Diabetes Is Killing Black America Faster Than Guns — And the Numbers Are Not Close

There is a killer moving through Black America that does not arrive with sirens or crime-scene tape, that does not produce marches or hashtags or the particular kind of performative grief that the media has learned to package and sell. It moves quietly, through bloodstreams, through nerve endings, through the small vessels that feed the eyes and kidneys and the extremities of the body, and it kills with a patience that makes it invisible to a community that has been conditioned to pay attention only to the violence that is loud and sudden and photogenic. Diabetes mellitus — primarily type 2 — kills more than 30,000 Black Americans every year. Gun homicide, the crisis that dominates the national conversation about Black death, kills approximately 10,000. The disparity between the attention these two killers receive and the actual number of lives they claim is one of the great misdirections in American public health, and Black America has been paying for that misdirection with limbs, with eyesight, with kidneys, and with lives.

The numbers should be spoken plainly, because the euphemisms and qualifications that typically surround this subject serve only to cushion a reality that deserves no cushioning. Black Americans are 60% more likely to be diagnosed with type 2 diabetes than white Americans. They are twice as likely to die from it. They are three times more likely to undergo a lower-limb amputation as a consequence of diabetic complications. They are two to four times more likely to experience kidney failure requiring dialysis. And these disparities have not narrowed over the past two decades of awareness campaigns, public health initiatives, and well-intentioned government programs. They have, by most measures, remained stubbornly, insistently, almost defiantly stable.

The Biology of Disparity

There are biological factors at work in the diabetes epidemic, and they deserve to be named honestly because dishonesty about biology serves no one. Research has documented that Black Americans, on average, exhibit higher rates of insulin resistance than white Americans, even when body mass index, diet, and physical activity are controlled for. This is not a moral failing. It is a physiological reality rooted in genetic variation, likely shaped by evolutionary pressures related to the ancestral environments of West Africa, and it means that the metabolic margin for error — the distance between a diet that produces health and a diet that produces disease — is narrower for many Black Americans than for their white counterparts.

This means that the standard American diet — which is killing white Americans at historically unprecedented rates as well — is even more lethal for Black Americans. It means that the sugar-laden, processed, calorie-dense food environment that has been constructed by the American food industry is a disproportionate threat to Black bodies. And it means that the advice that works for white patients with prediabetes — moderate your intake, exercise a bit more, lose ten pounds — may be insufficient for Black patients who are starting from a position of greater metabolic vulnerability.

“Not everything that is faced can be changed, but nothing can be changed until it is faced.”
— James Baldwin

The Food That Loves Us and Kills Us

The cultural dimension of this crisis cannot be avoided, and avoiding it is itself a form of violence — the soft violence of letting people die rather than risk the discomfort of an honest conversation. The foods that are central to the Black American culinary tradition — the foods that carry the memory of survival, that grandmother made, that taste like home and love and endurance — are, in their modern preparations, disproportionately high in sugar, sodium, refined carbohydrates, and saturated fat. Macaroni and cheese. Sweet potato pie. Fried chicken. Cornbread. Collard greens cooked in fatback. Sweet tea so thick with sugar that a spoon will nearly stand in it.

To say this is not to condemn a culture. It is to observe that the dietary patterns that were adaptive for people engaged in twelve hours of physical labor per day — the caloric density that kept enslaved people alive when they were fed the scraps and castoffs of the plantation — have become maladaptive in an era of sedentary work and abundant food. The cuisine was born of deprivation, of making something nourishing and beautiful from the parts of the animal that the slaveholder discarded, and it performed that function with extraordinary creativity. But the conditions that required those caloric strategies no longer exist, and the body does not know this, and the culture that venerates these foods as sacred has not yet reckoned with the fact that what sustained great-grandmothers who picked cotton from dawn to dusk is destroying grandchildren who sit at desks.

The Endocrinologist Desert

Access to specialized diabetes care in Black communities ranges from inadequate to nonexistent. An endocrinologist — the specialist best equipped to manage complex diabetes cases, to adjust insulin regimens, to catch complications before they become catastrophic — is, in many majority-Black neighborhoods, as rare as a bald eagle. The distribution of specialists in American medicine follows the distribution of money, and money, as always, has followed whiteness. The result is that the communities with the highest burden of diabetes have the fewest physicians trained to treat it.

A Black patient with type 2 diabetes in a rural Southern county or an underserved urban neighborhood is likely to receive her diabetes care from a primary care physician who manages dozens of conditions and cannot devote the focused attention that diabetes demands. She may wait months for a specialist appointment. She may not have transportation to reach the specialist once the appointment is available. She may not be able to take time off from the hourly-wage job that does not offer sick leave. And so her A1C drifts upward, and her kidneys begin to fail, and the numbness in her feet progresses from a nuisance to a crisis, and by the time she reaches the specialist, the damage has been done.

The cost of diabetes medication compounds the access problem. Insulin, a drug that has been available for over a century, has seen its list price increase by over 1,000% in the past two decades, a price trajectory that reflects nothing about the cost of production and everything about the moral bankruptcy of the American pharmaceutical industry. A month’s supply of insulin can cost over $300 without insurance, and even with insurance, copays can be prohibitive for families living on the economic margins. The result is rationing — documented, widespread, and lethal. Black patients are more likely than white patients to report skipping doses or reducing insulin intake due to cost, and every skipped dose accelerates the cascade of complications that ultimately kills.

