Risky cultures to risky genes: The racialised discursive construction of south Asian genetic diabetes risk

Abstract

Type 2 diabetes within UK South Asian populations has increasingly become the focus of health science discourse. Growing rates across the globe have been a public health concern for a number of decades. Diabetes discourse has focused on lifestyle and a generalized idea of “cultural” factors as contributory factors. These have become part of what I identify as a South Asian diabetes “risk-package.” This risk formulation is extended to an additional genetic discourse which generates new causal explanations for this heightened “risk.” South Asian groups are already the subject of discursive, racialized risk constructions, which positions them as active owners of “risky culture.” The mobilization of genetic arguments repositions them as additionally passive owners of “risky genes.” I argue that the use of racial categories in genetic diabetes science, despite the relative uncertainty and ambiguity of scientific knowledge claims, is problematic and requires critical re-situating.

Keywords:

• diabetes
• race
• South Asian

Introduction

Diabetes has been consistently reported in health policy and health research discourse as a global risk. The International Diabetes Federation estimates that in 2013 there were 382 million people worldwide with diabetes and that by 2035 this would rise to 535 million (www.IDF.org). In the UK, Diabetes UK estimates that there are over 3 million people currently living with the condition, with nearly £10 billion spent on diabetes care and prevention, and a further 7 million people possibly at risk (www.diabetes.org.uk). People of South Asian origin have higher rates of diabetes, especially of type 2 (non-insulin dependent) diabetes, between 2.5 and 5 times higher than the white population (D'Costa, Samanta, and Burden 2000; Mukhopadhyay et al. 2006; Bhopal 2013). The epidemiological knowledge base concerning incidence and prevalence is now well established and interlinked with official health policy bodies such as National Institute for Health Care and Excellence (NICE), as well as charities and organizations which work closely within government policy and research arenas.

In this article, I examine the discursive constructions of risk as they emerge in the cultural, lifestyle and genetic formulations of racialized risk. First, I situate the social science treatment of diabetes in relation to ethnicity, and discuss the move from cultural and lifestyle discourses in South Asian diabetes discourse toward genetic predisposition. The way in which these ideas take purchase is particularly interesting because of how they are framed in certainty and definitive scientific value. I use specific examples of research to briefly show how the positioning of South Asian diabetes is manifested in cultural, lifestyle and now genetic risk formulation. Such formulations build on ideas already embedded in the discourse, such as the “thrifty gene” (Neel 1962). I argue that the unintended consequence of such exploration is that a genetic formulation – despite the relative uncertainty inherent in the technology – presents a racialising narrative of risk, already critiqued by a variety of authors. Finally, genetic understandings of both general life and illness in particular have both a specific and general expediency, and I explore some possible areas of critique in these understandings.

Situating diabetes

Type 2 diabetes has been featured particularly prominently in social science, biomedical and public health discourse (Lawton et al. 2007). Social science attention has tended to only mention the possibility of genetic predispositions and has consistently focused on the experiences of living with the condition and the associated coping and management strategies (Kelleher 1988; Schoenberg, Amey, and Coward 1998; Campbell et al. 2003; Mercado-Martinez and Martin Ramos-Herrera 2002). Another strand of research has moved in the direction of health-care access and delivery of services (Greenhalgh, Collard, and Begum 2005; Lawton et al. 2006; Stone et al. 2013). Research which explicitly demarcates the discursive relationship between health and ethnicity and diabetes in the UK context is uncommon, but increasing (Keval 2009). Much of the research has also focused on the lifestyle management areas of diabetes, emphasizing the relationship between diabetes and obesity, cardiovascular disease, and various neuropathy-based impacts on the body (Zimmett and Thomas 2003; Gholap et al. 2011). Such is the relationship between obesity and diabetes that a new term was introduced into the lexicon – diabesity (Shafrir 1996; McNaughton 2013). Indeed, the concern for surveillance and vigilance of body mass and levels of obesity are clearly present in a variety of government and non-government guidance sources (e.g. NICE; Diabetes UK; International Diabetes Federation; and World Health Organization). The relationship between diabetes risk and obesity within the South Asian grouping is extensively established in health science discourse, with a very specific focus on truncal obesity (e.g. Nagi 2004; Bhopal 2013; Abate and Chandalia 2001; Tillin et al. 2013).

