Pharmaceutical meaning-making beyond marketing: Racialized subjects of generic thiazide

Journal of Law, Medicine and Ethics

Volumn 36, Issue 3, 2008, Pages 530-536

  Pollock, Anne ^a  

^a Georgia Tech

Author keywords

[No Author keywords available]

Indexed keywords

ANTIHYPERTENSIVE AGENT; GENERIC DRUG; THIAZIDE DIURETIC AGENT;

AFRICAN AMERICAN; CONFERENCE PAPER; ETHNOLOGY; HUMAN; HYPERTENSION; MARKETING; METABOLISM; SODIUM INTAKE; UNITED STATES;

AFRICAN AMERICANS; ANTIHYPERTENSIVE AGENTS; DRUGS, GENERIC; HUMANS; HYPERTENSION; MARKETING; SODIUM, DIETARY; THIAZIDES; UNITED STATES;

EID: 50249168773     PISSN: 10731105     EISSN: 1748720X     Source Type: Journal    
DOI: 10.1111/j.1748-720X.2008.301.x     Document Type: Conference Paper

References (25)

1. R. G. Fryer Understanding the Racial Difference in Life Expectancy presentation at the WEB Dubois Institute for African American Research Colloquium, October 20, 2004.
2. S. J. Dubner Toward A Unified Theory of Black America New York Times Magazine, March 20, 2005, at 54.
3. The fullest explication of the theory can be found at T. W. Wilson and C. E. Grim Biohistory of Slavery and Blood Pressure Differences in Blacks Today: A Hypothesis Hypertension 17, Supplement (January 1, 1991 1122 1128 and more recently in C. E. Grim and M. Robinson Commentary: Salt, Slavery and Survival - Hypertension in the African Diaspora Epidemiology 14, no. 1 (2003 120 122 discussion 124-126.
4. The argument has been well-described and critiqued by epidemiologist J. S. Kaufman in both nonacademic and academic venues. J. S. Kaufman The Anatomy of a Medical Myth Social Sciences Research Council Forum Is Race Real?, available at http://raceandgenomics.ssrc.org/Kaufman/ (last visited May 21, 2008) J. S. Kaufman and S. A. Hall The Slavery Hypertension Hypothesis: Dissemination and Appeal of a Modern Race Theory Epidemiology 14, no. 1 (2003 111 118. These pieces suggest that the theory has been widely accepted by medical professionals and the media despite the lack of any evidence for it because of the normalcy of racial essentialism in medicine, and argue that the theory fails on the bases of historical evidence, population genetics, the physiology of hypertension, and evolutionary biology.
5. Work Fryer did with his advisor, Steven Levitt, which also involves economists reaching well out of bounds of their own discipline to find surprising answers to social problems from other fields, has also found broad appeal. See S. D. Levitt and S. J. Dubner, Freakonomics: A Rogue Economist Explores the Hidden Side of Everything (New York: Harper Collins, 2005).
6. The historian was Evelynn Hammonds, who referenced Philip Curtin. His critique can be found at P. D. Curtin The Slavery Hypothesis for Hypertension among African Americans: The Historical Evidence American Journal of Public Health 82, no. 12 (1992 1681 1686.
7. According to Marx, a commodity is an external object that satisfies human needs of whatever kind and has a dual nature of both a use value and a bearer of value. Though all commodities are expressions of human labor, and so are purely social, they come to be understood outside of social relations and take on a magical quality. Marx makes an analogy with religion to explore the peculiar agency commodities come to take on. Like gods, commodities are "products of the human brain [that] appear as autonomous figures endowed with a life of their own, which enter into social relations both with each other and with the human race." K. Marx, Capital, trans. B. Fowkes, vol. 1 (London: Penguin, 1867 and 1976): at 165.
8. This taxonomy is analogous to that of Sherry Turkle regarding the computer. S. Turkle Whither Psychoanalysis in Computer Culture Psychoanalytic Psychology 21 (Winter 2004 16 30.
9. See especially J. Dumit, Drugs for Life: Managing Health and Identity through Facts and Pharmaceuticals (Duke University Press, forthcoming, manuscript cited with permission) see also N. Greenslit Pharmaceutical Branding: Identity, Individuality, and Illness Molecular Interventions 2, no. 6 (2002 342 345.
10. L. Althusser Ideology and State Aparatuses in Lenin and Philosophy and Other Essays, trans. B. Brewster (New York: Monthly Review Press, 1971 at 171.
11. TM (New York: Routledge, 1997 at 50.
12. See Dumit, supra note 9.
13. For example, H. L. Gates, Jr., ed., "Race," Writing, and Difference (Chicago: University of Chicago Press, 1986 H. L. Gates, Jr., Figures in Black: Words, Signs, and the "Racial" Self (New York: Oxford University Press, 1987).
14. Gates himself can be understood to be signifying the narrative process he describes in H. L. Gates, Jr., The Signifying Monkey: A Theory of Afro-American Literary Criticism (New York: Oxford University Press, 1988).
15. R. Barthes The Reality Effect in The Rustle of Language (New York: Farrar, Stauss, and Giroux, 1986 at 141-148.
16. A. Nelson Bio Science: Genetic Genealogy Testing and the Pursuit of African Ancestry Social Studies of Science (forthcoming, manuscript cited with permission).
17. This is connected to the theory of the cynical subject: S. Zizek, The Puppet and the Dwarf: The Perverse Core of Christianity (Cambridge: MIT Press, 2003).
18. P. Williams Salt in the Wound The Nation, June 6, 2005.
