Is otolaryngology black and white?

Race, ethnicity, and ancestry have historically been associated with otolaryngology conditions such as nasopharyngeal carcinoma, otosclerosis, acoustic neuroma, sickle cell anemia, Burkitt’s lymphoma, and skin malignancies. Advances in genetics present exciting prospects to move beyond the use of race, ethnicity, and ancestry as biological proxies. This would lead to a better understanding of the interplay between genetics and disease, and might facilitate the development of more exact and tailored therapeutic interventions. A study was presented at a recent international otolaryngology meeting that correlated the prevalence of human papillomavirus infection in oropharyngeal carcinoma with skin color (‘‘black’’ vs. ‘‘white’’). It raises the question of whether skin color is an accurate enough proxy for genetic profiles, social habits, and socioeconomic status for it to still have relevance in otolaryngology research and therapy. For race-based studies to have merit, the terms black and white need to be accurately defined and measured. The two groups should be relatively distinct and uniform for the results to have clinical relevance. Determining blackness and whiteness also needs to be applicable in clinical practice. How does one define black and white, and is it possible to accurately distinguish between the two groups? Black has many social and political meanings. Some use the term for any nonwhite person. Africanists reserve the term for those with African features. In New Zealand and Australia it is applied to those with Maori and Aborigine ancestry. Black is also commonly the fallback position for anyone with even a trace of black ancestry. Likewise, terminology reflecting groups such as Hispanic, African American, Mexican American, European, Asian, Caucasian, and Mongolic is ill defined. Social issues related to racial categories may vary regionally and over time. Therefore, studies that employ race as a proxy for social behavior and socioeconomic status may only be locally and temporally applicable. In order for the terms black and white to be universally applicable, they should be biologically defined. An advantage of genetics over race is that it is always universally applicable (if social context is controlled for). Black and white groups may be assigned using a combination of biological characteristics, such as skin color, hair type, and height. Even though most of these physical characteristics can be defined and measured, it is questionable whether they can be combined to define useful racial categories. Skin color alone is a poor proxy for a person’s genetic profile. Africans, tribes in southern India, and Australian Aborigines have similar skin color, yet they are genetically very dissimilar. Even within the closelyknit Khoisan community in Southern Africa, partial genome sequences are ‘‘more different from each other than, for example, a European and an Asian. ’’ Furthermore, Africans exhibit greater genetic diversity than do populations in the rest of the world. The connection between skin color and ancestry, and therefore the classification into racial groups, is relatively inaccurate, especially where people of different ancestry have mixed extensively. An analysis of genetic variants revealed that skin color is not closely associated with the percentage of a person’s recent African ancestors in Brazil. Many people who classify themselves as African American have some European ancestry, 23% in a sample of African Americans from New Orleans. Thirty percent of white college students at a U.S. university were estimated to have <90% European ancestry. Otolaryngologists need to move beyond race, ethnicity, and ancestry, as they are inadequate universal proxies for genetic, social, and socioeconomic issues, all of which can be measured more directly. Even if it were possible to overcome problems related to defining and measuring race, the value of employing racial categories in medical research should be balanced against the risk of entrenching racial thinking and bias, especially in racially sensitive societies. The use of genetics instead of race would promote the deracialization of medicine and society, and would avoid unfair stereotyping of members of racial, ethnic, and ancestral groups. Some medical journals require researchers to justify the use of race and ethnicity in their research, and for race to be precisely defined. Perhaps the same should apply to otolaryngology journals and to presentations at society meetings.