Outside of academic interest in this relationship between diabetes and South Asians the health intervention literature overlaps with many of the health-care evaluation interests of social science and biomedical academic arenas. In this realm the focus is placed on evaluation of service take-up, auditing of access to health-care services, and the monitoring of medication, exercise, and dietary compliance (Gupta, Belder, and Hughes 1995; Naeem 2003; Hill 2006; Fischbacher, Hunt, and Alexander 2004; Misra et al. 2009). Kelleher and Islam's studies (1994, 1996) are exceptions in the way they situate diabetes within dynamic ethnic and religio-cultural contexts which facilitate an understanding of fluid and malleable usage of ethnicity and culture-making processes. While the socially contextual and life experiential themes continue to characterize some of the diabetes-ethnicity research, there is a parallel discourse which locates the central concern as cultural and lifestyle. Within this academic and policy discourse there is a focus on the ways in which minority groups – such as South Asians – are often seen as unable or unwilling to mobilize individual change in their health habits such as diet, exercise, and willingness to access services (Rocheron 1988). These tendencies are then taken as forms of non-compliance due to culturally and ethnically specific reasons. The development of lifestyle risk factors is of course neither new nor limited just to specific communities, but part of a wider fabric of individualization of health-care responsibility. This process itself can be seen as a component of the gradual neo-liberalization of health care (Mcgregor 2001), and increases the amount of emphasis placed on an individual's actions in their health-care status. The management of risk therefore lies, according to official discourse, in “healthy” lifestyle choices. The social scientific framing of health has long since problematized understandings of “healthy,” the notions of “choice” and “lifestyle” (Bunton, Nettleton, and Burrows 1995) and situated them within a nexus of attributional and relational understandings (Bury 2005).

In the area of diabetes and ethnicity, “lifestyle,” diet, (Naeem 2003) and lack of activity (Gupta, Belder, and Hughes 1995; British Heart Foundation 2001; Department of Health 2002) became key causal or at least prime contributors to South Asian diabetes. These constructions have been critiqued elsewhere (Keval 2009), but to summarize, they use vaguely conceptualized notions of culture, belonging, and identity and neglect socio-economic factors, reifying concepts of ethnicity in the service of making definitive, group-based generalizations about health. The resulting discourse emphasizes these cultural differences and marks them as culpability factors in the diabetes incidence and prevalence rates. Critical writers have long since established the ways in which the health conditions of minority populations have been subjected to a racializing gaze which displaces structural inequalities and experiences of adversity with a “cultural difference” argument (Smaje 1995). Such formulations are reductionist, and result in the “pathologisation of culture” (Sheldon and Parker 1992; Ahmad 1993; Ahmad and Bradby 2007).

I have argued elsewhere that these discursive formulations result in specific constructions of South Asian diabetic risk. These run counter to the lived, everyday experiences of people navigating their condition in complex social and cultural landscapes (Reed 2003). By situating the wider, over-arching discursive constructions of cultural and lifestyle risk in these groups, it has been possible to identify networks of symbolic ideas and practices of defining, labeling, and treating “other” minorities in health discourse (Ahmad 1996).

In this paper I argue that in addition to this existing cultural and lifestyle “risk-package,” there is an increasing momentum toward genetic formulations of South Asian diabetes risk. This extension is not only an added dimension to the “risk-package” but remoulds the relationship between culture and lifestyle, and genetic risks in this arena. Such reformulation results in the utilization of still precarious genetic scientific understanding of these risks, being mobilized as definitive or “certain.” This opens up the possibility of mitigating the relative “uncertainty” and sheer complexity of cultural and lifestyle arguments. I argue that this ultimately racializes the health statuses of South Asian people by using a combination of cultural, lifestyle, and genetic lines of argument.

A number of writers such as Montoya (2011, 2007), Ferreira and Lang (2006), Scheper-Hughes (2006), and Smith-Morris (2006) have explored in great detail the complex interconnections between racializing processes, diabetes, and historical experiences of subjugation. These anthropological works excavate a variety of different but related levels of interactional processes mediated by discursive power relations. The resultant findings ultimately provide a nuanced and rich socio-cultural historical picture of diabetes in indigenous communities in North America and Mexico. Contemporary work (Keval 2009) and my reflections in this paper refer to elements of this established work, and focus on South Asians in the UK whose migration histories, ethnic identities, experiences, and material positioning are subject to different contexts. Nevertheless, there are many parallels in how categories of risk are subject to race-making processes. Throughout the paper I will situate some of the arguments regarding the lifestyle and culture risks which have emerged in the discourse, against the relationship between race and ethnicity, diabetes, and genetic understandings.

Diabetes, genetics, and “racing” the risk

Although the genetic predisposition argument for South Asian diabetes has been ever present in the literature (e.g. Neel 1962; Hu 2011) there was a tendency for these ideas to remain cautiously positioned, mentioning the possibilities of race-specific genetic predispositions rather than definitive arguments. Much of the literature has skirted around the perimeters of making absolute causal statements regarding genetic predisposition, and tends to prefer suggestions of genetic predispositions to insulin resistance (McKeigue, Shah, and Marmot 1991) and primary metabolic effects (Abate and Chandalia 2003; Zimmett and Thomas 2003).

