Race in Medicine: Data or Distraction?

December 16, 2021

Information

December 9, 2021

Yale Pathology Grand Rounds

Andrea Teresa Deyrup, MD, PhD, and Joseph Graves, Jr., MD

ID7299

To CiteDCA Citation Guide

00:09I'm delighted to welcome not just one,
00:11but two speakers for this week.
00:13Seattle School of Medicine
00:14Department of Pathology grand rounds.
00:17Doctor Joseph Graves Junior is a professor
00:19of Biological Sciences at North Carolina.
00:21A and T State University.
00:23He received his undergraduate
00:24degree from Oberlin College and
00:26pH D from Wayne State University.
00:28He began his career as faculty at the
00:30University of California, Irvine,
00:32followed by Arizona State University
00:34Main in West Campus is since 2005 has
00:37had has had positions at North Carolina.
00:40The Empty State University and the Joint
00:42School of Nanoscience and Nanoengineering,
00:45a joint program between his current
00:47institution and UNC Greensboro.
00:49During this time he's held
00:51leadership positions,
00:51including Dean of University Studies
00:54and associate Dean for research.
00:56His research focuses on the genomics
00:58of adaptation and biological and
01:01social conceptions of race in humans.
01:03He's involved many professional societies
01:05and has received numerous honors.
01:07He's been the principal investigator on
01:08grants from the National Institutes of
01:10Health and the National Science Foundation.
01:12He is a fellow of the Council
01:14of the American Association for
01:15the Advancement of Science.
01:17He has over 110 peer reviewed publications.
01:19Including multiple books,
01:20the most recent of which came out just
01:23recently and tighter and is entitled racism,
01:26not race answers to
01:28frequently asked questions.
01:29He recently participated in a roundtable
01:31discussion for the New England Journal of
01:33Medicine and titled Race and Medicine,
01:35Genetic Variations,
01:36social categories and Pasta
01:38HealthEquity and is currently preparing
01:40a manuscript for the New England
01:42Journal medicine entitled Ongoing
01:44Racial Misconceptions in medical
01:45education with today's Co presenter,
01:47and that brings me to doctor Andrea de Rock.
01:50Who is a professor of pathology at
01:52Duke University School of Medicine.
01:54She completed her undergraduate
01:55education at Princeton University
01:57and continued her academic pursuits
01:59at the University of Chicago,
02:00where she earned her PhD and MD and
02:03subsequently completed her anatomic
02:04pathology residency training.
02:06This was followed by a soft tissue
02:08pathology fellowship at Emory University,
02:09where she remained on as faculty
02:11before moving to the University
02:13of South Carolina and ultimately
02:15her current position at Duke.
02:17During this time,
02:17she has published extensively
02:19in the area of soft tissue.
02:20Apology in prestigious journals as
02:22well as chapters in the World Health
02:24Organization Classification of Tumors,
02:26among other textbooks.
02:29Since arriving at Duke in 2015,
02:30her primary focus has been on
02:32medical education.
02:32In 2019,
02:33she was named the director of
02:35Undergraduate Medical Education
02:36for the Department of Pathology.
02:38She is a Co editor for the New Robbins
02:40Central pathology and upcoming 11th
02:42edition of Robbins Basic Pathology.
02:44She participated in the Duke teaching
02:46for equity Fellows program and is a
02:48member of the Duke School of Medicine,
02:49Health Professions Anti Racism
02:51Task Force and the pathology,
02:53Diversity and Inclusion Focus group
02:56through medical student teaching,
02:57she has become interested in recent medicine.
02:59In medical text,
03:00including within Robbins and its
03:02representation in medical school curriculum,
03:04she recently launched Pathology Central,
03:06a YouTube channel where she presents
03:08various pathology topics concisely
03:10that anyone in medicine can work from.
03:11So with that doctors day open graves have
03:14been highly sought after presenters for
03:17topics they will discuss with us today.
03:20Their talk is entitled Race and medicine
03:22data or Distraction, and with that I
03:23will let them get started.
03:29All right? So first thank you so very
03:35much for inviting us to be here today.
03:38We're absolutely delighted to be here.
03:40We've enjoyed meeting with the faculty
03:42and are really looking forward to meeting
03:44with the residents and graduate students.
03:49So I'd like to begin with our disclosure,
03:51which as Doctor Barbieri mentioned,
03:53I'm a quarter Co editor and author
03:55of two of the Robbins pathology
03:57textbooks and Doctor Graves as a paid
03:59consultant for Robbins and Kumar basic
04:01pathology and will be focusing a bit on
04:04Robbins Basic Pathology, 10th edition.
04:07So during this talk we're going
04:09to discuss the impact of systemic
04:11racism in medical school curricula.
04:12Compare and contrast biological,
04:14race and socially defined race evaluate
04:17disparities in the pathophysiology
04:18of disease and describe an approach
04:21to addressing health disparities
04:22in medical education.
04:24So let's begin by asking how does
04:26race show up in the curriculum?
04:28Well, I'm a pathologist and this
04:30is my textbook,
04:31so I began by doing a search of the
04:33electronic book for terms like Caucasian,
04:36African, Asian and found more than
04:3945 diseases for which a disparity was
04:42mentioned based on socially defined race.
04:45Now, let's see how this actually
04:47turns up in the textbook.
04:48So here we have a quotation talking about
04:51African Americans and cardiac amyloidosis.
04:54My carrier frequency assisted
04:56fibrosis in Caucasians,
04:58cholesterol,
04:58gallstones and Native Americans
05:00and Factor 5 Leiden in whites.
05:03So let's set for aside from moment
05:06the outdated terms because those
05:09are simple enough to change.
05:11And let's recognize that when these
05:14sentences were written they were
05:16written with the best of intentions
05:17with the idea that these epidemiologic
05:20data would help future physicians
05:22to come up with a broad and.
05:24Reasonable differential diagnosis
05:25to order appropriate laboratory
05:27tests and then to design optimal
05:30treatment for their patients.
05:32So these sentences were all written
05:34with the best of intentions,
05:36but anyone who does DEI work knows
05:38it's not enough to simply say
05:40we have good intentions.
05:41You have to ask,
05:42are we actually causing harm in any way?
05:45So are we causing harm?
05:47I think we are and so there are three
05:50realms that I look at this with,
05:52so one is buzzword bingo.
05:54It would take very motivated,
05:55very bright students who are very
05:57good at multiple choice Question
05:59exams and we teach them simple word
06:01associations like white cystic fibrosis,
06:03black sickle cell disease and we
06:06reinforce this through clinical vignettes,
06:08multiple choice questions.
06:09The step exams and the test prep material,
06:13so we're reinforcing these associations.
06:16So let's take a look at how this
06:19shows up in how it's reinforced.
06:21So this comes from a 2015 website in
06:24which the author somewhat facetiously
06:26or sarcastically is giving advice for
06:29medical students preparing to take step one,
06:32and one of the points of advice
06:34is be as racist as possible.
06:36Now those of us who are older,
06:38attendings,
06:38and probably a number of younger
06:40attendings and maybe even residents
06:42will recognize these associations
06:44as things that we also were taught.
06:46That these were buzzwords quote
06:48high yield facts that we learn
06:51so we would do well on step one.
06:53Now here is a more recent look at this.
06:56This is from 2017 publication
06:58by Lundy Braun
07:00and what she and her colleague did was
07:03to look at you world, which is a test
07:06prep bank which is used by I would say,
07:08every medical student who takes a
07:11step exam and what they did was they
07:15queried the entire 2000 plus questions
07:17and looked to see how race was used.
