One Size Has Never Fit All

I’ve always wondered why shoes came in small half size increments and socks came in just two sizes that fit a broad range of shoe sizes. I have always been quite leery of advertisements that claimed that one size fits all. One of the main reasons for the efficiency of the industrial revolution was the switch to interchangeable parts that didn’t require each item, like a gun or wagon or pump, to be hand made. That works when you are working on inanimate objects, but it doesn’t work when you are talking about humans and their healthcare. Humans don’t fit well into a one size fits all world.

I have always been against the single payer government run healthcare because the government tries to classify people into the largest categories possible. Medicare starts when you are 65 no matter what your personal situation is. The VA’s drug formulary is only half the size of Medicare Part D. Do veterans only need access to half the medicines available? The government just has a tough time seeing people as individuals; it’s much easier to put patients on an assembly line. This goes against the personalized precision medicine treatment approach which is the direction our healthcare is headed. With our advanced understanding of DNA, the recognition of the subtle differences between how males and females and different ethnic groups deal with diseases and medicines, we are finding that lives can be saved, and the quality of life increased by using this new understanding to personalize the way we treat patients.

This month is National Minority Health Month, and it focusses on improving the health of minorities and reducing health disparities. I have noticed as I’ve written blogs about different diseases it always seems that at least one minority group has different outcomes when afflicted with a disease or during the diseases treatment than others do. These differences are important. You may remember as the different drug companies were racing to get their COVID-19 vaccines approved that it was noted that the clinical trials lacked some diversity. Some people were already leery of the speed that the trials were being conducted and this lack of trial diversity only increased their fears. Drug companies had to work hard to change that. It brought to light the fact that the lack of trial diversity has historically been a problem. Ensuring clinical trial diversity will give us more information on how medicines will impact this diverse populations and will help us understand these important differences.

Minority disparities with respect to risks and outcomes are evident for many chronic diseases including diabetes, kidney failure, heart failure, peripheral arterial disease, asthma, and cancer, as well as for pregnancy. Maternal and fetal outcomes are known to be worse for African American women and infants compared to their white counterparts. This is especially evident in diabetes and kidney diseases.

These two diseases are linked since people with diabetes are at a high risk of developing kidney disease. The excess sugars caused by diabetes harm the kidney as well as the probability that the hypertension that may have promoted the diabetes also is a key cause of kidney disease.

The disparity of minorities in contracting diabetes is apparent in the following statistics:

• 14.5% of American Indians/Alaskan Natives
• 12.1% of non-Hispanic blacks
• 11.8% of Hispanics
• 9.5% of Asian Americans
• 7.4% of non-Hispanic whites

When you consider kidney disease, we find that the differences in the rate of kidney disease between African Americans and white patients was not widely reported until 1982. In that report the authors found that in Jefferson County, Alabama, the risk of end-stage renal disease (the complete and permanent failure of the kidney) was approximately 18 times greater for African Americans relative to whites. Despite long term programs to address these disparities, they have persisted. The most recent report from the United States Renal Data Service shows an end-stage renal disease prevalence of 5,855 cases per million for African Americans, compared to 1,704 cases per million for white Americans.

It becomes starkly evident that the burden of these costly and life changing and life ending diseases fall disproportionately on minorities and this disparity cannot be explained by genetics and biology since they play only a minor role in excess risk. The major cause is focused on the social determinants of health, race, and racism.

A step toward personalized treatment means recognizing all the underlying causes. A Harvard Health Publishing report highlighted one situation that would help reduce this disparity. It stated:

As an additional step to improve outcomes of people of color with kidney disease, individuals with kidney disease should receive timely referrals for specialty care. Those from under-resourced communities are less likely to see a nephrologist prior to starting dialysis and are therefore also more likely to have poorer outcomes on dialysis. Furthermore, they are less likely to have been evaluated and listed for kidney transplantation prior to starting dialysis. Patients with kidney disease should be empowered to understand the stage of their kidney disease by knowing their eGFR (a way of measuring the kidney’s filtering function), to advocate for themselves for referral to a nephrologist, and to advocate for themselves for referral for kidney transplantation.

It is steps like this that will level the playing field and lighten the burden that weighs down people who experience these disparities in treatments. We can do this by rejecting the one size fits all approach and begin to practice personalized precision medicine that recognizes not only the genetic and biologic aspects of each patient but also the social determinants of their health, race, and racism. It is a goal worth fighting for.

Best, Thair

p.s. – We invite you to join us for our Facebook Live event on April 18 at 2:30 PM ET. Former Speaker of the U.S. House of Representatives Newt Gingrich will sit down with me to discuss the importance of seniors advocating for healthcare policies that will impact their lives. We plan to use this conversation as a time to review Congress’ recent legislative activity, such as the Inflation Reduction Act, and how this would affect seniors’ access to innovative treatments and medicines. You can find the event details by clicking here. Mark yourself as “going” on the event page if you plan on tuning in to our live event.