Dollar Meals and Diabetes
Logan County, West Virginia was the epicenter of the final battle of the “mine wars” of the 20th century: The Battle of Blair Mountain. In 1921, thousands of miners—white, Black and immigrant—stood together and took up arms against the forces of state and corporate terror that held them hostage in coal country. They were proud workers and they knew they deserved better. To the defeated and discouraged working class of present-day Appalachia, the story of the Battle of Blair Mountain must sound like a fairy tale.
Today, Logan County is ground zero for another battle—the struggle to survive in a region with the highest rates of Type 2 Diabetes (T2D) in the country. It is a place where all the risk factors for this global pandemic come together: chronic economic stress, broken communities, powerlessness, poverty, and toxic food.
Eighty years after conquering the major communicable diseases, the poor are still dying younger than the rich. In a shocking reversal rarely seen outside of wartime, 2017 saw a decline in life expectancy among some sectors of the poor in the U.S. A 2018 survey finds the same dismal reversal of longevity gains in Great Britain. Public health indicators between the rich and the poor continue to diverge, but now it is chronic illness, not infection, that is the killer. Insidious and poorly understood biologic processes are driving accelerating rates of cancer, heart disease, stroke and diabetes. And, like the infectious pandemics of the 18th and 19th centuries, these illnesses claim more victims among the poor.
The prevailing 19th century explanation for this disparity was “miasma:” a mysterious and invisible cloud of toxic air that was thought to hover over the slums of industrial England and sicken the residents. The first epidemiologist, John Snow, debunked this explanation forever by proving that it was tainted water, traced to a single pump, that was causing cholera. The germ theory took hold.
There is no germ theory for these modern-day scourges—no coherent, scientifically acceptable explanation for why poor people get more chronic illnesses. Medicine, the scientific lens through which we interpret and understand disease, is not a neutral force. When capitalism emerged from the ashes of the feudal realm, science took the place of religion as the legitimating ideology for the new social order. Who can dispute a scientific fact? But the focus of medical science is on individual habits, biology and genes. It’s an orientation that ignores environment, social relations and the now-undisputed unity of mind and body in the genesis of illness. Is health an individual problem with individual solutions? Or is health the social product of how we live in society? There are powerful repercussions depending on how these questions are answered. Modern medicine’s answer—that our individual biology determines our health—effectively eliminates the possibility that societal change can improve our wellbeing. We can only change ourselves, or submit to our genetic fate. It is a belief system that works very well to cement the status quo in place. But is it an accurate representation of how disease works?
What is diabetes?
Medically, T2D is the inability of cells to utilize insulin, with eventual failure of the pancreas to produce insulin. Insulin is the “key” that allows glucose (sugar) into the cells. If insulin is absent or blocked from entering the cell, blood sugar rises in the bloodstream, but cells are starved. A high blood sugar environment is uniquely toxic to cells. The failure of insulin—“insulin resistance”—is related to a pervasive high sugar diet and obesity. Researchers have characterized diabetes as a microcosm of the degenerative process of aging on a cellular level. The elevated blood sugar binds to cellular structures, producing inflammation that accelerates the damage of aging. Unsurprisingly, diabetes is the major risk factor for heart disease and stroke—diabetics have three times the risk of death from these cardiovascular conditions. Diabetics may suffer blindness due to retinopathy, amputation due to vascular disease, numbness and pain due to nerve damage and kidney failure requiring dialysis. It increases the risk for cancer and dementia. Diabetes is like speeding up the aging process. But it is premature aging with a preference for the poor.
The number of people diagnosed with diabetes has skyrocketed since 1980, increasing more than fourfold. The global prevalence has doubled. According to the World Health Organization, we are on track for one out of four people in the world to have diabetes by 2050. And estimates of undiagnosed illness is as high as 30-50 percent. Incidence is rising fastest in middle- and low-income countries.
Healthcare providers like myself are taught that diabetes is a hereditary affliction made worse by “lifestyle” factors: unhealthy food choices, a sedentary lifestyle and obesity. We are trained to treat one patient at a time and use the personal responsibility mantra to push our patients to improve their health status. Gluttony and sloth will get you sick.
Over the years I started to question these assumptions. If diabetes is primarily genetic, why has prevalence doubled in 40 years? It is impossible for genes to change that quickly. On the other hand, when we analyze maps of diabetes incidence, it is zip code, not genetic code, that appears to confer risk. Very poor localities like Appalachia, Native American reservations and impoverished urban neighborhoods all have outsized incidence. Endocrinologists blame the exceptionally high prevalence of T2D in Native American populations on “bad genetic substrate.” But I found studies comparing members of a Native American tribe who grew up with strikingly different socioeconomic circumstances (due to income-producing casinos on their land). The more economically secure section of the tribe has dramatically lower rates of T2D. Same genes, different outcome.