As Harvey (2011) has argued, there are distinctions between “genetic medicine” and “genomic medicine.” The former looks to DNA mutations in single gene disorders, while the latter is driven by a more nuanced exploration of the genetic components in common illnesses, and specifically the gene–environment interaction (Harvey 2011). These distinctions notwithstanding, there are discursive indications of a drive toward a more definite genetic line of medical scientific intervention. It is the symbolic and practical consequences of this which I aim to discuss in this paper. Not only is the South Asian diabetes “risk-package” (constituted by cultural and lifestyle notions) extended, but emerges as modified. By this I mean that the cultural and lifestyle argument remains intact as a set of vague causal mechanisms in the construction, but is placed in a different position by the addition of the genetic risk. Thus, subjects are active (choice making) owners of “risky” cultures, but also passive owners of “risky” genes. It might be feasible to argue that genetic predisposition is simply another addition to the range of factors that health scientists are working on. However, this issue is more complex. The extension to genetic risk situates a still precarious genetic science as definitive and unproblematic, and secondly introduces the dialectic of “uncertain–certain knowledge.” The uncertainty of cultural explanations (given the critique of cultural arguments) is somehow mitigated by the proposed and socially constructed certainty of genetic racial difference.

The critiques of biological and genetic race arguments as explanations for any number of differences that are either shown to exist (e.g. socio-economic differences) or assumed to exist (e.g. human intelligence) are long established (Gould 1981; Rose, Lewontin, and Kamin 1984; Duster 2005). However, as Montoya (2011) reminds us this is still contested academic, political, and intellectual space. Genetic understandings of illness appear generally to be perceived as less taboo than perceptions of genetic differences on the basis of intelligence. However, they are just as problematic in their political and discursive construction, especially where “racial medicine” is given prominence, as shown by Duster (2005).

As a specific metabolic life and life-quality threatening condition there have been a variety of attempts to establish links between diabetes and “ethnic” or “ethnoracial” (Montoya 2011) categories, due to the differential rates of diabetes in populations. I do not intend to wrestle with the complexities of genetic science here. However, to approach the area of ethnoracial geneticization in diabetes it is necessary to start with the geneticist's starting point: 99.9% of the human genome is identical (Ossorio and Duster 2005; Montoya 2011). This indicates that the seemingly miniscule genetic proportions under the biomedical gaze hold some form of fundamental answer to questions raised by epidemiological patterns. The underlining hypothesis driving much of this research in diabetes and genetics is known as the “thrifty genotype” hypothesis, proposed by Neel (1962). Neel speculated that the increased likelihood of developing diabetes in specific ethnic groups was the result of an evolutionary protective mechanism. Such a genetic mechanism would enable people in the early stage of human civilization to store fat in periods of abundance so that in periods of food crisis there would be a reserve of body fat storage to draw upon. Recent changes in food production, lifestyle, and consumption have allegedly left these particular ethnic groups at a disadvantage. The extra fat storage has a negative impact on how insulin and glucose levels are processed by the body and the related metabolic impact on body fat means an increase in weight and a change in insulin processing.

Although there has yet to be conclusive evidence to prove the existence of this “thrifty genotype,” the impact on diabetes discourse has been dramatic. The “racialising narrative,” as Fee (2006) has called it floats on an “unclear, scientific hypothesis … transformed into a clear-cut racializing account” (2990). It is this possible discursive articulation of genetic ethnoracial diabetes which I aim to signal in this paper. As Everett (2011) explains, despite this lack of evidence, and even a re-visitation of the theory by Neel himself, diabetes became known as the “classic multifactorial genetic disease” (Hedgecoe 2002, 9). This modification in nomenclature and the related impact has been discussed in some detail by Hedgecoe (2002). Various processes of representation and construction in the scientific research and publication arena helped to mobilize specific versions of knowledge rather than others. Although Hedgcoe does not specifically address how these genetic understandings of diabetes were applied to ethnic groups, there is a parallel here which I aim to explore. The discursive practices involved in the ethno-diabetes arena exist in a position of both certainty and uncertainty. This ambiguous positioning of racial/ethnic categories in human genetics has been explored by other authors (e.g. Hunt and Megyesi 2008), but here I focus specifically on diabetes and South Asian populations. This liminal knowledge space can be seen as the site of the racialized genetic construction of the “risky” South Asian body. In this discursive space there is a combination of diabetes-related entities pertaining to specific ethnic groups. The normative prescriptions of lifestyle, cultural, and diet formulations discussed above and elsewhere, any of which spell out pathology through non-compliance sit alongside and juxtaposed against the more recent genetic formulations of risk. It is this tension that requires exploration and problematizing as a site of ideological and discursive struggle.

