Addressing Undergraduate Content on Race and Healthcare
Turns out “23 and me” is a scam because ethnicity cannot be tested by DNA! (Just kidding)
I had a professor say that group differences in health outcomes are not due to genetics because race is a social construct. This is false and purely an ideological assertion that is scientifically unacceptable.
White People (European Ancestry)
When you talk about race, you have to say bad things about white people or you get in trouble. The most obvious ones are skin cancer and sun burns, but I will not be going into that.
Type 1 Diabetes
Type 1 diabetes is generally estimated to be around 50% heritable. Of that 50% heritability, around 80% of it (so 40% of the phenotypic variation) can be attributed to specific gene loci on the MHC gene complex. MHC stands for major histocompatibility complex, and I do not want to go into all of that but basically we found the genes. That’s all you need to know. I am sure you do not really care bout the major histocompatibility complex.
Atrial Fibrillation
Atrial fibrillation is a type of arrhythmia (abnormal heartbeat), it means an accelerated and unnatural heart beat. This is caused by misfiring of electrical impulses. While atrial fibrillation is not in the same realm as myocardial infarction (heart attack) for immediate health risk, it still does carry significant risks. A Korean study (Lee et al., 2018) found a death rate of patients with atrial fibrillation to be nearly 3.7 times higher than the general population.
Two quotes from a 2013 cohort analysis (Dewland et al., 2013) that found white Americans having a higher instance of are “The heightened AF risk among whites is most pronounced in the absence of cardiovascular comorbidities.” and “Factors that contribute to the elevated AF risk in whites are not well understood, but may include genetic effects or environmental exposures related to race.” One member of the team, Gregory Marcus, MD., stated “We found that consistently, every other race had a statistically significant lower risk of atrial fibrillation compared to whites… So this suggests that white race is itself a risk factor for atrial fibrillation.”
I think that it is probably genetic. I do not believe that the material conditions faced by white Americans would cause this in the same way socioeconomic conditions can be linked to higher rates of chronic conditions in other groups. Maybe drinking too much coffee, but even that would probably have some level of behavioral genetic component. This is not a serious explanation, in fact it takes a very large amount of caffeine to cause arrhythmia.
Cystic fibrosis
Honestly, most people know about CF. Cystic fibrosis is a monogenic genetic disease that impacts the lungs, digestive system, and reproductive system by causing excessive mucus linings. Fatal infections can occur. Here are the racial demographics of cystic fibrosis cases. Even with the minority group rates of cystic fibrosis, there is a clear correlation with European Admixture and the prevalence. I will bet anyone reading this that if you did blood quantum test on the CF patients who aren’t caucasian, they will have a greater % caucasian admixture than the average in their respective populations.
White is Heterogenous
A subgroup that is phenotypically white (think Bernie Sanders, Albert Einstein, Zac Effron, Scarlett Johansson, etc.), but genetically has unique characteristics is the Ashkenazi Jewish population. Ashkenazim frequently will see genetic counselors before having children due to a variety of genetic diseases being fairly common in the population. There is some expert disagreement on if these dieseases came to be more common as a result of bottlenecking, inbreeding, or a combination of both, but the cause is really of no relevance. Gaucher’s disease, Tay Sach’s, Niemann-Pick, Mucolipidosis IV, Bloom Syndrome, Fanconi Anemia, Canavan, Cystinuria, glycogen storage disease type VII, amongst many others are genetically linked to Ashkenazim. Social construct or not, there is a reality of group differences in health risks that we should have a healthy discussion about and seek to address each groups specific needs instead of scapegoating societal racism.
Obesity
BMI is meant to be a proxy measure to find body fat %, but there is error based on race. To deny that there are undeniably fewer fat black people in this country than the CDC says. I say error and not bias because it was not created with the intention of oppressing anyone and still has very strong validity for the general population — I even wrote in defense of BMI. The quick solution is to check the RFMI of anyone before increasing their insurance rates, which would help African Americans and Hispanics the most, and some say medicare for all totally eliminates the risk of measurement errors raising premiums. It has also been observed that in reproductive aged women, the body fat distribution is not equal across different groups. This raises more questions than answers, as trunk fat is linked to reproductive complications (and black women are more likely to have reproductive complications).
