A recent front-page story in the Boston Globe proclaimed that New England leads the nation in Ritalin prescription levels. Somewhat to my surprise, the prevalence of Ritalin ingestion was generally hailed as a good thing–as indeed it may be in cases of children with ADHD. But to me the most startling aspect of the Globe‘s analysis was the seeming embrace in many places of Ritalin as a “performance enhancer.” Prescription rates are highest in wealthy suburbs.
While the reasons for such a statistical skewing need more exploration than this article revealed, what I found particularly interesting was the speculation that New Englanders have a greater investment in academic achievement: “‘Our income is higher than in other states, and we value education,’ said Gene E. Harkless, director of the family nurse-practitioner program at the University of New Hampshire. ‘We have families that are seeking above-average children.'”
Aren’t we all. (And by “all,” I mean all–wouldn’t it be nice if everyone understood that those decades of lawsuits over affirmative action and school integration meant that poor and inner-city families also “value education” and are “seeking above- average children”?) But Ritalin, after all, works on the body as the pharmacological equivalent of cocaine or amphetamines. It does seem a little ironic that poor inner-city African-Americans, who from time to time do tend to get a little down about the mouth despite the joys of welfare reform, are so much more likely than richer suburban whites to be incarcerated for self-medicating with home-brewed, nonprescription cocaine derivatives. If in white neighborhoods Ritalin is being prescribed as a psychological “fix” no different from reading glasses or hearing aids, it’s no wonder the property values are higher. Clearly the way up for ghettos is to sweep those drugs off the street and into the hands of drug companies that can scientifically ladle the stuff into underprivileged young black children. I’ll bet that within a single generation, the number of African-Americans taking Ritalin–to say nothing of Prozac and Viagra–will equal rates among whites. Income and property values will rise accordingly. Dopamine for the masses!
Another potential reason for the disparity is, of course, the matter of access to medical care. Prescriptions for just about anything are likely to be higher where people can afford to see doctors on a regular basis–or where access to doctors is relatively greater: New England has one of the highest concentrations of doctors in the country. But access isn’t everything. Dr. Sally Satel, a fellow at the American Enterprise Institute, says that when she prescribes Prozac to her lucky African-American patients, “I start at a lower dose, 5 or 10 milligrams instead of the usual 10-to-20-milligram dose” because “blacks metabolize antidepressants more slowly than Caucasians and Asians.” Her bottom line is that the practice of medicine should not be “colorblind” and that race is a rough guide to “the reality” of biological differences. Indeed, her book, PC, M.D.: How Political Correctness Is Corrupting Medicine, is filled with broad assertions like “Asians tend to have a greater sensitivity to narcotics” and “Caucasians are far more likely to carry the gene mutations that cause multiple sclerosis and cystic fibrosis.” Unfortunately for her patients, Dr. Satel confuses a shifting political designation with a biological one. Take, for example, her statement that “many human genetic variations tend to cluster by racial groups–that is, by people whose ancestors came from a particular geographic region.” But what we call race does not reflect geographic ancestry with any kind of medical accuracy. While “black” or “white” may have sociological, economic and political consequence as reflected in how someone “looks” in the job market or “appears” while driving or “seems” when trying to rent an apartment, race is not a biological category. Color may have very real social significance, in other words, but it is not the same as demographic epidemiology.
It is one thing to acknowledge that people from certain regions of Central Europe may have a predisposition to Tay-Sachs, particularly Ashkenazi (but not Sephardic or Middle Eastern) Jews. This is a reality that reflects extended kinship resulting from geographic or social isolation, not racial difference. It reflects a difference at the mitochondrial level, yes, but certainly not a difference that can be detected by looking at someone when they come into the examining room. For that matter, the very term “Caucasian”–at least as Americans use it, i.e., to mean “white”–is ridiculously unscientific. Any given one of Dr. Satel’s “Asian” patients could probably more reliably claim affinity with the peoples of the Caucasus mountains than the English-, Irish- and Scandinavian-descended population of which the gene pool of “white” Americans is largely composed. In any event, a group’s predisposition to a given disease or lack of it can mislead in making individual diagnoses–as a black friend of mine found out to his detriment when his doctor put off doing a biopsy on a mole because “blacks aren’t prone to skin cancer.”
To be fair, Dr. Satel admits that “a black American may have dark skin–but her genes may well be a complex mix of ancestors from West Africa, Europe and Asia.” Still, she insists that racial profiling is of use because “an imprecise clue is better than no clue at all.” But let us consider a parallel truth: A white American may have light skin, but her genes may well be a complex mix of ancestors from West Africa, Europe and Asia. Given the complexly libidinous history of the United States of America, I worry that unless doctors take the time to talk to their patients, to ask, to develop nuanced family histories or, if circumstances warrant, to perform detailed genomic analyses, it would be safer if they assumed that, as a matter of fact, they haven’t a clue.
We live in a world where race is so buried in our language and habits of thought that unconscious prejudgments too easily channel us into empirical inconsistency; it is time we ceased allowing anyone, even scientists, to rationalize that consistent inconsistency as “difference.”