It is perhaps the most fundamental premise of any intro biology course that, although tremendously useful to study, our inherited anatomy (and by extension our genetic code) cannot alone explain the mysteries of life. Far from being a template for development, our “nature” is not deterministic; it’s a factor that, only when combined with the environment in which we’ve been “nurtured,” can help explain who we are. It’s also a concept that’s not very novel, a strand of common sense that every pre-med student here has had drilled into their head ad nauseum. Yet, it’s the one truth we’ve failed to truly integrate in medicine for generations.
To see this concept at work, look no further than me. As a goofy Indian kid born the youngest in a family of two immigrant doctors with a physician-scientist as an older brother, my interest in medicine was as predictable as my love for masala chai and Taco Bell. This stuff was in my blood, and honestly, thinking about health—especially through the lens of the basic sciences—was all I knew. Nature, check. Nurture, check. I spent the glory days of my childhood studying genetics at Duke TIP (you may be more familiar with the title “nerd camp”) and chilling as a science fair groupie, where I cultivated aspirations to pursue genomic medicine. You see, my 18-year-old self believed that solving the most pressing challenges in health—from cancer to HIV to malaria—was as simple as isolating a random gene, tinkering around with it for a few years and winning a Nobel Prize.
From my first days in the Genome Revolution FOCUS at Duke, professors planted a different seed: “Nature versus nurture, Sanjay, don’t oversimplify.” At a superficial level, I got it: In crude terms, it didn’t matter how much of a “genetic freak” LeBron James was, if he favored a dietary regiment of Twinkies every day (R.I.P.), he wouldn’t be the All Star he is today (or at least wouldn’t be as good as Kevin Durant). Recognizing the perils of biological determinism was a way of qualifying one’s thinking, just like every research paper calls for further study in its limitations—one had to control for the environment. We learned that differential environmental exposures affected biology, and this had important implications for health. I was trained to be able to tell you that malnutrition was bad for the physiological development of children, and I had the background to interpret and even run a randomized control trial to prove that to you. But, after a while, I realized there was one question we failed to even consider: Why was there no food for those kids to eat in the first place?
As I watched my brother encounter these issues and realize the inadequacy of his training in medical school from afar, the importance of these questions dawned on me in parallel. It became easy to see that the world we lived and operated in had overt ways of blockading progress in health, and the resulting existential questions plagued me. Did it really matter if I helped contribute to a cure for cancer if one out of every six Americans lacked health insurance to access it? And here’s where the artificial divides and false dichotomies materialized out of thin air. From conversations with professors, doctors and students, it was evident that questions of structural violence and social justice weren’t really in the realm of medicine, per se. Those fell under the jurisdiction of public policy, or philosophy, or heck, didn’t we have a global health institute created just so folks could think about those things?
True, but here’s my logic. Medicine is the science of health, a function of both nature and nurture. Whenever we discover a biological mechanism responsible for illness, physicians assume it is our role to dream up and execute interventions—no matter how absurd or expensive. Yet, when we encounter social mechanisms for disease, such as poverty and educational inequality, we’re conditioned to let someone else figure it out. If we’re serious about training the next generation of leaders to improve health, exposure to the social determinants of health should be more than just an elective or optional certificate—it’s got to be core. In my eyes, Rawls’ conceptions of fairness and equity are just as instrumental toward promoting health as Pasteur’s contributions to germ theory. Yet, nowhere in the intimidating gauntlet of pre-medical training—from the eight “weed-out” basic science courses to the checklist volunteer experiences to the marathon-long MCAT—is there an explicit introduction to the structures that actually dictate the environments in which we’re nurtured.
Indeed, the times are changing in the field of medicine, a trend also reflected in my own evolution as a student. At some level, we’re all products of nature and nurture—functions of innate predispositions and environmental influences that have reached a temporary equilibrium. Nowhere is that reality more crucial, at both the individual and systemic levels, than in the future of medicine.
Sanjay Kishore, Trinity ’13, is a Duke pre-med. This column is the fourth installment in a semester-long series of weekly columns written on the pre-med experience at Duke, as well as the diverse ways students can pursue and engage with the field of medicine.