07:20Was race mentioned and if it was
07:22mentioned was it used as a descriptor?
07:24So just casual sort of giving
07:25a little bit more background.
07:27Like sometimes I'll say it's a you know
07:2955 year old man who's a CEO in a company.
07:32Or was it something central like
07:34knowing what this person does?
07:36So for example, if you say someone
07:37is a is a coal miner, you you?
07:39We all know is pathologists,
07:40that's setting you up for
07:42particular diagnosis to think about.
07:43So was it descriptive or was it central?
07:46And what you can see here is that for the
07:48socially defined race of white or Caucasian,
07:51about 93% of the time it
07:53was completely incidental.
07:53The patient just happened to
07:55be white or Caucasian.
07:56And about 7% of the time,
07:58knowing that person,
07:59socially defined race was supposed to
08:01help you get to or understand the answer.
08:04So probably something like cystic fibrosis,
08:06for example.
08:07Now, by contrast,
08:09if you're Native American and
08:10you're showing up in a vignette,
08:12you're there because you're Native American,
08:14right?
08:15You didn't get into a motorcycle accident
08:17or brush up against some Poison Ivy.
08:19You have severe combined immune deficiency,
08:21diabetes or cholesterol gallstones, right?
08:23So we have this racialization of medicine.
08:27And how we're supposed to
08:29look at potential patients.
08:31So you may be thinking, well,
08:33you know these are the pre clinical years.
08:36And as our students go onto
08:37the wards and they go through
08:39residency and become attendings,
08:41they're going to see the full
08:42spectrum of human health and
08:44disease and they will recognize that
08:46these associations may be useful.
08:48Heuristics may be good for
08:50pretest probability,
08:50but they're just merely a shadow of
08:52what will be seen as physicians.
08:54And I will tell you to to counter that.
08:57There are things I learned 20 plus years ago.
08:59The University of Chicago that
09:01I did not learn were wrong,
09:03were false until I began seriously
09:05looking at race and medicine.
09:08So the next question we might have is,
09:10well, OK.
09:10Is there anyway that were
09:12causing patient harm?
09:13And again I would say yeah,
09:14I think we could be so say a young
09:16Navajo woman presents to an acute
09:18care clinic with right upper quadrant
09:20pain and you have the attending.
09:22Think American Indian.
09:24I'm going to go right towards
09:27gallstones and not thinking about acute
09:29appendicitis or ectopic pregnancy, right?
09:31Both of which can present in
09:33a similar fashion.
09:34Now you may think, OK, well,
09:35that's not going to happen.
09:36We have algorithms.
09:37We have checks and balances.
09:39We're not going to miss that.
09:41And I would say,
09:42well,
09:42here's an example taken from
09:44the literature of the misuse
09:45of race and medical diagnosis,
09:47in which the author recounts a story
09:49of a childhood friend who wasn't
09:51diagnosed with cystic fibrosis
09:52until she was eight years old.
09:54Despite presenting multiple
09:56times with suggestive symptoms,
09:58and in fact the diagnosis was only
10:00made when the clinician could not
10:02see the color of her skin when
10:04he was looking at a chest film
10:06and said who's the kid of cystic
10:08fibrosis that data fact of looking
10:10at it and seeing the color of skin.
10:12Turned clinicians away from
10:14the correct diagnosis,
10:15and cystic fibrosis is something
10:18that Doctor Grayson I've talked
10:20about a number of times.
10:22So finally, let's if,
10:23as long as we're looking at this,
10:24let's really step back and say.
10:26Is there a way we're causing societal harm,
10:28right?
10:29Is this perhaps more malignant than
10:31than we're even thinking about?
10:34Are we taking one population and
10:36elevating it, or taking another
10:38population and putting it down,
10:40saying bad genes,
10:42risky habits, non compliant?
10:44Is there some way that we are subtly or
10:48not so subtly setting up a social hierarchy?
10:52So to make this easier for you to visualize,
10:54I'm going to red line for you all
10:56of the diseases in Robins that
10:58are described as having a worse
11:00prognosis or higher incidence in
11:02individuals of African descent.
11:04And for comparison,
11:05you can see the ones here for
11:07individuals of European descent.
11:10So now we're starting to think about,
11:11well,
11:12what does race mean,
11:13and I'm going to ask Doctor Graves
11:15to talk a little bit about that.
11:18Thank you doctor Darrup.
11:20I'm one of the ongoing confusions that
11:23people have and and and these are
11:26people who are very highly educated.
11:28Is the conflation with the existence of
11:32geographically based genetic variation
11:33which is real and geographically
11:36based phenotypic variation with
11:38which is real with the idea that
11:41that means that biological races
11:43must exist within a species.
11:45Now it turns out in modern biology that
11:47races are defined by two criteria,
11:50the first of which is the amount
11:52of genetic variation within and
11:54between groups within that species
11:56and the second criterion is whether
11:58any group within that species.
11:59Can be considered a phylogenetically
12:02distinct or unique lineages.
12:04Now it's long been established
12:06that anatomically modern humans
12:09show more variability within their
12:13so-called races than between them.
12:17Uhm, and again while we have
12:19geographically based genetic
12:21and physical differences,
12:22all humans share 99.9% of their genome.
12:27Next please.
12:31So when we utilize our two criteria
12:35and apply them to our species,
12:38it turns out that biological
12:39race does not exist in monuments.
12:41Now that's very different from socially
12:45constructed or socially defined race which
12:48arbitrarily utilizes aspects of morphology,
12:51geography, culture, language,
12:52religion, but only does so in the
12:56surface of social dominance hierarchy.
12:59In other words, my colleague Alan Goodman.
13:01In our new book racism not race,
13:04make the point that it was
13:07racism that created race,
13:10not vice versa in our species.
13:13Now this is beginning and get
13:16wider recognition in some health
13:18disciplines such as epidemiology,
13:20for example,
13:22meryl's introduction to epidemiology
13:242017 states race is a socially
13:28constructed variable based on the
13:30idea that some human populations.
13:32Are just seeing from others according
13:34to external physical characteristics
13:36or places of origin next please.
13:41But they go on to point out that
13:44racial or ethnic variations in
13:46health related states or events,
13:48or explained primarily by exposure
13:52or vulnerability to behavioral,
13:55psychosocial, material or environmental
13:57risk factors and resources,
13:59and note what they do not say,
14:01is that these variations in health
14:04related states are the result
14:07of differences in the frequency
14:10of disease predisposition.
14:12Genetic variance next slide.
14:17So this confusion finds its way into
14:21a variety of our social institutions.
14:24For example, even EU.
14:25S. Census Bureau uses.
14:28So she defined categories.
14:30For example, white is a person having origins
14:33at any of the original peoples of Europe,
14:36the Middle East, or North Africa.
14:38But they actually don't decide how much
14:43ancestry in those regions makes you white.
14:47Black or African American.
14:49A person having origins on any.
14:52Of the black racial groups of Africa,
14:55and again we ask the same question, how much?
14:57Considering that there's more genetic
14:59variability on the continent of Africa and
15:02then the entire rest of the world combined.
15:05American Indian or Alaskan Native person
15:07having origins in any of the original
15:10peoples of North and South America.
15:12Including Central America,
15:14but who maintains tribal
15:16affiliation or community attachment?
15:18So in other words,
15:20a person with that ancestry who no
15:22longer maintains tribal affiliation
15:24is no longer considered American
15:27Indian by EU S Census Bureau and one
15:30of the categories that I find most
15:32egregious is the notion of Asian.
