Abstract
Despite the election of President Obama in 2008, beginnings of an economic recovery from the Great Recession in 2009, and the passage of the Affordable Care Act (ACA) in 2010, the connections among race, race-based medicine, and racial debt and indebtedness remain deeply ingrained in American society. In Subprime Health: Debt and Race in U.S. Medicine, Nadine Ehlers, Leslie Hinkson, and their contributors argue that race-based medicine creates race-based health disparities by racializing both access to and quality of care (p. viii).
Given the historical inequities between Americans by race over time, race-based medicine can be viewed as a way to overcome previous inequalities by focusing on individual-level solutions to racial health disparities. While U.S. medicine focuses on these individual-level solutions, this book connects racial health disparities to a broader system of socially constructed institutional racism, which continues to permeate the boundaries of the U.S. health care system. It is argued that in order for U.S. medicine to overcome years of substandard, inferior, and race-based care, medical policies and practices should focus on individual-level medical conditions in an attempt to redress previous health disparities. However, this focus on the individual by physicians, pharmaceutical companies, and insurers does not account for the social construction of race, which cuts across every meaningful demographic, economic, political, and social dimension of life in U.S. society. The contributors to this book contend that debt and indebtedness are central to any analysis of race-based medicine, but some of these manifestations are unintended rather than blatant.
The first four chapters examine how race-based medicine and monetary debt operate in an institutional racialized medical system. In the first chapter, Hinkson examines racial health disparities in medications developed and prescribed for people with hypertension. She evaluates differences in hypertension medicine use between blacks and whites as racialized patterns that are less about treatment efficacy and more about relying on historically and socially constructed categories of race. By relying on these racial categories, she concludes, the growing unequal segmentation of biological medicine over time continues to add to the debt of society, just as the historical categorical differences in wealth, income, housing, and health care will continue to do.
In the second chapter, Ehlers and Shiloh Krupar extend the argument by examining the practice of medical “hot spotting” in order to identify and serve medically vulnerable populations. They argue that while this focus seems thoughtful, the end result is contradictorily fortifying the cuts of race (p. 45). This creates a racially identified subpar group, which can then be shamed for their conditions and charged more for medicines based on this focus.
Later chapters in this section by Jenna Loyd and by Anne Pollock provide salient examples in support of the fact that health inequalities track racial and socioeconomic disparities (p. 65). Loyd argues that the implementation of the Affordable Care Act used existing historical stratification by race and class lines to further solidify institutional racism in medicine (p. 74). Pollock contends that BiDil, a medication for heart failure marketed to black patients, was both underdeveloped in its efficacy and overdeveloped in its cost by a pharmaceutical company who argued for the individual-level solution of the medication. However, the company lost track of the point Pollock makes that health disparities, like heart disease, are the results of living in a racially stratified society (p. 100).
The second half of the book changes direction, with a focus on the long-term indebtedness of blacks and other persons of color within a racially stratified, categorically unequal society. Catherine Bliss evaluates several examples of medical researchers examining race as a biological distinction and concludes that often medical researchers are studying racial differences in order to produce equality, but they do so by relying on socially constructed racial classifications. She concludes that scientific indebtedness and social indebtedness are historically linked, and we cannot solve racialized health disparities without examining each (pp. 123–124).
In Chapter Six, Ruha Benjamin and Hinkson examine experimental stem cell science, with a focus on the racialized differences of trust in the recruitment process for medical studies. Their findings support earlier arguments that the cultural concept of trust is racialized and that we cannot examine medical research without including details on the dynamics of the past debts incurred through a history of social stratification by race. In Chapter Seven, Khiara Bridges focuses on how the shift to a color-blind society, one which fails to address historical inequities of race, does not remedy societal discrimination. By presenting examples on the equal protection clause and comparing similarities to race-based medicine, she contends we cannot become a color-blind society where race is not viewed until white people acknowledge and own differentials in treatment by society as a result of white privilege (p. 175).
In the concluding chapter, the editors discuss the contributions of the previous chapters and draw together key themes and examples. They argue that although race-based medicine today is often positioned to compensate for the nation’s less than virtuous past, race-based medicine fails to acknowledge the ways in which a racialized societal structure over time created the race-based health system to begin with. Further, they contend that a poor theorization of race along individual lines, when the past treatment of people has been along unequal racial lines, creates an ahistorical understanding of how race has actually operated.
Rather than examining racial disparities in health by individual racial characteristics as if race were biological, Hinkson and Ehlers state that we must observe the rationing of care along with the rationalizations of underserving racialized individuals through a historical and social lens. The editors suggest three ways by which this may occur. First, in both biomedical care and research, the structural and social determinants of health disparities must receive attention. Second, current practices in race-based medicine need to be reevaluated so that race is not serving as a proxy for the social construction of race, which is in fact social, and not biological. Finally, rather than focusing exclusively on race-based medicine, the goal of inclusion needs to be extended to realms such as housing, education, criminal justice, and other systems where the social construction of race is lurking behind more benign explanations for a color-blind society (pp. 186–91).
This book offers a refreshing conceptualization of race and how it affects race-based medicine, racialized delivery systems, and color-blind societal explanations. The thesis of the book is clear and well thought out. The editors have done an outstanding job of selecting contributions that build evidence to create a convincing portrayal of how race-based medicine operates in society. Within each of the chapters, contributors use first-rate references and draw on relevant and timely source materials. The book is well written, and it makes a significant contribution to our understanding of subprime health and the conflation of socially constructed race and racialized medicine. I strongly recommend the book to lay readers interested in connections of race and medicine, undergraduate or graduate students of medical sociology or social stratification of medicine by race, and scholars interested in extending the social construction of race and issues of critical race theory into new areas of study.