Health, Ethnicity and Diabetes

Racialised Constructions of 'Risky' South Asian Bodies

Harshad Keval

• Publisher: Palgrave Macmillan
• Year: 2016
• ISBN:
  9781137457035
• Topic: Sozialwissenschaften
• Subtopic: Soziologie

This book explores the often contentious relationship between health, concepts of race and ethnicity, and the impact on South Asian groups. Using medical sociological and anthropological perspectives, it excavates racialised constructions of diabetes 'risk' within discourses, and highlights the contrasting counter narratives in people's accounts of their everyday lives.
By identifying a number of components to the discursive, racialised construction of 'risky' South Asian bodies, this book problematises taken for granted understandings of culture, lifestyle and genetic risk. The mobilisation of these mechanisms in health science and interventions result in a racialising gaze, directed at groups already experiencing historically embedded race-related issues. The book situates these constructions of risk against the emergent, fluid and dynamic counter narratives to risk constructions. The new found momentum in genetic science is also critiqued in its formulation of racial-genetic risk, especially in the case of diabetes in South Asian groups, and is identified as perpetuating a series of racializing processes.

© The Author(s) 2016

Harshad KevalHealth, Ethnicity and Diabetes10.1057/978-1-137-45703-5_1

Begin Abstract

1. Introduction

Harshad Keval¹

(1)

Canterbury Christ Church University, Canterbury, Kent, UK

End Abstract

This book is about the relationship between health, race, and ethnicity, and how people manage their experiences of type 2 diabetes, using a variety of tools located in their social and cultural contexts. More specifically, the book also aims to explore how the relationship between health and ethnicity in the UK has developed over the last few decades. These developments have witnessed a number of racialising tendencies, occurring at policy, political, and individual experiential levels. While the book is about the experience of diabetes amongst groups of South Asians in the UK, it is, more importantly, an analysis of the ways in which the health states of minority groups have become racialised in different ways and at different times. How people think about their health and illnesses, what they do about them, where they seek help—the array of impacts from socio-economic and structural factors and the long-term effects of these are all part of the rich intellectual and academic history of medical sociology and anthropology. In this book, I am focusing on how a condition such as diabetes becomes both part of everyday life for people, and also shows us how health and conditions are part of wider, socio-cultural processes. I often refer to these processes in this book as ‘constructions of risky South Asian bodies’. By this, I mean that in parallel to (not over and above) the daily experience of diabetes-related symptoms, seeking diagnosis and treatment, thinking about the impacts on one’s life, and using one’s cultural and ethnic identity to manage and deal with the illness are larger, overarching processes which shape people’s experiences. I want to contextualise people’s experiences within a socio-cultural framework that acknowledges that there are processes of discursive construction in operation. I define discursive practices as a series of actions that involve, over time and space, ways of thinking, conceptualising, viewing, writing, and impacting.

My mention above of ‘risky South Asian bodies’ is a term I use to signpost a series of discursive practices. There is a discernible pattern within health science discourse, which includes government policies and guidelines, academic literature within both biomedical and social sciences, as well as media representations, which have linked the racialised, ethnic, cultural, and social category of ‘South Asian’ to diabetes. There appears to be a widely accepted common-sensicality within academic public health discourses about the ‘racial’, ‘ethnic’, and/or ‘cultural’ nature of diabetes. Placed in the context of a number of wider issues, this emerges as a problematic relation for a number of reasons. First, there is an existing problematic relationship between Black and Minority Ethnic (BME) communities and health in the UK, which still in the process of being resolved. Second, as evidence over the last 40 years has established, general racial discrimination, differential access to healthcare, problematic attitudes to BME communities within healthcare services, and health promotion campaigns which have focused on specific ‘cultural’ traits of communities have all had a lasting impact on the health of BME groups in the UK. Third, there is a vast array of data, which indicates that on many socio-economic levels, BME communities suffer from structural, formal, and informal inequalities in opportunities in education, employment, housing, and healthcare. Fourth, the global and national burden of diabetes has rapidly increased at what most government agencies, media outlets, and academic writers regard as an alarming rate. This worldwide increase in diabetes becomes the backdrop health panic to more national and localised sets of panics. However, these health panics, of which diabetes is but one (obesity is another separate, but intimately related, health scare), are also characterised by ethnic and cultural specificity. In other words, although there is a generality to diabetes panics, that is, ‘the whole world is at risk’, the power and influence of expert knowledge systems, such as epidemiology, have proved beyond any ‘rational’ doubt that some groups are more at risk than others. In this book, I do not intend to debate the epidemiological evidence, although this is the subject of contestation. Rather, I examine what has been written about South Asian groups and diabetes, and what the symbolic and practical significance of this might be. The data generated as part of this study then shows us how we can locate people’s experiences in relation to discursive constructions. Talking with individuals, groups, observing people in situ, generated data which not only demonstrates what and how people do for the everyday management of diabetes but also gives us an indication that what some agencies call ‘culture’, or ‘ethnicity’—deemed fixed possessions that give apparently straightforward information to observers and researchers—are actually far more complex. They are what Neal et al. (2013) see as living multiculture, and subject to flex and change as the complex layers of socio-cultural and political interactions take place. In a sense, I am identifying how constructions of risky South Asian bodies are actively resisted in people’s everyday lives. On one level, official discourse and health practice in a wide range of interfaces (GP surgeries, community health centres, hospitals, etc.) create, maintain, and perpetuate specific versions of what it might mean to be South Asian and have diabetes. Usually, this involves having a vague ‘genetic’ risk (even though there is no known specific genetic mechanism identified as yet), and also, in tandem, being ‘culturally’ at risk (the belief/understanding that some groups do not engage in exercise and good diets, in addition to their beliefs and non-compliance with biomedical regimes).

