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Race-Based Medicine and Justice as Recognition: Exploring the Phenomenon of BiDil


In the United States, health disparities have been framed by categories of race. Racial health disparities have been documented for cardiovascular disease, cancer, diabetes, HIV/AIDS, and numerous other diseases and measures of health status. Although such disparities can be read as symptoms of disparities in healthcare access, pervasive social and economic inequities, and discrimination, some have suggested that the disparities might be due, at least in part, to biological differences based on race. Or, to be more precise, if race itself has no determined biological meaning, race may nonetheless be a proxy that collects a group of individuals who share certain physiological or genotypic features that affect health.

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1. Office of Minority Health and Health Disparities. Disease burden and risk factors. Atlanta: Centers for Disease Control and Prevention; 2007. Available from (updated 2007 Jun 7; retreived 2007 Aug 7).

2. Smedley BD, Stith AY, Nelson AR, Institute of Medicine (U.S.). Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2003.

3. Krieger N. Stormy weather: Race, gene expression, and the science of health disparities. American Journal of Public Health 2005;95(12):2155–60.

4. Burchard EG, Ziv E, Coyle N, Gomez SL, Tang H, Karter AJ, et al. The importance of race and ethnic background in biomedical research and clinical practice. The New England Journal of Medicine 2003;348(12):1170–5.

5. Bamshad M. Genetic influences on health—Does race matter? JAMA 2005;294(8):937–46.

6. Root M. The use of race in medicine as a proxy for genetic differences. Philosophy of Science 2003;70(Dec):1173–83.

7. Taylor AL, Ziesche S, Yancy C, Carson P, D'Agostino R, Jr., Ferdinand K, et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. The New England Journal of Medicine 2004;351(20):2049–57.

8. Daar AS, Singer PA. Pharmacogenetics and geographical ancestry: Implications for drug development and global health. Nature Reviews Genetics 2005;6(3):241–6.

9. Editorial. Is that it, then, for blockbuster drugs? Lancet 2004;364(9440):1100.

10. See Kahn J. From disparity to difference: How race-specific medicines may undermine policies to address inequalities in health care. Southern California Interdisciplinary Law Journal 2005;15(1):120–121; Montoya MJ. Bioethnic conscription: Genes, race, and mexicana/o ethnicity in diabetes research. Cultural Anthropology 2007;22(1):111–6.

11. Association of Black Cardiologists. Frequently asked questions about the A-HeFT Trial Background for ABC members. Atlanta: ABC; 2004 Nov 8. Available from (retrieved 2006 Sep 20); National Minority Health Month Foundation. Organizations unite to support BiDil's approval for heart failure, rebuff designation as "race-only" drug [press release]; 2005 Jun 24. Available from (retrieved 2006 Sep 20).

12. Cardiovascular and Renal Drugs Advisory Committee (CRDAC), Center for Drug Evaluation and Research, Food and Drug Administration, Department of Health and Human Services. Transcript of Committee Meeting; 2005 Jun 16. Available from–4145T2.pdf.

13. Crawley L. The paradox of race in the BiDil debate. Journal of the National Medical Association 2007;99(7):821–2.

14. Fraser N, Honneth A. Redistribution or Recognition?: A Political-Philosophical Exchange. London: Verso; 2003.

15. Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE, et al. Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. The New England Journal of Medicine 1986;314(24):1547–52.

16. Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. The New England Journal of Medicine 1991;325(5):303–10.

17. Ajayi AA. Angiotensin converting enzyme inhibitors in cardiovascular and renal disease in Africans: A review. African Journal of Medicine and Medical Sciences 1991;20(2):123–34; Dries DL, Exner DV, Gersh BJ, Cooper HA, Carson PE, Domanski MJ. Racial differences in the outcome of left ventricular dysfunction. The New England Journal of Medicine 1999;340(8):609–16.

18. Carson P, Ziesche S, Johnson G, Cohn JN. Racial differences in response to therapy for heart failure: Analysis of the vasodilator-heart failure trials. Vasodilator-Heart Failure Trial Study Group. Journal of Cardiac Failure 1999;5(3):178–87.

19. Taylor AL, Cohn JN, Worcel M, Franciosa JA. The African-American Heart Failure Trial: Background, rationale and significance. Journal of the National Medical Association 2002;94(9):762–9.

20. Food and Drug Administration. FDA approves BiDil heart failure drug for Black patients [press release]; 2005 Jun 23. Available from (retrieved 2007 Aug 8).

