Facts of Life

Facts of Life:
Issue Briefings for Health Reporters
Vol. 11, No. 2
February 2006

Different Risk: Race-based Health Care and Medicine

The Issue

The Facts

Targeted Prevention

Expert Sources

References

The Issue:

Scientists have long noted racial differences in the way patients respond to medicine or suffer from disease, says Dr. Esteban González Burchard, who studies genetic and biologic risk factors at the University of California, San Francisco. The charged nature of race enters discussions about racial differences, such as why white women have higher rates of osteoporosis.

Nature or Nurture?

Pediatrician Matthew M. Davis says, “To say that racial and ethnic identity has nothing to do with clinical care is to have our heads in the sand.”

Davis offers the example of an infant with chronic infections and signs of delayed growth and development.“ If that infant is Asian-American with no history of European heritage, it’s very unlikely that cystic fibrosis is the problem,” Davis said.

“ But if that child is European-American, I’ll do tests for cystic fibrosis much more quickly. Is that considered race-based medicine?”

“ Two groups living in different social contexts can have different responses. That may have nothing to do with underlying genetics,” says David R. Williams, a professor at the University of Michigan. “The gap in health for poor blacks and middle-class blacks is bigger than the black-white health gap.”

Harvard University health policy expert Brian Gibbs believes doctors must appreciate a patient’s background. “The thing to understand is their poor access to care, the influence of poverty, the influence of racism and its toll on how the body responds to those stressors.” Gibbs said.

The Facts:

• A 2003 study of asthma patients of Mexican and Puerto Rican heritage found that the Puerto Rican patients had poorer response to the asthma control drug Albuterol, a bronchodilator medicine used to improve breathing capacity.¹

• After a November 2004 New England Journal of Medicine study found that BiDil dramatically reduced black patients’ death rate, the combination drug received approval as a heart failure therapy for people who identify themselves as black.²

• A 2006 New England Journal of Medicine study found that blacks are more vulnerable to lung cancer from smoking cigarettes than whites, Japanese-Americans and Latinos.³

• A 2005 study that found that black and white girls process salt differently provides clues to racial differences in hypertension and osteoporosis rates. When the adolescents consumed high-salt diets, black girls retained both more calcium and more sodium than their white counterparts.⁴

• In March 2005, the cholesterol-lowering drug Crestor was relabeled to urge doctors to lower the starting dose of the medicine for Asian patients to decrease their risk of muscle damage, an uncommon side effect of drugs in the class called statins.

• Several studies, including a 2001 New England Journal of Medicine article, conclude that white patients benefit more than blacks when prescribed a class of blood-pressure control medicines called ACE inhibitors.⁵

• A 2005 analysis of a 33,000-patient blood pressure medicine study concludes that low-cost diuretics should be the first-step hypertension treatment for patients of all races.⁶

• A 1993 veterans-health study of six therapies for high-blood pressure found that race and age played a role in patient response to the hypertension drugs, and the researchers suggest that patient demographics be considered in initial drug selection.⁷

• Low bone-mineral density may be a good predictor of fracture risk for all women, but among women with the same bone density, black women are less likely to suffer fractures than white women, according to a 2005 Journal of the American Medical Association study.⁸

Targeted Prevention

It iPrevention gets short shrift in discussions on race-based medicine. “In this country we get more excited about race-based therapies than prevention,” says University of Michigan Health System internist-pediatrician Matthew Davis.

When the Food and Drug Administration approved the heart medication BiDil for just one ethnic group, that decision drew controversy. But Davis says the issue has also underscored an inequity.

“ African Americans with heart disease need better care than they are getting now,” he said. “BiDil is an opportunity to get them better care, attention - not just drug therapy - but overall care and prevention to a group that is underserved.”

The United States has a long track record of ethnic targeting in health policy and medical practice guidelines: American Indians and Native Alaskans once suffered disproportionate rates of hepatitis A. But in 1996 a federal advisory committee recommended routine hepatitis A immunizations for all American Indian and Alaska Native preschool children.⁹ Today the liver disease is less common in those ethnic populations than other groups.