As people are given the opportunity to talk and reveal their thoughts, feelings, and practices, the often simplistic, reified, and static way in which race, ethnicity, and culture have been treated in the health science discourses is rendered as dynamic, malleable, and adaptive as people navigate their complex socio-cultural landscapes. Constructions of South Asian diabetes risk require specific elements in order for these representations to be effective in discourse. Within this book, I point towards a number of specific elements we can identify. Culture and lifestyle are popular mechanisms, and indeed, metonyms used by discursive agencies to both explain and prepare the ground for associated treatment. I take particular issue with the way in which BME groups become identified as ‘culturally’ deviant in both their health choices and the related lifestyles they are perceived to have. These simplistic categories of ‘culture’ and ‘lifestyle’ also include diet and exercise, as well as people’s attitudes to using official biomedical forms of healthcare. Again, within this work, and as published elsewhere (Keval 2009a, 2015), I argue that, within the field of ‘race’ and health, the drive to establish causal explanations has often pathologised people’s cultures. This form of ‘cultural pathologising’ (Ahmad 1996) renders cultural and ethnic identity—a dynamic processual feature of all human social formations—static, creating fixed identities generated through stereotypes, incorrect assumptions, and possible discriminatory attitudes. Groups defined as ‘minorities’ then become categorised as having certain cultural faults, which lend themselves to higher health risks. The follow-on impact of this in terms of health intervention is, of course, diagnosis, treatment, and in parallel, health promotion campaigns. The crucial element here is that if the underlying conceptualisation of ethnic and/or cultural identity is simplistic and often problematic, then all of these related entities will also be subject to this problematic underwriting—a racialised gaze. With a condition as widespread in discourse and in people’s lives as diabetes, the importance of re-aligning this gaze becomes rather important.

A final element to the construction of South Asian risky bodies lies in the more recently ratified ‘new genetics’ arena. Diabetes, as Mcgee and Johnson (2013) point out, is not a single disease, but a cluster of conditions. While bio-scientists of many specialities have demonstrated their expert knowledge base in its mechanisms and associated disorders, there has yet to be a fundamental causal explanation for why some groups might be more susceptible than others. Genetic predisposition has long been a feature within the range of possibilities in high-risk BME group identification. Whilst early studies in Southall, London indicated six-fold increases in diabetes risk amongst South Asians (Mather 1985; Eapen et al. 2009; Barker et al. 1982), the causes of these increased risks could not be established. As I mentioned above, awareness of the condition, early detection, appropriate treatment, as well as dealing with perceived ‘barriers’ to healthcare, such as language, ‘cultural’ attitudes, and lifestyle factors such as lack of exercise and poor diets, were the main focus. However, in recent years, a parallel focus has emerged, and is gaining both widespread support and momentum—the genetic predisposition of South Asians to higher diabetes risk. Its importance is clear in the way in which South Asian diabetes has undergone a number of racialised and culturalised gazes, notwithstanding the great array of excellence in health intervention at all levels of healthcare. A new direction of diabetes risk has developed. My aim is to identify these discursive processes, and again, highlight the way the lived, experiential practice of social and cultural action provides people with the means to actively manage their conditions, but also, demonstrably resist the narrow confines of simplistic culturalised and geneticised pathology. I discuss some salient and emerging issues in the new genetic—racial diabetes discourse as they relate to the South Asian ‘risk-package’, and return to this in more detail in the Conclusion.

