Genetic research and reduction of health disparities

Abstract

The purpose of this paper is to evaluate whether genetic research is an adequate means to attain the very worthy goal of eliminating racial and ethnic healthcare inequalities. I argue that, in our present social and political context, even if genetic variation contributes to health disparities, and even if such knowledge allows us to develop new interventions, genetics and genomics research is unlikely to have any significant effect on their elimination or reduction. I explore also the possibility that attention to genetic research as the solution to persistent health inequalities might actually hinder our efforts to improve health status and healthcare outcomes for historically disadvantaged groups.

Keywords:

• genetics
• health disparities
• ethics

Introduction

Since the creation of the Human Genome Project, the growth of genetic science and technologies has been received with great hope. Much of the excitement about the genetic revolution results from its promises of knowing who and what we are, eliminating diseases, furthering health and quality of life for humankind, and giving our children the best possible future. Genetic science and technology also arouses optimism that the knowledge we gain about our biological capacities and limits might allow us to better allocate resources of time, money and intellectual energy. The result would be an improvement not only of ourselves as individuals, but also of our societies. We could have less disease, live longer, healthier lives, increase the number of people reaching their potential, and create more control over the course and content of our lives.

Because the appropriateness of trying to attain these goals seems obvious to most people, much of the discussion about genetic science and technology has focused on risks and benefits. The history of eugenics raises concerns that genetics will be used to support mistaken ideals of perfection or that genetic technologies will further unfair discrimination (Kass 2002). Others fear that the emphasis on an unchangeable genetics will call into question notions of responsibility to others or that the implementation of these new techniques will further disadvantage those who cannot have access to them (Habermas 2003). But others argue that these worries are unwarranted and that the cures that can result from genetic research will benefit humankind. They also make proposals about legislation that would prohibit discrimination for genetic reasons or advise that access to these technologies be made more equitably (Watson 2000, Collins and McKusick 2001).

Little attention, however, is given to the evaluation of the goals that genetic science and technology presumably will help us achieve. Who would deny that gaining knowledge about our biology, improving human health, or trying to ensure the best possible future for our children are laudable goals? But recognizing the worthiness of a goal should not prevent us from reflecting on whether we should pursue it. After all, we might have a variety of equally valuable goals and limited time and resources to fulfill them. We must then evaluate our ends in order to make decisions about which ones to try to reach at a particular moment.

No less important for an evaluation of goals is the issue of whether particular means are appropriate to achieve them. This analysis however, requires that we pay careful attention to the particular social and political context in which those means are used to achieve our goals. Again, this does not require that we doubt the value of the goal. On the contrary, it is precisely because we believe the goal to be worthy of our efforts and resources that we must assess the means to achieve it. For example, if one proposes the use of genetic testing as a way to promote autonomous decision making, we must evaluate whether information about our genetic make up enhances people's autonomy. Moreover, we must also evaluate whether this particular means is the best one, in a given social context, to achieve the desired goal or whether alternative means would be more appropriate.

One of the latest promises arising from the genetic revolution is that genetic science and technology will help us to reduce or eliminate health disparities1 (Olden and White 2005). Indeed, some see genetic science as necessary in order to achieve such ends (Burchard et al. 2003, Collins 2004).

As before, the value of this goal is beyond dispute, and few would argue that we must not devote significant time and resources to accomplish it. In fact, trying to understand the origins of, and alleviate, national and global health inequities has become a central objective of recent health policy initiatives. In 2003, for example, the National Institutes of Health (NIH) budgeted nearly $3 billion to fund initiatives for health disparities research (NIH 2002). In a recent pronouncement, HHS Secretary Mike Leavitt announced the awarding of $56.9 million by the NIH National Center on Minority Health and Health Disparities. The funds will support the advancement of health disparities research and its elimination among racial and ethnic minority and medically underserved communities (NIH 2006).

