Alec Smith was 26 years old and had recently been promoted to manager at the restaurant he worked at. He also had type 1 diabetes. His position as a manager meant he earned too much money to qualify for Medicaid, but not enough to afford insurance. So, when he was removed from his mother’s health insurance plan, he had no choice but to buy as much insulin as he could out of pocket. A few days later, Alec died as a result of having rationed his insulin.1Alec’s case is not as rare as you might think. His is one of many horrifying cases of young people who died of preventable reasons because of the commodification of a simple and life-saving medication. As the idea of profit runs amok in the US healthcare system, and healthcare becomes more and more unaffordable for low-income people, we have come to accept situations like this as part of life. Young deaths from type 1 diabetes are horrible of course, but they did have diabetes after all, and if they could not pay for treatment, that’s the unfortunate truth. We fail to see that the unattainability of insulin is the result of an unethical healthcare structure. Type 2 diabetes is also treated as something disconnected from larger structures. People with type 2 diabetes are blamed for causing their own illness; they must have chosen an unhealthy lifestyle and suffered as a consequence. We easily fall into this type of thinking – attributing misfortune to the person, their body, or their behavior – and fail to consider wider structures.
First, we have to distinguish between type 1 and type 2 diabetes – although I argue that perceptions of both are the result of an assault on poor people. Type 1 diabetes usually surfaces at a young age, is most likely the result of genetic and environmental factors, and causes the body to fail to produce insulin. Type 2 diabetes usually surfaces later in life, is caused by a combination of genetic, environmental, and lifestyle factors, and causes the body to not respond well to insulin or not make enough of it.2 Type 1 diabetes offers grounds for analysis of the unethical practices of pharmaceutical companies while type 2 diabetes is surrounded by structural issues related to inequality.
Starting my analysis with type 1 diabetes, the price of insulin shows the extremes we are willing to accept as a natural result of free market forces. Insulin costs more in the US than ten times the average price in any other developed country. Pharmaceutical companies argue that the high price of insulin results from the cost of development, the cost of innovation, and free market pressures. Those arguments are easily rebuttable. First, insulin is a drug that has existed on the market for more than a hundred years, and the process for making it is relatively cheap and uncomplicated. Second, there is a very limited need for innovation when it comes to insulin. Third, the price of insulin is not a result of the free market – there is nearly no competition for insulin, the buyer cannot negotiate, and the price has risen at a far higher rate than inflation can account for.4 So, if the price of insulin does not need to be so high, why is it? It stems from the blatantly unethical and predatory mindset of pharmaceutical companies who know that they can take advantage of a vulnerable population, with no regard of what it means for the poor.
When it comes to type 2 diabetes, we start by looking at the case study of Mrs. H, a 49-year-old Hispanic woman with metabolic syndrome, including type 2 diabetes. Her doctors initially pegged her as a noncompliant patient who refused to improve her health by exercising and eating more healthy food. But looking beyond the surface of Mrs. H’s case, we can uncover many underlying structural issues to her illness. Mrs. H emigrated from Honduras decades earlier, and never got to finish high school. She lived in a low-income neighborhood, which meant that her only local food store was a McDonalds, she did not feel the streets were safe to take walks on, and there were no parks. Mrs. H lived in a two-bedroom apartment with 4 other people, including her two grandchildren, who she stayed home to take care of. She was unemployed and uninsured, so she only took her medication at the rare times she could afford it.3
These are only some of the structural factors we can glean from an individual’s story, but they provide a much more accurate and thorough explanation than simply attributing a person’s illness to their own personal shortcomings. Low socioeconomic status puts people at greater risk of getting diabetes, and it is not something that they can simply get out of. There are deep-seated, oftentimes generational aspects to the inequality that contributes to the high prevalence of diabetes in low-income populations. The misdirected blame is often amplified when it comes to poor people. We could explore this through the history and practices of viewing poor people as “less than” individuals that have to work harder than anyone else to prove their worth, although that would be a whole new story.
As more research on the underlying causes of diabetes comes out, the question of preventing and treating diabetes has begun to shift, rightfully, onto structures. Public health campaigns on type 2 diabetes in the past have tended to emphasize individual responsibility, failing to understand that for many people, changing their habits is impossible in their current socioeconomic situation. Rather, we must acknowledge the ethical issues inherent in our perceptions and treatment of diabetes, more specifically, the blame we place on poor people for situations out of their control. We must also recognize the human right to healthcare no matter one’s socioeconomic status and stop treating medicine as just another commodity to profit from at any human cost. From here, we can begin to tackle diabetes as the structural assault on poor people that it is.
References
1. Shure, N. (2019, June 24). The Insulin Racket. The American Prospect. Retrieved October 23, 2021, from https://prospect.org/health/insulin-racket/.
2. Osborn, C. O. K. (2020, October 28). What are the differences between type 1 and type 2 diabetes? Healthline. Retrieved October 23, 2021, from https://www.healthline.com/health/difference-between-type-1-and-type-2-diabetes#How-does-diabetes-affect-the-body?
3. Endres, P. (2020, August 5). Structural Violence and Noncompliance: A 49-Year-Old Hispanic Woman with Metabolic Syndrome. In-Training. Retrieved October 23, 2021, from https://in-training.org/structural-violence-and-noncompliance-a-49-year-old-hispanic-woman-with-metabolic-syndrome-20009.
5. Rajkumar, S. V. (2020). The high cost of insulin in the United States: An urgent call to action. Mayo Clinic Proceedings, 95(1), 22–28. https://doi.org/10.1016/j.mayocp.2019.11.013