Race, Gender and Medicine

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Race, Gender and Medicine
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Race and the Clinic Good Science? Human genome
findings practically erase race as a biological
factor Ricki Lewis, The Scientist 16416,
Feb. 18, 2002 Race is a social concept, not a
scientific one. J. Craig Venter, CEO and chief
scientist, Celera Genomics
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• Concludes Howard L. McLeod, a professor of
  medicine at the Washington University School of
  Medicine in Missouri,
• "There is no clear link between skin pigment and
  drug metabolism genes. Skin pigment is a lousy
  surrogate for drug metabolism status or most any
  aspect of human physiology."

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To confirm that it makes more biological sense to
consider drug-metabolizing genes rather than skin
color in drug choice, James Wilson, David
Goldstein, and colleagues at University College,
London, compared 23 markers for such genes among
354 people representing eight classically defined
races white (Norwegian, Ashkenazi Jews,
Armenians), black (Bantu, Ethiopian, and
Afro-Caribbean), and Asian (Chinese and New
Guinean). Using a technique called hierarchical
cluster analysis, they found that the genetic
markers from four natural groupings that do not
correspond to any of the appearance-defined
categories.
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Genetic variations in mitochondria genome (color
differences in map)
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What is Race The Power of Illusionhttp//www.pb
s.org/race/005_MeMyRaceAndI/005_00-home.htm

• 1. Race is a modern idea
• 2. Race has no genetic basis
• 3. Human subspecies don't exist
• 4. Skin color really is only skin deep
• 5. Most variation is within, not between,
  "races."
• 6. Slavery predates race
• 7. Race and freedom evolved together
• 8. Race justified social inequalities as natural
• 9. Race isn't biological, but racism is still
  real
• 10. Colorblindness will not end racism

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Topic One Discrimination in Medical Practice

• Bad Blood, Bad Faith The Tuskegee Syphilis Study
  , 1932 - 1972

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• Black male recruits from Tuskegee with syphilis
  intentionally misinformed and untreated for the
  sake of scientific studies

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Tuskeegee ExperimentMore than 600
African-American men were part of the secret
syphilis study conducted by the US Public Health
Service in Tuskegee, Alabama, between 1932 and
1972.
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Topic Two

•   Racial and Gender inequality in medical
  professions and health care

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• 1986 78.8 and 84.8 of the medical doctors
  are male in Canada and the US respectively.
•  
• 1996 67 of US medical doctors are white male
  (only 37 of the US population are white male).
•  
• 1986 81 of women subjected to court-ordered
  obstetrical interventions were black, Hispanic or
  Asian.

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• Racial and Ethnic Disparities in Faculty
  Promotion in Academic Medicine (JAMA 2841085,
  2000)

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Topic Three

• Race-Based Medicine?
• On June 16, 2005, the FDA approved BiDil as a
  cardiovascular drug to be marketed exclusively to
  African-Americans.
• BiDil hydralazine and isosorbide dinitrate (H/I)
• BiDil was being marketed exclusively to
  African-American patients based on a higher
  efficacy of BiDil for their race or for targeted
  profits?

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Taylor, et.al. N Engl J Med. 2004 Nov
11351(20)2035-7. Combination of isosorbide
dinitrate and hydralazine in blacks with heart
failure.

