Experimental Futures brings together theoretically innovative, ethnographically rich interdisciplinary work that is emerging in response to the uneven networks and differentiating cultures brought about by globally extended, as well as locally produced, biotechnologies, information technologies, digital humanities, bio and electronic arts. Experimental Futures is home to scholarship produced at the intersection of anthropology, science and technology studies, medicine, political economy, and studies of new media and arts. Experimental Futures calls for a new generation of robust switches to translate legacy genealogies into new and different public futures. Culturally and cosmo-politically, Experimental Futures provides alternative proving grounds of modernities attuned to the current wave of globalization in which the calls are sent from and routed through switches, transducers, and translations in Amsterdam, Istanbul, the hinterlands of Hong Kong, the networking of Bandung, the organizing of Puerto Alegre and the conflicted political economies of Mumbai; and from the historical contexts of epistemologies and epistemes of the twentieth century to the competing promissory bets on futures, on worlds to come.

Anne Pollock is an Assistant Professor of Science and Technology Studies at Georgia Tech.

MEDICATING RACE

Heart Disease and Durable Preoccupations with DifferenceBy ANNE POLLOCK

Duke University Press

Copyright © 2012 Duke University Press
All right reserved.
ISBN: 978-0-8223-5329-4

Contents

Acknowledgments…………………………………………………………………………………………….viiIntroduction……………………………………………………………………………………………….11 • Racial Preoccupations and Early Cardiology…………………………………………………………….282 • Making Normal Populations and Making Difference in the Framingham and Jackson Heart Studies…………………523 • The Durability of African American Hypertension as a Disease Category…………………………………….834 • The Slavery Hypothesis beyond Genetic Determinism………………………………………………………1075 • Thiazide Diuretics at a Nexus of Associations: Racialized, Proven, Old, Cheap……………………………..1316 • BiDil: Medicating the Intersection of Race and Heart Failure…………………………………………….155Conclusion…………………………………………………………………………………………………180Notes……………………………………………………………………………………………………..197Works Cited………………………………………………………………………………………………..225Index……………………………………………………………………………………………………..253

Chapter One

Racial Preoccupations and Early Cardiology

At a special symposium of the American Society for Hypertension in 2005, the founder of the Association of Black Cardiologists (ABC), Richard Allen Williams, told an anecdote from his training. When he was a bright young student at Harvard in the 1960s, his mentor Paul Dudley White asked what his interest was. When Williams answered that he wanted to study coronary heart disease in blacks, his mentor was dismissive, and said that he hoped that the sharp young student would not waste his time—White told Williams that a “full-blooded Negro” never got coronary disease. This story got a laugh from the audience, and their reaction merits analysis.

On one level, Williams’s anecdote is a performative gesture of laughing at the ignorance of forefathers. Laughing at the naiveté of the great thinkers of the past is a frequent narrative device among physicians, and I observed it at many conferences. References to Paul Dudley White, a central figure in the founding of American cardiology in the 1910s and ’20s and a prolific leader in the field until his death in 1973, are particularly popular. The laughter shared by Williams and his audience could foster camaraderie among the physicians in the room, who could feel flattered that they had access to knowledge that visionary founders lacked. Perhaps emphasizing how far the field has come can also assuage anxiety about how small contemporary contributions can feel in a mature field like cardiology. Yet jokes about the ignorance of cardiology’s founders evoke both distance from the field’s founders and a connection to them. Williams’s joke both enrolls Paul Dudley White in the lineage of the Association of Black Cardiologists, and stakes a claim for the importance of ABC’s distinct contribution. But there is another important element here: how could it have been so clear to White that African Americans should be excluded from the population affected by coronary heart disease, and yet so clear to Williams that they be included—indeed, so clear to Williams’s contemporary audience that White’s error on that front becomes humorous? What has been at stake in debunking the notion that African Americans do not get coronary disease?

In this chapter, I argue that in Williams’s commitment to prove White wrong, we can see a dialectical response to the theses of the founding of cardiology. I suggest that existing explanations of cardiology’s rise in the period between 1910 and the Second World War—disease demographics shifting from infectious to degenerative disease, lifestyle changes in which mental strain replaced physical strain, and the professionalization and standardization of medicine—can be both enriched and problematized by analyzing the ways in which these accounts are imbued with the racial frameworks of the period. I read White and other founders of cardiology as theorists of a cardiovascularized modernity, in which both cardiovascularity and modernity are racialized. At the intersection of race, cardiovascular disease, and the modern American way of life in the early twentieth century, there was a freedom to exclude blacks from the attention of cardiology because of an idea that they didn’t get heart disease—or if they did, it was not in the same ways as modern whites, which was emblematically coronary heart disease. There has been continual contestation ever since—especially by black cardiologists—that blacks do get heart disease, and both in precisely the same ways and in ways of their own. Williams’s preoccupations are in this sense continuous with the physicians and statisticians writing in the 1910s, ’20s, and ’30s, because even today the facts of black coronary disease still keep being both important and surprising. The existence and prevalence of coronary disease among African Americans, and its relationship with other etiologies of heart disease, especially hypertension, remain unsettled. Data have not and cannot resolve the issue, and racial difference in heart disease remains a durable preoccupation.

