Kaufman and Cooper Respond to "'Race,' Racism, and the Practice of Epidemiology"

Jay S. Kaufman1,2 and Richard S. Cooper3

1 Department of Epidemiology, University of North Carolina School of Public Health, Chapel Hill, NC.
2 Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.
3 Department of Preventive Medicine and Epidemiology, Loyola University Stritch School of Medicine, Maywood, IL.

We appreciate very much Dr. Jones' invited commentary, which broadens the scope of the discussion considerably (1Go). Our essay sought merely to evaluate the technical limitations of common quantitative epidemiologic methods when race/ethnicity is used as a variable in etiologic research and to make recommendations concerning which analytical designs might produce a plausibly valid and interpretable effect estimate (2Go). We concluded that several research designs or analytical strategies by which researchers often seek to understand the etiology of racial/ethnic health disparities are inherently inadequate and have little hope of yielding valid etiologic insights. On the other hand, there are conceptualizations and uses of racial/ethnic information that do not entail these logical problems, and we note that these carefully formulated applications may provide more valid and interpretable effect estimates. Here we use the word "valid" only in the sense that a parameter estimated in the data analysis has some relation to a definable causal parameter of etiologic interest. The social utility of asking one set of questions or another or the "validity" of asking certain questions in the sense of their relation to public health values was not an issue that we addressed, and we find Dr. Jones' discussion of these broader sociologic questions to be both timely and persuasive.

A central concern of Dr. Jones' essay appears to be that our critique of some analytical approaches may discourage epidemiologists from grappling with important questions about the origin of existing racial/ethnic health disparities. Although we agree that the investigation of these inequities constitutes a research program of urgency and importance in terms of public health and social justice priorities, we caution that the enormous social utility of posing such questions does not ensure equal scientific validity of all the various epidemiologic approaches that are commonly applied to these problems. To make a simple analogy, although we may desperately need to build a house, the urgent necessity of doing so does not justify the use of any random object for the purpose of driving nails into wood. After some period of attempting to use an ineffectual object, such as a shoe, one might venture to suggest that the tool is inadequate and that we should go about searching for a hammer. Dr. Jones' concern seems to be that a critique of any of the current tools could be taken as an excuse to simply stop building the house. We concur that this concern is both real and important, but we suggest that this consideration must be weighed against the consequences of building flimsy houses that endanger their occupants. Returning to the matter at hand, we note that many etiologic studies of racial/ethnic disparities using epidemiologic adjustment in the designs we criticized actually serve to further confuse, rather than elucidate, these issues. To take just one example, in a study of migraine headaches, Stewart et al. adjusted race-specific prevalence estimates for "confounding" by education in order to conclude that there are genetic attributes of African Americans that make them resistant to this outcome, and they speculate that this may arise from innate "differences in response to pain" (3Go, p. 58). We assert that a great volume of etiologic studies, as in this example, use the race/ethnicity variable in ways that serve to undermine, rather than facilitate, scientific progress.

Dr. Jones stresses that the racial/ethnic identity of an individual does not reflect a fixed biologic quantity internal to the study subject, but rather a complex and historically contingent set of social relations that exist external to the study subject. Many previous authors have expressed this conceptual dichotomy as the distinction between "race" and "racism" (e.g., 4Go, 5Go). For hypotheses emerging from the external conceptualization that Dr. Jones advocates, however, we found that existing epidemiologic methods do offer high potential validity. For researchers who seek to explore hypotheses of innate predisposition of disease, on the other hand, we demonstrated that applications of common analytical approaches often yield uninterpretable or invalid results. Fixed traits that would be considered "internal" to the study subject include not only physiologic factors but also aspects of cultural heritage.

If common epidemiologic methods are limited in their utility for some hypotheses about race and health, might there exist alternative methods that would be preferable? If one wished to explore an etiologic hypothesis about, for example, a coping strategy that is culturally specific to African Americans, it seems likely to us that the tools of history, anthropology, and political economy are more appropriate than epidemiologic tools that were developed for assignable exposures. One successful example we would cite of exactly this sort of transdisciplinary research program would be the study of John Henryism (6Go, 7Go). Likewise, for hypotheses about genetic factors and disease, identifying the products of genes and describing a physiologic mechanism by which genetic variation affects the relevant organ system are ultimately more likely to provide an informed perspective on the question than any collection of epidemiologic analyses with various unrealistic and uninterpretable adjustments and inferential extrapolations. Epidemiologists ought not to be troubled by this proposition that some questions are best answered by resorting to other disciplinary sources of knowledge. Rather, this is simply an acknowledgment of the rather incontrovertible notion that, when encountering a nail, one should put intellectual provincialism aside and pick up a hammer.

NOTES

Correspondence to Dr. Jay S. Kaufman, Department of Epidemiology (CB#7430), University of North Carolina School of Public Health, McGavran-Greenberg Hall, Pittsboro Road, Chapel Hill, NC 27599-7430 (Jay_Kaufman{at}unc.edu).

REFERENCES

  1. Jones CP. Invited commentary: "race," racism, and the practice of epidemiology. Am J Epidemiol 2001;154:299–304.[Free Full Text]
  2. Kaufman JS, Cooper RS. Commentary: considerations for use of racial/ethnic classification in etiologic research. Am J Epidemiol 2001;154:291–8.[Abstract/Free Full Text]
  3. Stewart WF, Lipton RB, Liberman J. Variation in migraine prevalence by race. Neurology 1996;47:52–9.[Abstract]
  4. Smith EM. Race or racism? Addiction in the United States. Ann Epidemiol 1993;3:165–70.[Medline]
  5. David RJ, Collins JW Jr. Bad outcomes in black babies: race or racism? Ethn Dis 1991;1:236–44.[Medline]
  6. James SA. John Henryism and the health of African-Americans. Cult Med Psychiatry 1994;18:163–82.[ISI][Medline]
  7. James SA. The narrative of John Henry Martin. In: Southern cultures. Inaugural issue. Chapel Hill, NC: University of North Carolina Press, 1993:83–106.
Received for publication May 7, 2001. Accepted for publication May 11, 2001.