Diabetes is connected to patient stereotypes—the view that certain groups of people, sharing certain traits or behaviors, are more at risk. Promoted in the media and endorsed in the medical literature, the current patient stereotype is that diabetes disproportionately affects Black and Hispanic individuals, and the high rates of diabetes in these communities are driven by obesity and lifestyle choices.
However, this view badly oversimplifies the underlying causes of the current type 2 diabetes epidemic, as explained by Arleen Marcia Tuchman, a Vanderbilt University history professor, in her fascinating 2020 book titled Diabetes: A History of Race & Disease. The deeper problems, Tuchman writes, is how poverty and racism have made these at-risk populations vulnerable and how patients are more apt to be wrongly blamed for their condition than to be supported.
Diabetes stigma has been addressed by other scholars and patient advocates, but Tuchman is not content to simply analyze what is happening today. Rather, she has written a cultural history of diabetes. Her primary purpose, she writes, “is to excavate the ways that diabetes, in all its forms, has been the locus for the expression of anxieties about economic, social, and political changes over the past century, many of which explicitly involved issues of race.”
It is an ambitious goal, but the subject is personal for Tuchman, whose father developed diabetes in 1985 at the age of 63 years. Initially misdiagnosed with type 2 diabetes, he was later diagnosed with type 1 diabetes, and he took four insulin shots daily until his death 1 month shy of his 93rd birthday. The experience made Tuchman aware of the confusion surrounding diabetes, even among doctors, and made her sensitive to the fact that, regardless of circumstance, no one who develops diabetes should be blamed.
Even readers who are familiar with current racial and ethnic diabetes-related stereotypes will be surprised by how patient perceptions have changed over time. Diabetes, in fact, was once considered a Jewish disease.
In the first quarter of the 20th century, diabetes was so closely associated with Jews that it was referred to, in German-language literature, as Judenkrankheit, or “Jewish disease,” and that view became prominent in the United States. According to Tuchman, the data are unclear regarding whether Jews experienced higher rates of diabetes, but she is more interested in how this negative stereotype dovetailed with the rising anti- immigration sentiments and anti-Semitism of the day. At the time, diabetes was associated with eating sweets, and Jews, according to physicians of the era, had a penchant for “high living” and “parties” and “had a racial tendency to corpulence.” They also reportedly liked to inbreed, all of which, according to one health commissioner, spread this “great luxury disease.”
Not all characterizations were negative. People with diabetes were also depicted as highly civilized and as model citizens who drew on their intelligence and self-discipline to manage a difficult disease. That these citizens were white and wealthy went without saying. But by the 1950s, a new narrative emerged. Government health officials discovered that Native American populations had high rates of diabetes. This finding coincided with the articulation of the thrifty gene hypothesis, which connected diabetes to changes in diet and lifestyle.
“Diabetes lost its status as a disease of civilization,” Tuchman writes, “and slowly became a disease of ‘primitive’ populations that were unable to adapt quickly enough to Western lifestyle.”
Native American activists rejected this thesis, contending that high diabetes rates reflected the federal government’s longstanding racist practices against Native American peoples that led to poverty, lack of education, and high rates of overall disease, as well as the diminution of their traditional diet. Diabetes was not a marker of Native Americans’ primitive nature, these activists said, but rather “was symbolic of White people’s attempts to eradicate them either through assimilation or by extermination.”
Tuchman supports that view, noting that thrifty gene advocates have wrongly “geneticized” a disease that is widely accepted to be heavily dependent on environmental triggers. She uses that same framework to assess the depiction of other racial or ethnic groups that have high rates of diabetes.
A watershed moment occurred in 1985, when the federal government released the so-called Heckler report on the incidence of chronic disease among racial and ethnic minorities. According to one member of the task force that produced the report, diabetes had become a disease that “afflicted minority groups.”
This coincided with huge increases in immigration from Mexico and Asia, which only reinforced the changing perception of diabetes. At the same time, diabetes itself was being redefined. The main two types of diabetes had long been vaguely defined, but in 1979, medical experts referred to these two forms as IDDM (insulin-dependent diabetes mellitus) and NIDDM (non–insulin-dependent diabetes mellitus). Beginning in 1995, IDDM and NIDDM were renamed type 1 and type 2 diabetes, respectively.
As Tuchman notes, recategorizing diabetes just when the disease itself was becoming associated primarily with poor minorities had serious consequences. Epidemiologists as early as 1979 said that IDDM was more common among Whites, whereas NIDDM was more common among minority groups. “Eventually,” Tuchman writes, “these two types of diabetes would also generate quite different cultural images, with those with type 1 diabetes playing the part of the innocent victim, while those with type 2 were cast as irresponsible individuals making bad lifestyle choices.”
This is the crux of Tuchman’s argument—and her anger. Disparities clearly exist in both the incidence and outcomes for diabetes. Minority populations, including Native Americans, Blacks, Hispanics, and Asians, tend to fare worse than their White counterparts. However, the analyses focus on skin color rather than on poverty and racism. Women with diabetes also tend to fare worse than men, but women also have higher rates of poverty than men.
Moreover, these race-based judgments overlapped with censorious views of obesity and overweightness. Such judgments were longstanding; Dr. Elliott Joslin, America’s preeminent diabetologist in the first half of the 20th century, said that “diabetes is a penalty of obesity” and blamed overweight people with diabetes for their condition. That attitude merged with the racialization of diabetes by the end of the century. “Fat, poor, and increasingly Black,” Tuchman writes, “those with diabetes were also increasingly imagined as lacking the skills necessary to manage their own health.”
The racial transformation of diabetes has had a devastating effect on communities that need the greatest support, and there are no easy answers. But Tuchman’s book, with its sobering but enlightening revelations, is a good place to start.
