7/28/2017

Race and

Jonathan Jimenez, MD, MPH Mansi Shah, MD

Objectives What is ? • Is there a genetic • What are the basis for race? implications for us as • Why do health family physicians? disparities often exist • Further develop social along racial lines? and political understandings of race.

What is race? What is race? • Virginia legal “Race is indeed a pre-eminently socio-historical definitions of race concept. Racial categories and the meaning of change between 1705 race are given concrete expression by the and 1924 specific social relations and historical context in • Racial definitions in which they are embedded. Racial meanings , Brazil, have varied tremendously over time and South Africa – all between different societies.” different - Michael Omi and Howard Winant

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Is there a biologic basis for race?

Carl Linnaeus - Systema Naturae, 1735-1778

Georges Cuvier - History of the Natural Sciences (1829-1832)

Johann Friedrich Blumenbach – On the Natural Varieties of Mankind (1795)

Craniometry: Samuel Morton, MD PNAS (1849) Thomas Murrell, MD “Syphilis and the American Negro.” JAMA, 1910

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Seale Harris, MD “Tuberclosis and the Is there a biologic basis for Negro.” JAMA, 1903. race? • July 8, 1950: UNESCO • 1951: revised statement: “Statement on Race” “it is possible, though not declared that race “is proved, that some types not so much a of innate capacity for biological phenomenon intellectual and as a social myth.” emotional response are commoner in one human group than another.”

Is there a genetic basis for race? Is there a genetic basis for race? • , • 1990 1960s: 85% of all Project genetic variation is • 1998 Celera between two people Genomics in a local population • June 26, 2000: human species cannot be divided into Getty Images biological races

Is there a genetic basis for race? • Human species • 0.1% of genetic cannot be divided into difference is biological races meaningful but not • Humans are 99.9% organized by race genetically identical Clinal variation in genetic difference: Genetic differences are characterized by gradual changes across geographic regions, not sharp, categorical distinctions (races)

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The search for genetic variation The search for genetic variation

• Structure: program that divides sampled individuals into a pre- • Rosenberg, et. al 2002: DNA from 1,056 individuals defined number of clusters based on genetic sequences representing 52 global populations used Structure to identify 5 • Rosenberg, et. al 2002: used Structure to analyze DNA from main genetic clusters 1,056 individuals representing 52 global populations and – Structure makes computational guesses according to an arbitrary identified 5 main genetic clusters number of genetic clusters pre-determined by the computer user: analysis setting the range at 6-20 clusters showed multiple ways to – 5 genetic clusters corresponding to major geographic regions: Africa, divide the sampled individuals Eurasia, East Asia, Oceania, America – Within-group variation (93-95% of genetic variability) > between-group variation (5% of genetic variability

The search for genetic variation The search for genetic variation

• “Genetic differences among human populations derive mainly from gradations in frequencies rather than from distinctive ‘diagnostic’ genotypes.” – Rosenberg, et. al

What about geography? What about ancestry? • Can humans be naturally organized into definable, genetically • The statistical analysis of genomic science (differences in cohesive populations? frequencies) translates poorly to describing the ancestry of a • Geographic boundary lines are political, not drawn by natural single individual (absolute genetic distinctions between barriers, and do not correlate to genetic variation frequencies. groups). • The idea of continental populations as natural groupings is grounded in the concept of populations as natural, isolated, and static.

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If not biology, what is race? What is race? • There are no biological races in the human species. • Our understandings of race are constantly formed and re-formed by • Race must be a political category. legal, economic, cultural, educational, and medical institutions – From slavery to Jim Crow to mass incarceration • “Race is a political system that will not be brought down with – Citizenship cases: Ah Yup, Bhagat Singh Thind, Takao Ozawa scientific evidence alone. Race persists neither because it is – Cultural representation and stereotypes, from minstrel shows to Hollywood to the scientifically valid nor because its invalidity remains to be music industry – GI bill, Federal Housing Authority and redlining proven. Race persists because it continues to be politically – Immigration laws: Chinese immigration act, Asiatic barred zones, 1965 useful.” immigration laws – Dorothy Roberts, Fatal Invention – Post-9/11 Islamophobia and surveillance of Muslim communities – The model minority myth

Sickle cell allele prevalence and malaria Why do we care endemicity

Only 99.5% of African Americans have .

SCD is common in other tropijcal regions.

How do we understand racial If there are no biological differences health disparities? between races, how do we explain racial • We need to understand diseases in their social contexts, as disparities in health outcomes? politically produced diseases, and use social and political interventions to improve health outcomes.

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Racial health disparities Social policy improves health

• MI outcomes • Allostatic load outcomes • Breast cancer disparities • Epigenetics • Preterm delivery and • Stress exposure in utero • Creation of Medicaid and Medicare preterm birth • War on Poverty • Sickle cell disease • Civil Rights Act of 1964 • Court-ordered school desegregation

What do we do now? • Intrapersonal • Institutional – Implicit bias training – Start centering pregnancy • Interpersonal groups – Teach medical students this – Representation matters! material – race is not • Structural biological – Teach organizing skills – Stop assuming race, ask – Advocate for social safety patients what they identify Q&A net – Think critically about – Talk to your elected officials whether race modifiers are relevant – Learn medical Spanish

• Identify strategic goals “An appropriate strategy should have as its starting point the defeasible presumption that blacks and whites are at your home biologically the same with respect to disease and institution. treatment. Presumptions can be overturned, of course, and the strategy should recognize the possibility that biological • Who are potential difference in some contexts are possible. But the Action steps allies, opposition, or presumption of equality acknowledges that historically the unknown? greatest harm has come from the willingness to impute biological differences rather than the willingness to • Under what condition overlook them.” might the decision makers change make – Patricia King, The Dangers of Difference, 1992 the difference?

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Let your voice be heard! Acknowledgements Evaluate workshops on the NC app • Roberts, Dorothy. Fatal Invention: How Science, Politics, and Big Business Re-Create Race in the Twenty-First Century. New York: The New Press, 2011. • Fields, Karen and Barbara Fields. Racecraft: The Soul of Inequality in American Life. Verso, 2014. • Omi, Michael and Howard Winant. Racial Formation in the United States: From the 1960s to the 1990s. Routledge, 1994.

• Thanks to: Viviana Martinez-Bianchi, Duke Family Medicine, and the AAFP!

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