was
a moral necessity for a race-specific drug, while others found the statistical case for differential morbidity to be unconvincing [77].
By primarily relying on a clinical trial that only included black men and women, claims were made that the drug worked for those
who defined themselves as African American. Further, earlier studies that purported to show that ACE inhibitors—another
medication for heart failure and an alternative to the active therapies in BiDil—did not work as well on blacks failed to acknowledge
that this was not true for all black people in the study [51]. Other researchers who work on drug metabolizing enzymes have argued
bluntly that “skin pigment is a lousy surrogate for drug-metabolism status or most any aspect of human physiology ” [51].
BiDil’s real impact may therefore be less on actual patient care (since physicians are being encouraged to use the drug “off-label”
for anyone they please) and more on the fact that the US government gave its stamp of approval for what bioethicist Sandra SooJin Lee labels “racial profiling in biomedicine” [78]. Although the drug may reify race, this may not be a useful guide to determine
who needs it. In the end Dr. House may be right about how medicine is practiced and how drugs are marketed, but his patient
understands more about the underlying biology.
Thoughts for the 10-Minute Clinical Encounter
Improved medical training about race can sharpen diagnostic skills. Cultural competency instruction should be modified to include
information on the history of racial categories, current controversies about their biological significance, and the limits of their utility. A
teaching unit on race would also contrast the differences between race as a population concept with its meaning when applied to
the lives of individuals. In this context it would be appropriate to teach about geographical variations in specific allele frequencies
for genes linked to particular disease processes, as well as the cultural practices, historical trends, and environmental conditions
that favor their prevalence or not.
Physicians face huge demands for time efficiency and product output, often being called upon to process as many as six patients
per hour. No wonder that rapid racial assessment is an attractive means to figure out what to do with a presenting patient. But we
argue that even if there are short cuts for the medical interview, race is not a good one. There is, in the end (in addition to noting
physical symptoms), no substitute for an inquiry into family history, an assessment of current circumstances, and knowledge about
the biological and cultural histories of specific populations serviced by a particular treatment center.
What Is To Be Done?
In the long run, the problem of whether or how to use race as a diagnostic aid and research category requires an international
consensus meeting with representatives from all the biomedical fields. Such a meeting should be organized by the US National
Institutes of Health, the World Health Organization, and other international health institutes. In the short run, the National Institutes
of Health needs to re-examine its race-based research rules, weighing the balance between attempting to include minority
populations in our health care system, on the one hand, without forcing us into a misconstrual of race as biology on the other.
Medical courses also need to improve the teaching of the complexities of using race in the clinic. The overall goal of such an effort
would be to make clear that “For meaningful statements to be made about health disparities, careful consideration must be given to
the way in which race and ethnicity are conceptualized, the choice of definition categories, and the way in which individuals are
assigned to categories” [66]. Anthropologist Michael Montoya’s distinction between using ethnoracial categories in a descriptive
mode, to document progress in the health status of populations, but not using basically social categories to produce biological
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attribution of causes will be an essential part of this effort [7]. In the end we have to be able to answer the patient’s question—if all
hearts are red then why do we need different drugs for different individuals based on race? To provide the best health care we must
be able to say why and when race matters and why and when it doesn’t.
Acknowledgments
The authors would like to thank Jon Beckwith for helpful discussions and comments on this manuscript. Mae Clarke provided
essential assistance in organizing the footnotes scattered among eight collaborators. We also acknowledge the contributions of
participants in the Race, Medicine, and Science Workshop over the past nine years.
References
1. Witten M (2005) Humpty Dumpty. House MD. Fox Television. M. Witten2005Humpty Dumpty. House MD. Fox Television.Aired September 27, 2005.
Available: http://www.twiztv.com/scripts/house/season2/house-203.htm. Accessed 17 August 2007. Aired September 27, 2005. Available:
http://www.twiztv.com/scripts/house/season2/house-203.htm. Accessed 17 August 2007.
2. Garcia R (2003) The misuse of race in medical diagnosis. Chron High Educ 49: B15.R. Garcia2003The misuse of race in medical diagnosis.Chron High
Educ49B15
View Article
PubMed/NCBI
Google Scholar
3. Hacking I (2006) Genetics, biosocial groups and the future of identity. Daedalus 51: 81–95.I. Hacking2006Genetics, biosocial groups and the future of
identity.Daedalus518195
View Article
PubMed/NCBI
Google Scholar
4. Papas G, Queen S, Hadden W, Fisher G (1993) The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986.
New Engl J Med 329: 103–109.G. PapasS. QueenW. HaddenG. Fisher1993The increasing disparity in mortality between socioeconomic groups in the
United States, 1960 and 1986.New Engl J Med329103109
View Article
PubMed/NCBI
Google Scholar
5. Haynes MA, Smedley BD (1999) The unequal burden of cancer: An assessment of NIH research and programs for ethnic minorities and the medically
underserved. Washington (D. C): National Academy Press. MA HaynesBD Smedleyeditors. 1999The unequal burden of cancer: An assessment of NIH
research and programs for ethnic minorities and the medically underservedWashington (D. C)National Academy Press editors.
6. Banks J, Marmot M, Oldfield Z, Smith JP (2006) Disease and disadvantage in the United States and in England. JAMA 295: 2037–2045.J. BanksM.