Certain uncertainties in diabetes causality

The general trend of biomedical and epidemiological prescriptive models of health work is exemplified in, among others, Gholap et al. (2011). The general direction is a combination of both biomedical uncertainty in terms of fundamental cause and the traditional models of precise certainties which the medical gaze provides. Although clearly, biomedicine and epidemiology as applied to diabetes also operate on various levels of sophistication in how findings are interpreted and disseminated, they are far from the contingent and processual models of critical social science and anthropology. Thus, “South Asians are more insulin resistant than White Europeans … although the reasons are not very clear … it is thought to be mainly related to increased adiposity, central obesity … and high body fat percentage … ” (Gholap et al. 2011, 47).

The ambivalence in this knowledge base is commonly found and mitigated by the possibility of genetic predisposition. Recent reviews of scientific studies (Hartley 2014) indicate that there is no evidence that genetic risk profiling in screening programs contributes any additional high-risk indicator mechanisms. Regardless, mere possibility becomes the principal risk driver in South Asian diabetes discourse, mobilized by the now dated but often cited “thrifty gene” model. Here I would like to draw on what the direction symbolizes, rather than any sense of inherent accuracy or objective “truth” status allocated to the field. The symbolic and rhetorical direction is important because truth and knowledge claims, especially in diabetes and ethnicity science are part of a package of ideas about human categorization, especially as Fee (2006) reminds us, where cause and treatment are still in infancy.

A more robust and clear statement is made by Bhopal (2013) in his “four stage” model explaining the “higher risk of type 2 diabetes in South Asians.” This more nuanced approach to the possibilities of gene–environment interaction (Seabrook and Avison 2010) argues there are fundamental genetic and biological predisposing risk factors among South Asians. His four-stage model comprises the following requisites for high risk and includes a “three arrow linear relationship” between birth, childhood/early adulthood, and middle/old age:

a small, adipose, low-lean mass South Asian baby … (the) deposition of any excess energy intake preferentially in upper body and ectopic fat stores … exacerbated by an environment of low physical activity and excess calories, the accelerated appearance of high levels of plasma insulin … and the fatty liver vicious cycle … beta cell failure as a result of fewer beta cells at birth … especially energy dense hyperglycaemic diet and low physical activity play into this pathway.

In summary, the model describes the birth of a “small, relatively fatty baby,” which is predisposed to storing fat in specific areas of the body (“upper body, deep subcutaneous intra-abdominal and ectopic fat”), exacerbated by low physical activity, leading to insulin resistance and “fatty liver,” which finally leads to the deterioration of β-cells (essentially the malfunction of the pancreas, the core machinery in insulin regulation) (Bhopal 2013, 36). It is important to note here that Bhopal is stressing the need for a range of environmental, social, and cultural factors to be incorporated into the analysis of possible genetic causal mechanisms of diabetes in South Asian populations. The gene–environment interaction appears to be a focal point for much of the research in this area, and is driven by the fundamental question of raised incidence and prevalence.

It is not the scientific validity or health interventions developed by Bhopal and colleagues that is in question. Rather my argument moves in a parallel direction to Atkin and Ahmad's (1998) observation of the “new genetics” (Richards 1993) utilization of historically constructed meanings given life through social practices. The aim here is to reframe this issue epistemologically and identify some urgent discursive and impact risks for the groups in question. Genetic science, as with biomedical hegemony, presents a value freedom and objectivity, to the extent that South Asian groups can become characterized by a series of genetic traits, which fundamentally characterize their racialized health status.

I recognize that the construction and practice of scientific knowledge, here biomedicine and genetics, are seldom one dimensional, and are often characterized by both hegemonic directions and spaces of resistance and counter hegemony. However, I argue that where health, culture, race, and power intersect, these spaces potentially become minimized. These can be viewed as discursive constructions, produced and maintained by a variety of power relations (Foucault 1977) inherent in the empirical science process. Indeed writers have suggested this is a new form of disciplinary power, utilizing novel surveillance strategies (Raman and Tutton 2010). While Bhopal is rightly keen to emphasize the potential for harm in biological explanations by asserting the combined impacts of gene and environment, this contrasts with the symbolic and possibly practical consequences of these positions. By re-orienting the socio-cultural and economic terrain on which South Asian diabetes sits (Link and Mckinlay 2009), a genetic model of causality – even one which emphasizes the need to keep the social context in mind – may fuel the early racialized genetic discursive and material constructions of minority health further. Even Bhopal's careful statement of the need to bring a multifactorial analysis to bear on this issue inevitably leads to conclusions about evolutionary models “out of step with modern lifestyle” (2013, 37). Bhopal also cites research stating that “South Asians' cultural values place a high premium on the enjoyment of good, tasty food, which is at the heart of family life, and hospitality towards family and friends” (2013, 37). Focusing on specific “cultural” practices which in reality are a socially embedded practice for a range of ethnic groups does not provide a nuanced, explanatory possibility. This is especially the case when it is clear that food consumption is a social, cultural, and economically located practice (Schubert et al. 2012). Stating that a specific group of people enjoy tasty food rather than performing exercise cannot be viewed in isolation, or in an ideological vacuum.

