Going to the doctor is like going to the car mechanic. It falls right between "trip to DMV" and "post office during the holidays" on the list of errands that we all hate doing. Just like the car mechanic, it can be expensive and even if they don't fix the problem, you still have to pay. When they do find something wrong, you have to take their word for it and assume that whatever course of treatment they suggest is best. If you try to go against their recommendation they give a condescending stare and then ominously warn, "OK, it's your life do whatever you want, but it really isn't safe."
But at least some people know something about cars that can give some advice. We all have a friend who spends the weekend with their buddies fixing cars. I don't know anyone who sits around on a Sunday with friends working on each other's hypertension.
Whether it's your health or your transportation, it's disconcerting to have such critical parts of your life in a black box of decision making. You don't know how physicians are making their decisions. Surely they are thinking about what will make the best health impact, but what else are they considering? Cost? Pharmaceutical advertisements? Convenience? What about race?
In a time where white supremacy is no longer acceptable, a far more insidious form of racism is at play: unconscious bias. Implicit bias and microaggressions are difficult to describe and almost uniformly unintentional, but their impact is tremendous. Because medical decision-making is far more ambiguous than most people realize and involves the evaluation of subjective and incomplete data, it's particularly prone to unconscious bias.
The CDC estimates that two thirds of adult Americans have either hypertension or pre-hypertension. Deciding the best way to treat this disease impacts over 70 million people. So when the Joint National Committee, a panel of experts on hypertension, released their updated guidelines at the end of 2014, it caused quite a controversy. While the guidelines included a plethora of recommendations, the debate has largely surrounded their recommendation that patients over the age of 60 have a more relaxed blood pressure goal of 150/90 instead of 140/90.
It's been over a year since the new guidelines were released, but the debate continues. What's so baffling to me is not that we keep discussing the 150/90 thing, I agree it is important, but that in all this time the most controversial part of the guidelines hasn't been mentioned in public debate or the media: that physicians should treat black patients and non-black patients differently.
In a nutshell, the new guidelines
recommend that certain blood pressure medications, ACE inhibitor medications
(ACEs) and angiotensin receptor blockers (ARBs), which are recommended for
non-black people as treatment for lowering blood pressure, should not be
initially prescribed to black people. Given that,
as a society we have accepted race as a social construct as opposed to a
biological one, the implications of this recommendation are disturbing.
Guidelines based on shaky research
Guidelines are recommendations that are so strongly supported by research and expert opinion, that everyone should be doing them. This guideline was based solely on one study only (ALLHAT). Even from its conception that study failed to make consistent scientific sense: it did not define what it means to be biologically black.
In the study the researchers relied upon each patient's racial self-identification -- a social, not biological definition. Many people who are white and only black still identify as black because their skin color is still darker and/or they are treated as such by the people around them. But if they are white, does that make them biologically "more white?" Furthermore, the researchers categorized the groups into black versus white, Asian, other and Native American. How can you on one hand claim there is a biological basis to race and then at the same time decide that Asian, other, and Native American patients are similar enough to belong in the non-black category?
Confirmation bias
So how did such shaky research make the cut? It's simple. Physicians and researchers are subject to the same racial biases as the rest of our society. It doesn't matter how enlightened or non-racist you want to be, a racist society influences all its members. Couple unconscious bias with confirmation bias -- the tendency to over-weight facts that support beliefs we already have -- and it's easy to see how this concept made it into the guidelines. We inherently believe that races are different, so we are willing to take any evidence, no matter how flawed, as proof.
Rather than go through the trouble of sorting out cause from correlation, a white-dominated profession finds it much more comfortable to assume that racial differences in health outcomes are due to biology instead of the truth, which is that race is a complex issue that cannot be reduced to one variable. By incorporating such stereotypes into guidelines we cross the line from unconscious bias on an individual level to racism, because now we are implanting that bias systematically.
All of this echoes eerily back to old anthropological "research" that proved white superiority through the measurement of skull size between white and black people. Of course, I'm not saying that these modern researchers are white supremacists; their intentions are certainly nobler. But the same racist pitfall is at play: over attributing observations to race.
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