15:36A person having origins of any of the
15:38original peoples of the Far East,
15:39Southeast Asia, or Indian subcontinent,
15:42and when you look at the number of countries,
15:45for example, Cambodia, China, India,
15:47Japan, Korea, Malaysia, and so on.
15:50We're talking about huge geographical
15:53area and populations that differ in a
15:57number of physical and genetic attributes.
16:00So really, how useful is this?
16:02Finally,
16:03Hawaiian Native or Pacific Islander
16:05person having origins of any of the
16:08original peoples of Hawaii, Guam?
16:11Some on doctor Deborah?
16:15Alright, so thank you doctor
16:17Graves so we've just looked at some
16:19categories of socially defined race.
16:20Let's look at this in the context of disease.
16:23So this is a map that is showing
16:27the distribution of a variety of
16:30hemoglobinopathies and all of us as
16:33good clinicians and and focused on
16:36pathophysiology recognized as these
16:39hemoglobinopathies are linked to.
16:41Evolutionary pressure from malaria.
16:43OK, so as we look at this we can see here
16:46we have thalassemia and green hemoglobin,
16:49S in orange. Hemoglobin.
16:51See here and blueish grey.
16:53And you know, traditionally,
16:54make associations like I've
16:56seen him in board review books.
16:58Dallas EMEA is associated with with Asians,
17:00right?
17:01Well, there are huge areas of Asian with
17:03Asia which which don't have thalassemia.
17:06What really determines whether or not
17:08you have a risk for these these various?
17:12Diseases has to do whether or not your
17:14ancestors were at risk for malaria,
17:16so it's not dependent on country
17:18or continent it has to do purely
17:21with whether or not there were
17:23mosquitoes that carry malaria.
17:25So we look here at Africa,
17:26which is traditionally are or
17:27what we consider the sickle cell
17:29area in the United States.
17:31Here's this broad area of Africa that
17:33doesn't have any of the hemoglobinopathies.
17:35Now if anyone wants to put in
17:37the chat why that could be,
17:38there's this broad area here,
17:40right in the middle well.
17:42That's where the Sahara desert is,
17:43and you know the Sahara desert
17:44means there's no mosquitoes.
17:45No mosquitoes means no.
17:47Malaria means there's no predisposition
17:49to any of these these particular alleles.
17:51Now let's cone down a little
17:54bit more on Africa.
17:56Actually,
17:56let's see if I can go back.
17:58I wanted to make one of the point
18:00before I go on to sickle cell,
18:01which is that in the United States
18:03we really emphasize that African
18:05Americans have sickle cell.
18:07This is the the African American disease.
18:09But what we're overlooking then is the risk.
18:12Here in southern Europe,
18:13in the Middle East and in India, right?
18:16And so we're missing a large part
18:18of the potential possibilities here,
18:22but let's focus. Here on Africa.
18:24OK,
18:24so we already talked about this ahara desert.
18:26We have this area here in Sub Saharan Africa,
18:28where we have hemoglobin,
18:30S and just another point.
18:32I'd like to make right?
18:34So this area here is Kenya and
18:37if you think about Kenya,
18:38it's a very mountainous country.
18:41So if you're trying to think OK,
18:43I'm thinking about risk for
18:46particularly licks posure to to his
18:50historical exposure to malaria.
18:53Kenya is right there in that shadow,
18:54but if an individual's ancestors
18:56come from the mountain tribes
18:57where there weren't mosquitoes,
18:59then they have no greater risk for
19:02sickle cell anemia than someone
19:04from northern England right now.
19:07Of course,
19:08with a population admixture and global
19:10warming that that association is shifted.
19:12OK,
19:12so here we are looking at Africa,
19:14we have our our sickle cell.
19:16Here we have a hemoglobin C and
19:18if we were
19:18to compare that with a map that shows
19:21where enslaved people were taken.
19:23Historically, in our country's past
19:25you would see that even if you didn't
19:28know anything about modern day America,
19:30you would expect us to have a fair amount
19:33of hemoglobin, S, and hemoglobin C.
19:35And of course, you would be right here.
19:38This is from a a single study from Howard
19:40University of sickle Cell screening clinic,
19:43and you can see that we have a fair
19:45amount of hemoglobin S and hemoglobin C,
19:47so you may be thinking, OK,
19:48I'm starting to put this together.
19:49It's not just geography.
19:50I mean, I don't expect everyone to
19:52know the altitudes of, you know.
19:54Different countries and and whether
19:56they're mountainous or not,
19:57but you're starting to put together.
19:58There's more to this story,
19:59and maybe I can have some understanding.
20:02But you have to be careful because
20:04a rising share of EU. S.
20:06Black population is foreign born.
20:07So if you were to try to base some of
20:10your diagnostic heuristics on the the
20:13origin of enslaved people in this country,
20:16you have to be aware that a lot of EU.
20:18S black population is not coming from
20:20those areas that were historically
20:22associated with being African American,
20:25and in fact the mean amount of
20:27European ancestry is about 16% for the
20:30descendants of those enslaved persons.
20:32Now population admixture is a very
20:34important component as we're thinking
20:36about disease processes and doctor
20:38Graves is going to go into that now.
20:41Hey, thank you again Doctor Darrup.
20:43So when we look at the.
20:46Variation in European ancestry and
20:49persons socially defined as African
20:51American in the United States,
20:54it can vary dramatically
20:56by region of the country.
20:58So while the mean maybe
21:0016% of European ancestry,
21:04for example the state like West Virginia,
21:06it's in excess of 30% European
21:08ancestry and a state like Washington.
21:12It is also in excess of 30% of
21:16European ancestry, so the 16%.
21:18Tends to be more common in
21:23the South eastern states,
21:26which of course were the the the
21:29location of chattel slavery.
21:31The primary location of channel
21:33slavery in the United States.
21:34Next slide.
21:38Now when we look at people who
21:41are defined as Latino or Latina.
21:44The admixture percentages
21:46vary even more dramatically,
21:48and that's in part because these populations
21:52are a try admixture between European,
21:56Amerindian and African ancestry.
21:58Next slide.
22:03So for example, in Puerto Ricans
22:05and are now more Puerto Ricans
22:07in the United States than there
22:10are on the island of Puerto Rico,
22:1272% of their genetic ancestry
22:16is on average European,
22:1916% on average American
22:21Indian but 12% African.
22:24Now compare that to Mexican Americans
22:27who are the largest Latino Latino
22:31group in the United States where 51%
22:35of their ancestry is American Indian,
22:3846% European, but only three
22:40percent African now in Colombia.
22:45The mean percentage of African ancestry
22:47is only 7% with 29% American Indian
22:52ancestry and 64% European ancestry.
22:55But compare that to Peru,
22:58where it's 80% American Indian
23:01ancestry and only a sliver of African
23:04ancestry around 2% next slide.
23:09Even within the country of Colombia,
23:12admixture depends very much upon history.
23:15So in the city of Medellin.
23:19The population there more closely
23:22reflects the mean for the country
23:25with regard to the triad mixture,
23:28meaning predominantly European.
23:31A significant Amerindian ancestry,
23:34but very little African ancestry,
23:36but in the neighboring state of Choco,
23:38which was a focus of plantation agriculture.
23:42The vast majority of those
23:46people's ancestry is African.
23:49Similar to numbers that we
23:50would see in the United States,
23:52although there is more American Indian
23:55ancestry in Colombians from Choco
23:57than there are African Americans,
24:00now that both of these groups
24:02consider themselves Colombian,
24:03and if they came to the United States,
24:05they would call themselves Colombian.
