The videos contain rich and at times startling detail about life in communities roiled by gun violence, poverty and food insecurity. They tell the stories of families where amputations, strokes and other complications of diabetes are the norm. One video, “Perfect Soldiers,” is written and performed by Gabriel Cortez, a young poet who laments seeing his relatives struggle with diabetes, a disease, he says, that “is as common in our family as heartburn.” He talks about his grandfather, a military veteran with a habit of consuming multiple sugary drinks daily despite suffering from diabetes.
“At 66, we are scared that another stroke could do what no war ever could and cut him to the ground,” Gabriel says in his video poem. “He drinks, like aunt Maritza didn’t lose both of her legs to diabetes last year, like half of our neighborhood doesn’t look like the emergency ward of a hospital, like he hasn’t seen the pictures: How it is impossible to tell the difference between a roadside bomb victim, and someone who just forgot to take their insulin.”
From AIDS to Diabetes
The program is in part the brainchild of Dr. Dean Schillinger, a co-founder of the U.C.S.F. Center for Vulnerable Populations and a primary care doctor at Zuckerberg San Francisco General Hospital. Dr. Schillinger began his career at the hospital in the 1990s in the throes of the AIDS crisis, when nearly half of his patients were dying of the disease. Dr. Schillinger witnessed the number of cases plunge as activists, public health experts and the medical and scientific communities came together. But then the obesity crisis began and a new wave of disease flooded San Francisco General.
“The AIDS ward is now a diabetes ward,” Dr. Schillinger said. “Maybe one in 15 patients had diabetes when I started 25 years ago. Now one in two of my clinic visits are with patients who have diabetes.”
Between 2008 and 2013, Dr. Schillinger served as chief of the Diabetes Prevention and Control Program for the California Department of Public Health. In that role he saw up close the rapid spread of Type 2 diabetes among children, and he was particularly struck by the link between the disease and socioeconomic status.
Looking at maps of San Francisco, he said, he noticed that diabetes hospitalization rates differed tenfold from one neighborhood to the next, driven by factors like income, education levels, segregation and soda consumption rates. While the public discourse around Type 2 diabetes tended to revolve around “shame and blame” — the idea that people who develop the disease knowingly make bad choices — Dr. Schillinger looked at these diabetes hot spots and began to think of the crisis as a social and environmental problem.
Many of his diabetes patients live in poor neighborhoods awash in fast food chains, liquor stores and billboards advertising junk foods. With severely limited incomes, his patients are often forced to purchase the cheapest, highest-calorie meals to feed their families, which often means choosing packaged goods and fast foods instead of fresh produce. Many are riddled with chronic stress from poverty and the threat of violence in their neighborhoods.
“I have many patients who say they will not let their kids go outside and play after school or after dark because they’re afraid of gangs and shootouts,” he said.
One day he attended a Youth Speaks event where he saw a morbidly obese 16-year-old girl perform a poem about her body image issues, her addiction to junk food and the diabetes that runs in her family.
“She was describing how she was eating cupcakes even as she wheeled her aunt who had diabetes and kidney failure into her dialysis appointment,” he said. “It was basically a food addiction poem in the context of the diabetes epidemic, with the addiction being a consequence of poverty, stress and insecurity. There were so many forces acting on this child that the pathways inevitably led to diabetes.”
A light bulb went off for Dr. Schillinger and for James Kass, then executive director of Youth Speaks. With funding from the National Institutes of Health, the U.C.S.F. Diabetes Family Fund and other sources, they started The Bigger Picture project in San Francisco and spread it to seven other regions across California. The spoken-word poems have been presented to over 10,000 high school students and viewed 1.5 million times on YouTube.
The Bigger Picture team hopes to conduct a study to see if the campaign has any long-term impact on obesity or diabetes rates among youth. In the meantime, they say their goal is to change the national conversation about Type 2 diabetes. They say the young poets are removing the stigma around the disease and calling attention to the fact that it is often impossible for people to make good choices when their options are limited.
“To make healthy choices, you’ve got to have healthy choices to make that are accessible and affordable,” said Natasha Huey, a poet and project manager for The Bigger Picture. “I would really challenge folks to take $5 and walk through the neighborhoods that a lot of our young folks are coming from and feed themselves healthfully. It isn’t easy, and that’s why this isn’t a conversation about individual choices; it’s about systems.”