Type 2 Diabetes
For African Americans, there is a clear gradient in diabetes risk based on ancestry profile. Here it is correlated that % African ancestry is positively correlated with diabetes, even with confounds being controlled. I would go as far as to say that the decreased risk is due to % European ancestry (or maybe Asian for the small % with Asian admixture), because Latino Ancestry (which is part European) also often comes with risks for diabetes.
Knowing that the median African American is around 17.5% European, it is a not small that they found, “pooling the three cohorts together, the median percentage of African ancestry of diabetic participants was 1.6% greater than that of non-diabetic participants.” because that basically means they have around 10% more non African admixture. Had the researchers used a measure like RFMI or body fat % instead of BMI, the correlation would be stronger in my opinion. There are also specific parts of the genome linked. The real tragedy is that people have not done enough for diabetes compared to the level research for other diseases.
On Latinos and Type 2 Diabetes
“T2D is particularly prevalent in Latin Americans (14.4%, twice as high as for non-Hispanic whites in the US), where it is one of the leading causes of death (2, 3). While different environmental and lifestyle risk factors in Latin America partially explain the increased prevalence of T2D, unique genetic influences also contribute (4, 5).” Mercader and Flores, 2017
And particularly in the Mexican Population
“Here we analysed 9.2 million single nucleotide polymorphisms (SNPs) in each of 8,214 Mexicans and other Latin Americans: 3,848 with type 2 diabetes and 4,366 non-diabetic controls. In addition to replicating previous findings2,3,4, we identified a novel locus associated with type 2 diabetes at genome-wide significance spanning the solute carriers SLC16A11 and SLC16A13 (P = 3.9 × 10−13; odds ratio (OR) = 1.29). The association was stronger in younger, leaner people with type 2 diabetes, and replicated in independent samples (P = 1.1 × 10−4; OR = 1.20).” Williams, A., Jacobs, S., Moreno-Macías, H. et al., 2013
Pulmonary Health
For respiratory issues, it has been known forever that there are group differences in respiratory capacity. At one point it was used to argue for white supremacy (pretty terrible argument to base your superiority on this).
Tyrone Ceasar and Gary Hunter have made models that suggest how these trivial group differences may have long term impacts on health. More complex models that consider the behavioral impact of muscle fibers that are more quickly fatigued are also being explored. The cries of environmental racism are absurd. The methodology of data collection changed, not the amount of asthma.
Blood Pressure
There is overwhelming evidence that there are group differences in % of individuals with high levels of sodium sensitivity. Here is an extended quotation from Williams et al., 2014:
Several genetic variations (e.g., promoter region variants of the ATG gene) have been identified which may contribute to ethnic disparities in salt-sensitive hypertension and response to RAS blockade. Tiago et al[63] reported a marked influence of homozygosity for the -20A allele (n = 399) of the ATG on the relationship between body mass index and systolic blood pressure (r = 0.23; P < 0.0001) in over 1000 South Africans of African ancestry. More specific to the response to RAS inhibition, the African-American Study of Kidney Disease and Hypertension (AASK) study showed that African Americans who were homozygous for the ACE polymorphism 12269G > A experienced a more rapid reduction in blood pressure following ACE inhibition than those who were heterozygous for this variant (P < 0.001), but blood pressure response to calcium channel blockers did not vary by ACE polymorphism variants[64]. Similarly, ATG promoter region variants among a cohort of South Africans of African ancestry influenced the blood pressure response to an Angiotensin converting enzyme inhibitor (ACEI), but not to a calcium channel blocker[65]. Recent genome-wide admixture mapping studies have demonstrated genetic variation in the regions of MYH9 and APOL 1 on chromosome 22 that have been estimated to explain over 50% of the difference in the rates of non-diabetic end-stage renal disease (ESRD) between white and black Americans[13,66–69], but to date no reports have linked these gene variants to response to RAS inhibition therapy. Limited data exist for the study of ACE polymorphism variants in animal models of high BP.
One hypothesis is that the middle passage naturally selected for those that could retain sodium more easily. This is an incredibly sad possibility, but I do not see a serious reason why it would not be true to at least some capacity. The counterarguments generally make the false equivalency of the middle passage to the conditions of white Europeans coming to America.
