Abstract
Racial classifications form a long-standing and contentious area of interest in the social sciences, particularly where racial difference is linked to socio-economic disparity. As part of this interest, social scientists have convincingly shown the very category of race to be the outcome of social stratification processes rather than an actual, essential characteristic of human beings. In recent years, this perspective has also gained traction in other fields, most notably biology, where the existence of discrete races is now considered to be a fiction, due to the predominant genetic similarity of all human beings. It is therefore an important and, considering the issues of social justice associated with race, alarming observation that racial thought continues to be highly prevalent in medicine. Moreover, a paradoxical development is that racial classification appears to be expanding in the context of genomics, which was believed to be the very field that made race obsolete in biological terms. Concerns with race and social justice that have occupied social scientists for decades, thus increasingly play out in the domain of the life sciences and medicine. Books like the ones discussed here draw our attention to these important developments.
Jonathan Kahn, a legal scholar at Hamline School of Law, explicitly engages with an emerging understanding of race as a genetic category. He takes the drug BiDil – intended to treat heart failure in ‘self-identified’ black patients – as an entry point for investigating the relations between race and pharmaceuticals, produced in regulatory and commercial arenas. In his analysis of the BiDil controversy (in which Kahn himself figured by arguing against race-specific approval for the drug in a testimony to the Food and Drug Administration [FDA]), he stages three main protagonists: mandates from the US federal government to enhance diversity in biomedical research; a patent system actively stimulating expanded use of racial categories in applications for intellectual property protection; and drug companies eager to use this regulatory leeway around race to create new market niches and strengthen patent protection. These protagonists collectively contribute to a new drug market, where human genetic diversity – reverted into old categories of race and racial specificity – is widely advertised and sanctioned by a government sensitive to avoiding the resurrection of an implicit white norm.
The story Kahn tells is ultimately one of good intentions gone awry, with far-reaching implications. He identifies a number of factors contributing to the problematic persistence of race. One of them is the sloppy interpretation and unwarranted generalization of statistics indicating (often minor) differences between ‘races’ (a concept with no biological foundation) in disease incidence and response to drugs (Chapter 3). Another is the architecture of patent applications that contain layers of increasingly specific and racialized populations for which a drug has been proven to be effective, in order to have a fallback in case the US Patent and Trademark Office (PTO) strikes down broader claims of efficacy (Chapter 5). A third example is what Kahn calls ‘the politics of the “Meantime”’ (Chapter 6), through which he questions the assumption that racial classifications will disappear once more specific markers of genetic diversity are identified. As Kahn describes, within this assumption race is seen as ‘a useful fiction (…) that is to be discarded once its temporary utility has faded’ (p. 164) – but he considers it unlikely that racial categories disappear on their own. Rather, Kahn expresses his concern that race will come to explain social disparities in health, turning solutions to these disparities into individual responsibility for choosing the (racially) right drug. In the end, Kahn thus points to the socio-economic structure of American health care and medical research as the culprit for the resurrection of racial differences in medical science and continuation of racial disparities in medical care. The pharmaceutical industry (including the patent system), so Kahn implies, distorts medical research that, with more explicit and precise consideration of biologically justified differences, could contribute to forms of treatment more tailored to human diversity.
Where Kahn seeks to understand how race features in medicine as a placeholder for diversity in the genomic age, Pollock, an assistant professor in Science and Technology Studies at Georgia Tech, questions the notion that ‘genetic determinism’ underlies the persistence of racial differentiation in medicine. Focusing on racial understandings of cardiovascular disease, Pollock seeks to understand what she calls ‘durable preoccupations’ with race in medicine. This concept seeks to capture how resilient racial thinking is, even when it is not convincingly supported, or even contradicted, by medical research data. Race, from her perspective, then is always both a biological and a social category of classification that serves to order human diversity in various domains. Against this background, the title Medicating Race does not only refer to race as a distinguishing factor in prescribing medical treatment, but also to making race a matter of medical concern. The term shows Pollock’s commitment to tracing where and how ‘race’ has continuously been framed and re-framed as a medically relevant category – for better or worse, and both within and beyond medical science and clinical practice.