If T2D is not primarily hereditary, then certainly it is due to diet, obesity and lack of exercise. It is, after all, a condition in which the body has trouble turning food into energy. Is the globally pervasive Western diet the unseen contagion that is sickening modern humans and taking years off our lives? The answer is a qualified yes. The modern western diet is high in sugar, denatured white flour, vegetable oils, and meat; it is low in fresh vegetables, fruits and whole grains. More importantly, it is spiked with hidden sugar and fats, highly processed, and laced with chemicals to make it feel good in your mouth. The scientists Gary Taubes and Robert Lustig have shown that sugar, present in almost all processed foods, is physically addictive. Sugar and simple carbohydrates are also calming—they temporarily treat feelings of stress and depression through the release of endorphins, the body’s own opioid compounds. The impact of sugar alone could account for the entire obesity and diabetes epidemic.
Causes of the epidemic
The popular writer Michael Pollan has written persuasively and urgently about the disastrous health effects of corporate food production driven by powerful agribusiness interests. But his dietary mantra: “eat food, not too much, mostly plants,” is a tough ask for the residents of Logan County, home to 37 fast food restaurants; or those forced to live in the “food deserts” of dense impoverished urban neighborhoods, where there are Burger Kings with 64-ounce. sodas, but no greengrocers. The tax-subsidized food industry spends billions on saturation marketing, chemical flavor manipulation, and portion creep—this expenditure has been highly effective in changing eating behavior over the years. Opting out is a luxury that takes time and money.
Making the “choice” to eat real food means having access to affordable, high quality fresh fruits, vegetables, grains, and protein, and more importantly, the time to prep and cook a healthy meal from scratch every evening. Making the “choice” to be healthy means having safe streets to play in, bike lanes in neighborhoods that are walkable and time for informal group sports. Working Americans are exhausted and indebted, every family member is in the work force and work schedules are punishingly unpredictable by design—when parents finally pick up hungry and cranky children from day care, they want to treat them to something fun, delicious, fast and cheap. There is a straight road from Dollar Meals to diabetes.
The jaw-dropping explosion in diabetes having been normalized, treatment of this illness has become an industry. Lip service is given to “healthy lifestyles” by the pharmaceutical industry, but maintenance of an ever-growing market for expensive drugs used for a lifetime is the holy grail of Big Pharma. And profits continue to roll in as the disease destroys organs: the kidney dialysis industry has been wholly financialized and is now controlled by two corporate players, DaVita and Fresenius, whose stock is ascendant on Wall Street. Kidney failure preferentially affects the poor, but it is fully covered by Medicare at any age, so treating it is much more profitable than preventing it. A ProPublica investigation has found that fatality rates for dialysis in the U.S. are worse than anywhere else in the developed world—commercial dialysis care means short staffing, filth, high rates of infection and medication errors. A decade ago every major hospital had a diabetes center to focus on prevention—the vast majority have closed. The real money is in treating the complications.
So far in our story we have a corporate global food system that has replaced real food with highly profitable, adulterated, non-nutritive food-like substances for an expanding market around the world. Add to that an insurance industry that masquerades as healthcare; healthcare that profits from our illness; oppressive conditions of work that leave us stressed and exhausted with no time to prepare and enjoy real food, and communities built for machines that deprive us of the natural physical exercise our bodies need to survive. And yet we have only scratched the surface of the modern miasma.
The late Richard Levins was known as “the dialectical biologist.” A Marxist, a farmer, a biologist, and professor emeritus at Harvard, Levins insisted that a dialectical method was necessary to deal with complexity and change in the social and natural world. Medicine, on the other hand, divorces itself from the social, and deals in simple linear, causal relationships between biological parts: A causes B and is cured by C. But health and illness are always in dialectical relationship with environment, society, culture and history. We can’t chop reality into little pieces without losing the plot. The global pandemic of diabetes, and the social gradient that confers increased risk on the poor, is similarly complex. Biological feedback systems designed by evolution to protect us from danger have become the danger.
The role of stress
It turns out that our bodies generate substances that can cause diabetes, even in the presence of an optimal diet. These substances—hormones called cortisol and adrenalin—are produced by the adrenal glands to be released into the bloodstream under conditions of extreme life-threatening necessity. That is the evolutionary function, anyway—think tiger chasing prey on the savannah. The effect is to temporarily raise the blood sugar under stress to super-charge muscle and brain function. Robert Sapolsky is a neuroscientist who has been studying baboon populations in Africa for 30 years, and what he has discovered about a stress response gone awry is part of the puzzle of diabetes.
Humans are experiencing something new—chronic stress, stress that lasts for days, weeks, even years, and the physiologic consequences are devastating. When cortisol levels in the bloodstream are chronically elevated, the result is not only diabetes, but a cascade of related ills: impaired immunity to infection and malignancy, abdominal obesity, increased rates of dementia (high blood sugar is toxic to the brain’s hippocampus), high blood pressure, depression, diminished fertility and more. Pregnant women who experience frequent stress can have babies who secrete higher levels of glucocorticoids their whole lives—they are overweight and get more diabetes. According to physician and researcher Gabor Mate: “stress is not an abstract psychological event, it is a set of physical responses in the body.”