• Background We examined whether a fixed dose of
  both isosorbide dinitrate and hydralazine
  provides additional benefit in blacks with
  advanced heart failure, a subgroup previously
  noted to have a favorable response to this
  therapy.
• Methods A total of 1050 black patients who had
  New York Heart Association class III or IV heart
  failure with dilated ventricles were randomly
  assigned to receive a fixed dose of isosorbide
  dinitrate plus hydralazine or placebo in addition
  to standard therapy for heart failure. The
  primary end point was a composite score made up
  of weighted values for death from any cause, a
  first hospitalization for heart failure, and
  change in the quality of life.
• Results The study was terminated early owing to a
  significantly higher mortality rate in the
  placebo group than in the group given isosorbide
  dinitrate plus hydralazine (10.2 percent vs. 6.2
  percent, P0.02). The mean primary composite
  score was significantly better in the group given
  isosorbide dinitrate plus hydralazine than in the
  placebo group (0.11.9 vs. 0.52.0, P0.01
  range of possible values, 6 to 2), as were its
  individual components (43 percent reduction in
  the rate of death from any cause hazard ratio,
  0.57 P0.01 33 percent relative reduction in
  the rate of first hospitalization for heart
  failure 16.4 percent vs. 22.4 percent, P0.001,
  and an improvement in the quality of life change
  in score, 5.620.6 vs. 2.721.2, with lower
  scores indicating better quality of life P0.02
  range of possible values, 0 to 105).
• Conclusions The addition of a fixed dose of
  isosorbide dinitrate plus hydralazine to standard
  therapy for heart failure including neurohormonal
  blockers is efficacious and increases survival
  among black patients with advanced heart failure.

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Distributions of Cystic Fibrosis
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Microbial Flora Meet, Greet their Host Fauna,
J. L. Fox, Microbes, Sep, 2007

• To develop a more systematic profile of resident
  bacteria in humans, Larry Forney of the
  University of Idaho, Moscow and his collaborators
  analyzed vaginal microflora samples from dozens
  of women, about half of them Caucasian and half
  African-Americans, belonging to three age groups
  and living in five different regions in North
  America. Based on analysis at the genetic level,
  their vaginal microflora sort into 12 groups,
  which can be further condensed into 8
  supergroups of vaginal microbial communities.
• Novel clostridial clade was a near-exclusive
  colonizer of black but not white women who
  provided samples

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What are the anticipated benefits of
pharmacogenomics?More Powerful Medicines
Better, Safer Drugs the First Time More
Accurate Methods of Determining Appropriate Drug
DosagesAdvanced Screening for Disease Better
Vaccines Improvements in the Drug Discovery and
Approval Process Decrease in the Overall Cost of
Health Care

• Different ethnic groups do, on average, react
  differently to different drugs
• Cytochrome p450 gene, CYP 2D6 prevents the
  transformation of codeine into morphine.
• CYP 2D6 leaves about 7 percent of
  European-Americans unaffected by codeine, as
  compared to 1 to 3 percent among Asian-Americans
  or African-Americans.

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Figure 9.2
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Topic Four

• Population landscape of the USA, 1990 2060

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What This Means

• We need a diverse pool of medical doctors to
  serve a diverse population.

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• 1978 Bakke decision
• Alan Bakke The Univ. of California Davis medical
  school affirmative action program violated his
  right to equal protection.
• U C Davis Four purposes
• 1. Reduce deficit of black physicians
• 2. Counter effects of racial discrimination
• 3. Increase number of physicians available to
  blacks
• 4. Realize the educational benefits of a diverse
  student body.
•  

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16 positions held for minority applicantsBakkes
score surpassed all members of this group
84 positions were open to general applicants
Bakkes score was lower than anyones in this
group
84
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• California proposition 209, 1996
•  
• The state shall not discriminate against, or
  grant preferential treatment to, any individual
  or group on the basis of race, sex, color,
  ethnicity, or national origin in the operation of
  public employment, public education, or public
  contracting.

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• Recent trends in the training of medical
  doctors from Underrepresented Minority Groups in
  the US

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http//www.wheaton.edu/Biology/faculty/ppp/index.h
tml
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Next Steps

• The Demise of Affirmative Action and the Future
  of Health Care?

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Narrow use of affirmative action preserved in
college admissions

• Supreme Court ruled in June, 2003 that race can
  be a factor for universities shaping their
  admissions programs, saying a broad social value
  may be gained from diversity in the classroom
• In separate decisions the high court struck down
  a point system used by the University of
  Michigan's undergraduate programs but approved a
  separate policy used by the University of
  Michigan law school that gives race less
  prominence in the admissions decision-making
  process.

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On June 28, 2007, a sharply divided Court struck
down the Seattle and Lousville plans for high
schools to use race as an admissions factor .