In her book, Pollock traces durable preoccupations with race in the understanding and treatment of cardiovascular disease through the 20th century in the USA. She demonstrates how attention for the distinctive incidence, mechanisms and treatment of heart disease in African Americans reflects a deeply racialized social order that is linked to particular ways of understanding and explaining biological difference. Thus, from the early 20th century when cardiology emerged as a medical field onwards, specific biological and social characteristics have been associated with and linked together through race. From the early days, heart disease has been understood as a disease of modernity that was more common among white Americans, with the obvious implication that black Americans were somehow less modern. Similarly, in treating hypertension in African Americans, the implications of a postulated higher efficacy of (cheaper) generic drugs are that modern state-of-the-art brand-name drugs are not necessary for poorer populations, producing therapeutic forms of exclusion from modern American citizenship and social justice (Chapter 5). Yet Pollock also points out how complex and heterogeneous the relation between race and medicine can be, for example when discussing the heterogeneous meanings attached to BiDil by its various supporters – which, surprisingly, include organizations such as the National Association for the Advancement of Colored People (NAACP) and the Association of Black Cardiologists (ABC) – who have distinctive agendas (Chapter 6), or in her analysis of a controversy around TV personality Oprah Winfrey’s reference to the slavery hypothesis of hypertension (Chapter 4). Commentators who blame Winfrey for being naïve or having a defective understanding of science are misdirected, Pollock argues, since reference to the thesis that higher incidence of hypertension among African Americans is an effect of the slave trade is part of a different discourse here. For Winfrey, the hypothesis fits her long-standing anti-racist endeavors seeking to stimulate individuals to overcome the odds – whether they arise from oppressive social structures or a predisposition to hold onto salt in the blood stream. Thus, Pollock rejects the idea that all reference to race in medicine has negative implications by definition. The ethical question to consider, then, is not whether racial difference should be considered in medicine (since she considers this inevitable as long as race exists as a social category), but how to do so in a way that fosters social justice.
Pollock’s interest in the way social and medical concepts of race interact and create a heterogeneous landscape of racial thought offers a different vantage point from Kahn’s critique. At the heart of Kahn’s story is an interest in the way law and public policy may produce unwanted outcomes by channelling science in socially deleterious directions that take the form of geneticizing and essentializing racial difference. Pollock, on the other hand, takes a wider view of the circulation of medical knowledge in social arenas and the circulation of social orders in medical science. Both approaches have their weaknesses. By dismissing genetic determinism up front, Pollock denies that the emergence of genomics, a science that revolves around identifying and understanding difference within the human species, has any significant implications for how existing classifications of human difference may evolve. Kahn, on the other hand, implicitly maintains that a neat separation of the social and the natural must be possible at some level. He frames his analysis along those lines, by proposing procedural reforms to get closer to that ideal state and by attributing quite explicit blame to those actors and actions that blur a disinterested and neutral pursuit of science.
More interesting, however, is that these authors work with different models for the way medical science, pharmaceuticals and race may be approached as objects of social analysis. These models furthermore contain some specific pointers for sociologies of race and medicine. Kahn focuses on the detrimental effects the particular contemporary economic and political configurations of medical science can have and thus makes an argument for contextualizing science – and seeing where that context threatens an implicitly postulated purity of science. Pollock, on the other hand, rejects the notion that racial medicine revolves around a socio-political corruption of science’s access to the truth. Instead, her focus, to which I am more sympathetic, is on the diverse resources, including science, which people may tap into to make sense of their health and identity. She thereby offers a richer contextualization of the way race figures in medicine that positions medical science not as an exclusive or absolute authority, but one among many forms of ordering and reasoning about the simultaneously social and technical world we inhabit. While both authors thus propose to question contemporary science and technology as part of a critical social understanding of race, Pollock above all makes clear how different forms of knowledge, belief and reasoning are woven through the forms of collective organization and stratification sociology seeks to understand.