We know from post-mortem studies that the adrenal glands of poor people are abnormal and enlarged from overuse—the work of continually pumping cortisol and adrenalin into the blood. What causes this kind of chronic stress? Why do the poor get more of it? Arline Geronimus, a professor of public health at the University of Michigan, studies the health effects of the stressors of poverty, along with gender and race inequality. It is a catalogue of misery: unsafe living conditions, the constant threat of random violence, rampant everyday racism, discrimination and social exclusion, excessive caregiving responsibilities, deteriorated housing and crowded conditions, precarious employment and chronic financial insecurity. Geronimus calls the cellular damage wrought by this onslaught “weathering”—it prematurely ages every organ system in the body. As author Damon Young put it recently, writing in the New York Times about the premature death of Black men: “we age out of bullets and into high blood pressure.”
The levels of stress that cause this weathering occur when the threats to bare survival are always just beyond our ability to control. We then expend all of our energy simply trying to cope, but the threat is always close behind. We lack the power to control the forces that are buffeting our lives, and the lives of those we love. To be poor is to be at the bottom, always looking up.
It is this pyramid of hierarchy that is the most important factor in the social gradient of illness. In Sapolsky’s baboon tribe, it’s good to be the king. It’s also healthier—lower order members of the pack have higher stress hormone levels with resulting lower fertility, excess disease and shorter life spans. In the human tribe, “hierarchy” is a euphemism for our class position, and the consequences are the same. The health effects of an accident of birth are more diabetes, more cardiovascular disease, more cancer and a shorter life span.
This association is borne out in the famous Whitehall Studies. These longitudinal trials of health outcomes for thousands of British civil servants were begun in 1967 and are still ongoing. The subjects are not poor, and yet any job characterized by the experience of domination led to shortened life spans. According to Sir Michael Marmot, principal investigator: “We have strong evidence that there are two important influences on health in explaining the hierarchy in health. The first is autonomy, control, empowerment. People who are disempowered, people who don’t have autonomy, people who have little control over their lives, are at increased risk of heart disease, increased risk of mental illness. And we’ve also shown they had metabolic disturbances, the so-called metabolic syndrome, which increases risk of diabetes. We’ve shown that these work factors increase risk of the metabolic syndrome related to insulin resistance and lipid disturbances that, we think, increase risk of diabetes and heart disease.”
The antidote: community
We take for granted that for most Americans, work is hierarchical and alienating. But being dominated and powerless in the workplace literally makes us sick.
We also know that there are factors that are protective against the damaging effects of stress. The single highest predictor of elevated stress hormone levels in Sapolsky’s baboons is social isolation. The single most important buffer is social connectedness and community. The most damaging scenario for human health is lack of control over what is going on, no predictive information about the stressor, no outlets for the frustration caused by it, and no social support in coping with it.
So, it is not surprising that, according to Vicente Navarro, a researcher who has spent his life documenting the health consequences of capitalism, “the world’s healthiest societies are those with the lowest inequality—societies where leftwing forces are strong.” Navarro attributes this to the increased social cohesion and greater sense of power and participation in less unequal countries. Universal access to healthcare does not make the social gradient vanish because it cannot heal the weathering of body and spirit.
The quotidian, grinding violence that is life on the losing end of capitalism; a corporate assault that poisons our food and preys on the victims—this is the miasma that sickens us. The people of Logan County in Appalachia have endured decades of deindustrialization and layoffs that have all but destroyed their communities. With those losses go the institutions of collective support and connectedness that Sapolsky cites as essential to resilience and survival. In the wake of this trauma, the victims are disoriented, paralyzed, their sense of self-worth and autonomy shredded. It is that autonomy that is the prerequisite for power, and the antidote to the diseases of despair. The Battle for Blair Mountain occurred in the context of organized working people who knew their labor was indispensable and understood their power in withholding it. The response was rapid and brutal, and it continues to this day in Appalachia. “Stress” doesn’t begin to describe the experience of living in one of capital’s sacrifice zones.
As the globally dominant social and economic system, capitalism’s impact on our lives is all-encompassing. Diabetes may be a final common pathway of a toxic social environment that literally depletes life. Its disparate toll in zip codes like Logan County should be an urgent wake-up call. We are a product of our social relations, but we also shape them. It is that struggle—to forge human connections and locate our power—that brings health.
In 2018, teacher walkouts all over the country were sparked by a wildcat strike in West Virginia. The tipping point for the West Virginia teachers was the imposition of a “personal fitness wellness app,” refusal of which would incur a fine. The teachers saw the deception in a device that is not only personally invasive, but coercive and disempowering. In the face of the real threats to health—inadequate salaries, overcrowded classrooms, and unresponsive officials—the teachers’ united NO echoed with a strike wave across the country. It was the spirit of Blair Mountain.
Elizabeth Oram is a nurse and adjunct lecturer at Hunter College. She is a member of the Professional Staff Congress.
—Alliance for Sustainable Communities, October 27, 2019
https://www.sustainlv.org/focus-on/dollar-meals-and-diabetes/