Mixed Race Studies

Medicating Race: Heart Disease and Durable Preoccupations with Difference by Anne Pollock (review)

Bulletin of the History of Medicine
Volume 88, Number 2, Summer 2014
pages 393-395
DOI: 10.1353/bhm.2014.0025

Lundy Braun, Professor of Pathology and Laboratory Medicine; Africana Studies
Brown University, Providence, Rhode Island

Anne Pollock, Medicating Race: Heart Disease and Durable Preoccupations with Difference (Durham: Duke University Press, 2012).

Science and technology studies (STS) scholar Anne Pollock’s Medicating Race uses the lens of “durable preoccupations” to explore the racialization of different categories of heart disease from the early twentieth century when cardiology emerged as a medical specialty. The book is a useful reminder that the intense and sometimes vitriolic debate over BiDil, a medication for heart failure and the first race-based drug, is but one moment—though a very public one—in a long history of the mobilization of race in cardiology. Drawing on rich and varied sources, including archival materials, scientific articles, interviews, and professional conferences, Pollock extends prior analyses of BiDil to examine the intersection of race with the numerous epistemological debates that characterize the history of heart disease. Why, Pollock asks, has race proved so resilient in the history of heart disease, despite relentless critique?

This deeply theorized account tracks “epistemologically eclectical” racial preoccupations as they travel among the social worlds of science, the clinic, and the pharmaceutical industry. Weaving together three main themes—the role of heart disease research in constituting Americanness, the persistence of racial categorization throughout this history, and the social and political dimensions of health disparities activism—Pollock argues that the durability of race in theories of heart disease is a dynamic biosocial process enmeshed in ambiguous and changing classifications of both disease and race and the persistence of unequal access to power, resources, and treatment. As Pollock writes, “Preoccupations with racial differences always exceed the data itself” (p. 19).

Beginning with early twentieth-century beliefs about infectious etiologies of heart disease, racial discourses shaped the emergence and professionalization of cardiology in complex ways. So deeply entrenched were ideas of syphilitic heart disease in blacks, for example, that Booker T. Washington’s death from arteriosclerosis in 1915 remained a matter of dispute until the 2000s. For African American physicians committed to providing medical care to their neglected communities, engagement with black heart disease also provided them with access to the modern technologies of scientific medicine, albeit limited. As others have shown with diseases such as tuberculosis and cancer, discourses of modernity, stress, and civilization were central to the whitening of coronary heart disease by midcentury.

Particularly fascinating is Pollock’s detailed examination of the complicated relationship between the famed Framingham Heart Study organized in 1948 and the Jackson Heart Study organized in 2000. Framingham researchers constructed their population as both white and normal through changing coding practices, categorizations, computerization, and data analysis, all of which cohered to produce hypertension as a distinct disease category. Modeled on Framingham, the Jackson Heart Study recruited only self-identified blacks, constructing a population that was simultaneously representative and different. Unlike the Framingham investigators, the Jackson investigators incorporated the social dimensions of health disparities, in addition to lifestyle and genetics, into the study design. In chapter 3, Pollock traces the complexity of social processes that produced African American hypertension as a distinctive disease category—and the consequent emergence of the category of African American itself as a risk factor for heart disease. Moving to “durable preoccupations” in contemporary race science in later chapters, Medicating Race analyzes the debates about the salt-slavery hypothesis of hypertension, thiazide diuretics, and BiDil.

While arguing throughout the book for careful attention to biology in any constructivist analysis, for this reader Pollock underestimates the consequences of genetic essentialism and market imperatives in medicine. Yet, in making explicit the tensions in democracy embedded in the historical debates over black heart disease, this book provides fresh insight into a key aspect of the dilemma of difference: when and how to use race in contemporary research. Despite at least a decade of careful social and scientific scrutiny, the academic and public debate about race and race science is not, nor can it be, settled as long as race remains such a salient marker of inequality in U.S. society.

