Diabetes in the US: a social epidemic

A recent series of articles in the New York Times highlighted a phenomenon that has increasingly alarmed public health advocates in the United States: a virtual epidemic of Type 2 diabetes throughout the country, an epidemic that is growing at a faster pace in New York City than anywhere else.

The seriousness of this health crisis has been known for some time in medical circles. As the Times articles make clear, the disease in so prevalent in working class and poor communities that its victims take it almost as a matter of course. In terms of public recognition, however, diabetes is under the radar, so to speak, compared to more highly publicized health issues such as breast cancer and AIDS.

Type 1 diabetes, often called childhood diabetes, occurs when the pancreas does not produce the insulin required for the body’s metabolism, and those afflicted must take insulin daily for the rest of their lives. This variety of the disease is strongly identified with genetic predisposition.

Type 2 diabetes is the more common form, representing more than 90 percent of cases. It is also the type that is growing rapidly in the US. In this form of the disease, insulin is not properly used in the body. Type 2 diabetes is sometimes relatively mild in its manifestations, and more easily controlled with medication. Its first symptoms are either insidious or negligible, and it is often undetected for years, especially among people who do not see a doctor regularly. Untreated or inadequately treated Type 2 diabetes can be just as deadly in the long term as the less common Type 1, however. Typically seen in adults over the age of 40, it is linked more to conditions like obesity and physical inactivity, although there is also a genetic component.

An estimated 21 million Americans have diabetes, but another 41 million people have the prediabetic condition of high blood sugar, putting them at high risk for developing the disease in the near future. The American Diabetes Association estimates the cost of diabetes, including such expenses as disability payments and lost days at work, to be at least $132 billion a year as of 2002. An official of the Centers for Disease Control in Atlanta is quoted by the Times: “How bad is the diabetes epidemic? There are several ways of telling. One might be how many different occurrences in a 24-hour period of time, between when you wake up in the morning and when you go to sleep. So, 4,100 people are diagnosed with diabetes, 230 amputations in people with diabetes, 120 people enter end-stage kidney disease programs and 55 people who go blind.”

In New York City, the incidence of the disease is significantly worse. Some 800,000 people in New York, one in eight of the adult population, now have diabetes. One third of these, however, do not yet know they have the ailment. These figures are one-third higher than the rate for the US as a whole, and the rate at which the illness is being diagnosed is growing at almost twice the national pace—an 80 percent increase nationally in the past decade, compared to 140 percent in New York.

Type 2 diabetes, moreover, is being diagnosed more frequently in children, something that was virtually unheard of 25 years ago. The health care system, already facing enormous pressures, is facing a veritable catastrophe. Nearly every organ and body part can be affected by the complications of diabetes—leading to blindness, uncontrolled infections requiring amputations, kidney disease or heart disease. Diabetes is the leading cause of blindness among adults. The number of war veterans who lost limbs to amputations due to diabetes last year was the same as those who endured amputations due to combat injuries during the whole period of the Vietnam War.

The Times quotes one endocrinologist in New York on what the ongoing epidemic means for the future: “The work force 50 years from now is going to look fat, one-legged, blind, a diminution of able-bodied workers at every level.”

Just as significantly, hospitals and nursing homes will be jammed with diabetics in a far shorter time frame than 50 years. They will have to deal with patients needing therapy and rehabilitation following amputations, with advanced kidney disease and every other serious complication of the disease. The health care system will be unable to deal with major emergencies, such as those caused by an earthquake or other natural disaster.

How is this possible? Reading the mainstream media or watching television, one is constantly bombarded with the claim that, give or take a minor glitch here or there, the country has never been richer. Household income has risen, McMansions are being built in the suburbs and exurban areas, and the market for luxury goods keeps growing.

As for New York, the general tone in the media is one of celebration of the city’s long recovery from the bleak days of high crime and unemployment in the 1970s and 1980s. Former Mayor Rudolph Giuliani is credited with leading this renaissance. A current exhibition at the Museum of the City of New York celebrates the role of former mayor Ed Koch, the right-wing Democratic demagogue who presided for much of the 1980s. And the current mayor, billionaire Michael Bloomberg, just coasted to reelection last November after a campaign in which he spent $84 million of his own money to tell New Yorkers that the city was in great shape.

The diabetes crisis reveals the reality that exists in the “other” New York—the New York where few vote, where tourists rarely travel, where the wealthy Wall Street dealmakers and the upper middle class never venture.

Type 2 diabetes is in many important respects a disease of poverty. It is a social epidemic, spread not by a physical agent, but by the conditions of life affecting many millions of working people.

As numerous studies have shown, there is a connection between the material conditions and psychological stresses associated with poverty and the so-called “lifestyle” factors of obesity and inactivity. One study has indicated that a successful battle against obesity would prevent up to 58 percent of new cases of Type 2 diabetes. This runs up against entrenched social problems connected to poverty itself.

In many cases, the poor are unable to afford foods that are both healthy and appealing. They are either handicapped by a lack of education on good nutrition, or have the knowledge but are less likely to use it because the supermarkets in their neighborhood carry fewer healthy foods—or because, weighed down by the day-to-day pressures of low wages or unemployment or family problems, they simply lack the energy and motivation. Others eat unhealthily or overeat because it is one of the few pleasures that are within their reach. The end result is a substantially higher rate of obesity among the poor.

The same pattern applies to inactivity, associated as it is with unemployment, with being confined to congested neighborhoods and having no reason to leave them, and with depression and other emotional and psychological responses to the struggle for daily existence.