MarmotZ. OldfieldJP Smith2006Disease and disadvantage in the United States and in England.JAMA29520372045
View Article
PubMed/NCBI
Google Scholar
7. Montoya MJ (2007) Bioethnic conscription: Genes, race, and mexicana/o ethnicity in diabetes research. Cultural Anthropology 22: 94–128.MJ
Montoya2007Bioethnic conscription: Genes, race, and mexicana/o ethnicity in diabetes research.Cultural Anthropology2294128
View Article
PubMed/NCBI
Google Scholar
8. Warren P, Tomaskovic-Devey D, Smith W, Zingraff M, Mason M (2006) Driving while black: Bias and racial disparity in police stops. Criminology 44: 709–
738.P. WarrenD. Tomaskovic-DeveyW. SmithM. ZingraffM. Mason2006Driving while black: Bias and racial disparity in police stops.Criminology44709738
View Article
PubMed/NCBI
Google Scholar
9. Fiske ST (2005) This old stereotype: The pervasiveness and persistence of the elderly stereotype. J Soc Issues 6: 267–285.ST Fiske2005This old
stereotype: The pervasiveness and persistence of the elderly stereotype.J Soc Issues6267285
View Article
PubMed/NCBI
Google Scholar
10. Cooper R, Williams DR (1986) The biological concept of race and its application to public health epidemiology. J Health Polit Policy Law 11: 96–116.R.
CooperDR Williams1986The biological concept of race and its application to public health epidemiology.J Health Polit Policy Law1196116
View Article
PubMed/NCBI
Google Scholar
11. LaVeist TA (1994) Beyond dummy variable and sample selection: What health services researchers ought to know about race as a variable. Health Serv
Res 29: 1–16.TA LaVeist1994Beyond dummy variable and sample selection: What health services researchers ought to know about race as a
variable.Health Serv Res29116
View Article
PubMed/NCBI
Google Scholar
12. Muntaner C, Nieto FJ, O’Campo P (1996) The bell curve: On race, social class, and epidemiologic research. Am J Epidemiol 144: 531–536.C.
MuntanerFJ NietoP. O’Campo1996The bell curve: On race, social class, and epidemiologic research.Am J Epidemiol144531536
View Article
PubMed/NCBI
Google Scholar
13. Freeman H (1998) The meaning of race in science—Considerations for cancer research. Cancer 82: 219–225.H. Freeman1998The meaning of race in
science—Considerations for cancer research.Cancer82219225
View Article
PubMed/NCBI
Google Scholar
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040271
5/10
8/23/2017
Racial Categories in Medical Practice: How Useful Are They?
14. Krieger N (2003) Does racism harm health? Did child abuse exist before1962? On explicit questions, critical science, and current controversies: An
ecosocial perspective. Am J Public Health 93: 194–199.N. Krieger2003Does racism harm health? Did child abuse exist before1962? On explicit
questions, critical science, and current controversies: An ecosocial perspective.Am J Public Health93194199
View Article
PubMed/NCBI
Google Scholar
15. Kaufman JS, Cooper RS (2001) Commentary: Considerations for use of racial/ethnic classification in etiologic research. Am J Epidemiol 154: 291–298.JS
KaufmanRS Cooper2001Commentary: Considerations for use of racial/ethnic classification in etiologic research.Am J Epidemiol154291298
View Article
PubMed/NCBI
Google Scholar
16. Duster T (2005) Race and reification in science. Science 307: 1050–1051.T. Duster2005Race and reification in science.Science30710501051
View Article
PubMed/NCBI
Google Scholar
17. Shields AE, Hammonds EM, King PA, Lerman C, Rapp R, et al. (2005) The use of race variables in genetic studies of complex traits and the goal of
reducing health disparities: A transdisciplinary perspective. Am Psychol 60: 77–103.AE ShieldsEM HammondsPA KingC. LermanR. Rapp2005The use of
race variables in genetic studies of complex traits and the goal of reducing health disparities: A transdisciplinary perspective.Am Psychol6077103
View Article
PubMed/NCBI
Google Scholar
18. Jones C, LaVeist T, Lillie-Blanton M (1991) “Race” in epidemiologic literature: An examination of the American Journal of Epidemiology, 1921–1990. Am J
Epidemiol 134: 1079–1084.C. JonesT. LaVeistM. Lillie-Blanton1991“Race” in epidemiologic literature: An examination of the American Journal of
Epidemiology, 1921–1990.Am J Epidemiol13410791084
View Article
PubMed/NCBI
Google Scholar
19. Kreiger N, Rowley DL, Herman AA, Avery B, Phillips MT (1993) Racism, sexism, and social class: Implications for studies of health, disease, and well
being. Am J Prev Med 9(Suppl 6): 82–122.N. KreigerDL RowleyAA HermanB. AveryMT Phillips1993Racism, sexism, and social class: Implications for
studies of health, disease, and well being.Am J Prev Med9Suppl 682122
View Article
PubMed/NCBI
Google Scholar
20. Williams DR (1994) The concept of race in health services research. Health Serv Res 29: 216–274.DR Williams1994The concept of race in health
services research.Health Serv Res29216274
View Article
PubMed/NCBI
Google Scholar
21. Oppenheimer G (2001) Paradigm lost: Race, ethnicity, and the search for a new population taxonomy. Am J Public Health 91: 1049–1055.G.
Oppenheimer2001Paradigm lost: Race, ethnicity, and the search for a new population taxonomy.Am J Public Health9110491055
View Article
PubMed/NCBI
Google Scholar
22. Williams DR (1997) Race and health: Basic questions, emerging directions. Ann Epidemiol 7: 322–333.DR Williams1997Race and health: Basic
questions, emerging directions.Ann Epidemiol7322333
View Article
PubMed/NCBI
Google Scholar
23. Epstein S (2007) Inclusion: The politics of difference in medical research. Chicago: University of Chicago Press. S. Epstein2007Inclusion: The politics of
difference in medical researchChicagoUniversity of Chicago Press413
24. United States Code (1993) National Institutes of Health Revitalization Act of 1993. United States Code1993National Institutes of Health Revitalization Act
of 1993.Public Law 103–43 §§131–151, 107, Stat 122, 133–140. Codified as amended at 42 USC §§ 283–290 (2004). Public Law 103–43 §§131–151,
107, Stat 122, 133–140. Codified as amended at 42 USC §§ 283–290 (2004).