Degenerative Disease and the Boundary Work of Early Cardiology

Heart disease is conventionally understood as a disease that becomes more important in an aging society that has a decreasing infectious disease burden. This shift has been characterized as the “demographic transition” (initially described in 1929 as a shift from high birth and death rates to low birth and death rates), and as the “epidemiological transition” (initially described in 1971 as “degenerative and man-made diseases displace pandemics of infection as the primary causes of morbidity and mortality”). Historians of cardiology have also invoked this to explain the field’s rise. If medical needs were a driver of medical specialization, a change in population makeup and disease prevalence would cause the rise of cardiology.

However, as we will see, although cardiology has long been described as a medical specialty that would address the needs that humanity would face after infectious disease was eradicated, the succession turns out to be complicated. Explaining the rise of cardiology through the decreasing prevalence of infectious disease takes for granted that cardiology was, at its inception, focused exclusively on noninfectious disease. This ignores how common infectious heart disease was in the early twentieth century. Narration of cardiology by both its founders and its historians as postinfectious is not an observation but rather a preoccupation-laden claim about which kinds of heart disease characterize modernity. Heart disease was subcategorized into infectious and degenerative heart disease, and this categorization was racialized. Infectious heart disease, especially syphilitic, would come to be more associated with blacks, and degenerative heart disease, especially coronary, would come to be more associated with whites. This taxonomy of two types of heart disease for two racial types does not simply end once the etiology of heart disease becomes overwhelmingly noninfectious population-wide. Rather, as we will see, it is renewed in associations between whiteness and coronary disease and blackness and hypertension.

In an important sense, infectious heart disease led to the founding of the field of cardiology. One reason that Paul Dudley White took a fateful internship in England to study cardiovascular physiology in 1913 was that his sister had died of rheumatic heart disease, which was a common form of infectious heart disease. The technology that White would bring back to the United States would become important in defining degenerative heart disease, but his motivation was infectious heart disease. Heart disease had not yet become a major focus of medicine, and White describes being warned that study of heart disease would relegate his work to the “back few pages of textbooks” in which typhoid fever, pneumonia, diphtheria, and tuberculosis were “the infections [that] held the limelight.” Thus, White narrates the founding of cardiology as preceding the ascendance of degenerative disease over infectious disease:

As I returned to the Massachusetts General with my electrocardiograph, I felt like a lonely adventurer entering an unexplored and unknown country, planning to spend my life in a new and as yet unrecognized specialty limited to the heart and blood vessels, both normal and diseased. This was the decade before a handful of us founded the American Heart Association and two decades before we were permitted by our elders and even by most of our contemporaries to call ourselves cardiologists. It was the dark days B.C. (Before Cardiology), when the great White Plague, tuberculosis, was still the main cause of death, and rheumatic fever was responsible for the majority of our heart patients.

In cardiology’s first decades as a specialty, organizers around heart disease would model their efforts on campaigns combating infectious diseases, and infectious heart disease would remain a numerically important component of the field. As Joel Howell argues, the American Heart Association “arose directly from the antituberculosis movement, both conceptually and organizationally.” The landmark professionalizing events in the founding of cardiology—the 1915 founding of the Association for the Prevention and Relief of Heart Disease in New York City, and the 1924 founding of the American Heart Association—incorporated efforts to combat infectious forms of heart disease. A 1928 review comments, “It is fairly well established that there are three common types of heart disease: rheumatic, syphilitic, and arteriosclerotic,” and describes many local studies, all of which ascribed roughly half of the cases of heart diseases to infectious causes.

Early heart disease researchers did not so much claim that degenerative disease was already dominant, but that it was becoming so. In the 1928 review, we read that although half of heart disease was infectious in etiology, the increasing rate of heart disease was due to degenerative causes. Moreover, because “the possibility of prevention and cure remains open in the infectious group” but not in other heart disease, the latter category was promoted as where the field should direct its attention. In this declaration not of its dominance but of its ascendance, degenerative disease becomes emblematic of the future.

Cardiology’s founders were among the many physicians and others talking about the decline of infectious disease and bringing their focus to the degenerative diseases of aging. Here is how one important practitioner, Stewart R. Roberts, described the situation in 1925:

The outstanding fruition of the last fifty years of medicine is the increase in the length of the average life from 35 to 58 years…. The prevention and cure of acute infectious diseases, the wider range of a scientific surgery and a scientific sanitation are the chief influences. Typhoid fever, yellow fever, and diphtheria are nearly blotted out from civilization, and yet heart disease is on the increase. Organic heart disease is today the greatest cause of death. No more could John Bunyan call tuberculosis the “Captain of the men of death,” and no more could Osler apply the title to pneumonia.