These forms of culturally specific argument which strip the dynamic possibilities away from groups have been consistently contested (Ahmad 1993). A benign, health interventionist statement reveals itself to be locked into a network of loaded, ideologically formulated notions of difference which potentially have a range of reifying consequences. Differences in health between ethnic or cultural groups have been long under the gaze of critical social scientists (Kelleher and Hillier 1996), trying to ensure that cause of any difference is not automatically assumed to lie within essentialized aspects of a group's identity (Bradby 2012). The potential for Ahmad's (1993) warning regarding “pathologising culture” appears to be relatively unheeded.

The situating of genetic explanations for South Asian diabetes alongside formulations of cultural pathology provides an interesting dialectical relationship. This is characterized on the one hand by culture and lifestyle (which includes exercise and diet), and on the other hand by the genetic predisposition to a disease. We are then presented with a “risk-package” which relies both on the pathologization of culture and on the identification of culpable, racialized genetic material. With regards to the former, people can choose to make changes to their health, through modifications of lifestyle or indeed complying with cultural changes as prescribed to them. These are, however, contained within the group and the individual through supposedly “choosing” lifestyle, diet, and “cultural” practices, and therefore resulting in culpability in the final analysis. The latter however (genetic risk) reveals itself to be a powerful component in the production of ethnoracial (Montoya 2011) geneticization of South Asian diabetes. The genetic risk formulation therefore provides little room for ambiguity or modification, and therefore facilitates diabetes discourse operating within a framework of certainty. The genetic scientific understanding of health is part of the recent emergence of new genetic and genomic conceptualizations of contemporary life (Novas and Rose 2000a, 2000b). They are located within a contested area, and the application to diabetes emerges as a way of raising questions about the differential impact on South Asian groups, an issue I turn to next.

Risky genes and risky lives

Lippman's (1991) use of the term “geneticisation” provides a useful conceptual framework for exploring these discursive processes. Undoubtedly in a process as complex as human health, there is a complicated network of cultural, economic, political, and social factors at play. Genetic explanations for health and illness statuses are no exception and have been both welcomed and critiqued. The geneticization critics argue that the process renders all forms of human agency inactive, and produces a new form of determinism (Lippman 1991; Shakespeare 2006). Others, however, have argued that no such blanket determinism has taken place, and instead there is a subtle way in which genetic scientists carry out their work (Hedgecoe 2002). Rock (2005) for example asserts that diabetes has not been geneticized, but rather has undergone increased medicalization, while more positive observers such as ten Have (2001) prefer to emphasize the facilitating and enabling effect geneticization has on the public's engagement with the complex moral and ethical issues within genetics, essentially as a cultural tool.

The idea of “genetic risk” in an individual's life can be read as simply one aspect of a range of wider changes in personhood, in what Novas and Rose (2000a, 2000b) call “somatic individuality.” The molecular gaze re-envisions all of life itself, so that these genetic risks are the product of new biomedical languages, descriptions, and judgments. In contrast to much of the critical consensus in this area, rather than geneticization taking away people's agency, and resulting in objectification, subjugation, and oppression as one might expect from hegemonic ideologies, it potentially creates the possibility for agency. This agentive subject is created in a similar fashion to the way in which somatic illnesses of the corporeal body necessarily involved the patient as an active agent of control. As the clinical encounter required the patient to voice their symptoms in the interactive order of the relationship, so genetics requires subjects to develop new, agent-centered skills, rather than become passive recipients of expert knowledge. Patients and their families can thus exercise control over their medical prognosis and uncertainties, by partnering up with genetic science through the biomedical system. This, however, is a problem when we consider the case of race, ethnicity, and diabetes. While genetic attribution can in principle remove or alleviate some of the culpability and blame issues involved, in the case of South Asians and diabetes this is less straightforward. As I suggested above, ethno-diabetes discourse mobilizes the liminalty of the uncertainty–certainty dialectic by utilizing both cultural deficit and genetic pre-disposition. This form of double culpability means that geneticization of diabetes discourse fundamentally “racializes” the construction of risk in these populations.