21. Basil Halliday of BDH Clinical Research Services testified at the FDA advisory committee hearing, stating “If you have poor trial recruitment and retention, it then forces you to overlook the differential impact of disease by race, gender and ethnicity. Because clinical trials form the basis of modern medical practice, this overlook then forces a healthcare system that is then unresponsive to the needs of the people it is supposed to be serving. This perceived lack of responsiveness is then perceived as a lack of caring, which then affects trust. You mix all this together and what you end up with is the stuff of health disparities. I submit to you that with approval of BiDil we can at least begin to break this cycle.” See note 12, CRDAC 2005:237.

22. See note 12, CRDAC 2005:258, statement by Lucy Perez.

23. See note 12, CRDAC 2005:213–4, statement by Gary Puckrein.

24. See note 12, CRDAC 2005:211, statement by Gary Puckrein.

25. Kahn J. Race, pharmacogenomics, and marketing: Putting BiDil in context. American Journal of Bioethics 2006;6(5):W1–5; Sankar P, Kahn J. BiDil: Race medicine or race marketing? Health Affairs 2005;Suppl Web Exclusives:W5–455–63.

26. See Kahn J. Getting the numbers right: Statistical mischief and racial profiling in heart failure research. Perspectives in Biology and Medicine 2003;46(4):473–83; note 10, Kahn 2005:116–8.

27. Kahn J, Sankar P. Being specific about race-specific medicine. Health Affairs 2006;25(5):w375–7.

28. Saul S. Maker of heart drug intended for Blacks bases price on patients' wealth. New York Times 2005 Jul 8. Available from (retrieved 2007 Sep 14).

29. Two issues that complicate this charge of exploitation are whether generics are equivalent to BiDil and what costs are experienced by consumers.

30. Although community organizations have not been directly criticized, the potential for conflict of interest has been raised. See note 25, Sankar & Kahn 2005; Saul S. U.S. to review heart drug intended for one race. New York Times 2005 Jun 13. Available from (retrieved 2007 Sep 14); Czap A. Color blind, or just plain blind? Alternative Medicine Review 2005 10(2). Available from (retrieved 2006 Sep 20).

31. Duster T. Medicine. Race and reification in science. Science 2005;307(5712):1050–1.

32. Bibbins-Domingo K, Fernandez A. BiDil for heart failure in black patients: Implications of the U.S. Food and Drug Administration approval. Annals of Internal Medicine 2007;146(1):52–6.

33. Lee SS. Racializing drug design: Implications of pharmacogenomics for health disparities. American Journal of Public Health 2005;95(12):2133–8.

34. See note 14, Fraser, Honneth 2003:3. Fraser refers to this dualistic formulation of justice as a “perspectival dualist" understanding. Charles Taylor, Iris Marion Young, and Axel Honneth have articulated similar concepts of recognition.

35. See note 14, Fraser, Honneth 2003:15.

36. See note 14, Fraser, Honneth 2003:15.

37. See note 14, Fraser, Honneth 2003:15.

38. See note 14, Fraser, Honneth 2003:36.

39. For more on this iterative process, which Fraser argues involves some circularity but not vicious circularity, see note 14, Fraser, Honneth 2003:44.

40. See note 14, Fraser, Honneth 2003:76.

41. See note 14, Fraser, Honneth 2003:93.

42. See note 14, Fraser, Honneth 2003:22–3.

43. See McGary H. Race and Social Justice. Malden, MA: Blackwell; 1999.

44. Gamble VN. Under the shadow of Tuskegee: African Americans and health care. American Journal of Public Health 1997;87(11):1773–8.

45. Shaya FT, Gbarayor CM, Huiwen Keri Y, Agyeman-Duah M, Saunders E. A perspective on African American participation in clinical trials. Contemporary Clinical Trials 2007;28(2):213–7.

46. NAACP—New England area conference commends Prescription Pathway Medicare Prescription Drug Plan on availability of BiDil for plan members. Business Wire 2007 Jan 22. Available from (retrieved 2007 Mar 8).

47. National Minority Health Month Foundation. Foundation announces collaboration on clinical trial targeting cardiovascular risks: Patient enrollment efforts target at-risk African Americans [press release]; 2006 May 23. Available from (retrieved 2006 Sep 20).

48. Not “targeted” in the sense that a drug is developed with the expectation that it will only work in a single racial group, but rather that drug design would prioritize the defined therapeutic needs of specific, underserved, racial identities.

49. See note 30, Saul 2005. In an interview with the New York Times, Waine Kong, executive director of the Association of Black Cardiologists, stated that the drug company was “aware of the political fallout if they did not have African American participation.”

50. Goering S, Holland S, Fryer-Edwards K. Transforming genetic research practices with mar-ginalized communities: A case for responsive justice. Hastings Center Report 2008;38(2):43–53.

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Cambridge Quarterly of Healthcare Ethics
  • ISSN: 0963-1801
  • EISSN: 1469-2147
  • URL: /core/journals/cambridge-quarterly-of-healthcare-ethics
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