Specific Patient Characteristics and Ethnicity in Gastroenterology

A reserach paper looks at the issue of ethnic group summaries in US guidelines. What are the key recommendations relevant for experts and medical practice?

Medical terms need adapting

If not before, it was the Black Lives Matter movement that raised awareness among many medical professionals about the use of terms such as "race" and "ethnicity" and led to the challenging of generalisations inherent in these terms, also from a professional perspective. In a recent paper in Gastroenterology, Shazia Mehmood Siddique of the University of Pennsylvania and Folasade P. May of the University of California Los Angeles address the use of ethnic group summaries in current US guidelines. They advise replacing the outdated terms with more precise medical terms that do not unreasonably generalise and are more appropriate to individual patients.1

The term "ethnicity" is medically imprecise

In their article, the two authors first note that the terms "race" and "ethnicity" are social constructs whose biological basis is very limited. They cite a recent statement by the American Society of Human Genetics and a new article that support this assessment.2,3 This may seem surprising in view of the antiquity of these fundamental findings. However, it points mostly to the heated debates in American society about "race", "discrimination" and "identity".

Anyone reading the article will soon come across aspects that have great medical significance for Germany and Europe as well. Similar to the United States, Germany is home to large groups of immigrants who are often lumped together, not only in the media, under generic terms such as "Turks", "Arabs", "Afghans", and so on. Three aspects are often overlooked:

  1. the diversity represented within each of the groups mentioned, which can only be perceived as homogeneous from an ignorant external perspective;
  2. the actual way of life, which can differ enormously between new immigrants and members of the same "ethnic group" who have lived in the USA or Europe for a long time, and
  3. the mixing of members of different "ethnic groups", which has long been a reality in the USA and in Europe. This would make assigning diseases or increased risks of disease to ethnic groups even more audacious than it already was.

Following, Siddique and May discussed seven different gastroenterology guidelines in the US, eight of which make recommendations based on the ethnicity of the patients. According to the authors, these guidelines reduce the "ethnic" basis of their recommendations so much that they become essentially untenable.

Throughout, the authors strictly focus on the medical value of the guidelines and do not accuse them of racist tendencies, for example. They persistently and repeatedly point out that grouping patients on the basis of their assumed ethnicity is inaccurate, erroneous and misleading. For instance, one guideline on hepatocellular carcinoma screenings (HCC) in individuals infected with HBV pools Asian males and African Americans over forty with Asian females over fifty into a single cohort that should be screened every six months.4 By contrast, factors such as chronicity of the disease, route of infection, migration status, viremia status and prevalence of HBV in the country of origin do not play a role. The authors cite similar examples for guidelines on Helicobacter pylori infection, intestinal metaplasia of the stomach, and Barrett's oesophagus.

Accurate medical characterisation prevents errors

The authors consistently emphasised that ethnicity is too multifaceted, volatile and undefined a factor for medical decisions to be based on. They urge the professional societies that publish guidelines to revise their recommendations accordingly and, above all, to define them more precisely. Today, the so-called ethnic risks can very often be explained by the statistical accumulation or the statistically widespread absence of enzymes and similar biochemical variables. Applying these parameters as criteria for an increased screening frequency would not only constitute medical progress, but would also prevent exclusion and discrimination at a time of increasing ethnic mixing. They say that adjusting the recommendations accordingly is an important step towards individualised precision medicine.

In an interconnected world, this conclusion is just as relevant for Europe, where migration brings rapid and continuing diversification, as it is for the United States.

References
  1. Siddique SM, May FP. Race-Based Clinical Recommendations in Gastroenterology. Gastroenterology 2022; 162: 408–414.
  2. The American Society of Human Genetics. ASHG denounces attempts to link genetics and racial supremacy. Am J Hum Genet 2018; 103: 636.
  3. Borrell LN et al. Race and genetic ancestry in medicine – a time for reckoning with racism. N Engl J Med 2021; 384: 474–480.
  4. Terrault NA et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 Hepatitis B Guidance. Hepatology 2018; 67: 1560–1599.