19. Indeed, groups with high standing have had their credibility on their support of BiDil suffer because of financial interests. The NAACP received $1.5 million from NitroMed when they agreed to a strategic partnership; see "NAACP and NitroMed Announce Partnership to Narrow Disparities in Cardiovascular Healthcare," Business Wire, December 14, 2005. Many mentioned the money in the case of the Association of Black Cardiologists, in language such as the following: "Nitromed did what other pharmaceutical companies have always done. It gave money to people who later gave its medication the thumbs up. The Association of Black Cardiologists co-sponsored the clinical trials for Bidil, received $200,000 from Nitromed, and enthusiastically supported the drug's approval." M. Kimberly Rx for Black Hearts available at http://www.blackcommentator.com/143/143_freedom_rider_rx. html (last visited May 21, 2008).
20. The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial, available at http://www.nhlbi.nih.gov/health/allhat/facts.htm (last visited May 21, 2008). This trial, which ended in 2002, is the largest anti-hypertensive trial ever conducted, with over 42,000 participants, a third of whom were African American. It was conducted by the NIH to compare three classes of newer, more expensive anti-hypertensive drugs with a thiazide-type diuretic.
21. At a conference for the International Society for Hypertension in Blacks that I attended, an investigator on ALLHAT was criticized as biased because he was funded by the NIH, which already has an incentive to recommend cheap old drugs and perhaps can more easily get away with doing so on disadvantaged populations. In the newsletter of the American College of Physicians, the sense that low price may be correlated with low value is both acknowledged and disavowed. The piece suggests that "[b]ecause diuretics cost less and are much older than ACE inhibitors and calcium channel blockers, patients switched to diuretics from more high-profile drugs may think they are getting substandard care." Seeking to "dispel that notion," a Yale clinical professor of medicine said, "We aren't advocating good medicine for people who can afford it and bad medicine for people who can't. The data are clear: The less expensive medication is at least as good." J. van Steenburgh Diuretics for Hypertension Get a Big Boost, But Will Data Change Prescribing Patterns American College of Physicians Observer, April 2003.
22. The NHLBI guidelines for hypertension in minorities are a hodgepodge: BP control rates vary in minority populations and are lowest in Mexican Americans and Native Americans. In general, the treatment of hypertension is similar for all demographic groups, but socioeconomic factors and lifestyle may be important barriers to BP control in some minority patients. The prevalence, severity, and impact of hypertension are increased in African Americans, who also demonstrate somewhat reduced BP responses to monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs. These differential responses are largely eliminated by drug combinations that include adequate doses of a diuretic. ACEI-induced angioedema occurs 2-4 times more frequently in African American patients with hypertension than in other groups. (Footnote omitted.). National High Blood Pressure Education Program, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), December 2003, available at http://www.nhlbi.nih.gov/guidelines/ hypertension/express.pdf (last visited May 21, 2008). ISHIB's full guidelines also recommend diet and lifestyle changes, as well as the inclusion of every class of drug in the treatment of African Americans not only for blood pressure lowering but also protection from end-organ damage. See Douglas et al. Management of High Blood Pressure in African Americans: Consensus Statement of the Hypertension in African Americans Working Group of the International Society of Hypertension in Blacks Archives of Internal Medicine 163 (March 10, 2003 525 541, available at http://ishib.Org/supportfiles/ Mgt_of_Hypertension_in_African_Americans.pdf (last visited May 21, 2008). At the 2006 conference of the International Society of Hypertension in Blacks, there was a debate between an ALLHAT investigator and another physician over whether diuretics were overemphasized. Both allowed that its inclusion in a multidrug regimen was less controversial than as therapy.
23. J. A. Greene Releasing the Flood Waters: Diuril and the Reshaping of Hypertension Bulletin of the History of Medicine 79, no. 4 (Winter 2005 749 794.
24. N. Greenslit, unpublished material shared in personal communication, November 8, 2004.
25. In this, I am inspired by Keith Wailoo, who has described sickle cell as a commodity, exchanged through the 20th century between three groups of stakeholders: networks of emerging molecular medicine in the New South, political liberalism, and articulations of civil rights and black identities. K. Wailoo, Dying in the City of the Blues: Sickle Cell Anemia and the Politics of Race and Health (Chapel Hill: University of North Carolina Press, 2001). There are at least two key differences between sickle cell and HTN/thiazide. First, the possibility of treatment reduces stigma. Second, these thia-zide stakeholders are not yet fully in dialogue with each other, but after Fryer's piece is published, it will be a fascinating debate to continue to track.