The Amputation Crisis No One Discusses

There is a specific horror within the diabetes epidemic that deserves its own reckoning, because it reveals, with a brutality that statistics alone cannot convey, what happens when a treatable disease is allowed to progress unchecked. Black Americans with diabetes undergo lower-limb amputations at a rate three to four times that of white Americans with the same disease. In some communities, the rate is higher. In the Mississippi Delta, in parts of the rural South, in the neighborhoods of American cities where poverty and diabetes intersect, the amputation rate among Black diabetics is a quiet atrocity.

Amputation is almost never necessary when diabetes is well-managed. It is the end point of a cascade of failures: the failure to diagnose early, the failure to control blood sugar adequately, the failure to provide regular foot examinations, the failure to treat peripheral neuropathy before it progresses to the point where a patient cannot feel the wound on her foot that is becoming infected, that is deepening, that is threatening the viability of the tissue, that will ultimately require a surgeon to remove what could have been saved with adequate preventive care.

The racial disparity in amputation rates persists even after controlling for disease severity, insurance status, and comorbid conditions. A study published in Diabetes Care found that Black patients were significantly more likely to undergo major amputation than white patients presenting with similar clinical profiles at the same hospitals. The explanation, as with so much of what we have discussed, lies at the intersection of access, bias, and the cumulative disadvantage that accompanies Blackness in the American medical system.

What Is Working

The Diabetes Prevention Program — a landmark clinical trial funded by the National Institutes of Health — demonstrated that lifestyle intervention, specifically modest weight loss achieved through dietary changes and 150 minutes per week of physical activity, reduced the incidence of type 2 diabetes by 58% in adults at high risk. Among Black participants, the results were comparable. The intervention did not require medication. It did not require expensive technology. It required education, support, and the sustained attention of someone who gave a damn.

The translation of the DPP into community settings has produced some of the most encouraging results in the history of diabetes prevention. Church-based diabetes prevention programs — leveraging the institutional infrastructure that remains the strongest organizational force in Black America — have demonstrated that the DPP lifestyle intervention can be delivered effectively in non-clinical settings, at a fraction of the cost, with outcomes that rival the original trial. Programs in Black churches across the South and in urban centers have reported significant improvements in participants’ A1C levels, weight, blood pressure, and physical activity.

“If you want to fly, you have to give up the things that weigh you down.”
— Toni Morrison

The church-based model works for reasons that are not primarily medical. It works because it meets people where they are — in a trusted institution, surrounded by people they know, led by someone whose authority is moral rather than clinical. It works because it addresses the cultural dimension of the crisis without condemning the culture, finding ways to honor the culinary tradition while modifying it to reduce harm. Collard greens cooked in turkey neck instead of fatback. Sweet potatoes baked rather than candied. Sweet tea with a fraction of the sugar, served as a transitional step rather than an absolute prohibition. These are not dramatic interventions. They are small, sustainable, culturally respectful adjustments that, over time, can move a community’s health trajectory from catastrophe to survival.

The Work That Remains

Community health workers — trained laypeople from the communities they serve — have proven extraordinarily effective in diabetes management for Black patients. They bridge the cultural gap between the medical system and the patient. They provide the follow-up that overworked primary care physicians cannot. They catch the missed medication doses, the skipped appointments, the early signs of complications that would otherwise go unnoticed until they require emergency intervention. A study of community health worker programs in diabetes management found significant improvements in A1C levels, medication adherence, and patient self-management among Black participants.

The Affordable Care Act’s expansion of Medicaid brought millions of previously uninsured Black Americans into the healthcare system, and states that expanded Medicaid have seen measurable improvements in diabetes diagnosis, management, and outcomes among their Black populations. The states that refused to expand — disproportionately Southern states with large Black populations — have seen the diabetes crisis continue to worsen, a decision whose costs will be measured not in budget projections but in amputations, dialysis sessions, and premature deaths.

I write this not as a lecture but as a lament, and as a demand. The lament is for the 30,000 Black Americans who will die of diabetes this year, most of them preventably, most of them in communities where the resources to save them have never been adequately deployed. The demand is for an honest confrontation with the full scope of this crisis — the biological vulnerabilities, the cultural patterns, the access barriers, the medical biases, and the political failures that, taken together, have produced an epidemic that is hollowing out Black America from the inside while the cameras point elsewhere.

Diabetes does not march. It does not trend on social media. It does not produce the kind of dramatic, photogenic grief that moves the American conscience to temporary action. It works in silence, in the space between meals, in the darkness of unexamined blood sugar readings and unfilled prescriptions, and it kills with a thoroughness that should shame every institution that has chosen to look away. The programs that work exist. The evidence that supports them is overwhelming. The communities that need them are waiting. The only question is whether this country values Black lives enough to fund the interventions that would save them, or whether it will continue to pour its attention into the crises that make for better television while the quieter, larger, more devastating killer continues its work undisturbed.