Diabetes: A History of Race and Disease Open Access

Diabetes: A History of Race and Disease

Arleen Marcia Tuchman

Yale University Press, 2020

With an estimated 1.3 billion people living worldwide with diabetes by 2050, the Global Burden of Disease collaboration network has called diabetes “a monumental global health threat posing increasing challenges to public health and healthcare systems worldwide.”¹  Here, policymakers at both the state and federal levels are debating various proposals aimed at everything from preventing the disease to providing affordable access to insulin for the more than 37 million Americans— one in ten—with diabetes.²  Yet despite being the eighth leading cause of death in the United States, millions of Americans do not realize they are at risk of developing diabetes or may already have it.²  Given its impact on our country, how did we get here?

Historian Arleen Marcia Tuchman attempts to answer this question in her 2020 text Diabetes: A History of Race and Disease. As Tuchman poignantly reveals in a personal anecdote about her father's bout with the disease later in life, views—both domestically and globally—on diabetes and persons with diabetes have changed drastically. Our conceptions about who is vulnerable to diabetes, who was seemingly immune to it, and how those with diabetes contracted the disease have shaped scientific hypothesis, clinical practice, and even public policy.

With Diabetes weighing in at a scant 196 pages excluding footnotes, readers should not expect it to offer as comprehensive an analysis of diabetes as The Emperor of All Maladies does for cancer. Diabetes contains few references to the changing science of the disease. Rather, on page xiii, Tuchman offers a “cultural history of a disease.” She structures the first four chapters of Diabetes around four groups—Jews, Whites, Blacks, and Native Americans—with a final chapter being a hodgepodge of views in more modern times.

That structure is both the book's strength and weakness. On one hand, Tuchman is able to delve into various stereotypes connected to each of the four groups and how these preconceived notions affected medical research and clinical practice. Decades would pass before subsequent studies revealed the fallacies in these claims. A common theme in much of Diabetes is how we conceptualize race: for example, in the nineteenth century, Jewish people were thought to be prone to becoming persons with diabetes but not considered White; this view on race led to descriptions of diabetes as a Jewish—not a White—disease. As Tuchman carefully dissects prevailing societal definitions of race that existed at that time, we understand how arbitrary categories—combining Sephardic and Ashkenazi Jews together or including numerous tribes under one “Native American” rubric—obscured the data on the disease.

Tuchman also traces how racism, classism, and eugenics influenced views on diabetes. Horrifically, some of the ugliest caricatures did not completely disappear but merely transformed, retaining their racist overtones. For instance, initially clinicians believed that Blacks and Native Americans were too “simple” and “primitive” and thus immune to diabetes when it was initially viewed as a “civilized” disease associated with affluence. Such views ignored that due to economic inequities, these communities were dying earlier than their White counterparts, often due to communicable diseases and malnutrition. As the healthcare system evolved to reduce the spread of communicable diseases even in marginalized communities, the rates of diabetes and other chronic diseases began to rise in Black and Native American communities. But some medical researchers attributed this shift from communicable to chronic conditions to poor lifestyle choices or the inability to “catch up” to rapid modernization.

But the structure of Diabetes also presents some challenges for the reader to follow the narrative. For instance, the four initial chapters cover roughly the same timeframe, but segregating these chapters into four groups prevents the reader from seeing the passage of time holistically. Even within a chapter, Tuchman sometimes skips forward and backward in time. Certain figures such as Elliot Joslin appear throughout Diabetes whereas Tuchman describes others with some fanfare and backstory only for them to never appear in the book again. The fifth chapter, which seems intended to wrap up the different threads into a more modern frame, is largely segregated, too, and introduces newer immigrant populations, Asian and Mexican Americans. Perhaps expanding on the text or organizing the chapters differently could have made some of the chronology easier to follow.

Regardless, Diabetes challenges readers—particularly those of us in health policy and practice—to reconsider our preconceptions of the disease. Tuchman provides context for the evolution of how type 1 and type 2 diabetes are viewed differently, and given how each type manifests itself, type 2 diabetes lends itself to negative stereotypes of people of color. Further, as she concludes in her epilogue, such views have hidden the progression of diabetes among poor Whites in Appalachia, suggesting we should consider socioeconomic factors in our efforts to combat diabetes among all Americans. ■