Abstract

“There is a powerful, enervating anxiety created by the limits of our control over our small worlds and even over our inner selves. This is the existential fear that wakes us at 3 a.m. with night sweats and a dreaded inner voice that has us gnawing our lip, because of the threats to what matters most to us”

(Kleinman 2006b, p. 6)

“… it has long been clear that medical and public health interventions will fail if we are unable to understand the social determinants of disease”

(Farmer, Nizeye, Stulac, and Keshavjee 2006, p. 1686)

Introduction

Diabetes has become an epidemic problem in the U.S. (Boyle, Thompson, Gregg, Barker, and Williamson 2010; Centers for Disease Control and Prevention 2011). Approximately 8.3% of the population (or 25.8 million people) suffer from diabetes in the U.S., with the majority (nearly 95%) having type-2 diabetes (Centers for Disease Control and Prevention 2011). In addition, nearly one-fourth of the population has been diagnosed as pre-diabetic (Centers for Disease Control and Prevention 2008) and trends suggest that diabetes prevalence may increase to as many as 1-in-3 adults by 2050 (Boyle et al. 2010). These data demonstrate that diabetes is a compelling national problem, but the risk of diabetes is not uniform. There are significant disparities associated with diabetes based on race and ethnicity. Minority populations have a higher prevalence of diabetes as compared to non-Hispanic whites (Centers for Disease Control and Prevention 2011; Community Preventive Services Task Force 2011). Hispanics are 66% more likely, and Mexican Americans are 87% more likely to be diagnosed with diabetes (Centers for Disease Control and Prevention 2011). In Albuquerque, New Mexico, diabetes is the sixth leading cause of mortality (New Mexico Health Policy Comission 2009). In the Hispanic immigrant neighborhood where this study was conducted, our preliminary research found that the prevalence of diabetes and pre-diabetes among those sampled was 56%, with 29% of those undiagnosed and unaware of their compromised health status (Mishra et al. 2012).

Although ethnicity is one risk factor (Hanis, Hewett-Emmett, Bertin, and Schull 1991; Samet, Coultas, Howard, Skipper, and Hanis 1988), research has demonstrated a broad range of factors influences diabetes risk. Moreover, the findings of an Institute of Medicine report, (2002) identify the complicity of “policies and practices of health care systems…[with]…racial bias, discrimination, stereotyping and clinical uncertainty” (Smedley 2012, p. 993) as core factors in the creation and maintenance of disease and disparity. The etiology of diabetes, then, involves the complex intersection of multiple risk factors, some of which are not traditionally the focus of public health research. This reality has implications for prevention and treatment. Since the cause of diabetes is multidimensional, preventing it or treating it from a purely biomedical perspective is rarely effective; but without a comprehension of the relationship between health and broader social forces that produce disparity, efforts to improve health are not likely to result in meaningful change.

Despite research regarding broader factors involved in disease and disparity, the public health model for diabetes prevention and treatment has tended to continue to focus on getting individuals to change their behavior in terms of diet and levels of physical activity (Diabetes Prevention Program Research Group 2002) or to be “compliant” with prescribed actions and medications for diabetes maintenance (Bahati, Guy, and Gwadry-Sridhar 2012). Expanding the focus to include more expansive factors like historical and structural racism, changing relationships in the international economy that affect employment, housing policy that defines neighborhood residence, immigration policy, or government subsidies to industrial agriculture, is generally considered to be beyond the scope of study and therefore avoided in public health research. Increasingly though, because of the growing diabetes “epidemic” (Lam and LeRoith 2012) a social determinants of health perspective is seen as more adequate than a focus on individual behavior for addressing diabetes (Fisher, Chesla, Mullan, Skaff, and Kanter 2001; Peyrot, McMurry Jr, and Kruger 1999; Schulz, Zenk, Odoms-Young, Hollis-Neely, Nwankwo, Lockett, Ridella, and Kannan 2005). Groundbreaking research on social determinants of health (e.g., Kawachi and Bruce 2006; Marmot and Bell 2009; Syme and Frohlich 2002) and how “social factors ‘get into the body’ to cause disease (Syme 2005) helped to focus on disease mechanisms that had not previously been well understood or even imagined. For example, the impact of chronic stress (Cohen, Doyle, and Baum 2006; Kopp, Skrabski, Szé kely, Stauder, and Williams 2007) and the fact that individuals from low-income communities are exposed to higher levels of stress are now recognized as significant and cumulative influences on health and health disparities (Davey Smith 2003; Evans and Schamberg 2009; Raphael, Anstice, Raine, McGannon, Rizvi, and Yu 2003). The social determinants approach acknowledges that health behavior reflects more than individual desire or intention to change (Caban and Walker 2006; Cabassa, Hansen, Palinkas, and Ell 2008; Mendenhall, Seligman, Fernandez, and Jacobs 2010). The extent to which individual action is embedded in contexts external to individual authority and structured by institutionalized relations, environments, and policies is now well-documented in the social determinants literature (CSDH 2008). This has translated into a growing interest in environmental and policy change (e.g., http://www.cdc.gov/prc/about-prc-program/contributions/environment.htm, & http://www.rwjf.org/applications/solicited/cfp.jsp?ID=20804) and the need to promote “community empowerment” (Brennan Ramirez, Baker, and Metzler 2008) to overcome social determinants as “upstream” strategies for improving diabetes health outcomes.