25. National Institutes of Health (2001) NIH policy and guidelines on the inclusion of women and minorities as subjects in clinical research. Amended October
2001. National Institutes of Health2001NIH policy and guidelines on the inclusion of women and minorities as subjects in clinical research. Amended
October 2001.Available: http://grants.nih.gov/grants/funding/women_min/guidelines_amended_10_2001.htm. Accessed 17 August 2007. Available:
http://grants.nih.gov/grants/funding/women_min/guidelines_amended_10_2001.htm. Accessed 17 August 2007.
26. Epstein S (2004) Bodily differences and collective identities: The politics of gender and race in biomedical research in the United States. Body and Society
10: 183–203.S. Epstein2004Bodily differences and collective identities: The politics of gender and race in biomedical research in the United States.Body
and Society10183203
View Article
PubMed/NCBI
Google Scholar
27. Institute of Medicine (2003) Unequal treatment: Confronting racial and ethnic disparities in health care. Institute of Medicine2003Unequal treatment:
Confronting racial and ethnic disparities in health care.Available: http://www.nap.edu/openbook.php?isbn=030908265X. Accessed 20 August 2007.
Available: http://www.nap.edu/openbook.php?isbn=030908265X. Accessed 20 August 2007.
28. Wright L (1994) One drop of blood. The New Yorker. L. Wright1994One drop of blood. The New Yorker.Available: http://www.lawrencewright.com/artdrop.html. Accessed 20 August 2007. Available: http://www.lawrencewright.com/art-drop.html. Accessed 20 August 2007.
29. Bowker G, Leigh SS (1997) Sorting things out: Classification and its consequences. Cambridge (MA): MIT Press. G. BowkerSS Leigh1997Sorting things
out: Classification and its consequencesCambridge (MA)MIT Press377
30. Council of Biology Editors, Style Manual Committee (1994) Scientific style and format: The CBE manual for authors, editors, and publishers. 6th edition.
Cambridge: Cambridge University Press. Council of Biology Editors, Style Manual Committee1994Scientific style and format: The CBE manual for
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040271
6/10
8/23/2017
Racial Categories in Medical Practice: How Useful Are They?
authors, editors, and publishers6th editionCambridgeCambridge University Press825
31. Editor (2000) Census, race and science. Nat Genet 24: 97–98.Editor2000Census, race and science.Nat Genet249798
View Article
PubMed/NCBI
Google Scholar
32. Bhopal R, Donaldson L (1998) White, European, Western, Caucasian, or what? Inappropriate labeling in research on race, ethnicity, and health. Am J
Public Health 88: 1303–1307.R. BhopalL. Donaldson1998White, European, Western, Caucasian, or what? Inappropriate labeling in research on race,
ethnicity, and health.Am J Public Health8813031307
View Article
PubMed/NCBI
Google Scholar
33. Schwartz RS (2001) Racial profiling in medical research. N Engl J Med 344: 1392–1393.RS Schwartz2001Racial profiling in medical research.N Engl J
Med34413921393
View Article
PubMed/NCBI
Google Scholar
34. Wood AJ (2000) Racial differences in the response to drugs—Pointers to genetic differences. N Engl J Med 344: 1394–1396.AJ Wood2000Racial
differences in the response to drugs—Pointers to genetic differences.N Engl J Med34413941396
View Article
PubMed/NCBI
Google Scholar
35. [No authors listed] (2001) Genes, drugs, and race. Nat Genet 29: 239–240.[No authors listed]2001Genes, drugs, and race.Nat Genet29239240
View Article
PubMed/NCBI
Google Scholar
36. Burchard EG, Ziv E, Coyle N, Gomez SL, Tang H, et al. (2003) The importance of race and ethnic background in biomedical research and clinical practice.
N Engl J Med 348: 1170–1175.EG BurchardE. ZivN. CoyleSL GomezH. Tang2003The importance of race and ethnic background in biomedical research
and clinical practice.N Engl J Med34811701175
View Article
PubMed/NCBI
Google Scholar
37. Cooper RS (2003) Race, genes, and health—New wine in old bottles? Int J Epidemiol 32: 23–25.RS Cooper2003Race, genes, and health—New wine in
old bottles?Int J Epidemiol322325
View Article
PubMed/NCBI
Google Scholar
38. Karter AJ (2003) Commentary: Race, genetics, and disease—In search of a middle ground. Int J Epidemiol 32: 26–28.AJ Karter2003Commentary: Race,
genetics, and disease—In search of a middle ground.Int J Epidemiol322628
View Article
PubMed/NCBI
Google Scholar
39. Ellison GTH (2005) Population profiling and public health risk: When and how should we use race/ethnicity? Crit Public Health 15: 65–74.GTH
Ellison2005Population profiling and public health risk: When and how should we use race/ethnicity?Crit Public Health156574
View Article
PubMed/NCBI
Google Scholar
40. Braun L (2006) Reifying human difference: The debate on genetics, race, and health. Int J Health Serv 36: 557–573.L. Braun2006Reifying human
difference: The debate on genetics, race, and health.Int J Health Serv36557573
View Article
PubMed/NCBI
Google Scholar
41. Sankar P, Cho MK, Condit CM, Hunt LM, Koenig B, et al. (2004) Genetic research and health disparities. JAMA 291: 2985–2989.P. SankarMK ChoCM
ConditLM HuntB. Koenig2004Genetic research and health disparities.JAMA29129852989
View Article
PubMed/NCBI
Google Scholar
42. Risch N, Burchard E, Ziv E, Tang H (2002) Categorization of humans in biomedical research: Genes, race and disease. Genome Biol. 3. N. RischE.