The end result of these social factors is a close correlation between increased poverty and increased incidence of diabetes. The better-off neighborhoods of New York have rates of diabetes of less than 3 percent. In the wealthiest area, Manhattan’s Upper East Side, with a population of about 206,000, the rate is 1 percent or less. In East Harlem, directly north of the East Side, the rate among the neighborhood’s 106,000 residents is a whopping 16 percent, the highest in the city. East Harlem’s median household income is $20,111, only a bit more than 25 percent of the median income in the Upper East Side. A survey showed that food stores in the Upper East Side were more than three times as likely to carry healthier foods like fresh fruit, low-fat diary products and high-fiber bread as their counterparts in East Harlem. Hospitalizations caused by diabetes were 10 times more prevalent in the poor neighborhood, and deaths caused by diabetes were nearly 5 times greater (47 per 100,000, compared to 10 per 100,000).

Poverty is a major factor in the spread of diabetes, but it is not the only one. Declining living standards and increased stress for those struggling to just keep their heads above water also has an impact. While the poorest neighborhoods have the highest rates of incidence, it is rapidly growing in all working class communities.

There have also been significant demographic changes in the city that have had an impact. Well over 2 million newcomers have settled in New York in the past 25 years, for the most part fleeing intolerable poverty in almost every corner of the globe. The percentage of foreign-born residents is the highest in nearly a century. There are now hundreds of thousands of New Yorkers who were born in China, well over a million who were born in Puerto Rico and the rest of Latin America, and many tens of thousands more from South Asia, Africa and literally everywhere in between.

The immigrants remain disproportionately poor as they toil for subsistence wages and help to fuel the city’s economy, while pundits smugly dismiss their poverty as perfectly acceptable, because they would be even worse off if they had remained in their native lands.

In addition, for not fully understood genetic and environmental reasons, some groups of immigrants have higher rates of diabetes than the native-born. The Centers for Disease Control predicts that one in two children from Hispanic families born five years ago will become diabetic in their lifetimes, compared to one in three children for the country as a whole. Public health officials have also noted that Asian immigrants, including the fast-growing Chinese population, tend to develop diabetes even in the absence of obesity and other risk factors, a situation that is far rarer among the native-born. It has also been noted that many immigrant parents, fleeing conditions in which there was not enough to eat, are unaccustomed to restricting the caloric intake of their children, among whom obesity is growing.

Another major factor fuelling the diabetes crisis is the poor management of the disease. Health care for all but the wealthy is increasingly under attack, and in the poorest neighborhoods, with their higher percentages of the medically uninsured, the situation is grave. Many patients must choose between paying for their medication or their food. Some cut pills in half, even though control of the disease is extremely sensitive to precise dosage of medication. Some diabetics do not keep track of their blood glucose levels regularly because they cannot afford the equipment needed to administer the tests.

The profit-driven medical system itself is responsible for the abysmal level of diabetic care. There are relatively few endocrinologists, the specialists who treat diabetes and other diseases involving the endocrine system, because it is a comparatively lower-paid specialty.

Health insurers systematically discourage the kind of preventive care that would minimize the complications of diabetes. The reason is simply that there is less money to be made in this area. Insurance reimbursements for nutritionists and diabetes educators, as well as endocrinologists and podiatrists, are far below the cost of care. The treatment of the disabling and life-threatening complications—in hospitalizations, outpatient physical therapy for amputees, and the fitting of artificial limbs—is where profits are made. Hospitals collect a $20 reimbursement for a nutritionist, but up to $20,000 for an amputation.

A prime example of the irrationality of the present system is the closing down of several hospital clinics in New York that had pioneered the use of preventive care with some success. A center at Beth Israel Medical Center in Manhattan had quickly been able to get 60 percent of its patients to get their blood sugar under control, and a similar number had lost significant weight. The center was closed down, however, because it was losing money. The Joslin Diabetes Center in Boston, with 23 affiliates elsewhere in the country, is one of the few such centers that have been able to continue in operation, but only because of philanthropy. Its president and director told the Times that “the institutions which are doing much of the work in dealing with this major health epidemic [depend] on charity. In the long run, this is definitely not a tenable system.”

The unending cutbacks in all social spending are also having their impact. In New York, for instance, the city’s Health Department devotes only three people and a budget of $950,000 to the fight against diabetes.

There are numerous lessons to be drawn from the growing diabetes epidemic, over and above the immediate medical emergency. The growth of the epidemic tracks almost exactly the growth in social polarization and social inequality, the emergence of two-tier systems of health care, education and every single sphere of social life. It highlights the incurable contradictions of the profit system. In the precincts of the wealthy, countless billions of dollars are spent every day on speculative real estate investments and luxury goods, which the old term “conspicuous consumption” does not begin to adequately describe. In the rest of the city, public health conditions hark back more and more to the nineteenth century and the beginning of the twentieth.

In the long run, moreover, even the wealthy will be affected. The constantly increasing health costs, the impact of the disease on the workforce itself—all of this is not in the long-term interests of the ruling elite itself. The crisis of American capitalism means, however, that even the most minimal reforms, which in the past have propped up the system, are no longer forthcoming. The Times gives the example of one local politician who attempted to introduce a bill in the New York State Assembly in Albany to require all restaurants to post the calories, fat and salt in each menu item. The proposal was treated as a joke, and the effort was easily defeated.

The increasingly empty forms of elections and legislative activity conceal a system in which the interests of the vast majority are never even considered. American “democracy” has become utterly sclerotic. Millions of workers are well aware of this. As one East Harlem woman told the Times in commenting on the conditions in her neighborhood, “We are the poor people. We only get the crumbs. I used to advocate a lot. I got tired. I don’t do it any more.”

This is not the final word, of course. The appalling social conditions, and the utter callousness with which the political and corporate elite preside over them, are laying the basis for new battles. When all roads are blocked to achieving the most basic rights, the road is opened for social and political upheaval.