Pharmaceuticals and Ethnic Minorities

Amber Johnson
2011 M.D./M.B.A. Candidate, Jefferson Medical College

No two patients are the same.  As a result, health care professionals attempt to place patients in discrete categories as a way of reducing variability during the provision of care.  These categories can be based on one or more variables, including age, sex and race.  While the tendency to categorize patients is useful in customizing the most appropriate care, it can also be discriminatory, especially if patients are grouped inaccurately or if certain groups acquire preferential outcomes.

The use of race as a way to differentiate between patients is tricky.  Unlike age or sex, race is less clear-cut.  Indeed, the mere definition of the word “race” is debatable.  Race was once meant to describe the traditional divisions of humankind, including Caucasian, Mongoloid and Negro and was based on specific physical features.  That point of view is rarely used any longer.  Instead, today one finds an even more arbitrary classification based on things such as skin color and face shape.  It is also possible to group humans into races based on genetic markers and blood types.  Nevertheless, many scientists maintain that the genetic similarities between racial groups far outnumber the differences and state that race is more of a “social rather than a scientific concept” (Race, 2009).  Moreover, groupings determined by race can overlook other important factors such as cultural and economic differences.

Differential medical treatment based on the color of one’s skin can cause detrimental outcomes for minorities. Gerand and Pai, recognized experts in the fields of medical humanities and social sciences, have written an article entitled, “Social Determinants of Black-White Disparities in Breast Cancer Mortality.” In their article, the authors cite several reasons why Black women have higher rates of breast cancer morbidity than their White counterparts.  Of particular importance, they state that race-related social injustices can be suspected of contributing to some physicians’ treatment practices.  This sometimes has an impact on the outcomes of cancer treatment.  Although differences may be subtle, minority patients often have negative perceptions of such differential treatment.  Gerand and Pai state that, among other things, “negative patient perceptions could translate into differential access to breast cancer treatment and [dis]satisfaction with care” (Gerand & Pai, 2008).  Nevertheless, race and ethnicity are often used to help determine patients’ treatment.

Some experts suggest that, if used correctly, differential treatment can be beneficial.  An American Heart Journal article published in 2006 has gone so far as to exclaim that, “racial profiling is necessary” for better treatment of subclinical cardiovascular disease.  There are racial differences in coronary artery calcification (the precursor to the potentially devastating blockage of the arteries serving the heart’s muscular tissue), and researchers have found that whites are at higher risk than ethnic minorities.  Since different levels of disease states can be seen between different populations, the researchers conclude that it may be logical to treat people of different ethnic backgrounds with different pharmacological regimens (Orakzai et al., 2006).

Hypertension, an elevation of one’s blood pressure, is probably the quintessential disease for which ethnic differences are documented.  In fact, doctors have been analyzing the differences between Whites and Blacks and their responses to hypertension treatments for decades.  Of the several classes of drugs that can be used to treat hypertension, angiotensin-converting enzyme inhibitors and beta-blockers can significantly improve the health of African-Americans with hypertension.  However, studies show the improvement to be significantly lower than that of Caucasians.  The evidence suggests that African-Americans are more “salt-sensitive” and therefore do better with treatments such as thiazide diuretics and the aldosterone blocker eplerenone which help to alleviate the problems caused by excess sodium (Jamerson & DeQuattro, 1996).

Heart failure is yet another disease that can be treated differently based on ethnicity.  A diagnosis of heart failure means the heart’s ability to pump is so low that blood is unable to circulate properly throughout the body.  Heart failure in African-Americans has shown significant response to treatment with a pharmaceutical called BiDil, which is a combination of two drugs that help to stabilize vascular tone (hydralazine and isosorbide dinitrate).  The nitrate affects the body’s own supply of nitric oxide, which, according to the Association of Black Cardiologists, is said to be less active in African-Americans (Brower, 2002).  With an increase in the body’s nitric oxide activity, African-Americans were able to show significant improvements on BiDil.

In addition to the drugs treating the diseases of the cardiovascular system, responses to antidepressants may have ethnic differences as well.  Some physicians start their African-American patients on lower doses of Prozac (an antidepressant whose generic name is fluoxetine) than they do their Caucasian patients.  The thought behind this differential treatment of depression stems from the metabolism of fluoxetine.  Dr. Sally Satel, a psychiatrist, author, and ethicist, believes that side effects are more likely in African-Americans than in Caucasians or Asians because of this difference in metabolism (Satel, 2002).  She also has written that “clinical experience and pharmacological research” has given her the ability to become a “racially profiling doctor” in that she uses the race of a patient to help determine how she practices medicine (Satel, 2002).

Rheumatoid arthritis is a final example of a disease for which pharmaceuticals could target different ethnic groups.  One study found that allele frequencies in the methotrexate-folate pathway are significantly different between African-Americans and European-Americans with rheumatoid arthritis.  Methotrexate and folate are two key components of the cell cycle that, when not working properly, can lead to diseases such as rheumatoid arthritis.  There were 22 gene patterns among the different ethnicities studied, each coding for a variation of the methotrexate-folate pathway (Ranganathan et al., 2004).  The study suggests that treatment with methotrexate should differ depending on the patients’ genetic profile.

According to one hypertension study, “the goals of ethnicity-related research should be to describe the diversity of disease expression in humans and to target at-risk groups for prevention and early intervention” (Brower, 2002).  Since etiology, incidence, and outcomes are different among various ethnicities, clinicians should be aware of the documented differences in response to treatments. However, ethnicity alone is not always an accurate predictor of efficacy of treatment.  Rather, researchers who study race and its effect on response to medications agree that race is not always a reliable indicator of treatment response (Satel, 2002).  Confounding variables that are associated with race make it nearly impossible to pinpoint the exact mediators of medical outcomes.  Racial divisions may be placing artificial barriers between groups that do not actually exist.  Researcher and author Vicki Brower states that, “The debate continues about whether genetic variations among human individuals occur frequently enough to support the concept of race” (Brower, 2002).

Health care providers will often treat diverse populations.  They will see patients with different skin tones and genotypes while treating everything from depression to arthritis.  Although race can be an important variable, factors such as socioeconomic status, environment, and culture must not be overlooked when considering the roles of race-based drug regimens.

References
Brower, V. (2002). Is health only skin deep?: Do advances in genomics mandate racial profiling in medicine? European Molecular Biology Organization Reports 3.  8. 712–714. DOI:10.1093
Gerend, M. & Pai M. (2008). Social determinants of black-white disparities in breast cancer mortality: A review.  Cancer Epidemiology Biomarkers 17.  11.  2913–2923.
Jamerson, K.  & DeQuattro V. (1996). The impact of ethnicity on response to antihypertensive therapy.  American Journal of Medicine 30.  101. 22S–32S.
Orakzai, S. et al. (2006) “Subclinical coronary atherosclerosis: Racial profiling is necessary!” American Heart Journal. 152. 819–827.
“race.”  (n.d.).  The American Heritage® Science Dictionary.  Retrieved from: http://dictionary.reference.com/browse/race
Ranganathan, P. et al., (2004). Single nucleotide polymorphism profiling across the methotrexate pathway in normal subjects and patients with rheumatoid arthritis.  Pharmacogenomics 5.  5. 559–569.
Satel, S.  (2002). I am a racially profiling doctor. The New York Times. Retrieved from: http://www.sallysatelM.D..com/html/a-nytimes3.html

This article first appeared in the Summer 2010 JSNMA, Volume 15, Number 4

Filed Under: Global Health

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