The problem with race-based medicine | Dorothy Roberts

188,131 views ・ 2016-03-04

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15 years ago, I volunteered to participate in a research study
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that involved a genetic test.
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When I arrived at the clinic to be tested,
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I was handed a questionnaire.
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One of the very first questions asked me to check a box for my race:
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White, black, Asian, or Native American.
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I wasn't quite sure how to answer the question.
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Was it aimed at measuring the diversity
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of research participants' social backgrounds?
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In that case, I would answer with my social identity,
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and check the box for "black."
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But what if the researchers were interested in investigating
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some association between ancestry and the risk for certain genetic traits?
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In that case, wouldn't they want to know something about my ancestry,
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which is just as much European as African?
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And how could they make scientific findings about my genes
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if I put down my social identity as a black woman?
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After all, I consider myself a black woman with a white father
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rather than a white woman with a black mother
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entirely for social reasons.
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Which racial identity I check
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has nothing to do with my genes.
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Well, despite the obvious importance of this question
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to the study's scientific validity,
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I was told, "Don't worry about it,
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just put down however you identify yourself."
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So I check "black,"
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but I had no confidence in the results of a study
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that treated a critical variable so unscientifically.
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That personal experience with the use of race in genetic testing
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got me thinking:
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Where else in medicine is race used to make false biological predictions?
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Well, I found out that race runs deeply throughout all of medical practice.
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It shapes physicians' diagnoses,
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measurements, treatments,
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prescriptions,
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even the very definition of diseases.
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And the more I found out, the more disturbed I became.
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Sociologists like me have long explained
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that race is a social construction.
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When we identify people as black, white, Asian, Native American, Latina,
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we're referring to social groupings
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with made up demarcations that have changed over time
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and vary around the world.
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As a legal scholar, I've also studied
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how lawmakers, not biologists,
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have invented the legal definitions of races.
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And it's not just the view of social scientists.
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You remember when the map of the human genome
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was unveiled at a White House ceremony in June 2000?
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President Bill Clinton famously declared,
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"I believe one of the great truths
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to emerge from this triumphant expedition
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inside the human genome
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is that in genetic terms,
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human beings, regardless of race,
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are more than 99.9 percent the same."
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And he might have added
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that that less than one percent of genetic difference
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doesn't fall into racial boxes.
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Francis Collins, who led the Human Genome Project
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and now heads NIH,
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echoed President Clinton.
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"I am happy that today,
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the only race we're talking about is the human race."
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Doctors are supposed to practice evidence-based medicine,
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and they're increasingly called to join the genomic revolution.
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But their habit of treating patients by race lags far behind.
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Take the estimate
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of glomerular filtration rate, or GFR.
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Doctors routinely interpret GFR,
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this important indicator of kidney function, by race.
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As you can see in this lab test,
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the exact same creatinine level,
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the concentration in the blood of the patient,
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automatically produces a different GFR estimate
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depending on whether or not the patient is African-American.
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Why?
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I've been told it's based on an assumption
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that African-Americans have more muscle mass
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than people of other races.
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But what sense does it make
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for a doctor to automatically assume
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I have more muscle mass than that female bodybuilder?
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Wouldn't it be far more accurate and evidence-based
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to determine the muscle mass of individual patients
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just by looking at them?
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Well, doctors tell me they're using race as a shortcut.
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It's a crude but convenient proxy
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for more important factors, like muscle mass,
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enzyme level, genetic traits
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they just don't have time to look for.
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But race is a bad proxy.
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In many cases, race adds no relevant information at all.
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It's just a distraction.
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But race also tends to overwhelm the clinical measures.
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It blinds doctors to patients' symptoms,
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family illnesses,
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their history, their own illnesses they might have --
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all more evidence-based than the patient's race.
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Race can't substitute for these important clinical measures
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without sacrificing patient well-being.
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Doctors also tell me race is just one of many factors
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they take into account,
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but there are numerous medical tests,
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like the GFR,
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that use race categorically
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to treat black, white, Asian patients differently
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just because of their race.
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Race medicine also leaves patients of color especially vulnerable
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to harmful biases and stereotypes.
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Black and Latino patients are twice as likely
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to receive no pain medication as whites
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for the same painful long bone fractures
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because of stereotypes
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that black and brown people feel less pain,
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exaggerate their pain,
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and are predisposed to drug addiction.