Until recently, the main hypothesis for the origins of health disparities emphasized social factors such as racial discrimination and poverty that translated into unequal access to education, employment, housing and health services. Nonetheless, with the advent of the genetic revolution, interest in using genetic science and technology as a means to both explain and eliminate, or to reduce, health inequities has increased. Indeed, the purpose of several NIH-funded initiatives is to identify genetic contributions to health disparities (Sankar et al. 2004).

Much of the debate about genetics and health disparities has centered on whether such research will allow us to find genes that determine the susceptibility, prevalence and outcomes of human disease and on the risks and benefits of doing so. The assumption is that if such genetic determinants are found, then genetic research can assist us in reducing or eliminating health disparities. The debate is, thus, a technical one about whether genetic differences underlying health disparities exist and about whether we have the technical capabilities to find them. But little attention is paid to whether, even if such genetic differences exist, our finding them would help to achieve our goal. The assumption is then not just that our ends are acceptable but that the means are appropriate to achieve them.

The purpose of this paper is to evaluate whether genetic research is an adequate means, to attain this very worthy goal. In what follows, I will discuss the ways in which genetic research would presumably help us eliminate racial and ethnic health disparities. I will then review some of the social factors that contribute to such inequalities, with a focus on the status of African-Americans. I then argue that, given our current social and political context, even if genetic variation contributes to health inequalities, and even if such knowledge allows us to develop new interventions, genetics and genomics research is unlikely to have any significant effect on their elimination or reduction. Finally, I explore the possibility that attention to genetic research as the solution to persistent health inequalities might actually hinder our efforts to improve health status and healthcare outcomes for historically disadvantaged groups.

The role of genetics in health disparities

In spite of the improvements in the overall health of the United States, racial and ethnic minorities continue to receive a lower quality of health services and have higher rates of morbidity and mortality than non-minorities.2 According to the Centers for Disease Control and Prevention (CDC), for example, in 2001, the age-adjusted death rate for cancer was 25.4% higher for African-Americans than for white Americans. The infant mortality rate among African-Americans was more than twice the rate for white Americans. In 1999 the age-adjusted death rate for HIV was 32.7 per 100,000 for Puerto Ricans living on the mainland US, higher than any other racial or ethnic group, more than six times the national average and more than 13 times the rate for non-Hispanic whites. In 2001, the syphilis rate among American Indians and Alaska Natives was six times higher than the syphilis rate among the non-Hispanic white population, the Chlamydia rate was 5.5 times higher, and the gonorrhea rate was four times higher (CDC 2004).

Although most researchers agree that social factors, especially poverty, contribute to health inequalities, some of them also believe that it would be a mistake to ignore the role of genetics in the creation of such disparities (Burchard et al. 2003, Collins 2004). In the US, poor health disproportionally affects racial and ethnic minorities. Thus, the increased emphasis on genetic and genomic research as a way to alleviate health inequalities has focused on the association between genes and racial ancestry in order to determine the susceptibility, prevalence and outcomes of human disease. For some researchers, ignoring race and ethnic background would be detrimental to the very populations and persons that current emphasis on eliminating health inequalities seeks to protect (Burchard et al. 2003).

The association of rare Mendelian diseases, such as Tay Sachs and sickle cell anemia, with particular racial or ethnic groups is often used as evidence of the associations between genetic risks and race. This association appears to be further reinforced by recent studies that show genetic variation by race in complex disorders such as Crohn's disease (Basu et al. 2005), the prevalence in Caucasians of factor V Leiden, which is associated with risk of venous thrombosis (Dowling et al. 2003), and the occurrence of endothelial dysfunction and reduced nitric oxide bioavailability in African-Americans (Taylor 2005).

