Subprime Health: Debt and Race in U.S. Medicine is a volume written primarily by sociologists, with two geographers, an STS specialist, and a legal scholar also contributing. The book’s authors have attempted to theorise and even historicise the relationship between the twenty-first-century return of racialised medicine—in the form of pharmacogenomics, race-based prescribing, health care hotspotting, and racially inclusive recruitment in experimental trials—and two types of racial health disparities: unequal access to care and disproportionate risk for certain diseases and medical conditions. Subprime Health’s authors selected the heuristic of ‘debt’ as a way to locate and think through linkages between racialised medicine and health disparities. Most chapters tackle the ethical, political, economic and medical implications of the medical establishment’s naïve tendency to brand the return of racialised medicine as a form of restitution for the African American community’s longstanding lack of access to care. Although the precise focus of each chapter varies, most support the conclusion that racialised medicine reifies biological race in very imprecise ways, blames race-based health disparities on either black bodies or black culture, and absolves the medical establishment, neo-liberal policy makers and unequal socioeconomic structures of any complicity in or ‘indebtedness’ for the creation or maintenance of health care inequality. How each chapter uses the trope of ‘debt’ to examine the relationship between racialised medicine and racial inequality ranges from financial to ethical and political. Co-editor Leslie Hinkson’s chapter on African Americans and hypertension examines racialised patterns of drug prescriptions from 1988 to 1994 that, in addition to deviating from recommended anti-hypertensive drug guidelines without any explicit scientific rationale, compounded rising US health care costs and health care-related debt for African Americans. Anne Pollock, Catherine Bliss and Khiara M. Bridges’ chapters explored the much more deliberate use of race in pharmacogenomics, interrogating the claim that race-targeted medicine is, at the very least, a form of restitution for past medical neglect of African American health needs. Returning to a topic she had previously written about in 2012’s Medicating Race,1 Pollock points out that, contrary to the fears of many activists, BiDil—the first drug the FDA had approved for race-specific use with black cardiac patients in 2005—did not lead to increased medical debt for African Americans. Its woeful marketing campaign ensured that it was not widely prescribed. Instead, Pollock argues that this focus on technological fixes and their potential costs to individual black consumers distracts health activists from confronting the institutional racism endemic within the health care system. Tackling BiDil as well, Catherine Bliss analyses the NIH’s increasing support for the illusion that including African Americans in pharmacogenomic research on a racial basis could redress health disparities. She argues that this trend recasts ‘health disparity’ problematically as a lack of specific drugs tailored for socially constructed ‘races’ lacking any genomic basis rather than as an unequal medical outcome with complicated structural causes. Khiara M. Bridges’ chapter echoes that sentiment, arguing that the drive to tailor drugs for so-called races and blame racial disparities on heredity defeats the purpose of personalised medicine, obscuring the social conditions that have made blackness a marker of individual health risk. The three remaining chapters situate this rhetorical erasure of the historical circumstances that generated and maintained racial inequality in health outcomes within the contemporary context of neo-liberal political discourse. Within such discourse, the structural causes of racial health disparities are rendered invisible and the victims blamed for their personal failure to remedy their own situations through the market. Ruha Benjamin and Leslie Hinkson’s piece examines the medical community’s framing of black health care avoidance, finding that biomedical researchers have recently begun to argue that African Americans should be held individually responsible for overcoming their mistrust. Such a neo-liberal move denies that African Americans regularly encounter mistreatment that justifies such mistrust, effectively releasing the medical establishment from any duty or debt to the community whose trust they have broken. Jenna M. Lloyd’s essay on the Affordable Care Act and Nadine Ehlers and Shiloh Krupar’s chapter on health care hotspotting explore how, at the same time that race-targeted medications had been posited as an appropriately market-driven way to rectify racial health disparities, neo-liberal policy makers adopted health care laws and public health practices that ignore those racial disparities, recast them as personal failings and, in the case of the ACA in 2009, relieve the public sector of any responsibility to remedy their causes. Pioneered in blighted Camden, New Jersey in 2007, hotspotting involves the use of data-mining to identify high-cost patients and reduce that financial risk through cheaper preventive care. Ehlers and Krupar argue that the neo-liberal logic of that practice blames the racially marginalised for out-of-control health care costs. But rather than work to alleviate the structural conditions and lack of access that prompted Camden residents to use expensive emergency rooms as primary care, such programmes leave that marginalisation intact by only working to compel some individuals to change their health care usage. This is a thought-provoking volume that could potentially prompt historians of race and medicine to rethink the connections between pharmacogenomics and current health disparities and perhaps even research historical precedents for what these authors uncovered. As a work of sociology, it is probably not appropriate for use in an undergraduate history course. It has shortcomings that might confuse history students. The hotspotting and ACA chapters especially, while theoretically innovative, might be too reliant on complex jargon from philosophy, affect studies, social theory and critical race theory. Some chapters are also insufficiently or consistently historicised. For example, the introduction’s main body inexplicably ignores the impact of the 2009 ACA on black health, wrongly marshalling 2005 and 2008 data as evidence of current black medical debt and insurance coverage. But in the main, this is a challenging piece that provides much needed attention to the multiple problems plaguing pharmacogenomics and its dalliance with the race concept. Footnotes 1 Anne Pollock, Medicating Race (Durham, NC: Duke University Pres, 2012). © The Author(s) 2018. Published by Oxford University Press on behalf of the Society for the Social History of Medicine. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Social History of Medicine – Oxford University Press
Published: Aug 1, 2018
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