BurchardE. ZivH. Tang2002Categorization of humans in biomedical research: Genes, race and disease.Genome Biol3comment2007. E-pub 1 July 2002.
comment2007. E-pub 1 July 2002.
43. Tang HT, Quertermous T, Rodriguez B, Kardia SL, Zhu X, et al. (2005) Genetic structure, self-identified race/ethnicity, and confounding in case-control
association studies. Am J Hum Genet 76: 268–275.HT TangT. QuertermousB. RodriguezSL KardiaX. Zhu2005Genetic structure, self-identified
race/ethnicity, and confounding in case-control association studies.Am J Hum Genet76268275
View Article
PubMed/NCBI
Google Scholar
44. Baum BD (2006) The rise and fall of the Caucasian race: A political history of racial identity. New York: New York University Press. BD Baum2006The rise
and fall of the Caucasian race: A political history of racial identityNew YorkNew York University Press352
45. Bauchet M, McEvoy B, Pearson LN, Quillen EE, Sarkisian T, et al. (2007) Measuring European population stratification with microarray genotype data. Am
J Hum Genet 80: 948–956.M. BauchetB. McEvoyLN PearsonEE QuillenT. Sarkisian2007Measuring European population stratification with microarray
genotype data.Am J Hum Genet80948956
View Article
PubMed/NCBI
Google Scholar
46. Fullwiley D (2007) The molecularization of race. Sci Cult 16: 1–30.D. Fullwiley2007The molecularization of race.Sci Cult16130
View Article
PubMed/NCBI
Google Scholar
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040271
7/10
8/23/2017
Racial Categories in Medical Practice: How Useful Are They?
47. Cooper RS, Kaufman JS, Ward R (2003) Race and genomics. N Engl J Med 348: 1166–1170.RS CooperJS KaufmanR. Ward2003Race and genomics.N
Engl J Med34811661170
View Article
PubMed/NCBI
Google Scholar
48. Jackson F (1993) Evolutionary and political economic influences on biological diversity in African Americans. J Black Stud 23: 539–540.F.
Jackson1993Evolutionary and political economic influences on biological diversity in African Americans.J Black Stud23539540
View Article
PubMed/NCBI
Google Scholar
49. King RC (2000) Racialization, recognition, and rights: Lumping and splitting multiracial Asian Americans in the 2000 Census. J Asian-Am Stud 3.2: 191–
217.RC King2000Racialization, recognition, and rights: Lumping and splitting multiracial Asian Americans in the 2000 Census.J Asian-Am Stud3.2191217
View Article
PubMed/NCBI
Google Scholar
50. Tishkoff S, Kidd K (2004) Implications of biogeography of human populations for ‘race’ and medicine. Nat Genet 36(11 Suppl): S21–S27.S. TishkoffK.
Kidd2004Implications of biogeography of human populations for ‘race’ and medicine.Nat Genet3611 SupplS21S27
View Article
PubMed/NCBI
Google Scholar
51. McLeod HL (2001) Pharmacogenetics: More than skin deep. Nat Genet 29: 247–248.HL McLeod2001Pharmacogenetics: More than skin deep.Nat
Genet29247248
View Article
PubMed/NCBI
Google Scholar
52. Wilson JF, Weale ME, Smith AC, Gratrix F, Fletcher B, et al. (2001) Population genetic structure of variable drug response. Nat Genet 29: 265–269.JF
WilsonME WealeAC SmithF. GratrixB. Fletcher2001Population genetic structure of variable drug response.Nat Genet29265269
View Article
PubMed/NCBI
Google Scholar
53. Sankar P (2003) MEDLINE definitions of race and ethnicity and their application to genetic research. Nat Genet 34: 119.P. Sankar2003MEDLINE
definitions of race and ethnicity and their application to genetic research.Nat Genet34119
View Article
PubMed/NCBI
Google Scholar
54. Sankar P, Cho MK (2002) Toward a new vocabulary of human genetic variation. Science 298: 1337–1338.P. SankarMK Cho2002Toward a new
vocabulary of human genetic variation.Science29813371338
View Article
PubMed/NCBI
Google Scholar
55. Painter N (2003) Why white people are called ‘Caucasian.’ Proceedings of the Fifth Annual Gilder Lehman Center International Conference at Yale
University. N. Painter2003Why white people are called ‘Caucasian.’ Proceedings of the Fifth Annual Gilder Lehman Center International Conference at
Yale University.Available: http://www.yale.edu/glc/events/race/Painter.pdf. Accessed 20 August 2007. Available:
http://www.yale.edu/glc/events/race/Painter.pdf. Accessed 20 August 2007.
56. Nobles M (2000) Shades of citizenship: Race and the census in modern politics. Palo Alto (CA): Stanford University Press. M. Nobles2000Shades of
citizenship: Race and the census in modern politicsPalo Alto (CA)Stanford University Press248
57. Population Registration Act, Act No. 30 of 1950, Republic of South Africa, Government Gazette. Population Registration Act, Act No. 30 of 1950, Republic
of South Africa, Government Gazette.
58. Population Registration Act, Act No. 64 of 1967, Republic of South Africa, Government Gazette. Population Registration Act, Act No. 64 of 1967, Republic
of South Africa, Government Gazette.