Many researchers believe that understanding genetic variation across populations defined by race or genetic ancestry will assist in the identification, tracking and investigation of the genetic factors that underlie racial and ethnic differences in the prevalence and severity of diseases. It will also help us to determine differences in responses to drugs and other treatments. Moreover, identification of genetic factors that contribute to health disparities will then make possible the development of preventive and therapeutic measures that could address prevailing racial and ethnic health inequalities (Fine et al. 2005). For example, BiDil, a drug for congestive heart failure has been approved as the first “ethnic drug” because interim analyses showed it to be more effective in treating the African-American than the European-American participants (Carson et al. 1999).

Other researchers, however, argue that evidence that genes have a significant influence on complex diseases is scarce and that the distribution of polygenic phenotypes does not suggest that race or ethnicity are useful categories (Cooper et al. 2003). Others maintain that claims about medicines having differences in safety or efficacy among racial or ethnic groups are often unsupported (Tate and Goldstein 2004), or that it is impossible for race to offer the sensitivity and specificity necessary to determine DNA sequence variation to guide preventive or curative measures (Fine et al. 2005). Some believe that current data indicate that susceptibility alleles tend to be old and are shared among many populations (Cooper et al. 2003).

As the terms of the debate suggest, the focus is on a technical and scientific question. The disagreement is about whether genetic determinants for racial and ethnic health disparities exist and whether our current technologies will help us find them. Framed in these terms, the solution to this problem is obviously more research in order to ascertain the role of genetics in human health and disease.

But as important as these questions might be, our attention should be focused on a different one. Given that one of the main purported reasons to pursue this research is that it will assist in the efforts to alleviate racial and ethnic health disparities, we must ask whether the identification of genetic variants will help us to achieve such a goal. In what follows then, I will assume that genetic variation across populations defined by race or genetic ancestry exists and that it contributes to health inequalities. Nonetheless, I argue that, in our present context, genetic research is unlikely to help us attain the end of alleviating disparities in health status and outcomes. Of course, my claims here should not be interpreted as meaning that we should abandon genetic research. There may be good reasons to continue such research. My point here is simply to evaluate whether genetic research can do what some of its proponents claim it will do: contribute to the elimination or reduction of racial health disparities. Because scientific research does not occur in a vacuum, an evaluation of what means are appropriate to achieve a particular goal requires that we pay attention to the social and political context. When we do so in the case of racial health disparities, we realize that absent a significant transformation of our social context, genetic research will do little to contribute to their reduction or elimination.

Social factors contributing to health inequalities

There is considerable evidence indicating that socioeconomic status, racial discrimination, and their consequences play a substantial role in health disparities in the US3 (Sankar et al. 2004). Even those researchers who believe that information about patients' ethnic or racial groups is imperative for the identification, tracking and investigation of the reasons for racial and ethnic health inequalities recognize this much. Research indicates that racial and ethnic disparities in health are the result of both the existence of adverse social determinants that contribute to minorities' poor health and the fact that minorities tend to have less access to adequate healthcare.

Evidence shows that socioeconomic status significantly contributes to these disparities. Poverty rates for minority households are much higher than in the population as a whole. Thus, about 22% of Hispanic families and over 24% of blacks were below the poverty line in 2003. The percentage for non-Hispanic whites was 8.6% (DeNavas-Walt et al. 2005, p. 9). Statistics from the US Census Bureau for 2004 note that the median household income for blacks was $30,134, for Hispanics it was $34,241, while for non-Hispanic whites it was $48,977 (DeNavas-Walt et al. 2005, p. 4). Moreover, minorities have higher levels of unemployment and more often work part time, in service jobs, or in temporary jobs. For example, in early 2005 the unemployment rate for Hispanics was 2.7% higher, and for African-Americans over 6% higher than for non-Hispanic white people (US Department of Labor 2005, p. 2).

Additionally, lower socioeconomic status prevents them from having adequate health benefits. Persons of Hispanic origin and American Indians under 65 years of age are more likely to have no health insurance coverage than are those in other racial and ethnic groups. In 2004, the uninsured rate for blacks was nearly 19.7%, for Hispanics was 32.7%, while for non-Hispanic whites it was 11.3% (DeNavas-Walt et al. 2005).

