Germs Are Bad Enough; Is Social Injustice Enough to Make You Sick?

Wall Street Journal, January 17, 2001

By Scott Gottlieb

IN THE EARLY 1990s, some influential doctors touted experimental bone-marrow transplants as a breakthrough cure for breast cancer. But many ill women couldn’t get one. Insurance companies refused to pay.

Women’s groups cried foul, of course, including the National Organization for Women, which saw such a refusal as evidence of sexual discrimination. Many insurers relented, exploding the number of transplants performed, although no rigorous studies had yet shown whether the $150,000 procedure really worked. Luckily, some other insurers helped fund four large trials for exactly that purpose. When the trials were done, it turned out that the transplants were probably killing more women than they cured.

Doctors in training are taught “evidence-based medicine.” But in the case of such bone-marrow transplants and other procedures these days, the best medical evidence may collide with social goals and ideological expectations. And when it does, accusations of racial and sexual bias are never far behind. This is hardly surprising, argues Sally Satel in “PC, M.D.,” her excellent study of medicine and society. It is now our culture’s habit to presume that racial and sexual discrimination lies beneath the surface of nearly every aspect of American life.

Dr. Satel, a practicing psychiatrist, draws on her own clinical experience and public controversies to describe how activists are pursuing (supposedly) better health through social justice. And she shows how this dubious practice—defended in the academy by the “social production theory” of disease—is muddling doctors’ ability to deliver good medical care.

An example? A celebrated study published last year in the New England Journal of Medicine found differences in the treatment of lung cancer between black and white patients. Black patients were less likely to undergo curative surgery and to survive their illness. A sensible person might wonder: Are black patients more likely to have aggressive cancers, or do they “present late,” showing evidence of disease after cancer has already metastasized?

These are first-order medical questions, but the authors of the study did not answer them, offering only invidious innuendo. That didn’t sto

countless others who read the study, including the president of the National Medical Association, an organization of black doctors, from charging racial bias among doctors.

Another widely reported study—published in the same journal—looked at the number of black patients undergoing cardiac catheterization, discovering that black patients were 40% less likely to be referred for it than white counterparts. This “finding,” too, caused an enormous commotion. But the journal ended up retracting the study’s main conclusion six months later, due to a misleading use of statistics in the study, an event virtually ignored by the mainstream media.

A large share of the blame for this climate of accusation, Dr. Satel believes, rests with public-health officials, who allow ideology to infect their interpretation of illness and its causes, blaming large social forces and ignoring the particulars of conduct and environment. In my clinic, located in Spanish Harlem, black patients are more likely to follow dietary habits that promote diseases such as hypertension and diabetes. Unprotected sex is common in the inner city, too, where fear of AIDS infection is muted by the mistaken belief that it is a “gay disease.”

But the public-health crowd often ignores these kinds of unpopular truths, substituting social goals such as income redistribution and affirmative action for bona fide health prescriptions. As a result, the most practical measures for fighting disease are ignored, if not actively avoided. “Indoctrinologists who want nothing less than revolution in the name of health,” writes Dr. Satel, “have been quick to condemn practical hygiene efforts as dangerous social intrusion.” Little wonder that the official theme of a recent annual meeting of the American Public Health Association was “Empowering the Disadvantaged: Social Justice in Public Health.”

Lost in the din of identity politics are real differences, among groups, in the incidence of illness and response to therapy. For example, certain types of new and expensive anti-hypertension medications called ACE inhibitors don’t work as well in black patients as diuretics, an old and cheap alternative. Doctors routinely start black patients on the older drugs, not because they’re cheaper but because they work better. Where others find racial bias, doctors see good medicine.

It is appalling that such sound logic may one day be subject to an ideological assault. But in the current climate of politicized thinking, it is all too possible. Thank goodness that Dr. Satel brings more scientific precision and moral rigor to the treatment of her subject than some doctors and public-health officials bring to the treatment of their patients.

Dr. Gottlieb is a resident in Internal Medicine at the Mount Sinai Hospital in New York and a staff writer for the British Medical Journal.