Peer-to-Peer Interview with Andrea Deyrup: Part 2

Find part one of Ivan Damjanov’s interview with Andrea Deyrup here.

You previously mentioned your work in combating race-based medicine – could you explain where this interest began?
 

As a medical student at the University of Chicago, I learned about race-based associations from Robbins Pathologic Basis of Disease. When a colleague at Duke suggested removing race and ethnicity from our teaching materials, I initially resisted. He argued that including these terms reinforced the concept of biological race, while I had been taught that race-related data were helpful for diagnosing and providing patient care. It was difficult to change my perspective; however, as I researched more, I realized that these racial associations were not only problematic but harmful.

In February 2020, a Duke medical student questioned the link between hypertension and race. Although our curriculum emphasizes that race shouldn't be used as a proxy in healthcare, the week's Robbins reading contradicted this. After discussing the issue with students, I knew I needed to review our pathology content to ensure we weren't spreading misinformation.

What were your first steps when looking into this issue?
 

The first thing I did was search the electronic text using terms like “African”, “Asian”, “Hispanic”, and “Caucasian”. I was surprised by how many diseases were linked to race – more than 35! I wanted to understand the context of these associations and determine the validity of the science, which led to a deep dive into the literature, generating a document of about 90 pages with figures and references. I call this the Deyrup Disparities Document.

My goal was to provide my Duke medical students with accurate information concerning racialized medicine, but also to generate the necessary data to address race-based medicine as one of the editors of the 11^th edition of Robbins Basic Pathology. Dr Vinay Kumar invited me to join the editorial team in the fall of 2019 and I accepted with the condition that we address the problem of race-based medicine. I knew that this would be a difficult challenge and I needed data to convince the other editors of the importance and scientific validity of these changes.

From here, I looked for an expert to help clarify the science. Although I had a background in evolutionary biology from my undergraduate degree at Princeton, we needed an expert in the science of human biological variation and the history of race in medicine. I was quite fortunate that Dr Joseph L Graves Jr, an African American evolutionary biologist from North Carolina Agricultural and Technical State University, was interested in the project. Together, we worked through the text and made recommendations to the other editors based on the data we accumulated and Dr Graves’ expertise in this area.

This was the first time that a medical textbook was edited with a specific focus on evaluating the appropriate use of race and ethnicity. It wasn’t easy. The field of medicine is decades behind what is well understood by evolutionary biologists and biological anthropologists: biological races simply do not exist in our species. Unfortunately, the medical literature is replete with data that seem to support biological races and there was a lot of pushback against our recommendations. While most of our suggestions were implemented, many were not. Often the discussions became quite heated. After the publication of the 11^th edition, I decided that I no longer wanted to continue as a member of the Robbins editorial team.

Since early 2021, you’ve given more than 70 invited lectures on racism in medicine across the US – why do you think our colleagues are interested in this topic?
 

I partner with Dr Graves for nearly all these talks, giving a good one-two punch of medicine and basic science. Most of our talks have been to departments of pathology, though we’ve also spoken to departments of dermatology, pediatrics, family medicine, neurology, ophthalmology, radiology, critical care, internal medicine, and radiation oncology. Interestingly, we have never been invited by a department of surgery. As part of our advocacy work, we also met with the National Board of Medical Examiners, the National Board of Osteopathic Medical Examiners, the American Board of Pathology, and the College of American Pathology. Clearly, this isn’t a topic solely of interest to pathologists, though I do think that pathologists should be at the forefront of this discussion. We, more than any other specialty, focus on the pathogenesis and pathophysiology of disease. Who better to demonstrate that the emperor has no clothes?

These invitations have come through word of mouth or from people reaching out after hearing the NPR Code Switch podcast or reading one of our articles. I think our presentation is very accessible and objective with a data-driven approach. We provide background information on the biology of human variation that should be part of every medical school curriculum and work through how so much misinformation entered the scientific literature.

Many attendees have expressed a feeling of relief after our talks: “I always knew there was something wrong with what we were teaching, but I didn’t understand exactly what,” and “This changes everything about the way we need to teach medicine.” Comments like these reinforce the validity and importance of this teaching and give some insights into why our talks are so popular. In addition, trainees have reached out to let me know how validating it is for them to see an attending take on race-based medicine. Younger generations are very focused on equity and justice, but often feel that they are not supported in this work. The Accreditation Council for Graduate Medical Education (ACGME) recognizes the importance of DEI issues in the curriculum and requires competency in cultural humility and the ability to work with diverse populations. We are grateful for the strong role of the ACGME and trainees in amplifying this work.

The title you often use for your lectures is, “(Nearly) everything you learned about race in medicine is wrong!” Could you give some examples?
 

While there are numerous examples that I cover in my disparities document, it is not so much these individual diseases that are the problem but the overall approach to race in medicine. When we racialize medicine, we support the belief that race is a biological category and that disparities in incidence or prognosis can be explained away by an individual’s genetic background. This belief is incredibly widespread and deeply ingrained in our profession. In fact, one of the Robbins editors told me quite bluntly that Dr Graves and I were wrong in stating that humans do not have biological races. When one considers that Robbins is the most widely used textbook worldwide for pathology education, I think you get a sense of how important it was for us to address race-based medicine in the book. In fact, a physician who trained in a Taiwanese medical school told me that everything she learned about race, she learned from Robbins! In the 11^th edition, we are quite explicit that humans do not have biological races and we explain why.