Apart from a lack of, or insufficient access to, adequate healthcare, a low socioeconomic status also carries risks to health status and health decline over time. Some studies have shown that people with lower income and educational attainment are disproportionally affected by major life events, such as divorce or health problems of close family members, and chronic stressors, such as family problems, financial difficulties and job tensions (Lantz et al. 2005). Moreover, experiences of racial discrimination add greatly to the stressful factors affecting minorities. Such experiences are associated with decreased psychological well-being, and poorer physical and mental health (Cooper 2001, Din-Dzietham et al. 2004, King 2005).

Geographical location, in many cases influenced by socioeconomic status, also seems to contribute to the existence of health disparities. According to some studies, Blacks tend to live in parts of the country that have a disproportionate share of low-quality providers. Within those hospitals, both Whites and Blacks tend to receive low-quality care, but since Blacks are overrepresented in such areas, the quality of the hospital will cause an overstatement of the role that race plays in disparities at the level of the healthcare provider (Baicker et al. 2005). Local differences can significantly affect health outcomes for minority populations. For example, a recent study that analyzed disparities in cardiac revascularization procedures in hospitals from three New York City neighborhoods found that among patients hospitalized with myocardial infarction, the age-adjusted revascularization rates were 29.2% for Whites, 12.5% for Blacks and 19.9% for Hispanics (Fang and Alderman 2003). Moreover, in a recent evaluation of primary care physicians who treated patients enrolled in Medicare, the authors found that Black patients and White patients were treated by different physicians. The physicians treating Black patients were more often not board certified in their primary specialty, and were reported as facing obstacles in gaining access to high-quality services for their patients. The distribution of Black patients among physicians appeared to be largely a result of where Black patients and White patients live (Wheeler 2004).

Of course, geographic location influences not only the access to adequate healthcare, it also affects health status. It is well documented that minorities are more likely than affluent Whites to live and work in the most disadvantaged communities and hazardous environments. For example, 60% of African-Americans in the US live in areas endangered by hazardous waste landfills (Brulle and Pellow 2006). Similarly, an analysis of the US Environmental Protection Agency non-attainment data for national air quality standards found that Latinos and African-Americans were more likely than Whites to live in areas that exceed federal standards for toxic pollutants (Olden and White 2005).

The practices of real estate agents steering people of color into racially segregated neighborhoods, discrimination in lending procedures, and the so-called “White flight” to suburbia restricts minorities in their choice of residence. As a result, many people of color are concentrated in highly segregated communities that are significantly more disadvantaged than those of the White population (Brulle and Pellow 2006). For example, about 68% of urban Black children from low-income families are reported to have lead levels that exceeded safe limits compared with 15% for their more affluent counterparts who were largely White (Olden and White 2005). Toxic wastes, polluting factories and landfills are disproportionally located in such neighborhoods in part because they are more isolated socially and relatively powerless politically (Brulle and Pellow 2006). People living in these areas are at increased risk of cancers and respiratory problems.

Even when minorities do have access to healthcare they still face other problems. Thus a variety of studies have shown that when minorities are in the healthcare system they receive a lower quality of care (IOM 2002, Smedley et al. 2003, Betancourt and Maina 2004). And this is so even when controlling for social determinants and insurance status. For instance, some studies have revealed that African-Americans with coronary syndromes receive less aggressive medical therapy, and are less often referred for cardiac catheterization, percutaneous coronary interventions and bypass surgery than Whites (Peterson et al. 1997, Clark and Lingegowda 2005). Other studies have shown that they receive less surgery treatment than Whites for non small-cell lung cancer (DeShazer 2000), and that when African-Americans, both children and adults, have end-stage renal disease they are less likely to receive cadaveric kidney transplants than Whites (Ayanian et al. 1999, Furth et al. 2000). Further, racial and ethnic disparities in pain assessment and treatment have been found in post-operative and emergency room settings, and across all types of pain from acute, to cancer, to chronic non-malignant pain (Green et al. 2003).