24:07But in our socially defined racial scheme,
24:10these two groups of people would be
24:13treated dramatically differently.
24:14Doctor darrow
24:16right? So so I think that.
24:19Oh sorry. A hawk just went
24:22after my ducks in the backyard.
24:24Sorry, so race is not a
24:26biological useful construct.
24:27I hope that what we've shown you
24:29over the last few slides has shown that.
24:31So why, then, are there racial
24:34disparities in health and disease?
24:36So we have intrinsic causes of disparities,
24:38so genetic causes,
24:39and this comes back to what Meryl was
24:43saying in the 2017 book on Epidemiology.
24:45So these are a small contribution
24:48to the cause of disparities
24:50compared to the extrinsic causes.
24:51We'll talk about in a moment,
24:53so we all are familiar with a
24:55little bit of population genetics.
24:56At least we know about founder
24:58effects or population bottlenecks,
25:00so examples of this would be severe
25:03combined immune deficiency in the Navajo.
25:06And the Hickory,
25:07Apache or Tay Sachs in the Ashkenazi
25:10Jewish population following the
25:12decimation of those populations
25:14because of the American government
25:17and the Holocaust respectively.
25:19But these are affecting populations
25:21and not race is another possible
25:23'cause of genetic differentiation
25:25can be endogamy so marriage within
25:28or more specifically breeding within
25:30one group and this can be due to
25:33religion or caste or geography.
25:34But once again is not based
25:36on socially defined.
25:37Race, it's a it's a population.
25:39And then finally we have selective advantage,
25:41which refers to what we saw with geography.
25:45But what has a much larger
25:48impact on health disparities?
25:50Are the extrinsic causes.
25:51And that's what Meryl was
25:52referring to and what my doctor,
25:53grids and Doctor Goodman
25:54talked about in her book.
25:56Racism, not race.
25:57So poverty,
25:58access to care,
25:59health insurance,
26:00stress,
26:00neighborhood and a lot of these
26:02are linked and a lot of these fall
26:04under the influence of individual,
26:06institutional and systemic racism.
26:07And I'd like to take a moment to
26:09talk about those three because
26:11we're beginning to talk about
26:13them more in medicine.
26:14And it's important to have the same.
26:16Definition so this comes from the
26:20website dismantlingracism.org.
26:21I highly recommend this and it
26:23talks about individual or personal,
26:25institutional and cultural racism.
26:27And I think for many of us,
26:29and I can speak certainly for myself,
26:32that prior to the murder of George
26:34Floyd and a significant reevaluation
26:37of racism in this country,
26:39many of us and myself included
26:41considered racism to be something
26:43that was an individual act.
26:45So it was there were individual racists.
26:49What we now recognizes that there
26:52are policies and practices of
26:54institutions and beliefs and values
26:56of societies that have a tremendous.
26:58Impact as far as racism goes,
27:01so institutional racism would be
27:03the policies and practices of
27:05universities or hospitals that include
27:07or serve or uplift white people.
27:10And an example of this would
27:12be a phenylketonuria testing,
27:14which in the initial site
27:16for newborn screening.
27:17They only tested white children
27:18because of the belief it only
27:20happened in that population and then
27:22cultural racism would be the beliefs,
27:25values and norms of society
27:27that financially resource and.
27:28Validate and protect white people
27:30compared to people of color.
27:32So for example,
27:34our society does not believe in
27:36universal access to health care,
27:38which you know has a tremendous
27:40impact on health disparities.
27:41And then our government followed
27:43the practice of redlining,
27:45which made it more difficult for
27:47African American families to
27:48receive favorable mortgage rates.
27:49And this leads to generational poverty,
27:52which has an incredible impact
27:55on health disparities.
27:56So let's look at these extrinsic causes,
27:59and in the context of disease.
28:01So here's a quote from up to date that
28:03refers to the two studies listed below.
28:05As you're aware as physicians for
28:08women who need a hysterectomy,
28:10there are two large categories.
28:12There's an open hysterectomy which
28:15goes through the abdominal wall
28:17can have significant morbidity
28:20and takes a long time for recovery
28:22compared to a minimally invasive
28:24technique such as a laparoscopic,
28:26because directly or trans vaginal.
28:28Hysterectomy and these studies found that
28:31for women who are eligible for either
28:33type of hysterectomy if they were black,
28:35Hispanic or publicly insured,
28:36they were much less likely to
28:38receive this mentally invasive
28:39technique compared to white women.
28:41So you have a population that probably
28:43isn't able to take a whole lot of
28:45sick days and maybe working in a
28:47job where they have to lift heavy
28:49objects may not have child care or
28:51assistance and you're making it even
28:54more challenging for them to recover.
28:56And I would say that the
28:57factors involved in this.
28:58Would be systemic racism because
29:00of the link to public insurance,
29:02institutional racism,
29:03because the hospitals that treated
29:07these particular populations were
29:09did not have as many surgeons that
29:12perform these minimally invasive
29:14techniques and then poverty,
29:16education, access to care,
29:19health insurance were all factors.
29:21And then if we talk about the impact of
29:24high blood pressure on African Americans,
29:27I would say that all of these come to bear.
29:30There actually is no slavery gene,
29:32despite what you may have read
29:34in the popular media.
29:37So looking at all of this,
29:39this is the the full list of the
29:42diseases that I found in Robbins.
29:44One of the things that I did,
29:45and many of you have seen this as
29:47I put together a document which has
29:49about it's about 80 pages with figures
29:51and references going through each of
29:52these diseases and providing context.
29:54I'm not saying that population
29:56differences don't exist,
29:57but I'm saying we need to look at
29:59them in the appropriate context.
30:00I'm also putting together videos on a
30:02website I'll talk about in a moment,
30:04but to give you an idea of what
30:06it is that that.
30:06I'm doing let's focus on
30:09cardiac Emily ptosis.
30:10So here's the sentence from
30:12the 10th edition of Robbins,
30:134% of African Americans have a
30:17translate mutation increasing
30:18risk of cardiac amyloidosis.
30:21So translate written transports by Roxanne
30:23and retinol in the CSF and in the blood.
30:26It's accreted as a tetramer,
30:28but can break into monomers
30:30which can misfold and aggregate
30:32aggregate into amyloid fibrils.
30:34Depositing in the heart on
30:36nerves and and other tissues.
30:39Now in 1989,
30:40a pro emulator GENIC mutation was identified
30:43in a 68 year old African American man,
30:45and since that time we've found
30:47that about 3 to 4% of African
30:49Americans have this allele compared
30:51about .4% of European Americans.
30:54It's an AutoZone will dominant
30:56mutation with variable penetrance
30:58tends to affect older men,
31:00and this is important because it can
31:03mimic hypertensive cardiomyopathy,
31:04which is also seen predominantly
31:06in that population,
31:07and death ensues two to six years.
31:09After diagnosis now based
31:11on the allele frequency,
31:13it was thought there may be
31:14some sort of founder effect,
31:15and we're lucky that the research
31:17was actually done to show the
31:19distribution of this allele in Africa.
31:22So you can see here we have the
31:25highest prevalence in Western Africa
31:27and then expansion from there,
31:29and if once more we compare this to
31:31the map of the origin of enslaved
31:33people from the history of our country,
31:35you can see why we have an
31:37increased number of these alleles.
31:40In our population.
31:41And if this were all we had,
31:42it would be an interesting story.
31:44But you know what you do with that,
31:46but it turns out there's a
31:48treatment and there's a drug that
31:50can bind to the thyroxine binding
31:51site and prevent dissociation.