Roberts staked out prevention of heart disease as the next project of medicine: “Science and medicine have well attacked the acute infectious diseases. Vaccinate and there is no smallpox. The problem of heart disease is far more complex. The task of properly studying and preventing the cardiac is before us.” Physicians in popular media, too, emphasized the rising importance of degenerative disease over infectious disease. For example, a lecture by Dr. Haven Emerson at the Massachusetts Medical Society was reported in a 1921 Boston Globe article in this way: “He insisted that heart disease must be attacked as tuberculosis has been for the past 20 years, by creating a public consciousness in regard to the menace and by taking it in the incipient stages.” In the article, this demand is explicitly racialized: “The white race is more susceptible to heart disease than the colored race.” Similarly, a University of Pennsylvania physician, C. C. Wolferth, told the New York Times in 1930 that “degenerative diseases of the heart and blood vessels comprise what is probably the most important problem facing the white race.”

Although the racialization of a postinfectious paradigm was mostly implicit rather than explicit, staking the future of the field in degenerative disease should be read as part of racial discourse. To draw on Priscilla Wald’s evocative elaboration of Benedict Anderson’s terms, articulation of the population affected by degenerative heart disease configures an “imagined immunity” of the “imagined community” of modern Americans. Since, as we will see, blackness was so associated with infection, the imaginary of a postinfectious medical specialty was in an important sense articulating a field that did not concern African Americans. Thus, the idea of cardiology as a field that emerged once infectious disease was held at bay was not descriptive, but deeply ideological. The sociologist Thomas Gieryn coined the foundational STS term “boundary work” to describe the ways that science is demarcated from nonscience, and the concept is useful for understanding how privileged categories within science are constructed as well. Interest in noninfectious diseases of the heart preceded their majority in the caseload, and much thinking through relationships between heart disease and a racialized modernity was done in the boundary work between infectious and noninfectious disease. Ideological and cultural resonances of degenerative diseases and coronary disease in particular became ways to think through the American way of life before the diseases themselves dominated morbidity and mortality.

In this period, there was a discrepancy between what we might imagine to be the paradigmatic pathologies of blacks and of whites. While fears and hopes about black disease and health were focused on infection, an emerging discourse of heart disease would bring fears and hopes about white degeneration to the fore. In Donna Haraway’s charting of racial discourses of the twentieth century, she has suggested that the “paradigmatic pathology” of the first three decades of the twentieth century was “decadence, rotting, infection, tuberculosis,” whereas the “paradigmatic pathology” of the decades between 1940 and 1970 were “obsolescence, stress, overload.” In this sense, cardiology can be read as part of a transitional apparatus, starting to address white obsolescence and stress in a period in which blacks remained characterized as infectious and tubercular. Cardiology was coalescing in the first decades of the twentieth century, but it became a site for thinking through the paradigmatic pathologies of the future.

Modern Medicine for a Modern Way of Life

Heart disease was imagined to be characteristic of white Americans not only because their burden of infection was decreasing, but also because they lived a modern life of “stress and strain.” The physician and historian of medicine Robert Aronowitz has given a rich account of the centrality of racialized conceptualizations of the modern way of life to the emergence of the disease category of coronary heart disease, and Paul Dudley White is a key figure. Paul Dudley White was a particularly rich witness to the emergence of modern understandings of coronary heart disease because “for more than a generation,” he was “America’s most influential academic cardiologist,” an articulate witness to the transformations. For White, a key aspect of the strain of modernity was that it was characterized by speed, which has resonances with the Fordism of the period—the modernity of industrialization, with a pace set by machines rather than on a human scale. White argued in his 1931 textbook that “even allowing for missed diagnoses in the past, angina pectoris is evidently increased in frequency, and is encountered more in communities where the strain of life is great and a hurried existence the habit than in leisurely parts of the world. The situation is appalling and demands some action on our part. Almost certainly the most effective move that we can make is to call a halt on the war of mad rush today.” White was describing a very particular kind of strain, unique to a life considered to be fast-paced. Through his conflation of speed and strain, it became possible for White to articulate preoccupations with the strain caused by the perceived startling loss of leisure experienced by urbanites in prosperous countries.

Stewart R. Roberts is less remembered than Paul Dudley White, but was a successful elite physician at the time, a professor of clinical medicine at Emory from 1915 to 1941, and widely published on topics in internal medicine including pellagra and heart disease. He was a leader of professional medicine in his time, serving as president of the Southern Medical Society in 1924–25 and president of the American Heart Association in 1933– 34, and merited an obituary in the New York Times that characterized him as “a diagnostician and a specialist in internal medicine and heart diseases.” He was also part of the leadership of “the New South,” connected to the movement for race reform.

(Continues…)

Excerpted from MEDICATING RACEby ANNE POLLOCK Copyright © 2012 by Duke University Press. Excerpted by permission of Duke University Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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