I view the middle passage explanation as intellectually insufficient for 3 main reasons:
- Salt was always scarce in Africa before the Atlantic Slave Trade
- The climate in Africa had been selective for water and sodium retention for a long time
- Many people were dying on these ships from infectious diseases, so some level of selection against the highest levels of sodium sensitivity and retention most likely occurred as hypertension is often associated with an increased fatality rate for various infectious diseases.
Race Differences in Health Behaviors
Yeah, I do health science and biology, yeah, I plan on working for a health department, nope… I am not convinced that interventions work.
Soda Consumption
As much as people want to whine and complain about the chemicals of diet drinks, they are not as bad as full sugar drinks. If there are long term impacts of these diet drinks, then non-white people are in luck. I am pretty skeptical that they can be any worse than a full sugar soda.
Fast Food Consumption
Next we have fast food consumption — obviously, fast food is heterogenous, but it is generally bad for you. Even places like freshens that try to operate under the guise of nutrition are often very unhealthy. I have read that African Americans have more access to fast food. This is likely an artifact of consumer preference. I do not believe in food deserts.
Smoking
By smoking, I am referring to tobacco. I think that the menthol, black & mild stuff, backwoods, etc. is predatory and disgusting advertising that does target African Americans. Shannon Sharpe is one of the funniest people on television, but it is awful that he goes that go on TV laughing about smoking “milds” from time to time. The rate of tobacco use in multiracial Americans is particularly disturbing.
Sleep
From 2007–2010, there were massive differences in sleep between some groups. I do not know how much I sleep personally. I would like to see if the there is truth to this. If there is, this would explain a lot.
Physical Inactivity
I believe that there is a gender gap in physical inactivity for African Americans, I know that there is one for the obesity rate. There is much to be explored here. I have found it to be unlikely that building new parks and stuff actually works based on my experience with CDC data, but who knows.
Inbreeding and Migration Policy
Different populations have had different levels of inbreeding historically due to different culture. My unapologetic view is that I will not consider it as part of the multicultural cornucopia that provides cultural enrichment to America. This is not to say that we should assume everyone with roots back to this part of the world has inbred parents, or to stigmatize people’s heritage — people are not defined by national origin, they are defined by their unique attributes. When we are talking about mass migration policy, however, we have to talk in terms of generalities unless we want people to submit their DNA before trying to immigrate.
It was found that around half of the Syrian refugee families interviewed in Lebanon were in consanguineous marriages, the majority was aware of genetic screening, and just did not care (Sabeh et al., 2020). It has also been observed that the initial rates of consanguinity are very high in the initial years of resettlement* in England.
Being said, it has been observed that there are a lot of health issues linked to inbreeding. This is not surprising, as there is a causal relationship between increasing the inbreeding coefficient and increasing the mutational load. Childhood diastolic, systolic, and arterial blood pressure are positively correlated with inbreeding coefficients (Afzal, 1999). I am talking about a lot of different health issues, not just two or three. Here is a link to 752 genetic conditions in that Middle East — many of them are not confined to the region, but they tend to be more common there (take odds ratios with a pinch of salt for some diseases), and some are indeed monogenic as well as dominant. In the chart below, there is not a significant difference in presence of coronary heart disease — some of the more common ones are not really correlated with inbreeding, but there are a few of the more rare ones that are. These can include tetralogy of Fallot, valvar aortic stenosis, and atrial septal defect.
One impact of inbreeding is the increased risk of mental retardation (developmental cognitive impairment). Inbred people are about 5 times more likely to be cognitively impaired (Morton, 1978). A study of the Muslims in the Jammu region of India revealed that the full scale IQ average for non-inbred children was an average of 96.5, much higher than the inbred children who were only about a 72 on average (Fareed, Afzal, 2014). This gap is larger than a standard deviation, but I would assume that to some degree, the lower SES, the more likely inbreeding is. That would explain some of the difference — but it isn’t realistic to say that way would that explain the totality of the gap between near average in first world nations and being border line of mentally retarded (there are many criteria for diagnosing retardation, not just IQ). When quantifying the number of people our nation can bring in as refugees, IQ may be the best predictor of per capita fiscal impact (even if it is not perfect), where in the labor market they are going to compete,
Shaw A . 2009. Negotiating risk: British Pakistani experiences of genetics. New York: Berghahn books.
