Anne Pollock's Medicating Race: Heart Disease and Durable Preoccupations with Difference could be read as a collection of distinct stories about the racialization of heart disease and the issues and objects that surround it; however, the book makes an overarching argument about both the racialization of disease and racialized medicine in the United States. Medicating Race is also a call to action for scholars and antiracist activists to engage seriously with clinicians and researchers, who often have the same agenda but different approaches and epistemologies.
Pollock situates the debates that surrounded the approval of BiDil (a heart medication called "the first race-based prescription drug") within a longer battle over the place of race in American medicine, and in particular in cardiology and the treatment of heart disease. Though Medicating Race focuses on BiDil, the book broadens that focus by gathering moments in the history of American cardiology that have shown a similar preoccupation with race (including, for example, landmark scientific studies on heart disease and hypertension). Hence, Pollock offers a detailed and theoretically rich record of conflict and contestation in the history of cardiology, with each chapter being dedicated to one such instance, building up to the contemporary debates about BiDil. Medicating Race begins by excavating the racialized assumptions that surrounded the founding of American cardiology, critically analyzes the methodologies of the Framingham and Jackson heart studies, engages with the proponents of the slavery hypothesis (which says that hypertension in blacks is a result of the conditions of the slave trade), and finally returns to BiDil and the debates it unleashed.
The central question that gets partially answered, but never settled, in each of the chapters is this: What do the discourse around heart disease and the issues and objects that surround it — like the slavery hypothesis, or thiazide diuretics (a generic class of drugs prescribed for hypertension) — tell us about how a racialized medicine interacts with biocitizenship? Pollock's claim that we cannot understand the role of American medicine in biocitizenship without exposing the mechanisms through which that same medicine is also racialized, an argument that is implicit in how she structures each chapter, is one of the many useful analytical lessons that can be drawn from this book.
Pollock contextualizes her analyses amidst ongoing (and contemporaneous) debates on the consequences of racializing a particular aspect of heart disease. Somewhat surprisingly, she also uses these same debates as sources for her arguments. That move may seem confusing or disingenuous at first; however, it is very much in keeping with her stance that "there is no innocent place from which to judge" (139). Pollock does not consider herself above the fray when describing the complicated issues that surround race and medicine, which can make reading this book both difficult and rewarding. Indeed, as Medicating Race shows, scientists and medical researchers are always doing politics while doing science; to draw a distinction between the two would obscure the productive value of politicized networks of clinicians, researchers, and pharmaceuticals who aim to erase racial disparities in heart disease while also reifying race as difference.
Critiques of medicalization often implicitly posit a "real" or "exterior" body that precedes medicine, and upon which medicine performs acts; however, Pollock describes instead an ongoing process of "medicating" bodies. Pollock's "medicating" consciously does not draw a distinction between a body that is "real" and then "medicalized," but rather treats medicating as a process that unfolds continuously: "When bodies and technologies come together in medicine, neither precedes the other" (4). Thus, medicine and medicating are thoroughly tangled up in the social and political processes of race (re)construction, and it is hard to dissociate the raced body from the performance of medicine on it.
Pollock draws our attention, as well, to the role of medicine in mediating race; that is, both arbitrating it and intervening on it. In short, medicine's ability to give scientific credence to racial difference through research and the interaction that takes place between clinician and patient work together to make race flexible, and thus hard to dislodge from the theory and practice of medicine.
Given this flexibility, how can we understand the durability of the concept of race in the face of constant critique? By dwelling on the particularly racialized moments in the history of heart disease, including the most recent moment of debates around BiDil, Pollock shows how ideas about racialized disease and medicine were rejected, changed or reinforced, all of which contributed to the durability and flexibility of race itself. (This concept is also echoed by Ann Morning in her 2011 book The Nature of Race: How Scientists Think and Teach about Human Difference.) Furthermore, this preoccupation with race and difference is not necessarily rooted in malevolent ideologies of racism and inequality; rather, it is a coalition of governmental, medical, pharmaceutical and activist actors, with many different motivations, that make this preoccupation a lasting project. Indeed, when popular and scientific narratives include "telling stories of identities and difference through heart disease" (13), we need to pay close attention to such stories and what they reveal about our stake in their preoccupations with race.
Pollock starts, in the first chapter, with the founding of heart disease as a field of study and intervention in medicine. She characterizes cardiology as a racial project, reimagining the founders of this field as "theorists of cardiovascularized modernity, in which both cardiovascularity and modernity is racialized" (29). For example, as Pollock notes, early American cardiologists thought that black Americans could not possibly have coronary heart disease because they did not face the stresses and burdens of modern life that white men did. Pollock brings into focus the Framingham and Jackson heart-health studies and their respective sample populations — those sampled for the Framingham study were overwhelmingly white, and those sampled for the Jackson study were mostly black. The investigators in each study thought they could generalize their results to the entire population even though their sampling was not representative of such. Hence, whereas the Framingham study took part in making whiteness the standard from which to learn, the Jackson study similarly tried to do the same with blackness and its potential to be included within a representation of modern America: "who counts as fully American is expressed through the population that becomes the focus of heart disease research" (80). Whether the Jackson study did this as successfully as the Framingham study did is still an open question.