59. Ellison GTH, de Wet T, Ijsselmuiden CB, Richter LM (1996) Desegregating health statistics and health research in South Africa. S Afr Med J 86: 1257–
1262.GTH EllisonT. de WetCB IjsselmuidenLM Richter1996Desegregating health statistics and health research in South Africa.S Afr Med J8612571262
View Article
PubMed/NCBI
Google Scholar
60. Ellison CTH, de Wet T (1997) The use of ‘racial’ categories in contemporary South African health research. S Afr Med J 87: 1671–1679.CTH EllisonT. de
Wet1997The use of ‘racial’ categories in contemporary South African health research.S Afr Med J8716711679
View Article
PubMed/NCBI
Google Scholar
61. West ME, Boonzaier EA (1989) Population groups, politics and medical science. S Afr Med J 76: 185–186.ME WestEA Boonzaier1989Population groups,
politics and medical science.S Afr Med J76185186
View Article
PubMed/NCBI
Google Scholar
62. Callis HA (1929) Comparative therapy in syphilis. Journal of the National Medical Association. XXI. HA Callis1929Comparative therapy in syphilis.Journal
of the National Medical AssociationXXIJanuary–March. Reprinte. In: Wesley CH (1977) Henry Arthur Callis, life and legacy. Chicago: Foundation
Publishers. pp. 186–204. January–March. Reprinte. In: Wesley CH (1977) Henry Arthur Callis, life and legacy. Chicago: Foundation Publishers. pp. 186–
204.
63. Callis HA (1929) Primary syphilis. J Nat Med Assoc. XXI. HA Callis1929Primary syphilis.J Nat Med AssocXXIApril–June. Reprinte. In: Wesley CH (1977)
Henry Arthur Callis, life and legacy. Chicago: Foundation Publishers, pp.186–204. April–June. Reprinte. In: Wesley CH (1977) Henry Arthur Callis, life and
legacy. Chicago: Foundation Publishers, pp.186–204.
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040271
8/10
8/23/2017
Racial Categories in Medical Practice: How Useful Are They?
64. Schamberg J, Wright CS (1932) Treatment of syphilis. New York: D. Appleton. J. SchambergCS Wright1932Treatment of syphilisNew YorkD. Appleton525
65. Moore JE (1947) The modern management of syphilis. 2nd edition. Springfield: Charles C, Thomas Publishers. JE Moore1947The modern management
of syphilis2nd editionSpringfieldCharles C, Thomas Publishers717
66. Kaplan JB, Bennet T (2003) Use of race and ethnicity in biomedical publication. JAMA 289: 2709–2716.JB KaplanT. Bennet2003Use of race and ethnicity
in biomedical publication.JAMA28927092716
View Article
PubMed/NCBI
Google Scholar
67. Omi M, Winant H (1994) Racial formation in the United States: From the 1960’s to the 1990’s. New York: Routledge. M. OmiH. Winant1994Racial
formation in the United States: From the 1960’s to the 1990’sNew YorkRoutledge226
68. Lee J, Bean FD (2004) America’s changing color lines: Immigration, race/ethnicity, and multiracial identification. Annu Rev Sociol 30: 221–242.J. LeeFD
Bean2004America’s changing color lines: Immigration, race/ethnicity, and multiracial identification.Annu Rev Sociol30221242
View Article
PubMed/NCBI
Google Scholar
69. Roberts S (2005 February 21) More Africans enter U.S than in days of slavery. The New York Times. S. Roberts2005 February 21More Africans enter U.S
than in days of slavery. The New York Times.Available: http://www.nytimes.com/2005/02/21/nyregion/21africa.html?
ex=1266728400&en=0ea8084a4c263210&ei=5088&partner=rssnyt. Accessed 20 August 2007. Available:
http://www.nytimes.com/2005/02/21/nyregion/21africa.html?ex=1266728400&en=0ea8084a4c263210&ei=5088&partner=rssnyt. Accessed 20 August
2007.
70. World Health Organization (2006) Sickle-cell anaemia: Report by the Secretariat. World Health Organization2006Sickle-cell anaemia: Report by the
Secretariat.Available: http://www.who.int/gb/ebwha/pdf_files/EB117/B117_34-en.pdf. Accessed 20 August 2007. Available:
http://www.who.int/gb/ebwha/pdf_files/EB117/B117_34-en.pdf. Accessed 20 August 2007.
71. Ackerman H, Usen S, Jallow M, Sisay-Joof F, Pinder M, et al. (2005) A comparison of case-control and family-based association methods: The example
of sickle-cell and malaria. Ann Hum Genet 69(Pt 5): 559–565.H. AckermanS. UsenM. JallowF. Sisay-JoofM. Pinder2005A comparison of case-control and
family-based association methods: The example of sickle-cell and malaria.Ann Hum Genet69Pt 5559565
View Article
PubMed/NCBI
Google Scholar
72. Kate SL (2001) Health problems of tribal population groups from the state of Maharashtra. Indian J Med Sci 55: 99–108.SL Kate2001Health problems of
tribal population groups from the state of Maharashtra.Indian J Med Sci5599108
View Article
PubMed/NCBI
Google Scholar
73. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong IO (2003) Defining cultural competence: A practical framework for addressing racial/ethnic
disparities in health and health care. Public Health Rep 118: 293–302.JR BetancourtAR GreenJE CarrilloIO Ananeh-Firempong2003Defining cultural
competence: A practical framework for addressing racial/ethnic disparities in health and health care.Public Health Rep118293302
View Article
PubMed/NCBI
Google Scholar
74. Kleinman A, Benson P (2006) Anthropology in the clinic: The problem of cultural competency and how to fix It. PLoS Med 3: e294.A. KleinmanP.
Benson2006Anthropology in the clinic: The problem of cultural competency and how to fix It.PLoS Med3e294
View Article
PubMed/NCBI
Google Scholar
75. Wade N (2006 October 5) $10 million prize set up for speedy DNA decoding. The New York Times. N. Wade2006 October 5$10 million prize set up for
speedy DNA decoding. The New York Times.Available: http://select.nytimes.com/search/restricted/article?
res=F50F12FD3E540C768CDDA90994DE404482. Accessed 20 August 2007. Available: http://select.nytimes.com/search/restricted/article?
res=F50F12FD3E540C768CDDA90994DE404482. Accessed 20 August 2007.