This theoretically sophisticated book does an excellent job of making many familiar STS concepts relevant to medical history. Placing current arguments over race and heart disease in a broad historical context, Pollock adds valuable nuance to the historiography of race and heart disease and their material-semiotic natures. For all its semiotic ambiguity, heart…

Race in a Bottle: The Story of BiDil and Racialized Medicine in a Post-Genomic Age by Jonathan Kahn (review)

Bulletin of the History of Medicine
Volume 87, Number 4, Winter 2013
pages 708-709
DOI: 10.1353/bhm.2013.0067

Anne Pollock, Assistant Professor of Science, Technology and Culture
Georgia Institute of Technology, Atlanta, Georgia

Jonatha Kahn, Race in a Bottle: The Story of BiDil and Racialized Medicine in a Post-Genomic Age. New York: Columbia University Press, 2013. xi + 311 pp. Ill. (978-0-231-16298-2).

When BiDil was approved by the U.S. Food and Drug Administration in 2005 for heart failure in black patients, it became the first ever drug to receive a racial indication. Race in a Bottle is likely to be the most in-depth book that will ever be written about BiDil’s controversial regulatory approval. Its author, Jonathan Kahn, has followed the case of BiDil’s approval at least as closely as anyone else, probably including those most directly involved (the clinicians, the pharmaceutical company, the FDA). Ever since he first heard about BiDil in 2002 (p. 4), Kahn has pursued the story doggedly. He became part of BiDil’s story through the articles he wrote about it, starting with a 2003 piece in Perspectives in Biology and Medicine, which debunked the statistic that blacks were twice as likely as whites to die of heart failure. These articles were read by regulators, among others, and in 2005 Kahn testified against BiDil’s race-specific indication at the FDA hearings on the drug (p. 94). Kahn notes that material in this book has previously been published in sixteen different journal articles and book chapters (pp. ix–x); Race in a Bottle is the definitive compilation of that body of work.

Regulatory processes are at the center of Kahn’s account. According to Kahn, “Race enters biomedicine through many pathways. Foremost among these are federal initiatives that shape the production and use of racial categories in biomedical research” (p. 25). Kahn carefully traces the ways in which the terrain of BiDil was laid by mandates at the FDA and NIH to use OMB categories and, especially, by patent law. This regulatory focus is not inevitable as a way to approach how race enters biomedicine: we might start with lived experience in a structurally racist society, or with clinical encounters, or with social movements mobilized against health disparities, or elsewhere. But Kahn’s passion is for regulation, and this is where his expertise is on display.

Race in a Bottle is at its most effective in debunking two things: BiDil’s racialized indication and racialized medicine as a path toward pharmacogenomics. As Kahn fastidiously shows, the vasodilating drug combination that would become BiDil (isosorbide dinitrate and hydralazine) was originally conceived of as a treatment for anyone with heart failure, not just blacks, and it was commercial imperatives—specifically circumventing the fact that the patent on the drug without the racial indication was about to expire—rather than persuasive scientific evidence that led the pharmaceutical company to seek approval for it as a drug for blacks. Kahn also persuasively debunks the notion that racialized medicine is a step toward pharmacogenomics. Although many BiDil proponents argued that race was a “crude surrogate” but nevertheless useful “in the meantime” until more was known about the genetics of drug response (p. 157), Kahn shows that even when there are genetic tests available to indicate drug response (as in warfarin, the “poster child for pharmacogenomics” [p. 165]), “far from withering away, race is persisting and even proliferating as genetic information increases” (p. 168).

