While the historiography of racism and disease abounds with studies on infectious diseases, there are only a handful of books that address this relation with regard to chronic, non-communicable diseases, better known as “lifestyle diseases”. Arleen Marcia Tuchman’s Diabetes: A History of Race and Disease is among these few, and it offers an explanation for this gap. Over much of the twentieth century, she shows, health professionals and the public associated chronic diseases with wealth, civilization, and whiteness, considering people of color as rather immune to diabetes. This changed during the second half of the century. With the disease shifting its meaning from a sign of advancement and superior abilities to one of “primitivity” and a lack of self-control, public health declared African, Native, and Mexican Americans to be “diabetic race[s]” (p. 69, xiii).
Tuchman’s book is a history of these varying associations of diabetes with race, and of much more. Arranged both loosely chronologically and along different racial demarcations, the author shows how the shifting understandings of diabetes were connected not simply to people’s different disease vulnerability but to shifting understandings of race and disease. Seizing recent works on biological citizenship, Tuchman is interested in how concepts of diseases and disease vulnerability shaped citizenship and belonging.
In the first three chapters of the book, the author turns to roughly the first half of the twentieth century, showing how medical experts and the American public constructed the typical diabetes patient as white, systematically “misunderstanding” African American disease experiences and strengthening an association of whiteness with superior abilities and refinement. In the early twentieth century, according to Tuchman, the framing of diabetes as a Jewish disease contributed to sharpen the ambiguous understandings of both diabetes and Jewishness in science and culture. Conceptualizing diabetes as a disease of modern consumption resonated with antisemitic stereotypes of Jewish wealth and gluttony, and delineated both diabetes and Jewishness as “symbols of success taken to excess” (p. 17). While these understandings marked Jews as a distinct, disease-prone race, they eventually, as Tuchman suggests, contributed to making them white, by connecting diabetes to abilities associated with whiteness.
At that time, experts framed diabetes patients as “better citizens than the average” (p. 35) because they had to learn to live with and manage their disease. This practice of self-discipline and self-reliance was at the same time understood as a domain of middle-class whites, Tuchman shows. Thus, distinguishing “good” and “bad” diabetes patients in terms of their alleged ability to act self-responsibly was at the same time negotiating “how to define and protect what it meant to be white“ (p. 33) and middle-class.
Understanding diabetes as a “’clean’ disease of whites” (p. 36) and contrasting it to the allegedly “dirty” infectious diseases connected to people of color, disguised that Black people had diabetes, too, as Tuchman emphasizes. While she carefully considers the probability of high diabetes rates in African American communities in the early twentieth century, she shows that potentially high rates were rendered invisible by racist images of Black Americans as “not ‘advanced’ enough to suffer from diabetes” (p. 74). When this gradually changed towards the late 1930s, explanations of high diabetes rates among African Americans were equally pathologizing, as they began to focus on allegedly irresponsible behavior of particularly Black women: on wrong dietary choices, overindulgence, and “obesity”.
This shift was foreshadowing a more general change in the medical and popular image of diabetes around the middle of the century that Tuchman details in chapters four and five: the shift to it being understood as a disease of “primitivity”. After Native Americans had for decades been deemed immune to diabetes because they were considered not “civilized” enough to develop a “disease of civilization,” around the middle of the century, the “thrifty gene hypothesis” was employed to explain – and, as Tuchman argues, to make visible in the first place – high diabetes rates in Native communities. Diabetes experts took up James Neel’s 1962 hypothesis about “thrifty” genotypes that tended to store fat, and suggested that what had once been an evolutionary benefit had now turned into a problem and was responsible for rising diabetes rates among Native Americans. In this process, Tuchman explains, diabetes discourse racialized the concept of a thrifty genotype, explaining the assumption that Native peoples “were unable to adapt quickly enough to a Western lifestyle” (p. 101) with genetic difference – another example how diabetes made race and vice versa.
The framework of racial difference was equally powerful in the last decades of the twentieth century. The War on Poverty shed light on minority health problems, not only allowing for access to treatment, but more generally making visible the connection of poverty, structural racism, and health. Towards the 1980s, however, racial categorizations trumped critiques of structural inequality in medical and public diabetes discourse. When a growing Mexican and Asian American population became the new focus of diabetes research, experts found and framed high rates of diabetes as result of their particular “biological makeup rather than the outcome of decades (or centuries) of racist and discriminatory practices” (p. 181). At the same time, diabetes was differentiated in the now common type 1 and type 2 diabetes (then called “insulin dependent” or “non-insulin dependent diabetes mellitus”). Against the background of the significance of race for understandings of diabetes throughout the twentieth century, it is hardly surprising that this differentiation was racialized, with type 1 being associated with “innocent” whites, and type 2 with “irresponsible” people of color “making bad lifestyle choices” (p. 149), and coming along with very different access to visibility and resources for treatment. When the American Diabetes Association, in the 1990s, placarded that “Diabetes Favors Minorities,” its solution was to call upon individuals to visit their doctors “about how you can prevent or control diabetes” (p. 189).
Tuchman’s book is a brilliant and throughout instructive engagement with the co-constitution of race and health. The author shows how research on diabetes causes and vulnerabilities essentially only became “believable” (p. 29) and acted upon when it resonated with concurrent racial assumptions; and that it were changes in the understanding of race that led to shifts in understanding diabetes and researching and treating vulnerability. Also, and much more than reflected in this review, Tuchman tells her history with a sensibility toward its ambivalences. Acknowledging the realities of a deadly disease, she carefully unpacks the knowledge production about diabetes in its complexity and inconsistencies. Moreover, while she focuses on medical research and also considers public discourse, she sometimes gives voice to diabetes patients and health activists from minority communities, highlighting how they made sense of, appropriated and sometimes twisted pathologizing explanations of their disease vulnerability.
In its accessible prose and clear narrative, the book is not only great for teaching, but a compelling and timely contribution to our understanding of diseases, responsibility, and belonging. Tuchman offers a powerful reminder that we can only understand the history of a disease by inquiring into its interaction with ideas about race. Her book strongly suggests that the huge gap in the history of racism and “lifestyle diseases” might itself be the result of the racist division between “white” (chronic) and “Black” (infectious) diseases, and that it is past time to change that.
 Exceptions are: Keith Wailoo, How Cancer Crossed the Color Line, New York 2011; Anne Pollock, Medicating Race. Heart Disease and Durable Preoccupations with Difference, Durham 2012.
 Nikolas Rose / Carlos Novas, Biological Citizenship, in: A. Ong / S. Collier (eds.), Global Assemblages. Technology, Politics, and Ethics as Anthropological Problems, London 2004, pp. 439–463.