76. Reverby SM (2006 April 16) “Special treatment:” BiDil, Tuskegee and the logic of race. SM Reverby2006 April 16“Special treatment:” BiDil, Tuskegee and
the logic of race.Paper given at the MIT Conference on Race, Pharmaceuticals and Medical Technology. Paper given at the MIT Conference on Race,
Pharmaceuticals and Medical Technology.
77. Kahn J (2004) How a drug becomes ‘ethnic’: Law, commerce, and the production of racial categories in medicine. Yale J Health Policy Law Ethics 4: 1–
46.J. Kahn2004How a drug becomes ‘ethnic’: Law, commerce, and the production of racial categories in medicine.Yale J Health Policy Law Ethics4146
View Article
PubMed/NCBI
Google Scholar
78. Lee S-JS (2005) Racializing drug design: Implications of pharmacogenomics for health disparities. Am J Public Health 95: 2135–2138.S-JS
Lee2005Racializing drug design: Implications of pharmacogenomics for health disparities.Am J Public Health9521352138
View Article
PubMed/NCBI
Google Scholar
79. Cooper RS, Wolf-Maier K, Luke A, Adeyemo A, Banegas JR, et al. (2005) An international comparative study of blood pressure in populations of
European vs. African descent. BMC Med 3: 2.RS CooperK. Wolf-MaierA. LukeA. AdeyemoJR Banegas2005An international comparative study of blood
pressure in populations of European vs. African descent.BMC Med32
View Article
PubMed/NCBI
Google Scholar
80. Krieger N (2005) Defining and investigating social disparities in cancer: Critical issues. Cancer Causes Control 16: 5–14.N. Krieger2005Defining and
investigating social disparities in cancer: Critical issues.Cancer Causes Control16514
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040271
9/10
8/23/2017
Racial Categories in Medical Practice: How Useful Are They?
View Article
PubMed/NCBI
Google Scholar
81. Krieger N (2005) Stormy weather: Race, gene expression and the science of health disparities. Am J Public Health 95: 2155–2160.N. Krieger2005Stormy
weather: Race, gene expression and the science of health disparities.Am J Public Health9521552160
View Article
PubMed/NCBI
Google Scholar
82. Krieger N (2005) Embodiment: A glossary for epidemiology. J Epidemiol Community Health 59: 350–355.N. Krieger2005Embodiment: A glossary for
epidemiology.J Epidemiol Community Health59350355
View Article
PubMed/NCBI
Google Scholar
83. Krieger N, Smith K, Naishadham D, Hartman C, Barbeau EM (2005) Experiences of discrimination: Validity and reliability of a self-report measure for
population health research on racism and health. Soc Sci Med 61: 1576–1596.N. KriegerK. SmithD. NaishadhamC. HartmanEM
Barbeau2005Experiences of discrimination: Validity and reliability of a self-report measure for population health research on racism and health.Soc Sci
Med6115761596
View Article
PubMed/NCBI
Google Scholar
84. Fausto-Sterling A (2005) The bare bones of sex: Part I, sex and gender. Signs 30: 1491–1428.A. Fausto-Sterling2005The bare bones of sex: Part I, sex
and gender.Signs3014911428
View Article
PubMed/NCBI
Google Scholar
85. Masi C, Olopade O (2005) Racial and ethnic disparities in breast cancer: A multilevel perspective. Med Clin North Am 89: 753–770.C. MasiO.
Olopade2005Racial and ethnic disparities in breast cancer: A multilevel perspective.Med Clin North Am89753770
View Article
PubMed/NCBI
Google Scholar
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040271
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What Doctors Should Ignore – The New York Times
https://nyti.ms/2BML6EC
What Doctors Should Ignore
Science has revealed how arbitrary racial categories
are. Perhaps medicine will abandon them, too.
Moises Velasquez-Manoff
DEC. 8, 2017
Sickle cell anemia was first described in 1910 and was quickly labeled a “black” disease. At a time when many people were
preoccupied with an imagined racial hierarchy, with whites on top, the disease was cited as evidence that people of African
descent were inferior. But what of white people who presented with sickle cell anemia?
Doctors twisted themselves into knots trying to explain those cases away. White sickle cell patients must have mixed
backgrounds, they contended — a black forebear they didn’t know about perhaps, or one they didn’t want to mention. Or
maybe white patients’ symptoms didn’t stem from sickle cell anemia at all, but some other affliction. The bottom line was, the
disease was “black,” so by definition white people couldn’t get it.
Today, scientists understand the sickle cell trait as an adaptation to malaria, not evidence of inferiority. One copy of the
sickle cell trait protects against malaria. Having two can cause severe anemia and even death. Scientists also know that the
trait is common outside Africa across the “malaria belt” — the Arabian Peninsula, India and parts of the Mediterranean Basin.
And people historically considered white can, in fact, carry it. In the Greek town of Orchomenos, for example, the gene is more
prevalent than it is among African-Americans.
We know all this, and yet the racialization of the disease, the idea that it occurs only in people of sub-Saharan African
descent, persists. “When I talk to medical students, I get this all the time — ‘Sickle cell is a black trait,’ ” Michael Yudell,
chairman of the department of community health and prevention at the Dornsife School of Public Health at Drexel University,
told me.
That’s worrisome for many reasons, he says, chief among them that it may result in subpar medical care for some patients.
