The extent of the devastation became clear as the civil rights movement directed the nation’s attention to the intimate link between political disenfranchisement and economic inequality, and the War on Poverty made government resources available to tackle the problems that were coming to light.
When health activists and reformers traveled to the South, for example, they encountered towns where over 50 percent of the population was unemployed, 70 percent of the homes lacked running water, and only a few had toilets.
Conditions in inner cities were also eye-opening.
For all of these communities, the Office of Economic Opportunity’s funding of neighborhood health clinics had a significant impact.
From Mound Bayou, Mississippi, to Boston, Massachusetts, to Oakland, California, these clinics revealed the close connections among race, poverty, and disease, and made it clear that the so-called diseases of civilization no longer spared those living in extreme poverty.
Writing specifically about diabetes, the director of a clinic in the Mississippi Delta claimed, first, that the disease had gone undetected in the area because there had been no health professionals who might have diagnosed it, and second, that high rates of obesity masked the fact that people were actually malnourished ( Figure 5.1 ).
Calories from “potatoes, beans and hominy grits”, a poor person’s diet, do not, he pointed out, provide the nutrients people need to keep from getting sick.
Fig. 5.1. Home visit, neighborhood health center, Mound Bayou, Mississippi. From H. Jack Geiger, “Health Center in Mississippi,” Hospital Practice 4, no. 2 (1969): 68, 81. Reprinted by permission of the publisher Taylor & Francis Ltd., http://www.tandfonline.com .
Neighborhood health centers in urban areas also documented and sought to address high rates of diabetes among poor African Americans.
In 1963, for example, the City of Memphis Hospitals helped to create a decentralized network of seven neighborhood clinics and twenty satellite clinics to which the staff referred “patients with stabilized diabetes mellitus, cardiac or hypertensive disease.” Five years later, a similar system was established in Atlanta.
The clientele at both sites was more than 80 percent black.
In time, other clinics opened their doors, and epidemiological studies, such as one begun in Alameda County, California, in 1965, kept repeating the same message: not only did people of color have higher rates of diabetes than whites, but also the gap between black and white people was increasing.
By 1971, looking back over two decades of data, the head of the federal government’s Division of Vital Statistics noted that between 1950 and 1967 the diabetes mortality rate had increased just 5 percent for whites but 44 percent for “the color groups.” This message of disparity appeared as well in an official report delivered to Congress in December of 1975 that laid out a strategic plan for countering rising diabetes rates across the nation.
The head of the task force, who had been appointed by the director of the National Institutes of Health the previous year, announced that someone who was “non-white” had a 20 percent greater chance of developing diabetes than a person who was white.
Such statements may have been accurate, but they were also misleading, for they ignored data suggesting that poverty was linked to high diabetes rates as well.
As far back as 1935, 1936, the National Health Survey on Chronic Diseases and Disability had pointed out that individuals on relief were as much as 50 percent more likely to have diabetes as those “in comfortable circumstances.” Roughly a decade later, even Elliott Joslin was noting that the “bulk of all diabetics” were coming from “the lower income group.” In 1968, when the Department of Health, Education, and Welfare came out with a Diabetes Source Book to provide a concise summary of basic information about the disease to researchers and public health officials, it informed its readers that “diabetes prevalence rates are greatest in low income groups.” One year later, public health departments in parts of Appalachia began reporting a diabetes mortality rate twice that of the nation as a whole.
Diabetes rates may have been higher among “nonwhites” because a larger percent of them lived in poverty, but the rates among poor whites appeared every bit as high.
The image of the person most at risk of becoming diabetic was not only shifting from middle-class to poor, and from white to black; it was also becoming increasingly feminized.
What Leopold and Bowcock had noted in the 1930s, and Wilkerson had repeated in the 1940s, surfaced again in the 1960s as epidemiological studies revealed that the greatest disparity between blacks and whites occurred among women.
This was evident in two back-to-back reports published in the early 1960s, one based in Florida and the other in Georgia, both of which noted not only that black women had the highest death rate of any group, but also that their death rate was peaking a full twenty years earlier than for white women.
Researchers who mined national rather than state records uncovered similar patterns, noting in addition that the gap between white and black women had increased over time.
A review of a quarter century of national data revealed, for example, that between 1949, when the diabetes mortality rate for black women had first surpassed that for white women, and 1957, the gap had nearly doubled from 5.4 percent to 10.4 percent.
