Saturday, June 18, 2005

PC medicine?

It's a well-documented fact that Afro-Americans in this country suffer disproportionately from cardiovascular illness, and that when they do they are often less responsive to medication and other standard treatments. There have been many studies that attempt to determine why this is, and the majority of them indicate it's the usual combination of heredity and environment, including health care delivery concerns and behavioral factors such as the prevalence of obesity, as well as a relative dearth of treatment outcome studies that focus on Afro-Americans. In addition, there seems to be something physiologically different in the way these illnesses operate in many blacks, at least on average. It's been difficult (and controversial) to try to tease out which factors have been the most influential.

So when I saw the NY Times headline, "F.D.A. panel approves heart medication for blacks" I thought, "Great!"

A Food and Drug Administration advisory panel recommended the approval of a heart-failure drug specifically for African-Americans yesterday, after a discussion about race, genetics and medicine....In a study of the drug last year sponsored by the manufacturer, 1,050 African-American heart-failure patients showed a 43 percent reduction in mortality.

So it appears that this study was specifically geared to the Afro-American population, and this medication seems to hold promise for that especially difficult-to-treat group. But see this:

The panel's unanimous decision to recommend the drug came despite reservations from two members who said they were worried about moving toward racially specific medications without a sound scientific basis. Dr. Vivian Ota Wang, a geneticist at the National Institutes of Health who served on the panel, called race a "social and political construct" that should not be used as a substitute for genomic medicine. "What I'm hearing is that we're using race as a surrogate for a biological process," Dr. Wang said, adding: "I think that inconsistency gives us a false notion that race has a biological basis, when that isn't supported." In her vote to approve the drug, Dr. Wang said she thought it should be available to patients of all races...

Fortunately, Dr. Wang didn't go so far as to vote against the drug on the basis that it wasn't PC to approve it just for Afro-Americans. She just wanted inclusion for everyone, even though there is no evidence as yet that the drug is effective on any group other than Afro-Americans, since the study was limited to them.

Strange, isn't it? Here's something that I would think the PC crowd could get behind--a treatment targetted at a group that's often gotten short shrift both in medical research and in medical treatment. But no, theory seems to trump practicality for some people. No racial profiling in medicine!

Actually, in this case, I am in complete agreement with Dr. Wang that race is a social and political construct. But race is not just a social construct; it is also based on the statistical frequencies by which a series of physical traits occur in any given population--for example, skin color, hair type, and blood type. It might be more accurate to say that race is a construct based on a host of factors, including personal history and self-identification, as well as groupings of physical traits that occur more frequently in members of that race than in other groups. There are no hard biological boundaries between the races; what biological diffferences that exist are prevalences only. But there is no reason to doubt that certain medications might, statistically speaking, be more effective in certain races (the same is true for the sexes--certain pain drugs work differently in men and women, for example).

It would be tragic if PC considerations ever ended up hindering the sort of research that led to the development of this drug, although I can see that happening some day.


At 3:18 PM, June 18, 2005, Blogger Dr. Sanity said...

I actually envision individually tailored "designer" drugs--drugs that will take into account your own particular, individual physiology. Such drugs will be designed specifically to take into account your liver metabolism; any genetic or other biological vulnerabilities etc. etc. The major drug companies will be unable to compete with small ones that could say take a drug like zyprexa--its basic structure, for example--and add the necessary chemical groups for it to work for you. I always like Dr. McCoy waving his medical scanner around saying, "Jim! This man has a dopamine deficiency in his basal ganglia..." or words to that effect. When we can do that, we can make such drugs.

At 10:50 PM, June 18, 2005, Anonymous Anonymous said...

Ah, actually, drugs which are successful for blacks when other drugs are not present a problem.
What if blacks had the same death rate from cardiovascular issues as the white demographic?

Less griss for the victicrats.

Can't have that.

At 8:49 AM, June 19, 2005, Anonymous Anonymous said...

This sort of political correctness with regard to problems that plague certain groups more than others is even more harmful to African-Americans when it comes to social pathologies.

The overwhelming majority of violent crimes in the United States are perpetrated by young African-American men against other young African-American men, more of whom have been murdered in urban ghettoes in each of the past forty years than were lynched in the Jim Crow South during one hundred years of segregation. If black-on-black crimes were exempted from statistics, the United States would have the same rate of violent crimes as the rest of the developed world.

The good news is that we know where the problem is and therefore where to focus our resources. The bad news is that we can't do so without being labelled "racists" if white or "Uncle Toms" if black.