Another example: Guidelines from the American Cancer Society and the American Urological Association recommend that black men begin routine prostate cancer screening years earlier than white men, a reflection of African-Americans' increased risk for the disease.

Now some researchers are calling for similarly targeted guidelines to fix the pronounced differences in U.S. immunization rates. Among individuals age 65 years or older, influenza and pneumococcal disease rates for non-Hispanic blacks are only about one-half to two-thirds the rates for non-Hispanic whites.¹⁰

Health care professionals face these unexplained disparities along racial lines in all areas of medicine: in acute and chronic disease prevalence and in preventive care.

“ There's something there, whether a clinical or genetic difference; it merits further investigation,” said Dr. Esteban González Burchard, of the University of California, San Francisco. “I don't think we've done due diligence to rule in - or rule out - race as important in medicine” It's good medicine, Davis said, to aim prevention and treatment efforts at the most vulnerable populations. “There's the greatest chance for good if we understand who's at greatest risk and try extra hard to reach them,” he said.

When policy-makers begin to craft guidelines for the new human papillomavirus vaccine, Davis predicts that the race-based medicine debate will be renewed. If licensed and approved, the vaccine would be expected to be given to adolescents to protect them from HPV, a sexually transmitted disease that can develop into cervical cancer.

Black women have more than twice the number of cervical cancer deaths per 100,000 population compared to white women. So, Davis says, “that susceptibility may be factored into the recommendations about which groups would benefit most from the HPV vaccine.”

Expert Sources:

References

1. Burchard et al. (2004) Lower Bronchodilator Responsiveness in Puerto Rican than in Mexican Subjects with Asthma. American Journal of Respiratory and Critical Care Medicine, Vol. 169: 386-392.

2. Taylor et al. (November 2004) Combination of Isosorbide Dinitrate and Hydralazine in Blacks with Heart Failure. New England Journal of Medicine, Vol. 351, No. 20: 2049-2057.

3. C.A. Haiman et al. (January 2006) Ethnic and Racial Differences in the Smoking-Related Risk of Lung Cancer. New England Journal of Medicine, Vol. 354, No. 4: 333-342.

4. K. Wigertz et al. (April 2005) Racial differences in calcium retention in response to dietary salt in adolescent girls. American Journal of Clinical Nutrition, Vol. 81, No. 4: 845-850.

5. D.V. Exner et al. (May 2001) Lesser Response to Angiotensin-Converting-Enzyme Inhibitor Therapy in Black as Compared with White Patients with Left Ventricular Dysfunction. New England Journal of Medicine, Vol 344, No. 18: 1351-1357.

6. J.T. Wright et al. (April 2005) Outcomes in Hypertensive Black and Nonblack Patients Treated with Chlorthalidone, Amlodipine, and Lisinopril. Journal of the American Medical Association, Vol. 293, No. 13: 1595-1608.

7. B.J. Materson et al. (April 1993) Single-Drug Therapy for Hypertension in Men – A Comparison of Six Antihypertensive Agents with Placebo. New England Journal of Medicine, Vol. 328, No. 13: 914-921.

8. J.A. Cauley et al. (May 2005) Bone Mineral Density and the Risk of Incident Nonspinal Fractures in Black and White Women. Journal of the American Medical Association, Vol. 293, No. 17: 2102-2108.

9. National Center for Infectious Diseases, Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices, 1996 recommendations.

10. Centers for Disease Control and Prevention. Racial/ethnic disparities in influenza and pneumococcal vaccination levels among persons aged > or = 65 years—United States, 1989-2001. MMWR Morb Mortal Wkly Rep. 2003;52:958-962.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

For Information Contact:
Lisa Esposito
Editor, Health Behavior News Service
Center for the Advancement of Health
2000 Florida Ave., NW, Suite 210
Washington, DC 20009
p. 202.387.2829 / f. 202.387-2857
press@cfah.org
http://www.cfah.org

© Copyright 2006, Center for the Advancement of Health

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