Disease & Race
Diabetes History Has Present-Day Implications
A century ago, the first human received an insulin injection. Thanks to insulin, type 1 diabetes is survivable and manageable, but a new challenge arose: many now face serious diabetes-related complications. A historian recently discussed these different sides of diabetes and raised some often-overlooked questions that reverberate in today’s world.
“Broader questions of race, environment and technology help inform how we might understand the complications of diabetes,” said Dr. Richard Mizelle, Jr., associate professor of history at the University of Houston, who recently delivered the 14th annual James Cassedy Memorial Lecture in the History of Medicine at the National Library of Medicine (NLM).
“Much of my work deals with physicians, but also with other health professionals who have largely been ignored by historians, including nurses, dietitians and nutritionists,” said Mizelle. “Black people, particularly in rural parts of the country, were much more likely to come into contact with a nurse rather than a physician.”
An estimated 37 million people in the U.S. are living with diabetes. Some 500,000 are on dialysis and more than 8 million require insulin to live. A major cause of kidney failure, heart attacks, stroke, blindness, neuropathy and limb amputation, diabetes still disproportionately affects people experiencing poverty, African Americans and other minorities.
Race, Health & Environment
A focus of Mizelle’s research, and the subject of a teaching module he developed for NLM, is the intersection of disease with environment and policy.
People with low socioeconomic status and seniors are particularly vulnerable to extreme temperatures, natural disasters, contamination from toxic dumping and other environmental exposures.
Last year was the 40th anniversary of the Warren County, N.C., protests, in which a small, predominantly Black community objected to becoming a landfill site for toxic waste. It was the first large-scale environmental protest in U.S. history.
Other examples Mizelle cited were more recent. The 1995 heat wave in Chicago highlighted vulnerabilities of those with a lower or fixed income. On the South Side, dealing with extreme temperatures, the elderly were encumbered by the elements, such as uneven, cracked sidewalks. Many stayed in and died in their apartments, unable to afford air conditioning.
In 2005, Hurricane Katrina tore through Gulf states calling attention to the difficulties of evacuating patients from hospitals, particularly those on dialysis, and moving people with amputated legs or serious health conditions to safety.
Even a seemingly harmless skin break could be dangerous in such a disaster. “People had to wade through toxin-filled waters to the Superdome or other shelters,” Mizelle said. “Complications from skin breaks could turn deadly if not treated in a timely way.”
Diseases such as diabetes and asthma adversely affect people who are poor and those without insurance, who frequently die from these otherwise manageable conditions.
Consider diabetes not only as a chronic disease, he said, but also as being interconnected with “where people live, what policies are at play and how we as a society are thinking about this vulnerability that people are dealing with.”
The Stroke Belt
Since the 1940s, some southern states have had much higher incidence of diabetes, kidney failure and heart disease. This “stroke belt” sheds light on the urban-rural divide.
Out of more than 1,200 dialysis clinics in Alabama, Georgia, Louisiana, Mississippi and the Carolinas, only 104 are not-for-profit, or hospital-based, which tend to provide better care and resources. Most of these not-for-profit clinics are in White, urban, affluent areas, noted Mizelle, which means the for-profit industry largely targets poor Black and minority areas.
“It becomes difficult in many ways for individuals located in these deep south states to access dialysis and [other] resources required to manage their illness,” he said.
About 140,000 people in the U.S. have diabetes-related amputations each year. Black people are three to four times more likely to endure them.
“By the time someone needs an amputation,” Mizelle said, “the body has been ravaged to a point that there are likely other health issues going on related to diabetes, including heart failure.”
And yet, Black people also have much lower rates of angiogram screening, which could help prevent heart failure. One strategy that can prevent amputation is revascularization surgery, which can open blocked vessels going down to the legs.
“But the medical system in many ways bends toward amputations first,” he said, “and that is a problem we as a society must face and take on.”
In low-income communities, amputations are twice as likely, due to the high cost of insulin, lack of health insurance and lack of access to specialists. Many areas even lack hospitals, and small clinics usually are not equipped to do revascularization surgery.
Amputees face unique hurdles, often contending with limited employment options and reduced self-sufficiency. A distinct stigma though comes with having an amputated limb and being Black, said Mizelle. Non-White people, for example, have a tough time finding an artificial limb that matches their skin color.
“And a chronic invisibility comes with dialysis,” Mizelle noted. People disappear for hours, several times a week for treatment. “But we don’t talk about dialysis the way we talk about other forms of chronic disability and those questions are important and connected to a much longer history.”
When Disasters Collide
“From the beginning, those of us who work within the realm of public health and the history of medicine understood that Black people and minorities and socio-economically depressed groups would suffer disproportionately from the Covid-19 pandemic,” Mizelle said.
“Even during the height of the shutdown, people on dialysis had to go to their dialysis clinic [multiple] times a week, no matter how far, regardless of how many buses they had to take…because this was life or death.”
In fact, many diabetes clinics were shut down during the pandemic, which has led to more long-term damage and heightened amputations, particularly among certain groups.
“We see this narrative, a moment in which disasters collide, in a number of ways over the last century,” he said.
A Matter of Access
Mizelle urged historians and researchers to put on their policy hats and work with public officials to help more people better manage, and potentially prevent, diabetes and its complications.
For one, revamp neighborhoods and public spaces—parks, walking paths, free exercise equipment, trees, fresh air.
“All of these things [not only] make for a healthy environment,” he said, “but also help people deal with disease and, importantly, help to prevent disease.”
To read an NLM interview with Dr. Mizelle about his work, see: https://circulatingnow.nlm.nih.gov/2023/01/26/the-many-faces-of-diabetes-complications-and-debility-in-late-20th-century-america/