12/12/2003

Race in Medicine

Sociologist Troy Duster on the role of race in medicine.

By David Rotman

Troy Duster

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Position: Professor of sociology at New York University; Chancellor's Professor, University of California, Berkeley

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Issue: Are there scientific and medical justifications for targeting medicines at different ethnic and racial groups?

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Personal Point of Impact: Former chair of the Advisory Committee on Ethical, Legal, and Social Issues for the Human Genome Project; president-elect of the American Sociological Association; author of Backdoor to Eugenics

Technology Review: As researchers begin to better understand the genetic differences between populations, some are advocating using that information to develop and justify treatments and even particular medicines that target specific racial groups. Is this a good idea?
Troy Duster: There's not a quick and easy answer. I think under certain conditions, in certain contexts, race can be a proxy for looking at other factors. For example, we know that sickle cell anemia in this country is related to race because Americans of West African descent are at much higher risk. Where there are limited funds for a full-population screen, it would be legitimate to set up a screening program that is race related. But that is different than saying we're going to deliver a drug to a population defined by race. I think it is a mistake to begin with the assumption that race is a sufficiently precise category to deliver pharmaceuticals. Race is a huge and crude category with so much genetic variation that the idea of trying to come up with a drug specifically designed for such a population is counterintuitive and probably empirically wrong.

TR: And yet it is something being talked about by some drug companies.
Duster: Yes, I think it is because of profits and markets. Pharmaceutical companies don't sell drugs to individuals; they sell drugs to markets. So part of what is going on here is a market-driven biotechnology which is trying to find a population base for its product.

TR: But as you said, there are no easy answers. Are there potential benefits in looking at genetic-based medical differences between various population groups?
Duster: It is perfectly legitimate to ask why the rate of prostate cancer is more than double for group A than group B. And when that group A happens to be blacks in America and group B happens to be whites, then we come to the critical question of how to approach "whites" and "blacks." Given the genetic variation within any racial group, I think that the wrong approach is to assume a genetic basis as a first strategy to explain the difference. Rather, it is much more empirically valid to approach patterns of health disparities by focusing on external or environmental factors. To put it in plain language, it is fine to look at health disparities between any two groups-religious, gender, class, race, age, region of the country, et cetera-and ask why. But DNA should be the last place we look to try to explain those differences. Every molecular geneticist knows that there is far more genetic variation within what we call loosely African, European, and Asian continental ancestry than there is between these broad groupings.

TR: Yet the use of broad categories seems to be everywhere these days in medical research, from proposed U.S. Food and Drug Administration guidelines on clinical trials to reports on the success of various new drugs in a particular population. At the same time, most scientists have long maintained there is no biological basis for racial categories. How do you resolve these seemingly conflicting trends?
Duster: The contradiction is there, and it exists in the literature, sometimes inside a single article-and I must add, sometimes inside the brain of a single author. I think that the way to address the contradiction is to acknowledge that race is simultaneously a fluid, arbitrary, internally contradictory category in the way that it is used and that race is also a deeply embedded set of structural relationships between groups. Some people want to emphasize the arbitrariness of the biological category. But think of it this way: sub-Sahara Africans have the greatest genetic heterogeneity on the planet, yet when people from that part of the world travel outside of the continent, they are most likely to be treated as if they were genetically homogeneous. It is their treatment that results in patterned health disparities. The huge mistake is to then revert to the DNA, as if that were the source of the disparity.