31:53Now it doesn't cure the disease,
31:55it doesn't roll it back,
31:57but it does slow progression.
31:59Now one of the issues with this is
32:01that it costs about $225,000 a year,
32:03but one of the reasons for that is
32:06because it's considered an orphan drug.
32:08You know it's not used very much,
32:09so maybe if we were thinking about this.
32:11Disease we were able to identify
32:13patients who would benefit from
32:15it and we could work on policy.
32:16Would be able to be sure these patients
32:18were able to get the treatment they need.
32:21So this brings us finally
32:22to the question of our.
32:24Our title is race and medicine data
32:26or distraction and I hope by this
32:29point you are saying well race is
32:31not useful as a biological category.
32:33So let's think instead are disparities
32:35is a focus on disparities in
32:38medicine data or distraction.
32:40And I would say yes it can be both.
32:43So it's data.
32:44If we recognize a population and say
32:46we need to be aware of the possibility
32:49here and do an appropriate test.
32:51It's distraction if we're just
32:53teaching simple heuristics,
32:54let's think fast.
32:55Don't think slow and say this kid
32:58who keeps presenting with lung
33:00infections because she's of African
33:02descent does not have cystic fibrosis.
33:04So what do we do to turn these
33:08these disparities into data?
33:10So we need to be inclusive.
33:11We need to have a thoughtful,
33:12mindful analysis of material and
33:14it must be driven by data and
33:17we must provide context.
33:19So I begin every endeavour
33:20by building a team right?
33:22And you are all now part of my team.
33:23I hope to enlist you in all of the
33:25work that we have ahead of us.
33:27These are three individuals from
33:29Duke who began some of my early
33:31discussions about race and medicine.
33:33I'm particularly grateful to Doctor
33:35Royal because she introduced me to
33:37Doctor Graves and I'm just incredibly
33:39grateful to have him as a colleague.
33:41He's referred to the three books he's
33:43written, the most recent is racism,
33:44not race.
33:45I also really like the Emperor's new clothes,
33:48so.
33:48Please do check those out,
33:50but you have to keep building your
33:51team and it must continue to expand
33:53and that's why I'm inviting you
33:55to be part of my team because the
33:56more voices that we have in this,
33:58the more opportunities we have to
34:00recognize blind spots and areas
34:02that we need to fix.
34:04And I'm going to also put a call out.
34:07You have to bring the medical
34:08students in the residence, right?
34:09So this can be challenging because we
34:12have a very strong hierarchy in medicine.
34:16I'm a professor.
34:17I profess you can listen right,
34:19but as I was talking with with
34:22Doctor Barry Barry,
34:23you have to have humility and
34:26vulnerability and transparency
34:28to do this work.
34:29And as much as I think that I'm
34:31open minded and I look at things,
34:33I know that younger generations.
34:35Are much more plugged in and are
34:36looking at things in different ways
34:38and are seeing things in ways that I don't.
34:40So for my medical students I put up
34:42a Google Doc and I said would you?
34:44If you find a problem or re writing
34:45this book and you find a problem
34:46give me the page,
34:47the terminology quote and any notes.
34:48It's anonymous and I'll work on
34:50it because my students are so
34:52comfortable talking with me.
34:53They're basically just emailed me,
34:54which is why this this graph is is
34:56looking looks beautifully blank,
34:57but it's not because there weren't issues,
35:00but we have to actively engage
35:02and for those of
35:03you who are resistant to that who.
35:05Don't like to lean into that?
35:07Keep in mind that if you ask if you
35:10actively solicit and say look I,
35:11I want to know your thoughts on this,
35:13that that gives your your medical
35:15students and residents the
35:17opportunity to call you in to say hey,
35:19you know Derek, we know you're
35:20interested in this and we found this.
35:22If I don't ask for it then what
35:23I get is hey Derek, we watch this
35:25video and there's a problem right?
35:27I have said to them I with humility I.
35:30I know that there will be
35:31issues that I don't see.
35:32Please help me and that changes
35:33the dynamic and it helps us to.
35:35Actually make progress.
35:37And we have much to learn from our
35:39medical students and residents.
35:40This is a young man who is a medical student,
35:42United Kingdom who noticed that
35:44all of these skin lesions he was
35:46looking at were in white skin,
35:48which was not particularly helpful for
35:49him or the demographic he hoped to serve.
35:51So he began this resource with some
35:54of his faculty at Saint Georges,
35:56which I think many of us are now
35:58referring to because it's very hard to
36:00find images of lesions in pigmented skin,
36:02though we're fixing that in Robbins.
36:05And we're also fixing that at Duke,
36:07so at Dupli teaches in website and about
36:09five to six years ago I removed race
36:12and ethnicity from all of our vignettes,
36:14but you know,
36:15we still have clinical images and you
36:16don't really need someone to tell you
36:18this is an individual of European descent.
36:20You can look at what is commonly called a
36:22pearly papule in this lightly pigmented skin,
36:25and recognize that this is
36:27a basal cell carcinoma.
36:28But we now do to make this even more
36:30inclusive is that we show images of the
36:32same lesion in different skin colors,
36:34so we aren't associating one in particular.
36:37Patient would say,
36:37and this is what the lesion can look like,
36:39and this is particularly important in
36:41this case because it emphasizes that
36:44you know basal cell carcinoma may mimic
36:46a Melanoma in darker skin, right?
36:48So we need students to be able
36:50to recognize this,
36:51but it also reminds us that
36:53the text that we're using,
36:54the terminology pearly papule is not
36:57something that you see in all skin types,
36:59and we found this in an evaluation of a
37:02pediatric textbook for a paper that's
37:04impressed with academic medicine,
37:06in which.
37:07Acrocyanosis was described as the
37:11typically pink skin becomes bluish.
37:14It's like, well,
37:15not all babies have pink skin, right?
37:16So there is this subtle,
37:18but maybe not so subtle reinforcement
37:20through the literature that what's
37:22important is white people white skin.
37:24So we need to be inclusive.
37:27Now I'm really interested in data,
37:29right?
37:30This is because emotions can get into it
37:32and I just want to know what is the truth,
37:35what?
37:35What is the best approximation
37:37to the truth that
37:38I can find which can be hard?
37:39So this is a sentence from, UM,
37:42the 10th edition of Robbins,
37:43and I reached out to the author of
37:45that chapter, and I said, you know,
37:47I think we need to remove this word about,
37:49particularly those of African descent.
37:51This link, with keloid
37:52formation and his response,
37:53was this is what it says in up to date.
37:57Yeah, 5 to 16% of individuals of Hispanic
38:00and African ancestry have keloids,
38:02and because of the disparities
38:04document that I mentioned,
38:05I actually had read up to date as well
38:07as reference five as well as another
38:1030 or 40 other papers on keloids.
38:12And in addition to this 5 to 16%,
38:15it refers to this 15 times higher in dark
38:17skinned individuals compared with whites.
38:20Now 15 times higher is is a big number.
38:23It still may not be clinically significant,
38:24and that's a discussion we can have
38:26with the residents or the question.
38:27An answer,
38:28but 15 times is pretty is a pretty
38:30big number and it stuck in my
38:32mind in particular because I've
38:34seen it in four other papers.
38:36Now the first paper in which it
38:37appears is this one by preset,
38:39and this is what Brissett says in
38:412001 that in a review of 175 cases
38:44of keloids from various races,
38:46the authors found that keloids
38:47were 15 times more likely to occur
38:50in darker skinned individuals.