However, understanding of the social dynamics involved in the mechanisms and pathways of chronic disease continues to lag (Potvin, Gendron, Bilodeau, and Chabot 2005; Trickett 2009). It has become clear that curtailing the alarming rise in diabetes will require a more nuanced understanding of the broader social determinants of health if evidence-guided strategies for individuals at high risk for developing the disease are to be effective. Yet, conceptual frameworks from public health theory, while enlightening in many respects, have not sufficiently embraced the true vision of social determinants thinking (Kawachi and Bruce 2006; Marmot and Bell 2009; Syme 2005; Syme and Frohlich 2002). Current approaches tend to be insufficient for revealing the multi-dimensionality of the relationship between social determinants, chronic disease and health disparity (Chaufan, Constantino, and Davis 2011; Coleman 2011, p. 13). The move toward a perspective on social determinants of health has necessitated a broader conceptualization of factors influencing health, but rarely does research seek to go beyond identifying immediate barriers and promoters of disease to explore or address the inequitable power dynamics and the root causes involved. Potvin, et al. (2005) argue that public health operates from this incomplete knowledge base because there is an “acute need for theoretical innovation” (p. 591). Moira (2010) similarly suggests that because theory is not sufficiently incorporated into public health research, the focus fails to go beyond the specifics of what people say or do to developing a coherent interpretation exploring “the meanings and processes associated with the categories of behavior observed” (p. 287)—in other words, an interpretation of the data. As such, we have yet to develop a more complete and integrated understanding of the way that health and illness are “produced as a social phenomenon.” Like Potvin, et al. (2005) and Moira (2010), we believe that public health frameworks tend to be under-theorized, and that by expanding our theoretical repertoire to include conceptual approaches from social theory, we can not only illuminate dynamics underpinning the production of health disparity that are poorly understood in the public health literature, but can offer new perspectives to expand our ability to prevent and reduce health disparity.

Using data collected with a Hispanic, immigrant population in Albuquerque, New Mexico, we apply a structural violence framework (Bourgois 2002; Farmer, Nizeye, Stulac, and Keshavjee 2006; Galtung 1969; Scheper-Hughes 1992; Singer 2004) to develop the concepts presented in this article. When analyzing processes related to disease, a structural violence framework takes into consideration the extent to which people’s lives are embedded in, reflect, and are limited by institutionalized inequality. Social inequality, whether current or past, is produced by historical processes that create inequitable relationships, environments, and policies, influencing and often governing individual experience. The multi-dimensional nature of social inequality means that its influence in people’s lives is cross-cutting; institutionalized inequality affecting one realm of a person’s life (e.g., low educational attainment) spills over into other dimensions (e.g., health status) (Eide and Showalter 2011; Ross and Wu 1995). Although not commonly employed in public health, a theoretical framework based on structural violence offers a useful tool for analyzing this spill over. Using this approach can provide insights for understanding the landscape of diabetes disparities.