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Cornell University Press

Why we need to rethink diabetes

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by Emily Mendenhall

The rapid news cycle introduces the everyday traumas of people around the world. Experiences like trauma related to racism and xenophobia – or incarceration when seeking asylum – play a major role in the chronic distress that can eventually trigger diabetes. This is one of the pathways through which social and political determinants cause diabetes.

Diabetes has become a major cause of stress, disability, and death around the world. 90% of people have what is called Type 2 diabetes – the one you develop later in life. In some cases, type 2 diabetes can be reversed or managed through diet and exercise. This fact has made this disease the prototypical “lifestyle disease”. The idea that diabetes is caused by people’s lifestyles puts the fault on the individual. But this idea that individuals are solely responsible for diabetes is misled. Quite the contrary – diabetes is a product of society.

Diabetes is a product of both global and local factors. Global factors include commercial targeting of foods that are too fatty, salty, and sweet toward low-income populations who have a limited pool of good food options. Local factors involve experiences of domestic abuse, fear, and social isolation that cause too many stress hormones to be released into the blood stream. These factors can be the most insidious and invisible.

But this idea that individuals are solely responsible for diabetes is misled. Quite the contrary – diabetes is a product of society.

The incarceration of migrants at the border today exemplifies how trauma may trigger diabetes. Living in inhumane conditions at the border can have irreversible effects on the human body. Research on holocaust survivors demonstrated that such traumatic experiences had epigenetic effects. Epigenetics show how deleterious environments can trigger changes to genetics (literally “above genetics”). These impacts can influence risk for diabetes as well as other metabolic conditions.

But the most insidious link is between chronic, heightened cortisol (a stress hormone) that rages through people’s bodies. Chronically stressed people have higher rates of cortisol in their bodies and higher risk for diabetes. This is because cortisol actually works on your cells to make people more insulin resistant (that characterizes diabetes). Stress also is linked to diabetes through chronic inflammation.  Stress during childhood can be extremely damaging throughout people’s lives. The terror that many young people are facing at the border, therefore, will be carried with them throughout their lives.

The terror that many young people are facing at the border, therefore, will be carried with them throughout their lives.

My book, Rethinking Diabetes: Entanglements of Trauma, Poverty, and HIV, was recently published by Cornell University Press. In it, I argue that neoliberal capitalism fuels the intrinsic links between hunger and crisis, structural violence and fear, and cumulative trauma and psychiatric distress that are embodied in Type 2 diabetes. This gets to the psychophysiology of oppression, which so often links chronic stress and depression to diabetes.

From hundreds of interviews with low-income people with diabetes in urban spaces in the United States, India, South Africa, and Kenya, I argue that diabetes differs from place to place. People call diabetes different things, it co-occurs with different social problems and medical conditions, and biologically presents differently. In some contexts, obesity and diabetes are closely linked. In others, the link is less clear. The psychophysiology of oppression might be in part responsible for this, as chronic stress and distress are physiologically linked to insulin resistance.

People call diabetes different things, it co-occurs with different social problems and medical conditions, and biologically presents differently.

This means that, for instance, for Beatriz in Chicago, her diabetes was closely linked not only to depression but also the stress around losing her home due to medical debt, gun violence in her neighborhood that harmed two of her children, and the time and obligation required to care for her family. This narrative was contrasted with María who, as an undocumented immigrant, felt somewhat trapped in Chicago due to family responsibilities and her documented status.

Meena, a low-income woman residing in Old Delhi, India, similarly spent a great deal of her time caregiving. But her time was directed to her in-laws and children. Her stress was largely related to her mother-in-law’s rejection of her as a woman and consistent marginalization as a family member, which contributed to spousal abuse. These experiences were fundamental causes of her chronic, untreated depression along with diabetes.

Sibongile, a South African woman, faced similar types of violence and stress found elsewhere. But she also described how profoundly HIV influenced how people thought about diabetes. She thought many people considered diabetes to be worse than HIV because of its unfamiliarity within her community. Also, she felt stress related to changing her diet. Many with multiple health conditions also found their medical care untenable.

In Kenya, Kandance described how difficult it was to live with diabetes. Diet changes were especially hard. What Kandace found most difficult was the cost of paying for medical tests and medication for diabetes. This simple fact caused stress because she could not afford diabetes care.  Esther, a narrative I use to open the book, agreed with Kandace about the cost of diabetes.  Esther had lived with HIV for many years before her diabetes diagnosis and described how different it was to live with HIV and diabetes. Esther described how she was very compliant with her HIV medications (which were paid for my international donor money).  Esther, however, strategically took her diabetes medicine when she felt bad.  It cost too much to take it every day. She could not take insulin because it required a functioning fridge. (Which she did not have.)

Diabetes is not a problem of individual behaviors. Instead, it’s a problem of unequal societies.

It’s time that we rethink diabetes. First, we must understand that diabetes has become common among people facing poverty around the world. Living with diabetes without a reliable paycheck is nearly impossible. It is worse when medical care is unreliable too. Second, diabetes is not the same everywhere in the world. Social conditions that surround diabetes fundamentally change the disease. The co-occurring conditions with diabetes also impact how people experience it. Finally, interventions for diabetes must work upstream to address social policy and downstream to navigate clinical challenges and community-based solutions. Diabetes is not a problem of individual behaviors. Instead, it’s a problem of unequal societies.


Emily Mendenhall is a medical anthropologist and Provost’s Distinguished Associate Professor in the Edmund A. Walsh School of Foreign Service at Georgetown University. Mendenhall has published four dozen articles in high-impact journals in anthropology, medicine, and public health and led a Series of articles on Syndemics in The Lancet (2017). Mendenhall was awarded the George Foster Award for Practicing Medical Anthropology from the Society for Medical Anthropology in 2017.


Featured photo by Mae Mu on Unsplash

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