38:51So I went and got that paper by audience
38:54of anesthesia and this is what they say.
38:56It was a paper that was.
38:57Done in Malaysia and they say the
38:59relatively fair skinned Chinese appear
39:01to be slightly more prone to keloids and
39:03the dark skinned Indians and malaise so.
39:05The number I come up with is 2.4 to 3.3 fold,
39:10so the number is wrong and arrows pointing
39:12the wrong way and this information is
39:15being propagated through the literature.
39:17So after I gave all of that
39:18information to the author,
39:19this is what we came up with.
39:20Q information seems to be an
39:23individual predisposition.
39:23Now you may say we could have gotten
39:25there a lot faster if we just
39:27removed African descent and we just
39:29remove all of the ethnicities and
39:31races from Robins without thinking.
39:33But the truth of that, and I think,
39:35actually there's a basis for that
39:37because of population admixture,
39:38because the data are very muddy.
39:40If you look at it.
39:42How are races assigned, etc.
39:44You could say that that a lot of the
39:46data are not useful, so we'll remove it.
39:48But then you risk people saying you're
39:50being politically correct, right?
39:52I want to be scientifically correct,
39:53and so I have to find the data to show
39:55you on being scientifically correct,
39:57because otherwise will get pushed back.
39:59So we have to move forward
40:01in an intentional way.
40:02So now we can say keloid formation seems
40:04to be an individual predisposition,
40:06right?
40:06But let's get again to the
40:08clinical significance of
40:10this, right? So if someone is
40:12going to be key loader genic,
40:14they have a tendency towards that,
40:15and they're coming into you as a clinician,
40:17right? You can, you don't need to look
40:19at the color of that patient skin.
40:21You can look at that patients
40:22actual skin, right?
40:23Because we all fall over or get one or two.
40:27Or multiple piercings have scrapes,
40:29incisions, previous surgeries,
40:30and if we're going to get keloids,
40:32we're going to show a keloid.
40:33So look at that patient skin.
40:35Now kilo is gonna have a familial tendency,
40:38and so maybe we're looking at a young
40:40child so you get a good family history.
40:41Do your brothers and sisters
40:43have keloids your cousins,
40:44your parents, your aunts,
40:45your uncles, your grandparents,
40:46and that family?
40:47History is going to tell you more about
40:50that individual's genetic predispositions
40:52for disease then some big category,
40:55like socially defined race.
40:57And it's not just for keloids.
40:59In fact, it's for much more than that,
41:01because I can ask to find out what?
41:03Which diseases are running in a
41:05family and that will also bring
41:08in not just genetic ancestry,
41:09but can bring in cultural practices.
41:11Is there a food, a drink,
41:13and activity,
41:14a folk medicine that you use that might
41:16give me an insight into why you're
41:19presenting in this particular way?
41:20Now? The keloid story.
41:22I'm a I'm a soft tissue pathologist.
41:24By training and keloids for
41:25me or something that was not
41:28tremendously interesting,
41:29but believe it or not,
41:30I have a 20 minute video on looking
41:32at the scientific.
41:34Literature of keloids and where
41:36these statistics come from.
41:38It is an exercise in looking at systemic
41:40racism in the scientific literature.
41:42I go all the way back to 1931
41:44to the French literature.
41:45I personally find it very entertaining.
41:47I hope you will check it out.
41:49You can find it on my
41:51website pathologycentral.org,
41:52and there's a direct link there as well.
41:56Alright, so finally the other issue.
41:58We want to do is we want to be
41:59sure we're using appropriate
42:00terminology and providing context,
42:02and I talked about some
42:03of this with Doctor Camp.
42:04It's it.
42:04We don't want to just throw things out.
42:06There are things that we need
42:08to bring people's attention to,
42:09but we have to provide the context
42:11because otherwise we don't know what
42:12people are going to be thinking.
42:14So here we have a sentence from
42:16Robbins basic pathology about whites
42:17with Factor 5 Leiden mutation.
42:19OK,
42:19well we know this is genetic and
42:21so we don't want to be using whites
42:24because if we're using whites
42:25that really sets.
42:27It's up to say, well,
42:27why aren't you using Browns,
42:28yellows,
42:29blacks and Reds and we just
42:30don't want to do that,
42:32and we know it's genetics.
42:33We want to emphasize this European ancestry,
42:35but we want to be mindful here because we
42:37don't want to just make that association.
42:39You know kids.
42:40When they rip says European ancestry,
42:42she really means white. We want to say, OK,
42:44it seemed typically in European ancestry,
42:46but because of population admixture it
42:48can be seen in other American groups.
42:51Now, part of our goal in this
42:52and I know that we've gotten some
42:54questions from people when they say,
42:56well, you know, we're looking,
42:58you're looking for zebras.
42:59If if every African American
43:01child who presents with a cold,
43:02you start thinking cystic fibrosis,
43:04that's not going to be a useful
43:06way to think about resources.
43:07And I understand that.
43:09But the issue will be that.
43:12The sixth time, the third time that
43:14child presents with the symptoms.
43:16Think about it.
43:16You know maybe it is cystic
43:18fibrosis in that child,
43:19and when we're talking about Factor 5 Leiden,
43:21it's important as it particularly important
43:23to think about population admixture,
43:25because factor 5 Leiden,
43:26as you know,
43:27can have thrombophilia in the
43:30heterozygous state.
43:31So someone may look to you through
43:33your racialized glasses as this is
43:35an African American based on the
43:37population admixture data we showed
43:38you they could be 50% European
43:40ancestry and they could have.
43:42They could be homozygous or even
43:44heterozygotes for factor 5 Leiden.
43:47These are our references and
43:49I'd like to just finish with a
43:51couple of resources for you.
43:53This cartoon on the right.
43:55Please take a screenshot,
43:56take a take time to look at.
43:57It comes from a cardiology
43:59fellow at University of Chicago,
44:01a Shirley Noble.
44:03Be her drawings really communicate
44:06very concisely.
44:07A lot of the issues that doctor Graves and
44:10I have talked about in race and medicine,
44:13and that doctor Graves has
44:15written about for decades.
44:16My you can find me on Twitter here.
44:19This is my my website which has
44:22videos for you to watch and enjoy.
44:25Doctor Graves's contact information.
44:27I also recommend diversifying path.
44:31This is his Twitter handle on
44:33Michael Williams from UAB and he
44:35has a podcast in which actually I'm
44:37I'm in this week's episode and then
44:40this is the contact information
44:42if you want to follow Doctor OB,
44:45she has just really fantastic.
44:47Insights that she writes about.
44:49In addition to her cartoons,
44:50and with that,
44:52I'll stop sharing and take any questions.
44:55And my apologies for the the
44:57small disturbance.
44:58We have a small flock of ducks and we
45:00have Hawks that occasionally go after
45:02them and as I was in mid speech I heard.
45:04A disaster outside,
45:05but my husband will deal with that.
45:07So thank you very much.
45:10Thank
45:10you so much Doctor De Rock and Doctor
45:13Graves for this excellent discussion and
45:16really comprehensive overview for us.
45:20I'm seeing that. Let's see Rob Homer.
45:24Doctor Robert Homer has a comment in the
45:26chat that Robbins Atlas of Pathology has
45:29only light skin in its German chapter,
45:32so I guess bringing attention to that
45:35as an opportunity for more inclusive
45:38images in our pathology world.
45:42I I can I can address that.
45:44I actually knew about that and
45:46began frantically waving to the
45:49authors of that the they actually.
45:51There are some instances of
45:53black skin in that Atlas and
45:56they are associated with trauma.