When we make these racial associations with disease, it becomes easy to blame the patient for their illness and to believe that they are genetically deficient, have risky habits, or are non adherent with medical recommendations. This lets us, as a society, off the hook in addressing the social determinants of health that cause these health disparities. For example, there has been a lot of work looking for a genetic basis for asthma in African Americans and Latin Americans in the US. We know that formerly redlined neighborhoods, where many African Americans and Latin Americans still live, have increased levels of ultrafine particulate matter – a cause of pulmonary disease (1). If we blame asthma on the patients’ biology, then we don’t need to clean up these areas and protect public health.

Another racialized association is the link between diabetes and Native American ancestry. The 10^th edition of Robbins Basic Pathology stated “[T]here is a wide variability in prevalence [of diabetes] between different ethnic groups. For example, the prevalence of diabetes in American Indian/Alaskan Natives is almost twice that of Caucasians.”

The Pima Indians have an extremely high incidence of diabetes and there have been a number of studies trying to tease out the genetic basis in this population. However, an interesting study from 2006 compared rates of diabetes and obesity in two genetically similar cohorts of the Pima (2): one group in southeastern US, the descendants of people who lost their traditional livelihoods and diet due to genocide, and the other group in the Sierra Madre mountains of Mexico, who maintain their traditional livelihoods and diet. The elevated rates of diabetes and obesity were not seen in the Pima of Mexico, despite their genetic similarity to the Pima of Arizona. By focusing on genetics and biology, again we miss the chance to improve the health of the Arizona Pima by addressing the social determinants of health. Furthermore, the categorical association of Native American ancestry with a disease obscures the role of an individual patient’s lifestyle and risk factors.

One of the misleading statements in Robbins that really lit a fire under me was the association of African heritage with keloids. We address keloids in week two of our Duke course when we discuss wound healing. When I began looking at the keloid literature for my disparities document, I wasn’t particularly motivated for a deep dive because, well, everybody knows that keloids are associated with African ancestry, right? Wrong! When one of the editors sent around his chapter for us to review, I recommended that he remove the association between keloids and African descent. He responded with a quote from UpToDate: “Keloids have been reported in 5 to 16 percent of individuals of Hispanic and African ancestry.”

Because of my disparities document, I had the facts: 16 percent came from the non-peer reviewed discussion at a dermatologic meeting in Strasbourg, France… in 1931 (3)! That researcher looked at 1205 adult workers in the Belgian Congo and counted keloids, arriving at a figure of 16 percent. While it might be reasonable to say that among adult workers in the Belgian Congo, keloid frequencies were 16 percent in the early 20th century (largely due to smallpox vaccination scars), one can’t extrapolate to everyone of African descent, particularly considering that there is more genetic diversity in Africa than anywhere else in the world. Interestingly, at that same meeting in 1931, another researcher presented his work looking at keloids in Swiss adults (i.e., of European descent) and found a prevalence of 13.3 percent (4). Perhaps statistically significant but of questionable clinical significance. So why are we quoting this 16 percent figure 90 years later?

What do you hope to accomplish in your activism against race-based medicine?
 

We've already achieved a lot! Revising Robbins & Kumar Basic Pathology was groundbreaking – it’s the first medical textbook to address race-based medicine. Although Dr Graves and I couldn't remove all problematic content due to editorial disagreements, we did eliminate about 80 percent and updated images to show skin lesions across different skin tones. One of the editors of the upcoming 12th edition of Robbins Pathologic Basis of Disease told me that this edition will carry over many of our updates from Robbins & Kumar Basic Pathology. Dr Graves is now working on an Elsevier publication, Anti-Racist Medicine, with two clinicians from the UK, and we continue to give talks at medical schools and national meetings.

As for what’s next, I don’t plan too far ahead and prefer staying flexible to engage with new opportunities. This year, I’ve been invited to speak at Duke University undergraduate courses, and I’ve really enjoyed connecting with the students. I also have a side project looking at how race and ethnicity are used in high-stakes exam questions. It’s a complex study, and I’m hoping to find an enthusiastic collaborator – especially a social psychologist interested in stereotype threat. If you know anyone, send them my way!

What advice do you have for any allies in this combat?
 

I’ll take the term “allies” here to mean people who have enjoyed privilege and want to contribute to the fight against systemic racism in medicine. When the spirit catches and you’re committed to work for justice, it is essential that you begin by doing your own “work”. Which is to say, do the reading, get in touch with your role in perpetuating systemic racism, and hold yourself accountable for what you have and haven’t done. It is not the role of people who have been marginalized to teach us the history, point out the problems, or tell us what we need to do. They’ve got enough on their plates!

Of course, we want to be receptive and open to what is needed; there is no place here for the “white savior”. But we can’t simply wring our hands and expect someone to explain everything to us. I think White Fragility by Robin DiAngelo and Biased by Jennifer Eberhardt are great for opening one’s eyes. I also think that all the books by Dr Graves are outstanding. As we look more closely at race in medicine, Achieving Antiracism in Medical Education by Leona Hess and colleagues offers a great overview and systematic approach. I also really think Fatal Invention by Dr Dorothy Roberts (who was just awarded a MacArthur “genius” grant this year) and Dr Uché Blackstock’s book Legacy are critical in understanding the impact of race in medicine.

And just remember: this is a marathon that many people have been running for centuries. We must commit for the duration, not just dabble in justice work when it serves our career aims or is the hot topic of the month.