Diabetes and Race | Health affairs

There are times when a book opens my eyes wider. I enjoy when a book complements my primary care work and provides insight into the complex interpretations of race and health in the United States. Diabetes: A History of Race and Disease, by medical historian Arleen Marcia Tuchman, is such a book.

As the title suggests, the book explores the history of diabetes from the perspective of racial categorization. The five chapters span approximately a century, until the 1985 publication of the Heckler Report of the Secretary of Health and Human Services Task Force on Black and Minority Health. The Heckler Report was the first comprehensive federal assessment of chronic disease disparities.

By the end of the 19th century, diabetes was considered a Jewish disease. It was a time when noncommunicable diseases, including diabetes, were increasing in prevalence, and there was a lack of classification and diagnostic criteria for diabetes. Intensive efforts have also been made to classify and racially classify the peoples of the world, and the racial origin of the Jews has been debated. Tuchman notes that by epidemiological standards it would be difficult to show that diabetes was more common among Jews, but this view was widely accepted in medical circles. Various theories have been put forward: Jews were overweight and gluttonous, nervous and psychopathologically prone, educated and civilized, and persecuted religiously and politically. Each explanation was weak on the causal evidence and strong on the prejudices projected onto the Jewish community.

During the twentieth century, diabetes was increasingly recognized among whites. Tuchman describes how doctors and the secular press have described the discipline and sacrifices of white diabetic patients: following rigorous diets; exercise; hygiene; and the revolutionary new insulin therapy. White patients have been described as overpowering the excesses of modernity, embodying advanced civilization, and making exemplary citizens. These accounts presented the disturbing increase in the incidence of diabetes among whites as an indicator of a superior and adaptable social group. They countered the concerns of eugenics that diabetes posed a threat to the white race by causing disability and addiction.

While diabetes, whiteness, and civilization were linked, African Americans and Native Americans were considered “racially immune” to diabetes. Tuchman cites excerpts from the medical literature and presentations, in which African Americans have been described as lacking the mental and nervous system development necessary for diabetes. Other medical commentators believed that Native Americans were too “primitive” to develop diabetes. Yet the data began to tell a different story, challenging the theories of whiteness and diabetes. For African Americans, the data came from Metropolitan Life Insurance Company listings and studies by white and African American doctors. This data created dissonance, and Tuchman describes how data on African Americans was ultimately ignored and erased in the age of civil rights. Diabetes in Native Americans was attributed to the unique genetics of “primitive” people – supposedly thrifty genes. However, the data to support this claim was non-existent.

These are mind-boggling chapters. They cover the period when African Americans endured the terrorism of the Jim Crow era and the Great Migration from the rural South to the North, Midwest and West. Native Americans endured policies that undermined tribal sovereignty and resources. Their children were forced into boarding schools, disrupting family life and the intergenerational transmission of indigenous languages ​​and culture. Yet these social upheavals were invisible or rejected by white health professionals. Organized medicine has mostly remained in a constrained Eurocentric narrative of the advancement of civilization. In these chapters, Elliot Joslin, the first physician in the United States to specialize in diabetes, is presented as a welcome voice of moderation, as he has recognized that all races and ethnicities can develop diabetes. In the book, African American and Native American professionals and community leaders offer premonitory counter-narratives, challenging theories of racial immunity and racial stereotypes, and suggesting that the oppression and economic hardship of their communities may have played a role. a role in the incidence of diabetes.

The fifth chapter condenses a lot of material. It includes the recognition throughout the medical community of the high rates of diabetes in African Americans, the publication of the seminal Handbook on Diseases Related to Blacks edited by African-American cardiologist Richard Allen Williams, Studies Attributing Diabetes To Indigeneity In Mexican Americans In Texas, Cross-Country Studies On Diabetes In Japanese, And The Heckler Report And The Relatively Low-Profile Federal Response.

In the epilogue, and with a deeper understanding of the misconceptions of race in history, Tuchman describes how race remains conceptually linked to type 2 diabetes, now in people of color. Tuchman reflects that poverty (including among whites) and structural racism are not central to our understanding of diabetes. She also describes how diabetes is presented as a disease that originates in the health habits of individuals. Embedding diabetes in personal health choices obscures the social factors of diabetes and opens the door to blaming people of color for having diabetes.

In my reading of recent diabetes literature, I see two divergent bodies of knowledge. One is a growing literature describing new technologies and drugs for diabetes care, in accordance with a traditional clinical model. The forces propelling this model are strong but linked to the past that Tuchman insightfully describes. Due to the structure of our healthcare system, these innovations are available differently by insurance, class and race. The disparities could widen in the years to come. The second body of knowledge is emerging a general awareness of the social determinants of health, moving us beyond teaching and treating individuals to seek social remedies. These include universal health care, subsistence income, anti-racism initiatives and access to nutrition, among others. Important lessons from Diabetes: A History of Race and Disease can strengthen the commitment of organized medicine to address the social determinants of health and equity.

About Norma Wade

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