45:59So gunshot wounds and stabbings.
46:02So I think that takes it into an even
46:03worse realm that was in the earlier edition.
46:05I don't know what the most
46:07recent edition has.
46:08I do know that I began frantically
46:10waving and saying, please, please please.
46:12You need to fix this.
46:14And that.
46:15In Robbins basic pathology,
46:17we're bringing in multiple skin types for
46:20lesions addressing how it's discussed in
46:23the literature and keeping our eyes open.
46:26So recently there was something on Twitter
46:29about a Nigerian student who is providing
46:32illustrations of anatomy for with,
46:36you know,
46:37individuals of African descent,
46:38and I thought, oh,
46:39I should look at what our
46:40cartoons look like in Robins.
46:41And you know what?
46:42They are all white people,
46:44and so I brought this up with Doctor Kumar.
46:46We're talking with our illustrator,
46:48but this brings up an issue because it's
46:50one thing to show normal anatomy or to
46:53show skin lesion different skin types.
46:54But now as we say,
46:56when we're going to be providing
46:58different skin types,
46:59So what color do we make?
47:00The cirrhotic liver guy or the smoker,
47:02or the person with syphilis, you know,
47:05are we going to increase racialization now?
47:08Doctor Graves whimsically suggested we
47:10make them non human colors like like
47:13the little what is he is easy a mole.
47:17He's a professor.
47:19Arthur, yes Arthur.
47:20He's some small animal who's purple.
47:22No or not that would.
47:24I or maybe I'm thinking of another cartoon.
47:27Yes, well anyway, so so we are aware of that.
47:30I think that the differences is that
47:33while people have been aware of this,
47:36it hasn't always reached the people
47:38who had the power to change it,
47:40and that's what we're doing now.
47:41And we're working on multiple levels.
47:43We've presented the National Board
47:45of Medical Examiners about step one.
47:47We're engaged in discussions with the
47:49American Board of Pediatrics about how
47:52they look at race in their licensing exams
47:55for people in American Board of Pathology.
47:58I've reached out to some people there.
47:59We're looking at how race based medicine
48:01is is propagated and and this is something
48:04where everybody has a voice and gets to work.
48:06So so yeah, we need to.
48:08We need to not just make the
48:09observations to each other for coffee,
48:11we need to actually hold people accountable.
48:12And I sent my my keloids video to the
48:14up to date people and I'm going to keep
48:16pecking at them until they they fix it.
48:18So alright.
48:20Thank
48:21you for responding to that comment.
48:23Doctor David Rimm also has in the
48:26chat doctor Darrup. You're right,
48:28I was entertained and educated.
48:30Clearly there are genetic propensity's.
48:32Can you comment on how to integrate
48:35this genetic data into skin color?
48:37Or should that just not happen?
48:39Andrea? That yeah,
48:42I mean the first thing that
48:45people need to understand is that.
48:47Genetic variants are not correlated with
48:51each other and it's in anthropologists
48:53called the principle of discordance so well,
48:56physical traits and genetic traits
48:58are not correlated with each other,
49:00so the simple fact that individuals have dark
49:03skin does not indicate that they're going.
49:06They're going to have a specific
49:08genetic variants associated
49:09with predisposition for disease.
49:12For example taking you know
49:14sickle cell anemia.
49:15OK, that variant is found in Spain
49:18where people are light skinned and
49:20it's also found in central Africa
49:22where people are dark skinned.
49:24So associating that variant with
49:25skin color wouldn't help you.
49:27And and simultaneously while you
49:29know cystic fibrosis variants are
49:31more likely to be found in Northern
49:33Europeans who tend to have light skin
49:36and they're also found in people in
49:38Africa and India and other places
49:40around the world at lower frequencies.
49:43So so the end of the day.
49:45What one needs to be doing is they
49:48need to be examining individuals
49:51for their genetic composition,
49:53without assuming that that their skin
49:57color tells you necessarily which set of com,
50:01particularly complex diseases an
50:03individual is likely to have.
50:09Thank you very much for
50:10responding to that question.
50:11Doctor graves. Another question
50:13just popped up in the in the chat.
50:17Steven Holt asked,
50:18can you comment on the purported
50:22racial associations with lupus?
50:27Would you like to take? Yeah,
50:28I can take that one too because.
50:32Published on that. Well yeah,
50:33I mean what were the first examples
50:36of that got me interested in examining
50:39these false racial assumptions,
50:40and medicine was when a woman of African
50:44descent who is married to a man of
50:47predominantly African descent came into my
50:50office and described her husband symptoms,
50:53which very much sounded to
50:55me like they were lupus,
50:58but Hurvis position refused to diagnose.
51:02Yeah, with lupus because he took the
51:06position that Africans don't get lupus.
51:09And it turns out that when they
51:11went to another specialist,
51:12he did have lupus.
51:13In fact, my little sister suffers from lupus,
51:16so once again,
51:17we need to be cognizant of the
51:20fact that you know variants that
51:23predispose people to specific diseases.
51:26Are at different frequencies
51:29in all world populations.
51:31And then when you consider the fact that.
51:34For many of these diseases,
51:35we're actually looking at
51:37complex genetic foundation,
51:38not just simply one variant,
51:41but you really need to look
51:43you know across the genome,
51:45and then you have to also be
51:48cognizant of environmental
51:49and epigenomic contributions.
51:50You again you gotta get away from the
51:54idea that you know one particular ethnic
51:57group is far more likely to get X disease.
52:00I mean, yeah,
52:01it happens in some cases,
52:03but you also need to be aware.
52:05That you can also happen
52:06in groups that you wouldn't
52:08expect to have that disease.
52:11Right, so I think I think what
52:15Doctor Holt was mentioned is we
52:19actually frequently associate.
52:20African descent with with lupus?
52:22I mean, that's that's like a classic
52:24association and we have these,
52:26but with doctor Graves.
52:27His point is that that's so critical,
52:29is that right?
52:30Pretest probability can
52:31only get you so far right?
52:34And this is a point I made in the talk.
52:36Is that we're not saying that you know,
52:38every you know African American
52:40child who shows up with a cold you
52:43think could be cystic fibrosis,
52:45you know,
52:46but don't keep denying something
52:48based on socially defined race.
52:50And I'm just going to mention.
52:51Something else which is even more insidious
52:53on that which is that with Doctor Lanny Ross.
52:56I was talking back and forth with
52:58her about cystic fibrosis.
52:59She's published on it and she said
53:01the issue is she's a pediatrician
53:03is that you know if you have a
53:052 month old child who presents
53:06in the Ed with failure to thrive
53:08and it's a white kid they think
53:10oh could be cystic fibrosis.
53:11If it's a black kid they think
53:13neglect right and so this is part
53:15of what happens is what do the
53:17associations that we're teaching
53:18people is that neglect is more common.
53:21Then cystic fibrosis in African
53:23American children, right?
53:24So we really need to be mindful
53:27of how we do this,
53:28and it's just another aside is that?
53:32When with more and more people
53:34doing this 23 and me, right?
53:35So part of my interest in this
53:37came from one of the Association
53:39of pathology chair meetings.
53:41Someone said, you know,
53:42she and her husband got the, you know,
53:44the the genomic thing done and
53:46he'd had these symptoms for years.
53:48Blonde hair blue eyed guys had
53:50Mediterranean familial fever, right?
53:52And no one had ever diagnostics.
53:54His blonde hair, blue eyes, right?
53:56So so really.
53:59Have our minds open to the fact that
54:01we don't know what we're looking at.