A focus on hypertension and the related slavery hypothesis makes up the middle section of the book. The slavery hypothesis contends that the cause of hypertension and heart disease in African Americans can be traced back to the slave trade and thus one or more of the following factors: a purported deficiency of salt in West African diets, the inhumane conditions of the journey to the American colonies, and/or the conditions of slavery itself (Curtin, 1992). This hypothesis was popularized in the late 1980s and has, ever since, reared its head in both academic and popular debate, with opponents of the hypothesis contending that it lacks evidence, discounts everyday racism, and is therefore not useful and perhaps even dangerous. Observing the disputes surrounding the slavery hypothesis, Pollock looks at the way disease categories are simultaneously opened up to a new population for research and also closed down for clinical purposes.
What does this opening-and-closing of disease categories allow for? How is it productive? Pollock's answer: ambiguity. The gap of ambiguity that shows up between the deconstructed disease category and the operationalized one allows researcher-clinicians to both look for newer treatment technologies (such as pharmaceuticals) and advocate for their use at the bedside (pharmaceuticals again). This productivity in increased drug prescriptions is not necessarily negative for clinicians trying to improve the health of their African American patients, and in this case the civil rights agenda and the pharmaceutical agenda are intertwined in complex ways — many of which are meticulously teased out by Pollock in the last two chapters of the book. The slavery hypothesis further illustrates this point: the debate as to whether the theory is racist or not, useful or not, correct or not, itself opens up a space productive of racialization and also of pharmaceuticalization: the hypothesis has been used numerous times to justify the over-prescription of generic thiazide diuretics, a drug frequently used for the treatment of hypertension, to black patients.
The last part of the book — chapters 5 and 6 — focuses on the role of two classes of drugs in the overall project of racializing heart disease: the generic thiazide diuretics prescribed for hypertension, and the patented BiDil prescribed for heart failure and specifically targeted toward African Americans. Pollock analyzes the debates around the prescription of generic diuretics to African Americans using the lens of racialized biocitizenship, and argues that we cannot simply view the push of generic diuretics onto black people as a racialized project that aligns black with poor and cheap; we can also view it as a way of opening up citizenship to black people in a marketized state. When viewed as a commodity, drugs become a way of belonging to a nation, and the distinction between a generic and expensive drug becomes a site of contested belonging in a marketized state. The question, then, is this: If belonging is predicated on medical technologies, do blacks belong in a neoliberal United States through "minimum standard of care" treatments or through "state of the art" technologies? The more expensive and patented drug BiDil seems to have been one answer to this question, and the debates around it as well as its failure in the market give us complicated answers. Pollock exposes the various ways this drug interacted with the social terrain of a racialized market-state, from the grammar used to describe the drug, to the already resource-limited situation of many black patients and their doctors, to the discursive battles attempting to characterize the drug as either salve or poison. Medicating Race shows how mediating blackness into an overall narrative of modern America becomes much more complex than just the generic/branded binary.
Medicating Race is thick with theoretical observations, and has a sense of direction that Pollock sustains throughout the book. Most chapters start off with vignettes, usually about a conference, from which a conversation, a presentation or some other aspect of the larger debate is extracted as a starting point for a rich analysis of a specific issue or object (including heart disease, the Framingham and Jackson studies, the slavery hypothesis, hypertension, diuretics, and BiDil). Later in each chapter, Pollock extends the analysis through various other related cultural objects, like conversations in journal articles, popular shows, advertisements, the language of drug package inserts, and archival material such as study notes and data collection tools. The analysis of each chapter then turns toward how the particular story about heart disease and race in America is also a story about belonging in America, about both the violence and pleasure that is inherent in a movement toward inclusion.
One of the last points Pollock makes is that even though we all come from "noninnocent" (26) positions on any contested issue, we should still include an agenda of social justice (broadly defined) into our work. Pollock wants to engage more deeply with proponents of BiDil and the slavery hypothesis, many of whom are clinicians, because she understands them as having arrived at their position through complex epistemologies that include one of social justice through intervention. In their arguments against biologically deterministic medical strategies like the slavery hypothesis or BiDil, many antiracist scholars and activists do not take the reality of health disparities, and of more black bodies dying of heart failure, into serious enough consideration. They then miss the productive point of engagement with the activist-clinicians and health-disparities researchers who are proponents of those epistemologies. Some may consider Pollock an apologist for the proponents of race-based medicine, but they would miss her point, and the point of the book. Pollock insists that trying to attack each new manifestation of the deployment of race in medicine is misguided at best. Her call to action for displacing race in medicine depends on a producing a "shift in the preoccupations with race in society" (194). Pollock leaves open and undeveloped the question of how this shift will eventually happen.
- Curtin, P. D. (1992) 'The slavery hypothesis for hypertension among African Americans: the historical evidence.' American Journal of Public Health 82(12): 1681-1686.
- Morning, Ann. 2011. The Nature of Race: How Scientists Think and Teach about Human Difference. Berkeley, CA: University of California Press.