Within this study, a range of social, cultural, and biographically embedded diabetes stories emerged. The conceptualisation of the illness, the diagnostic process, the role of diet and nutrition, exercise and help seeking for the condition, and the role of biographies and histories in connection with community and place all became part of the stories and narratives that contextualised diabetes. These aspects, however, are not treated as isolated and static representatives of a medical model of disease management; rather, they are situated within the social and cultural contexts of lived social action. Allowing these stories to emerge provides a way to situate diabetes and the constellation of its impacts within a wider social and cultural landscape, and one which reminds us of the myriad ways in which people negotiate their lives. The picture rendered is not just a descriptive account of ‘what people do’. Rather, what concerns this study is the role cultural, social, and ethnic identity plays in facilitating the management of and coping with the disease. Locating the work within this framework also involves the exploration of migration-related settlement experiences, biographies, and existing connections the group has with the countries or continents they lived in prior to migration (usually, Africa and India). The stories which emerged in participants’ accounts framed the active construction of identity, rather than passive acceptance of identities, which have been maintained by caricature and reification of concepts of minority cultures and groups. A consistent theme I return to is the troubling and persistent relationship between health and race, as materially and discursively performed in a number of practices. The resultant manner in which health becomes ‘racialised’ through a re-codifying of ‘cultural signifiers’ is worthy of critical appraisal.

Throughout the book, I employ concepts of ethnicity, culture, and difference critically, so that the dynamic ways in which these ideas are used in people’s everyday practices are reflected. These notions of ‘difference’ and ‘sameness’ form the backbone of the methodology, and employ as their core concept a system of identity dialectics. Accessing individuals and groups, places and spaces, required negotiations of the delicately balanced terrain of ‘“insider” outside’ identities. Notions of identity within the research process are also subject to the ebb and flow of social action. These ‘cultural validations’ (Keval 2009a, b), a process of engagement and interaction of researcher and participant identities, allow for the interconnectivity of biographies and identities by making explicit the ‘researcher-researched’ relationship. There is an invocation here of the possibility of treading on the wrong side of identity absolutism—that is, you have to share absolute characteristics to carry out the research and generate these findings. However, this is neither the intention nor the stance taken here. The emphasis is on the role of cultural identity in research, and how various explicit connections between the researcher and the researched can, in the best traditions of general human relationships, enhance the research process. It is not by polarising the argument between value-free, culture blind approaches and supposed ‘authenticity’ that this debate can progress. Rather, unpacking the possible connectivities and what this may mean and come to symbolise for all parties is where some interesting insights might be gleaned.

While it is clear that in incidence and prevalence rates, to use the lexicon of epidemiology, there are clearly higher proportions of people categorised as South Asian with diabetes than White and other ethnic categories, it is problematic that neither ‘culture’ nor ‘genetic predisposition’ have been proven in any way to be part of the causal chain. And yet, the messages circulated by networks of health science discourse as well as popular health iconography (one only needs to look at posters for diabetes prevention, or websites providing information about high-risk groups) are that if a group’s ‘culture’ is modified, and their ‘genetic’ makeup accepted, then all would be well. This book principally seeks to undermine this assumption and contest these discourses, which are, as Foucault summarised, ‘practices that systematically form the objects of which they speak’ (1972: 49).

Outline of the Book

This book is divided into two parts. The first introduces, then explores, the ways in which constructions of culturalised and racialised risk play a role in the ethno-diabetes arena. In order to do this, I discuss health policy and academic research to focus on how notions of culture, lifestyle, and genetic factors are seen to be playing a role in South Asian diabetes. Part 2 aims to show how participants in this qualitative study demonstrably activate counter-narratives to these discursive constructions through the use of a variety of different cultural and socially embedded tools in their repertoire.

Chapter 2 locates the study within the general concepts and ideas used in the discussion of health and ethnicity. Rather than explicating foundational concepts, I aim to contextualise the ways in which health, ethnicity, and South Asian identities may be usefully explored. This necessarily requires that we look at how race and health have been treated in the past within academic and non-academic discourses. Chapter 3 first situates the sociological exploration of diabetes as a contextual, nuanced, and complex physiological disorder, whose varied and multifactorial impacts on people’s lives can only really be understood through the lenses provided by sociologies of chronic illness. It then goes on to provide a picture of diabetes in terms of prevalence and incidence. The expert knowledge base of epidemiolo...

Table of contents

• Cover
• Frontmatter
• 1. Introduction
• 1. Contextualising the ‘Risky’ South Asian Diabetic Body
• 2. Resisting Constructions of Risk: The Counter-Narratives
• Backmatter