54:02We don't know what people have.
54:06Thank you both for responding
54:08that question. Let's see,
54:10there's a couple questions.
54:13One in the QA
54:14chat says in a similar vein,
54:16is there a good way to Carly Dr.
54:20Carlene meiklejohn? Asked
54:20is in a similar meaning. Is there a good way
54:22to refer to population
54:24variation and disease risk?
54:26Should it always be with the caveat
54:28these are often based on social
54:30social determinants of health care?
54:33So Karlene thank you for letting us know
54:36that Arnold MO the Arthur is an aardvark.
54:38I knew that he was. He was not
54:40something else and it is something.
54:44So uhm, as far as sorry I got distracted
54:47by my by my witty comment on that.
54:50So the about making the issue about
54:53social determinants of health care right?
54:55So one of the points that doctor Graves
54:57makes that I think is incredibly powerful
54:59is that we're just and and there's a really
55:02excellent article written by Jenny thigh,
55:05who's here at Yale in emergency
55:07medicine about how we just say, well,
55:10it's it's social determinants of health.
55:11That's that's the thing.
55:12And then we stop paying attention to it,
55:14as if we.
55:14We can't change that as if we can't fix it,
55:16so doctor Graves will say,
55:17you know, we know you know health.
55:19Health disparities based on
55:21race as a solved problem.
55:22We know how to solve it, right?
55:24We put money into it.
55:25We make sure we are.
55:26We hire inclusively so that patients
55:29can see physicians they can trust.
55:31We'd be sure they have access to care
55:32they have access to medications.
55:33They can afford medications,
55:35and if we had universal healthcare
55:37just for example,
55:37that would go a long way towards
55:40curing health disparities, right?
55:42A lot of those things on that
55:43slide I showed would cease.
55:44To exist,
55:45if we could be sure people
55:47were taken care of.
55:48So it's it's and I see these papers
55:51that come out will they'll they'll say,
55:55well,
55:55we're going to see that even when we
55:57account for social determinants of health,
55:59there's still a different based on race.
56:01It's like you have no idea how broad
56:04the social determinants of health are,
56:06and the epigenetics and the stress,
56:08and we know that you know if if a female
56:10mouse is pregnant and distress there
56:13be epigenetic changes in the pups right?
56:15And we know about you know,
56:17generational trauma as far as.
56:19How people interact with their
56:21children and their children,
56:22children.
56:23So I think we have to be careful
56:25about just lumping things as their
56:28social determinants of health.
56:30Joe,
56:30do you want to comment on that?
56:32I mean one of the social determinants of
56:35health is racism and the exposure to racism.
56:38And in the cartoon that you showed
56:40at the end of the presentation,
56:42and that's something that will
56:44never be directly equalized in
56:46a racially stratified society.
56:48And so the main point of our new book,
56:51racism, not race is to indicate
56:54that we need to as a society,
56:57fix structural racism.
56:58Now this is not a case of as
57:02doctor Darrup is playing us,
57:04so it's not a case of lack of knowledge.
57:07It's a case of both a lack of political
57:09and moral will to do what's right.
57:12So if we really want a healthy society,
57:14they wanted to eliminate these disparities.
57:18That could be easily done,
57:20but there are strong vested
57:22interests who work to maintain
57:24these conditions of injustice,
57:26which happened to wreck results
57:28on how long people live and and
57:30and the quality of people's lives.
57:32And that's why you know we call on
57:34people to step up and to do what's right.
57:39Thank you both for that, so I think
57:42maybe we can wrap up with one more question
57:44which I think kind of touches on two.
57:46Another question in the chat.
57:47So these are doctor Matthew
57:50Goldenberg and Doctor Drew Bernheisel.
57:53Kind of both asked something related
57:55to the clinical the clinical sphere.
57:58So to word it here.
58:00So given the conclusion that
58:02biological race is a fallacy,
58:04but that socially constructed Reese
58:06is so important, how might we,
58:08in clinical encounters encounters?
58:10And I think this also is where it
58:12touches on what doctor Bernheisel
58:14said in notes or the clinical sphere.
58:18Appropriately acknowledged race and racism.
58:24Gosh graves. Goes down to two,
58:29one attempting to treat the patient as
58:32a human being and not making assumptions
58:35based upon their so C define race.
58:38So if I walk into an emergency room,
58:42people don't know that I'm
58:44a university professor.
58:46And I can, you know,
58:48have a physician who assumes all
58:50sorts of things about my occupation
58:53about where I live about my behavior.
58:55You know, I drink too much.
58:57Or, you know, I work in a factory
59:00simply because it covered my skin and
59:02not that I'm a university professor.
59:04And then, by the way,
59:05this has happened to me
59:06repeatedly throughout my life.
59:09So the question comes down to is
59:12a really basic things about you
59:13know how one would practice in?
59:16And I I don't practice medicine.
59:17My brother did,
59:18but you know how one treats
59:21patients when they come in with,
59:23you know a heuristic that
59:25actually attempts to understand
59:26them as an individual and not,
59:28you know,
59:29collapsing them into one's
59:30vision of what salty defined race
59:32actually is supposed to be.
59:36This is this is also something that
59:38we've been thinking about it Duke,
59:40you know, because you wanna ask questions,
59:44you know we teach our medical students.
59:45Ask questions about you, know,
59:46do you feel safe at home? Is there?
59:49Do you have access to, you know?
59:52Can you afford your medications?
59:53For example, right?
59:54And we discussed this in the teaching for
59:56equity fellowship and I said, you know,
59:58and one of the other participants is
60:00that you know I don't know how to
01:00:01how to model this for my students.
01:00:03And I said, you know,
01:00:04you should ask everybody.
01:00:06That just because I come in and I'm
01:00:09dressed well or whatever doesn't mean
01:00:11that I might have trouble affording a
01:00:13medication or or be able to get it.
01:00:16Or I may be an abusive relationship
01:00:17or whatever, and so I think we need
01:00:21to not make assumptions.
01:00:23You should ask everybody you know.
01:00:25Do you feel safe at home?
01:00:26Is there a gun in the home?
01:00:27Well, is there someone to
01:00:28take care of your children?
01:00:29Do you need help with care?
01:00:31I mean,
01:00:31this should be part of as Doctor
01:00:33Gray saying how we take care
01:00:35of our individual patients.
01:00:36Is is to find out what are their
01:00:38needs and an important component
01:00:40of this is that when you ask that
01:00:42when you when you actually ask
01:00:45your patients these questions.
01:00:46You're going to be able to take
01:00:48better care of them, right?
01:00:50You'll have better insight into them.
01:00:51You'll have a better connection,
01:00:53and I understand there's a huge problem with,
01:00:54you know you get 5 1/2 minutes
01:00:56with each patient,
01:00:56so that's a you know that's a systemic
01:00:58problem we need to fix a systems problem,
01:01:01but you know,
01:01:02if we really are serious about
01:01:05taking care of people,
01:01:05we have to take care of people,
01:01:07not colors or races or categories
01:01:10that I'm making quick guesses about.
01:01:15Well, thank you both so
01:01:17much for sharing this.
01:01:19All your answers and insight on this topic.
01:01:21I think it looks like many people stayed on
01:01:23even though we've gone a few minutes over.
01:01:25So I think that speaks to how it
01:01:28captured everyone's attention today.
01:01:29So with that, I think that concludes
01:01:33our grand rounds and we'll see you
01:01:35in the resident community section
01:01:37for Doctor Day reps at Doctor Damon.
01:01:39Doctor Graves, thank you very
01:01:41much everyone here today.