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The Food and Drug Administration has even approved a race-specific medicine.
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It's a pill called BiDil
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to treat heart failure in self-identified African-American patients.
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A cardiologist developed this drug without regard to race or genetics,
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but it became convenient
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for commercial reasons
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to market the drug to black patients.
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The FDA then allowed
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the company, the drug company,
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to test the efficacy in a clinical trial
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that only included African-American subjects.
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It speculated
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that race stood in as a proxy for some unknown genetic factor
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that affects heart disease
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or response to drugs.
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But think about the dangerous message it sent,
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that black people's bodies are so substandard,
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a drug tested in them
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is not guaranteed to work in other patients.
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In the end, the drug company's marketing scheme failed.
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For one thing, black patients were understandably wary
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of using a drug just for black people.
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One elderly black woman stood up in a community meeting and shouted,
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"Give me what the white people are taking!"
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(Laughter)
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And if you find race-specific medicine surprising,
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wait until you learn
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that many doctors in the United States
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still use an updated version
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of a diagnostic tool
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that was developed by a physician during the slavery era,
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a diagnostic tool that is tightly linked
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to justifications for slavery.
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Dr. Samuel Cartwright graduated
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from the University of Pennsylvania Medical School.
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He practiced in the Deep South before the Civil War,
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and he was a well-known expert on what was then called "Negro medicine."
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He promoted the racial concept of disease,
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that people of different races suffer from different diseases
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and experience common diseases differently.
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Cartwright argued in the 1850s
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that slavery was beneficial for black people
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for medical reasons.
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He claimed that because black people have lower lung capacity than whites,
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forced labor was good for them.
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He wrote in a medical journal,
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"It is the red vital blood sent to the brain
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that liberates their minds when under the white man's control,
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and it is the want of sufficiency of red vital blood
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that chains their minds to ignorance and barbarism when in freedom."
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To support this theory, Cartwright helped to perfect
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a medical device for measuring breathing called the spirometer
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to show the presumed deficiency in black people's lungs.
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Today, doctors still uphold Cartwright's claim
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the black people as a race
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have lower lung capacity than white people.
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Some even use a modern day spirometer
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that actually has a button labeled "race"
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so the machine adjusts the measurement
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for each patient according to his or her race.
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It's a well-known function called "correcting for race."
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The problem with race medicine extends far beyond misdiagnosing patients.
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Its focus on innate racial differences in disease
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diverts attention and resources
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from the social determinants
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that cause appalling racial gaps in health:
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lack of access to high-quality medical care;
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food deserts in poor neighborhoods;
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exposure to environmental toxins;
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high rates of incarceration;
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and experiencing the stress of racial discrimination.
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You see, race is not a biological category
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that naturally produces these health disparities
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because of genetic difference.
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Race is a social category
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that has staggering biological consequences,
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but because of the impact of social inequality on people's health.
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Yet race medicine pretends the answer to these gaps in health
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can be found in a race-specific pill.
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It's much easier and more lucrative
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to market a technological fix
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for these gaps in health
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than to deal with the structural inequities that produce them.
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The reason I'm so passionate about ending race medicine
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isn't just because it's bad medicine.
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I'm also on this mission
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because the way doctors practice medicine
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continues to promote a false and toxic view of humanity.
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Despite the many visionary breakthroughs in medicine we've been learning about,
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there's a failure of imagination
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when it comes to race.
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Would you imagine with me, just a moment:
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What would happen if doctors stopped treating patients by race?
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Suppose they rejected
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an 18th-century classification system
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and incorporated instead the most advanced knowledge
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of human genetic diversity and unity,
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that human beings cannot be categorized into biological races?
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What if, instead of using race as a crude proxy
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for some more important factor,
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doctors actually investigated and addressed that more important factor?
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What if doctors joined the forefront
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of a movement to end the structural inequities
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caused by racism,
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not by genetic difference?
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Race medicine is bad medicine,
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it's poor science
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and it's a false interpretation of humanity.
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It is more urgent than ever
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to finally abandon this backward legacy
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and to affirm our common humanity
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by ending the social inequalities that truly divide us.
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Thank you.
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(Applause)
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Thank you. Thanks.
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Thank you.
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