Race in a Bottle is less convincing as a window into “racialized medicine in a post-genomic age.” Situating BiDil in a “post-genomic age” is misleading. In Kahn’s own account, BiDil emerged from statistical signals in clinical trial data, not from genetic research. Related claims of racial differences in heart failure foregrounded pathophysiology, not genetics. BiDil’s FDA indication is for “self-identified black patients,” an explicitly social category rather than a genetic one. Yet the book opens by describing the White House ceremony on the occasion of the completion of the Human Genome Project (p. 1). This narrative choice is emblematic of a preoccupation with genetics in the account as a whole, and shows the intractable appeal of analyzing race in terms of genetics, even for those explicitly critiquing genetic understandings of race. Even if some (but not all) BiDil proponents simply slide the drug into a genetic frame, why should critique of BiDil do so?

Finally, because of the explicitness of its racialization, BiDil has become an obvious icon of racialized medicine, but it is actually not clear that BiDil is…

Medicating Race: Heart Disease and Durable Preoccupations with Difference

Duke University Press
October 2012
280 pages
5 illustrations
Paperback ISBN: 978-0-8223-5344-7
Cloth ISBN: 978-0-8223-5329-4

Anne Pollock, Assistant Professor of Science, Technology and Culture
Georgia Institute of Technology, Atlanta, Georgia

In Medicating Race, Anne Pollock traces the intersecting discourses of race, pharmaceuticals, and heart disease in the United States over the past century, from the founding of cardiology through the FDA’s approval of BiDil, the first drug sanctioned for use in a specific race. She examines wide-ranging aspects of the dynamic interplay of race and heart disease: articulations, among the founders of American cardiology, of heart disease as a modern, and therefore white, illness; constructions of “normal” populations in epidemiological research, including the influential Framingham Heart Study; debates about the distinctiveness African American hypertension, which turn on disparate yet intersecting arguments about genetic legacies of slavery and the comparative efficacy of generic drugs; and physician advocacy for the urgent needs of black patients on professional, scientific, and social justice grounds. Ultimately, Pollock insists that those grappling with the meaning of racialized medical technologies must consider not only the troubled history of race and biomedicine but also its fraught yet vital present. Medical treatment should be seen as a site of, rather than an alternative to, political and social contestation. The aim of scholarly analysis should not be to settle matters of race and genetics, but to hold medicine more broadly accountable to truth and justice.

Table of Contents

• Acknowledgments
• Introduction
• 1. Racial Preoccupations and Early Cardiology
• 2. Making Normal Populations and Making Difference in the Framingham and Jackson Heart Studies
• 3. The Durability of African American Hypertension as a Disease Category
• 4. The Slavery Hypothesis beyond Genetic Determinism
• 5. Thiazide Diuretics as a Nexus of Associations: Racialized, Proven, Old, Cheap
• 6. BiDil: Medicating the Intersection of Race and Heart Failure
• Conclusion
• Notes
• Works Cited
• Index

Medicating Race: Heart Disease and Durable Preoccupations with Difference

Massachusetts Institute of Technology
2007
250 pages

Anne Pollock, Assistant Professor of Science, Technology and Culture
Georgia Institute of Technology, Atlanta, Georgia

Submitted to the Program in Science, Technology and Society In Partial Fulfillment of the Requirements of the Degree of Doctor of Philosophy in the History and Social Study of Science and Technology At the Massachusetts Institute of Technology

This dissertation is an examination of intersections of race, pharmaceuticals, and heart disease over the course of the 20th century and today. Each of these parts has had a dynamic history, and when they are invoked together they provide a terrain for arguments about interventions in health and in justice in the present.

An enduring aspect of discourses of heart disease over the past century has been articulating connections between characterizations of the modem American way of life and of heart disease. In that process, heart disease research and practice has participated in differentiating Americans, especially by race. This dissertation uses heart disease categories and the drugs prescribed for them as windows into racialized medicine.

The chapters are organized in a way that is roughly chronological, beginning with the emergence of cardiology as a specialty just before World War II and the landmark longitudinal Framingham Heart Study that began shortly thereafter. A central chapter tracks the emergence and mobilization of African American hypertension as a disease category since the 1960s. Two final chapters attend to current racial invocations of two pharmaceuticals: thiazide and BiDil. Using methods from critical historiography of race, anthropology, and science studies, this thesis provides an account of race in medicine with interdisciplinary relevance.