• The Court found that the school districts had not
  carried their heavy burden of showing that the
  interest they seek to achieve justifies the
  extreme means they have chosen.
• Writing for the majority, Chief Justice Roberts
  stated that accepting racial balancing as a
  compelling state interest would justify the
  imposition of racial proportionality throughout
  American society.
• Justices Alito, Antonin Scalia and Clarence
  Thomas joined the plurality opinion. While
  Justice Anthony Kennedy joined the final
  decision, he disagreed with Roberts assertion
  that race should not have been taken into account
  in the cases at issue.
• Reading his concurring opinion from the bench,
  Kennedy said This nation has a moral and ethical
  obligation to fulfill its historic commitment to
  creating an integrated society that ensures equal
  opportunity for all its children.
• A compelling interest exists in avoiding racial
  isolation, an interest that a school district, in
  its discretion and expertise, may choose to
  pursue.

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The Race and Disease Fallacy? Cancer
incidence shows clear correlation with
socioeconomic data, and this correlation is much
larger in magnitude than reputed differentials
between races.
http//reserves.wheaton.edu/pdf/grav13082703.pdf
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A Theological Rationale for Diversity at Wheaton
Collegehttp//intra/Academic/ITIR/assessmentplan
s.htm

• Humans were created in the image of a triune God
  who exists eternally as Father, Son, and Holy
  Spirit. The one in whose image we are created
  establishes the basis for all human relations (Jn
  1720-23).
• God's first command to the human creatures was
  that they should fill and subdue the earth as
  God's representative caretakers (Gen
  128).Though initially Israel was to be God's
  chosen and holy people, from the beginning God
  made it clear to Abraham that all the families of
  the earth would be the recipients of his blessing.

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A Theological Rationale for Diversity at Wheaton
College

• But sin had intruded before the call to Abraham
  in humanity's desire to be like God (Gen
  31-7)strengthening our fallen tendencies to
  seek our own ways rather than God's and to serve
  ourselves rather than the needs of
  otherstendencies that often burrow their way
  into human systems and institutions, often as
  subtle or overt forms of racism, nationalism,
  cultural imperialism, and ethnocentrism (Eph
  612).
• The reversal of Babel (is) the prevision of a
  time in the New City when all peoples shall come
  to praise God (Rev 2124-26). The church's
  proclamation begins with the announcement that
  our justification comes through Jesus Christ
  alone. Therefore, we can stop attempting to
  justify ourselves in our efforts to establish our
  worth on something other than our new identity in
  Christ (Gal 328).

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A Theological Rationale for Diversity at Wheaton
College

• The church is to be a witness to the original
  fact that we cannot live and grow independently
  of one another and that our God-designated
  diversity is inseparable from Christian maturity
  (Eph 314-19, 411-16 1Cor 124-26). The church
  is to image God's character by showing no
  partiality and by responding to others as the
  brothers and sisters who they are (Deut 1017,
  1618 2Chron 197 Rom 211, Gal 26).
• Christians testify to the supernatural source
  of their unity by the manner in which they love
  one another (Jn 1334-35, 1723-26). The church
  point(s) the world to its future order (of
  Christs 2nd Coming in) which all Christians
  anticipate and the vision of which should guide
  us in our daily lived-out witness to the
  lordship, not of a culture, race, nation, or
  ideology, but of Jesus Christ.

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Creation Mandate

• Genesis 1 27, 28
• God created humankind in his own image,
• in the image of God he created them,
• male and female he created them.
• God blessed them and said to them,
• Be fruitful and multiply! Fill the earth and
  subdue it! Rule over the fish of the sea and the
  birds of the air and every creature that moves on
  the ground.

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Stewardship

• Matt. 25 21- 23
• The one who had received the five talents came
  and brought five more, saying, Sir, you
  entrusted me with five talents. See, I have
  gained five more. His master answered, Well
  done, good and faithful slave! You have been
  faithful in a few things. I will put you in
  charge of many things. Enter into the joy of your
  master. The one with the two talents also came
  and said, Sir, you entrusted two talents to me.
  See, I have gained two more. His master
  answered, Well done, good and faithful slave!
  You have been faithful with a few things. I will
  put you in charge of many things. Enter into the
  joy of your master.