Case in point: California’s universal blood disorder screening program has identified thousands of nonblack children with the
sickle cell trait and scores with the disease — patients who, had doctors stuck to received “wisdom,” might have been missed.
Professor Yudell belongs to a growing chorus of scholars and researchers who argue that in science at least, we need to
push past the race concept and, where possible, scrap it entirely. Professor Yudell and others contend that instead of talking
about race, we should talk about ancestry (which, unlike “race,” refers to one’s genetic heritage, not innate qualities); or the
specific gene variants that, like the sickle cell trait, affect disease risk; or environmental factors like poverty or diet that affect
some groups more than others.
The push to retire the race concept may seem to contradict another progressive trend in medicine: increased attention to
how race affects treatment. Research suggests that blacks and other minorities are less likely than whites to receive treatment
for pain and fare worse in a number of medical outcomes. The issue is complex, but some scientists think that doctors’
unconscious stereotyping partly drives these disparities.
So how can we fix the issue unless we frankly acknowledge what drives it — the perception of race? Indeed, rather than
discarding the idea of race, some medical schools now include “unconscious bias” training, classes in which students are
essentially asked to contemplate their own often unintentional racism.
https://www.nytimes.com/2017/12/08/opinion/sunday/should-medicine-discard-race.html
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What Doctors Should Ignore – The New York Times
Such initiatives are not entirely incongruous with the goal of superseding race. The idea in both cases is to push beyond
the clunky race labels we have inherited, as well as our own preconceptions about those labels, and to see people with greater
clarity and nuance than those categories and their attendant biases generally allow.
In biology, race is roughly analogous to the idea of subspecies, and the argument over its utility for humans has some
history. After championing the concept as useful for categorizing human variation in the mid-20th century, the evolutionary
biologist Theodosius Dobzhansky began to see that scientists needed a more precise way to talk about human diversity, and
said as much. The race concept had been used to justify so much cruelty and oppression that its value, he came to realize, was
questionable.
In the decades since, others have reiterated those points. What’s new today is that modern genetic science has revealed
just how arbitrary the old race categories — Negroid, Caucasoid, Mongoloid and so on — really are. Yes, there is variation in
the human family, but there are few sharp divides where one set of traits ends and another begins. Rather, traits exist in
gradients, reaching high frequency in some populations and lower frequency in others. As the geneticist Sarah Tishkoff of the
University of Pennsylvania reminded me, human beings are too young as a species, too promiscuous and full of wanderlust,
always moving and mixing, for the kind of separation and differentiation that would cause true speciation to have occurred.
The truth is that there is sometimes more variation within what we call races than there is between them. A study led by
the geneticist J. Craig Venter highlights this point. He compared his genome to that of James Watson, one of the two scientists
who discovered the double helix shape of DNA. Dr. Venter focused on six genes that affect how we respond to antidepressants
and antipsychotics, among other drugs. Dr. Venter and Dr. Watson are “Caucasian.” Dr. Venter had two copies of a
“Caucasian” variant of one of these genes, but Dr. Watson carried a version more common in East Asian populations. Judging
by self-reported race, Dr. Venter noted, a doctor might prescribe Dr. Watson the wrong dose of medicine.
The takeaway from studies like this is that rather than relying on race, doctors should focus on the genes important to
whatever puzzle they face — an approach often called “precision” or “personalized” medicine. The idea is that tailoring
treatment to the patient’s genotype, not to skin color or hair texture, would improve outcomes.
Consider the case of kidney disease. Scientists have found that African-Americans fare worse than whites when it comes to
this illness. The assumption had long been that some environmental factor explained the difference. But in recent years,
scientists have linked certain variants of a gene called APOL1 to worse kidney-related outcomes. Those variants are enriched in
people of African ancestry. Girish N. Nadkarni, a kidney specialist at Icahn School of Medicine at Mount Sinai in New York
City, explained to me that scientists think this may be because those variants protect against the sleeping sickness endemic to
some parts of Africa.
But not all African-Americans carry the variants. That is important because, in an attempt to account for the higher risk of
kidney problems among African-Americans, kidney donor registries include information about race. And kidneys from “black”
donors might be discarded on the assumption that they are more prone to failure. But by looking directly at whether patients
and donors carried this gene variant — in particular, two copies of it — scientists at the University of Alabama at Birmingham
recently found they could theoretically improve transplant outcomes. Kidneys donated from black donors that might otherwise
have been discarded could, with genotyping, go to patients who needed them.
Not everyone agrees that it is possible or even desirable to completely scrap the race concept. Alex Lickerman, founder of
ImagineMD, a medical concierge service in Chicago, cites the example of prostate cancer. For unclear reasons, AfricanAmericans have a higher risk than whites. One test for the cancer, which looks at prostate-specific antigen, is controversial
because it can yield false positives. Some recommend against using it at all.
But Dr. Lickerman says that merely being aware that African-Americans have a higher disease risk impels him to order the
test more often for African-American patients. To his mind, the elevated risk of cancer outweighs the risk of a false positive.
“Race is a crude marker, but it’s a usable marker,” he said. In that respect, it is no different from other factors doctors consider,
most of which are based on imperfect studies of limited size and scope, and need to be weighed carefully.
https://www.nytimes.com/2017/12/08/opinion/sunday/should-medicine-discard-race.html
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What Doctors Should Ignore – The New York Times
Furthermore, we still don’t know all the genes responsible for observed health disparities. In a future “utopia,” explains
Esteban Burchard, a professor of pharmaceutical sciences and medicine at the University of California, San Francisco, we’d
have this information. Patients’ medical files would contain information about their unique genomes. But we’re not there yet.
“We can’t even give people basic health care,” Dr. Burchard said. “Are we going to pay for everyone to get genotyped?”
