Washington University School of Medicine Commencement Address

Harold Varmus
President and Chief Executive Officer
Memorial Sloan-Kettering Cancer Center

May 19, 2000

My first job here this afternoon is an easy one: To congratulate the graduates. You have finished a hard course of study at one of the most distinguished medical schools in the world to enter a demanding and highly valued profession. So, yes. Congratulations!

But my congratulations go well beyond your own accomplishments. You should be congratulated on good timing. Take it from someone who abandoned his medical training to become a scientist and later a science administrator to There could be no more exciting time to become a practicing physician.

Why do I say this when many physicians bemoan the state of medical practice? Over the past few decades, modern biology has been dramatically unveiling the principles of cell function and their relationship to disease. Now this summer---thanks in large part to a team headed by Prof. Bob Waterston at this medical school---the full genetic blueprint of human beings will be rolled out. The results will affect every dimension of medicine.

For example, those of us focused on cancer believe that this new information will radically alter the ways we gauge each person's risk of various cancers. It will allow us to diagnose cancers earlier and classify them more accurately. And it will enable us to prevent and treat cancers with drugs and antibodies matched to the exact genetic mechanisms by which they arose. Similar things are happening in all fields of medicine. Nothing could be more exciting than to usher in the changes in medical practice that are bound to follow the current revolutions in biology.

Still---and this is where my job here becomes more difficult---it is also a tough time to enter medical practice, especially if you want to participate in these dramatic changes. Even at the most distinguished academic health centers, financial pressures are placing terrible limits on the time available for doctors to do the clinical research necessary to bring new methods into practice---or even to explain new methods to patients.

Financial concerns may restrain the use of innovations that cost more---at least initially---than existing methods. Many Americans still have no health insurance or are inadequately covered. Will new treatments then be available mainly to the insured and affluent? Will advances in science, which have been paid for by all taxpayers, not be available for all of them to use?

There is already abundant evidence that advances in medicine have not benefitted all of our citizens equally. Life expectancy---and years of good health, free of disability----have increased markedly for many people in this country during the century just ended. But greater burdens of disease are carried by people in certain locations, in lower socio-economic groups, or in minority ethnic and racial groups.

Of course, not all of these differences can be ascribed to deficiences in medical care or even in access to care. Educational levels and cultural and economic factors play important parts. Thus medical care and research cannot by themselves set everything right. But the medical profession can do things now to move towards greater equity.

Today I would like to briefly explore one of these things: the simple precept that health care professionals---and that now includes you----should provide care equally to all members of our society who ask for help.

Four studies published in the New England Journal of Medicine in the past year suggest that we still have a long way to go to meet this standard.

• In the first, professional actors were used to portray patients---black and white, male and female---with symptoms of coronary artery disease. Doctors attending a medical convention were then asked to view tapes of these "patients" and to recommend further steps. Despite similar symptoms, patients were less likely to be offered cardiac catherization if they were black or female, and especially if they were both.
• A second study aimed to explain a well-established fact: black patients with endstage renal disease are less likely than white patients to undergo renal transplantation. Black patients were found to be slightly less likely to want a transplant. But this difference did not account for very much of the large disparity in referral rates to transplant centers. Moreover, the desire for a transplant may have reflected inadequate information provided to patients in minority groups.
• In the third study, my new colleagues at MSKCC (forgive my parochial pride) reviewed records of Medicare patients with early stage lung cancer. They found that surgery was recommended more frequently for white than for black patients. This finding is especially important because the differences occurred despite good controls for insurance, access to care, economic status, and co-existing illnesses. For both racial groups, the decision to operate was important: patients receiving surgery had much better five year survival rates.
• In the fourth and most recent report, a survey of pharmacies in New York City showed that narcotics for treatment of severe pain were much more likely to be available in predominantly white than in non-white neighborhoods, even after correction for economic status and crime rates in the neighborhoods.

These were all difficult studies, and each has its methodological shortcomings. But, taken together, they make a very convincing case for a systematic defect in our delivery of health care. They describe a subtle underlying prejudice about how we match medical care to individuals, using the few physical characteristics that our society uses to assign people to racial categories----in other words, racial stereotyping.

These findings should concern all health care personnel and sound an alarm at all health professional schools. Health workers must become more sensitive to their own---perhaps even unconscious--- prejudices. And schools must review their curricula to prevent the transmission of a tradition of stereotyping.

This issue is, of course, only one among a much longer list of problems that the health professions will need to address to achieve the goals of equity in health and health care. This list includes training of more minority physicians and investigators, especially clinical investigators; research on biological differences among people of different origins that may account for differences in disease rates; and inclusion of minority subjects in the study of diseases and new treatments.

I know from personal experience at the NIH that the Federal government---and, in particular, the NIH---must take an active role in addressing these issues. It has tried to do so. But, let's face it, progress has been slow, policies have been contentious, and the problems must be tackled locally as well as nationally. For these reasons, it is important that individuals and institutions take up the challenge too. For example, in New York City, we at MSKCC are working with Dr. Harold Freeman, the new president of North General Hospital in Harlem, on plans to offer cancer detection services to people who often discover their neoplasms too late for effective therapies. The viability of such programs will require patient education, treatment free of racial bias, and access to the full range of technologies provided to patients at collaborating institutions, such as Memorial Hospital.

It is interesting---and also helpful---that a heightened interest in health disparities, especially those associated with race and ethnicity, is occurring at the same time that Bob Waterston and his colleagues around the world are providing our first complete views of the human genome and of genetic variation among human beings. Few things have impressed newcomers to genomics more than two facts: (i) any two human beings are likely to have identical DNA sequences at more than 99.9% of our three billion nucleotides and (ii) DNA variation is just as great within self-defined racial groups as it is between them.

This provides powerful scientific support for a recent plea from Dr. Freeman and my colleague at MSKCC, Dr. Richard Payne, commenting on one of the studies I cited. They wrote that physicians… "must learn to see people not through the lens of race,"----because race is a social construct, without basis in biology---"but instead as the individual persons they are."

I hope that, in the years ahead, all of you will heed their plea. If you do, you will make decisions that benefit your patients, you will set a standard for fairness that will improve our society, and you will enhance medicine as a profession.

Good luck and thank you.