A variety of reasons have been offered to account for racial disparities in treatment such as the existence of cultural and linguistic barriers, and the disproportionate enrollment of minorities in lower-cost health plans that often offer inadequate, and strictly controlled, benefits. Other factors that might influence the inequalities in treatment for a variety of diseases and disorders include physicians' bias or prejudice against minorities, a greater clinical uncertainty when interacting with minority patients, and beliefs or stereotypes about the lifestyle or health of minorities (IOM 2002, Haley 2006).

Using genetic research to alleviate health disparities

Few would deny that the evidence indicating that socioeconomic status and racial discrimination affect minorities' health and healthcare access is compelling. Nonetheless, many still argue that genetics should not be disregarded if we want to alleviate racial health disparities. However, although, as I mentioned earlier, knowledge of genetic differences might be very useful in a variety of ways, it is unlikely to contribute to the elimination or reduction of health inequalities. The question I want to address is then not whether genetics is likely to have something to do with health disparities. As the biological beings that we are, it is reasonable to believe that genetic factors influence such disparities in some way. The issue, however, is whether, given our current social and political context, genetic research will be useful in helping to alleviate them.

Consider the following example. Hypertension is a major public health problem in many countries because of its high prevalence and its association with coronary heart disease, stroke, renal disease, peripheral vascular disease and other disorders4 (Feldman 1999). The prevalence of this condition among African-Americans is twofold greater than among whites (Cooper and Zhu 2001, Hertz et al. 2005).

This consistent epidemiological observation has resulted in a variety of studies that have tried to ascertain the extent to which racial differences reflect genetic variation (Cooper and Zhu 2001, Hertz et al. 2005). Some have argued that the genetic factor increasing the propensity of black people of sub-Saharan African descent to develop high blood pressure is the relatively high activity creatine kinase in vascular and cardiac muscle tissue (Brewster et al. 2000). Others have indicated that such a genetic component can be found in the physiology of salt sensitivity (Grim and Robinson 1996, Swift and Macgregor 2004).

In spite of these studies, whether genetic variation is important in hypertension susceptibility is still unclear (Cooper et al. 2005, Gadegbeku et al. 2005). Nonetheless, I will assume here that such variation exists. In what way would this knowledge contribute to reducing or eliminating racial health disparities in hypertension? One answer is that knowledge of genetic variants will allow us to advance public health approaches. Measures such as promoting weight loss, foods with less dietary sodium, adequate intake of fresh fruits and vegetables, moderation in alcohol consumption and increased physical activity all can contribute to the prevention of hypertension (Krousel-Wood et al. 2004).

Certainly, the abundance of fast food eateries in minority communities, the inability to afford healthier food and the difficulty of finding it in convenient locations for grocery shopping presents serious problems for minorities. Thus, offering accessible food supplies with lower sodium content or caloric density could have a significant effect on blood pressure. Also the lack of accessible and safe opportunities for exercise makes it more difficult for minorities to reduce blood pressure. Creating parks, running trails and biking paths in African-American neighborhoods could help increase physical activity and thus contribute to a reduction of blood pressure in those most at risk. Of course, primary prevention mechanisms such as the ones just suggested would certainly be welcome. They would be good not just as contributors to a reduction of hypertension but to the general well-being of African-Americans.

It should come as no surprise, however, that these recommendations are already being made as mechanisms for reducing hypertension in the population in general and African-Americans in particular (Whelton et al. 2002). But if this is so, then knowledge about genetic variants in African-Americans would be of little help. The same recommendations would follow from the new knowledge as from existing information. It seems reasonable then that we would concentrate in promoting public policies that make it easier for minorities to gain and make use of the information that we already have about the relationship between hypertension and salt intake.