In some cases, it is precisely the nongenetic aspects of race that are important in understanding what ails a patient. If you
want to understand the life expectancy of people in Ferguson, Mo., for example — where the Justice Department found that
the police department needed to be overhauled in part because of racial bias — it is critical to know whether the person is
African-American. “Genetics don’t matter there,” Dr. Burchard said. What drives those disparities are environmental — that is,
social — factors.
African-Americans, who on average have about 20 percent European ancestry, suffer from high blood pressure more often
than whites do. Some studies indicate that among African-Americans, the darker one’s skin, the greater the risk of high blood
pressure. The pattern could indicate that African ancestry is responsible.
Yet Africans in Africa don’t generally have high blood pressure. So some argue that the experience of having dark skin in
the United States — of experiencing racism — is what’s raising blood pressure. In this case, Dr. Burchard says, even though
race is a social construct, the best way to talk about the associated disease risk may be to use the labels, since the societal
baggage that comes with them may be causing the problem.
But the hope is that one day we can use modern genetic tools to bypass the quagmire of race entirely. Consider the
research of Alan Wu, a lab director of the Zuckerberg San Francisco General Hospital. Dr. Wu is working to improve a basic
blood test that measures red blood cells, white blood cells and so forth.
Currently, when it comes to ancestry, the test compares everyone’s blood against a single standard. This is a problem
because what’s “normal” probably varies according to ancestry. Dr. Wu hopes to devise a version of the test that accounts for
variations in blood count according to ancestry. But instead of using self-reported race as a way to specify this variation, he is
trying to determine patients’ backgrounds directly with genetic testing — looking at what proportion of a person’s DNA comes
from East Asia, say, or Europe.
Science seeks to categorize nature, to sort it into discrete groupings to better understand it. That is one way to
comprehend the race concept: as an honest scientific attempt at understanding human variation. The problem is, the concept
is imprecise. It has repeatedly slid toward pseudoscience and has become a major divider of humanity. Now, at a time when we
desperately need ways to come together, there are scientists — intellectual descendants of the very people who helped give us
the race concept — who want to retire it.
Moises Velasquez-Manoff, the author of “An Epidemic of Absence: A New Way of Understanding Allergies and Autoimmune
Disease,” is a contributing opinion writer.
Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today
newsletter.
A version of this op-ed appears in print on December 10, 2017, on Page SR1 of the New York edition with the headline: Should Doctors Ignore Race?.
© 2018 The New York Times Company
https://www.nytimes.com/2017/12/08/opinion/sunday/should-medicine-discard-race.html
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Understanding Race and Medicine – The New York Times
https://nyti.ms/2kEJTbD
Opinion
|
LETTERS
Understanding Race and Medicine
DEC. 17, 2017
To the Editor:
Re “Should Doctors Ignore Race?,” by Moises Velasquez-Manoff (Sunday Review, Dec. 10):
I fully agree that race needs to be retired from genetic science, but the distinction between race and racism and the
importance of naming, understanding and addressing racism in medicine and public health cannot be overstated.
Racism — the system of power and oppression based on race — has real and persistent health consequences that have
been repeatedly demonstrated by public health and social science research. Racial health differences arise when groups face
serious and persistent disadvantages caused by racism at all levels.
Racism operates through and across institutions, policies and practices, creating differential access to opportunities and
resources.
So our health institutions need to do more to examine how racism shapes health. Advances in genetic science continue to
confirm that race has no genetic or biological basis, and for that reason our understanding of race needs to move beyond
genetics to a full accounting of the impacts of racism on health. Only then will we truly advance health for all.
ALETHA MAYBANK, NEW YORK
The writer, a doctor of preventive medicine, is deputy commissioner and director of the Center for Health Equity, New
York City Health Department.
To the Editor:
Yes, race is a social construct and ancestry may explain disease beyond racial categories. But from my time at an urban
safety-net hospital, I can tell you that doctors who ignore race do so at their patients’ peril.
It is undisputed that black people in the United States have worse prevention, treatment and outcomes across diseases
than any other racial group in the country. Because income and social resources are inextricably linked to health, the poverty
experienced by black Americans makes health adversity even more likely.
Add in longstanding inequities in educational access, accompanied by limited general and health literacy, and
neighborhood characteristics salient to health (crowded housing, absence of green spaces, food deserts and fear of arrest while
taking a walk), and we have a perfect storm for miserable health outcomes.
So the goal for doctors should be not to ignore race, but rather to understand what it means to our patients.
JARED W. MAGNANI, PITTSBURGH
The writer, a cardiologist, is an associate professor of medicine at the University of Pittsburgh.
To the Editor:
https://www.nytimes.com/2017/12/17/opinion/race-medicine.html
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Understanding Race and Medicine – The New York Times
As a law school professor, I taught a seminar on how American lawmakers have created different categories of race and
have varied them over time and space.
So when I went for a bone density test and the technician asked me my race, I asked her why. She replied that the bones of
black people were different from the bones of white people.
Like my parents, and like many other black Americans, I have white skin and am often mistaken for white. When I was
born in North Carolina, despite my white skin, blue eyes and blond hair, the hospital clerk put “colored” on my birth certificate
because my parents, also black Americans with white skin, were listed as “colored.”
The clerk knew that in America looks were not dispositive on the question of race. And some 60 years later, I knew that I
was paying for a bone structure analysis that would be useless.
Moises Velasquez-Manoff notes in his essay that considering the race of patients “may result in subpar medical care for
some patients.” It already has.
JUDY SCALES-TRENT
EAST AMHERST, N.Y.
The writer is the author of “Notes of a White Black Woman: Race, Color, Community.”
A version of this letter appears in print on December 18, 2017, on Page A20 of the New York edition with the headline: Understanding Race and Medicine.
© 2018 The New York Times Company
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