The problem with “genetic agency”

If we apply this type of idealism or “genetic optimism” (Conrad and Gabe 1999) to the South Asian diabetes “at risk” populations, questions need to be raised regarding the evidence base for this presumed agentive control. We can also question why fundamental issues in the processes of geneticization such as differential impact according to class, ethnicity, and gender are not explicitly attended to. As medical sociology, anthropology, and social epidemiology have established, taking control of one's health or illness, especially in the era of “biological citizenship” (Rose and Novas 2007), requires one to be in a position of relative privilege, materially, culturally, and linguistically. Possession of specific forms of capital can then facilitate a mediating relationship in related interactions. The supposedly newly emerging matrix of family centered, localized discourses – the “genetic network” – becomes the host of newly formed identities with an array of associated possible changes to lifestyle, diet, family relationships, community, and condition-specific interactions.

However, the genetic rendering of South Asian “risky” bodies reveals a compelling disjuncture between idealized genetic networks and the reality of daily applied, discursive racialized geneticization of groups of people with diabetes risk. The daily impact potentially occurs in doctor's surgeries, hospitals, clinics, and many other health-care encounters where providers understand and disseminate seemingly irrefutable genetic categories to people who may or indeed may not be in a position to contest or refute. This last point regarding contestation is crucial here, for the very assertion that this new genetic science actually creates spaces of contestation and discussion needs more depth and detailed research. Certainly, in-depth research which echoes existing North American and Mexican experiences is much needed for the UK South Asian population. If we take socio-economic positioning, geographical location, and de-homogenized racial and ethnic categories, what then would these spaces of contestation and refutation look like? Who would be in a position to utilize these sites of discursive and practical struggle? In advanced, industrial liberal societies, identities are dynamic, fluid, and characterized by situational contexts. However, there are enduring relationships between socio-economic materiality and race which render this fluidity a little more static. Genetic labeling could potentially make agentive, dynamic articulations of the negotiated order of diabetes more troublesome for minority populations including black and minority ethnic communities who are already in a proven disadvantaged position in terms of illness incidence, prevalence, adverse experiences, and access to health care (Atkin 2006). As other authors have already warned, the application of genetic science carries substantial risks of stigmatization and discrimination (Aspinall 2013). Despite recent nuanced writings which advance the complexity of genomic work, proposing that “variation is the norm” (Rose 2009, 11), such hypothetical democratization of genetic knowledge may do little for people already under particular gazes in contemporary health arenas. The issue is not genetic hegemony, but rather the differential impact of geneticization against a wider backdrop of searches for stability and certainty-framed epistemic readings of difference.

One of the problems with the optimistic view of this episteme lies in the way human individuality can be made more sense of in new ways and reorganized according to this new genomic understanding. As with all knowledge-making processes, the impact is mediated by positions of relative power and vulnerability. This critique is starkly contrasted to the role of the “lay” expert (Prior 2003), viewed as legitimate in and integral to health-care interactions. Within the “genetic gaze,” individuals and groups may need to navigate relationships with specialist techno-scientific knowledge which goes beyond their familiar, general medical practitioners. There is a need to explore the plausible sites of contestation and interaction in these spaces. As we have already seen with cultural and lifestyle constructions of health, genetic risk can become constructed as a moral issue, limit the available choices for individuals, and place them under psychosocial stresses (Hallowell 1999). For specific populations under a genetic gaze, there may be a range of potential issues that need to be acknowledged in a nuanced discussion of the gene–environment interaction model. We should therefore remain vigilant against wholesale acceptance of definitive genetic constructions of South Asian diabetes risks in the UK.

Racialized (un)certainties

What we might witness in both daily medical practice and scientific discourse is not the agentive reflexive capabilities of late modernity or the inevitable breakdown of “race” as new hybrid forms of difference and sameness emerge. Instead, for South Asian genetically labeled populations we can witness a re-envisaging of cultural and racial differences. They combine the scientific and health promotional currency of faulty lifestyles and cultures, with something far beyond intervention at local levels – the molecular and genetic. This parallels the mobilization of genomics as new forms of identity politics are utilized (Bliss 2013). These dialectical tensions between contestable cultural pathology and near irrefutable genetic pathology become discursively formulated, articulated, and practiced in localized health settings. Simultaneously they are driven by global concerns and policies, such as the public health burden. Such articulations contribute to a formal construction of South Asian “risky” bodies.