It could be argued that knowledge of genetic variants could be used by physicians in counseling African-Americans in particular. Doctors could inform them that they are at increased risk of hypertension and its adverse health consequences not just because of social factors but also because of genetic ones. Moreover, once we have knowledge of particular polymorphisms that contribute to the risk of hypertension, researchers could develop new drugs tailored to them. This might solve the problem pointed out by some studies that African-Americans with hypertension are less responsive than white patients when treated with angiotensin-converting enzyme inhibitors (Papademetriou et al. 2004). Doctors could then prescribe these new drugs to patients who have the genetic variants in question. If development of drugs is not feasible, then those with polymorphisms that increase their risk for hypertension could have more frequent screening. Additionally, knowledge of genetic risks could result in increased motivation and adherence to lifestyle modifications, such as better eating habits and exercise. Prescription of specific drugs also could be a better way to control hypertension in those who need it. These could reduce racial disparities in hypertension.

There are several problems with these proposals though. First, they presuppose that access to physicians is not a problem for African-Americans. As we saw in the prior section however, such is far from the case. Economic issues, lack of adequate insurance and geographical obstacles all might hinder African-American access to healthcare for hypertension (Moy et al. 1995).

Second, even if access to physicians were not a problem, difficulties in providing adequate diagnoses and treatments to minorities could still arise. As mentioned earlier, there is a significant body of research indicating that racial and ethnic differences between physicians and patients often constitute barriers to effective communication. Unintentional racial biases and racial and ethnic stereotypes can influence doctors' interpretation of patients' symptoms, and can distort predictions of patients' behaviors. Also, language barriers and a lack of understanding of patients' ethnic and cultural disease models can affect whether and how doctors treat their patients (Cooper-Patrick et al. 1999).

Third, even assuming that access to healthcare and effective communication exists, still additional difficulties persist and the availability of genetic information will do little to solve them. Thus, evidence from a variety of studies indicates that offering people genetic information about risks to their health does not increase motivation to change behavior beyond that achieved with non-genetic information (Marteau and Lerman 2001, Hicken and Tucker 2002). Moreover, some studies suggest that for some people genetic information may in fact reduce motivation to lifestyle changes and could thus encourage a lack of individual self-care and an attitude of fatalism (Wright et al. 2003). Some studies indicate that individuals found to be at risk of heart disease through the use of a genetic test are more likely to feel the development of the disease is inevitable and to think less can be done about it than do those whose assessment comes from clinical tests (Senior et al. 1999, Senior et al. 2000).

Fourth, not much evidence exists that drugs are more effective when taken by individuals with particular genotypes (Tate and Goldstein 2004). But let's assume, for the sake of the argument, that such drugs for hypertension and other conditions will be effective. If genotype is a contributing factor to health disparities in hypertension control, then drugs targeting particular polymorphisms can be developed and doctors can offer them to African-Americans. However, the ability to purchase the drugs will again be a problem. If we presuppose that those in need will have access to anti-hypertensive drugs, additional difficulties still persist. Studies have shown that although patients have access to healthcare and treatment, adherence to medication and difficulties in making lifestyle changes will still represent significant barriers to prevention and control of blood pressure (Borzecki et al. 2005, CDC 2005). These same problems will be present if more frequent screening, rather than drugs, is proposed as a solution to hypertension.

Fifth, if these problems were eliminated or reduced, the effectiveness of a drug directed to African-American patients with particular genetic variants might do little to alleviate health disparities in hypertension prevalence. For we must assume that a patient's self-identified race can be used as proxy for ancestry and as a way to predict genotype with accuracy. However, it is clear that in the US, with an extensive genetic admixture, this assumption is highly problematic. Thus, unless routine pharmacogenetic testing associated with drug efficacy is available, prescribing medications based on race would be inappropriate (Vivian 2006). Certainly, genetic tests could be developed, but it should be clear at this point that given all the problems mentioned before, it is unlikely that they will contribute significantly to the reduction of racial health disparities.

