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Editorials

Ethnic minority staff and patients: a health service failure

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2226 (Published 21 May 2019) Cite this as: BMJ 2019;365:l2226

Ethnic minority patients need equity not just equality

Kmietowicz refers to disparities affecting ethnic minorities across the health service [1].

It is widely accepted that race is a social rather than biological construct used to explain cultural differences, and as such ethnicity is rarely used to guide clinical practice. Indeed, some studies demonstrate that there is more genetic variation within a race than between races [2]. However, new clinical trials should make us reconsider whether being racially blind can also be harmful when deciding on treatment. Currently, the preference for calcium channel blockers over ACE inhibitors in the treatment of hypertension in Afro-Carribean patients represents one of the only concessions to racial differences represented in the national guidelines. There is surmounting evidence from clinical trials suggesting that ethnic minorities do not respond to recommended treatment in the same way as Caucasian patients, to the point that certain populations may not be being treated at all. Where treatments are largely guided by national guidelines, can we really treat individuals in a multicultural population in the same way?

A 2018 meta-analysis of randomised control trials comparing response to alendronate in East Asian and non-East Asian post-menopausal women found that although bone mineral density increased in both groups, the statistically significant risk reduction of vertebral fractures seen in non-East Asians was not seen in East Asians [3]. The difference in response is supported by the broad genetic variation found between Caucasian and Asian populations that suggest Caucasians are more likely to have a positive response to bisphosphonate therapy [4]. Current treatment guidelines favour Caucasian populations by recommending bisphosphonates, such as alendronate, as first line primary prevention of osteoporotic fragility fractures [5]. Furthermore, bone mineral density is used as a measure of drug response but results from this trial imply that the correlation between bone mineral density and fragility fractures is not as robust in East Asian women. These findings are limited by a small sample size, but it does question whether the current approach is leaving East Asian women at greater risk.
Ethnic minorities may be at increased risk of adverse effects from standard doses of anticoagulants and antiplatelet medications.

A genetic study in 2019 revealed that Asians often have lower warfarin requirements compared to Caucasians [6]. This difference may be due to genetic variation between CYP450 enzyme in ethnic groups, as mutations in these genes changed the average daily warfarin dosing requirements. The dosing of warfarin is notoriously complex. However, aggressive dosing of warfarin in the initial phase exposes patients to increased risk of bleeding, which can be catastrophic if it occurs in the brain or the gastrointestinal tract. This study suggests that East Asians may be overdosed on warfarin in the initial phase. However, the generalisability of this trial is limited by its small sample size, which is itself limited to patients in the city of Los Angeles.

A 2019 meta-analysis of seven randomised control trials suggested that the dosing of dual antiplatelet therapy [7], which has been optimised for a Caucasian population, may be inappropriate for the treatment of East Asian patients. The standard dose of aspirin and clopidogrel led to an unacceptably high bleeding risk in East Asian populations (hazard ratio [HR], 2.843). By contrast, although the non-East Asians had a slightly higher risk of cardiac events compared to East Asians (1.8% vs. 0.8%), there was no significant increase in the rate of bleeding. As the first tenet of medicine is “to do no harm,” it may be appropriate to lower the dose or shorten the duration of DAPT in East Asians in order to optimise the risk ratio between bleeding and ischaemia.

Ethnic minorities are underrepresented in clinical trials and as a result written out of treatment guidelines. It is the responsibility of clinicians to ‘provide effective treatment based on the best available evidence’ [8], and this should encompass evidence about treatments for different population groups. By ignoring these differences, we are failing 14% of the country [9] by prescribing ineffectively or even causing harm.

1. Kmietowicz, Z., Ladher, N., Rao, M., Salway, S., Abbasi, K. and Adebowale, V. (2019). Ethnic minority staff and patients: a health service failure. BMJ, p.l2226.
2. Gannon, M. (2016). Race Is a Social Construct, Scientists Argue. [online] Scientific American. Available at: https://www.scientificamerican.com/article/race-is-a-social-construct-sc... [Accessed 29 Jul. 2019].
3. Wang, Y., Jia, G., Song, J., Kong, X., Zhang, W. and Meng, C. (2018). Comparative Efficacy of Alendronate upon Vertebral Bone Mineral Density and Fracture Rates in East Asians Versus Non-East Asians with Postmenopausal Osteoporosis: A Systematic Review and Meta-Analysis. Hormone and Metabolic Research, 50(10), pp.738-746.
4. Olmos, J., Zarrabeitia, M., Hernández, J., Sañudo, C., González-Macías, J. and Riancho, J. (2010). Common allelic variants of the farnesyl diphosphate synthase gene influence the response of osteoporotic women to bisphosphonates. The Pharmacogenomics Journal, 12(3), pp.227-232.
5. Pathways.nice.org.uk. (2019). Osteoporosis - NICE Pathways. [online] Available at: https://pathways.nice.org.uk/pathways/osteoporosis [Accessed 29 Jul. 2019].
6. Mak, M., Lam, C., Pineda, S., Lou, M., Xu, L., Meeks, C., Lin, C., Stone, R., Rodgers, K. and Mitani, G. (2019). Pharmacogenetics of Warfarin in a Diverse Patient Population. Journal of Cardiovascular Pharmacology and Therapeutics, p.107424841984353.
7. Kang, J., Park, K., Palmerini, T., Stone, G., Lee, M., Colombo, A., Chieffo, A., Feres, F., Abizaid, A., Bhatt, D., Valgimigli, M., Hong, M., Jang, Y., Gilard, M., Morice, M., Park, D., Park, S., Jeong, Y., Park, J., Koo, B. and Kim, H. (2018). Racial Differences in Ischaemia/Bleeding Risk Trade-Off during Anti-Platelet Therapy: Individual Patient Level Landmark Meta-Analysis from Seven RCTs. Thrombosis and Haemostasis, 119(01), pp.149-162.
8. Gmc-uk.org. (2019). Good Medical Practice. [online] Available at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/goo... [Accessed 29 Jul. 2019].
9. Ethnicity-facts-figures.service.gov.uk. (2019). Population of England and Wales. [online] Available at: https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethn... [Accessed 29 Jul. 2019].

Competing interests: No competing interests

30 July 2019
Selena R Yang
Foundation doctor
London