At 9:23 AM, June 19, 2005, Anonymous Anonymous said...

It is clear that the concern is not about a drug that is targeted toward a particular race, but rather about the lack of understanding of why the drug might be better for some people than others. Race is not a terribly good marker for genetics--it is very unlikely that the drug's efficacy has anything to do with skin pigment. So for example, the drug might be good for some black people but harmful for others. So it would be better to understand what genes control the drug's effectiveness, and to test for those genes directly, as opposed to using race as a surrogate for a poorly understood genetic difference

At 1:28 PM, June 19, 2005, Anonymous Anonymous said...

Anonymous--I undestand your argument, and it's a valid one. But in the meantime, until a more finely-tuned genetic treatment is found-- in the practical world, research such as this has value and should be carried on without regard to PC concerns. Drug research hasn't for the most part reached the type of refinement that you, and others (including myself) would like it to for greatest efficacy. Most drug treatments right now work on broad generalities.

And race, by the way, is a cluster of traits, both physical and social, and skin color is only one of them. The range of skin colors in the Caucasian race reaches from lightest to darkest; it's the distribution of each trait in a given population, the way a group of traits cluster in that population, as well as social definitions, that combine to give us the idea of a race.

At 1:28 PM, June 19, 2005, Blogger Peter Moore said...

Let me be a vigorous second for the previous commentor. The doctor is not being PC, he is objecting to using a scientifically vague concept of race as a basis for diagnosis and treatment. You are the one who fell into the trap of Ideological Correctness in jumping to a pretty obvious misinterpretation of his statement.

At 4:02 PM, June 19, 2005, Anonymous Anonymous said...

Peter Moore, not to be too PC about it--but Dr. Wang is a "she," not a "he."

In my response to "anonymous" above, I was trying to say that I agree the definition is vague. I am not in total disagreement with the point being made. However, it is my contention that the approach in this study is still a useful approach, especially until we have a better one, and definitely an advance over past studies that failed to notice important factors such as racial (or gender) differences.

There are in fact statistical trends that indicate differences in the way members of certain races exhibit cardiovascular problems and respond to medications, on the average. We need to take this into account in order to serve everyone's health needs best. To ignore these facts, and wait for a more perfect way to define the genetic bases for the differences in order to treat them, is, I believe, an example of the perfect being the enemy of the good.

At 4:51 PM, June 19, 2005, Anonymous Anonymous said...

I believe that individually targeted drug therapy is an extremely promising avenue of research, and I think this drug is a step, however imperfect, in that direction. However, my understanding is that much of the criticism about the development of a drug specifically for a certain race does not have anything to do with political correctness, but rather with concern that the company was fishing for results and attempting to get the longest-lasting patent at the lowest cost. I am in no way of the opinion that the interests of drug companies and patients are inherently antagonistic, but I do find a few aspects of this story potentially questionable, and for reasons having nothing to do with political correctness. After all, the drug was first tested in a mixed-race population without significant results. When re-analysis of the data showed that it had worked better in blacks than in whites it was re-examined in blacks only. Re-analyzing only the successful part of a sample is not generally the best way to get accurate or complete results in a study. It seems that the proper (but more costly) response to this problem would have been to run the study again in a larger and perhaps more varied group to see exactly who it worked in. At the end of this trial the results might have shown that it did only work in blacks and it could have been marketed the same way it is now. However, the results might have shown that it worked in other groups, that it was unsafe in certain subgroups of blacks, etc. This would have yielded better results, to the benefit of all potential patients. But testing only in blacks was cheaper, and labeling the drug a race drug extended the patent by several years. In other words, I question the assertion that opposition to the drug is based on political correctness - if anything seems overly PC about this discussion, it is the claim that studying a drug which could potentially help people of various races only in blacks because is justifiable becausethey have historically had less access to good medical care.

At 9:05 PM, June 19, 2005, Anonymous Anonymous said...

The historic lack of good medical care is actually only a small part of the picture here. It's very complex, but there is a great deal of evidence that cardiovascular disease is both quantitatively different and qualitatively different in black people. It is somewhat mysterious as to why, but one of the links I gave in the original post goes into the phenomenon in some detail. In fact, even if black people are given the best of medical care they still suffer disproportionately from cardiovasular disease and die more from it, too. They are less responsive to the same drugs, so there is a need to test drugs in that population separately.

At 7:31 PM, June 20, 2005, Blogger junebee said...

Maybe the scientific community will get around to tailoring drugs for women. Most drugs are tailored for men and it is well-known that some problems such as heart disease are different in men and women.


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