Home >  Health & Science

There is expert debate over which is more important in treating different population groups

Tuesday, September 24, 2002

By Anita Srikameswaran, Post-Gazette Staff Writer

Ask Indians, Pakistanis or other South Asians, even those familiar with medical research, what box they check on surveys asking which race they belong to, and they will probably laugh.

	Despite having weight and blood pressure that were normal by U.S. standards, Ravi Sharma, who is Asian Indian, had several clogged arteries that required bypass surgery. (John Beale, Post-Gazette)

"It all depends what the form reads," said Dr. P.S. Reddy, a cardiologist at UPMC Health System. "If they have Asian Indian and Asian Pacific, I say Asian Indian. If they only have an Asian, then I say Asian. If they don't have either, then I say Caucasian."

"If you say Asian American, most people think of Orientals, like the Chinese or Vietnamese, as the Asian American," said Dr. Matcheri Keshavan, of Western Psychiatric Institute and Clinic. "So we really end up filling out the box as the 'Other' group. Even though we are 1 billion in population, we are in the 'Other' group."

What is meant by the term "race" and what role does it have in medical research? As scientists uncover more and more health differences among populations -- such as risk of cardiac disease -- how a person is classified is taking on greater importance.

According to the U.S. Census Bureau, in the 1970 census, Asian Indians were classified as white and Vietnamese people were in the "Other" category. The 1980 census offered six Asian categories, including Asian Indian, Chinese and Filipino. In the 2000 census, the race question became more elaborate by allowing people to check off the "other Asian" box and specify if the available options didn't fit them.

The 2000 census found that 11.9 million people, or 4.2 percent of the American population, said they belonged to what was labeled the Asian "race."

	His heart disease was hidden by normal numbers. Mental health care among different ethnic groups often overlooked. Read the previous installments in this series.

Race is a way of saying that humans can be divided into subspecies, explained Dr. Raj Bhopal, of the University of Edinburgh in Scotland. For the past few decades, scientists have said there is no biological support for the concept of race, a view reinforced by the Human Genome Project's finding that 99.9 percent of genetic makeup is the same in all humans.

Ethnicity, is the idea that groups of people differ for largely cultural reasons, such as language, religion and ancestry.

"What's happening in the states is that you're using the word race, but you're really beginning to mean ethnicity," Bhopal said. "What's happening in Europe is the word race is being abandoned fast and people have, for all intents and purposes, converted to the concept of ethnicity."

The ability to categorize people is a powerful tool for epidemiologists who study disease patterns in populations. Groups can be compared and contrasted, helping scientists understand disease and plan the delivery of health care.

For example, people of Chinese descent have the lowest risk of heart disease in the United Kingdom, Bhopal said. People of African-Caribbean origin have a slightly higher risk, and whites, or people of European ancestry, have twice the risk of the Chinese. South Asians, which includes Indians, Pakistanis, Bangladeshis and Sri Lankans, have three times the risk of the Chinese.

"So there's a three-fold disparity in the commonest cause of death," Bhopal said. "If we are delivering a service for the prevention and control and management of heart disease, that service has to be tailored to meet the needs of the South Asian population who have the highest risks."

Ontario researchers made similar comments in the March issue of the Canadian Medical Association Journal in their study of more than 500 South Asians and the same number of non-South Asians who were treated for heart attacks. The death rate from coronary artery disease is higher among Canadian South Asians, despite their lower body mass index, lower cholesterol levels and a greater tendency to be non-smokers than their counterparts. However, South Asians were more likely to have diabetes.

"Limited data are available for the South Asian population in Canada, although it is encouraging to note the recent emergence of ethnicity-based research in this country," the researchers wrote. They added that "public health efforts should be focused on increasing the awareness of symptoms of acute [heart attack] in South Asian communities, as has been done for Canadians of non-South Asian origin."

American studies have also found an elevated heart disease risk among South Asians.

If South Asians are grouped within the large Asian category with the Chinese, which wouldn't be unusual in medical research, their true risk of heart disease may be missed.

"That will indicate that Asians have heart disease rates that are probably lower than the white population, whereas the truth is some populations within that category have got very much lower rates and some have got very much higher rates," Bhopal explained. "Your Asian category in the states is hopeless."

Categorizing people by race can still be valuable, argue other researchers. Dr. Neil Risch, a population geneticist at Stanford University, said in the online journal Genome Biology that people likely inherit slightly different versions of the same gene depending upon which continent their origins lie, and racial categories based on those geographic and genetic distinctions could help identify variation in disease risks and treatment.

"I very firmly believe that race needs to be a part of our public health surveillance data," said Stephen Thomas, director of the Center for Minority Health at Pitt's Graduate School of Public Health. "To remove race as a variable in our data blinds us to the many ways in which racism still operates."

In a July 2001 article for the American Journal of Public Health, Thomas argued that collecting race-specific information allows identification and monitoring of health disparities. Ethnicity classification, on the other hand, could lead to what he called "victim blaming," in which a person's ill health is attributed to ingrained, unchangeable cultural practices.

"To focus exclusively on ethnicity moves away from the political and economic factors that are more central when the focus is on race," Thomas wrote. "It is in this latter 'political' context that the field of public health makes its unique contribution to improving the health and longevity of all Americans, especially the most vulnerable segments of our society."

He advocated use of the transition term "race/ethnicity" to acknowledge the history and legacy of racial classifications while incorporating the unique cultural factors, health beliefs and lifestyle issues reflected by ethnicity.

"Improving health status and eliminating health disparities has less to do with biology than with the social changes that need to take place," Thomas said.

Bhopal, who wrote a letter responding to Thomas's comments in a subsequent issue of the public health journal, agreed that race is a valid representation of sociological phenomena, and thus becomes more like what is meant by ethnicity, but it is not a good marker for biological differences. And, he added, ethnicity itself can only go so far.

"Now what we're learning here [in the U.K.] is that Indians are very different from Bangladeshis and Pakistanis," Bhopal said.