This is all the more problematic, when on the one hand every day, embedded, lived encounters of the racial genetic gaze (Gilroy 1998) proclaim certainty while in scientific reality the gene occupies an ambiguous, increasingly unknowable status (Lock 2007). This is precisely because of the huge variability in both knowable interactions between genes and the environment, and the as yet un-read and un-known outcomes of these interactions. Genetic explanations “naturalise racial and ethnic difference” (Braun 2002, 159), thereby potentially masking the varied and complex interactions between social structural forces and the mechanisms of biology. There is a long history of contingency in how populations are classified and defined, and a combination of scientific and social processes guide how frequencies of gene distributions are identified, constructed, and understood (Braun 2002). Explicitly stating that South Asians are genetically predisposed in a variety of ways may be confusing ethno-linguistic, historical, cultural, social, and material identities with each other, turning a social label into a natural one (Montoya 2011).

Drawing on Montoya's (2007, 2011) framing of diabetes as an “ethnoracial” disease, this becomes part of racial discourse, since in a Foucauldian (1972) sense the object is formed out of the systematic practices involved through racial-genetic discourse. The production of ethnoracial diabetes risk is not neutral and value free, but part of the prevailing political and social ideology, as it informs our understandings of human groups. The systemic practices are the packages of biomedicine, genetic techno-science, and the resulting capability of constructing and mobilizing causal explanations for difference. Diabetes and its related metabolic syndrome is far from a single disease, and is a condition that is firmly and inescapably intertwined with inequalities in a cause and effect relationship (McGee and Johnson 2013). Given the sheer complexity of a condition as multifaceted and embedded in its social situation, the notion of genetic science unraveling it from the “social” is far from plausible, and would require control of infinite combinations and impacts of socio-cultural factors (Happe 2013). Inevitably such problematizing of what appears to be a scientifically evident, molecular truth raises important questions about the impact of discursive constructions of diabetes risk.

Raising questions for UK South Asian diabetes

Critical social science provides conceptual, theoretical, and empirical indications to show social action and culture as dynamic landscapes within which the social actor moves, negotiates, and lives out tensions and concordance (Nagel 1994). Ethnoracial diabetes in contrast contracts this dynamicism with the assumed “irrefutability” of genetic truth and essentialism. Complexities and nuances in some writings notwithstanding, the policy trickle down results in advice, screening, and treatment based on these forceful scientific legitimations.

For many black and minority groups, this subtle recycling of biological-cultural racisms may symbolize the problematics of health–race relations in the UK since post-war immigration. These forms of biomedical and genetic science discourse may find a way to reduce the contingent nature of social scientific fluid explanations and insights. They may prefer instead to start with a genetically predisposed South Asian “fatty baby” (Bhopal 2013, 36) who for unknown (cultural, geographical, material) reasons may also lead an inactive life, and so be at extra high risk of this costly and potentially debilitating but preventable condition. There is an added internal contradiction here that while type 2 diabetes (also known as later or adult onset) is one of the most preventable of metabolic conditions, the implications of this recent genetic modeling is that it all begins at the genetic and molecular level, long before adulthood even beckons, so rendering early intervention (as proposed by biomedicine itself) problematic.

This bio-genetic gaze fuels the need to find irrefutable certainties in disease prognoses. If various indigenous populations such as the Pima of Arizona (Smith-Morris 2006) or Mexican groups (Montoya 2007, 2011) run the risk of being racialized and therefore discriminated against, what might the impact be on South Asian groups in the UK or wider indigenous and diasporic networks? The question cannot be considered without a lengthy and detailed analysis of socio-economic contexts in which different groups operate and live on a daily basis. The reductionist account of genetic essentialism – which may include “environment–gene” interaction (Seabrook and Avison 2010) – ensures that even where some mention of social context is made, the genetic underwriting process takes precedent. The object of a racializing genetic gaze (the individual with the condition) is left with a series of ongoing experiential somatic dilemmas. In addition, they may experience a disconnection from a powerful (and impenetrable) social and “political anatomy” (Armstrong 1983) in the process of constructing the South Asian diabetic body.

Mcdermott's (1998) identification of a “therapeutic nihilism,” whereby groups subjected to specific forms of bio-genetic construction and practice start to adopt the fatalism associated with non-curability, is appropriate here to signal the reification of dynamic processes. While critics of the geneticization argument might point out that no such production of docile bodies has in fact taken place, I would be keen to point out that it is not docile bodies that are necessarily the problem.

The potential issue is that these scientifically uncertain but “legitimated” formulations of genetic predisposition become embedded within local articulations and cultural “illness scripts” of specific target groups. There is a wide body of qualitative diabetes research which reveals how many groups express their understandings of diabetes causality in “blood,” “hereditary,” and lifestyle-based notions (Smith-Morris 2006; Montoya 2011). For South Asian groups categorized as high risk, the addition of official genetic articulations may well have an impact on this local, experiential knowledge and understanding.

