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Diary of a Mad Law Professor

Racial Prescriptions

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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."

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