By attending to continuities and discontinuities over the period, this thesis illustrates that race in heart disease research and practice has been a durable preoccupation. Racialized medicine has used epistemologically eclectic notions of race, drawing variously on heterogeneous aspects that are both material and semiotic. This underlying ambiguity is central to the productivity of the recorded category of race. American practices of medicating race have also been mediating it, arbitrating and intervening on new and renewed articulations of inclusion and difference in democratic and racialized American ways of life.

Table of Contents

• Abstract
• Acknowledgements
• Chapter 1: Introduction
• Chapter 2: Preoccupations with Racialized Modernity in Early Cardiology
• Chapter 3: Constructing and Supplementing Framingham’s Normal White Americans: The Framingham and Jackson Heart Studies
• Chapter 4: The Durability of African American Hypertension as a Disease Category
• Chapter 5: Thiazide and Racialization of a Generic Drug
• Chapter 6: BiDil: Medi©ating the Intersection of Race and Heart Failure
• Epilogue: Tracking Plural Noninnocent Discourses
• Works Cited

…Early Framingham investigators did their research in an all-white population, but they participated in larger conversations about black/white differences, too. The Framingham investigators themselves participated in the simultaneous constructions of hypertension and African American hypertension in the 1960s, an era that saw the ascendance both of hypertension as a risk factor and of the Civil Rights Movement. Their own study’s lack of inclusion of African Americans did not preclude their participation in arguments about racial differences in hypertension. Addressing “Environmental Factors in Hypertension” in a 1967 publication, the investigators wrote:

The principal population groups among whom blood pressures have been reported to be lower than among Americans and Europeans are various primitive peoples. The sample size has usually been small, especially in the older ages, and conclusions about age trends are complicated both by this fact, and by the fact that it is often not possible to accurately determine the age of the subjects. Among those population groups studied adequately, the following may be said:

Blood pressure distributions are similar among such diverse groups as: Caucasians living in Europe, the United States, and the West Indies; among Chinese living in Taiwan, and among Japanese in Japan.

Negro populations have higher blood pressures than whites living in the same areas and studied by the same investigators, particularly among females and in the older age groups. Distributions of blood pressures among Negro populations living in the United States and in the West Indies, whether rural or urban, high or low salt eaters, are similar. Their blood pressures are higher than those of Negroes in Liberia, a principal source of Negro migration to the Western Hemisphere. Admixture of the Negro races in the Western Hemisphere makes the interpretation of this data difficult. It is in this general background of unencouraging experience that the study of particular environmental factors, which could conceivably affect the blood pressure level, must be approached.

I will return to the question of African American Hypertension as a disease category in Chapter 4, but for now attend to other aspects of this quote. Here, we can see the distance between direct evidence or argument and the invocation of a common sense of racialization of cardiovascular disease. Although their phrasing evokes neutral grammars of data, there are no citations or evidence for these assertions about “Negro populations,” suggesting that the authors conceive of these statements less as arguments than as reflecting the consensus of the field. Unable to grapple with the embodied admixture that is not merely biological but also historical and cultural, much history is paved over in word choices such as “migration” to describe the slave trade and “admixture” to describe oppressive sexual relations under slavery.

Paucity of data is not actually the problem. The investigators make an odd claim about the cause of the difficulty of research into environmental causes of racial disease disparities: that “admixture” gets in the way of interpretation. Logically, assimilation would be the kind of mixing that would pose a problem for separating out environmental causes of disease by race, but the investigators lacked a language for cultural, in addition to biological admixture. The peculiarity of the investigators’ framing should alert us both to the fact of racialized hypertension’s existence at the nexus of the biological and the environmental, and that Framingham is telling both a white story and a universal one…

Read the entire dissertation here.