Widening the lens

Many medical anthropologists identify the large socio-historical and imperial colonial forces of history as sources of inter and intra-generational trauma and grief (Fee 2006; Ferreira and Lang 2006; Montoya 2011). In addition associated socio-economic and cultural deprivations also play important roles in how some subjugated groups have suffered biologically (Smith-Morris, 2005; Lock 2007). This raises a question for the UK's South Asian groups: is there a way of identifying similar processes among these groups? Would the trauma of multiple migrations, the multifactorial impacts of racism, and urban deprivations be a possible source of what Happe (2013) and Fee (2006) have already signposted?

Certainly, there is evidence that migration experiences present enough trauma for individual bodies and groups of people with a common experience to develop clusters of symptoms (Mooy et al. 2000). Other studies show the detrimental impact of racism on health (Krieger 1999; Karlsen 2007), mental health (Bhui et al. 2005), the impact of stress on type 2 diabetes (Heraclides et al. 2009), and social isolation (Picket and Wilson 2008). However, the emphasis generally remains on academic and community intervention on the lifestyle, culture, and genetic argument basis. Generalized prevention and treatment discourses surrounding diabetes take on “raciological” (Gilroy 2012) meanings when, over a period of time, South Asian “risk-package” constructions become normalized practice.

The racialized construction of a cultural and genetic pathologized South Asian diabetes experience is a feature of the overall landscape of rendering a picture of the human race. As Bradby warns, “ … structured genetic clusters,' ‘cultural’ and/or ‘ethnic groups’ can all be interpreted in racialized terms because of the long history of constructing the complexities of human variation as races” (2012, 956). In a sense this momentum toward an ethnoracial genetic modelling of South Asian type 2 diabetes revolves around the contrast to the often insecure, nuanced, and complex analytical processes involved in social and justice-based explanations of illness. The contrast which genetic science appears to offer is the potential of certainty, the immutability of the human, cellular, and molecular condition. The proposed genetic basis of South Asian diabetes runs the risk of reifying and mixing ethno-religious, linguistic, socio-economic, and culturally diverse groups into the unmovable realms of a discursive molecular fate.

Conclusion

In a sense what seems to have emerged from this discussion is the identification of a discursive question, which could be phrased as: “how do you solve the problem of South Asian diabetes?” This question really asks how do you deal with the complexities and problems involved in assessing and controlling the concept of culture in a multi-factorial disease like diabetes? Health interventions at the individual and community levels, and national frameworks giving advice and guidance, are well established. Similarly the epidemiological models which continuously assert the multiples of risk in South Asian groups are equally interlinked and given authoritative prominence. As the incidence and prevalence levels remain stable in their trajectory, the increasingly multicultural diversity of society rightly renders “cultural” explanations ever more complex and therefore difficult to establish as definitive reasons for diabetes levels.

I have argued that the increasing momentum of genetic arguments for South Asian diabetes emerges as a discursively generated answer to the question posed above. The relative certainty of genetic and indeed genomic lines of argument becomes a way of dealing with the myriad definitional and conceptual issues involved in the intersection of culture and health, and provides some epistemological stability. The substantial problem lies in the impact on what effectively become racialized subjects in health science discourse. Already at the problematic end of the health inequalities spectrum, South Asian groups are now placed under an additional and modifying gaze contributing to the overall discursive schema of risk construction.

I have argued that first health science discourse has mobilized a series of cultural and lifestyle arguments in exploring diabetes epidemiology. Secondly genetic arguments which in the past remained on the periphery of the debate have now started to be of central concern. Thirdly, this movement is based on a precarious certainty which is mobilized as definitive and utilizes a range of scientific legitimacies to proffer validity. Lastly, I have argued that this is not simply an additional element in the South Asian diabetes “risk-package” but actually modifies the relationship between culture, lifestyle, genetics, and diabetes. It does so by engendering the uncertainty–certainty dialectic. Thus, the complexities and uncertainties related to cultural factors in diabetes are mitigated by the new found “certainty” and irrefutability of genetic arguments. The impact of such racialized discursive constructions could be at service provision levels where clinicians tailor their advice and recommendations based on these racial-genetic understandings. They might also be evident as already shown in North American and Mexican contexts, at the individual and group levels. Here communities themselves begin to conceptualize their cultural and ethnic identities in racialized genetic hues. I argue that greater vigilance needs to be maintained if we are to avoid what Duster called the “fallacy of reification” (Duster 2005, 1050), and continue to develop dynamic, contingent, and politically nuanced intersectional analyses of health.

Acknowledgements

I would like to thank anonymous reviewers for helpful, constructive comments on earlier drafts of this paper.

Disclosure statement

No potential conflict of interest was reported by the author.