By 1969, the Diabetes Source Book was reporting that nonwhite females had roughly twice the rate of diabetes as white females and nonwhite males.
Ten years later, a headline in Ebony magazine identified black women as the “No. 1 Victims” of diabetes.
And by 1981, an article in the New York Amsterdam News warned that “except among certain Indian tribes, such as the Pima Indians, Black women suffer more diabetes than any other population groups.” No one, however, pointed out that after Native Americans, black women had the highest poverty rate of any demographic group in the country.
This was especially the case among the elderly, who were most prone to develop diabetes: statistics from 1981 revealed that while 20 percent of all elderly women lived below the poverty line, that number rose to 43.5 percent for black women.
Why rates were increasing for African Americans, and especially for African American women, remained unclear.
In fact, most studies at the time shied away from trying to explain the disparities they were identifying.
Instead, they read like fact-finding missions, focused primarily on detecting and documenting the places and populations where diabetes seemed to be most prevalent.
There were good reasons for waiting before drawing conclusions.
William Peter Uprichard Jackson, a South African diabetes specialist, complained in 1970 that despite the increase in epidemiological studies, “there is apparently no good knowledge of any prevalence rate among American Negroes.” Jackson, who was interested in the relationship between race and diabetes in different countries around the world, insisted that comparisons could not be made until standardized procedures were followed.
Yet most studies relied on restricted and “biased samples,” did not specify their methods, and did not explain their criteria for judging a particular result “abnormal.” Studies that relied on death certificates were particularly problematic, he added, since “fashions change” when it comes to recording cause of death.
None of this prevented him from providing an analysis of 125 articles on race and diabetes from a significant number of different countries, and concluding that “environmental factors, most clearly related to famine or feasting,” were probably most responsible for whatever variations appeared.
But he did not feel that he could rule out “intrin sic genetic ‘racial’ influences.”
Jackson’s reluctance either to privilege biological race or to rule it out was common in writings on African Americans and disease in the 1970s and 1980s.
The kind of genetically inflected theories that monopolized discussions of diabetes among Native Americans were simply absent.
The epidemiologist Kelly West, who played a central role in drawing attention to high diabetes rates among Native Americans, and whose 1978 text, Epidemiology of Diabetes and Its Vascular Lesions , provided the most thorough and up-to-date compendium of knowledge on the disease, made clear his preference for “environmental rather than racial factors” in explaining diabetes rates among black people.
The few researchers who did wonder about “innate” racial differences either expressed doubts or seemed hesitant, like Jackson, to make any definitive claims.
Instead, discussions of risk factors tended to emphasize the same risks that appeared in writings on diabetes in other populations, namely heredity and obesity.
Lewis Atkinson referred to them as “the two most important predisposing factors in the development of diabetes,” clarifying that by heredity he meant “family history.” Since he had analyzed patient records at Freedmen’s Hospital, and not the individuals themselves, he lacked information on the family histories of those who had received care at the hospital, but he did have their weights, and he calculated that 72 percent had been obese before they had been diagnosed with the disease.
Indeed, appearing to channel Joslin, he referred to diabetes as “largely a penalty of obesity,” adding that “the greater the obesity the greater the likelihood of the penalty.” His message was considered important enough that the Atlanta Daily World , the city’s oldest black-owned newspaper, covered his research in an article titled “72% of 506 Diabetic Clinic Patients Previously Overweight.” Clearly, the newspaper believed that this title would grab the attention of its readers.
Atkinson said nothing about the distribution of obesity by sex, although his data showed that 72 percent of the 506 individuals who had diabetes were obese and that the same percentage was female.
Other researchers were more forthright and attributed the gender disparity among black diabetes patients to women’s greater adiposity.
West believed the best explanation was that “black women are quite fat.” To support the link he was establishing between fat and diabetes, he mentioned studies about the inhabitants of Malta and Hawaii, the New Zealand Maoris, several Native American tribes, Australian Aboriginals, Sumo wrestlers in Japan, and others.
He also brought up earlier studies that had attributed high rates of diabetes among Jews to their propensity toward obesity.
He did not, however, suggest that any of this had to do with inherent racial traits.
On the contrary, although his position was unusual for the time, he seemed more inclined to attribute the high rate among black women to the fact that a high percentage of them lived below the poverty line.
This is consistent, he added, “with the possibility that the US poor now have more diabetes because poor women have become very fat.”