Genetic research and obstacles to eliminating health inequalities

Unless care is taken to prevent it, the unwarranted assumption that genetic research can contribute to reducing or eliminating health disparities might actually be an obstacle to attaining such a goal. First, such a presupposition might lead us to emphasize genetic research and might divert attention from some of the most central factors contributing to health disparities such as socioeconomic inequities or racist biases. In this case significant research funding will be devoted to, and researchers will be drawn to, genetic research as well as to investigating and developing genetic interventions. This could contribute to the limitation of research efforts aimed at broader-ranging, and perhaps more successful responses to public health, such as primary prevention. It also might hinder opportunities to improve aspects of our social, political, and legal systems that need to be bettered. Given that these factors contribute significantly to the existence of health disparities, to neglect them could have devastating effects on our attempts to alleviate such inequalities.

Second, the association between race or ethnicity and disease presupposed by genetic research might actually foster racist attitudes. If it does so, such attitudes could exacerbate problematic attitudes in healthcare practitioners that already contribute to health inequities (Lee et al. 2001). Some might argue that these potential social costs associated with linking race or ethnic background with genetics are outweighed by the benefits in terms of diagnosis and research (Burchard et al. 2003). Nevertheless, if my arguments here are correct, then such benefits are far from clear.

Third, assuming that genetic research will assist us in dealing with health disparities may reinforce notions of biological determinism. Such reinforcement might, in turn, contribute to the development of public policies that are overly favorable towards genetic research and genetic technologies. It could also encourage a lack of individual self-care and an attitude of unavoidable fate. As mentioned earlier, already some studies indicate that individuals who find they are at risk of particular disease through the use of a genetic test feel the disease is more inevitable than if they find out about the risk by other clinical tests.

Conclusion

The debate about whether genetic research can help alleviate persistent racial and ethnic health disparities has focused on technical and scientific issues related to whether genetic differences underlying such inequalities exist and about whether we have the technical capabilities to find them. But the underlying presupposition has been that genetic research is an adequate means for such a worthy goal. I have argued here that, when we take into account the present social and political context, we must conclude that such an assumption is mistaken. I have shown that even if genetic variation plays a role in the existence of health inequalities, and even if such knowledge allows us to develop new treatments, genetics and genomics research is unlikely to have any significant effect on their elimination or reduction. This is so because in many cases primary prevention strategies would be the same whether such differences exist or not. Additionally, new treatments and interventions would require access to economic resources and to healthcare. But these are precisely some of the main factors contributing to the existence of racial and ethnic health inequalities. Moreover, such genetic knowledge and the possible resulting treatments would do little to address the social factors that place minorities at a higher risk of disease in the first place.

Assuming that genetic research will contribute to the alleviation of racial and ethnic health disparities also might lead us to focus on genetic research as the primary, or exclusive, solution to persistent health inequalities. This might actually hinder our efforts to improve health status and healthcare outcomes for historically disadvantaged groups. If my arguments here are correct, to disregard the need for a careful evaluation of whether a particular means is appropriate to achieve a desired end might actually impede the achievement of a very worthy goal.

Acknowledgement

I would like to thank Craig Hanks for his help with prior versions of this paper.

Notes

1. I use here the terms “health disparities”, “health inequalities” and “health inequities” interchangeably.

2. My analysis here focuses on racial health disparities as they exist in the USA. Some of the contextual factors playing a role in the USA might not be relevant for other countries, e.g. issues of access to healthcare may be less prominent in countries where there is universal healthcare. Nonetheless, some of the factors might apply to other countries, e.g. effects on health and healthcare of socioeconomic status. In any case, my point here is to emphasize the importance of taking into account the particular social and political context in which research is being performed and implemented.

3. This is not an exhaustive description of social factors that contribute to racial and ethnic health disparities. My intention is to offer a summary of such factors so as to make my argument about genetic research in the next section.

4. My arguments here do not hinge on the example of hypertension. Other complex diseases or disorders can also be used to make the case.